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The aim of this study was to examine the influence of hormonal changes during the menstrual cycle on deep fasciae. A total of 29 women, 17 users, and 12 nonusers of hormonal contraceptives were examined clinically and by ultrasound, including shear wave elastography, at two phases of the menstrual cycle. The thickness and elasticity of the fascia lata, thoracolumbar fascia, and plantar fascia were measured, compared between hormonal contraceptive users and nonusers, and correlated with clinical data. There were statistically significant differences between users and nonusers of hormonal contraceptives: the thoracolumbar fascia was thicker in nonusers (P = 0.011), and nonusers had higher maximal and mean stiffnesses of the fascia lata (P = 0.01 and 0.0095, respectively). Generally, nonusers had a higher body mass index (BMI). The elasticity of the thoracolumbar and the plantar fasciae did not differ significantly between the groups. We found no correlation between thickness and elasticity in the fasciae. There were no statistically significant differences in hypermobility, cephalgia, or dysmenorrhea between users and nonusers of hormonal contraceptives. The results of this pilot study suggest that deep fasciae can be evaluated by shear wave elastography. Nonusers of contraceptives had greater stiffness of the fascia lata and higher BMI. Clin. Anat. 32:941–947, 2019. © 2019 Wiley Periodicals, Inc.
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ORIGINAL COMMUNICATION
Inuence of Female Hormones on Fascia
Elasticity: An Elastography Study
MARTIN VITA,
1
ZUZANA SEDLACKOVA ,
1
*MIROSLAV HERMAN,
1
TOMAS FURST,
1
DAVID SMEKAL,
2
AND ZDENEK CECH
3
1
Departments and faculties of Medicine and Dentistry, University Hospital Olomouc, Palacky University
Olomouc, Olomouc, Czech Republic
2
Departments and faculties of Physical Education, Palacky University Olomouc, Olomouc, Czech Republic
3
Second Faculty of Medicine, Department of Rehabilitation and Sports Medicine, Charles University
in Prague, Prague, Czech Republic
The aim of this study was to examine the inuence of hormonal changes during
the menstrual cycle on deep fasciae. A total of 29 women, 17 users, and
12 nonusers of hormonal contraceptives were examined clinically and by ultra-
sound, including shear wave elastography, at two phases of the menstrual cycle.
The thickness and elasticity of the fascia lata, thoracolumbar fascia, and plantar
fascia were measured, compared between hormonal contraceptive users and
nonusers, and correlated with clinical data. There were statistically signicant
differences between users and nonusers of hormonal contraceptives: the
thoracolumbar fascia was thicker in nonusers (P= 0.011), and nonusers had
higher maximal and mean stiffnesses of the fascia lata (P= 0.01 and 0.0095,
respectively). Generally, nonusers had a higher body mass index (BMI). The elas-
ticity of the thoracolumbar and the plantar fasciae did not differ signicantly
between the groups. We found no correlation between thickness and elasticity in
the fasciae. There were no statistically signicant differences in hypermobility,
cephalgia, or dysmenorrhea between users and nonusers of hormonal contracep-
tives. The results of this pilot study suggest that deep fasciae can be evaluated by
shear wave elastography. Nonusers of contraceptives had greater stiffness of the
fascia lata and higher BMI. Clin. Anat. 32:941947, 2019. © 2019 Wiley Periodicals, Inc.
Key words: elasticity imaging techniques; estrogens; fascia; fascialata;
lumbar fascia
INTRODUCTION
Fasciae have recently become a topic for discussion
and the subject of an increasing number of publications
(Condino et al., 2015; Fede et al., 2016; Petrofsky and
Lee, 2015; Stecco et al., 2019). International confer-
ences and courses have been dedicated to them
(International Fascia Research Congress and others
listed by Fascia Research Society). Fascial Man-
ipulation
®
, established by Luigi Stecco, focuses primarily
on deep fasciae. This method is justied by the view that
the condition of the deep fasciae projects into posture,
proprioception, and myofascial system pathologies.
Changes in connective tissue elasticity can affect, for
example, hypermobility, which is related to inadequate
joint stabilization and increases the risk of musculoskel-
etal injury (Balko et al., 2014). Several factors can
potentially affect the connective tissue elasticity. Sex
hormones appear to have signicant effects in women
(Russek, 1999), the key hormones being estrogen,
*Correspondence to: Zuzana Sedlackova, Departments and facul-
ties of Medicine and Dentistry, University Hospital Olomouc,
Palacky University Olomouc, I. P. Pavlova 6, 775 20 Olomouc,
Czech Republic. E-mail: zuzana.sedlackova@fnol.cz
Received 27 April 2019; Revised 19 June 2019; Accepted 8
July 2019
Published online 25 July 2019 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/ca.23428
© 2019 Wiley Periodicals, Inc.
