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Clinical and symptomatological reflections:

the fascial system

This article was published in the following Dove Press journal:

Journal of Multidisciplinary Healthcare
18 September 2014
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Bruno Bordoni 1,2 Abstract: Every body structure is wrapped in connective tissue, or fascia, creating a structural
Emiliano Zanier 2,3 continuity that gives form and function to every tissue and organ. Currently, there is still little
information on the functions and interactions between the fascial continuum and the body system;
1
Department of Cardiology,
IRCCS S Maria Nascente, unfortunately, in medical literature there are few texts explaining how fascial stasis or altered
Don Carlo Gnocchi Foundation, movement of the various connective layers can generate a clinical problem. Certainly, the fascia
Milan, Italy; 2CRESO Osteopathic
Centre for Research and Studies, plays a significant role in conveying mechanical tension, in order to control an inflammatory
3
EdiAcademy, Milan, Italy environment. The fascial continuum is essential for transmitting muscle force, for correct motor
coordination, and for preserving the organs in their site; the fascia is a vital instrument that enables
the individual to communicate and live independently. This article considers what the literature
offers on symptoms related to the fascial system, trying to connect the existing information on
the continuity of the connective tissue and symptoms that are not always clearly defined. In our
opinion, knowing and understanding this complex system of fascial layers is essential for the
clinician and other health practitioners in finding the best treatment strategy for the patient.
Keywords: fascia, osteopathic, low back pain, neck, pain

Introduction: definition of fascia

Every body structure is wrapped in connective tissue, or fascia, creating a structural
continuity that gives form and function to every tissue and organ.1–6 The human body
must be considered as a functional unit, where every area is in communication with
another through the fascial continuum, consequently originating perfect tensegritive
equilibrium.5 Medical literature does not suggest a sole definition of fascia, because
it varies in terms of thickness, function, composition, and direction depending on its
location. The fascial tissue is equally distributed throughout the entire body, envelop-
ing, interacting with, and permeating blood vessels, nerves, viscera, meninges, bones,
and muscles, creating various layers at different depths, and forming a tridimensional
metabolic and mechanical matrix.6,7 The fascia becomes an organ that can affect an
individual’s health.8 Awareness of its functions and of the areas it controls becomes
significant within a more general perspective concerning the patient’s wellness and
health (Figure 1).
From an embryological perspective, the fascial system originates in the meso-
derm, although according to some authors this connective network can be partially
found in the neural crests (ectoderm), with particular reference to the cranial and
Correspondence: Bruno Bordoni; cervical area.8–10
Emiliano Zanier
Email bordonibruno@hotmail.com;
The most external layer is denominated subcutaneous fascia or loose (areolar)
fisioheal@yahoo.it connective fascia.7,11 This layer is made up of several levels, each with variable

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Figure 1 Shape and arrangement of the muscles on the ventral (A), dorsal (B), and lateral (C) surface of the human body.
Notes: Copyright Edi.Ermes, Milano. Reproduced with permission from Anastasi et al. AA VV, Anatomia dell’uomo, 4th ed, Edi.Ermes, Milano [Human anatomy].113

amounts of fibroblasts (ie, connective cells) arranged in a blood pathways. It is called the Bonghan duct system, and
disorderly manner and soaked in a gelatinous substance supposedly eases communication among all body areas.17–21
known as extracellular matrix, where numerous molecules This system is composed of the same substance forming the
(ie, ­glycosaminoglycans, proteoglycans and polysaccharides superficial fascia.9
such as hyaluronic acid) can be found.3,12 This superficial The deep fascia is the last connective layer before coming
layer is not located exclusively under the derma, but it perme- in contact with the somatic structure (ie, bones and muscles),
ates the entire body, enveloping the organs and forming the and the visceral and vascular systems. It is characterized by
stroma, the neurovascular branches, and the different fascias various levels of loose connective tissue.3,22 Its vascular and
of the muscle districts, finally resting on the deep fascia.13–15 lymphatic system is well developed, with numerous ­corpuscles
The superficial fascia is made up of different layers, whose in charge of proprioception, particularly the ­Ruffini’s and
formation facilitates the sliding of one layer over another, as Pacini’s corpuscles.22 It is a less extendable fibrous layer, with
of the structures enveloped or in contact with the aforesaid collagen fibers arranged more regularly, thick and parallel to
fascia.12–15 The number of layers of the superficial fascia each other; it is rich in hyaluronic acid.7,22
and the amount of substances they contain depend on the According to some authors, the fascial layer enveloping
quantity of fat, the sex, and the body area concerned.12,13 The the organs is a serous fascia, but in fact it is the prolongation
superficial fascia is rich in water, arranged in liquid crystals.16 of the deep fascia.1,23
The various layers communicate by a microvacuolar system, All fascial layers contain a variable amount of fibroblasts
which is in turn composed of the same structures of the with the ability to contract, known as myofibroblasts. They
superficial fascia; it is a microscopic web, concerning vessels contain a type of actin similar to the one traceable in the mus-
and nerves, in varying directions, and is highly deformable.11 cles of the digestive system; ie, alpha-smooth muscle actin.6
According to some texts, within the superficial fascia there Scientific research has proven that the fascial continuum is
is a vascular network independent of the lymphatic and innervated by the autonomic sympathetic system.6

