All of us were taught about the nervous system in our manual therapy training. But we often learned anatomy and physiology (A&P) as stand-alone systems, and their integrated workings were missed or lost. For many of us, this resulted in an inadequate understanding of how systems influence each other in health and disease.
A&P helps us assess risk, identify contraindications, understand pathologies, and build client rapport through knowledge. Because some qualifications involve treating injuries (and pain), A&P supports evidence-informed practice (EIP) by building an appreciation of tissue damage, repair, and how we can assist recovery to promote a return to a pain-free active lifestyle (or sport).
However, EIP involves much more than A&P, and some may argue that A&P is not even relevant to EIP. EIP prompts us to be more discerning in our professional decisions, including how we describe how our therapy works, often called the ‘mechanism of action’. EIP also promotes best practice, where all therapists should regularly reflect on what they have been taught, how they practise, and any new evidence, science, and guidance. As a result, we replace outdated practice with contemporary evidence, continually providing the best care we can for our clients.
Fascia is often heralded as ‘the missing link in traditional healthcare’ (Barnes 1990). Most fascial commentary begins by describing fascia as previously thought of as a packing organ and then continues with new evidence supporting its greater role and responsibilities in health and disease. There is no doubt that fascia research is amazing and has offered scientific explanations, including the potential for fascia to be involved in the metastasis of cancer (Friedl and Alexander 2011), menopause symptoms (Fede et al. 2019), low back pain (Shilder et al. 2014) and myofascial pain syndromes including Fibromyalgia (Pratt 2021) and (Stecco et al. 2011). But this doesn't necessarily translate to how we can fix, stretch, release or resolve fascial dysfunction using fascia-oriented manual therapies such as Myofascial Release (MFR). Many studies researching fascia-oriented therapies report evidence of benefit, albeit low, compared to non-intervention such as fascia and headaches (Ajimsha 2011), low back pain (Wu 2021), temporomandibular pain (Kamir 2010), chronic musculoskeletal pain (Laimi 2018) and scar tissue therapy (de Valois 2021). However, many journal papers avoid mentioning the potential mechanism of action or state that the intervention's mechanism remains unclear. Additionally, bias, variability, and reliability require critical evaluation in all journal studies.
For decades, we have discussed fascia as a matrix that supports, separates, and protects everything else. We have described it as the container of the mind and the keeper of trauma. We also have described how we can touch the intricate fascial web, following its spirals, twists and turns that influence its structure and, as a result, we can release the body’s stored physical and emotional traumas. For every Myofascial Therapist reading this, you can identify with and appreciate what is being said, as it plausibly fits what we believe we feel under our hands and what our clients experience. I remember attending the Fascia Research Congress (FRC) in Amsterdam, Netherlands, in 2009, where a presenter challenged Tom Myers by suggesting that deep fascial tension and fascial connections could not be described as trains or lines. Tom’s reply was simply that he knew what he felt under his hands. What we feel, interpret, and intuit comes from experience and plays a part in EIP. However, despite clinical results, experience does not provide reliable scientific evidence; instead, it provides what is known as anecdotal evidence. Each of us has our own style, beliefs, and opinions that shape our treatment approach, regardless of our training. While this adds diversity to the ever-increasing assortment of clients' needs, it can lead to inconsistency and potentially poor practice standards. Additionally, we can become very protective of our titles, who we trained with, and preferred treatment approaches, which can be considered bias and also contradict an EIP.
Dr Robert Schleip, a prominent fascial researcher, described fascia as the ‘Cinderella of orthopaedic tissues’ (Schleip et al. 2010), as the fascial tissues have finally come to the ball and been noticed by the medical and research community. He also presented a lecture at the 2012 FRC in Vancouver, Canada, titled ‘Alice in Wonderland: Getting Curiouser and Curiouser ’, discussed by the Association of Massage Therapists Ltd in Australia in one of their magazine articles (Schleip 2014). The theme here is not Disney characters, although some critics may be quick to point this out, which, in itself, would be confirmation bias; Dr Schleip is indicating that there is still a great unknown regarding fascia and how we may be able to treat it, resulting in rabbit hole after rabbit hole.
