Does Fascia Matter? A detailed critical analysis of the clinical relevance of fascia science and fascia properties SHOW SUMMARY

Sheets of fascia can contract a bit like muscle … but how strongly? Enough to make a difference? Is fascia medically important? Does fascia — sheets and webs of fibrous connective tissue — have any properties that are relevant to healing and therapy? Are there good reasons to do manual therapy that is “aimed” at fascia specifically? Fascia gets discussed in therapy offices a lot these days, and even at conferences dedicated to the stuff. It is supposedly the key to many a therapeutic puzzle, and is now routinely targeted as a part of all kinds of alternative therapy (especially massage therapy and chiropractic), and also physical therapy.1 Fascia is fashionable. But does fascia actually matter in therapy? This article thoroughly explores and questions fascia excitement from a scientific perspective.2 About footnotes. There are 79 footnotes in this document. Click to make them pop up without losing your place. There are two types: more interesting extra content,1 and boring reference stuff.2 Try one! About green links. Standard blue links go to other pages on PainScience.com, or on other websites, as expected. But green links go to other sections of this page, like this link to the top of the page, or the links in the table of contents. Fascia-nating Fascia enthusiasts are worrisomely vague about why fascia matters, or how exactly “fascial work” can help people with common pain problems. They speak mainly about how complex and widespread fascia is — so are bones, muscles, nerves, and blood — as if that alone is a good enough reason to focus on fascia. Attempts to get more specific are usually sloppy. Poor clinical reasoning — therapy babble — about fascia seems to be too common, even among the most educated enthusiasts.3 It’s a strong theme in all the bizarre and medically illiterate “💩 massage therapists say.”4 Fascia babbling examples I was getting a massage on my 40th birthday (because I really do love massage). The therapist was doing fascial work, of course — you can’t get a massage in Vancouver these days without getting your fascia worked over. She was using some annoying pulling and twisting techniques, trying to “release” my fascia, instead of using the more satisfying, relaxing Swedish styles I craved. She launched into an awkward account of her technique, but words truly failed her: Well, your problem is fascia. The fascia is the thing you have to do something with. If you fix the fascia, everything gets more … well, the fascia will make everything better. I didn’t have any problem.5 But fascia fixing was going to help it! Somehow. I wish I could say this extremely murky explanation of fascial therapy was unusual, but I’ve actually heard this sort of thing many times over the years, even from the well-trained massage therapists around here, and physiotherapists too … Fascia apologists are forever trying to convince me that their fetish for this tissue is evidence-based, clinically relevant, and intellectually mature, and yet I just keep hearing stories like this (paraphrased anecdote from a reader, who was horrified): I nearly broke my hand, and I’ve been recovering from that injury. My physiotherapist was treating it with some massage. She described the technique as ‘fascial release,’ and warned me about a possible side effect: ‘You might feel sad, or even start to cry,’ she said. Any health care may involve sadness and crying, but “fascial release” is not emotional: being cared for, touched, and manipulated is emotional. Occasionally. But it’s probably not emotional for 99% of patients who just want some rehab help after a wrist sprain. Emphasizing sadness as “side effect” of fascial release in that scenario requires a bizarre meltdown of clinical communication priorities. It wasn’t said because it mattered to the patient — it was pure marketing, a bullet point about the potency and specialness of fascial release. Weird ideas about fascia are out there in a big way.

Barely known to science! 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.6 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. 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 GO TO TOP • CONTENTS • NOTES

En garde! The fascia science challenge 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. Reader suggestions and feedback are welcome, both critical and supportive. However, hate mail will be ignored. I receive a quite a bit of hate mail on this topic, which reflects poorly on the community of “fascia therapists” and their beliefs. Good ideas stand on their own just fine without rude defenders. So please think twice before you hit send. 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: several key examples of allegedly clinically relevant fascia research. We do not have a winner yet. There is a crack in everything

That’s how the light gets in. ~ Leonard Cohen, Anthem GO TO TOP • CONTENTS • NOTES

Definitions: what fascia is (and isn’t) The term “fascia” is imprecisely defined. Traditionally it refers to “masses of connective tissue large enough to be visible to the unaided eye” (Gray’s Anatomy) mainly consisting of wrappings around anatomical structures like muscles and organs. In other words, the gristle in your steak is fascia. Other fascia-wrappings include the relatively delicate sheaths around nerve and vessel sheaths, and the much tougher and fibrous joint capsules. In the last twenty-five years, a broader definition has emerged to serve the interests of people who believe that fascia is medically important. It is often imprecisely used to refer to medically important fibrous connective tissue, microscopic and macroscopic. The medical importance of fascia is often attributed to its ubiquity in the human body. Thus, a more inclusive definition supports the alleged therapeutic importance of fascia, and the people who have staked their reputations on it. This is what’s left of a pig’s heart when everything is gone except the gristle, exposing its fascial framework. This photo nicely demonstrates how fascia is everywhere, plus it’s a fine example of a genuine application of “fascia science”: someday, we may grow new human hearts using these as templates. Of course, none of this has the slightest thing to do with massage therapy. Photo courtesy of Doris Taylor. Any 1980 physician — and many doctors today — would have found it bizarre to stick the “fascia” label on so many connective tissue structures. Connective tissue is one of the four basic tissue types in the body, along with epithelial (skin), muscle, and nervous tissue. They are understood by experts in terms of their embyronic origins. Connective tissue arises from the mesoderm, one of the three germ layers of tissue in very young embryos. In addition to the most gristle-like tissues, it also includes tendons and ligaments, which are the most obviously connecting of the connective tissues. And then there’s also bone, cartilage, fat, and blood and lymph. You read that right: fat is connective tissue. But it is not fascia. The point of this is: all fascia is connective tissue, but not all connective tissue is fascia, not by a long shot. Fascia is rarely considered a meaningful type of connective tissue; it is just one humble sub-type, not even worth a mention in some definitions on connective tissue. Ironically, many people who enthusistically refer to any connective tissue they know about as “fascia” are actually unaware of many less obvious connective tissues (like bone, blood, and fat). GO TO TOP • CONTENTS • NOTES

