Wednesday, October 17, 2012

Does Fascia Matter?...Yes, it does!

I would consider this more of an "op-ed" piece rather than a true scientific discussion. Although op-ed pieces are authors who are non-affiliated with the "editorial board", I like the idea that the genesis for this post came from a slightly critical source. 

I should point out that this criticism wasn't levelled at me personally, rather on the growing enthusiasm for fascia and fascia science.  Further, I see it not as a negative manifestation but a positive one.  As per the image at the start of this post clearly says:  question everything!  This is the only way that "normal science" evolves...current paradigms are challenged, and if the paradigm still holds, it remains the viable construct. 

I recently read a very insightful article titled "Does Fascia Matter?"  and it was somewhat of an "eye-opener".  It presented a very intelligent and sage commentary on what can realistically be called "fascia fanaticism".  Although I wouldn't go as far as to suggest that there is anything fanatical about the current surge in interest, it is a very interesting perspective.  Further, it stimulates some introspection and generates some level of self-evaluation (and evaluation of a closely-held belief).  For this reason, I feel that this is perhaps one of the most refreshing articles I have read in quite awhile.  I actually contacted the author with some brief questions, but he "graciously" informed me that his email volume is staggering and that he only had time for "the interesting 20%".   Although I fully understand the busy nature of most professionals, however when it comes to the exchange of knowledge and concept, a few sentences or words are the hallmarks of a genuine quest for knowledge.  In a previous post, I reported that renowned author Leon Chaitow even took some time to send me a few words in feedback...which he regularly does on his social media sites.  My initial reaction was slight disappointment, but that quickly faded and I chalked it up as a learning experience to integrate into my working "harddrive".  More importantly, it gave birth to the (re)evaluation of a central-belief system that I have been championing for awhile now...and the end result is refreshing.  Without going into a "critique" per se, I will simply carve out some of the legitimate talking points from the article and address them individually: 

The author of the "Does Fascia Matter" article states that fascia enthusiasts routinely denounce his article.  I personally applaud it...for the simple reason that it does precisely what every intelligent article should do:  push the boundaries of our perception and question our own philosophy.  If someone is truly serious about their craft, this article will only serve to either re-inforce or re-evaluate the pillars of ones perspective...either way, they will come out more enlightened in the end. 

1)  Fascia is biologically interesting, but is it clinical relevant?

I found this to be a very, very good question.  Indeed, it is easy to get consumed by the elegance of fascia, but it is logical to step back and examine whether it has any clinical relevance.  I think that there is no real need to expand into any great physiological explanation, rather simply to identify the fundamentals of the human organism.  The term "clinically relevant", as I perceive it, refers to whether or not it is something that is either (a) adaptive and therefore able to undergo some change, and/or (b)  something that we can actually realistically target.  The very fact that it exists in such abundance indicates it is highly relevance to the establishment of systemic and biomechanical homeostasis.  Further, it has already been established that it is packed with sensory receptors (Ruffini, Golgi Tendon Organs, Pacini, Interstitial Receptors) therefore it serves as a fundamental source of mechanical information to the brain.  Perhaps the most important reality is that fascia is a subset of a much larger consideration:  Connective Tissue.  It belongs to the connective tissue "family", therefore it has equal relevance as every other tissue in the body.  When you consider the other "members" of the connective tissue family, this point becomes relatively clear. 

The above chart provides an elegant perspective on connective tissue.  It is essentially composed of two elements (cells and a matrix) and from there it differentiates quite significantly.  The relevance to fascia is derived from the matrix branch, which is clearly identified as being composed of a base ground substance and protein fibers.  The protein fibers demonstrate the mechanical contribution, while the diverse ground substance manifestations essentially describe the relevance within the human organism.  Mineralized ground substance is manifest as bone...which responds and adapts through cellular mechanotransduction.  The gelatinous/syrupy ground substance is what is widely considered as "fascia"...and it also responds through mechanotransduction. 

