During the publication of the first four parts of this series of articles on fascia, several people wrote to me asking about treatment of chronic soft tissue injuries. The ensuing discussions prompted me to write a followup about how and why Chinese medicine and its related Qi Gong and Gong Fu elements might be the primary choice for treating chronic soft tissue injuries.
Dr. Helen Langevin and her colleagues have conducted numerous studies on the possible mechanisms for the affects of acupuncture on the fascial system. These findings suggest that the location of acupuncture points, determined empirically by the ancient Chinese, was based on palpation of discrete locations, or “holes”, where the needle can access greater amounts of connective tissue.  An acupuncture needle inserted into dissected rat subcutaneous tissue reveals that a visible “whorl” of tissue can be produced with as little as one turn of the needle. When the needle is placed flat onto the subcutaneous tissue surface and then rotated, the tissue tends to adhere to and follow the rotating needle for 180 degrees, at which point the tissue adheres to itself and further rotation results in formation of a whorl. 
This winding creates a mechanism in which there is increased friction between the tissue and needle, creating a strong mechanical coupling of the tissue and the needle. The significance of this is that during manipulation there may be a pulling on collagen fibers, resulting in deformation of extracellular connective tissue matrix, which then creates a wide variety of effects “downstream” from the needle. These effects include cell contraction, gene expression, secretion of paracrine or autocrine factors, and neuromodulation of afferent sensory input. Also these effects may be prolonged, which could explain the ability of acupuncture to stimulate therapeutic effects lasting days, weeks or even much longer. 
Consistent with these findings is an electron microscopy study of debris found on acupuncture needles after insertion, manipulation, and removal in humans, which revealed that elastic and collagen fibers were entwined around the needle. Together, these observations support the hypothesis that connective tissue winds around the needle during needle rotation. 
Studies on cellular changes during acupuncture suggest that a mechanical signal is created by acupuncture needle manipulation and that this signal can induce intracellular cytoskeletal rearrangements in fibroblasts and possibly in other cells present within connective tissue, such as capillary endothelial cells. Cytoskeletal reorganization in response to mechanical load signals has been shown to induce cell contraction, migration, and protein synthesis. Other powerful effects also seem to occur.  During needle manipulation, the fibroblasts that manufacture connective tissue and dictate how collagen is secreted change shape. As the tissue stretches, the fibroblasts expand. As they expand, the fibroblasts release molecules including ATP into tissue, which may have a role in signaling within the tissue. 
Acupuncture needle manipulation can then cause a wide variety of sensory mechanoreceptors and/or nociceptors (pain receptors are nociceptors). The importance of this effect is that 1) connective tissue matrix deformation may not be restricted to the area of the needle, but may spread along interstitial connective tissue planes; 2) a wave of sensory receptor activation occurring over seconds to minutes may simultaneously follow the mechanical signal away from the needle site; 3) a second wave of cellular activation followed by altered gene expression, protein synthesis, and extracellular matrix modification, may ensue after a certain time delay and last hours to days; and 4) subsequent stimulation of these connective tissue sensory receptors by body movement may be modulated by this sequence of events. 
My own experiences with acupuncture over 30 years of practice and teaching is that acupuncture can produce remarkably quick changes in the tissue and in body function. Acupuncturists who needle appropriate points often achieve rapid results. A few examples of this that regularly happen in a clinical setting are:
- An irregular heartbeat returning to normal within a minute.
- Constipation for several days or even weeks relieved during a single treatment. The person gets up off the table and has to go to the bathroom.
- Sprained ankles blown up like a softball that slowly reduce before everyone’s eyes over 10 minutes.
- Needling through sheets of fascia or across planes of fascia that are spasmed and the tissue quickly relaxes and falls back into place.
- Needling though an ankle from GB 40 to KID 6 (with the ankle under traction to release the interosseous talocalcaneal ligament) and the ankle falls back into alignment with a very gentle Zheng Gu (“Correct the Bone”) technique.
