Interesting article about the non-deformability of fascia and its relevance to manual therapy

[AlexanderEgebak]

http://www.massage-stlouis.com/if-we-cannot-stretch-fascia-what-are-we-doing

The articles highlights the discussion about being evidence based and fitting a suitable explanation model for the intervention.

[dannyg]

This is a great post. I feel that you implicitly understand how that if you are consciously using conceptual model that has 'debunked' it is unethical. 

 

There's a great post on the 'Exploring Pain Science' Facebook group that talk about ethics. The post mentions Myers being fully aware of the research on Fascia, yet still 'selling' his product without mentioning it. 

 

What we do might not change, why we think we do it might. I have to bite my tongue regularly when talking about massage and treatment, I often refer to what I'm doing as 'Neuromodulation' and give a little explanation about what is happening. It's not as good business practice as telling someone they are 'mis-aligned' and getting them to come back for weekly adjustments, but I feel it is more ethical. 

 

 

[Jim Pickles]

As a scientist, I'm sorry I found the discussion under the link in Alexander's post rather depressing. There was so much speculation about the subtleties when in fact there was no actual evidence about what was happening. For a scientist, the obvious answer would be to test it directly - which cant (usually at least) be done on human beings, so that would need animals. I know this doesnt help therapists, who have to do the best with what they've got, but it was all an interesting discussion (and one close to my own thinking) which I could not bear to take part in.

My views, about some of the points raised in the dicussions (by the way, the link given to a Schleip paper was no longer valid):

1. Myofibrocytes (the motile cells in fascia discussed by Schleip) probably dont contribute much or at all in normal situations (I read the evidence on this years ago, cant find it now) though Schleip speculated about it in an interesting Medical Hypotheses paper.

2. We expect the layers of fascia to hydrate and become able to slide over each other as part of the sports "warm-up", so this will lead to increases in flexibility due to changes in the fascia.

3. Yes, collage molecules can't extend - and this means that fascia will not be able to stretch, in so far as it is limited by aligned collagen molecules. However in tendons, the collage molecules have a wavy arrangement (the "crimp") so that some degree of extension is possible, until the crimp is straightened out. Maybe fascia has collagen molecules arranged so as to allow some degree of extension.

4. Can fascia be fundamentally modified? It is suggested (and I did once find the evidence) that stretching leads to enhanced turnover of the collagen and other molecules (i.e. destruction and reformation) and this would allow reconstruction of the fascia over time. The old molecules are replaced with new "youthful" ones which are in the correct alignment. So stretching can keep your fascia young.

5. I'd be highly surprised if fascia cannot be stretched over time. Someone who has fundamentally increased their flexibility is highly likely to have remodelled their fascia and maybe muscles as well. But just as stretching is slow, we expect this process to be slow as well (over years).

I can find sources for some of this if anyone is interested, but not now as its late at night and I should have been in bed ages ago. None of this helps the Rolfing discussion however.

Jim.

[dannyg]

14 hours ago, Jim Pickles said:

As a scientist, I'm sorry I found the discussion under the link in Alexander's post rather depressing. There was so much speculation about the subtleties when in fact there was no actual evidence about what was happening. For a scientist, the obvious answer would be to test it directly - which cant (usually at least) be done on human beings, so that would need animals. I know this doesnt help therapists, who have to do the best with what they've got, but it was all an interesting discussion (and one close to my own thinking) which I could not bear to take part in.

My views, about some of the points raised in the dicussions (by the way, the link given to a Schleip paper was no longer valid):

1. Myofibrocytes (the motile cells in fascia discussed by Schleip) probably dont contribute much or at all in normal situations (I read the evidence on this years ago, cant find it now) though Schleip speculated about it in an interesting Medical Hypotheses paper.

2. We expect the layers of fascia to hydrate and become able to slide over each other as part of the sports "warm-up", so this will lead to increases in flexibility due to changes in the fascia.

3. Yes, collage molecules can't extend - and this means that fascia will not be able to stretch, in so far as it is limited by aligned collagen molecules. However in tendons, the collage molecules have a wavy arrangement (the "crimp") so that some degree of extension is possible, until the crimp is straightened out. Maybe fascia has collagen molecules arranged so as to allow some degree of extension.

