[vc_row][vc_column][vc_column_text]A recent tweet by a man calling himself the Grumpy Physio (I bet his patients just LOVE him) tells me that I am wasting my time in dissection and that the answer to pain and movement is in the living tissues.
Well that’s me put in my place then and this website is now closed. As if….
He is of course right in as much as the whole point of any learning is the application of the knowledge to help those that can still be helped. It’s a common idea from people who have limited exposure to an integral anatomy dissection, that somehow dead, preserved tissue can tell us nothing.
The issue that Mr Grumpy has missed is that even with an open mind, there is still a view point from which all assessment starts and from which assumptions are made. His original Tweet “Fascia is no more important than anything else” suggested not that he knows lots about everything else, but that he knows very little about the importance of fascia.
Hence the dissection work. The starting point for most therapeutic approaches will be named anatomy. No matter how much you move on from this, unless the anatomy is put in to perspective, the frame of reference will always be limited and wrong. Named anatomy tells us nothing about function, movement, pain or how to fix it.
A couple of hundred years ago some Scotsmen decided to give Latin and Greek names to things that had previously been numbered and thereby said “this is a big muscle on the medial side and there is another one on the other side” So Vastus Lateralis and Medialis were born. The origins and insertions became convenient points to cut them off and start another name, but have absolutely no logic most of the time. Muscles don’t attach to specific points or originate from others and the study of these specified named structures and the importance subsequently placed on them, has restricted the ability of the therapist to see body wide movement and has limited the study of them to an agonist and antagonist model, something not only limiting but against the entire laws of physics.
The tired argument that examining preserved dead tissue teaches us nothing, comes from those who continue to study the dead tissue in the same order and way that it has been done for a thousand years.
I don’t. I am not an anatomist or at least not a traditional one, but an inquisitor. My desire and intent is to go way beyond the traditional views. I want to show the old models as lacking, not to shore them up and validate ideas that don’t hold up. The connecting element to functional movement is fascia. It is the tissue that connects our ancient models and allows us to understand dysfunction.
Is it more important than other tissues? Well it’s a stupid question to posit in the first place, but certainly there is value in studying this very little studied tissue. Stiffness in fascia is like stiffness in opinion. They both lead to an inability to see the world around you in a wider context.
So here is my challenge. If you come on a dissection with me and DON’T learn something different about human functional movement, I will give you your money back. Terms and conditions apply naturally![/vc_column_text][/vc_column][/vc_row]
I am well used to the pace of a Gil Hedley six day dissection and the frustrations that come with having to blast through a layer that you want to hang out with and study for longer. It’s something I tried to address last year when I ran an eight day dissection course over four weekends and it worked very well, apart from the disappointing attendance.
Three weeks however is another ball game entirely. If I was concerned about the level of concentration required to spend so long on skin and superficial fascia, I needn’t have worried, as come the end of day five, the fascination and intrigue still being demonstrated by all involved was evidence enough that there is plenty to hold the attention for this long.
The week has presented its challenges for different reasons. Gil wants to document these layers and write about them, drawing comparisons and noting differences. In order to do this though, measurements need to be taken and two issues arise from this. As far as I know, no-one has ever really tried to document the thickness of superficial fascia in cadavers. We are well used to fat measurements in humans, used to tell people how inadequate they are, yet the true depth of the tissue as well as the lobular lengths in certain areas, remains unchartered territory. Similarly the patterns of circles on the underside of the skin.
Do these relate to areas of function or strain? How do they change around the body and is this consistent across all the forms? What is their purpose? How do they respond to scarring or wear? Because no-one has really asked these questions there isn’t really any system to follow, requiring a whole new method of study.
There is no doubt that Gil has thought long and hard about this, but faced with the reality of needing to get this information down, with 50 people in the room doing the measuring, the best laid plans will always need to be re-considered and in this case simplified. If we were to get any data at all, it had to be done in a way which was going to be at least consistent throughout the room.
Robyn, a graphic artist, leapt to the rescue and created a series of line drawings which we photographed and imported to a word document and to which tasks and questions were then added. Observation is an essential element of any measure and Gil has encouraged everyone to write down what they see, from skin onwards.
It’s a useful skill to apply to any practice. You only get one chance to observe so make it good. If you see something, anything on the surface, you have no idea how this will relate to layers further in to the body, so it’s vital that whatever you see first is noted.
The discussion of the circles was ironically enough an extended element of circle time midweek. It’s sometimes hard to be part of a debate that is clearly never going to be anything except speculative and this was one of those times. The ‘meaning of the circles isn’t something that is clear just yet, but the important thing here is to know that they have been studied and measured. At some stage someone will define them more clearly and these measurements will be the basis of the next step. Whatever the case I have no doubt that it’s going to change the way we look at and understand the body and thereby the way we treat it.
Similarly, understanding the variability of the adipose/superficial fascia/panicular layer, is going to be more relevant when referred to other studies or way of understanding how this tissue is distributed. For the body worker, the main thing is to fully appreciate that the skin and superficial layer is the workbench for manual therapy. We have no real interface with muscles or viscera except through this layer. The tricky thing is that it’s not as obvious as we might think.
One cadaver in the room is a big guy. 18 stone with a huge belly, yet with a superficial covering of less than half an inch at the front. Another table had a man with a similar build, maybe smaller, but with a superficial fascia layer of well over two inches. Being fat means man different things.