- Needling through the interosseous membrane of the lower leg allows a spiral fracture of the tibia to virtually realign itself.
These are not extraordinary occurrences. They occur with some regularity in clinical practice.
Interestingly, modern research on meridians and acu-points shows that meridians and points are generally located are between two muscles in the grooves, the connective tissue planes, that separate the muscles. The likelihood of an acupuncture needle getting deeper into the soft tissue is greater at these locations. These findings suggest that the location of acupuncture points, determined empirically by the ancient Chinese, was based on palpation of discrete locations or “holes” where the needle can access greater amounts of connective tissue.
We have found that needling across planes of fascia, or in the grooves of muscles, consistently relaxes the tissues the needle passes through. This does not just happen locally in the exact pathway of fibers touched by the needle, but can propagate outward from the needle or well past the tip of the needle. Needling through planes of fascia may be done by following the direction of the fascia, as in needling the Bonesetter’s Hua Tuo Jia Ji Line (outside of the normal Hua Tuo Jia Ji line where the rib heads articulate with the transverse process of the vertebrae), or across planes of fascia, as in needling in a curve around the neck beginning at the Bai Lao points of the neck.
Interesting new research into soft-tissue injuries shows that when there is an injury, an inflammatory response begins in the connective tissue. Fibroblasts attract inflammatory cells to heal the injury (this also happens with cuts and wounds). An inflammatory program is released which heals the wound, and rebuilds the collagen and connective tissue. However, if inflammatory cells stay in the tissue – a situation in which there is chronic inflammation – the fibroblasts secrete more and more tissue and then the injured area can become fibrotic. Helene Langevin relates that ultrasound studies of people with chronic low back pain show that connective tissue in the back is thicker and less mobile than normal connective tissue. 
Acupuncture is one treatment of choice in chronic injuries due to its ability to go into and release tissue bind, fibrotic tissue and even scar tissue adhesions, as well as relax and align ligaments, tendons and muscles. Probably some of this is due to the fact that channels and collaterals follow the planes of the fascia and connective tissue, and due to the connection between the Sinew Channels (Tendino-Muscular Meridian) and the fascia.
Tui Na and External Herbal Therapy
Tui Na hand techniques and manipulations provide many ways of modulating the tissue – bones, muscle, joint, tendons, ligaments, connective. Each hand technique sends a different “wave” into the body that penetrates to different depths, and affects the humors and substrates of the tissue differently. For example, Pinching (Qian Fa) lifts the soft tissue away from the bone, slowing it to enter the relatively empty space. Then the tissue is dropped, pushing Qi and blood forward toward the next segment of soft tissue. Pushing (Tui Fa), on the other hand, drives a wave of Qi, blood and body fluids through the soft tissue, while Rolling (Gun Fa), sends a rolling wave through muscle and connective tissue. These techniques are part of protocols for fibrotic tissue that is chronically “inflamed.” Some hand techniques like pushing are also designed to realign fibers or packets of fibers within the muscles and fascia.
Zheng Gu (Chinese Bone Setting) techniques realign muscle, bone and sinew. This realigning opens the channels and collaterals. It is not uncommon for Zheng Gu to immediately create large improvement in chronic injuries. An example is a “knee” injury that turned out to be a misalignment of the Quadriceps muscle. A simple acupuncture treatment followed by a manipulation of the knee restored the muscle to its normal track. Similarly, many people suffer from chronic hip pain that is due to a simple misalignment of the hip. This affects their gait and causes chronic pain. In many of these cases, adjusting the hip breaks adhesions and restores the soft tissue to normal alignment and functioning.