Origins and types of fascial therapy The idea that fascia is medically important has one main point of origin: physician Stephen Typaldos formulated the Fascial Distortion Model (FDM) in 1991, proposing that most musculoskeletal complaints are caused by deformations of fascia. Typaldos thought deformed fascia could be fixed by skilful force, kind of like banging the dents out of a car. Most modern ideas about fascia’s medical importance are directly inspired by FDM, but based on different notions about exactly how best to fix fascia: how hard, what to pull on, tools or no tools, and so on. Some of these derivatives have been so commercially successfully that they now shine brighter than the original. Prominent brands claim to “melt” fascia,7 “blast” it,8 and “fix pain fast.”9 Some methods try to change fascia by scraping it with hard-edged tools,10 while others — at the opposite extreme — are “subtle” and meant to lovingly coax fascia to de-distort.11 These are all just variations on a theme that has never been validated scientifically.12 No one has ever scientifically demonstrated that fascial distortions exist in the first place, or that anyone is actually helped by manual therapy techniques intended to correct these alleged distortions, or by any related technique. It was just an idea that went viral. Instead of research that fixes this, all we have is a mess of basic research into the nature and properties of fascia, none of which actually matters.13 Meanwhile, fragile fascia is actually a known pathology Fascial therapists are chasing speculative connective tissue bogeymen, there are real diseases of connective tissue that are actually common… and the last thing they need is “release.” Most importantly, there is a group of related conditions that cause connective tissue fragility.14 The symptom they mostly have in common is some degree of hypermobility, but they are also strongly associated with unexplained chronic widespread pain15 — exactly the kinds of symptoms that fascial therapy is supposedly good for. These conditions are rarely diagnosed, and most patients with these conditions don’t know what’s wrong.16 But what happens if you try to “release” their fascia? Or, eek, “blast” it? Probably nothing good! I shudder to think how many patients like this have been subjected to intense fascial therapy when they quite literally needed exactly the opposite. The fascia whisperers: more about gentle fascial release Subtler fascial therapy has unclear origins and an even murkier rationale than “traditional” FDM-inspired therapy. Although it mostly shares the fundamental goal of fixing “deformed” fascia, it takes a decisive leap away from the Typaldos legacy by proposing that fascial deformations can be repaired by just the right gentle manipulations, by working “smart” rather than hard. Vitalism looms in the background, and many therapists blur the differences between gentle fascial manipulation and “energy work” (see the meridians/acupuncture section below). There’s nothing to this idea that can’t be chalked up to an all-too-human breakdown of humility. Claiming to be able to change fascia gently implies great insight and skill; it is part of the culture of belief in semi-mystical healing powers. There is nothing supporting it except the claims of practitioners themselves. They ask us to take their word for it, and their case begins and ends with “trust me, I know, I can feel it” — just like a psychic or a dowser, with a fresh (but very thin) coat of scientific credibility applied by using jargon like “fascia.” There is no evidence or any reason to suspect that the state of fascia can be changed even by forceful manual therapy, let alone delicate manipulations. There is no way to think it can be changed gently without faith. It’s not completely implausible that skilful, gentle manipulations could have an effect on fascia, but there is absolutely no reason to believe it — or believe that it matters therapeutically — just because some massage therapists say it’s so. GO TO TOP • CONTENTS • NOTES

Why fascia actually matters medically (get ready to cringe) All theories and controversies aside, what is the clinical significance of fascia in mainstream medicine? Why would a family doctor or surgeon ever think about fascia? There’s the connective tissue diseases, of course — such as the hypermobility disorders just mentioned above (Ehlers–Danlos syndrome), as well as more obvious ones like Marfan syndrome. But what about the biological role of fascia in healthy people? In healthy people, fascia is boring but critical: it functions as an important infection barrier. Much like skin prevents pathogens from getting into the body in the first place, layers of fascia limit their spread.17 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,18 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. Some people leap from here to the idea that people who get compartment syndrome must have something wrong with their fascia — too tough, too tight, needs release to prevent further compartment syndromes. And that might sound like extremely reasonable clinical reasoning to some people, and indeed it’s a reasonable enough hypothesis on its face. But you have to check these things, and someone did, and it’s just not true.19 (And if it’s not true of something like compartment syndrome, it’s probably not true of subtler problems either.) 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 … GO TO TOP • CONTENTS • NOTES

Part 2 Sloppy fascia reasoning The next few sections dissect ideas about fascia that are unusually weak, either based on especially irrelevant science or none at all — the stuff that doesn’t really stand up to any scrutiny at all. Despite that, many of these ideas are extremely popular, so it’s important to deal with them, even if none of them are good representatives of fascia science. After making short work of these, I’ll get into some more credible fascia science. One quick pre-emptive rebuttal first: am I attacking “straw men” here? Easy targets that don’t actually represent meaningful beliefs about fascia? No: a straw man would be an idea that no one actually believes or takes seriously — and therefore meaningless to criticize. Certainly not everyone interested in fascia thinks that things like fascial piezeoelectricity or fascial “fuzz” are real or important. However, enough do that it’s no straw man! It may not represent the best thinking in the field, but it is definitely out there in force. This joke would be meaningless if it weren’t …

Electrified by piezoelectricity 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, including noted fascia researcher Robert Schleip (more below). 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.”20 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,21 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 stated 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.”22 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.23 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. GO TO TOP • CONTENTS • NOTES