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Dovepress The fascial system

Symptoms: facts and hypotheses altered, the fascial continuum generates a symptomatology
The fascial continuum is essential for transmitting the that deteriorates the health condition of the patient, very
muscle force, for correct motor coordination, and for pre- often developing symptoms that are more significant than
serving the organs in their sites: the fascia is a vital instru- the clinical parameters diagnosed through medical diagnostic
ment that enables the individual to communicate and live devices.38–41 Chronic fatigue, for instance, can be associated
independently. The transmission of the force is ensured by with the fascial system, particularly when the pathological
the fascial integrity, which is expressed by the motor activity disorder has persisted for several years.42 Recent experimental
produced; the tension produced by the sarcomeres results in studies have shown that common physiological mechanisms
muscle activity, using the various layers of the contractile may be involved in the causation of muscle pain and fatigue;
districts (epimysium, perimysium, endomysium), with dif- the nociceptive afferent inputs from the fascial system can
ferent directions and speed (Figure 2).6,11,24,25 modulate the afferent response from the central nervous
The connective tissue can control the orientation of the system.42 If the afferent is not physiological, the efferent will
muscle fibers, so as to reflect the vector of the force’s direc- be in dysfunction and in pathology.42
tion, and to render the transition of the tension more fluid An increased level of circulating cytokines originating
and ergonomic.24 The fascial system is rich in proprioceptors, in the connective system, due to systemic pathologies, could
particularly the Ruffini’s and the Pacini’s corpuscles, mostly develop neuropathic pain.43–46 The connective tissue can
in the areas of transition between the articulation and the fas- directly convey pain signals; in fact, it contains nociceptors
cia, and between the fascia and the muscular tissue, blending that can translate mechanical stimuli into pain information.
with the receptors of these structures.6,8 The fascial continuum Furthermore, if there are nonphysiological mechanical
can be considered a sense organ of human mechanics, which stimuli, the proprioceptors can turn into nociceptors.3,6,7
affects daily postural patterns.6,8,26 There are many reasons why the fascial continuum can
The muscle system is part of the fascial continuum, and turn into a source of pain. The nociceptors synthesize some
when it is affected by pathologies or systemic disorders such neuropeptides that can alter the surrounding tissue, and
as visceral, genetic, vascular, metabolic and alimentary dis- generate an inflammatory environment; the epineurium and
orders, its function undergoes a nonphysiological alteration; the perineurium, both belonging to the fascial system, are
there are many epigenetic processes that can lead to its adjust- innervated by the nervi nervorum, which can develop pain
ment as a response to mechanotransductive stimuli, resulting sensation creating a vicious circle, when they are in contact
in further decrease of its function and properties.27–37 Once with pro-inflammatory molecules.6,47 All the fascial layers
need hyaluronic acid to slide over each other; if its quantity
decreases or it is not regularly distributed, the local or systemic
sliding property of the connective tissue is ­compromised.12
There are some researchers who suggest strongly that any
change in the ­viscoelasticity of the fascial system activates
the nociceptors.3,12 The hyaluronic acid becomes adhesive and
less lubricated, altering the lines of forces within the various
fascial layers.3 This mechanism could be one of the causes of
articular stiffness and pain in the morning.11 In fact, the stiff-
ness experienced by some patients when they wake up in the
morning could be related not with the joint but with the fascial
system: if there is a minor quantity of hyaluronic acid or when
it is not equally distributed, the tissue is dehydrated and has
less possibility of sliding.3,11,12 The same dehydration prevents
the catabolites of cellular metabolism from being properly
removed, stimulating the nociceptors; the accumulation of
metabolites alters the pH inside the fascia, making a more acid
Figure 2 Transverse section at the level of the upper third of the leg.
Notes: 1, tibia; 2, muscular loggia; 3, interosseous membrane; 4, fibula; 5, intermuscular cell environment; this results in dysfunctional physiology of
septum. All tissues are enveloped by fascial continuum. Copyright Edi.Ermes, Milano.
Reproduced with permission from Anastasi et al. AA VV, Anatomia dell’uomo, 4th ed,
the hyaluronic acid, and complicates the sliding of the different
Edi.Ermes, Milano [Human anatomy].113 fascial layers, again stimulating the nociceptors.3,12