4. Can fascia be fundamentally modified? It is suggested (and I did once find the evidence) that stretching leads to enhanced turnover of the collagen and other molecules (i.e. destruction and reformation) and this would allow reconstruction of the fascia over time. The old molecules are replaced with new "youthful" ones which are in the correct alignment. So stretching can keep your fascia young.

5. I'd be highly surprised if fascia cannot be stretched over time. Someone who has fundamentally increased their flexibility is highly likely to have remodelled their fascia and maybe muscles as well. But just as stretching is slow, we expect this process to be slow as well (over years).

I can find sources for some of this if anyone is interested, but not now as its late at night and I should have been in bed ages ago. None of this helps the Rolfing discussion however.

Jim.

Ah, this is something that I like discussing. I suppose many people (mainly therapists) are aiming towards 'useful' models rather than 'accurate' ones - which is sometimes frustrating. 

 

Hyaluronic Acid is the proposed 'lubrication' molecule I believe, but that doesn't necessarily change the structure of the fascia. Unless you mean 'in' as in 'within the layers'. haha.

 

The argument I seem to bring up in situations like this is when we talk about 'stretching' fascia, or remodelling it - like it's special in some way. All tissue responds to load (or lack of load). I like the term 'bioplastic' to describe the 'plasticity' of all of our tissue. Fascia, like any of our tissue adapts to what it is made to do.

When I think about tendons I am reminded that strong, thick tendons are the best for preventing injury and transferring force. Tendon hypertrophy occurs and is quite useful. 

The rate at which tendons change is significantly slower than bone or muscle. Now, in my opinion, fascia would remodel (slowly, over time) upon loading to be stronger, and thicker (more dense?). Loaded stretches provide a bigger stimuli and a greater adaptation. Allowing the self to perceive the stretch as less of a 'threat'. 

In an injury like a minor ankle sprain, there can be ligamentous creep which can affect joint congruency - creating a laxity in the joint. This seems to be permanent (as far as the research I've read).

What I have noticed often happens in this situation is the muscular tissues take on a more 'protective' role. Often this manifests as peroneal (or fibularis) muscles, tibialis anterior and posterior getting rather tight and sore. What really seems to help is stability exercises to improve their function at this role.

Basically I'm suggesting that the way our fascia might change (unless there is a trauma), that fascia responds to the load of stretching by being better at producing Hyaluronic Acid and getting thicker/denser.

If there has been a trauma and permanent 'creep' has occurred, I believe this would unhelpfully affect the load distribution function of fascia. Requiring more muscular effort. 

I don't really have much to base this on however, as I'm sure that this only really occurs when we are 'loading' the stretches well. 

Please no-one mention the word 'tensegrity'.

Rates of change of connective tissues happens in months and years. There's a cool study about nuclear bombs and achilles tendons and how there seems to be NO turnover in the core of the achilles tenon. https://www.ncbi.nlm.nih.gov/pubmed/23401563

 

 

 

 

[Jim Pickles]

@dannyg - thanks for the link to that interesting paper. As pointed out in the discussion of the paper, there is a bit of a contradiction between the well-known finding that the Achilles tendon can adapt (in terms of strength and elasticity) to the types of stresses put on it (as well as repair itself after damage), and the finding that there is normally near-zero turnover (replacement ) of proteins in the core. They discuss some ideas (e.g. that the adaptations might happen in the outer part of the tendon, or that other associated molecules may be primarily involved in adaptation). However, the fact that it adapts, and can repair, shows that something that affects its mechanical properties can be modified over time. One would guess that the same would be for fascia - fibroblasts which are the cells within fascia that make new collagen can respond to stretch. Somewhere I found a paper (but cant find it now) showing that as fascia ages, the molecules become disorganised, and with training (stretching) they are replaced with ones in a more aligned organisation as in youthful fascia. One guess is that left alone, there may be not much change in fascia or tendons, but in response to a change of stress, remodelling occurs. Just stating the obvious, really.

Anyway, whatever the theory, obviously practitioners should use what works, even if they cannot come up with an explanation.

