Biodynamics the fascia of the PELVIC FLOOR MODEL OF TENSEGRITY. PROF.

ANDRZEJ PILAT Modern anatomical concepts developed new methods of preservation of cadavers (plastination) as well as dissections of fresh cadavers, bypassing the traditional process and investigation have yielded anatomical and structural details, and preserving its natural appearance, adapt to clinical realities, Von Hagen 1982. (1). These extensive investigations have allowed for a new vision of the fascia, unlike the "fibrous lamina" that "hides" the muscle. Usually accustomed to consider the muscle fascia wraps function as purely mechanical, sheet separation of certain muscles or expanded space for muscle attachments, such as the tensor fascia lata or abdominal muscles. However, the contemporary model fascial system assigned to multiple tasks. The body fascia is a continuous journey involving all structures somatic, visceral, and meninges. In a way We can say that the fascia is the packaging material that not only involves all structures of our body, but also connects them to each other, providing support and determining its shape. In addition to the functions of supporting and participating in body movement is assigned biomechanical and biochemical activities. The fascia separates organizes and ensures the protection and autonomy of every muscle and viscera, but also meets the separate body components into functional units by establishing the spatial relationships between them forming, in this way, sort of an unbroken body communication network. Its properties include the expansion of the nerves and lymph vessels, metabolic exchange for his relation with the metabolism of water, nutritive function in relation to blood and lymph, becoming the sophisticated means of transport within and across all systems the body. In one of the conclusions of the Second World Congress on Fascia Research at the Free University of Amsterdam in 2009, a qualified group of experts reached consensus to bring together under the name of FASCIA both lax and dense connective tissue (regular and irregular), the shallow and deep as well as the single layer and multilayer, Langevin and Huijing, 2009 (2). There are multiple terms that describe different aspects of the fascia, from which we could mention: or dense connective tissue or areolar connective tissue Superficial Fascia or or Deep Fascia or intermuscular septum or interosseous membrane or periosteum Neurovascular or Tract or epimysium or intra-and extramuscular Aponeurosis

or perimysium or endomysium o dura mater formed by connective tissue, dense and irregular, like the rest of the meninges. Regarding the musculoskeletal fascia refers to as the dense connective tissue forming regular and irregular fascia, joint capsules, muscle sheaths, and organized along the lines of tension, also forming ligament and tendon structures. Each part of the muscle, each of its fibers, microfibrils and bundles are surrounded by fascia. These "fascias" are not separated from each other but are connected together, or rather, form a single fascia, a sheath continuous path with folds that allow wrap and enclose the anatomical elements of our bodies. It can be suggested that in some ways it is the fascial system that determines the body structure. It is generally accepted the fact that the fascia participates passively in the dynamics of locomotor activity. Highlight three of its properties: stabilization limitation of movement transmission of forces But recent research reveals a fact, perhaps expected, but at the same time no less surprising: the fascia contracts actively.That way you can dynamically participate in the activities of the musculoskeletal system. Scientific evidence confirms this observation. Research, for example, in the thoracolumbar fascia, the fascia lata, or the fascia of the leg, reveal the activity of myofibroblasts present in an abundant, according to the histological studies, the fascial structure, operating withcontraction characteristic for smooth muscle cells. It is suggested that the fascial system is responsible for static and dynamic coordination of the body. Physiological basis of fascial structure The fascia is the unifying structure of the body dynamics, Vanacore 2009 (3), Langevin 2006 (2), Pilat 2003 (4). It appears as a continuous fibers, embedded in the ground substance, which accompanies the body structures without any interruption (Fig. 1).

The density, distribution and organoleptic characteristics of the fascial system differ in their journey through the body, but its continuity is essential, allowing to act as a synergistic whole, absorbing and distributing a local stimulus to all parts of the whole. The synergy inherent structural fascial system assures the human body, the relative independence of the gravitational force, as well as enjoy an enormous capacity to adapt, according to requirements from the outside and inside the body, or in relation to availability of energy and nutrients in the environment. In addition to its structural role, fascia takes and distributes the body receives stimuli: a network of receivers recorded pulse thermal,

chemical, pressure, vibration and movement sends them to the central nervous system and it generates the necessary corrective actions. Thus, it creates a load of information linked by the system with a specific purpose, Pilat & Testa 2009 (5). Dynamic fascial system transmitter One of the important mechanical characteristics of the fascial system is its fibrous construction. It underlines the property to accommodate and align the intrinsic and extrinsic tension requirements of the body (Fig2. and Fig.3). Pilat 2009 (6), Pilat 2011 (7). Figure 2. Normal collagen fibers, elastin fibers or elongated state of tension and compression of the collagen fibers.

