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A detailed critical analysis of the clinical relevance of fascia science and fascia properties
8,500 words, updated Aug 30th, 2012 Whats new?
by Paul Ingraham, Vancouver, Canada
SHOW SUMMARY Fascia therapy and science are considered an exciting frontier in massage
and manual therapy, with well-attended fascia conferences featuring rock star gurus in the
massage world. The main idea is that fascia tough connective tissue wrapping around all
muscles and organs can get tight and restrictive, and needs to be released by pulling on
it artfully. Unfortunately, although fascia science may be inherently interesting as biology, no
property of fascia has yet been shown to be clinically relevant. No fascial pathology seems
to be a factor in any common painful problem, and no method of fascial manipulation is
known to fix fascia or even change it.
I have challenged readers to cite clinically relevant fascia science. This article reviews three
good examples: studies about fascias toughness, its contractility, and its fibroblasts. None
confirm any clinical relevance of fascia, and one actually undermines it, showing that fascia
is too tough to release. I also discuss the irrelevance of piezoelectricity, and contradict Gil
Hedleys popular fascial fuzz theory of stiffness. The article criticizes fascia excitement
from a scientific perspective.
Introduction
ZOOM
Deja vu? Feel like youve seen this here before? You probably have. This is a like new
compilation of most of the fascia writing Ive done over the last year about four old
articles merged into one, with some re-writing and new information. You can now buy a $5
lecture version from Movement Lectures.
TABLE OF CONTENTS
1.
Introduction
4.
9.
Fascia enthusiasts routinely denounce this article, accusing me of ignorance of the current
Science of Fascia. Thats understandable. However, I am pretty up on massage-related
research its my full-time job so I feel confident challenging critics to cite even one
example of fascia research with clear, direct relevance to what happens in treatment. If such
a thing exists, I will be happy to publicly discuss it, and acknowledge my oversight. I could
be wrong about fascia. I even hope that I am. Maybe it is important to manipulate fascia
specifically.
This article covers three main examples of allegedly clinically relevant fascia research below.
(That may not sound like much, but the article is already several thousand words long, so be
careful what you wish for.) I will add more in time. All three are actually good examples of
fascia science with poor clinical relevance. We do not have a winner yet.
Before we get to that, though, Id like to start with a couple stranger examples of sloppy
fascia science piezoelectricity and fuzz and some of the general issues with fascial
therapy.
There is a crack in everything
Thats how the light gets in.
Leonard Cohen,
Anthem
PART 2
SLOPPY FASCIA REASONING
Electrified by piezoelectricity
A popular notion is that piezoelectric effect charge generated by flexing crystals is at
work in fascia. It is hardly clear that this is actually the case. However, even if we took it as a
fact, in what way is it at work? Do we know the physiological intricacies of that
phenomenon? Do we know why it evolved? What it does, how it does it? Can we affect it?
And, if we dont know these things, how can we possibly use it to devise a reliable therapy?
Obviously we cannot.
Is this a straw man? Nope. A straw man would be an idea that no one actually believes or
takes seriously and therefore meaningless to criticize. Certainly not everyone interested in
fascia thinks that fascial piezeoelectricity is real or important. However, enough do that its
no straw man! It may not represent the best thinking in the field, but it is certainly out there.
Piezoelectricity is barely mentioned in connection with fascia in the scientific literature.
Fascia is not discussed at all not even as a controversial concept in the Wikipedia page
on piezoelectricity, while other biological exploitations of the effect are mentioned.3 This
doesnt mean that there is no piezoelectric effect in fascia. But if there is, its a poorly
understood and exotic phenomenon, at best.
For contrast, consider the known example of piezoelectricity in bone: its well-documented
that piezoelectric effect is used as a way of guiding bone remodelling in response to
stresses,4 which is super cool. Its a terribly clever system!
Its also a terribly good example of a clinically irrelevant biological property. It has nothing to
do with anything a manual therapist could ever do to a bone. It is beautifully evolved to
change bone extremely slowly in response to extremely specific stimuli which, presumably,
cannot remotely be simulated by manual therapy. Trying to affect that system with your
hands would be quite futile, I think. And that is going to be the case for the great majority of
physiological systems, known and unknown even if you understand them, it doesnt mean
you can use them, or affect them with your hands.
Another fine example of imprecise scientific enthusiasm is Gil Hedleys extremely popular
fuzz speech. In this video with a bazillon views, Hedley plays fast and loose with a
dissection observation: there are cobwebby layers of fine, loose connective tissue between
thicker sheets of fascia. The anatomy is interesting anatomy is always interesting but
Gil Hedleys interpretations are dubious. His leaps of logic are charismatic, but also large and
precarious.
That stiff feeling you have is the solidifying of the fuzz, Hedley confidently explains. He
thoroughly makes the case that fuzz explains the sensation of stiffness.
