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The Science of Stretch

The study of connective tissue is shedding light on pain and providing new explanations for alternative medicine.

By | May 1, 2013

© STEVE JACOBS/ISTOCKPHOTO.COM

It joins your thigh to your calf; your hand to your arm; your breastbone to your clavicle. As you move, it allows your muscles to glide past one another. It acts like a net suspending your organs and a high-tech adhesive holding your cells in place while relaying messages between them. Connective tissue is one of the most integral components of the human machine. Indeed, one could draw a line between any two points of the body via a path of connective tissue. This network is so extensive and ubiquitous that if we were to lose every organ, muscle, bone, nerve, and blood vessel in our bodies, we would still maintain the same shape: our “connective-tissue body.”

Despite increasing evidence of its role in chronic pain and other diseases, connective tissue is not very well studied. I arrived at researching connective tissue by a circuitous route. Working as a clinical endocrinologist, I would see patients suffering from chronic pain, and quickly became frustrated with the treatment options I could offer—usually some combination of physical therapy and analgesics, which often were not very effective. Some of my patients would ask about trying acupuncture. But, having done research in neuroscience and being firmly rooted in the practice of Western medicine, I was skeptical. Eventually, I decided to learn more, if only to be able to respond to patient questions more intelligently.

In 1986, I took evening classes at the Tri-State Institute of Traditional Chinese Acupuncture in Stamford, Connecticut (now the Tri-State College of Acupuncture in New York City), which offers hands-on experience in acupuncture. The teacher described how to twirl the inserted acupuncture needles just enough to elicit a particular sensation in the patient, usually described as an ache in the area surrounding the needle, which can radiate some distance away from it. I was told that the acupuncturist is supposed to feel tightness or tugging on the needle, akin to when a fish gets caught on a hook. When I felt that tug myself, I became curious about the physical mechanism that was causing it. The teachers explained it as muscle contracting around the needle, but I could feel it in locations, such as the wrist, where there was no muscle at all. The needles had to be interacting with connective tissue.

A decade later, after I had moved to the then Department of Neurology at the University of Vermont (UVM) College of Medicine in Burlington, I had the opportunity to begin research on the acupuncture “needle grasp.” Here was a physiological phenomenon that one could feel with one’s fingers, but which had no obvious biological explanation. I started collaborating with Martin Krag, an orthopedic surgeon at UVM who had some experience testing alternative-medicine approaches using scientific methods. The logical first step was to quantify the tugging response to acupuncture needling. With the help of David Churchill, a biomedical engineer in the Orthopedic Department at UVM who designed a robotic acupuncture-needling instrument, we began measuring the force needed to pull out the needles in a reproducible manner from 16 different points on the body. We measured the “pullout force” in 60 human subjects and found that it did indeed increase after needle rotation, at times so dramatically that it exceeded the capacity of our 500 g load-measurement device.1

We then tested the possible mechanisms that could cause this phenomenon, starting with simple experiments in which we inserted and rotated a needle in a piece of rat abdominal wall. What we saw under the microscope was quite striking: when acupuncture needles were rotated, the loose connective tissue under the skin became mechanically attached to the needle. Even a small amount of rotation caused the connective tissue to wrap around the needle, like spaghetti winding around a fork.2 This winding caused the surrounding connective tissue to become stretched as it was pulled by the needle’s motion. Using ultrasound, we confirmed that the same phenomenon occurs in live tissue.3

In the years that followed, I became part of a small but growing community of scientists who were joining the ranks of molecular and physiological researchers dedicated to studying this neglected tissue. Connective tissue has been relegated to the role of passive viscoelastic material in traditional biomechanical models, but researchers are now beginning to demonstrate just how many systems of the body may be affected by mechanical changes in connective tissue, and some of these findings are beginning to inform clinical practice.

A growing field

Connective tissue is something of an orphan child in medicine: although it is an integral part of the musculoskeletal system, connective tissue is basically absent from orthopedic textbooks, which deal principally with bones, cartilage, and muscles. Orthopedic interest is almost exclusively restricted to the “specialized” connective tissues such as tendons and ligaments, which connect bone to muscles and to other bones, respectively. Nonspecialized connective tissues, which form what’s known as the fasciae and envelop all muscles, nerves, bones, and blood vessels, are typically allotted a short paragraph in current textbooks, if mentioned at all.