Figure 3. Elastin fiber network at rest and stretching.Schematic of collagen fibers at rest and stretching. The fixing of the tension lines can be created as a result of the presence of altered patterns of movement or positioning and can thus redirect the body dynamics. This process can occur through three channels of communication, Pilat 2011 (7): Physical links (mechanical - anatomical) Wang et al 2009 (8), Stecca 2008 (9), Pilat 2003 (4). These links are present at different levels of body construction, the macro and microscopic, while acting in a hierarchical manner, Wang 2009 (8). At macroscopic level, the findings of the dissections in fresh corpses Stecca 2008 (9), Pilat 2009 (6) reveal a mechanical continuity of the deep fascia where each muscle acts in a synergistic manner together with the attached muscles throughthe fascia, creating a link Myokinetic, Stecca et al 2008 (9), Pilat 2009 (6). At the microscopic level, the transmission and coordination of mechanical impulses were observed in the intrinsic structure of cells, Hu et al 2003 (10). In these structures, the mechanical impulse (the local force applied to the strands of collagen) is transmitted from the extracellular matrix to the cell membrane through integrins (adhesion receptors and intercommunication between the cytoskeleton and the extracellular matrix, activating signalingintracellular and informing the cell on the mechanical properties of the extracellular matrix), penetrating into the cytoskeleton and piercing the shell of the nucleus, changing, finally, the gene activity. Considering the fact that the body is constructed in a hierarchical design, we suggest the same type of behavior in order of increasing body construction. functional links Vaticn 2009 (12), Langevin 2006 (2). The fascia is a mechanosensitive structure. The mechanical changes are created mainly in the extracellular matrix characterized by piezoelectric and semiconducting properties (Fig. 4). That connection involves mainly the communication structure of loose connective tissue with its extraordinary network of mechanoreceptors, most notably interstitial mechanoreceptors, Pilat 2011 (7). The molecular signaling involves the immune environment, paracrine and endocrine Vaticn 2009 (12). Figure 4. Piezoelectric and semiconducting properties of the fundamental matrix of connective tissue.

Wang chemical bonds 2009 (8), Vanacore 2009 (3), Ingber 2008 (14) The mechanochemical process of integration within the system is based on the process of mecanotransducin.Ingber, in numerous studies, Ingber 2008 (14), identifies the structures mediating the process. Recently, Vanacore et al 2009 (3) identified the chemical bond that determines the behavior of collagen IV present in the basement membrane.They believe that the link ensures the structural integrity of tissue and acts as a ligand in chemical communication in the cell membrane via integrins. It seems that the link connects remote cartilage of all bones. Fascia and pain It is suggested that the three-dimensional fascial network in the form of a multicommunication system, participates in the transmission of pain. The pain experienced is usually referred pain, that is, perceived in remote areas of the site of injury. The reference of pain does not always follow the pattern of segmental pain, Travel & Bigelow 1946 (15). The theory of central hyperexcitability, Mense 1994 (16) explains the mechanism of pain from deep structures but does not clarify the presence of non-segmental pattern of the superficial muscles, for example, the neck, the latissimus dorsi and trapezius and limb muscles have 2009 (17). Recently, Han 2009 (17) proposed an alternative to that reasoning, considering the anatomical expansion of the fascia and the formation of unions and expansions Myokinetic above, theory suggests "connective tissue". Related signaling present in the loose connective tissue, capable of transmitting harmful momentum from the surface to muscles and other deep structures of cells through the vascular system and neural.Thus, peripheral pain states that can also be sourced directly in the connective tissue. Therefore, peripheral mechanisms may affect myofascial pain episodes. These observations suggest mechanical changes linked to alterations in nociception, particularly in cases of chronic pain.One of the most frequent alteration of the fascia is dynamic presence of the scar. Changes in the orientation and distribution of collagen in the scar, created in the fascial system, the formation of compensatory mechanisms and the resulting stress and premature aging process (Fig. 5 and Fig.6). Figure 5. Setting fibers to exert a torque

Figure 6. Repair Scheme of collagen fibers in response to rupture. Considering the peripheral sensitization of myofascial nociceptors as the likely key factor in this process, attention focuses on the intrinsic dynamics of the fascia as a probable factor in this. The explanation of the phenomena requires analysis raised the mechanical behavior of connective tissue at the cellular level, intracellular and intercellular. Fascia as a tensegrity structure In a contemporary biomechanical approach we try to find a conceptual model that allows us to integrate all the elements involved in the dynamic biomechanical bodily appearance and pathomechanics. In recent years the term "architectural design" is used with increasing frequency in the anatomical context. In the high impact journals published scientific papers known authors

