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.
This weekend saw me revisit some old friends. I say friends because I feel like I know them, even though they don’t have a clue who I am.
In fact you probably know them too as The Rolling Stones. I had been in California last year to see them at an event called Desert Trip, where the combined ages of the performers, who included The Who, Bob Dylan, the aforementioned stones, Paul McCartney and several more reached well above a thousand.
Watching Charlie Watts on the big screen my wife and I quipped about what he was thinking. “Ooh I could murder a cup of tea and a biscuit.” “I hope the missus has recorded Corrie”.
With his silver hair and brilliantly expensive white teeth, he also sat bolt upright at the drums, with a composure and dignity that many of half his age would die for.
Born in 1941 Charlie Watts will be 77 next year and with Ronnie Wood being the baby of the band at 70, you have to ask, how do they do it? Keith Richards has, over the years consumed several times his own weight in recreational drugs and still starts every day with a joint.
The fact that they have survived as long as they have is remarkable, but that they still tour regularly and energetically makes you ask, “what is it that they are doing right.?”
I suspect that the answer lies in the manner in which they live their life and the passion to which do their work. Being multi millionaires doesn’t hurt of course, as money is the key element to longevity the world over.
But watching them all on the stage the other night, it was clear that they all still get a terrific buzz from what they do. The sheer joy that they exude is not something you can fake and from start to finish they did nothing but entertain at full pace.
There aren’t many of us who will have the opportunity to experience the adrenaline rush of playing to 60,000 adoring fans, but perhaps the secret to a long life is to live a life where you experience fulfilment of a passion.
On top of that, not one of them stopped moving for over two hours on stage. Mick Jagger moves as a 74 year old more fluidly than I could hope for at 54 and probably hits his 10,00 step target in one show. Following him on Instagram, he is regularly posting videos of his dance workouts and training and seeing him live you know he’s not faking it.
“When you rest you rust,” my Auntie Joan used to say to me. Until her death at 89 she shouted at squirrels, me and the cat and got out into the garden every day if only to see what the gardener had done wrong.
I live lived to the full is a life lived. Move every day, find a passion. Mick and the boys are living proof of its effects.
The United Kingdom boasts, to my mind, one of the most incredible health services on the planet. Free at the point of delivery, the amount we pay in our National Insurance Contributions isn’t arduous and for most, a year’s payments would barely cover an overnight stay in a hospital let alone any extended treatment.
The pressures on staff and resources that we are currently witnessing, is placing an enormous strain on this, the crown jewel of our country. Various parties have played political football with the NHS over the years and we are at crisis point in many areas.
This is not a political or social comment on the state of the NHS by the way. There are good things and bad things about any system, but I know from visiting other countries, we will miss it when its gone! The strains on the service in the UK combined with certain underlying principles of approach, have prompted many to go in search of private health care, and private health insurance is a growing market.
There is however a third tier to the health system. Unregulated for the most part, yet with millions of adherents and customers and turning over billions of pounds. It is of course complementary medicine. Those with half an ounce of previous experience will know that going to the GP with aches and pains is, quite rightly going to get you with nothing more than advice to take some paracetamol and keep moving about.
The evidence suggests that this isn’t bad advice, but for many, there are longer term issues that they feel only a visit to a non-pmary health care provider will address. The list is endless. Chiropractic, Osteopathy all kinds of massage, Bowen, Reflexology, Cranio Sacral and so forth. One of the largest associations in the UK, the Federation of Holistic Therapists, has over 20,000 members, all of whom one assumes has some degree of work going on from week to week.
The cri de coeur of the medical profession is that there is little or no evidence for these therapies and that they have no credence from a health perspective. Whilst the ‘no evidence’ claim is out dated and tired, much of what is on offer on the high street could be seen as questionable. Yet there is a mountain of evidence relating to hands on and manual therapies, as well as the role that guided movement therapies have for a whole range of issues.
Although CAM therapies are often criticized for being used despite a lack of evidence, hundreds of systematic reviews have, in fact, evaluated specific CAM therapies; of these, some have been well conducted and have shown that the CAM therapy offers a clear benefit. State of Emerging Evidence of CAM
More to the point however is the role that this industry plays as a sticking plaster to the NHS. Imagine a scenario where all therapies were banned tomorrow and anyone with any kind of ache or pain had to report to their GP. A system strained to capacity already would collapse before lunchtime.
Dr Phil Hammond, he of MD in Private Eye, has never been an advocate of Complementary Medicine, but argues the case for this third tier being taken seriously. So are ALL doctors agains CM? While there is a large degree of scepticism from them, there is also an acceptance that therapies play a role in the overall management of patients and their ailments.
The industry is, for the most part unregulated. Chiropractors and Osteopaths being the exception are regulated in the same way as doctors, dentists and pharmacists, being part of the nine health care regulators in the UK alongside the General Medical Council and the HPC, which is the body regulating social care.
The question in this forum is; should Comp Med practitioners have access to educational dissection classes that enhance their knowledge? It seems obvious that any further training or anatomical education is only going to enhance the skill set of these practitioners, as well as by extension, increasing the protection offered to the public.
The die hard, old school academics out there might disagree and there have been many (successful) attempts to keep the doors closed to those who they personally consider unworthy. Dr Ian Scott of Nottingham University Hospital is one such academic who is happy fabricating evidence to support his own personal views, closing down a wider engagement.
Ultimately a bonafide interest in anatomy and the human body, based on a daily practice and with good reasons to wish to study, seems good enough reason to engage in a dissection class. Those who want to attend my classes are asked to provide a CV and a brief personal statement, explaining why attending a class would be of benefit to their work. Their work is checked and they are sometimes interviewed over the phone as well.
Times are changing and the hope is that eventually we can bring a wider knowledge base to bear across all health disciplines.