課程介紹

FM筋膜鬆動術Fascial Manipulation

Fascial Manipulation©是一種徒手療法,創始於北義大利物理治療師Luigi Stecco,歷經40年臨床實作及研究驗證淬煉至今,已成為眾多骨骼肌肉問題的治療金鑰。

ABOUT FASCIAL MANIPULATION


Fascial Manipulation©是一種徒手療法,創始於北義大利物理治療師Luigi Stecco,歷經40年臨床實作及研究驗證淬煉至今,已成為眾多骨骼肌肉問題的治療金鑰。
Fascial Manipulation© is a manual therapy method that has been developed by Luigi Stecco, an Italian physiotherapist from the north of Italy. This method has evolved over the last 40 years through study and practice in the treatment of a vast caseload of musculoskeletal problems.



此手法著重在「筋膜」―尤其是深層肌筋膜,包括「肌外膜」及「支持帶」,並視肌筋膜為三維的連續結構。
It focuses on the fascia, in particular the deep muscular fascia, including the epimysium and the retinacula and considers that the myofascial system is a three-dimensional continuum.

 

筋膜鬆動術的發展之初歸功於法國巴黎笛卡爾解剖學院義大利帕多瓦大學,近幾年Carla Stecco及Antonio Stecco博士也加入合作,藉由解剖未經防腐處理的屍體,更加拓廣展解剖及組織學研究的深度與廣度。這些細膩的解剖研究提供了新的組織及解剖學數據,將Luigi Stecco博士舊有的生物力學模型提升到更高的層次。
Initially via collaboration with the Anatomy Faculties of the René Descartes University, Paris, France and the University of Padova in Italy and more recently with a host of different collaborations, Dr. Carla Stecco and Dr. Antonio Stecco have carried out extensive research into the anatomy and histology of the fascia via dissection of unembalmed cadavers. These dissections have enhanced the pre-existing biomechanical model already elaborated by Luigi Stecco (1,2) by providing new histological and anatomical data.


 

此法不但展現了完整的生物力學模型,更能夠解密這個大家最想問的問題―當肌肉骨骼失衡時,筋膜扮演了什麼腳色?
Fascial Manipulation中心目標就是去抽絲剝繭、找出導致動作受限的失衡筋膜。當分析疼痛或受限的動作、抓出幕後主嫌(筋膜)後,即以適切的治療手法,針對該處筋膜做鬆動,使患者能夠回復正常動作。
This method presents a complete biomechanical model that assists in deciphering the role of fascia in musculoskeletal disorders.

The mainstay of this manual method lies in the identification of a specific, localised area of the fascia in connection with a specific limited movement. Once a limited or painful movement is identified, then a specific point on the fascia is implicated and, through the appropriate manipulation of this precise part of the fascia, movement can be restored.

 

Stecco分析肌肉骨骼解剖時,發現我們的身體可以分成14個部分,每一個部分都被6個肌筋膜單元調控著,包括單關節、雙關節及單一方向肌肉纖維。他們的深層筋膜(包括肌外膜)及關節使他們能夠在單一方向、單一平面上活動。許多肌纖維的起始點都在他們本身的筋膜上,筋膜終點則會延伸到不同肌肉群,形成肌筋膜序列(myofascial sequences)。也就是說,相鄰的單向肌筋膜單元藉由肌腱的延伸和雙關節肌肉纖維的相互連結,與其他區域結構組織合併,最終形成肌筋膜序列。
 In fact, by analysing musculoskeletal anatomy, Luigi Stecco realised that the body can be divided into 14 segments and that each body segment is essentially served by six myofascial units (mf units) consisting of monoarticular and biarticular unidirectional muscle fibres, their deep fascia (including epimysium) and the articulation that they move in one direction on one plane. Numerous muscle fibres originate from the fascia itself (3, 4) and, in turn, myofascial insertions extend between different muscle groups to form myofascial sequences. Therefore, adjacent unidirectional myofascial units are united via myotendinous expansions and biarticular fibres (3) to form myofascial sequences.