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Reduced sliding of the various layers limits the by a tensional anomaly experienced by fibroblasts, is related
f­ unctionality of the endocannabinoid system. There is a to one of the causes of local and systemic pathologies, such
close relationship between the endocannabinoid or endor- as the formation of tumors.52 The sensitization of nociceptors
phin system and the fibroblasts. The cannabinoid receptor, could derive from a local ischemia, caused by nonphysiologi-
or CB1, is mainly housed in the nervous system, but it can cal fascial tension, which hinders the skeletal muscle from
be found in the fascial system and in the fibroblasts as well, functioning properly, for instance in trigger points.56,57 Pain
particularly near the neuromuscular junction.48 This relation- receptors could be activated by inflammatory molecules, ATP
ship is believed to better manage any inflammation and pain and glutamate (an important neurostimulator), a decrease
information originating in the fascial tissue, as the fascia in pH, and other neuropeptides (such as substance P and
undergoes continuous remodeling during the day.48,49 calcitonin gene-related peptide).56 These alterations, which
It is hypothesized that the axoplasmic flow originating are mostly considered muscular alterations, can also be
in the dorsal ganglionic roots carries some molecules to the determined by visceral effects on the muscle tissues, proving
distal nerve endings, in an attempt to reduce pain informa- the continuity of the fascial system.57–59
tion deriving from the nociceptors in the fascial continuum; The fibroblasts (the foundations of the fascial system)
if there is a mechanical barrier owing to a reduction of the affect the immune system, and as a consequence bone
fascial sliding, the axoplasmic flow will be hindered, with tissue; this phenomenon is called osteoimmunology.47,60 The
consequent onset of hyperalgia.48 The nerve has the ability immune system and bone tissue share molecular interactions,
to adjust itself in case of length variations of the extremities including transcription factors, signal molecules and
and trunk, in order to preserve its functions; in case of dif- membrane receptors; in particular, osteoclasts are sensitized
ficulty in sliding of the different layers that are crossed by by cytokines, and vice versa.61 When the layers of the fascial
the nerve structure, there is a neural tension or neurodynamic continuum do not slide properly over one another, from the
dysfunction, developing sensations of pain.3,50 This is due to most superficial layer to the periosteum, an inflammatory
a reduction in the intraneural blood flow, and to the release environment develops, either acute or chronic; the resultant
of inflammatory neuropeptides.50 According to some authors, cytokines could activate the osteoclasts and bone resorption,
the loss of a correct sliding of the layers is demonstrated generating osteoporosis in the long run.7,61 This is probably
by an increased density of the fascial thickness, which can one of the causes producing articular disorders in rheumatoid
be detected through ultrasonography, explaining atypical arthritis.47
symptomatology of chronic pain; this phenomenon is not Densification can develop into fibrosis. Fibrosis or
termed fibrosis but fascial densification.3,51 fibromatosis results from a disorder of the connective tissue
Defective sliding, for instance due to a scar, gener- affected by hyperplasia and hypertrophy of the fibroblasts,
ates anomalous tension, which then affects the fascial due to a chronic inflammatory environment, nonphysiological
continuum, developing painful symptoms.1,52 Tensional mechanical stress and immobility; ­calcification phenomena
alterations can derive from the contractile property of can be observable as well. 47 These morphological and
fibroblasts, creating a fascial tonus that is independent of functional variations have been verified in elbow ­tendonitis
neurological intervention.1,52,53 A nonphysiological mechani- and in plantar fasciitis.47 The fibroblasts lose their physiological
cal environment stimulates an inflammatory environment, direction, which is determined by new pathological force vec-
with resultant fibroblasts’ hyperplasia and further fascial tors, revealing a chaotic organization.47,62 In the presence of
densification, which then develops into chronic inflam- a fibromatosis similar to the cicatricial tissue, for instance in
mation and into the sensitization of nociceptors.10,47,54,55 Dupuytren’s contracture, there is an increase in the percent-
The inflammation experienced by fibroblasts increases the age of fibroblasts, which then change into myofibroblasts,
extracellular edema; this edema depends not only on an with consequent altered tension experienced by the fascial
increased vascular permeability, but also on loose fascial continuum; the result is a vicious circle of inflammation and
tissue, which draws ­liquids inside.52 The edema determines activation of the nociceptors.62 The important event that must
an increase in tension and stiffness, resulting in difficult slid- be underlined is that the connective tissue found next to an
ing of the fascial layers and pain.52 This scenario makes the ailing fascial area undergoes nonphysiological mechanical
fibroblast release ­adenosine triphosphate (ATP), stimulating stimuli, ­resulting in further functional deterioration of the
the nociceptors.52,55 It is probable that the alteration of the fascial layers.62 This mechanism, which alters the correct
physiological flow of fluids such as lymph and blood, caused distribution of the tension generated and perceived, concerns

