Does Fascia Matter?

There is a lot of fascia research going on these days. None of that research is clearly relevant to therapy. Some of it might be, but it’s all quite debatable. There are no slam dunks. In place of firm theories based on hard data, there’s a lot of speculating about why fascia is important, which leads to some claims that it has (clinically relevant) properties and functions that are still barely known to science. For instance, perhaps fascia can actively cinch up like a corset around muscles, or maybe it is the medium of a liquid crystal communication system, or even maybe it melts like butter when you move. Who knows! Anything’s possible!

In the history of science and medicine, knowledge gaps get filled with guesses, and the guesses usually turn out to be wrong.4 Exotic biology is rarely useful biology. Interesting, but not useful. No one can get safe, effective, reliable treatment protocols out of barely understood biology. If you could, the biology wouldn’t be poorly understood anymore — and you’d be famous for pushing back the frontiers of human knowledge and reducing human suffering. Exotic biology is rarely useful biology.

Some fascia research is truly intriguing. What many researchers are saying about fascia is reasonable. Many are not reaching awkwardly beyond the data. Unfortunately, many therapists fascinated by fascia are reaching beyond — way beyond — what the science can actually support, or probably ever will. In some cases, in fact, we already know enough to know that an interesting property of fascia is only interesting, and irrelevant to working with patients.

Please beware the implication of therapeutic significance from scraps of basic biology. It is easy to sound cool talking about new biology, because biology is cool. It is hard to make biology useful. Few basic biology facts ever become the basis for any kind of treatment. Certainly a lot of fascia science is “right,” but I question whether or not it matters that it is right.

In fact, on one occasion, a rather pedantic experimental psychologist was telling him about a long, complicated experiment he had done, incorporating all the proper controls and using considerable technical virtuosity. When he saw Crick’s exasperated expression he said, “but Dr. Crick, we have got it right — we know it’s right,” Crick’s response was, “The point is not whether it’s right. The point is: does it even matter whether its right or wrong?”

V.S. Ramachandran, telling a story about Francis Crick

Fascia is biologically interesting! All biology is. But clinical relevance is the central question of this article: if fascia science cannot actually improve treatment, then it makes no sense to be fascinated by it in a therapeutic context. You might as well get excited about the biology of the immune system, or olfaction, or epigenetics, for all they have to do with hands-on healing.

Fascia enthusiasts routinely denounce this article, accusing me of ignorance of the current Science of Fascia. However, you should know that I am pretty up on massage-related research — it’s basically my full-time job — so I feel confident challenging critics to cite even one example of fascia research with clear, direct relevance to what happens in treatment. If such a thing exists, I will be happy to publicly discuss it, and acknowledge my oversight. I could be wrong about fascia. I even hope that I am. Maybe it is important to manipulate fascia specifically.

This article covers:

• For context, some fascia basics from mainstream medicine, which sounds boring, but get ready to cringe: it involves amputation!
• For more context, several of the stranger and sloppier examples fascia “science”: piezoelectricity, fuzz, thixotropy, and the acupuncture connection.
• And the main event: three key examples of allegedly clinically relevant fascia research below.

Three key examples may not sound like much, but the article is already several thousand words long, so be careful what you wish for. And all three are excellent examples of fascia science with low clinical relevance or worse. We do not have a winner yet.

All theories and controversies aside, what is the actual clinical significance of fascia in medicine? Why would it come up for a family doctor or surgeon?

It’s boring but critical: fascia functions as an important infection barrier. Much like skin prevents pathogens from getting into the bottom in the first place, layers of fascia limit their spread.5

But there’s a dark side to this vital function — one of the most unpleasant phenomena in all of medicine (which is saying something). If fascia stops the spread of disease, what happens behind the barrier? Well, it can get grim: a blocked infection is also a trapped infection, which can destroy a compartment, with dire consequences. Journalist Miles O’Brien lost a forearm to “compartment syndrome,” a raging infection that came out of nowhere and inflated his forearm like a high-pressure sausage.Journalist Miles O’Brien lost a forearm to compartment syndrome,6 a raging infection that came out of nowhere and inflated his forearm like a high-pressure sausage. Since fascia is so tough and will not yield, circulation gets cut off and all the flesh in the compartment begins to die. The compartment must be sliced wide open to bleed off the pressure — a huge, grisly wound and a slow, difficult recovery even if all goes well. And it didn’t all go well for O’Brien:

Things tanked even further once I was on the table. And when I lost blood pressure during the surgery due to the complications of compartment syndrome, the doctor made a real-time call and amputated my arm just above the elbow. He later told me it all boiled down to a choice…between a life and a limb.

“Just a Flesh Wound”, O'Brien (Milesobrien.com)

Now that is clinical relevance. That’s how the properties of fascia medically matter — its toughness as a wrapping, primarily.

Perhaps there are subtler fascial properties that also matter. But keep this life-or-death example in mind as we look at why massage therapists and chiropractors think fascia might medically matter, starting with the most dubious ideas…

There is a crack in everything
That’s how the light gets in.

Leonard Cohen, Anthem

The piezoelectric effect is an electric charge generated by flexing crystals. It’s a popular notion that this fascinating property of crystals is at work in fascia, and that it’s the mechanism for fascial “release.” These ideas have never been more than speculation. The first is possible but unproven. The second goes much too far and is demonstrably false and clearly contradicted by modern researchers.

Crystalline properties are a firm pre-requisite for peizoelectricity. To get a piezoelectric “spark,” you have to have crystals. In the famous 1987 book Job’s Body — which I read three times, back in the day — Juhan proposes that connective tissue may behave like a “liquid crystal.”7 A strong emphasis on may: this has never actually been shown to be the case. Juhan was speculating. This doesn’t mean that there is no piezoelectric effect in fascia, and there are plenty of problems with the idea, but it’s not totally out to lunch. We do know that piezoelectricity “sparks” fly when bone is flexed and stressed, and this guides the slow remodelling of bone,8 which is super cool. It’s a terribly clever system!

It’s also a great example of a clinically irrelevant biological property. It has nothing to do with anything a manual therapist could ever do to a bone. It is beautifully evolved to change bone extremely slowly in response to extremely specific stimuli which, presumably, cannot remotely be simulated by manual therapy. Trying to affect that system with your hands is quite futile. That’s going to be the case for the great majority of physiological systems, known and unknown — even if you understand them, it doesn’t mean you can use them, or affect them with your hands.

Maybe fascia does something similar to bone with piezeoelectric effect. It wouldn’t “shock” me. But no one has ever demonstrated that it actually does. Indeed, no one has even tried to find that property of fascia, as far as I can tell.

Some people have run with the idea like it’s a proven fact, though. For instance, James Oschman states unequivocally and overconfidently that “connective tissue is piezoelectric,” a fact that can be used as a firm foundation for the further speculation that it accounts for the fascial “releases.”9

And it’s simply inconsistent with the reality of fascial plasticity, which we do know quite a lot about. There’s no point in speculating about how fascia responds quickly to manipulation, because it can’t and doesn’t: it’s too tough and slow-changing.10 In contrast to the total absence of research into fascial piezeoelectricity, the properties of fascial plasticity are well studied, and there simply is no short term change in fascia to explain! It can’t respond to the pressures of massage therapy any more than bone can. In addition to the footnote, this will be substantiated in various ways throughout the rest of the article.

Could piezoelectricity be at work in some other way in fascia? Anything’s possible. But now we’re cruising into pure guess work. Do we know anything at all about it, let alone the physiological intricacies of such a phenomenon? Do we know why it evolved? What it does, how it does it? Can we affect it? And, if we don’t know these things, how can we possibly use it to devise a reliable therapy? Obviously we cannot.

Another fine example of imprecise scientific enthusiasm is Gil Hedley’s extremely popular “fuzz” speech. In this video with a bazillon views, Hedley plays fast and loose with a dissection observation: there are cobwebby layers of fine, loose connective tissue between thicker sheets of fascia. The anatomy is interesting — anatomy is always interesting — but Gil Hedley’s interpretations are dubious. His leaps of logic are charismatic, but also large and precarious.

“That stiff feeling you have is the solidifying of the fuzz,” Hedley confidently explains. He thoroughly makes the case that fuzz explains the sensation of stiffness.

