I’ve spent most of my adult life convincing myself that what I do works and that my own particular brand of therapeutic intervention has some kind of mechanism that makes people ‘better’, whatever that means.
It stands to reason that I need to have some level of conviction that what I practice, teach, write about and study has some level of efficacy. This conviction however comes with little real evidence to back it up, save for the thousands of other people who have the same conviction. This conviction sometime extends way beyond what we might often think of as a reasonable confidence and is mirrored in the behaviour that we indulge ourselves in all through life.
We tend to surround ourselves with this who agree with us and who confirm our view of the world. Whether it be through religion, culture, politics, therapy or science, we associate and fraternise with those who’s world view closely resembles our own. In science this is called confirmation bias; we tend to confirm as fact what we want to be true.
As I’ve got older and more cynical, it’s hard to separate fact from fiction when it comes to therapeutic intervention, but I still regularly face fierce conviction from those who are utterly convinced that what they do has a clearly defined mechanism of action, even when it is is patently obvious that any such mechanism or at least an understanding of it, is entirely absent.
These people will send me emails that contain pages of research documents that back up their stance and confirm their strongly held belief that what they do is scientifically proven beyond doubt, an excellent demonstration of confirmation bias. Much as the evangelist will use the bible to demonstrate proof of the word of god, anything that might directly contradict or question this view has not been sought out or researched and someone like this is unlikely to have a balanced view.
Whilst understandable, it often makes for uncomfortable conversation. Whilst I totally believe, having had the same experiences, that the most incredible things happen with unerring regularity in treatment rooms all over the world, I have yet to be presented with anything that remotely resembles evidence to support an understanding of how these events actually occur.
Accepting something as part of a faith or a deep belief is one thing, but trying to justify that faith against a world of counter intuitive evidence is going to end badly. Placebo, meaning ‘to please’, is a word often used to bash the therapist by those with a sceptical axe to grind, conveniently ignoring the simple truth that ALL medicine is to some degree placebo by its very nature. You can’t take the doctor out of medicine.
Derren Brown’s ‘Miracle’ available on Netflix, makes for uncomfortable watching for those who might feel that what they do is something more than contextual, yet should be required viewing for anyone who aspires to be a therapist. Does it prove that all healing, or anything without a paper is hocus? No. Brown is a consummate showman and demonstrates the power of hypnotism and mass hysteria in a great show. It would be naive to suggest that what takes place in a treatment room is the same.
Manual therapy has many benefits and the power of touch can and should never be underestimated. But the actual mechanisms by which we change things and how this takes place is very poorly understood, however hotly debated.
Subjects like fascia have become popular and widely bandied around, but are often used by those who have little grasp of the subject to support or justify approaches which have little evidence to validate them. Science and scientists aren’t immune from this self justification as human nature takes over easily, even where deeply held principles of scientific objectivity might be expected to take precedent. It’s hard for anyone to have their work or understanding contradicted.
We are all prejudiced to some degree. We all have deeply held personal beliefs and convictions that will always have the potential to influence even the most guarded of principles. Owning this truth as a starting point for trying to understand our approaches would be a great start.
How does that feel then? Any better?
I have spent years around therapists, doctors surgeons and practitioners of all kinds and have been one myself for most of my life.
The key motivation of being a therapist is that you want to help people. To improve the quality of their lives, to relieve pain and to alleviate suffering.
Every year I run a class where therapists from all over the world converge to take part in a dissection class at medical school in Scotland. The facilities include an extensive clinical skills suite where therapy tables are available and the swapping of treatments and ideas is a popular pastime.
I have been fortunate to be the recipient of many of the therapeutic approaches that are brought to the class and as a touch junkie, it’s no hardship for me to lie down and let someone work their magic on me.
What I struggle with however, is answering the question that I generally get asked at the end of the session, which might include, “How does that feel? Better? Is that easier? Is that less stiff?” and so forth.
It begs the return question of, “What do you think the mechanism of action might be whereby what you have done might change the way that I am physiologically responding?” In other words, how in hell’s name is what you have just done going to change 45 years of structural development to the point that my shoulders don’t hurt any more?
The feeling I am left with is that I am almost expected to say that it feels better in order not to hurt the feelings of the person who is working on me. The trouble is that humans are not cars or machines that have specific, duplicatable problems that can be fixed by addressing, changing or removing one part.