Many of the externally applied poultices and plasters, soaks ointments, and liniments used in Chinese medicine also restore normal circulation, and prevent the build up of inflammatory by-products which interfere with normal circulation leading to the production of granulations in the tissue and thickened fibrous tissue. These externally applied herbal medicines are easy to use, and in conjunction with acupuncture, Tui Na and Zhen Gu methods can help return injured connective tissue to its normal pliable elastic state. One particularly interesting external therapy is called ironing therapy – herbs cooked and placed in a soft bag, sometimes with heated “iron sand”, and the tissues are the ironed with the bag. This allows the herbal ingredients, which improve local circulation and relax spasm and binding, to penetrate into local tissues, while the action of ironing simultaneously aligns and literally “irons out” anomalies in the fascia.
Zang Fu Tui Na (Organ Regulating Tu Na) is another method of treatment that works indirectly with the fascia that suspends and wraps the internal organs. The facial chains that connect and suspend the organs also connect to the joints, tendons, ligaments and muscles. These tissues have global effects on the body. The liver and pericardial sac connect with the neck, and are often part of a pattern of chronic neck pain. Similarly, fascial binds in the liver’s suspensory system are commonly involved with right shoulder pain. With Zang Fu Tui Na, “unwinding” fascial binds in the tissues that suspend the pericardium or liver can be a key factor in changing neck and shoulder patterns in which the soft tissue is bound and rigid. These ideas tie in with the concept of tensegrity. A misalignment or abnormal tension in one part of the structure affects the whole structure. Therefore, releasing the tension or misalignment in one area can produce observable global effects.
Fascia And “Tissue Memory”
Some bodywork practitioners have proposed the idea that memory is stored in soft tissue – in the fascia. It is common in clinical practice to see a ”bad knee” that can never quite “remember” its orientation and function from when the knee was normal. The knee improves with treatment, but it never becomes like the “good knee”, even when there is little significant organic damage.
According to the tensegrity model, the whole body is a three-dimensional viscoelastic matrix, balanced by an integrated system of compression-tensional forces in dynamic equilibrium. Studies have also shown that fascia seems to have both the properties of a sol-liquid conductor and a crystalline structure. This means that fascia seems to have the properties in common with a crystal generator system, due to the polarity within in its molecular structure. Hence the ability of fascia to generate piezoelectricity and conduct direct currents, as well as vibrations. The orderly arrangement of collagen fibers in a crystalline arrays system produces oscillations that can move rapidly throughout the living matrix. 
Mechanical forces acting upon the internal and/or external environment, such as in postures, movements and strains, dictate the sites where collagen is deposited. Thus, a “tensional memory” is created in a particular connective tissue architecture formed by oriented collagen fibres. T this ability seems to be present not only in the collagen network but also in elastin fibres and in various cells throughout the connective tissue: fibroblasts, mast cells, plasma cells, and fat cells. Since these are relatively durable and long-lasting cells, they may represent a kind of “long-term memory” of the ground substance. 
Therefore, it can be proposed that manually releasing fascial tensions and binds through vibration, massage, acupuncture, etc. may stimulate fascial mechanoreceptors that send signals throughout this unified matrix, creating effects on many levels, electrical, mechanical, neurological and chemical. Exercise, stretching and “internal exercises”, like those practiced in internal martial arts, may also modify and change “memories” stored in the fascia.
Most people would agree with the idea that stretching helps reduce the possibility of injury, and that regular stretching can reduce pain and stiffness. The questions that are increasingly being asked about stretching are: What kind of Stretching? How often? Before or after other exercise or sports activities?
There is increasing evidence and agreement that stretching before running or athletic activities is not only not helpful but may be harmful. Dr. Ian Shrier conducted a systemic review of 24 studies on stretching. His conclusion:
There are many different ways to stretch. Static stretching was used in most of the studies, but the effects were observed with PNF stretching as well. Dynamic stretching is a combination of both stretching and warm-up (i.e., muscle is contracting). This review found that the effects were consistent across different modes of stretching for isometric force, isokinetic torque, and jump height. Although different modes of stretching in running produced conflicting results, another methodological difference was the duration of stretch, with the longer stretch producing worse results. 24 studies. 