Furthermore, because fascia can morph and adapt to stimuli, statements like ‘fascia is alive’ (Schleip et al. 2022, p. 265) and comparisons to spiral energy and bird murmurations imply a somewhat mystical, magical quality. On one hand, this embraces holism, attracting a personality type who resonates with this style of language and, as such, becomes a meaningful component of their clinical results. Yet, on the other hand, arguably this places fascia-oriented therapies into pseudoscience and often leads to them being criticised by traditional healthcare professionals.
Is it time to take a serious look at current evidence and become more evidence-informed, refining our terminology, language and explanations of the properties attributed to fascia?
As an MFR training provider, I have always made it a priority to stay up to date with current research and evidence, integrating it into all our training programmes so our students not only gain valuable practical skills but also a fundamental theoretical framework to evaluate, consider, and reflect on treatment approaches.
Now, in my 3rd decade of teaching MFR, however, one question remains unanswered: ‘what happens when we touch?’ Anecdotally, I know MFR makes a difference not just for my clients, but for the thousands of clients treated by the wealth of skilled therapists who have trained with me. Despite my experience, science still hasn't identified exactly what makes MFR different from any other style of manual therapy (if it is different at all) or why it can have such a profound effect on our clients.
There are many models and hypotheses as to how MFR may mechanically work, including piezoelectricity and the semi-conductive nature of fascia (Oschman in Schleip et al. 2022 p188), thixotropy (Schleip 2003), viscoelasticity (Yahia 1993) and fluid dynamics (Meert in Schleip et al. 2022, p. 294) and (Bordoni 2018). Many models also describe fascia's structure, including biotensegrity, chains, bags, and lines. Yet, none of these models offers definitive answers on what we actually do to the fascia, if anything.
However, an ever-growing body of evidence addresses touch, sensation, and pain. The power of touch has been researched for decades with the most familiar researcher on touch being Tiffany Field from the Miami Touch Institute. Her research generally indicates that touch benefits wellness, reduces stress and improves relaxation and sleep. More recently, a complex interplay of biomechanical and neurophysiological mechanisms has been suggested as an appropriate and worthy concept as a potential mechanism of action for manual therapy, including MFR (Bialosky et al. 2009) and (Bialosky et al. 2018). This correlates with the concept discussed by Dr Schleip for almost two decades and is a current and ongoing area of fascia research (Schleip 2003).
Fascia has been heralded as a sensory organ due to its high mechanosensitivity. According to Dr Helene Langevin, ‘connective tissue functions as a body-wide mechanosensitive signalling network’ (Langevin 2005) and, as a result, may influence the experience of pain (Langevin 2021; Shilder et al. 2014). This is because fascia contains nerve receptors that detect pressure and loading, as well as chemical and temperature changes in tissue. All tissues have this capability: identifying changes in their structures and accommodating and adapting as necessary to maintain balance and harmony (allostasis).
But how could the sensory nature of fascia help us understand how we might influence it?
You will have all heard about the 5 senses: taste, sight, hearing, smell and touch. You may have been taught about the integumentary system, that is, the skin, hair, nails and exocrine glands. Most likely, you were taught about the skin, since that's what we physically touch in all manual therapy. You may have been taught that the skin is a sensory organ because it senses, or discriminates against, different types of touch. A long, light, nurturing effleurage stroke is mediated by different nerve receptors embedded in the skin than those that determine cross-fibre friction, and the physiological changes resulting from these different styles of touch can also differ.
Most literature discusses the skin as being the largest sensory organ. However, fascial anatomy research is disputing this, as it is now suggested that the fascial system contains approximately 250 million sensory nerve endings (Fede et al. 2022) and (Schleip 2022, p. 157), whereas the skin is said to have only 200 million nerve endings.
Given this, touch transmitted via the skin, including MFR, could stimulate millions of nerve endings, sending signals to the brain and triggering physiological changes that depend on many factors unique to each individual, as suggested in the Bialosky et al. (2018) model. This differs from previous suggestions of a more mechanistic approach to tissue change through manipulation that I previously mentioned.
The nervous system is a 2-way street. When impulses are generated in the periphery, outside the brain and spinal cord, such as touch from manual therapy, they travel along nerves as action potentials (electrical signals) toward the brain. This is called afferent signalling. Hence the term ‘affective touch ’, as it affects the body. When impulses are generated in the brain and spinal cord and travel to the periphery along nerves, they affect the body, such as moving a joint. This is called efferent signalling. Simply put, affect is to influence change in the body, and effect is a response due to change. With this 2-way street of afferent and efferent processing, the skin can't do it alone.