It’s also led me to ask, “Is this something I do as a therapist?” I hope not. What actually happens during a hands on session in terms of a change in the physiology of an individual is…? Probably not that much!
We can be reasonably sure that in the space of 45-60 minutes and with the usual degrees of mechanical force, using hands, equipment or needles, fascia isn’t going to change, muscle isn’t going to change and bone isn’t going to change.
So what’s left? The central and autonomous nervous systems are being prompted to be involved for sure and there may well be physiological responses in respect of a change in blood pressure and heart rate. But actual changes are going to take quite some time: weeks maybe months before sessions are truly integrated and absorbed into the structural behaviour of an individual.
To my mind, the changes happen after the session, not during it and anything a hands on therapist does is not a means to an end, but a contribution to a process that is on going.
Put simply, the therapist is not the ‘fixer’. The therapist does not get someone ‘better’ whatever that means. The therapist simply provides information to a system that then gets interpreted and hopefully acted upon in some way.
So no, right now I don’t feel better, but it was a very nice/painful/boring/intense/interesting/awesome session thank you and I’ll let you know if I notice anything.
When is a door not a door? When it’s a jar.
There has been a lot of activity on Facebook recently, with John Sharkey stating that bone is fascia. I have a problem with this in a couple of ways. Firstly because it’s not a discussion point that is being raised, but a statement. BONE IS FASCIA.
This statement of fact doesn’t leave anyone with any option except to agree or disagree and creates a polarisation that I find uncomfortable and unhelpful.
Instead of a reasoned argument that follows a hypothesis, we are instead faced with a crowd of people in a video, chanting “bone is fascia, bone is fascia”, as if saying something factually questionable over and over again makes it true.
So let’s ask the question and discuss the possibilities, raise some relevant points and let the reader make up their own mind.
Before I dive in here, this kind of discussion/argument, whilst reasonable and vital in a scientific forum, has the tendency to be seen as confrontational when addressed to a more ‘touchy feely’ audience. So please let me state that none of this is about personality or personal enmity. I like John Sharkey and have an enormous amount of respect and time for him. That I disagree with him and feel able to do so publicly is a mark of that respect.
Here is a picture of a railway track.
Here is a picture of a road.
They are different things, but have some elements in common. They are both surfaces for transport and the things that travel on them have wheels. They both convey people from one place to another. There are different gauges of railway and sizes of trains. The railway track can carry different types of trains at different speeds to different places. The road can support different types of vehicles and there are different types of road, road surface and classification.
However even though they have things in common a railway track is not a road and a road is not a railway track and confusing the two would be both unwise and potentially dangerous.
Now I’ve rather laboured that comparison, let’s talk about bone and fascia. They are both connective tissues, and have things in common. Lots of collagen for one. There are two types of bone, cancellous (or trabecular) and cortical, that do different things and have different purposes and functions.
If as John suggests, bone is just “starched fascia” then “starched fascia” should be able to do the job of bone. Let’s reverse the bone is fascia statement, say that fascia is bone and see how it stands up.
If it were true, it should be able to have the cells within it to allow it to regulate calcium levels in the body, which lets face it is one of the more important jobs that bone has. It should be able to store calcium. Yet 97% of the calcium reserves in the body are in bone. Original osteoblasts get trapped in newly forming bone and mature into osteocytes which cannot divide further.
Osteocytes stay in contact with each other in the bone via gap junction and maintain the integrity of bone by releasing calcium ions which then get incorporated in to bone tissue. Fascia does not have this capacity.
Bone contains about 33% collagen and 39% calcium. The remainder is made up of phosphate, carbonate and other mineral salts.
Collagen allows bone to bend slightly and resist stretching forces. Without collagen bone would be too brittle and without mineral salts, bone would be too rubbery.
For fascia to be bone, the starched fascia should have a balance of both collagen and calcium and contain heamapoetic stem cells within its structure that would then give rise to red blood cells. No prizes for guessing that it doesn’t.
If fascia were bone, then it would receive signals from the parathyroid gland when there was a fall in calcium levels in the blood and would be able to release calcium from its starchy insides to balance out blood calcium levels.
The list is pretty endless in terms of the differences, and this is why bone has its own classification as a connective tissue, along with cartilage, blood and proper (within which the stuff we refer to as fascia has several entries). The classifications of connective tissues may not be very extensive and certainly there is a lot of tissue that is poorly described and understood. Much more work is needed to expand some of the tissues that are only given a few words in anatomy books. Bone however is not one of these tissues.
