What’s it all about?
In 1998 I started to study the practice and theory of what we would today called hands on therapy. Learning Bowen, reflexology and massage, I was introduced in a very small way to anatomy and physiology and began to appreciate the value in learning about the human body.
Over the years however, the approaches that were presented in anatomy books and the explanations of how things moved and worked, didn’t match up with my experience of hands on body work. I could see and feel imbalances and changes in movement that were body wide, yet the standard anatomical teaching didn’t seem to incorporate that idea.
In 2006 I met Tom Myers and spent time with him studying his idea of imaginary lines of strain around the body as outlined in the phenomenal Anatomy Trains series. It was whilst in New York with Tom, that I first heard of Gil Hedley and his approach to anatomy and dissection and in 2007, travelled to San Francisco to take what would be the first of many classes in human dissection.
Gil’s approach to dissection and anatomy was completely radical, as can be experienced first hand on his YouTube channel. An incredible dissector, what Gil doesn’t know about the body isn’t worth knowing and time spent in his company in a dissection lab is invaluable. What he isn’t however, is a hands on body worker with a practice. A gifted story teller and a passionate advocate for what he believes to be the truth, his eloquence can often drift into realms of beautiful prose, which whilst charming, can leave the more practical minded struggling to extract meaning or relevance.
I have long been fascinated with the stories that therapists tell their clients about what they are doing and why their treatments work. The theories that surround our therapies are ones that as we train we accept, without really having much point of reference. What is actually happening when we feel changes under our hands? What is the mechanism of action that changes something from stiff or tight to relaxed and soft?
The evidence for outcomes in terms of hands on therapy is fairly conclusive that touch therapy is beneficial. Yet why and how still remains a source of debate and there is little consensus. The rise of interest in fascia has spawned dozens of approaches that claim to treat, release, stretch and otherwise alter fascia, with little evidence to suggest that they do any of the above and plenty to suggest that human touch can’t change fascia at all. Yet people feel better and something is happening. My efforts in the dissection lab aim to examine some of the thinking around this and explore how the tissues we see might respond to our own particular type of input.
There is no question that a lot of the tissues we refer to as fascia are very poorly described and understood. Traditional dissection has tended to trim the tissues that get in the way of muscles and the more vital tissues, leaving us with a gap in our knowledge and understanding of how hands on and movement therapies relate to these layers.
There is a lot of science out there in relation to fascia and some research taking place that will no doubt change the way we understand functional movement and hands on therapy. Much of it is beyond the remit of the practicing therapist and falls in to the theoretical knowledge basket for many.
A journey in to a dissection room is one where you are encouraged to explore your own attitudes and ideas, to change your mind where you can and reform your way of thinking. Shifting the narrative to change the imperative.
If as a result of your dissection experience you are able to better help and benefit another person who is in pain or distress, then the work is done.
What is Fascia?
There are several types of tissues that we can refer to as fascia around the body and not everybody agrees on the nomenclature or naming. I am going to follow the path that has always worked for me, mainly my own, in order to explain some of the layers that we include in our fascial family, what they do and why they might be considered important.
Fat or Friend?
Our first stop on this tour is probably the most argued about, least studied and yet most intriguing, the superficial fascia. This layer is often called the adipose, the pannicular layer or subcutaneous tissue and although contains the two types adipose tissue, white and brown, it is also much more than just a fatty layer and is the layer of tissue that we have the biggest direct relationship with in our daily life, in particular if we are therapists who put their hands on people.
The superficial fascia gives us the springy feel to our body and acts as a huge shock absorber as well as a very important infection fighting layer. It’s ability to easily store fat is one of the reasons that we experience obesity but it is also an endocrine organ, secreting hormones such as leptin,(Kershaw and Flier 2004) involved in the regulation of metabolism and appetite, and resistin, increased levels of which are suspected as playing a role in obesity and insulin resistance. In addition cytokines – cells secreted by the immune system- which regulate and control inflammation and emergency responses throughout the body are stored in the adipose. This means that superficial fascia as an adipose layer, has all the equipment it needs, not just to store energy, but to communicate with all the other organs of the body, including the central nervous system. And we thought it was just fat! This layer is a loose, aureolar layer of tissue, which when examined has the appearance of bubble wrap. One can push ones fingers in between the loose pockets of fatty, yellow material and gently tease it apart. Yet at the same time as being almost fluffy and flexible, it is incredibly strong and able to absorb large pressures placed upon it.
If for example you were to press hard and quickly onto it, then just like bubble wrap, the layers would close on themselves and protect the underling tissues from penetration or heavy pressure. It is adhered to the skin in an intimate arrangement that defies manual separation and the only way to examine this layer away from the skin is to use a very sharp blade and forcibly take them apart. Once apart the layer is still incredibly strong, dense and continuous and even prolonged and strenuous pulling will not rip the layer.
As well as the ability to contain fat, it is also a layer of connective tissue, which is three-dimensional and, like the skin sits in a continuous layer all over the body. The globular fatty deposits that are so prevalent here, are held in place by strong white, fibrous structures that give the whole layer a body wide continuity and integrity that is unique in the human form. No layer other than the skin, has this degree of continuity.
This image is taken from the Integral Anatomy Series by Gil Hedley. It shows the superficial layer removed from a cadaver in its entirety. It’s a beautiful layer and one that Gil movingly refers to as this lady’s “wedding dress.”
In dissection, the removal of the superficial fascia can be quite a laborious task, but the change once completed is remarkable. By taking away the entire covering, we can see clearly that what is left behind lacks identity and becomes androgynous and anatomical. The shape we see in the picture above is clearly female. What is left behind is not.
The superficial fascia varies in thickness from a couple of millimetres to several centimetres, but is always connected to skin at its outer surface. In much the same way that the skin is the interlocutor between the inside body and the outside world, the superficial layer is also acting on the internal organs. It is heavily supplied with blood and fluids from the rest of the body and is perforated throughout its surface with blood vessels and nerve endings that reach through it to end on the surface of the skin.
It is also a particularly poor conductor of heat, which means that it is very helpful in retaining the heat of the body and keeping us warm. So with all these useful qualities we have to wonder why we have such a poor relationship with it. The fatty layer that is our superficial fascia is often demonised. We are concerned about having less fat in and on our body, which is fine, but also go to great lengths to lose weight and burn fat and see it as something to be excised, even going to such extremes as liposuction and plastic surgery.
For the physical therapist, this is the layer that we have most in common with and through which we work when trying to reach into other structures of the body. This is the layer which is always present underneath our hands and however much we wish to think about muscle, bone, deep fascia and so forth, it is this layer which is the translator of our touch to the deeper tissues beneath. When working around the gluteal area for instance, the depth of tissue is such that we are feeling a distant resonance of gluteus maximus, and whilst we are able to define tension, tone and feeling of the underlying muscle, much of the quality of this palpatory sense will be subject to the sensitivity of how we approach the superficial fascia.
There are many deep tissue approaches in the world of bodywork, many of these applying great pressure to delve through the superficial tissues in order to work on ‘deep tissues’ such as psoas or even less likely quadtratus lumboruam -QL. In theory you can access any areas of the body you wish to but generally the factor that will keep you out is the tension of the practitioner and the way in which the superficial fascia responds to this tension. If we work through the superficial layer with patience and a light touch, our ability to reach in, palpate and treat deeper tissues without creating pain or being invasive, is straightforward, although I doubt whether the psoas is really touched to any meaningful degree.
My ultimate concerns arise from those therapists who think that in order to go deep you have to go in hard. You don’t and you shouldn’t.
Deep Fascia
This is the subject of most of the fascia world’s obsession. It’s what everyone feels that they know about and is what is depicted or visualised when thinking about a white covering of muscle. This isn’t incorrect, but neither is it the full picture. The tendency of prosectors and those depicting anatomy, is to cut away the bits of the deep fascia that ‘gets in the way,’ and leave the bits behind that are more famous or more visually pleasing.
Then there are the rafts of therapies that have arisen over the past few years, that suggest that this or that ‘fascial release’ treatment is able to somehow change this deep layer of connective tissue. It’s not clear why fascia should be released and if it is, where it should be released to, but that’s not to say the treatments aren’t pleasant and effective, just that it’s highly improbable that much, if anything in relation to fascia, is going to change in the space of a one hour session.
Deep fascia is not one specific or particular thing, except for the main ingredient which forms it, collagen. Collagen is the most common protein in the human body, accounting for over 30% of all the proteins we possess. It’s the material that creates our structural framework and is found to some degree at least, in pretty much every bit of tissue we have.
The white sheets we see when fascia is depicted, are referred to as aponeurotic tissues and are the strong bands of fibrous tissue that we can often feel through our hands, such as the ilio-tibial band on the side of the leg. The strength of these structures are all down to the number of fibres that are present and the job they have to do. The lower body tends to have more deep fascia and aponeurotic structures, simply because there is more stability needed through the legs. In the upper body, where more mobility is required, such as through the shoulders, we see less in the way of strong, multiple layered sheets of thick fascia.
Collagen fibres and by extension fascia, will present in different ways, depending, as already mentioned on the function needed. The strong wrapping around the muscle will be composed of millions of fibres coming together, but as they descend into the muscle itself, the fibres will spread out, become wetter and take on a different role as well as a different name. Epimysium, perimysium, endomysium are all terms that apply to these varied forms of collagen but are in essence all fascia.
The role of fascia is to provide support, texture, structure and strength to muscle, which is incredibly weak by itself. When we eat meat, it’s the fascia that determines how chewy or tender it is and we understand that certain cuts of meat will need much more cooking. It’s the fascia we’re cooking out!
The plethora of therapeutic techniques in the market place that claim to release fascia or to somehow have an effect on fascia has grown enormously over the last few years, all of them with one thing in common, which is that non of them have anything to do with fascia. The idea that we can somehow affect this strong connective tissue by rubbing, poking, shoving or stretching bits of the body, either gently or deeply is, at best biologically implausible. Certainly there is an effect taking place the subject of which is for another arena, but these will not be because the fascia has changed.
Deep fascia does have adaptive properties and can change both in terms of its density, fibrous depth and even length. But these changes don’t happen quickly and certainly don’t happen because a therapist applies manual techniques to the body. My personal view is that we as therapists are working in tandem with the central nervous system, but again, a subject for another time and forum. In conclusion, the understanding of fascia, its role in body wide communication and structural integrity is a fascinating and important subject and should be something that anyone with an interest in the body should study and understand. However it is one type of connective tissue, within a wide and complex family and shouldn’t be considered to be any more or less important than any of the others. Neither should it be claimed as something it is not. Bone is not fascia.