Clinical Anatomy 32:941947 (2019)
... According to their methodological design, most of papers included in the review were cross-sectional studies (28%; n = 11) [17,18,22,31,32,34,36,40,45,49,51]. The other studies were as follows: original articles (n = 6) [19,27,37,41,43,54], experimental laboratory studies (n = 4) [26,28,48,52], case-control studies (n = 3) [20,29,33], case reports (n = 3) [34,45,46]; randomized clinical trials (n = 3) [25,42,50], clinical trials (n = 2) [21,30], reviews (n = 3) [3,39,53], pilot studies (n = 1) [24], before and after experimental studies (n = 1) [23] and prospective studies (n = 1) [44] (Table 3). Most of the articles (85%) focused on ultrasound diagnosis, as the rest of articles (15%) assessed treatment benefits by ultrasound imaging. ...
... The papers included in this review addressed the deep fascial layers of TLF [3,[17][18][19][20][21][22][23]25,[27][28][29][30]33,35,37,38,41,42,[45][46][47][48][50][51][52], the posterior layer of TLF [17][18][19][20][21][22][23]25,[27][28][29][30]33,37,38,41,42,[45][46][47][48][49][50][51][52], the superficial layer of the deep fascia of the back [22], the TLF and lumbar multifidus muscles [19,26], the TLF and erector spinae muscles [35], the TLF and diaphragm [24], the TLF and trasversus abdominis and internal oblique muscles [31,39], paravertebral muscles and perimuscular connective tissue [32], dorsal trunk and ventrolateral abdominal wall soft tissue [34,40], paraspinal muscular compartment [43], TLF and fascia lata and plantar fascia [44], TLF and various components of the lumbar spine [3,53], and TLF and semitendinosus (STF)/semimembranosus fascia (SMF) [18]. ...
... Across the studies included, multiple US devices were used, each equipped with linear or curvilinear array transducers. These devices featured distinct central frequencies and operated in various modes including B-mode [3,[17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][38][39][40][41][42][43][44][45][46][47][48][49][50][51][52][53][54], M-mode [24], or Bmode with elastography in particular shear-wave elastography [18,23,27,[37][38][39]41,43,44]. The data indicated that B-mode was the predominant mode used across the majority of studies, followed by B-mode with elastography. ...
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Over the past decade, there has been a notable increase in research focused on ultrasound imaging of thoracolumbar fascia (TLF). Nevertheless, published papers’ results about the application of US imaging in TLF examination are still sparse. Background and Objevtives: Hence, this systematic review was performed aiming to firstly investigate the use and the methodology of ultrasound imaging to assess pathologic and healthy TLF. Secondarily, we aim to assess intra- and inter-observer reproducibility of US imaging in TLF assessment. Materials and Methods: The search was done on PubMed and Web of Science database from inception to April 2024. Furthermore, the references of included papers were thoroughly checked to find eligible publications. The MeSH keywords used were: “Thoracolumbar fascia”, “Ultrasound Imaging”, “Ultrasound”, “Ultrasonography”, and “Ultrasound examination”. Results: Studies were aimed primarily at TLF diagnosis, treatment monitoring, or evaluating movement-related changes, underscoring the diverse clinical applications. The US parameters assessed included TLF thickness, echogenicity, stiffness, deformation, shear strain, and displacement, providing comprehensive insights into TLF features. Conclusions: Advanced US imaging holds promise as a reliable tool in musculoskeletal assessment, offering insights into TLF pathology/disfunction, treatment outcomes, and movement dynamics.
... Studies have begun to investigate the impact of hormones on connective tissue and fascia (Fan et al., 2020, Herzberg et al., 2017, and Vita et al., 2019 but there is still much to investigate here. Additionally, another factor to consider is childbirth. ...
... The authors commented how caesarean sections may be the greatest contributor to dysfunctional gliding within the fascia plane which could contribute to LBP cases, muscle deficits and muscle asymmetries. Interestingly, a contraceptive study by Vita and colleagues (2019) investigated the thickness and elasticity of fascia of women using hormonal contraceptives compared to a control group and found that, women without a history of hormonal contraceptive use have significantly stiffer thoracolumbar fascia and greater perimuscular thoracolumbar fascia thickness than those using hormonal contraceptives (Vita et al., 2019). ...
... Consequently, efforts have been made to computationally predict the kinematics and kinetics of the PA during walking and running using motion capture and biomechanical modeling [11][12][13] . For this, previous studies attempted to capture the mechanical behaviors of the human PA in vitro using a tensile testing machine 14-16 , while recent studies captured the mechanical behaviors of the PA in vivo using ultrasound elasticity imaging [17][18][19][20][21][22][23][24][25][26][27][28][29] . Based on the measured mechanical properties, the PA is modeled as a single or a bundle of linear springs 11,13,30,31 . ...