[AlexanderEgebak]

This commentary is relevant to the fascia discussion a little bit:

https://www.tandfonline.com/doi/full/10.1080/10669817.2018.1447185

+ It has references!

[Jim Pickles]

So could it be that in many cases manual therapy has its effects ONLY via neural effects/learning/reflexes/expectations? - e.g. by showing that it is possible to move in a certain way, that does not give pain - whereas before the manipulation it did give pain? Since (as far as I am aware*) it has not benerally been shown that the types of manipulation being discussed produce direct mechanical changes (and I am very happy to be corrected or further informed on that) this is a possibility one should bear in mind. This is a point that I think Schleip has been making (sometimes).

(*There are however some clear exceptions - e.g. fascia release of gracilis and inner hamstring.)

I may seem to be disagreeing with my own previous arguments, since I have always believed in a mechanical explanation for increases in flexibility. I should qualify my view on that, to large long-term increases that may take a long time to develop. I know from my own experience (of leg flexibility enhanced as a result of a relaxing massage of my neck) that short-term increases in flexibility can in some circumstances be produced by non-direct-mechanical i.e. (presumably) neural effects. But this was a special case, where sensations from a preceding minor injury were holding me back; after the massage I did not feel the painful sensations, and stretched further. However the non-injured llmb was not affected by the manipulation.

Edited April 1, 2018 by Jim Pickles
Second thoughts

[AlexanderEgebak]

Why do you believe that the fascial release of gracillis and inner hamstring is an exception?

[Jim Pickles]

Because the effects are so large and clear.

However, in the end, the problem is that we have no objective measures of how these effects work in practice. We are going by impressions, which means there is enormous room for personal interpretation (and misinterpretation).

 

[AlexanderEgebak]

So what you are saying it that you believe a release of fascia is happening based on observations by the eye only due to the remarkable changes that occur?

The theory says that fascia may only be deformed immediately by almost tearing itself. Considering the amount of force required to tear fascia I find it unlikely that an immediate mechanical release of fascia can happen at any point. If we also look at force application throughout the tissue layers of the body the skin, muscles, bones etc. will each absorb a certain amount of force by moving in a certain direction and it will be hard to direct a certain amount of force towards a specific structure (I have a study somewhere which I will link when I find). 

Though some thing is happening which most likely is a result of a neurophysiological reflex in my opinion. Moseley writes in Explain Pain Supercharged about Puccini (or Ruffini, I do not remember) sensory organs responding to stretch over time; this may result in a release from the common technique of pressure, pull away and twist. I find that to be a more likely explanation though it is just guess work. And, of course, decreasing threat levels in the body will also decrease structural tension.

In the end I believe that extraordinary claims require extraordinary evidence. I find that a mechanical fascial release applied by hands are very unlikely and therefore the original idea must be proved and not just widely accepted before trying to use this biomechanical explanatory model.

This is not to criticize the manual techniques because they obviously work in practice. More like to make sure that it is delivered with an updated explanatory model to improve correct clinical reasoning and to prevent nocebo delivered to the patient.

 

[Jim Pickles]

@AlexanderEgebak

It is usual to distinguish two things:

1. Separation of the layers of fascia - this can occur through different mechanisms, such as hydration of the surfaces of the fascia, which allows the different layers of the fascia to slide over each other more easily. Alternatively manual separation may be used to separate the layers of the fascia (as is thought to occur when the gracilis and hamstring are separated).

2. Stretch or elongation of the layers of fascia itself. This, as is pointed out in the links above, is likely to be small and/or slow. However there is evidence that over time stretch encourages the molecules of fascia to reorganise to produce anatomical changes within the sheets of fascia.

In earlier postings (which you should be able to find) I have described evidence, as far as it can be determined from scientific studies (including animal studies), for these processes. However I agree entirely (if that is the point you are making) that in the intact human being we usually do not have direct evidence for what is going on, so ideas of mechanisms are guesswork, based on previous ideas (which of course may themselves be wrong).

Jim.

