Fascia Science: Stretching the power of manual therapy.
Purpose: Fascia is everywhere, provides a fantastic structural support for the body and has the ability to transmit force from force generating muscles. But we as therapists tend to get ahead of ourselves and make statements about treatments and the body's function that I am not sure make sense and haven't made sense for the past decade that I've questioned it.
The fascial treatment fallacy.
Fascia is laid out everywhere in the body... we can even use some sharp scissors to dissect it in such a way to create lines of fascia that show how muscles that follow a limb or the trunk are connected. We can even give these lines names and call them trains. I think this stuff is really neat. But then we go and suggest that we can actually influence that line with our hands or some tool. Without a doubt I would support the idea that strength training tensions this connective tissue and we would expect adaptations in the fascia. Super, nothing new there. But then we might get in trouble with what we say we can and should do with manual therapy. Two examples...
Two examples of things I wish were true but probably aren't when it comes to fascia therapy
1. If we "rub, pin, release, contact, shear or roll-out" fascia while pressing our digits/utensils against the skin we can somehow modify fascia.
We also assume that if we palpate the skin we can find "restrictions, adhesions or scar tissue" in the fascia. As if the normal response to activities of daily living or strength training is to build "restrictions, adhesions or scar tissue" in this important connective tissue. Why do we think that rubbing through skin will somehow make fascia change? How is this even possible? Does mechanotransduction work this way? Mechanotransduction is typically meant to refer to how the forces produced within body (e.g strength training) might yield some biological changes in tissues.
But rubbing on skin and hoping that this is influencing fascia is not the same as strength training. No one would suggest that if you rub a muscle it will hypertrophy and become stronger. Yet, we postulate a theory of mechanotransduction to influence fascia that no one would even consider if we applied it to muscle. And what is more responsive to change? Muscle or fascial connective tissue? Why muscle of course. So the more responsive tissue to mechanotranduction would not get stronger after your rub it but fascia, the less responsive soft tissue, will naturally warp and bend to your genius hand wishes. Makes sense to me.
2. If you have pain in one part of the body you have to follow that fascial line/link/chain/train and treat the whole thing.
Lets forget about the questionable possibility of even influencing the mechanical properties of fascia with your hands (if you talk neural properties of the nervous system I will listen) lets just look at the idea that everything is connected and you need to treat that bloody chain. I have two biomechanical questions/issues with this:
a. Why just follow that fascial line that you read about in a book? Fascia seems to be continuous and some brighter than I anatomist even suggests that our fascial lines are just arbitrarily created during dissection (link here). For example, if you have a patient with bicep pain someone might tell you that you have to treat the entire anterior arm line because it is "all connected". But with fascia I was under the impression that we really know that it is all connected and if you follow this reasoning you should just treat everything around the arm. And why stop there, just treat the whole body since it is one fascial web. Again, this assumes that you can influence it. Good luck.
b. So you have picked the fascial line that you want to treat. You've been told that the problem in the biceps could be coming from some "problem/restriction/adhesion" in the fascial line somewhere down or up the chain. Lets assume you even have some reliable way of detecting this. How would a fascial dysfunction 30 cm away from the biceps pain mechanically influence that biceps? I am not talking about regional interdependence when you can make a case based on link segment mechanics. I am talking about the fascial "butterfly effect" which assumes you will be treating dysfunction down the fascial chain because of some "dysfunction" up stream. I don't know how this works. From the studies that have actually looked at the force transmission of fascia and how different muscles seem linked through fascia (e.g the glutmax and opposite latissimus dorsi) we know that the force transmission along these fascial lines is minimal and only transmits force a few centimeters. Therefore a dysfunction up the chain has limited biomechanical reach. Lets look at the thoracodorsal fascial research in greater detail. Because one, it will illustrate my point and two, it is very cool research. See, I don't hate fascia. I think its amazing. Its how we extend our reach in our explanations that I hold issue with.
Thoracadorsal fascia - how far can the effects of tension be seen
The thoracolumbar fascia partially links the gluteus maximus with the contralateral latissimus dorsi. Fascially fantastic! Vleeming (1995) did some very interesting cadaver dissections and then pulled on different parts of those dead bodies to show that movement occurred elsewhere in the body. Neat-O. First, lets looks at this beautiful study and some related research.
The Vleeming study showed us how different muscles attach to the superficial layer of the thoracodorsal fascial. Contracting these muscles will then tension the fascia and the authors propose that this leads to increases in stability. The authors looked at what would happen when they tractioned different muscles to the movement in the superficial fascia. They found the following displacements in the superficial lamina:
- tug on lat dorsi and get homolateral movement of 2-4 cm
- tug on the caudal part of the lat dorsi and get midline displacement of 8-10 cm
-traction of the glut max and get some movement of 4 to 7 cm
-traction the trapezius and you're lucky to get 2 cm of displacement
Stretching the clinical relevance of this research
This wonderful research shows how limited the fascial reach is. The largest change was only seen 10 cm (4 inches) downstream. Your wife might think four inches is big but that's an illusion dude. Even if you think biomechanics of fascia is important the biomechanical research suggests that it is not.