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Dovepress The fascial system

the entire fascial continuum, and all the structures it surrounds continuum can also develop symptoms in areas which are
and sustains.63–65 far from the original dysfunctional point, making it more
difficult to diagnose the patient’s clinical scenario. For this
Clinical scenarios: facts reason, a patient must be observed as a sole entity and not
and hypotheses as a collection of single body segments.1,65
Research has proven that patients who suffer from chronic In atypical cervicalgia an alteration in the thickness of the
lumbar backache present an inflammation of the local fascial fascial layers has been verified, with consequent altered spinal
area, and experience degenerating variations of collagen mobility and pain.3,51,79 This reduction of movement of the
fibers and microcalcifications, besides a 25% increase in layers is called fascial stasis, because in this state the fascial
thickening of the perimuscular fascial tissue if compared fluids flow with difficulty. The cervical tract has a fundamental
with nonsuffering subjects.47 The entire thoracolumbar fascia importance for correct occlusion and postural balance; its
plays a fundamental role in this pathological condition.66 dysfunction alters mastication and balance.80–83 The muscles
The absence of sliding of the different layers in the lumbar involved in mastication, with opening and closing of the jaw,
area and the morphological alteration of the tissue generate are surrounded by the cervical fascia: suprahyoid, masseteric,
a nonphysiological mechanical tension, resulting in lumbar pterygoid, lingual and temporal muscles.84,85 We can reason-
pain symptoms.66 This nonphysiological condition develops ably assert that a dental disorder can directly originate in the
a lack of coordination in the activation of the muscles of the thickening of the cervical fascial layers; in this event, a therapy
thoracolumbar fascia involved, with resultant mechanical merely aimed at restoring the functionality of the occlusion
instability of the lumbar column and pain.67 Pain symptoms will be ineffective, if the cervical area is not treated.
are intensified by stress, as the fascia is innervated by the Cervical fascia and visual control are closely related. There
sympathetic nervous system, especially in the area near the is a variety of reflexes, such as the vestibulo-ocular reflex
blood vessels; therefore, it is likely to produce vasospasm (ie, the eyes move as a result of vestibular ­information), the
and ischemic pain.47,68 This negatively affects posture and optokinetic reflex (they move in response to the stimulation
walking.6,66 From the current data in the literature, we can of visual movement), and the cervico-ocular reflex, occurring
strongly assume that the connective tissue is more responsive when the head is turned, in order to stabilize the image on the
than the muscular tissue in the activation of nociceptors, retina while the head is moving.86,87 Any dysfunction in the
and examination on animals has proven that the medullar cervical fascial area will be problematic for these reflexes.86,87
neurons receiving fascial nociceptive afferents are acti- This is due to the lack of coordination of the muscular areas
vated 4% to 15% more than a noninflamed fascia, with an belonging to the cervical fascial layers, and the connection
experimentally-induced inflammation of a low back pain with the cranial fascia.87 The posterior superficial cervical
muscle (multifidus).68–70 The thoracolumbar fascia proceeds fascia (the continuation of the thoracolumbar fascia), which
with the gluteus maximus and the lower extremity, involving surrounds the nuchal line, merges with the superior lateral
the fascia of the thigh, the leg, and the plantar fascia of the two-thirds of the occipitofrontalis muscle.65,88 The occipito-
foot, and is closely related to the pelvic floor.65,71–77 We can frontalis muscle runs from the condylar area of the occiput
logically hypothesize a problem of instability in the ankle under the superficial cranial fascia, and then through an ample
caused by the anatomical connection with the thoracolumbar aponeurosis called Galea aponeurotica comes in contact with
fascia, because of a proprioceptive alteration of the fascial the frontal venter musculi, bridging the gap between the
continuum and of its relevant muscular coordination. An occipital bone and the frontal one.88 The superficial fascia
aching ankle has been proven to cause urogenital and vis- of the skull concerns the temporoparietal fascia, which then
ceral disorders, such as dyspareunia.64 This event can be combines with the venter musculi of the frontal portion.88 The
explained by the muscular connections existing between occipitofrontalis muscle is connected with Muller’s muscle;
the pelvic floor and the ankle (rectum abdominis, adduc- ie, musculus levator palpebrae (Figure 3).88
tor lungus and triceps surae), producing hypertonus of the The connective tissue of Muller’s muscle is rich in
pelvic musculature, and by nociceptive information, which mechanoreceptors, so as to induce a reflex contraction of
at the medullar level can develop a metabolic and electrical the occipitofrontalis muscle, and to keep the eyes aligned
antidromic communication, and involve a greater number of for correct posture.89 When there is hyperreflexia of the
neurons of the metameric segment, consequently concern- mechanoreceptors in Muller’s muscle, the contraction of the
ing the viscera (somaticovisceral reflex).64,65,78 The fascial occipitofrontalis muscle is hyperstimulated, with resultant