[AlexanderEgebak]

Diana Jacobs wrote this book about dermoneuromodulation which essentially is fascial release techniques targeted at skin receptors and with a better model of explanation. Since it is freely available through a google search I thought of linking it here:

http://cstminnesota.com/resources/dermoneuromodulation.pdf

At some point I might attend the course that Diana is running. This is one of the few manual techniques for treatment that I know of that has (positive) specific effects which can be documented. Not only placebo effects related to contextual factors, beliefs and expectations.

[Konrad Maggenti]

Hello

When stretching:

From what I understand after reading a number of forums and Kit's article in ST, 'What gets stretched'?  The fascial system is the last neural structure in the chain that will get stretched and then we have reached our full limitation? If so, when do we know we are about to stretch the fascia?  What sensations will we be experiencing?

In Kit's article, one sensation is 'aversion'. I know/feel I am at this point and would like to know which neural structure is the cause of this sensation as would like to go past this if possible? 

Note: I have being doing ST for many years and have three sticking points which is telling me that I am not at my full ROM and haven't yet 'let go'.

[Kit_L]

On 8/8/2020 at 3:15 PM, Konrad Maggenti said:

I know/feel I am at this point and would like to know which neural structure is the cause of this sensation as would like to go past this if possible? 

@Konrad Maggenti: There is too much focus on the physical mechanisms that may control any elongation, in my opinion; if becoming flexible is your goal. What everyone seems to forget is that what's going on in the mind controls the neural activity in all of the structures; this must include fascia, as well. What I have described as "aversion" is the strong momentary experience/emotion of recoiling from the moment of this experience; it happens extremely quickly. Most cannot see it, in fact — Which is why people are typically so vague about explaining why they have just pulled themselves out of a stretching end position.

The answer to your question Konrad is simple: relax more. In my considered experience, everyone thinks that they are relaxed when they're at an endpoint in stretching and they are far from that point in fact. It is extremely difficult to relax in the face of aversion.

So, to test this, take a breath when you're at that point the next time you stretch, pause everything, let your tummy go completely soft (and get someone else to check it if you have to), and then see if you can go further into the stretch. If you can it was your mind holding you back – but not your conscious mind. If you can't, then you simply go on as far as you can today, and try again next week. There is no schedule for these kinds of changes.

@AlexanderEgebak: @Jim Picklesis referring at least to one occasion he has seen for himself: a woman on a workshop who was sitting in a pancake, completely unable to go past 45°. I did a simple fascial release on her left leg only, wherein I separated these two muscles for about half their length on the inner thigh, and she leant forward with a perfectly straight back, and put her stomach and chest on the floor. The video is on YouTube if you're interested. This was not faked; there were about 80 other practitioners in the room, and many watched the interaction.

I found the article linked in your original post to be completely unconvincing — long on speculation and short on evidence. I know this kind of fascial release is a real thing, because I have done it hundreds of times on workshops with similar results. Nothing that the individuals invoved were doing themselves could change the experience of being stuck in this position. Perhaps you have felt it yourself in the past. When I found the place relatively high up on the thigh where these two muscles are always separated, and slid my fingers in between the inner hamstring and gracilis, I could feel clearly that downstream of where I was pulling up that the muscles were "stuck" together. A relatively gentle pull, and you can feel them separate, and they stay separated. You or anyone else can feel this easily. What are the mechanisms of separation? I have no idea. I invented this release myself by working on the legs of people trying to do the pancake and realising that because of attachment points these muscles would need to elongate at different rates to do a pancake. Plus the practitioners were reporting to me that they felt that only one small place on the inside of the leg was stopping them bending forwards at the hips – so I let my fingers do the walking, so to speak, and that is what I found.

[AlexanderEgebak]

On 8/10/2020 at 8:06 AM, Kit_L said:

@Konrad Maggenti: There is too much focus on the physical mechanisms that may control any elongation, in my opinion; if becoming flexible is your goal. What everyone seems to forget is that what's going on in the mind controls the neural activity in all of the structures; this must include fascia, as well. What I have described as "aversion" is the strong momentary experience/emotion of recoiling from the moment of this experience; it happens extremely quickly. Most cannot see it, in fact — Which is why people are typically so vague about explaining why they have just pulled themselves out of a stretching end position.

