Treating Disease is not an Option.

It’s understandable that when someone presents with a specific problem, we want to try and come up with solutions that aim to ‘fix’ it.

Therapy forums on Facebook often feature questions along the lines of, “I have someone coming with –insert name of disease or problem here- are there any things anyone can suggest?”

People then of course suggest things.  These suggestions may or may not be helpful, but the motivation and indeed the question itself misses an important aspect of what holistic treatment is all about.  The fundamentals of connective tissue, suggests that the connected nature of everything in the body means that the possibilities for cause and effect on a wider scale are limitless.

I am not suggesting that for example the reflexology argument that there are zones in your feet that are related to your organs is one that holds true, just that you can’t chop your feet off and leave them with someone to fix, any more than you can your kidneys.  However vaguely they are connected.

Put another way, a human body is not a car.

If tomorrow morning you try and start your car and nothing happens, there is one reason and one reason only that this has occurred.  The variables are non-existent and if you reproduced the same fault in any other car the same thing would happen.

My knowledge of mechanics is something akin to zero, but I can be pretty sure that your car malfunctioning has nothing to do with it feeling depressed, unloved or fat.

I can also be reasonably certain that the rust on the side panel, the broken wing mirror and two under inflated tyres have no impact either.  Yet this is kind of how we go about trying to treat a human.

Every human has a a history and a wealth of circumstance that will contribute to their current experience.  A huge element of the presentation of any injury or illness, particularly chronic ones, will be influenced by patterns of learned behaviour.  How much of the pain is fear based?  How much of the nausea is responsive?  How much of what we are experiencing now has roots from deep in the past?

An understanding of how someone moves might point us towards looking at ankle work for a back pain or addressing the TMJ for a knee issue.  Again my implication isn’t that there the teeth have some mystical control over the joints, but that basic load bearing function is at play on a wide scale.

The basic rule of natural treatment, is that the body be treated as a whole, without referral to named disease.

Naming diseases is pretty straightforward and, let’s face it important when it comes to being able to treat life threatening problems.  For everything else, the rules change.

Back pain is the classic example.  Our human frame experiences back pain on a huge scale, second only to mental illness for work days lost to industry.  Yet medicine, for all its ability to conduct hear transplants and brain surgery, remains stumped by a good old fashioned back pain.

The trouble is that the back is subjected to a wide number of influences.  Physical work, emotional tension and just general movement.  Muscular structures all over the body will affect and change the way we use our back and learned patterns of behaviour and movement will give us postural patterns that will limit our movements.

Our environment and social situation, even our socio economic status will help to define how we sit, move, defecate and sleep and our back will bear the brunt of whatever and however we use it.

Even when we have a specific diagnosis of a bulging disc, this is isn’t a full picture and in many situations is an example of the diagnosis hindering rather than helping; most people with a bulging disc don’t have back pain and most people with back pain don’t have a bulging disc.

So next time someone presents with something you’ve never heard of, take a step back and ask, “what’s the problem?”

The problem with the client isn’t the same as the condition they are suffering and the two shouldn’t be confused.

Collagen and Fascia, Twist and Shout!

Collagen and Fascia, Twist and Shout!

 

Twist and Shout!

When we look at or talk about anatomical structures or humans in general, it feels like sometimes that there is a disconnect between us and the rest of nature.

It’s as if the rest of the animal kingdom exists in separation to that of the human species.  Certainly we don’t seem to be ‘at one’ with our environment, as countless examples of environmental vandalism bear witness and it feels like we set ourselves aside as different or special in some way.

The  human condition strives for a desperate sense of order.  Straight lines and linear ideas rule our thinking and understanding and we cut swathes of rod like structures out of surroundings where nothing is ever in a straight line.

Nature abhors a straight line however.  In straightness there is weakness and angles that will instigate collapse more readily than support.  When we see a tree, a plant, a bush or a bird flying, we are seeing movements of spirals and curves in action.

Humans are no different.  A skeleton (as much as a skeleton exists by itself), is a myriad of curves and offset angles with thankfully absolutely no horizontals that would cause us to dislocate our joints.

The structure of the tissues that hold us together, connective issues, are prime examples of non-linear tissues.  Collagen is the most common protein in the body and the collagen fibres that form our fascia and much of our connective tissue coiled and spring like, giving our bodies the elastic recoil that allows us to absorb forces and tensions.

Collagen is a triple helix structure.  Three thin strands wind themselves together to form a spiral type structure which, when fully formed, is stronger pound for pound than steel rope.  These helices don’t follow the line of muscle travelling around the body, but instead criss cross muscle and bone in a myriad of different directions.

