Kubo Asako, et al.. Japanese Acupuncture and Moxibustion; 2019; Vol.15(1): 1-8

Review article

New finding on fascia-traditional target of acupuncture
KUBO Asako 1, 2), YAMAGUCHI Satoru 1)
1) Department of Oriental Medicine, Saitama Medical University2) Department of Physiology, Nihon University, School of Dentistry
Abstract
Acupuncture has often been applied for pain relief, improving motor functions, and manipulating the autonomic
nervous system. Depending on the disease, the condition of the patient, or the purpose of the treatment, the target
tissue is different. The stimuli by acupuncture and moxibustion may be mechanical, chemical, and/or thermal in the
periphery, so that the afferent fibers innervating the tissue can respond to the stimuli and the signals can betransmitted to the central nervous system. This peripheral acceptance may be the first step to elicit the acupuncture
effect. It is well known that thin afferents innervating the skin and muscles accept and respond to the mechanical,
chemical, and/or thermal stimuli. These thin afferents consist of Aδ and C fibers. In addition to the skin and muscles,
there is another tissue, the fascia, which is a connective tissue wrapping the muscle. Although it appears that the
fascia can perceive a noxious stimulus, limited information is available about its function in nociception. In thisarticle, we review recent reports about fascial nociception in both animal and human subjects. The recent basic
research results clearly indicate the existence of nociceptive Aδ and C fibers in the fascia. First, we introduce thebasic structure of fascia and knowledge regarding nociceptive nerve fibers. Second, we review a recent anatomicaland physiological study about fascial nociception in rats. Next, we summarize the results from a psychophysiologicalstudy with human subjects. Finally, we discuss the possibility of the fascia as the third tissue for acupuncture
following the skin and muscles.
Key words: myofascia, polymodal receptor, afferent, nociception, pain, thin fiber, myofascial pain syndrome, trigger
point
I. Introduction
Muscle fascia (myofascia) is a type of connective
tissue that is present throughout the body1). The word
“myofascia” anatomically indicates some type of fascia.
The outermost layer is the superficial fascia, while thedeep fascia is underneath this. Furthermore,
endomysium, perimysium, and epimysium wrap themuscles, muscle bundles, and muscle fibers, respectively.
In this review, myofascia is used in the sense of a
thickening of deep fascia, which consists of denseconnective tissue layers covering the muscles andconnecting the skeletal muscle each other, thereby
creating continuous myofascial linkages throughout the
body. Fascia is referred to as the second skeletal
structure because of its three-dimensional distribution.
The functional roles of fascia had been classicallyconsidered to be maintenance of posture and control ofbody position, as well as production of smooth andcoordinated movement. Other classical roles include
protection by covering the organs and making thepassageway for nerve, blood, and lymphatic vessels2, 3).
An acupuncture needle sometimes stimulates theconnective tissue, including fascia. Langevin et al. havereported that the needle rotation produced changes inconnective tissue structure4) and referred to the sensory
innervation of the connective tissues5). In fact,acupuncture therapists know that the fascia may have afunction as a nociceptive sensor because the acupunctureneedle sometimes causes a pain sensation when it is at
this depth. It has been reported that the electrical pain
threshold around the fascia is remarkably low in the
deep tissue in human subjects6). A well-known
pathological condition originating from the fascia,
myofascial pain syndrome (MPS), is characterized by alocalized tender region with a palpable band (a so-called
trigger point). Ito et al. have shown a localized sensitive
region that was generated at the palpable band of the
fascia using experimental muscle contraction in
animals7). These results suggest the possibility that thesensory receptor exists on the fascia and it may sensitize
following muscle contraction or damage to generate aCorresponding author: Kubo Asako, Department of Physiology, Nihon University School of Dentistry 1-8-13 Kandasurugadai,
Chiyoda-ku, Tokyo, 101-8310, JAPAN2
Kubo Asako, et al.. Japanese Acupuncture and Moxibustion; 2019; Vol.15(1): 1-8