 


筋膜的一部分固定在骨頭上,另一部份則可以自由滑動。這個可以自由滑動的筋膜使得肌肉牽拉及肌筋膜向量力匯集到一個特定的點,稱為向量中心(Vectorial Centre of Coordination o簡稱CC)。藉由加總每一個人體動作向量,我們可以定位出每一個向量中心的位置。
While part of the fascia is anchored to bone, part is also always free to slide. The free part of the fascia allows the muscular traction, or the myofascial vectors, to converge at a specific point, named the vectorial Centre of Coordination or CC (5). The location of each CC has been calculated by taking into consideration the sum of the vectorial forces involved in the execution of each movement.



三維空間中的六個動作通常會結合在一起、相互形成中間軌跡―類似本體感覺神經誘發術(PNF)的動作模式。為了整合這些複雜的動作,我們必須先定位一些筋膜的特定點(通常在支持帶上),我們稱這些點為融合中心(Centres of Fusion,簡稱CF).
The six movements made on the three spatial planes are rarely carried out separately but, more commonly, are combined together to form intermediate trajectories, similar to the PNF patterns. In order to synchronize these complex movements other specific points of the fascia (often over retinacula) have been identified and, subsequently, named Centres of Fusion or CF.




筋膜由波狀膠原蛋白纖維及彈性纖維組成,每一層的纖維走向皆不同。由於波狀膠原蛋白纖維的關係,筋膜可被延展;另一方面,拜彈性纖維所賜,筋膜被延展之後得以回復原狀。值得注意的是,筋膜會適應肌肉的牽拉,但無法像肌腱或腱膜一樣傳遞力量;如果沒有考慮到這些組織學知識和其功能,很容易把筋膜與腱膜混淆,或者把深層筋膜與皮下結締組織(淺層筋膜)混為一談。皮下結締組織是一張具良好彈性、能夠滑動的膜,可調節溫度、供代謝物質交換、保護血管及神經。深層筋膜則包覆著肌肉及腱膜,並與它們一起走到連接骨頭的地方。
Fascia is formed by undulated collagen fibres and elastic fibres arranged in distinct layers, and within each layer the fibres are aligned in a different direction. Due to its undulated collagen fibres, fascia can be stretched and, thanks to its elastic fibres, it can then return to its original resting state. Given that fascia adapts to muscle stretch, it is unable to transmit force like a tendon or an aponeurosis. If these histological and functional distinctions are not taken into consideration, then one can confuse fascia with aponeuroses or, likewise, confuse the deep fascia with the subcutaneous connective tissue (superficial fascia). Subcutaneous connective tissue forms a very elastic, sliding membrane essential for thermal regulation, metabolic exchanges and the protection of vessels and nerves, whereas the deep fascia envelops the muscles, and surrounds the muscle’s aponeurosis up to where it inserts onto bone.



 
上述提到的解剖研究,身體及四肢的深層筋膜還是有所不同。軀幹筋膜分為三層,每層包覆不同肌肉群,分別為淺層(擴背肌、臀大肌、腹外斜肌)、中層(後下、後上鋸肌及髂肋肌)及深層(棘間肌、橫突間肌、多裂肌、腹橫肌)。四肢的深層筋膜特別厚,類似腱膜,其膠原蛋白纖維排列整齊,連結下肢肌肉,呈現序列及螺旋狀排列。
The above-mentioned anatomical studies have, however, evidenced differences between the deep fascia of the trunk and that of the limbs (6). The first is formed by three layers, each of which includes or surrounds different muscle groups, namely a superficial layer (latissimus dorsi, gluteus maximus, external obliques), a middle layer (serratus posterior inferior and superior, iliocostalis) and a deep layer (interspinali, intertraversarii, multifidus, trasversus abdominus). In the limbs, the deep fascia is particularly thick, resembling an aponeurosis, and well organised, connecting and synergizing the muscles of the lower limb via its collagen fibres arranged in sequences and spiral formations.