develop the mechanical linkages between different tissues based on the principles of architectural thinking. Among the models tested most often in health sciences highlights the tensegrity model. Tensegrity is an architectural model created in the 60's. It was at this time, a revolutionary model. This broke the paradigm in architecture from the dawn of civilization when the architectural structures followed the principle of "distribution of weights", ie the ability of a system based on achieving stability as to which components meetgravitational attraction. Efforts in this model are almost exclusively controlled by compression, and downloads are aligned with the vertical support. One of the changes related to the architectural approach to the structure, made Gaud. In his blend suggestions from nature with complex and elegant geometric principles extrapolations from basic structural concepts, such as the catenary arch. Disappears angle and the straight line. The forms are an insinuating harmony of design. In the mid-fifties, an interest in spreading the revolutionary structural class, which includes rigid elements subject to compression with flexible subject to traction. It's called Simplex. From design to several authors attributed the "paternity" of the tensegrity. If it is true that the name was coined by a genius of contemporary architecture, Bucminster Fuller (18) (19), we should mention other contemporary inventors, Kenneth Snelson (20), David Emmerich amazing synchronicity that reached the same conclusions. Fuller realized that it was possible to integrate cables and rods into a new type of structure with unusual characteristics, a tensegrity structure consists of isolated rigid rods whose ends are connected by pre-tensioned cable (these cables can match elastic strips ). It is precisely the claim, ie the availability of the cables to be stretched during installation, giving the structure its characteristic flexibility: the forces applied at any point is transmitted to all other constituents, the strains are distributed in all elements and the whole global reacts. A tensegrity structure can be oriented in all directions, without variation by the weight distribution of its elements is practically independent of gravity. In addition, growing complexity, increases its resistance to deformation. The novel features of the structures that respond to the concept of tensegrity aroused the concern of researchers in the field of organic chemistry and biology. In 1998, a biologist at Harvard University, Donald Ingber (12), published his original ideas, developed from the 80's, the famous article "The architecture of life" in the magazine Scientific American. According to Ingber the structure and dynamics of cell tensegrity principles obey. His argument focuses on the internal structure of the cell, the cytoskeleton. The role of the bars is assumed by the microtubules, while actin microfilaments extended assume ownership of the tensile elements, for their part, the intermediate filaments act as connecting means. This configuration allows the cell to assume different forms according to their position and role in their direct environment, indeed, allows anchored to the extracellular matrix and facilitates the transmission of nutrients and different signals through the membrane to the nucleus. Another fascinating feature, reminiscent of the typical depth and flexibility of tensegrity structures is that by altering the external shape of the cell can activate different genetic programs: a cell-free external stimuli flat has a propensity to divide, a compressed ball tends to die (apoptosis), while in the intermediate exalts tissue specificity, ie the cell develops according to the guidelines laid down in RNA for the organ in which it is contained. The strict relationship between the cells and the

extracellular matrix, which is done through filaments and globular proteins exchanging messages with mechanical and chemical (chemo-receptors and mechano-receptors) allows the hypothesis of a supra-cellular set ( intimately synergistic) that extends throughout the body. This approach differs from the orthodox model based on Newtonian laws, present in biomechanics. The body is made of a rigid material but of a viscoelastic material, ie a deformable material. The fact that the body is deformed is one of their characteristics, the deformation does not hurt. One of its remarkable properties. Biomechanical models under study in a routine manner in the conventional biomechanical not include the deformation (viscoelasticity). In their study assumes that the body is made of rigid elements. This capacity for deformation, or rather of adapting itself to the structure is tensegrity. In the tensegrity model of the body expands blood from the ground substance of connective tissue, ligaments, blood vessels, nerves, fascia, giving you the strength, endurance and integrity, through the claim.Compression exercised by the bones and fluid compartments incomprehensible. The bones act as spacers, keeping open spaces. The ability of the tensegrity structure to withstand the forces omnidirectional means that when the balance of our body changes, the integrity is maintained. Tensegrity works in any position of the body and any of its activities. Innervation of the fascia The fascial system is richly innervated by nerves with abundant fiber Ruffini's corpuscles, which respond to sustained pressure and slow pulse. Especially tangential and transverse forces Kruger, 1987 (21). Consequently there is a reduction of the sympathetic nervous system tone and relaxation. Pacinian corpuscles that are sensitive to vibration and rapid variations. They provide a dynamic response. Golgi tendon organs, mainly present in the joints mioaponeurticas. Free nerve endings, and some fibers similar to those of the nervous system. The type III myelinated (sensory fibers) and myelinated type IV no. IV-like receptors respond to pressure and mechanical stress Schleip, 2002 (22). Low-threshold mechanoreceptors are to very mild stimuli (pen or brush). It is also related to the sympathetic nervous system. Larger gauge filaments are surrounded by loose connective tissue, which gives them a certain independence of motion of the fascia, minors, however, are closely connected to the collagen fibers. The nerve endings have an orientation almost perpendicular to the arrangement of collagen fibers, depending on the direction of stretching of the tissue can depolarize or not, causing trains proprioceptive impulses in relation to the direction of motion. Due to the existence of these sensory nerve endings and pain Hepelmann, 1995 (23) have allowed for the pathophysiological basis of ligament pain through pressure or traction applied in the clinical sign of Santos, Santos, 2009 (24 ), Santos, 2011 (25). Santos maneuver consists of application of gynecological physical exam by: lateral digital palpation of the fascial attachments with previous damage: in the parametrial and uterosacral at the dome or paravaginal in the upper 2 / 3 of the vagina: the production of palpatory pain.

