“The fascia will make everything better”: a pattern of flawed clinical reasoning about fascia • Fascia enthusiasts are rarely specific about why fascia matters, and tend to speak with general excitement about the complexity and ubiquity of fascia as if that were reason enough to target it.

“Fascia” gets talked about in therapy offices a lot these days. These sheets of tough connective tissue that wrap everything in the body — even cells — are allegedly the key to many a therapeutic puzzle, and are now routinely targetted by therapists of all kinds. This article challenges and criticizes that paradigm, and is quite “negative,” but that’s actually a good thing. Criticism and deconstruction of ideas is normal and healthy and necessary for therapy professions to grow and change. Consider that the enthusiasm for fascial therapy emerged in part from criticism of the ideas came before it!

Barely known to science!

Practitioners and proponents of fascia-focussed therapy are rarely specific about why fascia matters, and tend to focus on general excitement about the complexity and ubiquity of fascia, as though the complexity and wide extent of a tissue type is reason enough to make it the target of a therapy. They often claim that it has functions barely known to science, but then they claim to be able to exploit those barely known properties for the benefit of their patients. This is a strong pattern in medical history: guesses tend to fill knowledge gaps.

Some fascia research is quite interesting, and what most (not all) researchers are saying about fascia is reasonable and does not reach beyond what the data indicates. Unfortunately, too many therapists fascinated by fascia are reaching well beyond what the science can actually support so far.

Beware the implication of therapeutic significance from scraps of basic biology. It is easy to sound cool talking about biology, because biology is cool. It is hard to make it useful. 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

Electrified by piezoelectricity

For instance, a popular idea is that piezoelectric effect is at work in fascia. It is hardly clear that this is actually the case. However, even if we took it as fact, in what way is it at work? Do we know the physiological intricacies of that 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. Piezoelectricity is barely mentioned in connection with fascia in the scientific literature. Fascia is not discussed at all — not even as a controversial concept — in the Wikipedia page on piezoelectricity, while other biological exploitations of the effect are mentioned. This doesn’t mean that there is no piezoelectric effect in fascia. But if there is, we have a very poor understanding of the phenomenon, at best.

Consider the known example of piezeoelectricity in bone: it’s pretty well-documented that piezoelectric effect is used as a way of guiding bone remodelling in response to stresses, which is super cool. It’s a terribly clever system! And it also has absolutely 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 absolutely cannot be simulated by manual therapy. Trying to affect that system with your hands would be entirely futile. And that is 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 exploit them. Proponents protest that we should not dismiss fascial therapy because “not enough is yet known,” but it’s just the opposite: because not enough is known, we should not use it to rationalize a therapeutic modality.

This is the basic problem with most of the hand-waving about the supposedly neato properties of fascia: some of it might be real and biologically interesting, but little or none of it can actually inform clinical reasoning. There simply are no properties of fascia that have useful implications for manual therapy.

Fuzzy logic

Update: I have corresponded briefly with Gil Hedley about my criticisms of him below, which naturally concerned him. He explains that the video was “never meant to be anything but a light, goofy rant to inspire folks to move more.” I conceded that my tone is harsh, and apologized to him for the unfairness of judging him on the basis of a single old video, without acknowledging the context his much larger body of work. Nevertheless, I stand by my criticisms of this video and believe that my “tone” is irrelevant to their validity. My wording is unchanged for now, for the record.

Another fine example of vague scientific enthusiasm is Gil Hedley’s popular “fuzz” speech. In this widely circulated video, 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 rambling, sloppy interpretations of what he sees are not. He makes a great many assumptions about the significance of that tissue. His leaps of logic are large. “That stiff feeling you have is the solidifying of the fuzz,” Hedley confidently explains.

At best, that is an extremely unsafe assumption, and one that conspicuously ignores many other highly relevant factors (like, oh, neurology). He does not know what happens to that tissue in a living body. For all he knows, that fuzzy texture only manifests post mortem! At worst, and more likely, his theory is hopelessly wrong. Almost any amount of reasonably normal movement is quite sufficient to sustain mobility, strongly suggesting that “fuzz solidification” either isn’t happening or doesn’t matter. There are quite a few much better explanations for the sensation of stiffness — many of which have nothing to do fascia or its fuzz.

Hedley wants the credibility of what appears to be a scientific perspective on fascia, but he confesses his own disrespect for science: “Science to me is another religion among many, whose dogmas I am attempting to shed.” That kind of talk could be the the lyrics for a pseudoscience anthem, and it’s a dead giveaway that Hedley really has no idea what science is or how it works, even as he’s abusing its methodology. And yet his incoherent fuzz theory has been accepted by countless fascia enthusiasts as a serious, scientific explanation for stiffness, and a rationale for fascial “release” and stretching.

Not so exotic after all

Despite all the talk of exotic properties of fascia, fascia’s clinical importance is too often reduced to simplistic rationales: it’s everywhere (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.)

The central idea is that this stuff can get tight and restrictive, and then 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 implementations of fascial therapy can be among the most painful of all hands-on techniques. (Some fascial therapy is gentle, but I have personally encountered intense fascial therapy in the wild on numerous occasions. I prefer gentler therapy and usually request it. Despite being a confident and assertive communicator about my preferences, I have still had many unpleasantly intense fascial therapy experiences.)

That’s what fascial therapy boils down to — an extremely simplistic explanation, a long way from the pretentious talk of exotic biological properties! It amounts to “fascia good” …

“The fascia will make everything better”

Not all fascia talk is fancy, and I have encountered much too much overly simplistic communication about fascia. Many therapists are perfectly capable of discussing the topic intelligently, of course, but my point is that low quality communication about fascia is distressingly common (and my exposure is quite extensive, due to the large volume of email I receive). For instance, in a recent massage appointment, a therapist said this to me, with lots of “ums”:

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.

Come again? In my experience, this is the low intellectual level of many casual pronouncements about fascia — worse than just oversimplified. Or consider this gem of simplistic rationalization, described by Barrett Dorko, PT (he didn’t say it himself, he reported it):

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.

Nonsense. Again, I’ll emphasize that this kind of overconfident, poor quality clinical reasoning isn’t universal — just excessively common within the culture of fascia enthusiasts.