... Such information on the mechanical properties of the PA contributes to the detailed biomechanical modeling of the human foot, leading to an improved understanding of the mechanical functions of the PA during movements, such as walking, running, and jump landing, and of the pathogenesis of the plantar fasciitis and plantar fibromatosis 23,36 . Our value of PA Young's modulus (SWV = 4.6 m/s) was lower than previously reported (SWV = 5.1-8.6 m/s) [17][18][19][20][21][23][24][25][26][27][28][29] . Although the exact cause of this discrepancy remains unclear, it might be attributable to the difference in the leg posture during measurement. ...
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This study aimed to identify the stiffness and natural length of the human plantar aponeurosis (PA) during quiet standing using ultrasound shear wave elastography. The shear wave velocity (SWV) of the PA in young healthy males and females (10 participants each) was measured by placing a probe in a hole in the floor plate. The change in the SWV with the passive dorsiflexion of the metatarsophalangeal (MP) joint was measured. The Young’s modulus of the PA was estimated to be 64.7 ± 9.4 kPa, which exponentially increased with MP joint dorsiflexion. The PA was estimated to have the natural length when the MP joint was plantarflexed by 13.8°, indicating that the PA is stretched by arch compression during standing. However, the present study demonstrated that the estimated stiffness for the natural length in quiet standing was significantly larger than that in the unloaded condition, revealing that the PA during standing is stiffened by elongation and through the possible activation of intrinsic muscles. Such quantitative information possibly contributes to the detailed biomechanical modeling of the human foot, facilitating an improved understanding of the mechanical functions and pathogenetic mechanisms of the PA during movements.
... From this perspective, passive force (baseline strength) could have been influenced by hormonal changes during the MC, but no changes were found. Vita et al. [58] examined the influence of female hormones on the thickness and elasticity of the fasciae in users and non-users of hormonal contraceptives and found a borderline significant difference between the first (during the first 5 days of the MC) and second (between day 9 and day 13) measurements of the fascia lata among the non-users, and no significant changes in the thicknesses of the thoracolumbar and plantar fasciae. ...
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Pelvic floor muscle (PFM) strength is a critical factor for optimal pelvic floor function. Fluctuations in strength values based on different phases of the menstrual cycle (MC) could signify a need for a paradigm shift in evaluating, approaching, and planning training. This research aims to examine and contrast the pelvic floor muscle strength during different phases of the menstrual cycle. A prospective observational study employing digital assessment with the modified Oxford scale and vaginal dynamometry measurements was performed, in order to assess the baseline strength and the contraction strength of the PFMs in eumenorrheic females at three different phases of the MC: the early follicular phase (EFP), the late follicular phase (LFP), and the mid-luteal phase (MLP). During two complete cycles, tympanic temperature and body weight were measured and the urinary luteinizing hormone concentration was tested to determine the time of ovulation. In total, 216 dynamometric measurements of PFM strength were obtained from eighteen nulliparous women (25.72 ± 5.03 years). There were no differences between the baseline strength (p = 0.886) and the contraction strength (p = 0.756) with the dynamometric speculum. In the post hoc analysis, the baseline strength, contraction strength, and strength showed no significant differences between MC phases. As no differences in PFM strength in women were found, the PFMs do not seem to be weaker at any time during the menstrual cycle. It appears that the assessment, establishment, and monitoring of a PFM training program could be initiated at any point in the cycle.
... Hormones directly influence fascial stiffness and pain sensitization throughout the lifespan of people who menstruate, due to hormonal inhibition of fibrosis and inflammation resulting in ECM remodeling (25). This has major consequences in the consideration of athletes at any age, especially those with a hyperflexible fascial system, with or without the presence of joint hypermobility, and with or without the use of hormone therapies or oral contraceptives (124). People experiencing perimenopause and menopause may subsequently be more susceptible to fibromyalgia in the absence of premenopausal hormone concentrations (125). ...
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Neurology and connective tissue are intimately interdependent systems and are critical in regulating many of the body’s systems. Unlocking their multifaceted relationship can transform clinical understanding of the mechanisms involved in multisystemic regulation and dysregulation. The fascial system is highly innervated and rich with blood vessels, lymphatics, and hormonal and neurotransmitter receptors. Given its ubiquity, fascia may serve as a “watchman,” receiving and processing information on whole body health. This paper reviews what constitutes fascia, why it is clinically important, and its contiguous and interdependent relationship with the nervous system. Unquestionably, fascial integrity is paramount to human locomotion, interaction with our environment, bodily sense, and general physical and emotional wellbeing, so an understanding of the fascial dysregulation that defines a range of pathological states, including hypermobility syndromes, autonomic dysregulation, mast cell activation, and acquired connective tissue disorders is critical in ensuring recognition, research, and appropriate management of these conditions, to the satisfaction of the patient as well as the treating practitioner.
