In response to “Fascia Science: Stretching the power of manual therapy – by Dr. Greg Lehman”
A few days ago Dr. Greg Lehman of TheBodyMechanic.ca posted a great article challenging some of the tenants of fascial release therapy. I was asked to comment on this article….most of which I could not have agreed with more. There are some components where we have a differing view of the current state of scientific knowledge. Some of these points are discussed in my comment below. Although a long winded comment…there is much more to discuss. What you see below is just what came to me off the top of my head (and therefore please excuse any grammatical errors)
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Hey Greg
As always you have provided a clear and concise argument that is stimulating and thought provoking. Excellent post.
While I can honestly say that I agree with most of your thought process, as per our earlier discussion, here are some alternative angles forged out of my humble opinion.
First off, the term ‘fascia’ has been utilized, as of late, to represent ALL tissue in the body which is not “muscle.” Let us first realize that fascia is but one form of a more broad category of tissues – Connective Tissues (CT) (one of the 4 main tissues in the human form). Other forms of CT including bone, tendon, capsule, blood vessel, ligament, cartilage, 80% of nerve structure, etc. The inherent defining feature of this tissue form is the precursor cell, Fibroblasts, serving to produce and secrete its definitive features of cells, fibers, & ground substance. Each of the aforementioned CT derive from a derivitive of a Fibroblast. Tenocytes produce tendons, Osteoblasts produce bone, Chondroblasts produce collagen, etc. I mention this fact to support a later argument of Fibroblastic responses to load induction.
Speaking to the ‘myth’ of palpating “adhesions,” I could not agree with you more. First off, and ‘adhesion’ implies a singular piece of tissue that would by definition ‘adhere’ one structure to another. The only component of connective tissue that would be capable of such a feat would be a collagen fiber. I find it very difficult to believe that anyone (including myself who teaches soft tissue palpation around the world) can honestly claim to be able to palpate a piece of collagen (nor any other individual protein molecule for that matter). Thus the concept of adhesion palpation is simply not logical, nor possible.
Contemplating a more realistic ‘target,’ and area of multiple ‘adhesions’ would be referring to an area of fibrotic development (fibrosis….scar tissue). In your article you note that if what people are claiming to treat is scar tissue “than there is no way you are breaking it up with your hands. Not possible. Surgeons use knives for this.” Further you note that if it is “stickiness” between tissues that we are looking/feeling for than “Don’t worry about it. When you move, warm up, strength train it will go away.” I feel that here, assuming that the definitive conclusions made were at least in part for artistic effect, you may be missing a key point. If we can agree that fibrosis can develop (see for example surgical case reports on ‘Hamstring Syndrome’), then it most definitely does not develop all at once. Thus there must exist a continuum between fibrosis that is amendable to simple movement (warm up, strength training, etc) that that which requires the assistance of a scalpel. I believe that at least is theory, it is this in between state of fibrotic development/maturity that the target may lie.
Even when considering the above concept, we would still be correct on questioning whether or not said fibrosis is in fact palpable, to which my conclusion would still be “probably not.” In my seminars I have omitted that concept of palpating for scarring or fibrosis as there is no real way to create an objective outcome measure in my own mind whilst treating. In other words, I have never been able to feel a difference pre and post treatment when for example feeling for the popular “grittyness” often quoted as representing scar tissue. This is a problem because without a treatment focused outcome measure how do you know what to treat, when to treat, and when treatment is done? I speak to this point in the following blog post which examines some of the most commonly sited treatment oriented outcome measures like pain, ROM, “grittness”, etc. To summarize, none hold up to scrutiny….my personal fav is the ‘bumpy’ feeling felt under what you termed “kitchen utensils” (instrument assisted techniques)…for some strange reason people have forgotten the fact that there are supposed to be bumps under the skin in the subcutaneous layer…they represent pockets of fat separated into fascial pockets (fascia superficialis).
In my personal practice, as well as in my seminars, I encourage/teach to palpate for “aberrant tension” which can be defined as “Tension felt in tissue DURING motion WITHIN the NORMAL range of motion across a particular articulation.” Now the explaination…..At the end range of any motion one would palpate the rapid onset of “tension” which would mark the motion’s end point. This tension can be thought of as ‘negative’ force which is in direct contrast to the motion which is being performed. Of course the end range tension is normal….without it we would be ‘Gumby.” However, if in a particular portion of a tissue being moved, this tension is palpated before the end range, then one can logically conclude that whatever is causing this negative force is directly impeding said motion. What is creating this negative force, fibrosis offers an interesting, and at least theoretically defensible candidate. In clinical practice I have noticed that treatment (in my case in the form of Functional Range Release technique) is able to eliminate this aberrant line of tension (at least temporarily) thus removing a force that is countering the main goal of efficient, flowing motion/movement. This finding then provides an opportunity to then apply internal loading parameters (exercise) with the intent on inducing progressive adaptation to said tissue to solidify normal motion. To this point, I believe that we can both agree that based on the available research, internal loading in the form of exercise can in fact induce such adaptations….which brings me to my next point below.
I believe that where your main question lies is whether or not the application of external loads can create the same cascade of events that are known to occur with the application of internal loads…namely progressive adaptation. To this point we agree on several things such as the fact that ‘rubbing’ or ‘rolling out’ the skin will not produce any significant tissue loading. To expand on this point please see this blog post that I wrote not too long ago:
However, in a stretched tissue, I would argue that the application of an external load would indeed translate into an internal load in the tissues simply due to the ‘bowing’ effect. IOW – when compressing a tissue being stretched you are physically increasing said stretch under your contact finger by creating a bowing effect. By increasing a focal point of stretch, one could theoretically justify that they are deforming connective tissues and if held long enough, are inducing cellular responses that are known to occur with internal loading applications. This leads into my next point below.
“Mechanotransduction refers to the many mechanisms by which cells convert mechanical stimulus into chemical activity.” Absolutely true! When considering research in the field of molecular biophysics we learn that many cellular processes/responses such as growth, differentiation, polarity, motility, contractility, and even programmed cell death are all influenced by physical distortion of cells through their extracellular matrix (ECM) adhesions. To add to this, cells have traditionally been though of as tensioned bags of liquid ‘protoplasm’ housing a central nucleus in which chemical mediators ‘float’ as they undergo reactions vital for cell function. However…many enzymes & substrates that mediate protein synthesis, glycolysis & signal transduction are actually IMMOBILZED on insoluble networks within the cytoskeleton. Even regulatory molecules involved in DNA synth. & RNA processing are also ‘held’ in the nucleus scaffold. At the tissue level, growth factors & tissue-remodeling enzymes are similarly immobilized on insoluble ECM scaffolds or on the external surface of transmembrane ECM receptors. All of this creates what is now referred to as “Solid-State Biochemistry.” Put more simply, the application of physical load on cells will translate into chemical responses. When considering this in the context of Tensegrity…ie. The fact that all cells are connected to all other cells via membrane proteins (e.x. Integrins), tissue cells make intimate connections with the surrounding matrix such that perturbations of tissue fibers can be ‘felt’ by each cell. Extracellular connections are known to continue into the cell by way of cytoskeletal filaments (microtubules, microfilaments, intermediate filaments, etc)…..even into the nucleus itself which is itself a tensegrity structure….and even further as RNA & DNA molecules are all thought to be prestressed tensegrity structures (Ingber, 1998; Ingber, 2000; Farell et al. 2002). Thus any tissue/cellular deformation will in the very least be ‘perceived’ in cells removed from the actual point of the original deforming stimulus (via cell-cell signaling). Any stress on cells far removed will lead to chemical and/or structural change. Said change may theoretically be on a scale that we are not yet able to test…and thus we, as you note, test for FORCE as you outline in your commentary regarding the TL fascia.
To make a long story short, just because our instruments cannot measure the resultant change in cells removed from the source of the loading, we cannot conclude that no changes are occurring. In fact, due to the structure of the intercellular communications, we should assume that said connections are there for a reason…..
Bringing me to my next point…..In Theoretical Physics work, there is value, when research is unavailable or impossible to conduct on a particular topic, to the assumption that if a framework is present…it must be present for a reason. Thus I personally find it hard to believe the evolution has created such intimate cellular connections, as well as celluar responses to minute physical distortions, if there was no intent on utilizing said connections. Thus I would theorize that although we cannot ‘feel the force’ very far ‘down stream,’ the fact that the lattice work is present leads me to believe that physical distortions do in fact lead to chemical processes removed from the application that are yet undetermined. This might explain the clinical evidence offered by VARIOUS practitioners that work in a distal area can have an effect on the painful area — of course we all know that in absence of direct research, such clinical evidence does constitute BEST evidence.
Regarding your distinction of “muscle” vs other. “What is more responsive to change? Muscle or fascial connective tissue? Why muscle of course.” I can’t say that I can personally make a distinction between “muscle” and “fascia” and I am sure that may anatomists would agree. After all, what is muscle? It is simply contractile proteins (actin, myosin, etc.) with an innervating motor neuron….wrapped in connective tissue. To say that muscle is more responsive means that you are dividing a “muscle” into its “muscle” and “non-muscle” components…..namely fascia…and muscle??? I don’t know that such a distinction can be made. I also question weather we can make a definitive conclusion that one component is ‘more reactive’ than another. Perhaps we can say that with the outcome measures, and measuring instruments that we utilize one is more responsive at best.
Speaking to the section where you ask “and why do we get adhesions? Sure, we can get scar tissue after some major trauma or surgery. But why would we get adhesions with regular working out.” Further that this would be “a shitty evolutionary adaptation.” Well, when contemplating the Darwinian order of things…we do have to consider that fact that the evolution of technology and consciousness is far faster than that of physical adaptation. As I often tell my patients, our bodies still think that we are in the woods hunting and gathering our food….they don’t understand sitting at a computer for 8 hours per day, nor driving posture, sitting in a bath for prolonged periods….etc. Further, the inflammation response could also be considered a shitty evolutionary adaptation – for example the fact that spraining a tiny ligament like the ATFL can lead to such a long, painful, over drawn response. I have to disagree with your point here simply because of the fact that it is well known in the study of evolution that adaptations are said to accomplish a goal…however the adaptation DOES NOT have to be, nor is it in many, many situations, optimal.
Regarding the sexy “Myofascial Lines”…..I agree 100%. If we say that fascia goes “everywhere” in the body making a body-wide connective signaling structure…how can we then on the other hand say that they follow distinct lines? This makes little to no sense. When I am teaching my seminar participants, I encourage them to feel for lines of tension where ever they go….not along pre-determined paths as outlined by someone who purposefully cut them out with the sharp blade of a scalpel. Further, as I tweeted in the past:
@DrAndreoSpina: Anatomy dictates function…but function dictates anatomy
IOW – physical adapations to tissue will result from usage…and thus your “fascial lines” and my “fascial lines” would be different upon close inspection. Further, the fascial lines of a gymnast would be different from that of a hockey player due to the fact that they will stress different areas over the long term and thus cause different fascial adaptations to imposed demands.
ANYWAY….I am sure I can go on….actually I am just noticing that this short commentary is not so ‘short’ and for that I apologize. I also apologize for any grammar issues, or my traing of thought jumping around because I literally just sat down and began writing off the top of my head and did not stop until………………..now.
Greg, we need more people like you my friend. I hope that what I offered above will at least stimulate some more thought into the matter. Much of it is theoretical I know…some philosophical…..but great philosophy always precedes great science.
Take care my friend….we will do lunch soon. I leave you with a quote…from myself (the narcissist)
“Some think outside the box because they lack understanding of what’s in it. Others use what’s in it to make the box bigger”
Dr. Andreo Spina
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