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patient a satisfactory quality of life in terms of socialization

21 and independence (Figure 4).
The vascular tree is surrounded by the connective system,
1
and its continuity enables the myocardium to affect all the
areas permeated by blood with its systole and diastole.7,94
2
20
The heart itself is surrounded by a tridimensional system of
3

19
connective tissue, which connects it to the lungs and to the
4

5 endothoracic fascia (Figure 5).65,95–97

18 6 The latter is the continuation of the cervical fasciae,
7
which enter the extracranial and intracranial fasciae through
17
8 the dural leaflets.65 The cardiovascular tree embriologically
9
originates in the ectoderm and mesoderm, as does the fascial
10
16
11 continuum.8–10,98,99 The pathway of the nervous system, whether
12 it is central or peripheral, concerns the fascial continuum.7,13–15
13 This close connection explains the cerebral motility caused by
14
cardiovascular pulsatility; the cerebral oscillatory activity is
15
synchronized with the systole and diastole of the heart.100 This
Figure 3 Presentation of the mimic muscles of the head. These muscles occupy a
activity concerns the entire spinal axis, and involves a caudal
superficial position.
Notes: 1, frontal muscle; 2, orbicularis oculi muscle, part of the eyelid; 3, procero thrust to the cerebellar foramen magnum, during the systole,
muscle; 4, medial palpebral ligament; 5, nasal muscle; 6, elevator muscle of the upper
lip and of the wing of nose muscle; 7, elevator of the upper lip muscle; 8, small
and a cranial reflex, during the diastole.100 The aforementioned
zygomatic muscle; 9, great zygomatic muscle; 10, orbicularis oris muscle; 11, risorio cerebral oscillation is perceived by osteopaths through cranial
muscle; 12, squared muscle of the inferior lip; 13, mentalis muscle; 14, triangular
muscle; 15, platysma muscle; 16, parotid fascia; 17, fascia masseter; 18, anterior movement.100,101 Recent research has proven that human touch
auricular muscle; 19, occipital muscle; 20, temporoparietal and upper auricular can distinguish extremely light objects or slight vibrations. In
muscles; 21, aponeurotic galea. Copyright Edi.Ermes, Milano. Reproduced with
permission from Anastasi et al. AA VV, Anatomia dell’uomo, 4th ed, Edi.Ermes, static palpation, the range of discrimination in case of vibra-
Milano [Human anatomy].113 tions reaches 0.2 mm, whereas discrimination while touching a
moving surface is measured in microns.102 Cerebral oscilla-
chronic tension in the cervical area and headache.90 The more tions affect the production of cerebrospinal fluid or liquor.100
the eyelid is lowered, the greater the extension of the high Recent studies have demonstrated that the liquor is mostly
cervical tract is needed, in order to keep a good visual field,
with involuntary involvement of the muscular connective
system, generating further hypertonia.88 The occipitofrontalis
1
muscle is significant from an ontological perspective as well
2
as for a child’s growth, because its tension is fundamental for 3
correct development and regular morphology of the skull, and
8
again it is essential for its influence on the spheno-occipital 4