Increasingly, current fascial research seems to indicate that “Dynamic Stretching“, or “bouncing stretches”, the staple of warm-up exercises many years ago, may more effectively train the fascia than the slow static methods of stretching that are often advocated.
Although stretching immediately before competition can be counterproductive, it seems that long-term and regular use of such dynamic stretching can positively influence the architecture of the connective tissue in that it becomes more elastic when correctly performed. Indeed, when practiced regularly, static as well as dynamic stretching have shown to yield long term improvements in force, jump height, and speed. 
A study on stretching compared three approaches to stretching: 1) Static stretching of the quadriceps muscle; 2) PNF Stretching of the quadriceps – briefly contracting the muscle against resistance and then stretching it and 3) Dynamic Stretching, consisting of a “butt-kick” exercise, which involved standing in place while individually bringing the heel of each foot toward the buttocks in a repetitive and alternating fashion. The percentage increases in knee extensor power showed that the dynamic stretching protocol resulted in significantly larger percentage increases than for either of the other protocols or the controls.
The authors of this study speculate that neuromuscular phenomena elicited from a dynamic stretch – post-activation potentiation following the contractile force and increased neural activity in spinal dorsal roots after muscular contractions (Post-Activation Sensory Discharge) may lead to a more rapid and forceful response from the muscle being activated. 
Schleip and Mueller point out that different stretching styles seem to reach different fascial tissue components. Classic weight stretches strengthen the fascial tissues that are arranged in series with the active muscle fibres, while also stretching and stimulating the transverse fibres that go across the muscular envelope, but there is little effect on extra-muscular fasciae or intra-muscular fascial fibres that are arranged in parallel to the active muscle fibres.
In contrast, classic Hatha Yoga stretches, have little effect on those fascial tissues, which are arranged in series with the muscle fibres. However they do seem to stimulate the extra-muscular fasciae and the intra-muscular fasciae oriented in parallel to the muscle fibers. Dynamic muscular loading patterns, in which the muscle is briefly activated in its lengthened position (Cyclical Loading), promises to be the most comprehensive way of stimulating fascial tissues. With this type of training, increase in collagen production is produced by even a few repetitions. 
In an interesting study on the effect of stretching on soft tissue inflammation in rats, it was found that induced connective tissue inflammation in the rat characterized by macrophage infiltration, increased local mechanical sensitivity as well as impaired gait. With the stretching technique used in this study, the animal was partially suspended by the tail, the animals were pulled slowly backwards as they grabbed onto the edge of the table with their front paws. This encouraged the rats to stretch the full length of their body, holding a position of stretch that was slightly beyond its usual range of motion. The rats underwent ultrasound imaging and analysis and histology and macrophage testing.
The altered gait, increased local mechanical sensitivity and macrophage infiltration of connective tissues were all ameliorated by stretching the tissues. Inflammation markers were reduced through stretching.  The authors stress that:
the rodent model of “active” stretching was not intended to simulate a clinical stretching treatment that can be directly applied to humans. For example, the duration of stretching in the study (10 minutes) is longer than typically used in physical therapy or yoga. It will therefore be important in further studies to determine the shortest duration of stretching that can have pro-resolution effects. On the other hand, the position adopted by the rats during active stretching, with pulling of the thoracolumbar fascia resulting from simultaneous extension of fore and hind-limbs, is remarkably similar to some basic yoga and “core” exercises. 
Irwin and Olmstead found that exercises like Tai Ji Quan, which has a cyclic loading, stretching and meditation components, decreases levels of circulating pro-inflammatory cytokines in older adults with risks of inflammatory disorders. 
In general, most fascial experts advocate a mix of stretching styles – static and dynamic (elastic), and changing the angle of a stretch to access different fascial planes. For example, in the classic “cat stretch”, one reaches out while kneeling to stretch the posterior connective tissue chain from the fingertips to the sit bones, and from the coccyx to the heels and the top of the head. By slightly turning and changing the angle of the stretch, different parts of these chains, including the frontal chain from the pubic bone to the chin, can be affected.