Every tissue type, organ, bone and vessel is innervated. Even nerves have their own nervous system, called nervi nervorum. This means that all information about your internal and external environment is sent to your brain via nerves. This obviously includes the fascial system and suggests that when the skin and all underlying structures feel pressure from manual therapy, they transmit this information via the nervous system to the brain, resulting in a response or action, some of which are experienced as feelings. These experienced feelings result in physiological changes involving hormones, neurotransmitters and cellular exchanges which reduce stress, modulate tissue tone and reduce the experience of pain, amongst others.
In the second edition of Fascia: Tensional Network of the Human Body published in 2021, Dr Schleip validates these concepts with this quote stating :
‘However, today an increasing number of practitioners are basing their concepts to some extent on the mechanical sensory nature of the fascia, and it's assumed ability to respond to skilful stimulation of its various sensory receptors’
(p. 158).
He also describes in many articles and books his own experience with providing fascia-oriented therapy to anaesthetised patients who had provided him permission for his non-empirical study. He conceded that anaesthetised patients did not respond to his treatments the same way as fully conscious patients (Schleip 2022 p.157). This leads us to assume that the nervous system is likely to be a key player in manual therapy.
In addition, physiological changes are also derived from contextual meaning and play an important role in the Biopsychosocial approach within an EIP. You may have previously known contextual meaning as placebo, but in fact, these are meaningful measures that ask your client what matters to them and not what's the matter with them. For example, a client may want treatment from you as they believe in your capabilities as you helped their friend. It may matter that a client gets treatment from a specialist in scar tissue or MFR therapy as they have read on social media that these treatments are the best for their pain. These beliefs can potentially enhance treatment outcomes. The question here is, however, how much of our treatment outcomes are actually related to the belief that a therapy works versus the actual mechanical tissue changes by our chosen therapy?
The science of touch and pain is vitally important. Yet, despite the value of the A&P of touch, most therapists are not taught enough about the nervous system or how psychosocial factors influence health to use them to their advantage in practice. This may perpetuate confusion and unsupported claims about how manual therapy works and what it can fix.
Additionally, touch means something different to everyone. It is not as simple as the nervous system alone. It involves beliefs about what that touch may do as well as culture and previous experiences. It also involves the trust and rapport between client and therapist, now called the therapeutic alliance, and it involves the entire contextual environment of the treatment session. All these components influence what your touch means to each individual client.
While we seem closer than ever to extrapolating a mechanism of action, it is still unclear whether fascia-oriented therapies affect the body differently from other manual therapies. Additionally, we must accept that all manual therapies may be more similar than we would like to believe, and that no model or trademarked method, known as a modality empire, is superior (Ingraham 2022). However, the therapeutic relationship involves many components, such as client communication, psychosocial factors, self-efficacy, resilience, and beliefs, and should not rely solely on a mechanism of action, shifting from a ‘doing to’ relationship to a ‘being with’ relationship.
As a result, it is becoming increasingly evident that both teaching and the practice of fascia-oriented therapies need revision, as current evidence does not support many of the claims routinely used. Furthermore, the terms ‘fascia-focused’ and ‘fascia-oriented’ are somewhat obsolete. The only thing we can definitely address is the skin. While some research suggests we can influence deeper structures, such as the gliding mechanisms attributed to hyaluronan (Pratt 2021), further studies are needed.
In our Certificate in Integrated Myofascial Therapy (CiMFT), I introduce mechanosensation and how touch discrimination can offer insight into how MFR may affect the body via the nervous system. By understanding fascia anatomy, its innervation, and the importance of touch to your client, you are better equipped to choose appropriate MFR techniques to meet client needs, resulting in more productive, client-focused treatment outcomes.
There is definitely an ‘out with the old and in with the new’ attitude across the profession, especially regarding the mechanisms of action.
Question what you were taught. It's perhaps time to re-evaluate, revise and update.
Train with MFR UK. In-Touch Education.
References
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© Fascia Research Society. Photography by Thomas Stephan.
