Have you ever noticed that your patients with inflammatory conditions (AS, RA, PMR etc) are unusually stiff?
Chances are you have and if you are like me, you would have thought it was the joints.
And depending on how far down the line they are, that might be true.
However, ask a patient with AS how they feel at lunchtime compared first thing in the morning.
A hot shower and some movement, and often they are like a different person.
That cannot be joints un-fusing, that is the fascia and muscles breaking down the micro-scarring that has developed overnight.
Within the muscles, between the layers of muscle and fascia, between the fascia.
Remember inflammation knows one language: DAMAGE.
Damage via free radicals, creating OXIDATIVE DAMAGE.
This is how your immune system kills infections, and partly how it removes damaged tissues from fractures and torn tissues.
It is even part of how cell “talk” or signal to each other.
In these cases, inflammation is running riot and, overnight, it damages you and your tissues.
That damage must be repaired.
The initial laying down of new tissue, is very disorganised, it is a scar.
Healthy connective tissue is very ORGANISED, in layers that allow free movement in some directions
While scar tissue is like a basket weave, it resists motions in all directions, its FUNCTION is compromised.
The reason this is so bad in the mornings?
Overnight you are IMMOBILE and immobility allows deposition of collagen and cross-linking between fascial layers to build up as your are not pulling the tissue apart wiht motion.
See this study on rats, one group allowed to roam, one with a limb immobilised and the limb develops thick collagen. RED = Collagen
Think about patients coming out of a plaster cast with a joint immobilised for a few months – very stiff.
You can even see it on ultrasound and the difference between patients with low back pain and those with no pain.
You can click the image below for an amazing video showing fascial theathering in low back patients vs controls.
So, if you have a SUSTAINED INFLAMMATORY RESPONSE, creating constant low grade OXIDIATIVE DAMAGE, then you will have constant scar tissue being laid down.
We would call this a SUSTAINED REPAIR RESPONSE.
It is a perpetual attempt to heal, but the damage never ends.
And that changes function, which means stiffness in the myo-fascia and poor response to neuro-mechanical care.
You do that magic adjustment, the soft tissue release with your hands or a blade, and yes, it improves the ROM, but next time you check them, bang, it’s back again.
We all have them.
This is another mismatch, if they have very persistent stiffness and poor ROM, in the absence of significant degenerative change that could create that, it is MISMATCH and we should be wary about starting care without considering why?
What could the causes be, and how do we tackle them?
Now that is exactly what we teach on the CCCN course.