Fuzzy logic: Gil Hedley’s “fuzz” speech Another fine example of imprecise scientific enthusiasm is Gil Hedley’s extremely popular “fuzz” speech. In this video with a bazillion 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 blithely ignores many well-established explanations for the sensation of stiffness, and other highly relevant factors — like 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.24 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” — also often called “adhesions” — 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 Why Do Muscles Feel Stiff and Tight? GO TO TOP • CONTENTS • NOTES

“Fascial distortions,” especially tightness (contracture) and stuckness (adhesions) At the heart of most fascial therapy lurks the extremely vague idea that something is wrong with your fascia. This is explicitly the Big Idea in the modality that started it all in 1991, the Fascial Distortion Model, and it is had been recycled extensively ever since. Again, physician Stephen Typaldos proposed that many if not most musculoskeletal complaints are caused by deformations of fascia, and he thought he could repair these with his hands. Most modern modalities are based on this, and in turn it is based on … nothing at all. This idea is not fascia science but just pure speculation about fascia. There is nothing even close to any biology to back it up,25 so it can’t be a candidate for potentially important fascia science: I cannot emphasize strongly enough that it’s just an idea someone had once. I’ll examine it only briefly, because there is so little to examine. But for those who want to delve, there is a formal paper critiquing fascial distortions, by Christoph Thalhamer. How might fascia be “distorted” exactly? Supposedly some people’s fascia is like poorly maintained ship’s rigging, too tight or short in some places, too loose in others. Or perhaps maybe it’s stuck (“adhesions”), or lumpy, or frayed, or too thick, or too thin. Virtually any idea you’ve ever heard about what might be wrong with fascia can and has been included in the idea of “fascial distortion,” but tight and/or stuck are the main ones. Those informal terms correspond loosely to the more technical concepts of contracture and adhesions. There is no evidence that these things actually happens without frank pathology, or — even if they do — that they would be either clinically significant and/or treatable with anyone’s clever hands. Contracture is certainly a real phenomenon: it’s the pathological shortening of tissue. For instance, Dupuytren’s Contracture is a mysterious contracture of the fascia of the hand, but even in the early stages it’s obvious that something’s wrong: the hand starts to claw up! This is probably the most obvious problem with idea of fascial distortions: if they happened, they’d be more obvious, just like the other known examples of pathological contracture. It’s also worth noting that Dupuytren’s contracture isn’t even a very painful condition, even as it actually deforms the hand and significantly restricts range of motion: it’s just restrictive. So the idea that much less obvious contractures are the cause of most/all painful musculoskeletal problems is a mighty reach. Adhesion is a little murkier than contracture. There’s not much doubt that it occurs — there are clear mechanisms by which layers of connective tissue get “sticky” and tend to cling to each other — but it’s probably either trivial or pathological and beyond the powers of manual therapists to deal with. The idea of adhesions that are both important to our musculoskeletal health, and which can be treated by “releasing” them, has never been validated. GO TO TOP • CONTENTS • NOTES

Ida’s idea about thixotropy 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:26 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!27 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. What makes these substances gooey and slimy? Why, a family of carbohydrate molecules, of course: the glycosaminoglycans. Also known as the snot molecule. Think of any movie monster with tons of ropy saliva — that’s glycosaminoglycans! 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.”28 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.29 Even if it works in some small way, thixotropic effect is going to be temporary, fading within seconds or minutes after hands are removed. 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 the effect is much smaller than what exercise does!30 Perspective matters. And another similar thought experiment: if sustained pressures or shearing could significantly change connective tissue, then working a chair all day long — or any prolongued postural stress — 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-focused therapy, and trying to explain what they do. Unfortunately, it was never a good idea in the first place, even decades ago. GO TO TOP • CONTENTS • NOTES

The acupuncture connection: is fascia actually magic? 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 1930s.3132 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.33 Even its alleged popularity and widespread use in China is trumped up — it is, for instance, not actually used for anaesthesia,34 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: Does Acupuncture Work for Pain? A review of modern acupuncture evidence and myths, focused on treatment of back pain & other common chronic pains ~ 7,500 words 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.35 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. GO TO TOP • CONTENTS • NOTES

Not so exotic after all Piezoelectricity, fuzz, thixotropy, and fascial meridians are four good examples of popular but poor reasons why fascia supposedly matters. There are other better reasons, and discussion of genuine fascia science is coming up. 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: it’s everywhere and connects everything (well, yeah), 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.36 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 GO TO TOP • CONTENTS • NOTES

Part 3 Real fascia science that supposedly matters

Fascia is much too tough to “release” “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, undermining 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 fascia37 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 deformation38) 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.39 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.”40 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 … GO TO TOP • CONTENTS • NOTES

“Release” may not even be real The idea of a “release” refers to the yielding of tissue to an externally applied pressure. It’s the goal of fascial therapy, but it’s more poetry than biology. It does not refer to any known, specific state of soft tissue. It’s vague massage-speak for “better in some way, hopefully for more than ten minutes.” As commonly used, the word strongly suggests an actual change in the flesh … but this assumption derives only from blurry, erratic sensory cues. Most therapists say — not all of them, importantly, but most — that they can feel tissue changing texture as they work, but that could easily be misinterpreted muscle behaviour and palpatory pareidolia. Patients talk about releasing too: they may experience a kaleidoscopic array of sensations during massage, and call it a release if they perceive an especially significant improvement (from feeling “stuck” to feeling “relieved,” say). But we have almost no idea what any of these sensations imply about tissue state, if anything. People also have profound shifts in sensation from a good back scratch, fervent prayer, and eating cheesecake! Let’s define release a little more precisely. 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? Yes, I do have experience. Many readers accuse me of having no practical experience with patients, when in many cases I clearly have more (and better) than they do. Not that it’s a contest, but it’s just so deeply ironic and amusing when people assume that the only possible explanation for my opinions is that I must not have any work experience as a massage therapist. I have a decade of it, and this fact is readily available in my bio. 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.41 So while I certainly felt something change, I rarely thought of those changes as a meaningful “release.” Dr. Schleip’s 2003 paper about fascial plasticity42 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. In other words, people react when poked and prodded, which doesn’t have anything to do with fascia in particular, which has some 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? Most releases are probably 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, knowable, and helpful is going on. But we round it up 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 misleading to pretend that it describes a particular biological event with clinical meaning and value — which is exactly how most therapists imagine it. Why? A thick stew of good intentions, ego, and the human habit of selective perception and imposing simplistic explanations on chaotic systems. GO TO TOP • CONTENTS • NOTES