synchondrosis during the growth, and to facilitate the devel- 7

opment of a good phonatory system.91 Muller’s muscle is

connected with Tenon’s capsule, where the eyeball is located;
particularly, they share extraocular muscles; Tenon’s capsule
surrounds the optical nerve where it terminates in the eye,
blending with the meningeal tissue.92,93 We can theorize that 5
6
a tension in the fascial area of the high cervical tract will
affect the movement of the eyeball, altering the visual field
and posture, or causing dysfunction related to the fascial Figure 4 Diagram showing the elevator muscle of the upper eyelid and extrinsic
traction on the optical nerve, with resultant alteration in the muscle of the eyeball, after lifting the cranial vault and the lateral wall of the orbit.
Notes: 1, Superior oblique muscle; 2, optic nerve; 3, superior rectus muscle;
ocular reflexes. Further studies are needed. The functional 4, tendinous ring of Zinn; 5, inferior rectus muscle; 6, inferior oblique muscle;
7, lateral rectus muscle; 8, superioris levator palpebrae muscle. Copyright Edi.
and tensional integrity of the fascial continuum plays a major Ermes, Milano. Reproduced with permission from Anastasi et al. AA VV, Anatomia
role in the nonpathological homeostasis, and guarantees the dell’uomo, 4th ed, Edi.Ermes, Milano [Human anatomy].113

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Dovepress The fascial system

37 1

36 2

35 3

34 4
33 5

6
32
7
31

30 8

29
9
28

27 10

26 11

25 12

24
13
23
14
22

15

21

20

16

19

17
18

Figure 5 Aspect of the pericardium after resection and removal of its anterior wall, the great vessels, and heart.
Notes: In evidence the base of the heart, the posterior wall and the areas of folding of the serous pericardium at the level of the great vessels. 1, left clavicle; 2, left external
jugular vein; 3, left subclavian artery; 4, left internal jugular vein; 5, sternal manubrium; 6, left subclavian artery; 7, left common carotid artery; 8, carotid arch; 9, pulmonary
trunk; 10, right pulmonary artery; 11, left pulmonary artery; 12, left lung; 13, left upper pulmonary vein; 14, left inferior pulmonary vein; 15, posterior wall; 16, left mediastinal
pleura; 17, pericardial sac; 18, diaphragm; 19, base; 20, pericardial sac (dissected); 21, inferior vena cava; 22, right lower pulmonary vein; 23, right mediastinal pleura; 24, right
lung; 25, diverticulum Haller; 26, upper right pulmonary vein; 27, transverse sinus of the pericardium; 28, visceral layer; 29, serous pericardium, parietal layer; 30, apex of
the pericardial sac; 31, superior vena cava; 32, brachiocephalic trunk; 33, right first rib; 34, left common carotid artery; 35, right common artery; 36, right subclavian vein;
37, right internal jugular vein. Copyright Edi.Ermes, Milano. Reproduced with permission from Anastasi et al. AA VV, Anatomia dell’uomo, 4th ed, Edi.Ermes, Milano [Human
anatomy].113

drained by the lymphatic system, flowing from the perineural We can hypothesize that pharmacological or surgical
and perivascular sheaths to the lymphatic vessels; when it is in treatment that regulates cardiac frequency, as well as the
the lymphatic system, the liquor flows to the cribriform plate pathological alteration of the rhythm, alters the production
of the ethmoid bone, and then to the epithelium and the nasal of the cerebrospinal liquor, and as a consequence negatively
mucosa (Figure 6).103,104 affects the environment of nasal mucosa, resulting in rhini-
From here, a system of vessels and lymphatic nodes carry tis or sinusitis. An imbalance in the quantity of liquor can
the liquor to the buccal floor and the neck, finally involving alter the immunological environment, whether cerebral or
the venous system.105–107 When the heart suffers from rhythm systemic, as it transports many substances (ie, electrolytes,
alteration, patients are treated with drugs to regulate the catabolites, hormones and neuropeptides).100,104,107 Altered
rhythm and arrhythmia, or they are surgically treated, for homeostasis of the nasal mucosa and of the olfactory nerve
instance with ablations, or with temporary/permanent place- can develop disorders in the superior respiratory tract, which
ment of pacemakers and defibrillators (implantable cardiac can convey germs to the cerebral area, through the lymphatic
defibrillators) (Figure 7).108–110 pathways departing from the brain.104

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Figure 8 Pacemaker biventricular-bicameral/implantable cardiac defibrillator.