At best, that is an unsafe assumption, and one that ignores many other highly relevant factors — like neurology, say, or the fact that he’s looking at a dead person. He does not know what happens to that tissue in a living body. In fact, that fuzzy texture only manifests post mortem — according to biotensegrity expert, Dr. Steven Levin.11 This is a very interesting passage, worth reading carefully, but note the emphasized phrase particularly:

In Guimberteau’s video, ‘Strolling Under The Skin’, what you see there is that the ‘fuzzy’ stuff is really dynamic tissue that is under constant change. Tissues don’t ‘slide’, there is no shear, they reconfigure with each movement. The dynamics of a cell ceases with death. Ca++ [calcium ions] flood into the cell and it stiffens — that’s rigor mortis. It starts within minutes of death, as soon as the circulating ATP [energy molecule] runs out. The ‘fuzz’ is connective tissue that is stiffened during rigor mortis, and it doesn’t happen unless you die. It occurs within minutes of death, and you can almost watch it happen. It is like snot hardening. The mucus booger that comes out of your nose quickly hardens and becomes quite stiff; at death, the mucus that connects all our tissues, does the same.

All that ‘melting the fuzz’ is conjecture based on misinterpreted observations on dead tissue. Even so called “fresh” cadavers are but poor players in the game of life.

Almost any amount of normal movement is sufficient to sustain a normal range of motion. “Fuzz solidification” either isn’t happening or doesn’t matter, because it’s effortless to move through. Also, there are other explanations for the sensation of stiffness: better, evidence-based, and un-fuzzy explanations. I discuss them in some detail in Quite a Stretch.

A shabby, decades-old idea is still often seriously cited as the explanation for how fascial therapy works: because it softens fascia with “thixotropic effect.” The idea came from Ida Rolf (founder of “Rolfing”). Fascia researcher Robert Schleip:12

Many of the current training schools which focus on myofascial treatment have been profoundly influenced by Rolf (1977). In her own work Rolf applied considerable manual or elbow pressure to fascial sheets in order to change their density and arrangement. Rolf’s own explanation was that connective tissue is a colloidal substance in which the ground substance can be influenced by the application of energy (heat or mechanical pressure) to change its aggregate form from a more dense ‘gel’ state to a more fluid ‘sol’ state.

A quick look at how thixotropy works in human physiology shows that this just doesn’t add up. The thixotropic effect is nifty physiology, but it’s not a therapeutic effect in itself, nor is it the mechanism of one. Ida’s idea was wrong. And, in Ida’s defense, she knew it was! In fact, she called it nonsense herself!13

Thixotropy is an obscure physical property of certain slimy body fluids that get thinner when agitated or stressed. You can easily observe thixotropic effect in beach sand, near the water’s edge: stamp your feet in the sand, and it starts to liquify.

Thixotropic fluids in the human body include synovial fluid in joints, mucus, semen, and the gelatinous and poorly-named goo called “ground substance” — the stuff that gristly connective tissue fibres are embedded in like bits of coconut in Jello. Ground substance is the most plentiful thixotropic substance in the body.

But thixotropy is minor, slow, and temporary, and fascia is too tough to change.

Fascial sheets are incredibly tough, and you can’t “change their density and arrangement” quickly or easily. And thixotropy just isn’t fast enough to explain the relatively speedy, dramatic effects on tissues that therapists claim to achieve. Dr. Schleip: “either much longer amounts of time or significantly more force are required for permanent deformation of dense connective tissues.”14 Thixotropy might slowly make fascia more pliable, but not stretchier. If thixotropy had the power to increase the extensibility of connective tissue, then we would become obviously more flexible just from sitting in a sauna — I’ve tested this repeatedly and never observed any increase in flexibility just from being hot.15

Even if it works in some small way, thixotropic effect is going to be temporary, fading within seconds or minutes after hands are removed. When the stimulation stops, so does the thixotropy, and a therapy can’t work if the affected tissue immediately reverts to its previous state.Thixotropy will stop when the stimulation stops … but a therapy can’t work if the affected tissue immediately reverts to its previous state. Dr. Schleip calls this the “reversibility problem” and “definitely not an attractive implication of this model for the practitioner.”

Last but not least, thixotropic effect is simply a minor effect. It’s occurring a little bit all the time, with or without massage. Massage surely does induce it a little, but just as surely much less than ordinary physical activity — like with circulation. Massage therapists are very fond of claiming that massage “increases circulation,” but if it does so at all, the effect is much smaller than what exercise does! Perspective matters. Another similar thought experiment: if sustained pressures or sheering could significantly change connective tissue, then working a chair all day long — or any long-duration posture — would also deform your fascia.

The idea of thixotropy is hardly state-of-the-art thinking about fascia, but it is certainly still prevalent among therapists practicing fascially-focussed therapy, and trying to explain what they do. Unfortunately, it was never even a good idea in the first place, even decades ago.

Another disconcertingly popular notion about why fascia matters is that the meridians of Chinese medicine correspond directly to fascial anatomy and function. If you polled therapists doing fascial manipulation, I think you would find that a great many believe that they are doing the same thing that an acupuncturist is doing — just in a different way. They believe that fascial therapy works for the same reasons acupuncture works.

Indeed, most fascial therapists probably believe that acupuncture works. And therein lies the problem. Unfortunately for fascial release therapy, acupuncture is not a good ally: it has been failing many fair, good quality scientific tests for years now, and is simply not what it seems to be.

Acupuncture as we know it today is not so ancient after all: its current form is a modern (not ancient) invention of the pediatrician Cheng Dan’an (承淡安, 1899-1957) in the early 1930s1617 For most of history, acupuncture existed primarily as a method of bloodletting — exactly like the prescientific medieval European practice.Before that, for most of history, it existed primarily as a method of bloodletting — much like the prescientific medieval European practice. And then there’s the myth of acupuncture’s popularity.18 Even its alleged popularity and widespread use in China is trumped up — it is, for instance, not actually used for anaesthesia,19 despite widespread belief in this phenomenon.

These are embarrassing facts for acupuncture. All of this and more is discussed in more detail (and heavily referenced) in my main acupuncture article:

I was not a skeptic about acupuncture originally. I came to this position only after a long, uncomfortable period of eduation and gradually eroding faith. But I now accept that acupuncture is obsolete Eastern folk medicine propped up by Western hype and wishful thinking.

Therefore, the proposed association between “fascial meridians” and the “chi meridians” of traditional Chinese medicine is meaningless. Even if meridians and all the other rubric of acupuncture were real, acupuncturists are unable to demonstrate their power clearly: their needles are consistently no more helpful than placebos.20 Even pro-acupuncture researchers have repeatedly admitted that the effect of the needles is small at best. And if the acupuncturists can’t manipulate these meridians effectively enough to achieve clearly measurable effects, why would pulling on fascia be able to do it?

Acupuncture lore has no business in a serious discussion about fascia and its possible importance in therapy.

Piezoelectricity, fuzz, and fascial meridians are three good examples of popular but poor reasons why fascia supposedly matters. There are other reasons, both better and worse, and discussion of genuine fascia science is still coming. But first I want to make it clear that common fascia talk often fails to even reach the level of being “science-y.” Despite all the talk of exotic properties of fascia, fascia’s clinical importance is usually expressed only in terms of a couple extremely simplistic rationales, which don’t seem exotic at all:

1. it’s everywhere and connects everything (well, yeah),
2. and it gets tight (not clear, see below).

A strong theme in fascial therapy is the emphasis on the interconnectedness of anatomy via fascia, always making the point that pulling on any one part of fascia affects the whole body, like pulling on the corner of a sweater affects all the threads. (That sweater analogy appears virtually everywhere online that fascia is mentioned. It gets really tiresome, actually. Didn’t think it mattered much ten years ago. Still don’t.)

The main idea of fascial therapy is that the stuff can get tight and restrictive, like clothing a size too small, and needs to be “released,” and that therapists can achieve this by various methods of yanking on it. The yanking may be extremely intense, too — some flavours of fascial therapy are among the most painful of all hands-on techniques.21

And that’s what fascial therapy boils down to most of the time, in the wild. I have personally encountered lots of talking about fascia that is exactly this rudimentary … and even worse, like the example I quoted in the introduction — “The fascia will make everything better!” Many therapists are perfectly capable of discussing the topic more intelligently, of course, but low quality reasoning and communication about fascia is distressingly common (and my exposure is quite extensive, due to the large volume of email I receive).