Where muscle has a start and an end point, the collagen based fascia doesn’t.  Overlapping standard muscle insertions, the fascia invariably carries on from the end of one muscle and into the beginning of another.

This picture shows the adductor longus fascia as it traverses the pubic symphysis and continues in to the fascia of both the rectus abdominus and external oblique.  The temptation is to assign function or meaning to this kind of continuity and whilst it can be fun to do, there is little to be gained except to appreciate fascial continuity.

Example of Fascial continuity.

Adductor Longus Fascia overlapping the pubis

This kind of relationship is not unusual in the body and is not just surface tissue either.  It dips and dives into the pockets of muscle tissue, creating divisions; ceilings and walls that give the muscle a container in which to operate.

Muscle relies entirely on fascia for its integrity. Without the fascia, the muscle would have no form and no integrity and would be unable to function.

What’s it like to attend a cadaver dissection?

I’d finally decided to do it. After a long time thinking about it and talking about it with my partner, this was it. A 6 day dissection class. With real cadavers.

Ascending the lift, I was apprehensive. I had dissected animals as part of my degree but I had never seen a cadaver, let alone used one as a teaching tool.

In a locker room, with other students, we were all quiet. Some were returners, others were, like me, new to this. After locking our phones and valuables away, and putting on our white coats, we were led into the lab.

As we walked into the lab, it was impossible not to notice all of the 5 shiny humidors that contained our bodies. The lab was large and cold, with specimens persevered in formaldehyde on workbenches.

We sat on stools in a circle, introduced ourselves and were off on an incredible journey.

Once we had discussed what was about to happen, we gloved up and were led over to the humidors, which were now open, revealing linen wrapped forms. The coverings were removed and we were invited to look carefully at each and make a choice as to the one we were drawn to work on. I chose a man – I couldn’t honestly say why. He was an elderly gentleman, well built.  He was lying face up. There was a line of stitches in his groin – the closure of the hole to get to the femoral artery to input the embalming fluid. His head was shaved and his arms and legs were freckled.

Now it was crunch time. You think about death abstractly. You know that it is the absence of life. You know that there will be no warmth. You’ve heard about rigor mortis but nothing can prepare you for actually laying your hands on an embalmed cadaver. I was, oddly, surprised by how stiff and cold it was. Note here that I say ‘it’ and not ‘he.’ My initial reaction was that whatever had made this form ‘human’ was no longer there. This thought would change as the dissection progressed.

Having been shown how to use the forceps  and scalpel, we were now asked to remove the skin. Yes, you read that correctly, remove the skin. This conjures up pictures of flaying, of Silence of the Lambs but no, it was nothing like that. Skin is attached very firmly to the superficial fascia layer beneath. At one point we had to turn the body over to remove the, much thicker, skin on the back. I now appreciate the term “dead weight.”

Many blunted scalpels later, we could look at our form without his skin – barring his hands, feet and face; the superficial fascia or adipose layer is so thin in some areas, that it takes a degree of skill to dissect it beautifully.  The colour was most shocking – yellow – especially when all 5 of the cadavers were placed side by side on their gurneys. But they were still recognisable as male or female, the rounded curves of the women, their breasts and hips given form by this superficial fascial layer.

Day 2 was the removal of this layer. It was soft and oily – a result of the fat cells breaking down as we cut through them with our scalpels. Careful not to cut too deep and hence into the deep fascia underneath, we began to peel back this blanket. One group of more experienced dissectors managed to remove the whole of the superficial layer in one go. They laid it on a gurney next to the body from which it was removed – a woman.  Apart from her genitals, she was no longer recognisable as a woman; this covering had given her form and now it was gone.

The  layer of deep fascia is one of the most difficult to dissect. It clings to the muscles, wrapping around each, separating them. It is strong, pliable, criss-crossed like a matrix and it is everywhere!

Muscles next; now we were into more familiar territory, but even this was far removed from the conventional anatomy in books like Netter or Grays. Each muscle was wrapped in superficial fascia, but when this was removed, the muscle just came apart in our hands. It made us realise that what we think of as knots in our muscles, couldn’t possibly exist. So what are we doing when we massage or treat someone as a therapist? Bearing in mind the layer of superficial fascia over the top of the muscles, are we actually doing anything to them?

Nothing about this experience is normal, yet it has become routine. On into the viscera; I held the heart in my hands, shone a light through the diaphragm, watched as the teacher used a bag to inflate the lungs, amazed as they ‘pinked up.’  One group removed the brain and the central and peripheral nervous system, laying it out like an ethereal skeleton.

And finally, when our week was done – there was not enough time I can tell you now – we laid everything in a body bag in a coffin and held a moving ceremony where we thanked the donors for what they had allowed us to see and learn. I admit, it was emotional and I shed a few tears. The camaraderie in the room had been fantastic and we had participated in something very few people have had the privilege to do. I would be back!

Evidenced Based Medicine. The Mythical Holy Grail

Evidenced Based Medicine. The Mythical Holy Grail

“Absence of evidence is not evidence of absence.” – Carl Sagan

Complementary medicine seems to some, like a dirty word.   Fuelled by some idea that all Complementary and Alternative (CAM) therapists are shamans and quacks, frothed and indignant bloggers flood cyberspace in the name of science to scoff and sneer at anything which might not be found in the annals of the BMJ, not that they have ever read it.  This is the pseudo-scientist, who happily lumps his conveniently dim witted  and proudly ‘sceptical’ views into two categories: those things that have been proven according to science and everything else which is junk, bogus and a scam, peddled by charlatans.

Generally speaking, these people represent the type of reasonably intelligent but naive buffoon, who whilst holding forth on science, perhaps even reading the summary of a paper or two, has never actually considered how you go about proving, or for that matter disproving anything scientifically.

The mistake they make is demanding that all CAM based therapies should be ‘evidenced based’ with most of them having not the slightest clue what this means, or what the comparison is.  It is a commonly accepted principle amongst most medical practitioners, nurses, surgeons and clinicians, that a big chunk of daily medical practice often has little in the way of evidence to back it up and as much as 50% of general practice work is not evidenced based.

Most of it is based on what has been always done, hunches, ‘best practice’ and so forth.  Pharmaceutical intervention fairs even less favourably and the US hosts thousands of deaths per year from drug overdoses and medical negligence.  A lot of pharmaceutical testing has hidden outcomes and there are lots involving combinations of older drugs, that just don’t get tested at all.  ‘Proof’ is not all it’s cracked up to be.

Now comes a study in the current issue of the Journal of Patient Safety that says between 210,000 and 440,000 patients each year who go to the hospital in the USA for care, suffer some type of preventable harm that contributes to their death.

The starting point for CAM therapies is to understand that however useless the sceptics might claim them to be, they tend to be generally harmless, as long as they do not attempt to convert the recipient away from their conventional treatment.  Jumping through the hoops to demonstrate efficacy is no easy matter however.  I am not for a minute supporting those who make wild claims to cure cancer with crystals, or generally talk unscientific bollocks to big up their own nonsense.  What I am saying is that there is other stuff out there that we don’t understand and that it is foolhardy and arrogant to assume that we know it all.  ‘Science’ should help more to develop ways of helping CAM to demonstrate efficacy instead of snidely sniping from comment pages in the Guardian.

To validate a physical therapy approach for instance, requires a treatment protocol to be written which sets a standardised approach and has everyone treated the same way.  For most, this flies in the face of what CAM is all about, which is to treat the person presenting with the disease or problem, rather than treating the disease itself.

This presents a problem in itself, but this is only the start.  The research paper might have to be submitted to an ethics committee (check here), to decide that the protocol being used is appropriate and does not adversely affect any control group.  Then the study itself needs to be undertaken and funded, followed by this paper being written up, with statistics, a literature review and couched in a language which is generally not very accessible. There is a big disconnect between the academic designing a study and a therapist who, whilst having a good practical knowledge of their technique is not trained or equipped to undertake a serious piece of research.

But then surely once I’ve proved my theory/practice/lotion works everyone will accept it?  Not a bit of it.  Why the hell not?

“Ahh you see, you’re biased.”
“What do you mean I’m biased?”
“Well you had a vested interest in proving the outcome.”
“Of course I bloody well did, who else is going to do it?”
“No-one, but that’s not the point.  It’s still first hand research and doesn’t really count.”
“What does then?”
“Well someone else has to do it again.”
“So I ask someone to do it again?”
“Oh no you can’t do that.  You’d be influencing them.”
“What so I just have to wait around until someone decides to test out whether what I found out was true?”
“Precisely.”
“So until then can’t say it was?”
“Oh you can say it was, it’s just that no-one will take you seriously. Because you introduced a bias.”
“I give up.”
“Yes well that’s because you’re not an academic.”

The paper then has to find a publisher which will peer review it.  Invariably the publication itself will be subject to derision or criticism, simply because it is publishing research papers which address CAM outcomes, irrespective of the quality of the research or the writing.  The goal posts are hardly equal.  The baseline is this: all CAM is effectively shit and if you go out and try and prove its not, then you are biased and your research isn’t valid.  Tim Minchin, a funny and famous sceptic echoes the naive view of the majority of those of his religious persuasion, when he says “There is a name for alternative medicine that works.  It’s called medicine.”  It’s a sweet idea, but bears no resemblance to the complex and difficult arena which is called proof and is a bit like saying “If everyone laid down their weapons there would be no more war.”  It’s true, but a bit more complex than that.

With hundreds of thousands of treatments being conducted every year and millions of pounds being spent, it seems backward to sit on the sidelines and scoff, even suggest that it’s rubbish, when a pro-active investigation could perhaps shed some light and help the so called victims of CAM.

It behoves us to understand that the things that define us as humans: love, sexual attraction, love of spinach, loneliness, fear, sexual orientation, even pain, have no consensus when it comes to defining them scientifically. Lack of evidence is not the same as evidence of lack.

The Fascia-ists are Coming!

Fascia Kittens For Everyone!

It’s fair to be said that the only people who really take the fascia thing very seriously are those who are invested in the word or the concept for whatever reason.

Fascial Manipulators, Fascial Releasers, Fascial Roller Manufacturers the list goes on.  It’s no surprise that all of these will tell us that whatever it is that they do, has an effect on fascia.

The supporting claims made for the effects on fascia by these modalities and pieces of equipment is accompanied for the most part by a whole raft of scientific bunkum that often lumps fascia into one bundle and addresses it as a single unit or type of tissue, without basic facts getting in the way.

The science side of things often does no better.  The bi-annual festival of fascial backslapping that takes place under the banner of the Fascia Research Congress, brings together a wide range of scientists keen to present their latest ideas and theories under one roof.

For the most part the research, to the untrained eye (indeed to even the trained one sometimes) seems either pointless, unintelligible or both, but little matter.  Research is being done and the field is being moved forward slowly but surely. Hooray and fascial treatments all round!

The trouble is that from this very early, very inconclusive and often very poor research base, the world of complementary ‘bollocks speak’ is having a field day.

Every other treatment now releases fascia, hydrates fascia, lengthens fascia or does something miraculous to the fascia, which in turn gives you more of whatever it is you want.  Flexibility, less pain, tighter buns, eternal life and so on.  These days if you want to be sexy, you’d better be working on the fascia.  Stretching is so last year darling.

I hold my hands up to jumping on the fascia bandwagon myself, having renamed The Bowen Technique, Bowen ‘Fascial Release’ Technique.  The unashamed rebranding was for no better a reason than to at least try and give Bowen a peg on which to hang its hat and move it away from the crazed evangelist guardians intent on suffocating it.  But of that another time.

So what does fascial release even mean?  To be honest I’m not really sure.  The idea that you can in some way change the properties of fascia by applying manual therapy to it is far fetched at best and the pressures required to create change in fascial tissue are, probably, more likely to rip it before it changes.  Is Bowen working fascia?  Probably but not exclusively and that’s the point. Nothing is.

So what about taping the fascia?  Again I have watched YouTube videos, where sensible people demonstrate applying tape, of various colours and let’s not forget price, to bits of the body whilst climbing that this tape will adjust the fascia around the SI joint.  Again the likelihood of this being the case is not high.

This all makes for a fairly sad state of affairs and one which often draws snorts of derision from anatomical academics and serious scientists when the F word is mentioned.  Fascia, beaten to death on the commercial imperative of the complementary medicine field, desperate to find something of gravitas to justify its own existence, is in danger of becoming something of a laughing stock to the rest of the world.  The irony is that an industry that preaches holism and addressing body wide issues, has chosen one bit of (admittedly neglected) connective tissue and obsessed over it.

While I’m beating up on my own doorstep, I’d hate to let the academics off with a pat on the head for being so outrageously smug.  Connective tissue in the form of fascias of various kinds, clearly has more of a role to play than just being a container for muscle and much more understanding and good research is needed to understand how it responds.

It’s not all bad of course.  There are some serious researchers out there and in the midst of the codswallop and bad science being bandied around, a real interest is being shown in this interface which has been woefully ignored for a long time.  If the focus can be shifted to this much needed area of understanding, then I believe that we can probably create a better understanding of body wide function than currently exists.

Wild and outrageous claims need not apply.