... Moreover, changes in deep fascia thickness are believed to be associated with fascial alterations, some of which may be physiological and some pathological. An increase of dense connective tissue layer as an adaptation to loading or hormonal changes, but with physiological fascial sublayers with retained interfascial free gliding, could be considered physiological [28]. On the other hand, pathological conditions such as densification (increased viscosity of the LCT layer showing decreased gliding properties) which is easily reversible, or fibrosis (an excessive accumulation of collagen within the dense connective tissue sublayers that can interconnect them pathologically and create an adhesion) could be observed [13]. ...
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Purpose The deep fascia has recently been a current topic in many medical fields, including rehabilitation. Some research has already focused on assessing deep fascia, however results of individual authors differ in certain aspects. This study focuses on the inter-rater reliability of ultrasound (US) measurement of the thickness of deep fascia and loose connective tissue (LCT). The aim was to define the causes of any discrepancies in measurement that could contribute to the unification of management of evaluating fascia. Methods An observational study was performed including 20 healthy individuals in whom fascia lata of the anterior thigh was examined by US imaging and then measured in Image J software. Three raters participated in this study: the first with 6 years of US imaging experience, other two were newly trained. The measurement of fascial parameters was conducted in two phases with special consultation between them resulting in an agreement of the research team on the more precise way of measurement. Results Results revealed the value of inter-rater reliability ICC3,1 = 0.454 for deep fascia thickness and ICC3,1 = 0.265 for LCT thickness in the first phase and any significant difference in the second phase. This poor inter-rater reliability led to a search for possible causes of discrepancies, which authors subsequently highlighted. Conclusion The findings of the study show the main pitfalls of deep fascia measurement that should contribute to the unification of evaluation.
... And Rankin et al. [39] reported that greater muscles(the deep posterior muscles and semispinalis) strength or size in males. A reasonable explanation might be there were significant differences in hormone secretion levels (such as estrogen) between males and females after puberty, leading to significant gender differences in the thickness and function of muscle or fascia [40,41]. ...
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... Moreover, the overweight aggravated by the long-standing in the kitchen or stressful activities rose a severe discomfort. Furthermore, the hormonal changes of their periods in this age group (40-49) years could worsen their suffering [8]. Moreover, morbid obesity is the cause of plantar fasciitis in all age groups. ...
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Eighty-two percent of sexually active women aged 15-44 have used oral contraceptive pills (OCP) in the United States. The OCP, an exogenous source of synthetic forms of steroid hormones, prevents ovulation. Hormone changes during the menstrual cycle (MC) are believed to have an impact on anterior cruciate ligament (ACL) laxity due to estrogen. Because the estrogen receptor β resides on human connective tissue, OCP may have potential impact on tendon and ligament synthesis, structure, and biomechanical properties. Temperature has also been known to have an effect on tissue elasticity. Therefore, the purpose of this study was to investigate the differences in ACL elasticity, force to flex the knee (FFK), and knee flexion-extension hysteresis (KFEH) between OCP users and non-OCP users. To investigate these changes, two different knee temperatures were measured. Nineteen young females were divided into two groups: OCP users and non-OCP users. Blood for estradiol serum concentration (E2) was taken before beginning the tests. ACL elasticity, FFK, and KFEH were assessed both at ambient temperature (22 °C) and after 38 °C warming of the leg to stabilize tissue temperature. Assessments were performed four times during the MC. Throughout the MC, ACL elasticity, FFK, and KFEH fluctuated in non-OCP users, but not in OCP users. At ambient temperature, ACL elasticity was significantly lower and FFK and KFEH were significantly higher in OCP users than non-OCP users (p < 0.05). But, no significant differences in FFK and KFEH between the two groups were found after warming to 38 °C.
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The purpose of this study was to conduct a systematic review regarding the purported differences in anterior cruciate ligament (ACL) laxity throughout the course of the menstrual cycle. A systematic review was performed by searching electronic databases, along with hand-searching of journals and reference tracking for any study that assessed ACL integrity throughout the menstrual cycle from 1998 until 2011. Studies that met the pre-defined inclusion criteria were evaluated using the Modified Sackett Score (MSS) instrument that assessed their methodological quality. Thirteen articles out of a possible 28 met the inclusion criteria. This systematic review found 13 clinical trials investigating the effect of the menstrual cycle on ACL laxity. There is evidence to support the hypothesis that the ACL changes throughout the menstrual cycle, with it becoming more lax during the pre-ovulatory (luteal) phase. Overall, these reviews found statistically significant differences for variation in ACL laxity and injury throughout the menstrual cycle, especially during the pre-ovulatory phase. Female athletes may need to take precautions in order to reduce the likelihood of ACL injury. However, the quality of the assessments was low and the evidence is still very limited. More and better quality research is needed in this area.