Study of rat gut massage is not really fascia science Our first serious candidate for relevant fascia science has often been suggested to me as an example of evidence of “fascial release”… of rat guts. But the connection to fascia here is weak. “Visceral massage reduces postoperative ileus in a rat model”

Chapelle et al. Journal of Bodywork & Movement Therapies. Volume 17, Number 1, 83–8. Jan 2013. In this odd rat study, Susan Chappele and Geoffrey Bove tested the effect of “visceral massage” on rat intestines. For context, visceral massage is often perceived as being about fascial manipulation, without much justification, or perhaps any at all. For better or worse, many massage therapists believe that visceral massage is all about releasing adhesions, and that’s the main reason this study is widely regarded as “fascia science.” Rats were harmed in the making of this science: they were subjected to abominal surgery (an emulation of “running of the bowel,” which is examining the entire bowel for abnormalities). The point of this was to see if the massage would prevent a common post-surgical complication: postoperative ileus, AKA impaired bowel motility, AKA constipation. The poop chute gets balky. This is a real thing that happens to both rats and humans after abdominal surgery, usually temporary, but occasionally more serious and long-lasting. And apparently massage helped: the treatment “reduced experimental postoperative ileus.” The treated rats had “increased gastrointestinal transit and reduced time to first fecal pellet discharge,” and fewer inflammatory cells in their GI tract. The authors speculate that reducing inflammation may be the mechanism. Chapelle and Bove were so confident in their conclusion that they baked the good news right into the title. Since then, fascia enthusiasts have often used this study as a basis for speculation that massage can have a measurable effect on connective tissue, and as justification for visceral manipulation especially. But those are a big leaps with many problems. For starters, obviously we can’t take the results at face value: “just one study,” needs replication, bias risk, yada yada yada. But the bigger leap is from the results to their meaning. Even if we do accept the results at face value, would it matter? The alleged importance of the study is that it demonstrates a meaningful biological effect on fascial tissue. If it’s demonstrable in rats, maybe it’s helpful in humans too? And there might be other effects with more practical clinical implications than trying to reduce post-surgical adhesions.43 That’s fair enough as optimistic speculation, but it is very clearly just optimistic speculation, based on the results of one study of rat gut massage. And even that speculation has problems. Off the top of my head: The paper does not actually report an effect on fascial tissue or adhesions. (It discusses the speculative potential of massage to prevent adhesions: if it reduces post-operative ileus, then it might reduce adhesions.) So it’s not actually clear why anyone would assume that it constitutes evidence of an effect on adhesions/connective tissue, other than just plain wishful thinking and ignoring the details.

It’s questionable whether massage helped these rats recover by “reducing inflammation.” There’s no good evidence that massage reduces inflammation in any context.44 While they reported, “decreased … numbers of intraperitoneal inflammatory cells,” that is hardly confirmation that massage reduces acute bowel inflammation. This study was not designed to detect changes in pathology (it couldn’t be in principle, because the pathology of ileus is so poorly understood, and you can’t measure meaningul changes in a process no one actually understands).

Even if massage did help the rats by reducing bowel inflammation, it’s unlikely that this effect is going to be demonstrable anywhere else. Postoperative ileus is a unique phenomenon, specific to bowels that have just been surgically disturbed, and it’s mysterious: we just don’t know why it happens (but it’s certainly not because of adhesions). If massage does indeed help it, we have no idea why, and there’s really no reason to think it has anything to do with how massage affects anything else — and certainly not “fascia” specifically!

The results are actually quite unsurprising, because we know that there are other easy ways to ease ileus. According to a 2013 study published shortly after Chapelle et al, chewing gum also does the job, just by stimulating bowel contractions.45 This casts strong doubt on the specialness and clinical utility of massage for the same purpose. To be clinically useful, a massage technique should accomplish something that is not otherwise easily accomplished. If chewing gum works, the only reason to add massage is if it’s significantly better somehow — which is conceivable, but simply unknown.

Abdominal massage for any reason is rarely practiced in general — few patients seek it out, therapists rarely offer it — and massage to prevent post-operative ileus is a special case that most massage therapists have never tried and would probably wisely avoid for safety reasons. There’s no direct clinical relevance of the results because, in the real world, massage therapists almost never do to humans what the researchers did to rats … and they shouldn’t try to, either, because there is not and may never be enough evidence on this topic to justify it. It’s nice to think massage might help get the bowel moving again after abdominal surgery, but I don’t see how it counts as “fascia science.” It does not show any effect that has anything whatsoever to do with fascia. You could argue that it’s clinically relevant to massage therapy, insofar as it suggests something good that massage might do … but I fail to see how it suggests that anyone should be trying to massage fascia. This is mildly interesting massage science, not fascia science. It definitely does not constitute evidence of an effect of manipulation on connective tissue at all, let alone one that is robust and relevant to common aches and pains and the day-to-day work of most manual therapists. GO TO TOP • CONTENTS • NOTES

Does stimulating fascia reduce post-exercise muscle soreness? 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.46 There’s a lot of research showing that exercise-induced soreness is basically invincible anyway.47 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 patients’ 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. GO TO TOP • CONTENTS • NOTES