However, interest in the field has been growing. One area that has attracted many researchers at the cellular level is the study of mechanotransduction: how the integrin family of adhesion molecules forms a physical and informational link between the extracellular matrix and the interior of cells. Through these cell-matrix connections, cells sense forces and transform these mechanical signals into cellular responses such as the activation or deactivation of signaling molecules, translocation of transcription factors into the nucleus, and ultimately, changes in gene expression.4 In addition, substantial evidence supports the notion that mechanical signals can be transmitted directly through the cytoskeleton into the interior of the nucleus. (See “Full Speed Ahead,” The Scientist, December 2009.)

Some of the most well-established work in this field has involved the study of fibroblasts—the cells that are responsible for synthesizing all the proteins that make up the extracellular matrix. These cells reside within the matrix they create, responding to mechanical stimulation by regulating the amount of collagen and other matrix proteins produced, and by secreting matrix-degrading enzymes in response to chronic changes in tissue forces. Such changes can be induced by repetitive motion and are thought to be an important factor in work-related musculoskeletal injuries such as tendinitis of the shoulder or wrist.5

Here was a physiological phenomenon that one could feel with one’s fingers, but which had no obvious biological explanation.

Fibroblasts also play a major role in the response to acute injury, particularly when they transform into myofibroblasts. Before the availability of surgery and surgical sutures, gaping wounds needed a powerful mechanism in order to pull shut and heal. Myofibroblasts serve this function by secreting large amounts of collagen and expressing α-smooth muscle actin protein, which make the cells contractile.6 Then, by exerting tension on the collagen matrix, these cells pull the edges of the wound together. Myofibroblasts normally die once this job is done and a stable scar has formed. However, during chronic inflammation, myofibroblasts can drive an excessive deposition of collagen, and the increased tissue tension can result in the development of tissue contractures that restrict full range of motion. This response is also thought to play a role in the development of some types of tissue fibroses and cancer. Indeed, fibrotic, or scarred tissues, become stiffer, and cancer cells have been shown to spread more easily on fibrotic matrices.7

WHEN CONNECTIVE TISSUE STRETCHES
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© TAMI TOLPA
Although much of the work in this area to date has been performed in cell culture, rather than in whole tissue, some of this basic research is beginning to inform clinical research and practice, especially in the area of chronic musculoskeletal pain, including low-back pain. One of the reasons that low-back pain is so difficult to manage is that large numbers of patients have no detectable abnormalities of the spine and associated tissues, and the source of their pain is unknown. Some groups have begun to investigate the possibility that the pain is arising from the nonspecialized connective tissues on either side of the spine.

Indeed, researchers at the University of Heidelberg found in 2008 that connective tissues contain sensory nerve endings that can transmit pain when these tissues are stretched in the presence of inflammation.8 Until then, it had not been clear whether connective tissue had its own sensory nerve supply capable of generating sensations. Subsequently, ultrasound studies in my laboratory demonstrated that the connective tissues that surround the muscles of the back are, on average, thicker in people with chronic low back pain.9 Normally, these connective tissues are composed of alternating layers of tightly woven dense fibers that can bear substantial loads, and loose areolar tissue, which contains large quantities of water and allows the adjacent dense layers to glide past one another. In addition to having thicker connective tissue overall, people with low-back pain show a decreased gliding motion of dense layers, suggesting that a fibrotic process could cause the decreased mobility.

Connecting the dots

TISSUE TENTING: A twisted acupuncture needle creates a localized stretch by gripping the underlying connective tissue. This effect can be observed as a “tenting” of the skin as the needle is pulled out.© ZILLI/ISTOCKPHOTO.COMDespite these recent advances, the overwhelming majority of research on connective tissue still involves cells grown in culture dishes. And recent studies suggest that, especially for fibroblasts, the mechanical behavior of cells may be quite different when cells are grown on 2-D surfaces compared to cell behavior in a 3-D environment that is more similar to that of whole tissue, such as a thick collagen gel. For example, it is becoming apparent that the ubiquitous intracellular “stress fibers” characteristic of fibroblasts grown on 2-D surfaces are not present in fibroblasts grown in 3-D-culture environments or in whole tissue, and that these fibers may in fact be an artifact of cell culture, rather than a phenomenon that has physiological meaning. The fact that the study of fibroblasts in whole tissue is lagging far behind that of fibroblasts in vitro, combined with the general lack of attention to nonspecialized connective tissue at the whole-body level, has limited the understanding of natural connective-tissue function.

I began my research into connective tissue on the whole-animal level, but quickly began to investigate the cellular components involved in the winding response to acupuncture needles. After dissecting some of the tissue we had manipulated, we saw that the fibroblasts residing in the connective tissue as far as several centimeters away from the needle began to reorganize their internal cytoskeleton and change shape, becoming large and flat. We also found that the same reorganization response could be elicited by simply stretching a piece of connective tissue between two grips and holding the tissue in the stretched position for about 30 minutes, or even stretching an anesthetized mouse by bending its body to one side.10 Interestingly, 30 minutes is typically the amount of time that needles are left in place during an acupuncture treatment. Furthermore, if one lets go of the needle after rotating it, the needle does not unwind right away. Thus, the “whorl” of connective tissue remains intact as long as the needle remains under the skin, causing the tissue to be stretched for a prolonged period.

Ongoing studies in my lab are addressing why the fibroblasts change shape in response to sustained stretching. So far we have found that the changes are associated with a large-scale relaxation of the connective tissue. We also saw that the fibroblasts initiated a specific Rho-dependent cytoskeletal reorganization that was required for the tissue to fully relax. Rho is an intracellular signaling molecule known to play a role in cell motility and the remodeling of cell-surface proteins that connect the fibroblast to its surrounding matrix. The molecule’s involvement in fibroblast shape change suggested that the cells are able to reduce the tissue tension by adjusting how strongly and where they are gripping the surrounding connective tissue or muscle. (See illustration above.) In addition, we found that the shape change is also associated with a sustained release of ATP from the fibroblast.11 Within the cell, ATP acts as fuel, but outside of the membrane, ATP can function as a signaling molecule. Extracellular ATP can be converted to other purines such as adenosine, which can act as a local analgesic, thus providing a possible cellular and physiological mechanism to explain the pain relief experienced by some acupuncture patients.12 (See “Puncturing the Myth,” The Scientist, September 2011.)

Acupuncture-needle manipu­lation results in sustained stretching, and therefore constitutes a useful tool that can be used to study this biomechanical function.

The possibility that connective tissue dynamically regulates its level of tension is intriguing, as it could dampen fluctuations in tissue tension. Connective tissue surrounds nerves, blood vessels, and lymphatics, and reducing changes in tissue tension could affect how these structures function. Importantly, fibroblast cytoskeletal reorganization is a rather slow process, taking several minutes, and therefore would occur in response to sustained changes in tissue length such as changes in posture and body positions. Remarkably little is known about the effects of static tissue stretching, though repetitive, cyclical stretching has been extensively studied because of its relevance to breathing, walking, and cardiovascular pulsations. Acupuncture-needle manipulation results in sustained stretching, and therefore constitutes a useful tool that can be used to study this biomechanical function.

In contrast to the general neglect of connective tissue in the conventional medical and scientific fields, “alternative-medicine”  researchers, and especially clinical practitioners, have for many years recognized the potential importance of connective tissue in health and disease. In conventional physical therapy, stretching of surgical scars and joint tissue that has contracted and stiffened after prolonged immobilization is widely believed to cause remodeling of connective tissue. Alternative therapies such as myofascial release and Rolfing focus on stretching as a treatment modality for musculoskeletal pain, even in the absence of an obvious past injury or scarring. Indeed, a variety of alternative manual and movement-based therapies work under the collective assumption that connective-tissue pathology lies at the source of musculoskeletal pain, and that this can be ameliorated with manual treatments.

Connection to acupuncture meridians

The mysterious “acupuncture meridians,” defined as lines or tracks connecting acupuncture points, also may be related to connective tissue, as they seem to be preferentially located along connective-tissue planes between muscles, or between muscle and bone. We have found that more than 80 percent of acupuncture points in the arm are located along connective-tissue planes.13 This makes sense, since loose connective tissue houses blood vessels and nerves, suggesting that mechanical stimulation of connective tissue generated by needle manipulation could transmit a mechanical signal to sensory nerves, as well as intrinsic sensory afferents directly innervating connective tissue.

Clearly, connective tissue needs more attention. A simple PubMed search illustrates this problem, as specific subject headings for “nonspecialized connective tissue” do not exist. By default, alternative medicine has become a motivating force in connective-tissue research and clinical practice. This is an example of an area in which the combination of conventional and alternative medicine, typically referred to as “integrative medicine,” should be understood in a broader sense as integration within medicine itself, inspired by alternative-medicine concepts. The growth and maturation of the field of connective-tissue research will no doubt benefit from exciting new developments resulting from this integration. 

Helene M. Langevin is a visiting professor of medicine and Director of the Osher Center for Integrative Medicine at Brigham and Women’s Hospital, Harvard Medical School, and a professor of neurological sciences at the University of Vermont.

References

  1. H.M. Langevin et al., “Biomechanical response to acupuncture needling in humans,” J Appl Physiol, 91:2471-78, 2001.
  2. H.M. Langevin et al., “Mechanical signaling through connective tissue: A mechanism for the therapeutic effect of acupuncture,” FASEB J, 15:2275-82, 2001.
  3. H.M. Langevin et al., “Tissue displacements during acupuncture using ultrasound elastography techniques,” Ultrasound Med Biol, 30:1173-83, 2004.
  4. A. Mammoto et al., “Mechanosensitive mechanisms in transcriptional regulation,” J Cell Sci, 125:3061-73, 2012.
  5. S.M. Abdelmagid et al., “Performance of repetitive tasks induces decreased grip strength and increased fibrogenic proteins in skeletal muscle: role of force and inflammation,” PLOS ONE, 7:e38359, 2012.
  6. G. Gabbiani, “The myofibroblast in wound healing and fibrocontractive diseases,” J Pathol, 200:500-03, 2003.
  7. H.M. Yu et al., “Forcing form and function: biomechanical regulation of tumor evolution,” Trends Cell Biol, 21:47-56, 2011.
  8. T. Taguchi et al., “Dorsal horn neurons having input from low back structures in rats,” Pain, 138:119-29, 2008
  9. H.M. Langevin et al., “Ultrasound evidence of altered lumbar connective tissue structure in human subjects with chronic low back pain,” BMC Musculoskelet Disord, 10:151, 2009.
  10. H.M. Langevin et al., “Dynamic fibroblast cytoskeletal response to subcutaneous tissue stretch ex vivo and in vivo,” Am J Physiol Cell Physiol, 288:C747-56, 2005.
  11. H.M. Langevin et al., “Fibroblast cytoskeletal remodeling contributes to connective tissue tension,” J Cell Physiol, 226:1166-75, 2011.
  12. N. Goldman et al., “Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture,” Nat Neurosci, 13:883–88, 2010.
  13. H.M. Langevin, J.A. Yandow, “Relationship of acupuncture points and meridians to connective
    tissue planes,” Anat Rec, 269:257-65, 2002.
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Comments

Avatar of: T S Raman

T S Raman

Posts: 32

May 5, 2013

(I have posted the same comments under the companion article in The Scientist which includes a video)

"The Scientist", I believe, is a "reviewing" journal, not one that publishes original peer reviewed papers or other articles. The majority of its readers are not experts, and some do not even have a scientific background. These readers all depend on journals like The Scientist to enable them to get a general view of the latest developments in science. Therefore, The Scientist has to be extremely careful NOT to publish spurious science. In this particular case, The Scientist ought to have taken notice of the fact that the so-called "meridians", the very basis of acupuncture, are mythical. Meridians exist only in the minds of acupuncturists, and do not have a physical existence.


One of the characteristics of every "system" of "alternative medicine" is that they all build, as the essential part of their armament, “Entire vocabularies of unintelligible jargon (to) describe kingdoms of non-existent thought.” (To quote Lewis Lapham from another context.)


I said at the outset that I am "surprised". It is much more than that. I am perplexed and shocked.

Avatar of: Pwake

Pwake

Posts: 1

May 7, 2013

TS Raman, acupuncture methodology doesn't exist "in our minds", it is based on thousands of years of practice and "proven" results.  Just because you don't have any idea how it works, doesn't mean the foundation of it isn't real and doesn't follow a very detailed system.  To scoff at alternative medicine is ignorant and if your mind is closed or chooses to believe something is not what it appears to be, that it will be as you wish.  We cannot assume that we know even a smidgin (yes that is a made up word) of what there is to know about anything.  So allowing the possibility of something new into our minds and into science, such as the importance of connective tissue and the possible connection with acupuncture, is a small thing in the scheme of things, but a big thing in learning more about the human body.  