Saturday and it’s a voluntary day to ‘discharge’ as Gil so neatly puts it. Get out and blow the cobwebs away. About half the group have come in to tidy up and follow up on what was left over from the end of the week. Weighing and measuring samples, trimming up under the axilla to develop a clear space for the week to come.
For me my partner Jane had arrived the night before, so it was the tourist trail for us, jumping on and off trams and trolley buses and taking in the sights of SF. A big week ahead with muscles!
I love San Francisco. My first dissection proper was at this medical centre, (note the correct spelling of centre) and with this to be the last dissection to be done in this building, it feels fitting for me that I should be here. The city is a vibrant, colourful celebration of US life and every few blocks there seems to be an area or part of town that houses ideas and cultures that feedback into the fabric of the city.
Today’s reflection of the skin down to superficial fascia came almost at the end of a day which although not containing an awful lot of scalpel time, seemed busy enough, sometimes at times too busy.
Gil Hedley has decided that these three week exercises are going to give enough data to write the world’s first Atlas of Integral Anatomy. I’m not exactly sure what that means, but then again, not exactly sure is something we all have in common when around Gil.
It’s probably something that geniuses have in common, where lots of things are going on in their heads, but getting it out and down on paper is often tricky. Just getting to this point has been a logistical Everest and the amount of kit that Gil has bought and then shipped up to California from Florida is mind boggling.
Never one to be beholden to a single person or entity, Gil has bought a mixing desk, three cameras, tripods, lenses, lighting rigs, cable ties and enough gaffer tape to keep the whole bay BDSM community happy until Thanksgiving.
On top of that he has taught himself how to use all this gear and eventually will work out how to transfer the data into something usable. It’s therefore forgivable if not all the plans of how the data will be gathered have been fully committed to paper.
Yet the workings are there, and today 15 areas of skin were marked and the process of skin removal begun. The marked areas will then be cut and compared, creating a chart that shows the degrees of thickness around the body and how these compare. I am guessing that observations will go along with this. Does the mottled bubbling effect happen everywhere and on everyone? Is skin thickness consistent throughout the body on all the samples?
It was good to get ‘stuck in’ again in the lab and begin that laborious yet fascinating and compelling process of removing skin from a human form. The feel of the scalpel blade sliding beneath the surface of the skin and creating and image of skin being an entity separate from its underlying structure.
There is a satisfaction in being mildly competent in this regard, seeing the skin lift cleanly away to reveal the bright yellow bubbles of the multi named adipose beneath.
Day two is a continuation of the skin/superficial fascia, reflection. The luxury of being able to spend plenty of time on this layer and get lots of cutting in, is not lost on the more experienced dissectors in the room. By now we would normally have all the skin off and be on to the next layer, with barely a chance to blink. This is different. Not exactly leisurely by any stretch of the imagination. Perhaps considered is a better word.
Gil revels in the size of the group and his ability to captivate them with his style of discussion and his overwhelming sense of human ridiculousness. Whilst being blessed with a sensitivity that is finely tuned to the room, he also conveys a distinct lack of bullshit. A swear word or a dirty laugh brings out his boyish delight in the profane and he absorbs and reflects the enthusiasm and ebullience of those around him.
Energetically he can be a worry. The sheer effort to get to day one has been enormous, and to then keep this running at full tilt, for three weeks presents a challenge, the steepness of which will become apparent in the next few days.
As for me, well I am still feeling the effects of my body trying to tell me that I should have been asleep about six hours ago and I am struggling to keep the energy levels where they should be and stay focussed on the job in hand.
If something is in use, but not proven to the satisfaction of those not using it, at what point does it become accepted as fact and when does belief become all that is needed?
Just a thought.
Discussions! The word holistic has long been used as a whipping tool for those who would suggest that a whole person approach is in some way flaky or flawed. As patients visiting a doctor, we go with a problem to be solved and the doctor in his wisdom sets about finding the way to treat the condition we present with.
It would be naive to suggest that with our current medical model, the medic at the front line of disease fighting has the time, training or inclination to consider the subtleties of the individual. Yet disease is rarely standardised in humans. Common symptoms exist, but each person will have a learned response to each situation they find themselves in.
Similarly physical pains can have a myriad of reasons for their manifestation, even though at first glance the pain may be standard. NSLBP as it is often referred to. Non Specific Lower Back Pain. The scourge of most nations, it is one of the biggest causes of lost work time and hence a costly affair for industry and health care alike.
Most nations are traditionally terrible at treating it, for the very reason that our anatomy fails us when looking at the back. We see a collection of spinal muscles, some fatty stuff at the base, a joint that moves or doesn’t move, depending on who you believe and oh so many theories and stories.
The same pain in a hundred people could and probably does, have a hundred different causes and thereby approaches. This man’s knees were injured and he compensated when recovering through poor use of his crutches. This woman carried a toddler for two years on slim hips and used her neck to take most of the weight.
This lady leant over her husband every day for many years to help him get out of bed. And so on and so forth. We treat people as conditions, yet don’t often consider the person with the condition.
By considering who a person is, rather than what they are presenting with, our focus changes and our ability to see a different outcome as possible becomes an opportunity.