Where I believe these clinical observations become extended too far is when we make claims that this link between the two muscles (and muscles or joints further down this extended chain) and the possible implications for dysfunction are somehow more robust than they are. The research above shows a minor connection between the two muscles where tugging on one muscle lead to a small amount of strain 7-10 cm at a distance from where the tug started. This is interesting but maybe we run a little too far with this in our clinical application. Tugging on the glutes did not cause the shoulder to extend. Yet, if you are a fly on the wall in a clinic this is what you will hear. Nor does any other work suggest that dysfunction in one muscle will lead to dysfunction in the other muscle along its entire length and how that muscle works. Yet, that is how this research is extended. At its simplest some guru will tell you that "it is all connected" so they ended up rubbing the butt of someone with shoulder pain and this study or Anatomy Trains will be held up as the "scientific reasoning".
As for function...yes we will see the Lats fire at the same time as the opposite glutes during some activities (not really walking but running). But does this mean that the fascia is the communication system linking the two and that there is a special relationship between two? I would suggest that there is a special relationship between the glutes and ALL the muscles of the trunk that are involved in spinal rotation not just the lats. But because we have this interesting fascial link between the two and pretty pictures we put a greater emphasis on the lats:glutes relationship rather than the glutes:erector spine or glutes:obliques relationship. These aren't linked in a beautiful fascial manner but they sure are linked functionally.
One big issue with fascia - What is the dysfunction?
Adhesions, adhesions, scar tissue, scar tissue, restrictions, restrictions. I have heard this for over a decade and I still don't get it. The use of the word "adhesion" sounds identical to the use of the word "subluxations" in chiropractic land. Believe it or not there is more research behind subluxation than there is behind an adhesion. I don't know what an adhesion is. It makes no sense. If it is scar tissue than there is no way you are breaking it up with your hands. Not possible. Surgeons use knives for this. Is it some stickiness between tissues. Well don't worry about it. When you move, warm up, strength train it will go away. Welcome to viscosity land.
And why do we get adhesions? Sure, we can get scar tissue after some major trauma or surgery. But why would be get adhesions with regular working out. And this is what we hear. We hear that adhesions follow because of microtrauma. You know the same microtrauma that we create everytime we work out. The same microtrauma that causes us to adapt, get stronger, jump higher, have a better immune system, stronger bones, denser tendons, better functioning nervous system. But somehow this wonderful tissue stress causes the Hobgoblin "Adhesion". This makes no sense. What a shitty evolutionary adaptation. So those fit, strong, healthy people who have never had any "body work" must be riddled with adhesions. Poor souls.
Recap of salient points
1. Is it reasonable that activities of daiy living or strength training result in "adhesion or scar tissue formation" in fascia. Is the body that stupid?
2. By what means can your hands actually mold, shape or cause some change in fascia? Why can't they do this in muscle - the far more responsive tissue to stress.
3. If fascia is everywhere and connects everything why should you let your treatment be guided by arbitrary lines of fascia?
4. The reach of fascia is limited. While structures may be connected biomechanical studies show that displacement along a fascial line may only be 10 cm maximum
I'm open minded: please change me
I would like nothing better than to say with confidence that my hands are breaking down adhesions and that these fascial chains are relevant in manual therapy. This is a beautiful model and easy to explain to patients. I would also love to write about "the four best exercises to prevent low back pain" but both of these wishes just seem to be made of fairy dust. So, if you have some research that addresses two areas I would love to see it. My two wishes:
1. Any work showing the existence of an adhesion and how this relates to pain or dysfunction (The langevin study on the back is not an adhesion)
2. Once you find an adhesion show some work that shows that you can manually change this fascial adhesion
Treatment away from the location that a patient feels pain can be justified. "Fascial" treatments can also 'work". But they probably work for different reasons than what we attempt to justify with molding fascia with our hands. So to conclude I am not Knocking any results that people get with their treatment. A lot of fantastic therapists explain their treatments with this model. What I am questioning is the model itself. I want a better model.
This just in...
just read a link to Paul Ingraham's (at saveyourself.ca) further insights on fascia with Dr. Schleip at Paul's site here: This stuff is great and suggests that I'm saying nothing that is really that new....http://saveyourself.ca/blog/0415.php
Alice Sanvito has a great blog post on this similar topic. Also read her comment section where good questions are posed and she responds quite well.
Some related links (if you have interesting links please let me know)
7. Dr. Andreo Spina from Functiona lAnatomic Palpation Systems writes a detailed comment in the comments section below. Please have a look. Dr Spina was also kind enough to post his comments as a blog post on his own website. I think his comments are a great standalone post worthy of discussing so have a look there.