Therefore the question of clinical relevance is indeed logical...however, relevance is largely subjective and can only be evaluated through specific "prisms".  I have had the luxury of working exclusively over the last 6-7 years with severely affected children with Cerebral Palsy...who can realistically be categorized as some of the most profoundly weak individuals.  The most efficient, reliable, measureable, and permanent  way to improve their condition is the focused emphasis on the extended connective tissue system! As the chart describes, the connective tissue is a large contributor to biomechanical competence therefore if manual intervention is applied with very specific loading properties and using specific stress transfer mediums, the connective tissue will respond through the process of mechanotransduction.  Perhaps more importantly, the movement of interstitial fluid through the extracellular matrix (via specialized manual applications) contributes to the improvement in lymphatic drainage, nutrient transport, and the removal of metabolic by-product.  This is seen quite clearly in these profoundly weak individuals...and is somewhat "blurred" when you are working within the "healthy" community.  Is fascia/connective tissue relevant?  WITHOUT QUESTION.  

2) Fascia is not exotic and "too tight to release"

This is perhaps the most critical error that is made by the vast majority...including the author.  He states that there are essentially two simplistic rationales that fascia "enthusiasts" cling to that explain why fascia is important:  Its everywhere and connects everything, and it gets tight.  This statement is actually largely accurate...this is indeed a widely accepted "mantra" for most.  The author is correct in suggesting that this is a primitive perspective...however he simply points out this fact without going into any further "sophisticated" enhancement.  This statement, at best, only describes 50% of the reality...and I will explain why.  Further, this explanation will in fact demonstrate that fascia/connective tissue is indeed exotic!  The common conceptual "trap" is to consider connective tissue within its "connective" physiological appearance ONLY.  Although it is intuitive, it is extremely primitive and quite mis-leading.  The exotic nature of connective tissue is that is has a paradoxical physiological function of DIS-CONNECTING as well!  Loose connective tissue (what is largely thought of when thinking of fascia) serves the role of separating specific muscle groups and bundles as well as synthesizing lubricant to allow for un-interrupted sliding between muscle groups.   This mechanism is in place to increase force transmission efficiency...without which, movement and function would be significantly disturbed.  In essence, the exotic nature lies in this paradoxical dual purpose.

The other notion that fascia is too strong to be released is not anything that I have a particular comment on.  Rather, it is the idea that fascia/connective tissue ONLY gets tight...or is only somehow "overstrong".  This is the most unproductive mindset I can think of.  In reality, "tightness" is a relative expression, NOT an absolute one.  To be specific, it is always assumed that one "sheet" is too tight and needs to be released. The overwhelming failure lies in the fact that this perceived tightness is in relation to the adjacent it really tight, or are both of them weak with one of them being "less weak?".  Therefore, with respect to the absolute true status of the fascial band, if you disregard the potential that it may in fact be have effectively reduced your chances of success by a minimum of 50%.  It is already widely known (and researched) that a spastic muscle is approximately 4 times stronger than a healthy muscle...but the connective tissue matrix is 30-40 times weaker!  Therefore, it may in fact be true that healthy fascia need not be may even be a viable extrapolation to claim that it CAN'T be released...however, this paradigm excludes the reality that connective tissue can indeed manifest weakness and that this weakness can contribute to an alteration of the biotensegral homeostasis of the human organism (both mechanically and systemically). 

In summary, the author is right in the claim that physically changing fascia by force would be "medievil"...however this falls squarely within the "tight-only" paradigm.  Weak connective tissue systems can be gradually strengthened over time with appropriate loading properties and adequate stress transfer mediums. 

3) Does it matter that fascia contains muscle cells?

The simple reality is that the human organism is the most efficiently constructed "machine" on the planet.  In essence, if it exists, it matters!  It is true that, when compared to actual muscle tissue, its contractile potential is significantly less...but muscle tissue has the singular purpose of contraction!  It is a specialized tissue that does nothing else but contract and relax.  Conversely, connective tissue (fascia) has diverse and widespread physiological roles.  Therefore if you gauge connective tissue solely on contractile will obviously fall very short.  The fact that it extends throughout the entire organism from top to bottom, inside and out reflects the significant impact it has even with limited contractile other words, its effect on the organism is cummulative.  If the entire connective tissue network were to contract, it would generate significant force...which is quite regularly manifest in the "fight or flight" response where individuals are reported to perform feats of "superhuman strength".  This is the automatic recruitment of the contractile properties of conenctive tissue. 

4) What does Dr. Schleip think?

For those who are unfamiliar with Dr. Schleip, he is widely considered as one of the leading experts in fascia research.  The author makes a point to mention that he has forwarded his position to Dr. Schleip (which is a noble and respectable gesture) for his feedback.  According to the article, Schleip shares the authors reserved attitude in making any "God particle" claims with respect to fascia...additionally, that there are some people making some claims that are made from no facts, extrapolation of fact, or theory regarding fascia.  However, the mere fact that Dr. Schleip exists...and that he has been sought out for comment by the author...indicates that fascia IS important.  The reality is that there have been no real advances in physical therapy since the invention of the EMG.  The current "muscular" paradigm we currently follow is based on the idea that anything important must generate an electrical signal...if not, it isnt important.  The consideration of fascia/connective tissue as active "players" is a relative "stretch" within this paradigm.  Therefore, I can confidently say that the current environment is consistent with what Kuhn calls a "Model Crisis".  A Model Crisis is when there are accumulating anomalies that the current paradigm cannot explain.

Kuhn Cycle for Scientific Revolutions
This inevitably leads to a model revolution and a subsequent paradigm shift.  The typical crisis stage is characterized by a polarization of philosophy and perspective with those resisting the "revolution" and those who are attempting to drive the paradigm shift forward.  It is my personal belief that the current fascia science is stimulating and perpetuating this cycle through the most sensitive (and challenging) phase.  The ultimate result is a likely paradigm shift that reconfigures the working mindset and will therefore re-shape the manner in which "normal science" is done how research methods are approached.

Fascia matters.  Case closed.



Saturday, October 13, 2012

Cerebral Palsy Guidebook: Symptomatic or Problematic?

The two previous "Guidebook" post on the blog have received quite a few reads...just over 1000 reads in about 3 weeks.  I have decided to add an "insert" here on the Facebook page as a complement to the first "Developmental VS Choronological" entry.  The essential framework of this note is identical...presenting a given perspective on the daily challenges associated with CP and how they impact the fundamental decision making process within the family unit.

 Although they may seem mutually exclusive, the reality is that symptomatic and problematic are intimately related.  Within the CP landscape, they are essentially "blurred" together and it seems that everything is defined as problematic.  It is important to make very clear distinctions between them, however...because this distinction will ultimately have a direct impact on how these challenges are received (anxiety, panic, worry) and, more importantly, how they are addressed.  In order to make this distinction, I have chosen an analogy that is likely to be the most "universal"...the famous "Check Engine" light.

As simple as it sounds, the check engine light is an indicator of more profound problems within the engine itself.  Even if the engine seems to be running smoothly, the "check engine" light may blink on to signal that some intervention is needed in the immediate future and that some form of assessment is required.  As many of you have already experienced, as soon as this light comes on, you immediately get a typical "what now?"  reaction (which may have a few expletives added to the front).  In alot of cases, myself included, the light itself becomes a nuisance...and therefore the immediate problem.  The reality is that it can be realistically considered as a "symptom" of the internal engine problem...therefore, the immediate (and instinctive) reaction is often directed at the symptomatic manifestation as opposed to the more fundamental under-lying issue.

This analogy translates quite effectively into the CP landscape.  There are multiple "check engine" lights going on and off (muscular tension, seizure activity, digestive dysfunction, joint dysfunction, immune system deficit, etc..) that instinctively grab almost 100% of the attention.  All of these challenges are indeed difficult in their own right...this is not to say that they are any less important or challenging.  The main message of this note is to understand the relationship between symptomatic and problematic.  To be precise, the alarming majority of strategies are centered purely on symptomatic resolution.  Using our analogy, this is the equivalent of "turning the check engine lights off".  Having had this discussion many times in the past, I am acutely aware that this distinction may still be somewhat elusive...therefore I will be more explicit:

1.  Symptoms are typically the most visible...Problems are essentially "hidden".  This is an important fundamental understanding to integrate.  The most immediate, obvious, and intuitive challenges are typically those that are easy to spot and identify (chaotic movement, convulsions, fever, feeding dysfunction, spastic muscles, etc.).  Although often quite difficult and challenging to manage, they stem from a general subset of systemic problems that "lie underneath the surface".

2. Symptoms have the potential for some immediate short-term relief, while Problems require a more comprehensive and long-term strategy Another important reality is that the symptomatic challenges have a relatively well-established list of tools for their immediate resolve.  Whether it is in the form of pharmaceuticals, manual techniques, or nutrition...the current "menu" is quite extensive.  In addition, the itemson this "symptomatic menu" have the most appeal: "immediate relief of...."   The resolution "menu" is relatively non-existent and falls short of any true appeal simply due to the idea that it is long-term and the progress is evaluated over months and years as opposed to days and weeks.

3.  Problematic issues are the most detrimental to overall health, systemic homeostasis, and general quality of life.  Although this statement could realistically be debated, when you accurately identify the problematic issues it becomes somewhat less obscure as to the true root of most challenges.  They can be outlined in this general format:

a. Profound deficiency in the connective tissue quality and integrity----- leading to joint dysfunction and irregular muscular activation
b. Reduction in the quality of interstitial fluid flow----leading to immune system dysfunction, poor tissue (skin) quality, and spastic conditions
c. Insufficient lymphatic function ---- leading to higher systemic sensitivity and susceptibility to viral / bacterial infection
d. Profound insufficiency in CSF flow --- leading to reduction in brain metabolism, poor processing potential of the brain, poor nutritional maintenance of the spinal cord, electrolyte dysfunction within the brain, convulsions

This of a basic description, of course...the list is actually alot more comprehensive and complex.  However the main message should be quite obvious.  The underlying, hidden, and fundamental problems are the true source of the more obvious and external symptomatic manifestations. 

In summary, the most successful rehabilitative strategies take both  into consideration and designate selective interventions to address the entire organism.  Refering back to the original analogy, there is a fundamental understanding that should be well integrated into youe mental "hard-drive":  There is no need to WAIT until the check engine light comes on before you act"The unfortunate reality is that most are not given this option...nor is it generally even considered.  This is a result of the Pathogenetic paradigm that currently overwhelms the thought process and therefore manifests in most treatment strategies.  The pathogenetic paradigm is also considered as the "disease fighting"  paradigm and can be equated with the idea of waiting until the engine light comes on.  This is quite common and has become almost expected as standard operating procedure:  "the x-ray shows the hip is at 20 degrees, but when/if it gets to 30 we will have to consider surgery...the spine is curved now at 33 degrees, but when it gets to 43 degress, you will need a corset...the EEG shows some irregular activity, but it isnt too bad at the moment."  Although the pathogenetic approach is an essential component of any successful strategy, it shouldnt be the singular focus.  There is also a Salutogenetic Paradigm that exists as well...which essentially is the promotion of health and maintenance of systemic homeostasis.  In other words, during periods of relative health and stability there should be some active intervention in place to address the underlying systemic deficits...or "implementing a regular maintenance program so that the engine light doesnt come on at all".  As with the car analogy, the human organism is dependant an adequate fluid flow, efficient thermoregulation, and regular structural assessment and evaluation.

Although the human organism is exponentially more complex, the general philosophy and mindset applies for both.  The symptomatic challenges are addressed within the pathogenetic paradigm for immediate resolve, while the consistent implementation of salutogenetic strategies address the underlying problematic roots.  The most recent research and investigation demonstrates undeniable and significant positive results in progress when salutogenetic interventions are adopted...and therefore should become an integrated part of the rehabilitative protocol.