A fascinating etymological digression: are “fascia” and “fascism” related? A Roman & his fascis. He also has a bunch of fascia & fascicles. The words fascia and fascism are indeed closely related. They both come from the Latin word fascis, which first referred to leather straps, then to a bundle of sticks held together by those straps, and then a bundle that includes an axe. The fascis represented strength in numbers, and it is extremely old imagery: it emerged from the Etruscan civilization well before the Ancient Romans adopted it as a symbol of political power, law, and jurisdiction. They made it a physical thing, toted around by some actual Romans, the lictors, the bodyguards of magistrates. The fascis limped into the modern world as an abstract symbol of collective action, which was notoriously revitalized by the National Fascist Party in Italy in 1921: the National Strength-In-Numbers Party, in other words. But it was eclipsed by another symbol of fascism from the ancient world, the swastika, and today hardly anyone recognizes a fascis, even though it persists in all kinds of political and military iconography, despite the negative associations. “How the fasces survived is a mystery: Americans are sensitive, if not hypersensitive, to any potential endorsement of an enemy’s culture, language, or creed in times of war.” The fascis is the spittin’ image of a bundle of muscle cells wrapped in connective tissue, and so we call that a fascicle, wrapped in fascia — the canonical example of fascia in the human body. A fascis only symbolized strength in numbers, but it is the literal purpose and function of a fascicle. That’s a whole bunch of linguistic and conceptual convergence. Etymologically rich trash talk Skeptics about the clinical significance of fascia sometimes snarkily refer to fascia enthusiasts as “fascia-ists,” which is mostly intended as the cheap pun it sounds like. But its etymological roots go as deep as history, and the insult is much more apt than they realize: it references the empty populism of fascism, suggesting that advocates for fascial therapy have nothing going for their claims except strength in numbers.

Fasces are used everywhere in the imagery of power, but the strongest link to fascism is in the symbol of Italy’s National Fascist Party, founded in 1921. And what about “fascinate”? That word similarity actually is just a coincience. Or is it? Fascination is closely related to enchantment and still strongly connotes a magical effect: to be fascinated is to have one’s attention captured, as if under a spell. In ancient times, it was meant more literally. The Latin fascinum was a phallus-shaped amulet, a penis charm, and to “fascinate” was to use the power of the fascinum to enchant or bewitch. And what’s more enchanting than a penis, amiright? The Romans were really into their penis power, and I can’t imagine anything more Roman than superstitiously wearing a little cock-and-balls around your neck. So this word similarity seems like a coincidence, but… I can’t help but notice that a fascis is also a rather phallic symbol. To a Roman, the fascis and fascinum might well have seemed like siblings, each broadly symbolizing potency, just in different contexts with different connotations. Accuracy disclaimer This is all oversimplified to the brink of error, but history and etymology are messy, and there’s just too much detail and nuance and uncertainty to ever really get this kind of thing truly complete and correct. For instance, it’s not even clear whether it’s a “fascis” or a “fasces,” each one being used by credible sources. If I have readers with relevant expertise, please set me straight. GO TO TOP • CONTENTS • NOTES

Does it matter that fascia contains muscle cells? 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 — sort of48 — 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?” “Fascia Contractility FAQ,” Robert Schleip, FasciaResearch.de. 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. GO TO TOP • CONTENTS • NOTES

Fascia strong like bull! Or … mouse? Before we get to clinical relevance, I’ll quickly explain what Schleip et al. found: a slightly muscular cell in rat fascia, which they described as “rather unexpected.”49 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.50 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.51 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. GO TO TOP • CONTENTS • NOTES

Do weak fascial contractions matter? 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.52 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.5354 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.55 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.56 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.57 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. GO TO TOP • CONTENTS • NOTES

No clinical relevance at all? Not even a teensy bit? 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.58 What about fascia and trigger points? Schleip et al. don’t bring trigger points (muscle knots) into this discussion, but a lot of other people certainly have. The notion is that a trigger point is being squeezed and sustained by clenching fascia, but this clinical concept suffers even more than other examples from the relative weakness of fascial contractions. I explore this specific claim of clinical relevance in detail in my trigger points tutorial. 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 ,59 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 example60 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).61 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. And then there’s the fact that we know from Dahl et al that “structural and mechanical properties are unlikely to explain chronic compartment syndrome. To prevent chronic exertional compartment syndrome, it is necessary to address aspects other than the muscle fascia.” So you see how this goes: for one candidate example after another, the clinical relevance of fascial contraction is dubious or minor. GO TO TOP • CONTENTS • NOTES

Is fascial contraction even interesting? 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,62 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. 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 hosts 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. GO TO TOP • CONTENTS • NOTES

What does Dr. Schleip think? 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. 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. GO TO TOP • CONTENTS • NOTES

Thicker, stiffer thoracolumbar fascia in back pain: what does it mean? Over the last couple years, by far the most common answer to my fascia science challenge has been: Langevin, Langevin, Langevin. Specifically Langevin et al.’s 2009 and 2011 papers presenting evidence that the thoracolumbar fascia is thicker and stiffer in people with chronic low back pain.6364 A pair of follow-up studies established that the same fascial stiffness occurs in pigs if you torture them,65 and that it is fairly stubborn once it sets in.66 This is all interesting evidence that comes as close to being a good answer to my fascia science challenge as anything I’ve seen yet, but I still don’t think it actually achieves clinical significance. The thoracolumbar fascia is the shield-shaped sheet of thick fascia that more or less completely covers the low back. I’m not going to question the findings at all for now — though of course that is also fair game.67 I’m going to take their results at face value and write only about what they mean to us as thoughtful therapists and patients, keen on biology but wishing to avoid false hope. Exactly what Langevin et al. have found so far In people with chronic low back pain: The thoracolumbar fascia was about 25% thicker in people with back pain, which is quite a bit, and a surprising finding with potentially major — but unknown — clinical significance. The authors suggest that it could be related to “genetic factors, abnormal movement patterns and chronic inflammation.”68

The thoracolumbar fascia had about 20% reduced “shear strain,” a measurement of the deformation of a structure. In other words, it was 20% stiffer than in people without back pain. Again, that’s quite a bit.69 And in tortured pigs … Ethics! These pig experiments are macabre to a degree that we have rarely seen in musculoskeletal medicine. I question whether the 2011 experiment by the same researchers established a clear enough need for more research, or high enough medical stakes, to justify torturing a lot of pigs. Injured and/or hobbled pigs exhibit the same kind of increased fascial stiffness as humans with low back pain — and quite a bit more when combined.70 To some extent this constitutes replication of the key finding of Langevin et al.

Once you’ve given pigs stiffer back fascia, it doesn’t readily loosen up. If you set them free, they return to normal movement, but their fascia stays stiff. If you stretch them for 10 minutes per day — yes, that’s actually what they did — that doesn’t help either.71 What’s it all mean? Chronic back pain is a notoriously inexplicable and invisible condition. Things that turn up on MRI that seem like they might explain the pain are often irrelevant. A clear, consistent, measurable biological sign of chronic low back pain like thickened fascia would be inherently interesting — downright cool, even! But that thickened, stiffened fascia is probably not the cause of back pain. At best, it’s probably a clue about the nature of back pain — inflammatory, perhaps?72 But it’s probably even less meaningful: it could be a consequence of pain and limited mobility, something that happens because you’re in trouble.73 And that’s also exactly what the pig-torture experiments showed! So the most likely explanation is very boring: a simple case of “use it or lose it” — we stiffen up a bit when we’re in pain for a long time. •mind blown• And if that’s all there is to it, it’s really a big whoop-de-doo. And if that’s all there is to it, it’s really a big whoop-de-doo. But no one knows. The research didn’t explain a phenomenon, it just identified one … maybe. Clinical relevance The purpose of this article is to challenge hype about fascia. The point of the fascia science challenge is that most science does not at this time inform diagnosis or treatment, and therefore there is no scientific justification at this time for “fascial therapy” to be a popular phenomenon. Langevin et al.’s research clearing comes closer to influencing diagnosis or treatment than anything else I’ve seen, but I think it’s a case of so-close-yet-so-far. Does knowing that the thoracolumbar fascia is thicker and stiffer inform diagnosis? Not really. Because no clinician can (a) know whether or not it’s actually the case, or (b) has any idea whether it’s a cause of back pain or just a trivial consequence of it. Not that stretching for 10 minutes per day is likely to be adequate or relevant to human back pain, but it’s worth noting that stretching failed. Does knowing it inform treatment? No, because (a) no one has the slightest idea if it’s possible to make the thoracolumbar fascia thinner or more pliable with their bare hands (and it’s rather unlikely), and (b) there’s not much point in even trying unless you actually know it’s a cause or complication of back pain. Yes, you could gamble and try to manipulate it and see what happens — but hands-on therapy ain’t cheap, and this is about as experimental as it gets. And bear in mind that stretching did not help the poor pigs.74 It’s conceivable that follow-up research could fill in some of these blanks, but, until then, this research isn’t good for much beyond raising eyebrows. It’s only clinically relevant insofar as it could lead somewhere clinically relevant. If the findings can reproduced. If they can be explained. If the explanation does in fact turn out to be clinically relevant. That’s a lot of ifs. A real fascia contracture disease: frozen shoulder Frozen shoulder is one of the few common, familiar musculoskeletal problems that definitely can be blamed on misbehaving fascia. Its medical name, adhesive capsulitis, pegs it is a disease of “stickyness” of the joint capsule, but in fact the best available evidence to date suggest that it is more a disease of shrinkage — connective tissue contracture.75 Maybe this contracture has something in common with what Langevin et al. observed in the low back? Anything’s possible. In the case of the shoulder, joint capsule contracture is quite clearly an etiologic factor: it’s freezing shoulders and causing much woe. In fact, it’s one form of a disease process that also sometimes afflicts the palms (Dupuytren’s contracture), knuckles (Garrod’s pads), foot (Ledderhose disease), and — rather alarmingly — the penis (Peyronie’s disease). Could something like it happen to the back too? In the case of the back, it’s technically conceivable but extremely unlikely that fascial contracture is the cause of low back pain. But, just for the sake of argument, let’s say it is: imagine that people do get back pain because their thoracolumbar fascia seizes up for mysterious biological reasons, very much like frozen shoulder. It’s not a completely absurd notion, but I don’t actually believe it for a moment: it would be the biggest discovery in the history of musculoskeletal medicine. This is just a thought experiment! No one — no one honest and humble, anyway — has the foggiest notion how to “melt” a frozen shoulder. That joint capsule is exceedingly tough. When it contractures, that’s it: it yields only to intense, traumatic forces. Frozen shoulder defies manual therapists all the time, despite cocky claims to the contrary. And so, even if back pain is like frozen shoulder and caused by fascial contracture, I don’t think there’s a snowball’s chance in hell that it could be treated with any kind of hands-on manipulation. Both shoulder capsules and the thoracolumbar fascia are super tough human gristle, and are unlikely to change much or for long — if at all — in response to any non-traumatic external stimulus. And the thoracolumbar fascia is not only much tougher — the biggest and thickest sheet of fascia in the body — but it is much harder to apply force to than the shoulder joint (which has a giant lever). So even in the most spectacular hypothetical scenario, where the thoracolumbar fascia is truly a major cause of back pain … even then it’s still not going to translate into a good treatment option. And so Langevin et al. cannot and should not be used as justification for a clinical obsession with fascia. GO TO TOP • CONTENTS • NOTES