Pamela Wake, Licensed Acupuncturist

Avatar of: CarlaG

CarlaG

Posts: 1

May 7, 2013

There have been plenty of examples over the centuries in science where discoveries were made based on postulations without the 'visible' evidence - Albert Einstein and the existence of the atom and now sub-atomic particles.....

There is clinical evidence and more today that acupuncture works and the existence of pathways in which it works 'meridians' - or call it another word that makes you happy to fit into the 'box' you deem credible.  

Your negation of the existence of 'meridians' goes against the entire spirit of what The Scientific Method stands for.   

Avatar of: H Dunning

H Dunning

Posts: 1

May 9, 2013

I think this comments discussion has gone off the rails by missing the point, or, more likely, people not reading the entire article.

It does not explicitly support the philosophy of acupuncture. It just suggests that there may be a physiological mechanism for some of its purported benefits. The mention of possible real "meridians" - in the physiological sense of being centres of connective tissue - is a part of this musing, but as the author states, this is an under-researched area.

Raman, you are also more than a little hyperbolic in suggested that there's no peer-reviewed science here - there is a rigorous reference list at the end.

The point is, we should look where the evidnce leads. At present, acupuncture has been discredited for a whole range of ailments, but may have a real effect (beyond placebo) on certain pain and nausea conditions. This research may provide a mechanism for this benefit. Understanding it better can only help us all lead healthier lives. The only way to understand it is to research it - even if that research eventually concludes there is no real effect.

That's the real scientific method, whcih The Scientist has every right to publish.

Avatar of: casmith24

casmith24

Posts: 1

May 11, 2013

 

Without entering into the fray of alternative medicine and its place in The Scientist, as a former medical librarian I do feel compelled to respond to this assertion by Dr. Langevin: "Clearly, connective tissue needs more attention. A simple PubMed search illustrates this problem, as specific subject headings for “nonspecialized connective tissue” do not exist."

 MeSH, like other controlled vocabularies used in high-quality databases, relies on the principle of "literary warrant": a term that isn't found frequently in the literature being indexed is not promoted to subject heading status. Dr. Langevin is correct in implying a relationship between the popularity of a concept and its presence as a subject heading. However, this does not mean that a concept unrepresented by a MeSH term is entirely ignored; MeSH does not represent every known concept in biomedicine. This is why information retrieval in PubMed Medline requires use of both MeSH terms and keywords to be comprehensive.

There is in fact a specific subject heading (MeSH, or Medical Subject Headings) for "connective tissue". It is "Connective Tissue." There are more specific connective tissue type subject headings available in the MeSH "tree" below this upper-level heading, several of which appear to denote the"loose" or nonspecialized type which Dr. Langevin is referring to.

 
Avatar of: Metamorphosis

Metamorphosis

Posts: 1

May 13, 2013

So many modalities -- acupuncture, yoga, massage -- are connecting into this part of the healing in the body. Thank you for writing about this!

Avatar of: Mister Wu

Mister Wu

Posts: 1

May 13, 2013

Constellations may only exist in the minds of Astronomy but try to find individual stars in the night sky with out them. The meridian system point names were more useful in Europe for point identification as easier than remembering hundreds of Chinese names for individual points. Kid 3 for Kun Lun for example.

As to any tangible evidence to an existence of a channel system will whisper two words, "auxilary nipples"

May 15, 2013

The title not convey the content of the article clearly, and I was disappointed with the author's long-winded rambling writing style.  

Avatar of: Kathy Barker

Kathy Barker

Posts: 24

May 15, 2013

Research is discovery, crossing disciplines and philosophies. Dr. Langevin is navigating between 2 compartmentalized explanations of the natural world, asking  big questions, looking for data, making connections, a true scientist. And this work has great potential to help many, many people. Will thie the present explanations hold up? As for all research, time and more research will tell. But it is a terrific voyage, this search for mechanism in a long-observed phenomenon. 

Avatar of: S abdelmagid

S abdelmagid

Posts: 1

May 18, 2013

Awesome. It is always exciting when you see the publics interested in what we do. This animal model definitely helped scientists to investigate musculoskeletal injury on the bench and we will continue to explore it and find out therapeutic modalities that could treat or will at least improve the life quality of patients with work-related musculoskeletal injuries. We are all excited about it.

Avatar of: BeckyOTR

BeckyOTR

Posts: 1

May 20, 2013

Seriously?

Ah, have you never heard of Myofascial Pain Syndrome? Your whole article talks about what a new area of research this is. You couldn't be farther from the truth. Myofascial tissue has been researched extensively since at least the 1950's

You may also want to look into the work of Janet G Travell (JFK's back doctor). Along with David Simons she wrote a little two volume set titled "Myofascial Pain and Dysfuntion: The Trigger Point Manual". 

A simple google search of "myofascial pain acupunture" gave me about 300,000 results. PubMed search of "myofascial pain" gave me over 2000 results. It even has been studied by Acupuncturists <gasp>.

 

Avatar of: Collin Stoll

Collin Stoll

Posts: 1

May 24, 2013

Interesting article, although Langevin's use of George Soulie de Morant's mythological term "meridian" reveals a common misunderstanding since the 1920's by western medical science and healing arts and popular culture of the historical and functional understanding of Acupuncture and Chinese medicine.  In China, Japan, Korea and the majority of Acupuncturist in the world acupunture points or zones are found along mai most commonly translated by philologists as channels or vessels.  Also the term Qi or "Chi" does not mean some mysterious energy. The more accurate historical context and distinctions are well documented in Donald Kendall's Dao of Chinese Medicine and Wang Ju ye's Applied Channel Theory In Chinese Medicine . I refer the naysayers of acupunture with unbound intellectually curiosity and fortitude to read the books above before commenting with absolute certainty.  Also you may find the beautifully filmed Strolling Under The Skin by Dr. Jean Claude Guimberteau interesting.

Avatar of: jnd

jnd

Posts: 1

June 20, 2013

We have yet to determine that acupuncture actually relieves pain, so it seems a bit premature to provide a mechanism of action to a process that has no action.

David Colquhoun and Steven Novella have written an excellent article ”Acupuncture is Theatrical Placebo” at http://www.anesthesia-analgesia.org/content/116/6/1360.full.

My initial impression is that the author may be describing the body trying to isolate and wall off a foreign body which may survive occam's razor better than the sugested effect.

Avatar of: meganket

meganket

Posts: 1

July 20, 2013

This is so well written and interesting. So many things I've gone through make more sense now. You are eloquent and brilliant! Thank you for sharing this knowledge.
Avatar of: Perth MFR

Perth MFR

Posts: 1

August 12, 2013

Thank you for sharing this information. You may also be interested in Dr. Paul Standley's research at Arizona State University which has shown that the there are key reasons why gentle, sustained pressure is critical in treating restrictions, tightness, and pain in the body. Dr. Standley's research has shown that sustained pressure into restricted connective tissue for 3 minutes starts to stimulate interleukin production, a crystalline communication protein essential for healing. At 5 minutes of sustained pressure, interleukin levels double. The result? Free radicals associated with the inflammatory process are neutralized and blood cell production is stimulated.  Through science, we know that we can elicit anti-inflammatory capabilities from within using sustained hands-on pressure into the connective tissue. The only form of myofascial release that involves sustained, gentle pressure into the connective tissue is the John F. Barnes approach. He teaches based on years of clinical experience and having trained more than 75,000 practitioners, that the connective tissue ground substance “melts” through phase change with heat and sustained hands-on pressure on dry skin due to the piezoelectric effect. This allows the fascia, or connective tissue, to elongate and open up to allow reduced pressure on pain-sensitive structures throughout the body for improved posture, functional mobility, and fluidity. More information on John and his work can be found at www.myofascialrelease.com.

Avatar of: DukeAbbaddon

DukeAbbaddon

Posts: 1

September 19, 2013

fantastic work :-)

intuition becomes fact ...

you can also remember that one of the early muscle and nerve models ever made was in china , if you remember the photographs of the statues

Avatar of: deZengo

deZengo

Posts: 1

November 26, 2013

Great article.  I would like to request that we give credit to the photographer of the photo :  his name & contact info is :

Steve Jacobs - https://www.facebook.com/steve.jacobs.56884

 

Thank you in advance for your assistance in this matter.

deZengo M

Avatar of: SBM

SBM

Posts: 1

June 8, 2014

Fascinating article!  I wonder if the auther has studied or interested in Ehlers Danlos Syndrome?

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