The 5th international fascia congress was held November 13 to 15, 2018 in Berlin, Germany. The previous congress was in 2015, so 3 years have passed. What new and exciting revelations occurred in these 3 years? I can’t say that anything presented this year was completely revolutionary but a lot of research has been done expanding our basic understanding of fascia at both a cellular and physiological level. Of interest was the fact that researchers in medical silos far afield from fascia (from cancer to evolutionary biology) were present and presenting—fascia is finally being accepted and recognized as a critical component of understanding our bodies and health. (One oncologist/liver specialist noted in fascination that fascia is piezoelectric—generates electricity—and speculated that this may be what chi or prana is. He got lots of applause for this observation but fascianistas have been saying this for years.)
As always, it is challenging to see immediately the clinical implications of the basic research presented, but some very interesting studies and explanations certainly helped to deepen my understanding of what fascia is, and why it is. The following notes are from many presentations and plenary sessions, but I have not made an attempt to document the complete state of research nor summarize all the reports presented. Rather, I have compiled the reports that are of interest to me and ones that I feel may have a bearing on how we teach yoga asanas. Let me start by citing a 2017 consensus definition of what fascia is:
“The fascial system consists of the three-dimensional continuum of soft, collagen containing, loose and dense fibrous connective tissues that permeate the body. It incorporates elements such as adipose tissue, adventitia and neurovascular sheaths, aponeuroses, deep and superficial fasciae, epineurium, joint capsules, ligaments, membranes, meninges, myofascial expansions, periosteum, retinacula, septa, tendons, visceral fasciae, and all the intramuscular and intermuscular connective tissues including endo-/peri-/epimysium. The fascial system interpenetrates and surrounds all organs, muscles, bones and nerve fibers, endowing the body with a functional structure, and providing an environment that enables all body systems to operate in an integrated manner.”
That is quite a mouthful but the make-up and function of fascia continues to be uncovered. Carla Stecco, one of the Fascia-world Rock Stars, gave a presentation that culminated in a long, standing ovation. Here are a couple of her concluding tables. The first slide shows what makes up fascia: cells (4 different types!), the matrix of materials outside the cells (ECM), and nerves.
The roles of each component are summarized in the next table, which shows what the cells, ECM and nerves are doing. You can easily see that fascia is a very complex structure with all the various elements stimulated in different ways.
Fascia facilitates gliding
One over-arching theme I noticed in the congress is that the deep fascia must move. Deep fascia allows, facilitates and requires gliding. If for any of many reasons it cannot serve this function, pain develops which may over time lead to dysfunctional movement patterns and possibly structural damage which may finally be detected through imaging (MRIs or X-rays).
Carla Stecco’s brother, Antonio Stecco, gave a great talk on this. He is a founder of the Fascial Manipulation (FM) style of therapy. In this view, there are centers of coordination (CC) where the fascia may become stuck or may adhere to other layers and there are centers of perception (CP) where pain may arise. The pain is a reaction of the nerve endings becoming stressed (through stretching, impingement or compression). If the CC is in just the right place (which really means “exactly the wrong place”), then the restriction may cause the stress on some of the nerves in the CP. In other words, where the pain is is not where the problem is (as many therapists know). Fascial manipulation helps to resolve the stiffness, stuckness or adhesion at the CC, thus permanently resolving the pain at the CP (unlike many other therapies that treat only the location of the pain, which does nothing to help the cause of the pain.)
Deep fascia is the layer of fascia beneath the thick layer of superficial fascia, which in turn is found just beneath the skin. Deep fascia surrounds the muscles and organs. It is not very thick: on the order of ~1.5mm! There are many layers to the deep fascia, like multiple layers of a plastic wrap, but each of these layers can glide upon the others, at least in healthy, pain free fascia. Between the layers is loose connective tissues containing an appropriate amount of hyaluronic acid (HA). HA, produced by fasciacytes (listed in the first table), is a Goldilocks-kind of molecule: if we have too little, our fascia won’t glide, but if we have too much the molecules become entangled creating densification of the fascia and again gliding won’t happen. The increase in viscosity of the loose connective tissue between the gliding layers of deep fascia does not show up in MRIs or X-rays but we now know that when fascia doesn’t glide, nerves can become trapped creating a burning pain. This entrapment within fascia is a more common cause of pain than nerves becoming entrapped by bony growths (osteophytes).
This is a new realization: we can have too much HA! Normally we want HA because it is a lubricant, necessary for fascial gliding. But, if we have too much, it reduces gliding as well. The resulting densification of the fascia causes the layers to become stuck together. For example, many sciatica sufferers have the layers of the IT band stuck together around the level of the hip. Rigidity between layers of the deep fascia is sometimes called fibrosis or even scar tissue, often caused by the increased viscosity of the intervening loose connective tissue (due to too much HA).
In the trunk of the body, the deep fascia is intimately connected to the epimysium of the underlying muscles, but not so in the limbs. In the limbs the deep fascia plays more of a proprioceptive role than in the trunk, presumably because it is more difficult for the body to know where our limbs are than where our trunk is. As we approach a joint, there are more mechanoreceptors in the deep fascia than further away: mechanical stresses such as pulling or squeezing will activate them.
Can we get rid of fibrosis or scar tissue? Yes, but! It takes a long time. It takes on average about 2 years to replace collagen (rates vary depending on which tissue you look at. Consider the superficial fascia where someone has a tattoo—if this was done as a young child, remodeling of this fascia eliminates the tattoo in time, but for adults the tattoos will remain for the rest of their lives.) Stress will dictate the direction of the new collagen fibers thus repairing scar tissue requires movement, stresses, pulling, etc. Otherwise the new fibers will just follow the chaotic orientation of the old fibers. However, even with the best therapy, the new tissues will never be as functional as the original tissues.
Antonio points out that HA is a tricky substance. Immobility increases HA. So does exercise! If after exercise the HA is left alone, it aggregates, creating large, sticky blocks (this may be a primary cause of delayed onset muscles soreness—DOMS). This is also termed macromolecular crowding and it leaves little room for water in the loose connective tissue. Water of course is the lubricant we need for gliding layers of deep fascia. Helen Langevin discovered, back in 2010, that people suffering lower back pain have 25% thicker deep fascia in their lower back and 52% less gliding available there.
So, what can we do to dis-aggregate the HA blocks? Increased PH (increased alkalinity/decreased acidity) will do it. If we can lower the acidity in the tissues the blocks are dissolved. However, it is difficult to reduce tissue acidity. Another technique is to increase temperature. Where the HA is gel-like (think of Jell-O) at around 38C, it becomes liquid (the Sol state) at around 41C. In this liquid state the adhesions are dissolved and toxic particles can be flushed out of the fascia into the lymph system. There are many ways to heat up our tissues: massage, movement, exercise, vigorous vinyasa yogas, steam baths, hot tubs, etc.
Another approach to reducing stuckness in the fascia is stress: fascial manipulation includes friction with pressure over time which increases stress and temperature in the deep fascia. This changes the gel state of the HA and permanently breaks apart the adhesions between the gliding layers. The residual particles of the broken up HA macromolecules create a short-term inflammation in the tissues which in turn triggers the immune system to help clean up the area and heal any damage. This approach for reducing lack of movement or pain due to fascial adhesions is certainly something that we can do in our yoga practice too—we have to move and apply stress to the fascia. At the very least it can help to prevent these situations from arising
One closing quote from Antonio Stecco, “Fascia is the connecting tissue connecting Eastern and Western medicine!” For example, he claims the fascial myokinetic chain found in the arms is equivalent to the lung meridian.
- People within one ethnic population compared to other populations differ by about 14%, however the range of variation within any single population is 86%, so ethnicity variations are very minor compared to the wide range of all human variation. (In other words, don’t refer to “race”! There is no such thing.) (D. Lieberman)
- 20% of knee replacement surgeries do not resolve pain—the cause of the pain was not where the pain was. (A. Stecco.)
- The rate of knee osteoarthritis has doubled since 1945. Why? Not genetics so must be environmental (lifestyle?) (D. Lieberman)
- Why do modern doctors know so little about fascia? Because this new knowledge is not in the textbooks, the consequences of it are not measurable, there is no pill to fix fascia problems, and doctors prefer to work with discreet parts (not extensive and complicated systems.) (D. Lieberman)
- IT Band syndrome is primarily caused by poor walking/running technique (overstriding). (D. Lieberman)
- Plantar fasciitis is due to weak feet caused by arch supports leading to stiff calf muscles. We treat the symptom but not the cause. (D. Lieberman)
- Our fascia is a wet system, and when the water is liquid (the sol state as opposed to the Jell-o or gel state) the water can flow out of the fascia (also called the interstitium) into the lymph system. The lymph system helps to drives fluid flow through the fascia. Movement and massage can help push fluid into the lymphatic system, but negative pressure within the lymph system also draws in fluids from the fascia. (Melody Swartz)
- It is hard for large molecules to move through the fascial gel, but once they are in the lymph system, they move quickly. (Melody Swartz)
- Fibroblasts remodel the local extracellular matrix to reduce stress. (Melody Swartz)
- Fascia is an auxetic material: this strange word means that they exhibit negative Poisson ratios, and that means that when they are stretched in one direction, instead of becoming thinner in the other directions, they expand in all directions! In other words, when we stress fascia, it hardens instead of thinning.
- While running, the Achilles tendon stretches 10-12mm (4~6%). The muscle fibers of the vastii lengthen by 25% while running and 20% while walking. (A Arampatzis)
- Hyaluronidase (an enzyme that dissolves hyaluronic acid) injections frequently reduce pain and stiffness. This is because it reduces HA agglomeration.
- Immobilization will increase HA in the epimysium and perimysium and in the deep fascia.
- Injection of HA into a joint capsule does not lead to densification or thickening of the HA, but this does happen if HA is injected into small regions of deep fascia.
- Fascia is thicker in our limbs, so we are more likely to feel bumps, ridges, cords, etc there than in our torso.
- As we age we lose muscle mass, but we lose strength faster than we lose mass and we lose power faster than strength. Muscle quality is more important to quality of life than muscle quantity.
- Dental pain comes from the periosteum of the bones: we can resolve the pain there but the underlying and deeper infection may not be resolved.
- There are sex hormone receptors in our fascia: this leads to gender differences. Estradiol decreases collagen type 1 (stiff fibers) but increases type 3 (more elastic fibers). This means less strength and more elasticity when estradiol rises (which may be one reason women tend to be more flexible than men.)
- Sex hormones vary with women’s menstrual cycles which affects fascia remodeling and proprioceptive sensitivity.
- Exercise has an anti-inflammatory effect because it reduces type 1 collagen and increases type 3. Exercise is much better for resolving chronic inflammation than pills.
- Fibrosis (scar tissue), even in 60 year olds, can be reduced through exercise. Both muscle training and fascia training is important.
- Oral collagen supplementation has been shown in many studies to be beneficial. Another way to increase collagen levels is through exercising 3 times a week. To improve coordination, exercise daily.
- For diastasis abdominis (separation of the stomach muscles): the posterior fibers of the transverse abdominis (TA) are stiff horizontally but elastic vertically. Any replacement tissue inserted to repair diastasis abdominis must have similar properties. The TA is separate from the rectus abdominis (RA): they slide along each other and this means that co-contraction of the TA and RA can control diastasis: they actually pull the belly inward, not apart. (Andree Vleeming)
- Finally, on the last evening Gil Hedley shared a 10-minute fascia video. What a treat! You can watch it at his website
Our knowledge of and understanding of fascia and what it does is still growing. It is a complicaged system that touches every part of the body, connecting, coordinating and communicating throughout the matrix. The more we learn about it, the more we know that we don’t know enough. But, we do know that movement and stress is heatlhy and necessary to keep the fascia functioning optimally. Whether that movement comes from exercise, yoga, massage or other physical therapies doesn’t seem to be as nearly important as the simple requirement to keep moving the body. The International Fascia Congresses are great ways to stay current with the research, but figuring out how to apply this growing body of knoweldge clinically, or in a yoga classroom, takes some creativity and experimentation. Since we are all unique, what works for most people may not work for you, so stay alert and aware.
The 6th International Fascia Congress will be held in Montreal, Canada in 2021.
- — Here are some commentaries on the 2015 Congress.
- — I did write an article about Fascia in March of 2018.
- — From Adstrum S, Hedley G, Schleip R, Stecco C, Yucesoy CA. Defining the fascial system. J Bodyw Mov Ther. 2017 Jan;21(1):173-177.
- — See Jaime M. Cyphert, Carol S. Trempus, and Stavros Garantziotis, “Size Matters: Molecular Weight Specificity of Hyaluronan Effects in Cell Biology” in Int J Cell Biol. 2015; 2015: 563818.