Most of you have probably never heard of fascia, or if you have, it may be in the context of “blasting” it to treat cellulite. But talking about fascia has become trendy recently, and not only in the context of looking better in your swimsuit.
A Google search returns more than 79 million hits for the term, and there is even a conference, now in its fifth year, that is entirely devoted to fascia research.
What is fascia?
According to Stedman’s Medical Dictionary, fascia is “a sheet of fibrous tissue that envelops the body beneath the skin; it also encloses muscles and groups of muscles and separates their several layers or groups.”
But this definition is incomplete. Fascia can actually be classified into four types, each with different properties, functions and characteristics.
The superficial fascia surrounds the body and includes subcutaneous fat; the deep fascia surrounds the musculoskeletal system; the meningeal fascia surrounds the nervous system; the visceral fascia surrounds body cavities and organs.
In mainstream medicine, fascia is rarely considered in isolation as the cause of chronic pain disorders. One exception is plantar fasciitis, a painful and relatively common condition in which the fascia that is responsible for maintaining the arch in your foot is inflamed.
The inflammation is directly attributed to a stiffening and a decrease in the flexibility of the fascia, according to orthopedic surgeon and sports medicine physician Dr. Shabi Khan.
The Mayo Clinic references fascia when describing myofascial pain syndrome (“myo” is short for muscle), but according to Khan, there is “little sophisticated knowledge in terms of the functionality or treatment of problems with the fascia,” and “when compared with the muscle and tendon structure, fascia has a much less dynamic role.”
He does note that fascia, like most connective tissue in the body, stiffens with age, overuse and injury. The direct role of fascial changes in causing pain and structural changes in conditions such as chronic lower back pain, headaches and cellulite is less clear.
Some body work practitioners including massage therapists, osteopaths, Rolfers, craniosacral therapists and physical therapists claim that fascial restrictions (essentially tightening) -- caused by injury, inflammation, trauma, disuse, overuse, misuse or abuse -- play an important role in contributing to the pain associated with a wide array of conditions including migraines, fibromyalgia, headaches, lower back pain and women’s health issues.
Fascia specialists claim that treating these fascial restrictions with a variety of methods, including proprietary bodywork methods and/or specialized tools, is an important aspect of overcoming these chronic and painful conditions.
But what does the science say? Is fascia really that important, and if it is, is there anything we can do to “fix” the fascia and get rid of the pain?
Is fascia real science?
Despite the growing interest, the science of fascia, its clinical relevance and how best to treat it (assuming it is clinically relevant) remains controversial, and there is very limited high-quality research to evaluate and support it.
After interviewing nearly a dozen experts including medical doctors specializing in anatomy, pathology and orthopedic surgery, and bodywork experts including massage therapists and a physical therapist, I have come to the conclusion that there are two major challenges to fascia research and scientific validation.
First, there are major issues with the definition of fascia. Many in traditional medicine consider fascia as simply the tough, fibrous connective tissue surrounding muscle tissue and separating soft tissue areas (including fat) throughout the body.
But those who focus on treating it have a broader definition that includes a more dynamic component of fascia (not just the less flexible fibrous tissue), called the extracellular matrix, which is made up of fluid, proteins and carbohydrates.
Lending support to this broader definition, pathologist Dr. Neil Theise published a study this year in which he described newly discovered features of the interstitium: fluid-filled spaces within and between all tissues in your body. Thiese believes that interstitium is a component of fascia, and since it is fluid, it can be manipulated.
“Traditional medicine was wrong to dismiss that idea” that fascia is more than merely connective tissue, Theise said. “Nomenclature is an issue: If you focus on the connective tissue, you call it ‘fascia’; if you focus on the fluid, it’s ‘interstitium.’ We have a lot of talking and work to do across disciplines to sort this out.”
Though many fascia manipulation advocates claim that lengthening the restricted fascia is the key to successful treatment, Tom Myers, a prolific author, practitioner and educator of fascial and myofascial anatomy and treatment for more than 40 years, has changed his position over the past decade and now admits that the fibrous component of fascia is actually very difficult to lengthen through manual therapy.
He still believes in the clinical relevance and treatment of fascia, but he admits that skin, nerves and muscle are also involved.
Are fascia treatments proven?
Myers’ approach to treating fascial restrictions evolved from the work of Ida Rolf, a pioneering female scientist in the 1920s who developed a method of treating fascia called Structural Integration (commonly referred to today as Rolfing.) .
According to the official Rolfing website, the method works “to release, realign and balance the whole body, thus potentially resolving discomfort, reducing compensations and alleviating pain.” Myers claims that this type of treatment, performed over a number of sessions, improves the movement between layers of fascia surrounding structures including tendons, nerves, muscle and ligaments.
Physical therapist Valerie McGraw, who has worked closely for 28 years with John Barnes, the creator of the Myofascial Release Approach (MFR), supports the concept of modifying the fluid component of fascia. According to the official MFR website, “Myofascial Release is a safe and very effective hands-on technique that involves applying gentle sustained pressure into the Myofascial connective tissue restrictions to eliminate pain and restore motion.”
McGraw describes improvements in the fascial fluid as one of the benefits of their manual technique that differs from others, she says, in that it reaches deeper into the tissue and manually engages it for three to five minutes or more before moving on, rather than sliding on the surface like other forms of bodywork. In a way, it is similar to yoga in that the pressure in a specific region is held for longer, just like yoga poses can be held for longer periods instead of the rapid movement of weight lifting or running.
McGraw also explained that myofascial release practitioners incorporate numerous treatment methods including elongation stretching, a form of cupping (using a sustained pull for three to five minutes or more), and self-treatment utilizing simple pressure tools such as a small air-filled ball and a foam roller into their treatment plans.
Though manual therapies like Myofascial Release and Rolfing are probably not modifying the length of the fibrous component of the fascia, they might be affecting the flexibility of fascia, which could provide the purported beneficial effects. In fact, a very small 2017 study in healthy men using dynamic ultrasound imaging found that myofascial release decreased the stiffness of the fascia in the lower back, and another study found 20% greater stiffness of the lower back fascia in subjects with chronic lower back pain.
Another study evaluated two sessions of fascial manipulation added to standard care after hip surgery and found a modest improvement in the flexibility in the hip joint. There are other case reports of the benefits of various fascial treatment methods, but overall evidence of the effectiveness of treatment is limited.
Another major issue with putting so much emphasis on fascia and how to treat it effectively is that it is highly unlikely that fascia ever works or can be treated in isolation from other tissues. Muscles, tendons, ligaments and nerves play an essential and more clearly established role in many chronic pain conditions. The complex interaction and interconnection of all the tissues involved presents a significant challenge to defining and isolating the relevance of fascia.
What’s the bottom line? If a bodywork practitioner or specialized tool claims to be treating your fascia to relieve your chronic pain (or help you get rid of cellulite), you may indeed get the hoped-for results, but it’s a lot more complicated than just fixing the fascia.