Consider this gem of simplistic rationalization:

Restricted fascia is full of pockets. When the tissue starts to release, these pockets are opened up. When these pockets open, the sensations that were trapped in them are released.

Such overconfident, poor quality clinical reasoning isn’t universal — just excessively common within the culture of fascia enthusiasts.

Now, let’s get to some real fascia science.

The greatest enemy of knowledge is not ignorance, it is the illusion of knowledge.

Stephen Hawking

This is one of the most striking stories of incompetent and harmful manual therapy that I have ever received from a reader. (And I get a lot.) It is notable not only for the seriousness of the outcome, but also for the glaring excess of the treatment: so unnecessary! If condemnation and negativity isn’t justified here, I don’t know where it is: the degree of fascia-o-centric incompetence and poor clinical judgement is just appalling. What happened to this patient needs to be discussed openly. Although this is an unusually nasty example, negative outcomes like this are shockingly common, and almost never reported to the therapist who perpetrated them — or, if it is, the therapist rationalizes it away as a “healing crisis” or any one of a list of other intellectually dishonest evasions.

Funny drawing for a most unfunny story. (Drawing by Claude Serre.)

The story

I have re-written the story a little to anonymize and condense it, but it is otherwise presented as it was received:

I visited a massage therapist a month ago for treatment for soreness/achiness in the balls of both feet and in the toes. Claiming that tight calf muscles and hamstrings were causing my heel to lift too far (thus placing pressure on the balls of my feet), she proceeded with a half hour fascial release therapy on my calves, using her full weight and her elbows.

It was extremely painful, but I gritted my teeth, thinking it necessary "to break up the knotty muscles." She moved from point to point up and down my calves, twice. A week later I had another such treatment, and she also also persuaded me to buy a rubber roll so that I could do the "therapy" at home. She told me I should try to reproduce the same pain level, on calves and hamstrings. I did this every day for one hour for five days. I did the same with a wooden roller under my feet, using my own weight.

During that time, I started getting stabbing and burning pains in my feet, the backs of my legs, and then later my hands and armpits. The stabbing pains varied from a pinprick feeling to electric-shock/lance-like, and they varied in their frequency rate. The burning was either tingly or felt like bad sunburn. The pain seemed to be aggravated by walking, and was always worse by afternoon/evening. I had trouble sleeping, because I could not have heavy bedclothes on my feet, and nor could I put one leg on top of the other, without pain.

I returned to my GP, had blood tests, x-rays, a CT scan. Because my symptoms seemed neuropathic in nature, I was referred to a neurologist. After eliminating a number of other diagnoses, the neurologist thinks the problem is biomechanical or related to muscles, and that the MFR may have caused an oversensitivity to pain.

I then searched the Internet for information about myofascial release being damaging or making pain worse. It was very difficult to find, because of all the "positive" hype around MFR. Fortunately, I found your website …

The implications

What happened here? Aggressive and intense manual therapy with no regard for the state of the patient’s nervous system or the potential to provoke an extremely serious chronic pain state, probably via the mechanism of “central sensitization.” This patient’s prognosis is impossible to call: it could last another week, or this patient could suffer excessively for the rest of her life.

For the duration of my decade as a massage therapist, I had a reputation as a gentle therapist, and many of my patients were “refugees” from excessively intense treatment, many of whom vented angrily to me about the abuse they had received from other therapists. Vancouver is a “fascial release” mecca, with many therapists who believe that there is no gain without pain, and many or all painful problems are caused by fascial “restrictions” that must be painfully “released.” As a therapist who defined himself in opposition to this obvious trend, I was treated to many, many outraged patient anecdotes about the brutality of other therapists.

Having also personally experienced that intense style of fascial release many times, I knew all too well what these patients were talking about. Almost none had found the courage to discuss their concerns with the confident (overbearing?) therapists who had mistreated them. Almost all had even earnestly tried to like it, at first. Sometimes, rather sadly, they were even still trying to rationalize it as positive, i.e. “I’m sure it was probably what I needed, but I just couldn’t take it anymore!”

Of course some people enjoy intense therapy — and hey, if your nervous system is okay with it, that’s fine. Most of those therapists have many devoted patients who, for various reasons biological and psychological, are more willing and able to tolerate extreme therapy. However, they are also leaving behind them a trail of angry, injured patients … patients who never raised a word of objection.

That’s why stories like this are important. There are bound be therapists reading this who have actually done this to patients, who do it every day. Many will react defensively. Many will delude themselves into believing that they are the more judicious exception to the rule. But some, perhaps a few who are already questioning their own methods, will probably be moved further in that direction. I hope.

Better still if patients feel emboldened to reject such treatment more quickly.

The conceptual cancers at the heart of this incident are structuralism and the for-profit trademarking and packaging of treatment methods, what I call modality empires — and “fascia” is a defining, central feature of several of the most famous modality empires. Fascia sells. It’s prevalence in the marketplace has much more to do with marketing than sound clinical reasoning.

Now, back to the science.

“Manual therapists need not feel threatened by the news that we cannot stretch fascia.”

If We Cannot Stretch Fascia, What Are We Doing? Alice Sanvito, Massage Therapist

My original challenge to readers (in the fall of 2011) to suggest fascia science that supports fascial therapy was kicked off with a fine example: one that is just about the exact opposite of what I asked for, underminding the clinical relevance of fascia rather than supporting it. Despite the extraordinary number of comments I received on early versions of this article, few readers answered my challenge directly. Of the handful of scientific papers that were suggested to me, this was the most “interesting”:

“Three-dimensional mathematical model for deformation of human fasciae in manual therapy”
Chaudhry et al. Journal of the American Osteopathic Association. Volume 108, Number 8, 379–90. Aug 2008.

The Chaudhry et al article is indeed “clinically relevant” to fascial therapy … but not in a supportive way. This fascia science actually contradicts the big idea of fascial therapy.

The main point of manipulating fascia22 is to physically change it in some way — to achieve what is usually described as a “release.” Although the concept of release may correspond to some other physiological phenomenon — another discussion — it certainly cannot be explained in general by physically changing the fascia.

What Chaudhry and colleagues showed is that fascia is much too tough to “release" (mechanical deformation23) by stretching it. Although they oddly imply in their summary that it might be possible to do so with the superficial nasal fascia, the main text of the paper makes it clear that even that thin tissue is extremely tough, and would only mechanically deform if subjected to surprisingly intense forces. This is consistent with well-established properties of fascia, namely that it’s extremely tough stuff. Collagen is like that.

If I could write my own conclusion to this paper, it would go more like this:

CONCLUSION: You cannot change the structure of fascia, because it is tougher than Kevlar. If the stuff were thicker, people would be bulletproof.24

CLINICAL IMPLICATIONS: If you want to physically change someone's fascia by force, you're going to have to get medieval. This directly contradicts a major popular rationale for fascial manipulation.

This paper is only clinically relevant to fascial therapy insofar as it presents evidence that discourages and undermines existing common practices and beliefs. Therefore, perhaps it was a poor choice to cite it in this context.

It’s also just old news that fascia is too tough to change. For instance, Dr. Robert Schleip debunked the idea in his 2003 paper about fascial plasticity, and if you don’t take his word for it — a well-respected fascia researcher — then whose opinion would be credible enough? He dismisses the traditional explanations of thixotropy and peizoelectric-effect-mediated adaptation, and thoroughly describes fascial toughness. He concludes that plastic fascial change in response to moderate loading is “impossible to conceive.”25

As strongly stated as that may be, I’ll go even further. Dr. Schleip (and virtually everyone else) assumes that “release” is a real thing that needs explaining. I’m not so sure…

Hat tip to TheAwesomePT.com for the awesome fascia meme.

In the context of fascial therapy, a “release” is:

• a palpable, relatively quick change in tissue texture
• clinically meaningful (makes some kind of real difference to the patient)
• somewhat lasting (if it didn’t last, what would be the point?)
• somewhat predictable (that is, it’s happening because of treatment)

And fascial therapists more or less unanimously assume that it’s fascia, specifically, that is doing the releasing.