The answer to your question Konrad is simple: relax more. In my considered experience, everyone thinks that they are relaxed when they're at an endpoint in stretching and they are far from that point in fact. It is extremely difficult to relax in the face of aversion.

So, to test this, take a breath when you're at that point the next time you stretch, pause everything, let your tummy go completely soft (and get someone else to check it if you have to), and then see if you can go further into the stretch. If you can it was your mind holding you back – but not your conscious mind. If you can't, then you simply go on as far as you can today, and try again next week. There is no schedule for these kinds of changes.

@AlexanderEgebak: @Jim Picklesis referring at least to one occasion he has seen for himself: a woman on a workshop who was sitting in a pancake, completely unable to go past 45°. I did a simple fascial release on her left leg only, wherein I separated these two muscles for about half their length on the inner thigh, and she leant forward with a perfectly straight back, and put her stomach and chest on the floor. The video is on YouTube if you're interested. This was not faked; there were about 80 other practitioners in the room, and many watched the interaction.

I found the article linked in your original post to be completely unconvincing — long on speculation and short on evidence. I know this kind of fascial release is a real thing, because I have done it hundreds of times on workshops with similar results. Nothing that the individuals invoved were doing themselves could change the experience of being stuck in this position. Perhaps you have felt it yourself in the past. When I found the place relatively high up on the thigh where these two muscles are always separated, and slid my fingers in between the inner hamstring and gracilis, I could feel clearly that downstream of where I was pulling up that the muscles were "stuck" together. A relatively gentle pull, and you can feel them separate, and they stay separated. You or anyone else can feel this easily. What are the mechanisms of separation? I have no idea. I invented this release myself by working on the legs of people trying to do the pancake and realising that because of attachment points these muscles would need to elongate at different rates to do a pancake. Plus the practitioners were reporting to me that they felt that only one small place on the inside of the leg was stopping them bending forwards at the hips – so I let my fingers do the walking, so to speak, and that is what I found.

I agree that there is too much emphasis on the physical mechanisms of what exactly is going on.
 

The clinical phenomenon of a 'release' is real, of course, you only need to see a few examples of it happening. As you have done.

However, what is seen by eyes, felt by hands and experienced via perception is not evidence to what is actually going on beneath your hands; in the skin, muscles, fascia, bones and the nervous system. The inherint risk of a post hoc, ergo prompter hoc-fallacy is even higher through a confirmation bias where many instances of the same phenomenon is happening and the same conclusion is being drawn.

The burden of proof lies with the ones claiming that fascial release is happening through a mechanical mechanism. And given the force needed to seperate fascia, I believe it is an extraordinary claim to say that hands can mechanically seperate fascia when 1) hands are not able to produce much force, and 2) the force is being applied to and absorbed by many of the underlying structures.

Extraordinary require extraordinary evidence, and I will refer to Hitchen's Razor: 'What can be asserted without evidence can also be dismissed without evidence'. I find the neurobiological explanation much more plausible with the absence of any actual evidence

@Jim Pickles I am not being entirely dismissive about the point about seperation vs elongation of fascia. But I still see it as unlikely. It could be interesting to have an ultrasound device scanning mid-release although that does not do much to confirm the hypothesis anyway, I guess.

[Kit_L]

13 hours ago, AlexanderEgebak said:

And given the force needed to seperate fascia

What force is required to separate adjoining muscles in this situation? Has it ever been experimentally tested? Have you ever tried to do this? What is your evidence for the claim that this release requires force (and 'how much force'?).

My personal experience having done this particular release perhaps a few hundred times, the force required is in the order of 20 to 30 kg, which my fingers can produce. The more interesting aspect of this release, which you can see in the Suzie video mentioned above, is that as soon as the release is done the movement which was not possible is possible. As well, this movement persists in time, months and years, if the new range of movement is used occasionally.

A better approach, intellectually, rather than dismissing any perspective in the absence of evidence, is to ask the question, the more open question, "how could this work?" 

A more general point: if you're attempting something that is new, you will never be able to act if you need the support of evidence before moving forward—if this is an area where no research has been done. I recall mentioning something similar to you when you first started posting here, years ago.

[Jim Pickles]

@AlexanderEgebak - if you dont know it already, this video and similar ones are rather illuminating: