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.
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.
Great spirits have always encountered violent opposition from mediocre minds.
The mediocre mind is incapable of understanding the man who refuses to bow blindly to conventional prejudices and chooses instead to express his opinions courageously and honestly. Albert Einstein
The Human Tissue Act 2004 is an act of the UK parliament in England and Wales which was brought about in response to the Alder Hay scandals in the 1990s. The Human Tissue Authority was also created and given the responsibility for regulating and enforcing the act.
Each premises conducting work with human tissue is required to be licensed and a designated individual – DI – is assigned to oversee this work and given discretion as to the kind of work and access given to licensed premises.
For the most part the HTA does a good job of working with the anatomy world, but in the case of giving DIs power, the potential for a disconnect can happen. The HTA gives no written guidance to the DI in terms of who should be allowed in, assuming that they are intelligent people with a degree of common sense. The primary responsibilities of the DI are threefold:
- that suitable practices are used in undertaking the licensed activity
- that other persons working under the licence are suitable
- that the conditions of the licence are complied with.
In 2016 I was invited to run courses at Nottingham University Hospital and offered an NHS service level agreement by the trust. The feedback from the courses I ran was outstanding and I was invited to take part in anatomical research by a surgical team from within the trust. The team running the centre are on record as saying that my classes were among the very best they had ever seen and everyone seemed very happy. Attendees from physiotherapy positions at Premier League football clubs, Formula One racing teams and clinical specialists from within the NHS had attended and were massively impressed with the content and teaching.
In November 2017 however, the DI, Dr Ian Scott, decided that he would move to terminate my activity at Nottingham University Hospital, and aided in this by the trust secretary Mike O’Daly, issued a letter which, even though based on false content, stopped my work in its tracks and resulted in the cancellation of classes already booked and agreed with by NUH.
The reason? Dr Scott, a published scientist of the highest order and presumably a stickler for accurate referencing, didn’t like my opinion based blog posts. From emails obtained after three months of pressing the NUH to comply with a freedom of information act request, it can be seen that Dr Scott used out of context quotes and ad hominem arguments to support his stopping of my work to his trust secretary Mr O’Daly.
He reasons also that the study of fascia is “an abstract sideline of anatomy”, although a simple Google search of ‘study of fascia’ might have helped to counter that thought, returning 286,000 results in 0.3 seconds. The idea that perhaps he should attend one of my classes and actually engage with the process didn’t occur to him, even when invited to sit in. Indeed he was urged to do so by his own team, who praised and strongly supported me and my work and wished to see the classes continue in Nottingham.
Dr Scott did not phone me, write to me, interview me, or in any way attempt to ascertain what I was doing on the premises. He refused to enter a mediation process and refused to allow any independent assessment of my work, insisting that in spite of ten years of experience in dissection, I was “not qualified” to teach anatomy, regardless of the fact that I have never claimed to ‘teach anatomy.’ The Scientific Method indeed.
Although promising to be guided by the team running the centre, and to defer to his clinical lead in the teaching of anatomy, he went against their advice and opinion. The issues that Dr Scott as DI had to satisfy himself were simply the three mentioned above. From my own perspective and as a matter of record of that of the team involved in the day to day running of the centre, all three conditions were met. At no stage was there any suggestion or claim of wrongdoing on my part from Dr Scott or his team, and no reason was given for the termination of my classes, details supporting his decision only coming to light after a freedom of information request.
Science and its progress has no room for personal enmity or beliefs, yet Dr Scott seemed to have the personally held and demonstrably unfounded belief that what I did was not appropriate, without having properly evaluated the content and ironically at the same time, cherry picking my own blog posts to suggest how unscientific I am. Feedback and comments from the many clinicians who have attended and witnessed my class was also ignored. His assertion that the classes were “unlawful” under the terms of the act and the permissions obtained by NUH was concerning but according to the HTA and independent legal opinion, was not the case. Dr Scott is not a lawyer. A collaborative approach, where willingness to work together and develop better systems and clearer permission forms, would have seen Nottingham become a worldwide centre of excellence for the teaching, study and understanding of human movement and muscular skeletal pain and discomfort and was on course to attract research and interest from around the globe.
The attendees themselves were also the target of Dr Scott. Apparently unaware of the existence of the nine regulatory health care bodies in the UK including Chiropractic and Osteopathy, Dr Scott is on record as saying that he, “didn’t consider Chiropractors or Osteopaths as professional,” that they were “unregulated” and that, “…we see the adverse effects of that practice. Torn ligaments. They do things we have to put right.” Only HPC practitioners (including dieticians and art therapists) registered in the UK are acceptable to attend dissection classes as far as he is concerned . He even expressed incredulity that a nurse practitioner should attend a class on the thorax, heart and lungs, in spite of her being a regulated health professional.
Holding up scientific progress and important medical research and preventing inward investment and income for the NHS, while at the same time making poorly judged and incorrect comments about regulated health professionals is not something you would expect from someone holding a position of major responsibility. With power comes responsibility. Decisions which affect the future of medical endeavours should not be made without due consideration to evidence and fabrication and hyperbole are not a basis for sound decision making.
What this highlights is the distance between the regulation and enforcement of the Human Tissue Act and those who use their ‘discretion’ to prevent wider engagement for reasons that are in Dr Scott’s case, unclear or unsound. Perhaps the time has come for a debate about how best to control access to those who sincerely wish to study and understand anatomy and human movement, but who are not registered health professionals.
The Human Tissue Act places no restrictions in terms of access, but simply asks that appropriate permissions have been given by donors. The interest in anatomy and the study of the human form is growing. Thousands of practitioners all over the world are taking care of the aches, pains and problems of populations. Without them the UK’s NHS would implode. They should be taught properly and fully and have access to good study material, including dissection classes. Far from being a drain on NHS resources, classes such as we offer, bring income to otherwise under or even unused facilities as well as providing research opportunities to advance the understanding of the human form.
Everyone entering a dissection room should be (and in our case is) carefully vetted and strict guidelines put in place. Institutions and operators can and should collaborate to ensure that respect and diligence is applied when dealing with cadaveric material. But putting up a wall, creating an ‘us and them’ environment does not help.
Dr Scott is of course welcome to comment and engage in discussion at any stage and I would be delighted to debate both his actions and understanding of the wider issues at stake.
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.