 palpation of the fascia level pubocervical pubourethral clinically ligament may be accompanied or not, emergency and / or incontinence of urine, but if not prescient of them. These tests are extremely important in assessing dyspareunia or Coitalgia. Importance of endopelvic fascial system The dynamic behavior of the fascial system, described above, is represented in the structures of the pelvic floor. The interrelationship between the anatomical elements, usually assigned to the control of locomotor involves virtually the same way all the structures of the pelvic floor. Studies show that a high percentage of patients with diseases related to dysfunctions of the pelvic floor to start the disease process locomotor region with consequent formation of lumbo-pelvic dysfunction in the pelvic floor. Thus the fascial system would be able to control both segments: direct the locomotive of the region as well lumbopelvic endopelvic structures. Some observations on the morphology endopelvic fascia in the region in partnership with the functional dynamics: Facilitating the creation of complex functional units of the endopelvic region, such as elevators: the pubococcygeus muscle and muscle Puborectal. The orientation of collagen fibers, particularly at the perimysium, Purslow, 1989 (26). The fascial network is changing as morphological sphincter function or function of elevation of the year, always in synergy to the process of evacuation. Perineal Body or core tendon of the perineum is the center vector of muscle forces of the different compartments: superficial, medium and deep. This would create an anchor to the perimeter of the bony pelvis, pubis, Branches ischiopubic, ischial spines and especially the coccyx. As a unit laterally with the pelvic muscles radial, which allows the damping of the intra-abdominal forces, for example, efforts and facilitate flexible labor. In the study of viscerofascia, Bochenek, 1997 (27), Robertson 2001 (28) have found anatomical connections with the thoracic abdominal cavity, pleura and peritoneum, along with the fascial tissue that supports the viscera and covers them, continuing with epimysium of the abdominal muscles, perineal and pelvic. Just as the connections of the perirenal fascia and periureteral Told's fascia and the diaphragm. Saints (25), applies the concepts of the fascial system, integrating the functional unit tensegrity of the endopelvic fascia, myofascial and viscerofascia. Consider the continuity of the fascial system between the insertions of the pelvic bones through tendons and fascia interaction with the aponeurosis or fascia of levator ani muscle and fascia of the perineum. Also notes the importance of the fascia below the adventitia of blood vessels and nerves of the hypogastric plexus passing through the endopelvic fascia in the form of uterine vessels, vagina, bladder, urethral and ureteral forming a "skeleton" fascial Annex. Thus the myofascial system is integrated into the system as a functional unit viscerofascial of increasing complexity Santos 2009 (25). In this approach the fascial planes are true penetration routes of the vessels and nerves to all the muscles, fascia (adventitia) can join with the walls of the veins or lymph vessels act as suction and thus participate in the circulation process. Following the observations of Richter (29) 1985, Santos 2009 (25) defines the classical discussion of plans for "fibroglia" or "pods hypogastric" in the tissue as similar to subperitoneal pelvic fascia. But reconciling the two concepts in a more

complex structure, initial densification of loose connective tissue by the vascular-nerve pathways that develop in the ontogenesis of the pelvic viscera and fascial structures denser. Identifies three types of tracks and directed three sources at three levels: The plan vein runs in a "transverse or horizontal plane."Considering the standing position of women, is directed toward the side walls of the pelvis forming the Parametrium, or Mackenrodt Cardinal ligament, described as a central part of the "fibroglia." The plane passes blood in cranio-caudal in a frontal plane. It consists of the internal iliac artery or hypogastric. Its different branches acquired in the form of densifying tissue fascial network, thus producing the pattern of hypogastric sheath. The Neuro-vegetative pathway originating in the sacral foramina above and arranged in a sagittal plane. A loose connective tissue remains between the areas of densification and is the "surgical plane can be dissected without causing trauma." The above authors concluded that it is not possible without mobilizing the myofascial active or passive viscerofascia.Barral and Meciar in 1989 (30) described the movements of the viscerofascia. Coined the expression of so-called "visceral ligaments" to define support structures in relation to the way of guidance and local thickening of the structure viscerofascial. Conclusion Can be considered the fascial system as a unifying structure, protective and corrective in the body. The fascial system healthy and balanced with the ability of free and intrinsic and extrinsic full swing body ensures the possibility of a movement, with a full breadth and coordinated, always seeking the best effect with a minimum expenditure of energy .