trigger point on the fascia. From this point of view, theacupuncture manipulation of the fascia may be effective
for disorders originating from there, such as MPS. As
has already been reviewed, the effect of acupuncture
may be mediated by the activation of afferent nerve
fibers including Aδ and C fibers innervating the skin andmuscles8), and thus the existence of these nociceptive
fibers in the fascia may make it a nociceptive tissue that
responds to acupuncture stimulation.
In last decade, some basic research reports haveshown the existence of nociceptive Aδ and C fibers not
only in the skin and muscles but also in the fascia. In
medical experiments with animals, thoracolumbar or
crural fascia (CF) has often been examined byimmunohistochemical and functional studies using anelectrophysiological approach. In addition, results from a
psychophysiological study with human subjects havealso been reported. The present review focuses on the
fascia as a nociceptive tissue, introduces the recent
knowledge gained from basic research, and addresses theimportance that fascia can be a pain generator, andfurthermore, a functional target for acupuncture therapy.
Ⅱ．Studies with rat fascia
1. Basic structures of the fascia
Thoracolumbar fascia (TLF) covering the elector
spinae and multifidi muscle in the low back is very thickand easily separable from the adjacent tissues (i.e. theskin and muscles). TLF has often been studied for basic
research with animals (mainly rats). It has beensuggested that the TLF plays a role in non-specific low
back pain9, 10). However, there is little data regarding the
TLF as a potential source of pain, even though low backpain has become a major problem in our health caresystem. The rat TLF has three layers that are visible
medially close to the spinous processes11) (Fig. 1A). The
outer (superficial), middle, and inner (deep) layers arecomposed of transversely oriented densely packed
collagen fibers, massive collagen fiber bundles, andloose connective tissue, respectively. The outer layer of
the TLF includes dermal adipose tissue that supports
dermis. The innermost layer, deep fascia, links with theepimysium surrounding the muscles. In contrast, CF,
which is another thick fascia covering the tibialis
anterior muscle, does not have any critical separated
layers.
2. Basic knowledge about the nociceptive fibers
Nociceptive input such as noxious heat, mechanical,
or chemical stimuli on terminal tissue is generally
conducted by thin fibers (Aδ and C). Several peptides,
such as calcitonin gene-related peptide (CGRP) andsubstance P (SP), have been identified in the peripheral
terminal of nociceptive neurons. In general, almost halfof all thin fibers are peptidergic, containing the peptides
such as CGRP or SP. They are released from sensory
nerve endings to induce many of the signs of acuteinflammation including vasodilatation and plasma
extravasation, and to play roles such as the principal
mediators of neurogenic inflammation and axon reflex
flare12). Without going into detail, both peptidergic andFig. 1. Structure of the rat thoracolumbar fascia (TLF) close to the spinous processes L4/L5. (A) Transversal section the threelayers of the TLF: OL, outer layer with transversely oriented collagen fibers; ML, middle layer composed of collagen fiber bundles
oriented diagonally to the long axis of the body; IL, inner layer of loose connective tissue covering the multifidus muscle (muscle).
SCT, subcutaneous tissue. (B) PGP9.5-ir nerve fibers in the layers of the TLF. Black arrows, fibers on passage; open arrows, nerve
endings. (C) Mean fiber length of PGP9.5-ir fibers in the TLF. The majority of the fibers were located in the OL of the fascia and in
the SCT. White part of the bar: SCT plus OL of the TLF; black: ML; hatched: IL. n, number of sections evaluated. Republishedwith permission of ELSEVIER BV from “Sensory innervation of the thoracolumbar fascia in rats and humans” in Neuroscience, J.
Tesarz, U. Hoheisel, B. Wiedenhofer and S. Mense, 194, 2011 of copyright; permission conveyed through Copyright ClearanceCenter, Inc.

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non-peptidergic neurons are involved in nociceptive
signal transduction.
3. Anatomical analysis with intact fascia
One of the methods frequently used for anatomical
study is immunohistochemical analysis with a specificantibody for peptides/proteins. Some universal peptide/protein markers to visualize primary afferent fibers arewell established, such as protein gene product 9.5 (PGP9.5), peripherin, and CGRP (or SP). These are neuronalmarkers for general, non-peptidergic and peptidergic
fibers, respectively. Tesarz et al. have reported that theimmuno-reactive (IR) fibers for these markers wereobserved not only in rats but also in the human TLF 11).
In a more detailed analysis, they analyzed the nerve
ending distribution in each of the three layers (i.e. outer,
middle and inner layer) in the rat TLF. The distributionof nerve endings were dense in the outmost layer anddecreased at the innermost layer (Fig. 1B, C). Moreover,they showed that both rat and human fascia had a richinnervation with sympathetic fibers using tyrosinehydroxylase as a marker for postganglionic sympathetic
nerve fibers. These results suggest both sensory andsympathetic nerve fibers containing neuronal peptides
innervate to the TLF the same as skin, muscle or othertissue. The existence of CGRP-, peripherin-, and PGP
9.5-IR nerve fibers was also evident in the CF (Fig. 2)13).
CGRP- and peripherin-IR fibers were more dense on the

superficial side (skin side) rather than on the deeper side
facing the muscle. Few nerve fibers ran among and/or
across the collagen fiber bundles in the CF.
4. Physiological analysis with intact fascia
Several reports of neuronal activity recordings fromboth the primary and secondary afferent fibers
innervating the fascia have been published. The result
using a single-fiber recording technique from thecommon peroneal nerve in a rat has shown the existenceof functionally active C- and Aδ-fibers innervating theCF13). The fascial neuronal activities were recorded
under three types of stimuli (mechanical, chemical, andthermal) and the identified fibers were categorized bytheir sensitivities (Fig. 3). First, they roughly searched amechanically sensitive receptive field (RF) by manual
pinching of CF with blunt forceps. The CF alone could
be stimulated separately from the muscle underneathbecause it has sufficient thickness and is connected tothe muscle with a loose connective tissue. Fibers with
conduction velocity (CV) of <2.0 m/s were classified as
C-fibers, whereas those with CV of 2.0 to 20 m/s wereclassified as Aδ-fibers. After nerve detection, pinchingwith sharpened forceps, quantitative ramp mechanical(392 mN/40 sec), chemical (bradykinin), thermal (cold(32C to 8C), and heat (32C to 50C)) stimuli wereapplied to the identified RF (Fig. 3B-F). Finally, 43% of
C-fibers were concluded to be polymodal receptors,

Fig. 2. CGRP- and peripherin-ir nerve fibers in the crural fascia (CF). Whole-mount fascia preparations. (A) A CGRP-ir terminal
axon with a long chain of varicosities and its nerve terminal. (B) A peripherin-ir receptor terminal axon and its nerve terminal.
Filled arrowheads: axon of immunoreactive nerve. Open arrowheads: peripheral nerve terminal. (C-E) Distribution of nerve fibers
with CGRP- (C), peripherin- (D), and PGP 9.5-ir (E) in whole-mount preparations of the CF. They were traced under a lightmicroscope and drawn on a plane. In the peripherin staining, peripheral nerve terminals are indicated by dots. Note that
presumptive nociceptive nerve fibers (and their terminals) labeled with CGRP- and peripherin-ir were located in the distal third of
the CF, and that there was some tendency for the labeling to be dense along the medial and lateral edge and relatively sparse in thecenter of the CF. On the other hand, PGP 9.5-ir (general marker for nerve fibers) was distributed all over the CF. Republished withpermission of Wolters Kluwer Health, Inc. from “Nociception originating from the crural fascia in rats” in PAIN, T. Taguchi, M.
Yasui, A. Kubo, M. Abe, H. Kiyama, A. Yamanaka and K. Mizumura, 154, 2013 of copyright; permission conveyed throughCopyright Clearance Center, Inc.

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which responded to all types of noxious stimuli (i.e.
mechanical, thermal, and chemical), whereas almost allAδ-fibers behave similar to mechanical nociceptors,
responding only to mechanical stimuli. Moreover, 52%
of C-fibers innervating CF responded to both mechanicaland heat stimuli. Based on the previous single-fiber
recording results, the proportion of the fiber responding
to both mechanical and heat stimuli in the skin andmuscle was about 80-90% and 40%, respectively14, 15),
therefore the result from fascial afferents seems to beappropriate.
The activities of the secondary afferent fiber (i.e.
dorsal horn neurons) innervating the TLF have also beenreported16). Hoheisel et al. performed the systematic
extracellular recording of dorsal horn neurons that were
examined in the lumbar spinal cord at segmental levels
L1-L5, and in the thoracic spinal segment Th13 (ratsusually have 13 thoracic and 6 lumbar spinal cordsegments). In addition, the dorsal horn neurons having
RF in the TLF were searched. The recording was madefrom a total of 211 neurons and 8 of them received input
from the TLF (3.8%), while input from the multifidus(MF) muscle underneath the TLF was 9.5% and thatfrom the skin was 51.7%. All of the TLF neurons werelocated in spinal segments between Th13 and L2. There
were no neurons with TLF input found in the spinal

segments L3-L5. They also indicated that most dorsal
horn neurons with input from the TLF had convergent
input from the MF muscle (87%), or from both the MF
muscle and the skin (50%).
5. Anatomical and physiological changes underchronic inflammation of rat fascia
Even in a normal (i.e. intact) state, the functional
afferents are innervating the fascia, which could sense
the same kind of stimuli as the skin and muscles as
described above. Moreover, it has been reported that
inflammation induces both anatomical and physiologicalchanges in the fascia17, 18). Complete Freund’s Adjuvant(CFA), which is generally used as a reagent in animal
experiments, was applied to the fascia to cause chronic
inflammation. After inflammation occurred by CFA
injection into the TLF, the density of SP-positive(presumably nociceptive) fibers significantly increased
in all layers of the TLF. The CGRP-positive fibers werealso significantly increased in the inner layer of the
TLF17).
The fascial inflammation also induced physiologicalchanges18).
Hoheiseletal.
performed
anelectrophysiological recording from dorsal horn neurons
in the lumbar segment L3. As described in the section II4, the TLF neurons did not exist in the L3 segment in theFig. 3. Responses to various noxious stimuli of a C-afferent fiber having a receptive field in the crural fascia. (A) Receptive field of
the fiber (arrowhead), (B) Responses to pinching of the CF with sharpened watchmaker’s forceps, (C) quantitative ramp
mechanical stimulus (392 mN in 40 seconds), (D) bradykinin 10 M for 60 seconds, (E) cold (from 32 to 8C in 40 seconds), (F)heat (from 32 to 50C in 30 seconds), (G) 5% hypertonic saline for 30 seconds. Bradykinin and 5% hypertonic saline were appliedwith a small cotton ball soaked in the solution. Filled bars under the abscissas of the histograms indicate the time point and theduration of each stimulus. CV = 0.50 m/s. Republished with permission of Wolters Kluwer Health, Inc. from “Nociception
originating from the crural fascia in rats” in PAIN, T. Taguchi, M. Yasui, A. Kubo, M. Abe, H. Kiyama, A. Yamanaka and K.
Mizumura, 154, 2013 of copyright; permission conveyed through Copyright Clearance Center, Inc.

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normal state. However, the proportion of dorsal hornneurons innervating deep tissues (i.e. muscles andfascia) significantly increased and there was a tendency
to increase neuron proportion with TLF input following
fascia inflammation. The new fascial RFs acquired by
L3 neurons in an inflamed fascia were locatedexclusively at the level of the inflammation ipsilateral to
the recording site (Fig. 4A). The locations of the RFs inother deep tissues were found outside the low backregion, namely in the hip and in the entire hindlimb
regions (Fig. 4B). The number of neurons having deep
RFs in the hip and hindlimb was significantly greater inanimals with an inflamed TLF.
Muscle inflammation has also exerted a physiologicalchange in the fascia over the muscle16). Compared with
intact animals, the proportion of neurons with RFs in the
TLF following the MF muscle inflammation rosesignificantly. Specifically, 4 of 33 neurons in spinal
segment L3 were found to respond to input from the
TLF with an inflamed muscle, while none of 38 TLF
neurons in L3 showed a response in an intact one (Fig.
5A). They also showed that the size of the RF in the TLF
became wider under muscle inflammation than those in
an intact muscle (Fig. 5B).

Ⅲ．Studies with human fascia
1. Human study focused on fascial nociception
Tesarz et al. have shown the preliminary
immunohistochemical results of human TLF11). Similar
to in rats, PGP 9.5-, TH-, SP- and CGRP-IR nerve fibers(or free nerve endings) also innervated in the human
TLF. More clinically, the psychophysiological study
with human subjects has been reported19). Schilder et al.
performed bolus injections (400L) of hypertonic saline
into the posterior layer of the TLF, erector spinae muscle,or the overlying subcutis at L3/L4 level, approximately 4
cm lateral to the spinous processes using ultrasoundimages. They evaluated spontaneous pain intensity, pain
quality, and pain distribution in response to isotonic or
hypertonic saline. Overall, the injection of hypertonic
saline induced higher and longer-lasting pain ratings in
all tissues than stimulation by isotonic saline. The
injection of hypertonic saline into the fascia evoked
longer pain duration within 25 minutes post injection
and higher pain intensities compared to subcutis andmuscle injections. Moreover, the hypertonic saline
injection led to a more widespread pain radiation after
fascia than with the other tissue stimulation.

Fig. 4. Location and size of the deep receptive fields (RFs). (A) RFs in the thoracolumbar fascia. (B) RFs in deep tissues other than
the thoracolumbar fascia. The numbers in parentheses are the number of neurons relative to the dorsal horn neurons recorded.
Arrows in the upper panels indicate the spinous process L5. Open outlines: RFs in the fascia (A) or other deep tissues of the lowback (B), Filled grey areas in (B): RFs in deep tissues outside the low back in the hip and hindlimb. The inset in (B) shows the
responses of a neuron to noxious stimuli applied to the gastrocnemius-soleus muscle. Nox. P., noxious pressure; NaCl, injection of
hypertonic saline (5%, 50 L). Republished with permission of W.B. SAUNDERS CO. LTD. from “Inflammation of thethoracolumbar fascia excites sensitizes rat dorsal horn neurons” in European Journal of Pain, U. Hoheisel, S. Mense, 19, 2015 ofcopyright; permission conveyed through Copyright Clearance Center, Inc.

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Ⅳ．Discussion
1. Can acupuncture and moxibustion manipulatefascia?
As we have briefly outlined in this review, there
seems to be no doubt that fascia can accept a painful
input. It has nociceptive fibers like the skin, muscles andviscera, and its anatomical distribution and physiological
function changes in the pathological situation. Afterinflammation, density of nociceptive fibers increased,
and the RF of nerve fiber innervating the fascia became
wider and to innervate other tissue (i.e. skin or muscles).
As also mentioned at the beginning, it has been
discussed which type of afferent can accept the input by
acupuncture. As manual acupuncture can induce diffuse
noxious inhibitory controls (DNIC)-like response andthe activation of thin afferent fibers (Aδ and C fibers) is
required by DNIC, the most plausible hypothesis is that
acupuncture stimulation could excite these thin fibers20).
It is well known that Aδ and C fibers are mainly
nociceptors activated by a noxious mechanical, heat, andchemical stimuli. The nociceptors, especially polymodal
receptors (nociceptors responding to multiple stimulus

modalities), may be the best potential candidate as aperipheral receptor for acupuncture and moxibustion, as
they would be mechanical, chemical or heat stimuli. The
polymodal fibers are widely distributed in the skin,muscles, and viscera. The studies discussed in thepresent review have given new aspects on the fascia as afunctionally active nociceptive tissue innervated by bothAδ and C fibers. These results suggest fascia can accept
an input from acupuncture stimulation and be directly
manipulated by acupuncture therapy. The fascia can also
respond to moxibustion stimulation, as the polymodal
fibers innervating it are also able to receive heat stimuli.
Presently, it is unclear which receptor is activated by
moxibustion, although transient receptor potential
vanilloid receptor, such as TRPV1 and TRPV2,
expressing on polymodal receptor terminals andactivated by heat stimuli, are promising candidates.
These findings may support that de qi sensation
originates from the activation of these fibers innervatingfascia during the acupuncture needle penetration. In
some cases, local twitch response is also observed
synchronously with de qi sensation. This phenomenon

Fig. 5. Proportion of dorsal horn neurons with input from TLF after CFA injection into the MF muscle. (A) Proportion of dorsal
horn neurons with TLF input in spinal segment L2: (a) and spinal segment L3 (b), black bars (intact), data from animals with anintact MF muscle. The numbers underneath the bars are those of the neurons from which the bars were constructed. (B) Locationand size of the receptive fields in the TLF: (a) intact animals, (b) inflamed animals; n: number of neurons. Arrows indicate thelumbar spinous processes L1 and L6. Republished with permission of W.B. SAUNDERS CO. LTD. from “Nociceptive input fromthe rat thoracolumbar fascia to lumbar dorsal horn neurons” in European Journal of Pain, U. Hoheisel, T. Taguchi, R.D. Treede, S.
Mense, 15, 2011 of copyright; permission conveyed through Copyright Clearance Center, Inc.

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may be supported by the presence of contractile
fibroblasts containing -smooth muscle actin (-SMA)in the fascia10). In fact, the gene expression of -SMA
has been reported, but it is currently unclear whether the
myofascia has contractility similar to muscle or not.
Further studies are necessary to clarify such possibilities.
2. Does fascia cause low back pain?
As mentioned in the introduction, it is believed that
the TLF is potentially involved in non-specific low backpain9,10). The TLF is innervated by nociceptive freenerve endings and lumbar dorsal horn neurons. Thesefibers could respond to fascial noxious inputs andconduct the information to the spinal cord and brain.
Interestingly, as most of the dorsal horn neurons
innervating TLF had convergent inputs from the muscle
and/or skin especially with an inflamed fascia, thereferred pain between the muscle and fascia may becaused in a way similar to visceral pain. The input fromthe fascia not only at the original levels but also at lower
levels of the spinal cord was observed following
inflammation. Moreover, both rat and human TLF has arich innervation with sympathetic nerve fibers. Thisfinding may explain why patients with low back pain
report increased intensities of pain when they are underpsychological stress. In general, acupuncture therapy canalso manipulate the autonomic nerve system by central
mechanism. In terms of this effect, low back pain
generated not only from muscle but also the TLF could
be treated by acupuncture through both a peripheral andcentral mechanism.
Ⅴ．Conclusion
Recent studies presented us new aspect about the
fascia as a nociceptive generator and the possibility thatthe fascia could respond to acupuncture stimuli has beenraised. An acupuncture needle is a good device fordirectly stimulating the deep tissue (i.e. fascia, muscle,etc.) with less (or no) injury to the skin. This uniqueability of acupuncture may lead to a distinctive effect byacupuncture therapy.
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