Nerve entrapment Nerves can get a little tangled up in connective tissue and cause peripheral neuropathy. This may be a good example of “fascia” science that actually matters, at least a little. And yet I came across it myself. No one defending fascial therapy hype has ever brought this idea to my attention — I am including it on my own intiative, not as a response to a claim made by fascial therapists. Apparently it isn’t even on fascia enthusiasts’ radar even though some nerve entrapment may really and truly actually be caused by fascial “distortion” or “adhesions,” by the accumulation of webs of fascia in such a way that nerves that were once free and clear start to snag and pinch. To the extent that this causes peripheral neuropathy, it is obviously clinically relevant. However, there are also things that probably limit its clinical relevance quite a bit: Physical entrapment itself is probably only be part of the story. The true cause of pain may actually be biological vulnerability to the nerve’s predicament. Even if the physical entrapment is the main issue, it’s not clear that “fascia” is actually to blame. And, regardless, it’s doubtful that a nerve can be sprung from such a trap with manual therapy. A good example to study: cluneal nerve entrapment The cluneal nerves pass from the low back and sacrum into the buttocks, just under the skin, and they can get snared in connective tissue on their way. Cluneal nerve entrapment is a good example because it may be a common undiagnosed cause of back pain that is not obviously neuropathic in character. That is, some cases probably don’t feel like classic back pain, but back pain with a fairly obvious nervy character (superficial, electrical, with some tingling and other distorted sensation). #1 marks the site of the superior cluneal nerves & where the first surgery freed nerves from “adhesions.” #2 marks the middle cluneal nerve, where the second surgery freed it from entrapment in the ligament. In 2016, Aota reported on “a case of severe low back pain, which was completely treated by surgical release of the middle cluneal nerve.”76 The patient suffered from “back and buttock pain radiating to both legs” which was “continuous and severe,” and had come on gradually over a decade. She’d been operated on already, a clean miss, a pointless diskectomy. She was lucky enough to have a doctor who figured it out and talked her into a surgery I doubt that I would have agreed to: exploratory surgery to identify nerves “entrapped in adhesions.” Freeing it up definitely helped part of the problem, but it didn’t solve it. It took a second attempt to find the main problem, a surgery I would definitely have been reluctant to try myself. But it’s a good thing she did! They found a tiny spot where the nerve passed through a ligament, cut it free, and that was the ticket: she was decisively cured. Which is pretty cool. On its face, this seems like an open-and-shut case of a nasty pain problem caused by connective tissue in an abnormal state, and therefore a good example of how fascia can actually matter. (Which no fascial therapist has ever actually mentioned to me as a reason why they are doing fascial therapy.) But now let’s dampen our enthusiasm. Entrapment may not be the problem (or not the whole problem anyway) Maybe her problem was not the nerve “snag” per se but a biological vulnerability to feeling it. The physical predicament of the nerve may have been like kindling for a fire — a fire that was then lit by something else (and then burned for years).77 Admittedly, even if that was the case — and it would certainly be fascinating — diagnosing the vulnerability and solving it might be next to impossible. It might be much more pragmatic to just free the poor nerve, rather than trying to fiddle with the biological dials so that the nerve stops being bothered. No kindling, no fire. Or it could be as simple as getting off a certain medication, or taking some vitamin D. Who knows. Was “fascia” really even involved? The authors of the paper about this case describe the entrapment of the superior cluneal nerve as “entrapped in adhesions,” which was part of the problem, but the case was ultimately solved by freeing the middle cluneal nerve from where it was stuck as it passed through: “entrapped under the deeper layer of the long posterior sacroiliac ligament where it penetrates the ligament.” Nerves often pierce ligaments and layers of fascia — just normal anatomy, or common variations — and it’s usually not a problem. There are many unanswered questions here. Was there something abnormal about the pathway of this patient’s middle cluneal nerve? Was there any abnormal tissue there, or was the passageway through the ligament just too narrow? Had it always been narrow, and only eventually became a problem for some other reason? Or had it become a problem? Did the pathway get narrower, or stickier? Was the nerve actually impinged, or more like stuck — couldn’t slide freely? Without the answers to those questions, we can’t really say whether fascia, per se, was the problem. But clearly it was not necessarily so. Manual release of nerves entrapped in fascia … is implausible in most cases. Imagine a hair stuck to a hardwood floor by some spilled honey, and covered with a Persian rug. Now try to “release” the hair through the rug. Good luck with that. This patient probably actually needed surgery. It’s seems unlikely to me that any amount of trying to manipulate that tissue from the outside — through a thick layer of skin, no matter how clever or forceful — was ever going to “free” that nerve. GO TO TOP • CONTENTS • NOTES

Part 4 Case study: Frank the adhesion machine Frank was an “adhesion machine” — for no apparent reason, he was rapidly forming abnormal adhesions in his abdominal cavity, thick cobwebs of connective tissue strung admist his guts. His surgeon described his abdomen as a haunted house. Frank had survived a chronic pancreatitis nightmare, a disease that runs in his family. His pancreas, spleen, duodenum and part of his stomach were removed in 2016, after several years of ominous medical misery. He was probably dying, and the radical surgery saved his life. But the adhesions continued to form, probably driven by the same pathology that had almost destroyed him. Medicine is full of mysteries still. Eighteen months after his surgery, Frank was suffering severe chronic pain and bowel obstructions. Surgery to rescue once again! The surgeon found extensive new adhesions strangling his intestines. They were cut free, and once again Frank was all right for a while. Now that is a fascial “release.” Six months later, a third surgery was necessary. The surgeon reported that he found, “more adhesions than he would have expected.” Frank was okay again, but for how long? He decided to try Barnes-style myofascial release the next time… and the next time came soon enough. Often alleged to be a gentle style of therapy, this was an excellent example of the more typical reality: weeks of brutal sessions in which the goal was to literally rip his abdominal adhesions with hands-on stretching of the abdominal contents. The work was so savage that it put him in the ER a few times. You have to admire Frank’s courage! As he explained, it was a calculated risk his physicians were well aware of. But I can’t help but think “What could possibly go wrong?” I never would have signed off on it — knowing what I know about fascial release would make it impossible to endorse. I don’t think the therapist had any business attempting this. Frank’s history should have completely disqualified him for intense abdominal manipulations. I think she could have killed him. Of course, he was truly desperate: the enemy was a serious and persistent pathology. And the only other option — surgery — is also potentially disastrous and to be avoided if at all possible. But that’s a devil we know, and the manual fascial release was very much a devil he did not — could not — know. And there wasn’t any trace of the common conceit that the therapy was “melting” his adhesions. This was just brute force, period. The goal was to rip them apart. And… it seemed to work. Frank got better again, without surgery, despite the rough ride. That’s about when he found this article and first wrote to me: calm, sensible, open-minded, curious. He was curious if I had any comments on his experience. But he was mainly reporting that fascial release seemed to be efficacious for him. A year later At the best of times, it can take me weeks to answer non-critical email, often months, and a delay served another purpose in this case — would the results be lasting? So often when I get “therapy X worked for me” messages, that confidence evaporates over the next few months (or people cling to it as “the one thing that helped” even though they continue to have a problem). Only a few weeks later, Frank was back in hospital, having another surgery that found and cut a major new adhesion, this time choking his liver. It was too serious a medical situation to trust it to manual fascial release. This situation developed so soon after the manual therapy that I have to wonder if it actually partly precipitated it, by causing a lot of extra inflammation while ripping up adhesions. Why, Frank wanted to know, had he felt better for a while just from fascial release? I can think of a couple reasons: First, top-down modulation of pain is a potent and common phenomenon.78 Virtually any strong sensory experience, combined with a bit of reasonable hope, can blunt a lot pain for quite a while. Pain is incredibly sensitive to the brain’s “opinion” of the situation, and a boost in confidence can tame it substantially, for a while. This is well understood by many pain experts and researchers, but largely unknown to most clinicians, who are almost exclusively obsessed with their claims of being able to “fix” tissue and don’t tend to think of their work as a potent theatrical placebo — even though all medical interventions involve a certain amount of that (even surgery). Second and more obvious: probably the therapist did manage to destroy a few adhesions! With that brutal approach, and such a clearly abnormal target, that’s hardly a surprising outcome. Doesn’t mean it was a good idea. Doesn’t mean it wasn’t dumb luck she didn’t seriously injure him trying. It might have even made the problem worse with a bunch of post-traumatic inflammation, leading directly to the crisis with his liver. Even if the therapy really did break some adhesions, it’s clear that it was pissing into the hurricane of whatever pathology is making Frank “an adhesion machine.” Even if it worked, it was clearly doomed to be temporary. That does not look like a success story to me. It looks like a desperate, risky attempt that didn’t really work. And the fact that any therapist was willing to do it is horrifying to me professionally — but completely unsurprising, more or less exactly the kind of fascia-inspired overconfidence I have come to expect from massage therapists.

Part 5 Conclusions Results of the Fascia Science Challenge so far … Piezeoelectricity may occur in fascia, but its clinical relevance is nil — not enough is known about it to even speculate about how it could be exploited in manual therapy.

may occur in fascia, but its clinical relevance is nil — not enough is known about it to even speculate about how it could be exploited in manual therapy. Gil Hedley’s theory that congealing fascial “fuzz” causes stiffness is simplistic and wrong. It is not a plausible explanation for the sensation of stiffness, or a mechanism of action for fascial therapy or stretching.

is simplistic and wrong. It is not a plausible explanation for the sensation of stiffness, or a mechanism of action for fascial therapy or stretching. Fascial “meridians” relate fascial therapy to the “meridians” of acupuncture, which don’t exist or — even if they do — can’t actually be exploited for any therapeutic effect even by acupuncturists.

Chaudhry et al showed that fascia is too tough to “release.” Indeed, even thin fascia is so tough that it is basically inconceivable that it could be physically changed (stretched, loosened) without vice grips. This directly contradicts a major popular rationale for fascial manipulation, and is only clinically relevant to fascial therapy insofar as it presents evidence that discourages and undermines existing common practices and beliefs.

Indeed, even thin fascia is so tough that it is basically inconceivable that it could be physically changed (stretched, loosened) without vice grips. This directly contradicts a major popular rationale for fascial manipulation, and is only clinically relevant to fascial therapy insofar as it presents evidence that discourages and undermines existing common practices and beliefs. Meltzer et al concluded that stimulated fibroblasts might be happier fibroblasts — specifically, they might be more resistant to post-exercise soreness. The results of this test tube study are questionable, but even if you take the data and interpretation at face value, it is a long reach from a test tube study to clinical reality. Treating post-exercise muscle soreness is not even a common goal for manual therapy.

— specifically, they might be more resistant to post-exercise soreness. The results of this test tube study are questionable, but even if you take the data and interpretation at face value, it is a long reach from a test tube study to clinical reality. Treating post-exercise muscle soreness is not even a common goal for manual therapy. Schleip et al established that fascia is contractile , but this isn’t biologically surprising, and it’s clinically trivial. It is definitely not a factor in any of the common problems most manual therapists work with — maybe none at all — and, even if it was, it is somewhat unlikely that hands-on therapy could make a difference.

, but this isn’t biologically surprising, and it’s clinically trivial. It is definitely not a factor in any of the common problems most manual therapists work with — maybe none at all — and, even if it was, it is somewhat unlikely that hands-on therapy could make a difference. Chapelle et al hurt some rats to prove that abdominal massage prevents post-surgical constipation, but so does chewing gum. Although this has been widely regarded as an important “fascia” study and justification for visceral manipulation, the paper does not actually report an effect on fascial tissue or adhesions, and it would have very limited clinical utility even if it did. It’s mildly interesting massage science, not fascia science.

Langevin et al and subsequent s