No doubt the first thing — a quick change in texture — happens in the course of manual therapy. It is not safe to assume the rest, though. And what’s left of the concept of a release if you take away the clinically meaningful, lasting, and predictable parts? What if it’s just a change in texture, a bit of movement under the skin?

In my many years working as a massage therapist, I felt various and sundry ripplings, twitchings, and shifts under the skin. But in order to qualify as “releases,” those movements should have correlated strongly with my intentions and with the patient’s experience. Sometimes they did, but often they did not. So I always thought they were really quite random, occurring with great variety pretty much no matter what I did, or what patients reported.26 So while I certainly felt something change, I rarely thought of those changes as a meaningful “release.”

Dr. Schleip’s 2003 paper about fascial plasticity basically just said that fascia is too tough to change, but muscle may react to touch and pressures, and that this is probably mediated by sensory nerve endings in all soft tissues. This is hardly surprising — it basically just means that people react when poked and prodded — and it doesn’t really have anything to do with fascia in particular, except insofar as fascia has nerves in it, just like everything else. We have no idea whether or not any of that actually constitutes a meaningful mechanism for a “therapy.” I can also make someone twitch their quadriceps by bonking their patellar tendon: does it matter, other than as a test of the reflex itself?

Releases are probably mostly just trivial tissue “noise” in the hands-on experience, not a pivotal event in therapy. Or, if they are more meaningful, they are nearly impossible to interpret. It’s not that nothing’s going on … it’s that nothing in particular and knowable is going on. But we have trouble grappling with that, so we round it off to something more specific and definite and meaningful, an oversimplification that is more poetic than biologic. I have no objection to using “release” as a description of an experience, but I think it is quite misleading to pretend that it describes a particular biological event with clinical meaning and value — which is exactly how most therapists imagine it, which is the only thing that really needs explaining. (And that’s not difficult: it boils down to a thick stew of good intentions, ego, and the human habit of imposing simplistic explanations on chaotic systems.)

For some folks, this visual joke probably needs some splainin’. If you don’t know Pulp Fiction, there’s a legendary scene in which Samuel L. Jackson scares the hell out of a punk who keeps answering his questions with a stunned “what?” Jackson dares him (and then double-dares him) to say it again, and then shoots him. The phrase “say ____ again” has become a catchphrase: fill in the blank with anything you’re sick of hearing about. It implies that you’re so fed up you might just shoot the next person who says it. So the other part of the joke: “release” is an exasperatingly meaningless and misleading term. In particular, the term has reached annoying buzzword status when paired with faddish excitement about fascia. Many therapists will have trouble understanding the frustration, but many professionals really are pretty fed up hearing about fascia in general, and release in particular, so hence the joke. We find it hilarious.

Perhaps … but the clinical relevance of this data is tenuous at best — so low that I would never normally be interested in this paper. In fact, I would never have chosen to read it myself, because I don’t think it’s good enough science. I spent some time on it only as an gesture of good faith to a critic, who supplied the paper as an example of basic fascia science that matters. It was probably not a good choice for that purpose.

“In vitro modeling of repetitive motion injury and myofascial release”
Meltzer et al. Journal of Bodywork & Movement Therapies. Volume 14, Number 2, 162–71. Apr 2010.

This is a test tube study showing that naked cells handled stress better (fewer signs of harm) if they were treated with “simulated myofascial release” (MFR). A meaningful, accurate simulation of manual therapy on naked cells is an amusing notion, and it’s clear that what happened to those cells differs dramatically from what would happen in a real living body.

Even if true and reproducible, this data would mainly support the rationale for MFR specifically for post-exercise soreness — something of a dead end for clinical relevance, because exercise-induced soreness has little to do with the main claims of fascial release therapy, which primarily concerns correcting postural asymmetries, eliminating alleged restrictions, and treating chronic pain.

Post-exercise soreness is comparatively trivial, and patients usually don’t seek therapy for it.27 There’s a lot of research showing that exercise-induced soreness is basically invincible anyway.28 A meaningful, accurate simulation of manual therapy on naked cells is an amusing notion.For this property of fascia to be clinically relevant, it would have to imply that MFR might be able to treat chronic pain from other causes … not the transient annoyance of soreness after a game of soccer.

This isn’t a rejection of all possible clinical relevance of the data. My point is that there are so many problems that its relevance is watered down to quite a thin sauce — way too thin.

I do concede that the paper shows some evidence that fibroblasts have interesting and perhaps positive responses to mechanical forces. That is inherently interesting biology, and perhaps well worth investigating further — but it’s a long reach to postulate any clinical relevance to what most therapists do, most of the time, with patient’s fascia.

“Reach” is what the authors do, however. I suspect they are deeply interested in validating the notion that “fascia is important,” because they seem to be seeking evidence to support their pre-conceptions — typical of The National Center for Complementary and Alternative Medicine-funded research, and a hallmark of low quality science. It’s quite likely that if neutral researchers — with no interest in fascial therapy — did this experiment they would not get or report the same results.

The next example of fascia science was suggested to me by Gil Hedley. Since he clearly believed me to be ignorant of fascia science and in dire need of educating, I asked him to recommend some reading to me — a favourite paper showing something interesting and clinically relevant about fascia. As expected, he recommended a paper I was already familiar with, because it is something of a classic of fascia science: Robert Schleip’s 2006 dissertation on the contractile properties of fascia. Much more interesting stuff than the previous two examples. I will get into much more detail about this paper than the first two.

“Fascia is able to contract in a smooth muscle-like manner and thereby influence musculoskeletal mechanics”
Schleip et al. Proceedings of the 5th World Congress of Biomechanics, Munich. Volume , Number , 51–54. 2006.

Schleip and colleagues convincingly showed that fascia contains muscle cells and that they can contract — slowly and weakly. That is undeniably interesting biology! But the point of this analysis is to ask: Does it even matter whether its right or wrong? Is it clinically relevant? Does it improve how we do therapy? Can we use the knowledge to affect the body with hands? That is the question.

It is also a question that Dr. Schleip and his colleagues have addressed themelves on their website, FasciaResearch.de. What follows is my own analysis, which is generally consistent with theirs. However, interested readers should definitely have a look at their article: it is readable and chock full of useful perspective, answering questions like “Does fascia contract in response to emotional stress?” and “Can fascia contract on its own?”

Important update: Dr. Schleip has read this article and corresponded with me about it amiably, and expressed clear agreement with my main point. Although he also had some thoughtful criticisms, we agree on what matters, and he shares my frustration with clinical overconfidence in fascia. I invited him to make a statement for my readers about this: look for it at the end of this part of the discussion.

Before we get to clinical relevance, I’ll quickly explain what Schleip et al. found: a kind of muscle cell in rat fascia, which they described as “rather unexpected.”29 They also tried out various methods of stimulating them in vitro (test tube) and found that, by golly, those muscle cells did what muscle cells do: they contracted! Slow, weak contractions. But they contracted.

Perspective

By any measure, fascial contractions are dramatically less powerful than muscular contractions. If anything, this diagram gives far too much credit to the power of fascia, which would barely register at all if depicted more accurately.

It’s certainly not difficult research to understand.

Some important context that fascia fans will appreciate: for a long time, fascia was and often still is incorrectly thought of as a fairly lifeless, inert substance, the Saran Wrap of biology. I still hear various educated people referring to it in this way. However, massage therapists and chiropractors (in particular) are prone to swinging to the opposite extreme and talking about fascia as though it is more interesting than a lifetime subscription to National Geographic. The truth is somewhere in the middle.30 Dr. Schleip’s research demonstrates this. Fascia is not inert.

But neither is it all that lively — at least not in terms of contractility. We are not talking about a lot of muscle cells here. If you had blueberries with your cereal in the same proportion, you’d be disappointed — not enough blueberries! It’s just a few muscle cells scattered throughout the fascia. There’s so few that they are visible only when you look very closely and in just the right way.

Nor are we talking about particularly strong contractions. Fascia isn’t going to be ripping apart any chains with its bare hands. The maximum force generated by a small bundle of contractile rat fascia was around 35mN.31 In plain English that’s “not very dang much” or the somewhat more precise “about what it takes to set an AA battery rolling on a nice smooth surface.” (It took me a long time to work that out. I have a weird job.) That’s not bad for a bundle of rat fascia, perhaps, but it doesn’t really hold a candle to middle-of-the-night charlie horses either.

Compared to the power of muscle contraction, fascia power barely even registers.

The “bull versus mouse” comparison is a little unfair though, because it’s not just a matter of strong versus weak. Although fascial contractions may be weak compared to muscles, they could nevertheless be powerful in another way — their effects might, for instance, accumulate over time to produce contractures (permanent “seizing up” of tissues). So it’s still worth considering how these contractions might be clinically relevant.

Schleip et al.’s basic finding seems sound enough, and I see no reason at this time to dispute the observation that fascia can contract. If there’s anything wrong with their research methods, I don’t know what it is. But for the property they described to matter to therapists who are choosing to focus their therapeutic attention on fascia — for any biological property to be clinically relevant — it must be significant enough to have an effect on health. (It then must also be something that we can do something about, but let’s start with it mattering in the first place.)

Schleip et al. characterized the raw power of fascial contraction quite differently than I just did. I deliberately made it sound trivial, within the bounds of their numbers.32 In their words, however, in the large sheets of fascia in the low back, the contraction could be “strong enough to influence low back stability and other aspects of human biomechanics.”

Stability? Even if you exaggerate their numbers, they would still only account for a small fraction of the postural muscle power involved in dynamic spinal stabilization, never mind the generally astounding structural toughness and resilience of the human spine. The idea that low back stability could be affected in any way by such a small, slow-motion force is a bit much for me to swallow.3334

And that’s based on an estimate of the theoretical maximum force generated by the biggest, thickest blankets of fascia in human anatomy. In most places in the body, fascia is much less substantial — tough for its weight, but mostly quite thin and wispy, and a lot of it even microscopic.35 The forces generated must be dwarfed by that of muscle itself — in rough proportion to the number and size of contractile cells involved.

That fascial contractions might influence “other aspects of human biomechanics” is a bit vague. A general example of such “aspects” might be that contracting fascia could be involved in biomechanical asymmetries — tighter on one side than the other. The validity of such a concern depends on just how sensitive you think human biomechanics are to forces so subtle that no one really had any idea that fascia contraction was even happening before this study. As regular readers here will know, I think biomechanics are over-rated as a factor in all kinds of pain problems, and there’s extensive evidence that human beings are wonderfully adaptable and cope surprisingly well even with gross deformities, never mind subtle asymmetries and “imbalances.” I make that case in great detail in another article.36

The wording of the conclusions of Schleip et al.’s paper is synonymous with saying that fascial contraction is relevant only if structuralism is a useful mode for doing and thinking about therapy. Also, their phrasing shows a strong bias in favour of the “importance” of fascia. And the study was funded by the International Society of Biomechanics, the Rolf Institute of Structural Integration, and the European Rolfing Association.37

Weak, slow fascial contractions strike me as being scientifically valid and interesting, but clinically minor. Once again, far from making me interested in fascia as a target for therapy, fascia science is convincing me of just the opposite.

If it makes anyone feel better about all this, I’m happy to concede that fascial contractility might be a little bit clinically relevant. Other evidence might even reveal something important — although that would surprise me. It doesn’t hurt my main point to make these concessions. To make my point, all I have to establish is that the clinical relevance is debatable and probably minor at best, rather than the slam dunk it would have to be to support even half of the “excitement” about fascia you see in the therapy industry today.38

In his original dissertation, Schleip limited his speculation about clinical implications to the broad generalization that it can “influence musculoskeletal mechanics,” such as spinal stability. In a follow-up paper for Medical Hypotheses,39 he and several colleagues generally suggest that fascial contractility is a factor in muscle stiffness. The high water mark for potential clinical relevance is spelled out in this passage:

This offers the possibility of a new understanding for many pathologies that involve a chronically increased myofascial tonus. Examples include conditions such as torticollis, low back pain associated with paraspinal compartment syndrome, tension headaches, and others. Similarly a decreased fascial tone could be a contributing factor in conditions that are often associated with decreased myofascial tension, such as in back pain due to segmental spinal instability, peripartum pelvic pain, or fibromyalgia. While usually other factors play a major role as well in these pathologies, it is possible that their progress could be influenced additionally by the regulation of fascial tissue tone …

The emphasized phrase is key — it’s an understatement. For instance, other factors don’t “usually” play a major role in those conditions, they always do. And the role of those factors isn’t just “major,” but probably nearly total — relative to the presumably minor (and still unconfirmed) contribution of a little fascial tension. Some of the items listed are particularly implausible to me. I’ve already mentioned how hyperbolic it is to suggest that fascia could have any serious impact on spinal stability.

Another peculiar item here is fibromyalgia, a fascinating condition that might conceivably be affected in some small way by fascial contraction, but which is overwhelmingly a nasty disease of the nervous system. Suggesting it as a main example40 of how fascial contraction might matter makes about as much sense to me as saying that people with cancer might have some contracted fascia — would it matter if they did?

The most interesting item listed is “compartment syndrome,” which is decidedly not a common complication or cause of back pain, but certainly is a problem (especially in the shins).41 Compartment syndrome is excessive pressure in a fascial compartment, like a sausage swollen in its wrapping. If fascia were to start squeezing a compartment for some reason, it might be a problem. It is the one item listed where there is a clear, direct and logical connection between “fascia can contract” and a way that it could contribute significantly to a health problem. That is clinical relevance. And yet there is still a clear problem with the scale of the forces here. Compartment syndrome is by definition only a problem when the pressure is significant, probably dramatically exceeding the maximum force with which fascia could squeeze the compartment. Visualize a hot water heater that isn’t venting pressure — the valve is busted, and it’s in danger of blowing. The pressure inside is immense, and it would make no practical difference if the hot water heater itself was a little larger or smaller. Again, fascial contraction is probably not nearly strong enough to matter. Still, at least it’s easy to see how it could matter in principle, and the numbers might favour fascial contraction as factor.

So you see how this goes: for one candidate example after another, the clinical relevance of fascial contraction is dubious or minor.

One of the lower moments in biology history was the labelling of non-coding DNA as “junk DNA” in 1972. The first time anyone with a scrap of imagination heard that, they thought, “Yeah, right.” As biologists slowly figured out what all that “junk” is for,42 there was a lot of “Well, yeah, okay, that’s more like it. Of course.” It’s interesting science, but in some ways those discoveries are still overshadowed by the way we’re all not so very surprised.

Similarly, the presence of muscle cells in fascia is no shocker. I never believed fascia was entirely inert any more than I believed in the junkiness of any DNA. If you spend much time studying biology, it quickly becomes apparent that there are no sharp lines or divisions, and that we consist of an incomprehensibly diverse and interconnected community of cells. That connective tissue has a small population of muscle cells strikes me as blindingly unsurprising. Muscle blends exquisitely into tendon, with no clear demarcation at the cellular level: at the microscopic level, it’s like walking through the overlapping zone of two heavily integrated adjacent neighbourhoods, and the further you go away from the muscle, the fewer muscle cells you see, and the more fibroblasts and their fibres. That connective tissue has a small population of muscle cells strikes me as blindingly unsurprising. Fascia surrounds and fractally wraps every muscle inside and out, for crying out loud — how could it not have a few muscle cells and overlapping properties?

I didn’t know that before it was confirmed, but I certainly don’t find it particularly surprising. I suspect that the slightly contractile properties of fascia are simply at one end of a continuum of motor function. Our muscular system is overwhelmingly our primary means of reacting to stimuli — the major output of our nervous systems — and in general terms the slight contractility of fascia is probably just the fringes of that functionality, a little bit more of the same. There are probably some subtle differences, but they are subtle and arcane and ultimately just a slight variation on the biological theme of muscularity. I’m not saying it’s completely uninteresting, but it’s overshadowed by the much more interesting muscular system as a whole, about which fascia is simply a mildly intriguing subtopic. And, in terms of clinical relevance, the muscular system itself is in turn overshadowed by neurology.