 
假設,富含神經的筋膜因為連接了不同肌肉纖維,使得筋膜可以在休息狀態下維持張力。這個休息狀態下的張力稱為基礎張力,筋膜組織裡的游離神經末梢及感覺受器則是各種張力變化的守門員,首當其衝,準備好感受每一個當下的張力變化。
It is hypothesised, that the richly innervated fascia (7) could be maintained in a resting state of tension due to the different muscular fibres that insert onto it. Due to this optimal resting state, or basal tension, of the fascia, the free nerve endings and receptors within the fascial tissue are primed to perceive any variation in tension and, therefore, any movement of the body, whenever it occurs.


 

深層筋膜乃理想的感覺結構,可以協助動作調整。事實上,除非這個感覺輸入在空間意義上極為重要,否則中樞神經對單一向量或神經傳入脈衝沒有興趣;而且,人類的身體活動非常複雜,一部分早已經交託給脊椎做同步交叉處理,以協調四肢、調整姿勢。無論身體怎麼移動,相關的筋膜張力會不斷調整。鑲嵌在筋膜裡面的傳入神經一旦被刺激,就會發出正確運動方向的訊息;所以,任何筋膜滑動受限都會改變這些訊息傳入,導致動作支離破碎。
Deep fascia is effectively an ideal structure for perceiving and, consequently, assisting in organizing movements. In fact, one vector, or afferent impulse, has no more significance to the Central Nervous System than any other vector unless these vectors are mapped out and given a spatial significance. In human beings, the complexity of physical activity is, in part, determined by the crossover synchrony between the limbs and a refined variability in gestures. Whenever a body part moves in any given direction in space there is a myofascial, tensional re-arrangement within the corresponding fascia. Afferents embedded within the fascia are stimulated, producing accurate directional information. Any impediment in the gliding of the fascia could alter afferent input resulting in incoherent movement.





我們假設,筋膜也參與本體感覺及周邊運動控制,與中樞神經系統嚴格協作。
It is hypothesised that fascia is involved in proprioception and peripheral motor control in strict collaboration with the CNS.



 
Therapeutic implications 
Therapeutic implications The fascia is very extensive and so it would be difficult and inappropriate to work over the entire area. The localisation of precise points or key areas can render manipulation more effective. An accurate analysis of the myofascial connections based on an understanding of fascial anatomy can provide indications as to where it is best to intervene.
治療意義
筋膜的範圍廣大,要同時治療整個筋膜不僅困難而且也不恰當;因此,精確定位關鍵的筋膜受限區域能使治療更有效率,而精準的肌筋膜分析有賴對筋膜解剖的熟悉,進而知道哪裡是最佳介入點。

深層筋膜的非生理改變會使張力改變,導致神經接受器錯誤激活、引發不協調的動作,最終疼痛感覺傳入。
Any non-physiological alteration of deep fascia could cause tensional changes along a related sequence resulting in incorrect activation of nerve receptors, uncoordinated movements, and consequent nociceptive afferents.



深層按摩這些特定點(向量中心及融合中心)的目標就是要使張力平衡。代償的張力會沿著肌筋膜序列走到遠端,加上筋膜的連續性,就算神經根未受影響,疼痛也會沿著肢體,形成放射性疼痛或轉移痛。臨床實例如:類坐骨神經痛及頸肩疼痛,這些都是神經根未受影響,卻有轉移/放射疼痛的案例,而且非常常見。
Deep massage on these specific points (CC and CF) aims at restoring tensional balance. Compensatory tension may extend along a myofascial sequence so myofascial continuity could be involved in the referral of pain along a limb or at a distance, even in the absence of specific nerve root disturbance. In clinical practice, cases of sciatic-like pain and cervicobrachialgia without detectable nerve root irritation are common (8).



治療師可以從遠端治療疼痛,這些區域本身雖然不會疼痛,但由於非生理張力的改變,導致此處發炎。事實上,治療的重點就是去找尋異常張力的根源;或者,更精確地說,就是深層筋膜裡的向量中心及融合中心。
This method allows therapists to work at a distance from the actual site of pain, which is often inflamed due to non-physiological tension. For each mf unit, the area where pain is commonly felt has been mapped out and is known as the Centre of Perception (CP). In fact, it is important to place our attention on the cause of pain, tracing back to the origin of this anomalous tension, or more specifically to the CC and CF located  within the deep fascia.


 

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