Notes: X-ray shows a slight elevation of the left hemidiaphragm due to a lesion of
the phrenic nerve following sternotomy after heart surgery.

A lesion in the phrenic or vagal nerve results in

dysfunction of the contractile activity of the diaphragmatic
muscle.65 The respiratory diaphragm and the nerves that elec-
trically activate the muscle belong to the fascial continuum,
which merges with the intracranial meningeal tissue, pass-
ing through the endothoracic, thoracolumbar and cervical
fascia, and involving the viscera in the thoracic cage.65,111,112
Respiration, particularly forced respiration, has been proven
Figure 6 Schematic representation of the front section of the nasal cavity viewed to affect cerebral motility and the synthesis of cerebrospinal
from the rear face. liquor.100 Forced expiration generates a caudal movement
Notes: The section captures the outlet of the maxillary sinus into the nasal cavity
(red arrow). 1, frontal sinus; 2, cribriform plate; 3, crista galli; 4, ethmoid bone; of the brain, whereas forced inspiration causes the cephalic
5, ethmoidal cells; 6, perpendicular plate; 7, media nasal concha; 8, inferior nasal drainage.100 We can theorize that if the diaphragmatic muscle
concha; 9, hard palate; 10, nasal cavity; 11, mucosa of the nasal cavity; 12, mucosa
of the maxillary sinus; 13, maxillary sinus; 14, orbital plate; 15, orbit. Copyright Edi. does not have a regular contraction, it negatively affects the
Ermes, Milano. Reproduced with permission from Anastasi et al. AA VV, Anatomia
dell’uomo, 4th ed, Edi.Ermes, Milano [Human anatomy].113
production of liquor, endangering one’s health (Figure 8).
The same vasomotor activity of blood and lymphatic
vessels that is controlled by the autonomous system can
affect the synthesis of liquor, although less importantly
and independently of the cardiac and respiratory rhythm.100
Again, we can assume that a dysfunction of the sympathetic
system, resulting from chronic nociceptive information of the
fascial continuum (for instance, due to a cicatricial adhesion),
alters the synthesis of cerebrospinal liquid, with consequent
reduction of systemic homeostasis.1

Conclusion
Currently, there is still little information on the functions
and interactions between the fascial continuum and the body
system; unfortunately, in medical literature there are few
texts explaining how fascial stasis or altered movement of
the various connective layers can generate a clinical problem.
Figure 7 X-ray shows an implantable cardiac defibrillator/pacemaker following
heart surgery. Certainly, the fascia plays a significant role in conveying

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Dovepress The fascial system

mechanical tension, in order to control an inflammatory 17. Li HY, Chen M, Yang JF, et al. Fluid flow along venous adventitia in
rabbits: is it a potential drainage system complementary to vascular
environment. The fascia is the philosophy of the body, mean- circulations? PLoS One. 2012;7(7):e41395.
ing that each body region is connected to another, whereas 18. Lee BC, Yoon JW, Park SH, Yoon SZ. Toward a theory of the primo
osteopathy is the philosophy of medicine, meaning that the vascular system: a hypothetical circulatory system at the subcel-
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entire human body must work in harmony. Knowing and 961957.
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22. Stecco C, Tiengo C, Stecco A, et  al. Fascia redefined: anatomical
Osteopathic Centre for Research and Studies, for her friend- features and technical relevance in fascial flap surgery. Surg Radiol
ship and support. Anat. 2013;35(5):369–376.
23. Lee S, Joo KB, Song SY. Accurate definition of superficial and deep fascia.
Radiology. 2011;261(3):994; author reply 994–995; author reply 995.
Disclosure 24. Turrina A, Martínez-González MA, Stecco C. The muscular force
The authors report no conflicts of interest in this work. transmission system: role of the intramuscular connective tissue.
J Bodyw Mov Ther. 2013;17(1):95–102.
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