Recently Dr. Schleip read my article and wrote to express his basic agreement with my key point about his research: “Your comments on the small size of fascial contractions are right on, at least when viewing these within the periods of seconds to minutes, as is usually applicable for bodywork techniques.” He also wanted me to know that he shares my annoyance with the “over-zealous claims and projections” of therapists doing fascial work. He is not thrilled with the way his research is being used to justify premature overconfidence in fascial therapy.

He also offered some thoughtful criticism on some specific points (and I made some changes, and will probably make more). Nevertheless, he had no major objections, and was generally pleased with what he read here: “You have my respect for your detailed and critical analysis of the present work on fascia. Most of the people who criticize you have not done a portion of your reading work and could certainly learn a lot from the debate you started.”

I invited him to make a statement for my readers about this. Here is it in full, with some emphasized highlights:

I share your emotional frustration with the current trend among bodyworkers of attributing anything wonderful or astonishing to the properties of fascia. In fact, our Fascia Research Group at Ulm University has been receiving an almost exponentially increasing number of inquiries from enthusiastic healers (and martial art teachers) worldwide who wish that we would sanctify their claims that fascial contraction provides the explanation for their observed miracle powers. While I do tend to believe that the fascial net plays much larger roles in human functioning than previously assumed in orthopedic medicine, I am afraid that such over-zealous claims and projections are undermining the seriousness of the investigation and academic rigor that characterizes the work of the current leaders in fascia research, such as P. Huijing, H. Langevin, T. Findley, P. Standley and A. Vleeming.

As a bodywork clinician myself, I have learned that there is hardly a more dangerous attitude among therapists than the hero healer/manipulator who is damn sure about his diagnosis and supposed treatment effects . This of course applies as much to fascia-oriented therapists as it does to those who base their work on supposed neuromuscular or other physiological effects, most of which are still unproven. “There is hardly a more dangerous attitude among therapists than the hero healer who is damn sure about his diagnosis & supposed treatment effects.”While scientists can learn a whole lot from the intuitive and experiential wisdom of complementary therapists, particularly about the non-fragmented and connecting properties of the fascial net, we bodyworkers can learn at least as much from the careful, questioning approach of good scientists, who are willing to doubt their own assumptions and to refrain from premature confidence and over interpretation of their findings. It is this mutual learning and interdisciplinary enrichment which in my opinion characterizes the best qualities of the current fascia research field, as expressed in the international Fascia Congress series and associated activities.

Again, Dr. Schleip and I do not agree about everything — but that is unimportant compared to our shared values and commitment to cautiously reserving judgement. We have each placed our bets on this topic, but not closed our minds. I fully support and endorse his enthusiasm to explore the biology … and he supports and endorses the value of my critical analysis.

There is more fascia science, and I will extend this article with more analysis in the future. I honestly hope that there is clinically relevant fascia science — that would be terrific. So far, however, I see no good reason for therapists to be fascinated by fascia and to make it a target tissue.

Other alleged fascial properties and clinical relevance issues I intend to address eventually (definitely not a complete list):

• The claim that connective tissue is a colloidal substance in which the ground substance can be “melted” by heat or mechanical deformation (thixotropy), and that this is the basis of a therapeutic “release.” Done February 2013.
• The claim that fascia is a “liquid crystal.” While it certainly has some elements of truth in it, the relevance to therapy is extremely dubious. This is closely related to the piezeoelectricity claim already covered by the article, but there is more to say about the liquid crystal idea specifically. Done February 2013.
• The claim that fascia contains “memories” in some sense. I will likely dispute both the property and its relevance.
• The claim that fascia is structurally important and tensegrity is interesting (agree), and that this is clinically relevant (disagree). Much of my rebuttal on this score already exists in my article about structuralism. For another sneak preview, see also this amusingly vague bit of junk science about “tensegrity-based” massage.
• The claim that the phenomenon of “force-transmission” means that much “muscle” tightness is actually attributable to fascial restriction. Although there is little doubt that fascia transmits and distributes force in interesting and probably counter-inuititive ways, I will probably dispute that the phenomenon is clinically relevant, because I doubt that it is either abnormal or treatable.
• The claim that there are fascial adhesions that matter and can be released/treated with the right manipulation.

What better way to end this article than with the momentous news that Tom Myers is “pulling back from that old ‘fascia’ buzzword” … but cells are still neat, therefore therapy!

I’m genuinely pleased to see Myers write this (and he must have known when he wrote it that it would be enthusiastically quoted by his critics):

I am so over the word ‘fascia’. I have touted it for 40 years — I was even called the ‘Father of Fascia’ the other day in New York (it was meant kindly, but…) — now that ‘fascia’ has become a buzzword and is being used for everything and anything, I am pulling back from it in top-speed reverse. Fascia‬ is important, of course, and folks need to understand its implications for biomechanics, but it is not a panacea, the answer to all questions, and it doesn’t do half the things even some of my friends say it does.

I don’t think it has important implications for biomechanics, and I don’t think it does a tenth as much. But this is still progress!

Cells are neat, therefore therapy

After pulling back from that old “fascia” buzzword in top-speed reverse, Myers goes on to tell us about some science about how cells sense the texture of their surroundings:

Organismic movement and stretching — yoga‬, pilates, training‬, manual therapy — can help cells to their proper tension environment by relieving pressure or strain, and this results in better functioning all over. Why should yoga help digestive problems, or some of my bodywork clients report increased regularity of their periods? This points the way.

No, there is no way-pointing here: it’s nifty cellular biology, but it’s about as relevant to our macroscopic activities as knowing how oxygen binds to hemoglobin. We’re talking about molecular scale structures that are the functional equivalent of nerve endings, “feelers” that tell cells “whether they are on a rigid or a soft surface,” cell proprioception. I’m glad for the cells, and I’m glad someone maybe identified how they do this. That’s great, truly it is, go Team Science!

But it’s also about as surprising in principle as a tree in a forest. Such a mechanism more or less had to be there. Cells are marvellous little critters, so of course they must know all about what’s going on around them, and doubtless they do it in many clever ways.

Connecting that to yoga and manual therapy is an odd but inevitable spin. Read that again: he goes from cells have cool molecules that detect tension to bodywork makes periods more regular. That’s quite a leap — over a thousand other variables and mechanisms of vitality!

And this is a perfect example of what has always been the problem with the fascia hype: torturing basic biology until it confesses to being relevant to $1+/minute manual therapy. That is really what this article is about.

• PS Your Back Is Not Out of Alignment — Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain.
• PS Pain is Weird — Pain science reveals a volatile, misleading sensation that is often more than just a symptom, and sometimes worse than whatever started it. The role of the nervous system in chronic pain is the major alternative to focussing on fascia. It has much clearer clinical relevance.
• PS Does Massage Therapy Work? — A review of the science of massage therapy … such as it is.
• PS Trigger Points & Myofascial Pain Syndrome — A guide to the unfinished science of muscle pain, with reviews of every theory and self-treatment and therapy option. Includes a section on the relationship between fascia and trigger points (e-book customers only).
• Greg Lehman, a chiropractor and physiotherapist has a thoughtful new fascia article, “Fascia Science: Stretching the power of manual therapy.”
• Todd Hargrove, a Rolfer and writer (BetterMovement.org), has a good post on fascia and foam rolling and fascia under the microscope.
• “If We Cannot Stretch Fascia, What Are We Doing?,” a webpage on Massage-StLouis.com. Massage therapist Alice Sanvito’s clear summary of Dr. Robert Schleip’s theory that fascial “release” may be attributable to changes in muscle tone stimulated by mechanoreceptors in fascia and other soft tissues, and not by plastic deformation of fascia.

New conclusion (Jan 16 '16, section #4.2) — See section #4.2, The “Father of Fascia” is so over it.

Minor update (Mar 13 '15, section #1) — Small addendum regarding physical therapy. See section #1, Introduction.

Minor update (Nov 28 '14) — More introduction editing for readability.

New section (Dec 11 '13, section #3) — Well, sort of new. I blogged about this in the summer of 2011, and I’m just now getting around to transplanting it here. But “here” was always its ultimate destination. See section #3, Real fascia science that supposedly matters.

Minor update (Jul 19 '13) — Edited introduction for clarity, and added a couple new “to-do” topics.

Minor update (May 9 '13, section #2.3) — Interesting new information about what Ida Rolf believed about the relationship beween thixotropy and the idea of fascial release (hint: “nonsense”). See section #2.3, Ida’s idea about thixotropy.

Rewritten (Feb 20 '13, section #2.1) — A major editing job, particularly to include the much more specific idea that piezoelectricity accounts for releases. See section #2.1, Electrified by piezoelectricity.

New section (Feb 19 '13, section #2.3) — No notes. Just a new section. See section #2.3, Ida’s idea about thixotropy.

New section (Feb 15 '13, section #3.2) — No notes. Just a new section. See section #3.2, “Release” may not even be real.

Minor update (Jan 31 '13) — Several minor additions and edits.

Minor update (Aug 30 '12, section #3.5) — Added some acknowledgement that fascia contractility may still have some slow-motion “power” even if it is quite weak. I’ll probably expand on this soon. See section #3.5, Fascia strong like bull! Or … mouse?

Minor update (Aug 30 '12, section #3.4) — Added a very useful link to FasciaResearch.de. See section #3.4, Does it matter that fascia contains muscle cells?

New section (Jul 31 '12, section #2.4) — No notes. Just a new section. See section #2.4, The acupuncture connection: is fascia actually magic?

Major update (Jul 25 '12) — Article launched as a compilation of about four previous articles on this topic, with revisions and some new information.

1. Physical therapists are less likely to be excited about fascia than their colleagues in alternative medicine, but they are certainly not immune to it, or other dubious treatment ideas. One of the largest fascia-centric modality empires was founded by a physical therapist. BACK TO TEXT
2. This article is quite “negative” — in the sense that critical analysis is always negative. But I have fun taking therapy seriously. Criticism and deconstruction of ideas is normal and healthy and necessary for therapy professions to grow and change. See Why So “Negative”? BACK TO TEXT
3. I hadn’t presented her with any musculoskeletal problem. She was pathologizing at random. It was supposed to be a relaxation massage, in a spa. And yet she was a Registered Massage Therapist — unusually well-trained in this neck of the woods. And that’s probably exactly why she felt compelled to strut her stuff and “troubleshoot” my case and talk about fascia. BACK TO TEXT
4. The poor track record people have guessing about how things really work is a well-known principle. It is enshrined in a scientific concept: the “null hypothesis,” the assumption that ideas are probably wrong until proven right. BACK TO TEXT

5. Gray’s Anatomy for Students:

   Clinically fascias are extremely important because they often limit the spread of infection and malignant disease. When infection or malignant diseases cross a fascial plain, a primary surgical clearance may require a far more extensive dissection to render the area free of tumor or infection.

   A typical example of a fascial layer would be that overlying the psoas muscle. Infection within an intervertebral body secondary to tuberculosis can pass laterally into the psoas muscle. Pus fills the psoas muscle but is limited from further spread by the psoas fascia, which surrounds the muscle and extends inferiorly into the groin pointing below the inguinal ligament.

   BACK TO TEXT
6. Milesobrien.com [Internet]. O'Brien M. “Just a Flesh Wound”; 2014 Jun 22 [cited 14 Nov 27]. BACK TO TEXT
7. Juhan D. Job’s body: a handbook for bodywork. expanded ed. Barrytown; 1998. If you can manage the density of the language, Job’s Body is thick with creative insights into physiology and healing. Perhaps too many of them, and perhaps too creative — but very stimulating! Juhan tries to explain why bodyworkers often seem so uncannily effective. This is a job that certainly needed doing. In trying to explain bodywork, Job’s Body is a philosophical introduction to the science of the human body — a physiology textbook with a heart. Many chapters are devoted to pure science — just barely accessible to the hard-reading layperson, and mainly offering perspective for the health care professional. Still more chapters are devoted to pure philosophy. Juhan frequently dares to ask (and answer) the hardest questions in the health sciences: why and so what? I took a workshop with Juhan many years later. I’m sorry to say that he seemed cocky and jaded. My main impression was that he was bored and had drunk to much of his own Kool-Aid. BACK TO TEXT
8. The full details of how bone responds to stress are spelled out in Dr. Harold Frost’s Mechanostat model. For more information, see Tissue Provocation Therapies. BACK TO TEXT
9. This kind of (wild) speculation is hardly unusual for Oschman: his writings are laced with much stranger ideas. BACK TO TEXT
10. Dr. Robert Schleip, from his 2003 article, “Fascial plasticity: a new neurobiological explanation”:

    The half-life span of non-traumatized collagen has been shown to be 300–500 days, and the half-life of ground substance 1.7–7 days (Cantu & Grodin 1992). While it is definitely conceivable that the production of both materials could be influenced by piezoelectricity, both life cycles appear too slow to account for immediate tissue changes that are significant enough to be palpated by the working practitioner.

    BACK TO TEXT
11. The quoted passage is from my personal correspondence with Dr. Levin, and is used with his permission and endorsement. For information about Dr. Levin’s work, see Biotensegrity: A new way of modeling biologic forms. BACK TO TEXT
12. Schleip R. Fascial plasticity: a new neurobiological explanation. Journal of Bodywork & Movement Therapies. 2003 Jan;7(1):11–19. PainSci #54759. BACK TO TEXT

13. Reader Jeff Linn, “something of an apostate Rolfer and instructor at one of the major structural integration schools,” offers a nifty clarification for me on this point. He has done extensive research in the Rolf Institute and Guild for Structural Integration archives and has listened to quite a bit of Rolf’s lectures. He has an audio clip of Rolf saying that the sol/gel idea is a “nonsense teaching.” Transcript:

    …under your hands you feel the change.  Now this is going to call for some smart researching sometime.  And who’s going to do this I don’t know.  I hope somebody is going to come out of the blue who is going  to be peculiarly well-fitted for this kind of a job.  And I haven’t the foggiest idea what it means. Possibly it means a general change in pH of the tissue locally. Possibly it means, this is the simplest way to express it, the greater energy that goes in there and makes the sol, the gel a sol. Possibly this is what it means.  This is what I’ve taught that it means.  But this is a nonsense teaching really!  What does it make into ‘sol’?  Does it make the wall of the blood vessel sol?  This is absurd!

    Mr. Linn: “My impression from listening to somewhere around 100 hours of Rolf’s lectures is that many of her ideas regarding her theory were preliminary and/or provisional and that she expected research to be done (which never really was). Her provisional ideas were simply assumed to be gospel and elevated to dogma and transmitted accordingly.” The transcript is from Tape A5 1970, Side 1, available to members only on www.rolfguild.org.

    BACK TO TEXT

14. Here’s Dr. Schleip’s full reasoning from his article, “Fascial plasticity: a new neurobiological explanation”:

    In most systems of myofascial manipulation, the duration of an individual ‘stroke’ or technique on a particular spot of tissue is between a few seconds and 1½ minute. Rarely is a practitioner seen — or is it taught — to apply uninterrupted manual pressure for more than 2 minutes. Yet often the practitioners report feeling a palpable tissue release within a particular ‘stroke’. Such rapid — i.e. below 2 minutes — tissue transformation appears to be more difficult to explain with the thixotropy model. As will be shown later, studies on the subject of ‘time and force dependency’ of connective tissue plasticity (in terms of creep and stress relaxation) have shown that either much longer amounts of time or significantly more force are required for permanent deformation of dense connective tissues (Currier & Nelson 1992).

    BACK TO TEXT
15. Some people will undoubtedly protest this, claiming that they certainly get more flexible in a sauna. Heat alone, without stretching, will definitely make us feel less stiff (a change in sensation), but does not actually increase flexibility. I’ve tested this very carefully myself: see A Stretching Experiment. BACK TO TEXT
16. ScienceBasedMedicine.org [Internet]. Kavoussi B. The Acupuncture and Fasciae Fallacy; 2011 Jan 13 [cited 14 Sep 24]. BACK TO TEXT
17. ScienceBasedMedicine.org [Internet]. Ramey D. Acupuncture and history: The “ancient” therapy that’s been around for several decades; 2010 Oct 18 [cited 14 Nov 27]. BACK TO TEXT
18. ScienceBasedMedicine.org [Internet]. McKenzie B. How popular is acupuncture?; 2011 Mar 28 [cited 12 Feb 19].) BACK TO TEXT
19. ScienceBasedMedicine.org [Internet]. Atwood KC. Acupuncture Anesthesia: A proclamation from Chairman Mao; 2009 May 15 [cited 12 Feb 19]. BACK TO TEXT
20. Berman BM, Langevin HH, Witt CM, Dubner R. Acupuncture for Chronic Low Back Pain. N Engl J Med. 2010 Jul 29;(363):454–461. PubMed #20818865. PainSci #54942.