Similarly, in the Nei Jia exercise the Phoenix Stretch (see: How I Cured My Low Back Pain: The Phoenix Stretch), or the Xing Yi Nei Gong Exercise ‘Strengthening the Meridians by Rubbing the Knees & Stretching the Body’, slight adjustments are made throughout the exercise in conjunction with breathing into the low back and sacrum, thereby changing the fascial planes that are being affected. Additionally, breathing into the low back and sacrum increase the intra-abdominal pressure, adding other dimensions to the stretch.
The work of Pete Egoscue is also interesting in this regard as he recommends positional stretches that can be held for in some cases as long as 20 minutes, in order to release soft-tissue restrictions.  The Back Stretch Exercise for realigning the neck uses a principle similar to Mr. Egoscue’s work. Egoscue recommends the positional stretch pictured below to help align and unlock the hip and groin muscles. 
 Relationship of Acupuncture Points and Meridians to Connective Tissue Planes.” Helene M. Langevin* and Jason A. Yandow. The Anatomical Record (New Anat) 269: 257-265, 2002.
 “Biomechanical response to acupuncture needling in humans” Helene M. Langevin, David L. Churchill (Journal of Apllied Physiology 91: 2471–2478, 2001.
 “Mechanical signaling through connective tissue: a mechanism for the therapeutic effect of acupuncture” Helene m. Langevin, David L. Churchill and Marilyn J. Cipolla (Department of Neurology, University of Vermont, Burlington, Vermont) FASEB J. 15, 2275–2282 (2001).
 Interview with Helene Langevin https://oshercenter.org/2017/09/18/acutalks-interviews-dr-helene-langevin-connective-tissue-plays-role-acupuncture/
 Mechanical signaling through connective tissue: a mechanism for the therapeutic effect of acupuncture.” Helene M. Langevin, David L. Churchill and Marilyn J. Cipolla.
 Interview with Helene Langevin https://oshercenter.org/2017/09/18/acutalks-interviews-dr-helene-langevin-connective-tissue-plays-role-acupuncture/
 Does Fascia Hold Memories” Journal of Bodywork and Movement Therapies (2014) 18, p. 259-265.
 “Does Stretching Improve Performance: A systemic and Critical Review of the Literature.” Ian Shrier, MD, PhD. Clinical Journal of Sports Medicine. Volume 14, No. 5, Sep. 2004.
 “Acute Effects of Static, Dynamic, and Proprioceptive Neuromuscular Facilitation” Stretching on Muscle Power in Women. Mateus E. Manoel et als. The Journal of Strength and Conditioning Research (Volume 22 No. 5, September 2008).
 Training Principles for Fascial Connective Tissues: Scientific Foundation and Suggested Practical Applications. Robert Schleip, PhD, MA and Divo Gitta Mueller, HP (Journal of Bodywork and Movement Therapies (2012) xx, p1-13.
 Stretching of the Back Improves Gait, Mechanical Sensitivity and Connective Tissue Inflammation in a Rodent Model” Sarah M. Cory et als Plos One (January 2012 , Volume 7: Issue 1, e29831)
 “Stretching Impacts Inflammation Resolution in Connective Tissue.” Lisbeth Berrueta, Igla Muskaj, Helene M. Lagevin et als. Journal of Cell Physiology (2016, July 231(7) 1621-1627 doi: 10 1002/j 25263) p. 1621-1627.
 “Mitigating cellular inflammation in older adults: a randomized controlled trial of Tai Chi Chih” M.R. Irwin, R. Olmstead. The American Journal of Geriatric Psychiatry 2012;20(9):764–772.
 Pain Free: A Revolutionary Method for Stopping Chronic Pain (New York: Bantam Books 1998).
 Ibid, p. 72.