At best, that is an unsafe assumption, and one that ignores many other highly relevant
factors like neurology, say, or the fact that hes looking at a dead person. He does not
know what happens to that tissue in a living body. In fact, that fuzzy texture only manifests
post mortem according to biotensegrity expert, Dr. Steven Levin.5 This is a very
interesting passage, worth reading carefully, but note the emphasized phrase particularly:
In Guimberteaus video, Strolling Under The Skin, what you see there is that the fuzzy
stuff is really dynamic tissue that is under constant change. Tissues dont slide, there is no
shear, they reconfigure with each movement. The dynamics of a cell ceases with death.
Ca++ [calcium ions] flood into the cell and it stiffens thats rigor mortis. It starts within
minutes of death, as soon as the circulating ATP [energy molecule] runs out. The fuzz is
connective tissue that is stiffened during rigor mortis, and it doesnt happen unless you
die. It occurs within minutes of death, and you can almost watch it happen. It is like snot
hardening. The mucus booger that comes out of your nose quickly hardens and becomes
quite stiff; at death, the mucus that connects all our tissues, does the same.
All that melting the fuzz is conjecture based on misinterpreted observations on dead tissue.
Even so called fresh cadavers are but poor players in the game of life.
Almost any amount of normal movement is sufficient to sustain a normal range of motion.
Fuzz solidification either isnt happening or doesnt matter, because its effortless to move
through. Also, there are other explanations for the sensation of stiffness: better, evidencebased, and un-fuzzy explanations. I discuss them in some detail in Quite a Stretch.
SY Does Acupuncture Work for Pain? A review of modern acupuncture evidence and
myths, particularly with regards to treating low back pain and other common pain problems
PART 3
REAL FASCIA SCIENCE THAT SUPPOSEDLY
MATTERS
This is a test tube study showing that naked cells handled stress better (fewer signs of harm)
if they were treated with simulated myofascial release (MFR). A meaningful, accurate
simulation of manual therapy on naked cells is an amusing notion, and its clear that what
happened to those cells differs dramatically from what would happen in a real living body.
Even if true and reproducible, this data would mainly support the rationale for MFR
specifically for post-exercise soreness something of a dead end for clinical relevance,
because exercise-induced soreness has little to do with the main claims of fascial release
therapy, which primarily concerns correcting postural asymmetries, eliminating alleged
restrictions, and treating chronic pain.
Post-exercise soreness is comparatively trivial, and patients usually dont seek therapy for
it.13 Theres a lot of research showing that exercise-induced soreness is basically invincible
anyway.14 A meaningful, accurate simulation of manual therapy on naked cells is an
amusing notion.For this property of fascia to be clinically relevant, it would have to imply
that MFR might be able to treat chronic pain from other causes not the transient
annoyance of soreness after a game of soccer.
This isnt a rejection of all possible clinical relevance of the data. My point is that there are
so many problems that its relevance is watered down to quite a thin sauce way too thin.
I do concede that the paper shows some evidence that fibroblasts have interesting and
perhaps positive responses to mechanical forces. That is inherently interesting biology, and
perhaps well worth investigating further but its a long reach to postulate any clinical
relevance to what most therapists do, most of the time, with patients fascia.
Reach is what the authors do, however. I suspect they are deeply interested in validating
the notion that fascia is important, because they seem to be seeking evidence to support
their pre-conceptions typical of The National Center for Complementary and Alternative
Medicine-funded research, and a hallmark of low quality science. Its quite likely that if
neutral researchers with no interest in fascial therapy did this experiment they would
not get or report the same results.
Schleip and colleagues convincingly showed that fascia contains muscle cells and that they
can contract slowly and weakly. That is undeniably interesting biology! But the point of
this analysis is to ask: Does it even matter whether its right or wrong? Is it clinically
relevant? Does it improve how we do therapy? Can we use the knowledge to affect the body
with hands? That is the question.
It is also a question that Dr. Schleip and his colleagues have addressed themelves on their
website, FasciaResearch.de. What follows is my own analysis, which is generally consistent
with theirs. However, interested readers should definitely have a look at their article: it is
readable and chock full of useful perspective, answering questions like Does fascia contract
in response to emotional stress? and Can fascia contract on its own?
Fascia Contractility FAQ, a webpage on www.fasciaresearch.de.
Important update: Dr. Schleip has read this article and corresponded with me about it
amiably, and expressed clear agreement with my main point. Although he also had some
thoughtful criticisms, we agree on what matters, and he shares my frustration with clinical
overconfidence in fascia. I invited him to make a statement for my readers about this: look
for it at the end of this part of the discussion.
Perspective
By any measure, fascial contractions are dramatically less
powerful than muscular contractions. If anything, this
diagram gives far too much credit to the power of fascia,
which would barely register at all if depicted
more accurately.
