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. I subsequently found myself on a plane to San Francisco in 2007 and the process of falling in love with dissection and anatomy began.
It was the dawning of a new era for me and the scales fell from my eyes when I realise that everything I had learned anatomy wise was at best incomplete and inapplicable to understanding manual therapy. 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. In truth I only asked because I was pretty sure I could find somewhere to work from. St George’s hospital London and Professor Ceri Davies, the then professor of anatomy, offered 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, bringing him over to the UK to run classes that I had established, at the same time building my own understanding and methods of both embalming, dissection and anatomy. I doubt that I will ever get to the level of Gil in terms of dissection skill and depth of knowledge, but I like to think that with him as a role model, 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. I have moved more towards cellular structures and behaviour and construct a more scientific based approach to explaining what we are working on. The actual dissection principles I use remain for the most part, 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; 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 who has been the first to call BS when something is, well BS.
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. It is however something I will always value even if it means that distance between two people is created.
Gil was and is my inspiration for dissecting and challenging the sometimes illogical concepts of classical anatomy that still hold fast today. 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 twelve years later their lives were dedicated to the same process and path that started in San Francisco all those years ago.
The complicated relationship that we as humans have with fat is one that has lots of strands and interests.
Our cultural referencing tends to create the idea that fat is a bad thing and certainly the link between obesity and poor health is one that has mileage. Obesity in isolation as a health risk tends to do what all these arguments do, which is to set aside accompanying factors.
Being fat is no longer the domain of the wealthy, with fat jolly upper class gentlemen depicted in Dickensian novels as the ruling classes, contrasting with the poor, wraith like creatures of the slums.
Fat has therefore sociological aspects to be considered as well as dietary. The rise of sugar consumption being parallel to that of obesity seems fairly obvious, yet the link remains associative rather than causative.
Nutritional science has little in the way of consensus and there is wide spread disagreement relating to even the most basic ideas of how much and what type of fat should be in our daily diet. Similarly ideas about weight, fat distribution within the body and what type of exercise is best for you, still contradict themselves on a daily basis.
Then there is the ‘burn belly fat,’ websites that scream at you to buy their most scientific finding of utter rubbish. My personal self loathing is my fat wrists and I am therefore under a strict exercise and diet regime aimed at burning the fat at the bottom of my arms.
The terms we use for fat are also something of a misnomer. Superficial fascia is something that could more agreeably used to describe the tissue found directly beneath the skin. There seems to be an idea that this is a tissue that is simply a fatty layer and therefore undesirable wherever it may be.
Adipose, superficial fascia, the pannicular layer are all terms that cover the same tissue. Recent attempts to classify the superficial fascia as having separate layers, with one more defined as distinct from the fascia cutis is interesting.
However the studies undertaken have only looked at the layer around the abdomen and attempts to classify the whole body based on such a small area of study would seem a little ambitious.
In this video of fresh abdominal superficial fascia, you can see that there is a weaving of collagenous like tissue (no samples were taken) through the fatty layer.
This is consistent throughout all the dissections I have been in, with the superficial fascia a continuous structure that running around the whole body. This theory has never been more clearly demonstrated than by the unique approach taken by Gil Hedley, whereby the skin and superficial fascia is removed from the underlying deep fascial layer and laid side by side as below.
Some areas are of course thicker than others, but the principle is consistent. Even if you were to take all the fat away from this layer, then the fibrous content would remain.
The principle of fat containment within fascia is the same as that of muscle containment within fascia and obeys a basic biological principal: you cannot have cells without something to hold them in place. In the case of both the muscle and the fat, the container is the connective tissue we know as fascia.
In addition we know that adipose itself has a major role to play in the functioning of the body, with evidence suggesting that adipose might even function as an endocrine organ.
The debate about what to call it, what it does, as well as a clear understanding of how it gets there, genetically as well as environmentally, will no doubt continue for some time to come. In the meantime our battle with the bulge will no doubt continue, profitably for many and miserably for many more.