All connective tissue is mostly inert. This means that it is mostly made up of non-cellular material. That doesn’t mean that connective tissue doesn’t have any cells, but that it mostly isn’t cellular. The non cellular stuff in connective tissue is however as important and interesting as the cells that are there and components within the extra cellular (ie non cellular) matrix are infinitely interesting and important.
In blood plasma for instance, there is a range of elements vital for every breath we take and every move we make; yet plasma is essentially a non-cellular connective tissue. Please bear in mind that none of this is my opinion, just that boring old stuff we call science and fact.
So is bone fascia? Is a railway a road? Having things in common doesn’t make them the same.
Dissection and Ethics. Who Makes the Call?
It can be hard for someone not invested in the process, to understand why dissection is either necessary, or what the process entails. There is understandably, an emotional component surrounding the fact that the cadavers we are dissecting are people who gave their bodies up specifically for the purpose of learning, study and enquiry. For the most part this emotion comes not from the potential donors themselves but from the sensitivities of those dealing with the business of who should or shouldn’t be allowed in a dissecting room. (more…)
In 2006 I travelled to New York to attend a workshop with Tom Myers hoping to drag him over to tour and teach Bowen people in the UK, which he subsequently did. We also did a dissection together which is another story!
His workshop was being held at The Breathing Project in Manhattan and whilst chatting one day a man called Leslie Kaminoff told me about Gil Hedley and how I should get on one of his classes.
Long story short, I found myself in 2007 on a plane to San Francisco and the process of falling in love with dissection and anatomy began.
Gil was already an old hand at this business and in the layers around the muscle and deep fascia held no drama for me. In the visceral tissues I found myself freaking out and it took me several years for me to find my way around these tissues with any degree of confidence, urged on my Gil and his deep love of visceral tissues. In the last year, adding to my understanding the deep function, cellular behaviour and chemistry of what is going on in these tissues has only increased my love of the area and even the toughest day working in this tissue is now a pleasure and thrill.
At the end of the 2007 class, I asked Gil if he would come to the UK. Being asked that kind of question regularly myself, my response is always, “Yes sure!” I am fairly confident that I will walk away from that conversation and it’ll be last time I ever hear from that person.
Gil was no different and felt pretty sure that I’d never be heard from again. Point being, I only asked because I was pretty sure I could find somewhere to work from. St George’s hospital London and Cery Davies, the then professor of anatomy, were only too pleased to take our cash and offer us the chance to run a course, leaving Gil with no option but to agree to come over to the UK.
So began ten years of working with Gil and learning his approaches to dissection, at the same time building my own understanding and methods of both embalming and dissection and studying like a demon to raise my knowledge. I doubt that I will ever get to the level of Gil in terms of dissection skill and knowledge, but I like to think that with his guidance, I have developed myself and my eye over the years to bring a certain something to a dissection room.
My approach these days is somewhat different to Gil in terms of defining what it is we are doing in a lab, but only from the side of how the content is thought about and delivered . The dissection principles remain pretty much how Gil designed it. Why change what works?
Gil is a master dissector, anatomist, story teller and human being and my approaches and ways of dissecting are learned almost entirely from him. His hard work, dedication, forward thinking and sheer determination have laid the ground for people like me to follow, on the shoulders of giants indeed.
The methods of reflecting skin and then superficial fascia as a separate entity is something he pioneered and although not something that I generally do in such depth any more mainly due to time limits, it has created an understanding of these tissues as a unit which is unique. The ability to challenge some of the more worrying ideas around this layer has come almost entirely from Gil.
I would be the first to admit that Gil and I have not always seen eye to eye in terms of approach, content or management in various aspects, but the ability to disagree, argue and even fall out is perhaps something that is the result of getting close to people.
Gil was and is my inspiration for dissecting and challenging the illogical and old fashioned concepts of anatomy that still reign supreme today, even in the face of challenges. A dissection workshop with Gil is truly a remarkable experience and one that anyone with aspirations to understand the human form should attend.
Many people will have been on a workshop with Gil and have their lives changed. Few however would be able to say that ten years later their lives were dedicated to the same process and path that started in San Francisco all those years ago in an experience for which I will always remain profoundly grateful.