Its certainly not difficult research to understand.
Some important context that fascia fans will appreciate: for a long time, fascia was and often
still is incorrectly thought of as a fairly lifeless, inert substance, the Saran Wrap of biology. I
still hear various educated people referring to it in this way. However, massage therapists
and chiropractors (in particular) are prone to swinging to the opposite extreme and talking
about fascia as though it is more interesting than a lifetime subscription to National
Geographic. The truth is somewhere in the middle.16 Dr. Schleips research demonstrates
this. Fascia is not inert.
But neither is it all that lively at least not in terms of contractility. We are not talking about
a lot of muscle cells here. If you had blueberries with your cereal in the same proportion,
youd be disappointed not enough blueberries! Its just a few muscle cells scattered
throughout the fascia. Theres so few that they are visible only when you look very closely
and in just the right way.
Nor are we talking about particularly strong contractions. Fascia isnt going to be ripping
apart any chains with its bare hands. The maximum force generated by a small bundle of
contractile rat fascia was around 35mN.17 In plain English thats not very dang much or
the somewhat more precise about what it takes to set an AA battery rolling on a nice
smooth surface. (It took me a long time to work that out. I have a weird job.) Thats not bad
for a bundle of rat fascia, perhaps, but it doesnt really hold a candle to middle-of-the-night
charlie horses either.
Compared to the power of muscle contraction, fascia power barely even registers.
The bull versus mouse comparison is a little unfair though, because its not just a matter
of strong versus weak. Although fascial contractions may be weak compared to muscles,
they could nevertheless be powerful in another way their effects might, for instance,
accumulate over time to produce contractures (permanent seizing up of tissues). So its
still worth considering how these contractions might be clinically relevant.
The wording of the conclusions of Schleip et al.s paper is synonymous with saying that
fascial contraction is relevant only if structuralism is a useful mode for doing and thinking
about therapy. Also, their phrasing shows a strong bias in favour of the importance of
fascia. And the study was funded by the International Society of Biomechanics, the Rolf
Institute of Structural Integration, and the European Rolfing Association.23
Weak, slow fascial contractions strike me as being scientifically valid and interesting, but
clinically minor. Once again, far from making me interested in fascia as a target for therapy,
fascia science is convincing me of just the opposite.
of the same. There are probably some subtle differences, but they are subtle and arcane and
ultimately just a slight variation on the biological theme of muscularity. Im not saying its
completely uninteresting, but its overshadowed by the much more interesting muscular
system as a whole, about which fascia is simply a mildly intriguing subtopic. And, in terms of
clinical relevance, the muscular system itself is in turn overshadowed by neurology.
Piezeoelectricity may occur in fascia, but its clinical relevance is nil not
enough is known about it to even speculate about how it could be exploited in
manual therapy.
To be continued
There is more fascia science, and I will extend this article with more analysis in the future. I
honestly hope that there is clinically relevant fascia science that would be terrific. So far,
however, I see no good reason for therapists to be fascinated by fascia and to make it a
target tissue.
Other alleged fascial properties and clinical relevance issues I intend to address eventually
(definitely not a complete list):
The claim that fascia contains memories in some sense. I will likely dispute both
the property and its relevance.
PART 5
APPENDICES
Further Reading
SY Your Back Is Not Out and Your Leg Length is Fine The story of the
obsession with crookedness in the physical therapies.
SY Pain is an Opinion What recent pain science can do for your chronic pain
right now. The role of the nervous system in chronic pain is the major alternative
to focussing on fascia. It has much clearer clinical relevance.
Notes
1. It is quite negative. I have fun taking therapy seriously. Criticism and
deconstruction of ideas is normal and healthy and necessary for therapy
professions to grow and change. BACK TO TEXT
4. The full details of how bone responds to stress are spelled out in Dr. Harold
Frosts Mechanostat model. For more information, see Tissue Provocation
Therapies. BACK TO TEXT
5. The quoted passage is from my personal correspondence with Dr. Levin, and is
used with his permission. For information about Dr. Levins work, see
Biotensegrity: A new way of modeling biologic forms. BACK TO TEXT
7. Ramey. Acupuncture and history: The ancient therapy thats been around for
several decades. ScienceBasedMedicine.org. 2010. BACK TO TEXT
10. Some fascial therapy is gentle, but I have personally encountered intense fascial
therapy in the wild on numerous occasions. I prefer gentler therapy and usually
request it. Despite being a confident and assertive communicator about my
preferences, I have still had many unpleasantly intense fascial therapy
experiences. BACK TO TEXT
11. According to a great many therapists. Not all, but probably most. Its spelled out
clearly by a prominent fascial therapy pioneer, Luigi Inventor of Fascial
Manipulation Stecco. This is someone who has the respect of large numbers of
fascial therapists; his thinking about how fascial therapy works can be
considered strongly representative not only of common thinking about fascial
therapy, but the bleeding edge. In a review of ther rationale for a workshop, he
repeats the basic idea of tissue stuckness in need of releasing in an impressive
array of fancier terms. This is just a small sample:
BACK TO TEXT
12. People are not bullet proof thanks to their fascia, alas wouldnt that be handy!
And yet the hyperbole is definitely true in a sense. Fascia is mostly much too
thin to actually be bulletproof. If fascia was just as thick as a Kevlar vest, it might
well be just as bulletproof (or a little more, or a little less). This is just like how
spider silk is stronger than steel cable pound for pound, it is. The catch in
the comparison is probably that Fascia probably doesnt have the same
puncture resistance property that Kevlar does. There are many kinds of
toughness (i.e. bones resist compression exceedingly well, but are quite
vulnerable to torsion). The point was simply that the research showed quite
clearly that the forces required for plastic deformation of fascia significantly
exceed what can be applied to it with hands. Whatever therapists are feeling
when they claim to detect a release, its not that. BACK TO TEXT
13. If its bad enough to think that you need help, youre also too sore to want
anyone to touch you (let alone push on you). In any case, post-exercise muscle
sorness is usually all wrapped up before patients can get to an appointment.
BACK TO TEXT
14. SY Ingraham. Delayed Onset Muscle Soreness (DOMS): The mysteries of muscle
fever, natures little tax on exercise. SaveYourself.ca. 5662 words. BACK TO
TEXT
15. Is it really surprising? Ill return to that question below. That phrasing doesnt
actually come from the paper, so you wont find it there, but from a poster they
made to summarize the paper. BACK TO TEXT
18. Id like to think I made it sound accurate, and the result just happens to be
trivial. BACK TO TEXT
19. A little personal perspective: my lovely wife has titanium in her back, installed to
stabilize a massive fracture of her T12 vertebra in 2010. Such is the toughness
of spines that the titanium fixations installed to protect her actually broke on
both sides came loose from the brackets screwed into her bones. Similarly,
severe scoliosis can twist titanium fixations like pretzels as it advances. Those
are the kinds of forces involved in the back. Fascial contractions are a miniscule
part of such impressive equations. BACK TO TEXT
20. It is also noteworthy that the contractions they described were slow motion
contractions, taking many seconds to develop at their fastest. BACK TO TEXT
21. Analogy: in the circulatory system, there are only a few gigantic blood vessels,
but countless fine and microscopic ones. The fascial system is similar: a few
large, obvious sheets of fascia, a bunch of more modest and delicate structures,
and then a nearly infinite network of extremely thin and microscopic structures.
This is why I say that we are wrapped in fascia fractally. BACK TO TEXT
22. SY Ingraham. Your Back Is Not Out and Your Leg Length is Fine: The story of
the obsession with crookedness in the physical therapies. SaveYourself.ca.
10040 words. BACK TO TEXT
23. Despite what it seems like, I am not actually accusing Schleip et al. of having
any overt or serious conflicts of interest. In general, COIs are more common and
less of a big deal in science than people think: where there is science there is
funding, such is life, and funding sources affect science in muddy, complicated
degrees ranging from not really at all to truly, madly, deeply. This seems like a
borderline case to me, somewhere on the edge of being a problem. Its safe to
say that these organizations probably would not fund or continue to fund
research that came to the opposite conclusion, i.e. not strong enough to
influence low back stability and other aspects of human biomechanics. BACK
TO TEXT
24. This is another form of what I call failing the impress me test. Usually I bring
that up to make the point that there needs to be strong evidence that
treatments works before they can be considered proven small and
temporary treatment effects should not impress anyone. In this case, though, its
the clinical relevance of fascial contractility that is failing to impress. BACK TO
TEXT
25. Schleip et al. Passive muscle stiffness may be influenced by active contractility
of intramuscular connective tissue. Medical Hypotheses. 2006.
PubMed #16209907. BACK TO TEXT
26. If youre not going to list really good, relevant examples here, where are you
going to do it? BACK TO TEXT
27. I have written quite a lot about compartment syndrome with regards to their role
in shin splints (see Save Yourself from Shin Splints!). The lower leg is by far the
most common place in the body for compartment syndromes, both in the shins
and the calf. They are more or less unheard of elsewhere in the body rare and
generally minor and self-limiting. If fascial compartments were prone to
problematic contraction, wed constantly be getting compartment syndromes
all over the body. BACK TO TEXT
28. Basically, only a fraction of the genome is for coding proteins, but that important
minority is regulated and tweaked by the rest of the non-coding DNA. So a (very
rough) analogy is that the coding DNA is like software that makes you who you
are, but the junk DNA is the operating system that it needs to run on. Not so
junky. BACK TO TEXT