    A bizarre and already infamous paper: bizarre because the authors clearly acknowledge that acupuncture is no better than a placebo, and bizarre because they conclude that it should be recommended, and most bizarre of all because it is published in The New England Journal of Medicine. Truly, one of the lowest moments in the history of that famous journal!

    The best criticisms of the NEJM’s editorial choices here can both be found on Science-Based Medicine, by Drs. Crislip (NEJM and Acupuncture: Even the best can publish nonsense) and Novella (Acupuncture Pseudoscience in the New England Journal of Medicine). Dr. Crislip’s post is really quite funny.

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21. Some fascial therapy is gentle, but I have personally encountered intense fascial therapy in the wild on numerous occasions. I prefer gentler therapy and usually request it. Despite being a confident and assertive communicator about my preferences, I have still had many unpleasantly intense fascial therapy experiences. BACK TO TEXT

22. According to a great many therapists. Not all, but probably most. It’s spelled out clearly by a prominent fascial therapy pioneer, Luigi “Inventor of Fascial Manipulation” Stecco. This is someone who has the respect of large numbers of fascial therapists; his thinking about how fascial therapy works can be considered strongly representative not only of common thinking about fascial therapy, but also of its bleeding edge. In a review of the rationale for a workshop, he repeats the basic idea of tissue stuckness in need of releasing in an impressive array of fancier terms. This is just a small sample:

    Once a limited or painful movement is identified, then a specific point on the fascia is implicated and, through the appropriate manipulation … movement can be restored.

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23. “Mechanical deformation” is lasting change in the shape of the tissue, like working clay. This is in contrast to elastic deformation, where the tissue snaps back to its pre-manipulation state. To “deform” in this context is not a bad thing (as in deformity), but a change in form — the goal that therapists generally have, in fact. BACK TO TEXT
24. People are not bullet proof thanks to their fascia, alas — wouldn’t that be handy! And yet the hyperbole is definitely true in a sense. Fascia is mostly much too thin to actually be bulletproof. If fascia was just as thick as a Kevlar vest, it might well be just as bulletproof (or a little more, or a little less). This is just like how spider silk is “stronger than steel cable” — pound for pound, it is. The catch in the comparison is that fascia most likely doesn’t have the same “puncture resistance” property that Kevlar does. There are many kinds of toughness (i.e. bones resist compression exceedingly well, but are quite vulnerable to torsion). The point was simply that the research showed quite clearly that the forces required for plastic deformation of fascia significantly exceed what can be applied to it with hands. Whatever therapists are feeling when they claim to detect a “release,” it’s not that. BACK TO TEXT
25. Schleip R. Fascial plasticity: a new neurobiological explanation. Journal of Bodywork & Movement Therapies. 2003 Jan;7(1):11–19. PainSci #54759.

    While high-velocity thrust techniques might create forces within that range, it seems clear that the slower soft tissue manipulation techniques are hardly strong enough to create the described tissue response [plastic deformation of fascia]. This research leads to a simple thought experiment. In everyday life the body is often exposed to pressure similar to the application of manual pressure in a myofascial treatment session. While the body naturally adapts structurally to long-term furniture use, it is impossible to conceive that adaptations could occur so rapidly that any uneven load distribution in sitting (e.g. while reading this article) would permanently alter the shape of your pelvis within a minute.

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26. Sometimes I felt things that seemed “big” that the patient seemed not to notice at all. Sometimes the patient had a profound sensory experience when I had noticed no change in the tissue whatsoever. I could not consistently elicit anything clearly. I am not a dumb guy, but I found it all quite uninterpretable and mostly unpredictable. I got tired of trying to find meaning in my sensations, and by my last three years in practice I abandoned all conceit that I could induce specific changes in tissue, and focussed pretty much exclusively on my patients’ sensations — not mine. BACK TO TEXT
27. If it’s bad enough to think that you need help, you’re also too sore to want anyone to touch you (let alone push on you). In any case, post-exercise muscle sorness is usually all wrapped up before patients can get to an appointment. BACK TO TEXT
28. PS Ingraham. Delayed Onset Muscle Soreness (DOMS): The biological mysteries of “muscle fever,” nature’s little tax on exercise. PainScience.com. 7893 words. BACK TO TEXT
29. Is it really surprising? I’ll return to that question below. That phrasing doesn’t actually come from the paper, so you won’t find it there, but from a poster they made to summarize the paper. BACK TO TEXT
30. Or perhaps somewhat to one side of the middle… BACK TO TEXT
31. A millinewton is 1000^th of Newton, which is a measurement of force. A full Newton is not a lot: enough to accelerate a mass of one kilogram at a rate of one meter per second squared, without friction. Imagine what it would take to get a small weight moving a little bit … in space. Now divide by a thousand. BACK TO TEXT
32. I’d like to think I made it sound “accurate,” and the result just happens to be trivial. BACK TO TEXT
33. A little personal perspective: my lovely wife has titanium in her back, installed to stabilize a massive fracture of her T12 vertebra in 2010. Such is the toughness of spines that the titanium fixations installed to protect her actually broke on both sides — came loose from the brackets screwed into her bones. Similarly, severe scoliosis can twist titanium fixations like pretzels as it advances. Those are the kinds of forces involved in the back. Fascial contractions are a miniscule part of such impressive equations. BACK TO TEXT
34. It is also noteworthy that the contractions they described were slow motion contractions, taking many seconds to develop at their fastest. BACK TO TEXT
35. Analogy: in the circulatory system, there are only a few gigantic blood vessels, but countless fine and microscopic ones. The fascial system is similar: a few large, obvious sheets of fascia, a bunch of more modest and delicate structures, and then a nearly infinite network of extremely thin and microscopic structures. This is why I say that we are wrapped in fascia “fractally.” BACK TO TEXT
36. PS Ingraham. Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain. PainScience.com. 14259 words. BACK TO TEXT
37. Despite what it seems like, I am not actually accusing Schleip et al. of having any overt or serious conflicts of interest. In general, COIs are more common and less of a big deal in science than people think: where there is science there is funding, such is life, and funding sources affect science in muddy, complicated degrees ranging from not really at all to truly, madly, deeply. This seems like a borderline case to me, somewhere on the edge of being a problem. It’s safe to say that these organizations probably would not fund — or continue to fund — research that came to the opposite conclusion, i.e. not “strong enough to influence low back stability and other aspects of human biomechanics.” BACK TO TEXT
38. This is another form of what I call failing “the impress me test.” Usually I bring that up to make the point that there needs to be strong evidence that treatments works before they can be considered “proven” — small and temporary treatment effects should not impress anyone. In this case, though, it’s the clinical relevance of fascial contractility that is failing to impress. BACK TO TEXT
39. Schleip R, Naylor IL, Ursu D, et al. Passive muscle stiffness may be influenced by active contractility of intramuscular connective tissue. Med Hypotheses. 2006;66(1):66–71. PubMed #16209907. BACK TO TEXT
40. If you’re not going to list really good, relevant examples here, where are you going to do it? BACK TO TEXT
41. I have written quite a lot about compartment syndrome with regards to their role in shin splints (see Save Yourself from Shin Splints!). The lower leg is by far the most common place in the body for compartment syndromes, both in the shins and the calf. They are more or less unheard of elsewhere in the body — rare and generally minor and self-limiting. If fascial compartments were prone to problematic contraction, we’d constantly be getting “compartment syndromes” all over the body. BACK TO TEXT
42. Basically, only a fraction of the genome is for coding proteins, but that important minority is regulated and tweaked by the rest of the non-coding DNA. So a (very rough) analogy is that the coding DNA is like software that makes you who you are, but the “junk” DNA is the operating system that it needs to run on. Not so junky. BACK TO TEXT