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What is
Fascia?
June 18, 2000
Question:
I am in massage therapy school. Today, we began covering the tissues of
the body. Our anatomy and physiology instructor, who is a Ph.D., was
describing all the types of tissues. The lady sitting next to me ask him
if the term "fascia" was a kind of generic term for the
membranes covering muscle bundles. He said that a lot of doctors don’t
realize that fascia is only at the top of the head, on the abdominal
region, the knees, ankles, and areas like the tensor fasciae latae.
She said that in classes taught around the country, instructors say
that everything in the body is covered by fascia. They say fascia is like
a webbing that covers everything, and that an injury, say to the shoulder,
may cause the fascia there to contract and become stuck. Both the other
student and I were taught this by John Barnes. The instructor said
absolutely not; that fascia is found only in certain areas. Can you shed
some light on this for me.
Dr.
Lowe: The differing views of your instructor on the one hand, and teachers of myofascial therapies (such as John Barnes and me) on the other, are understandable. The different views make sense when we consider the history of two separate fields of study: that of anatomy, and that of myofascial therapy.
You mentioned that your instructor is a Ph.D. His degree may be the key to understanding his point of view—that we should restrict our use of the term "fascia" only to the connective tissues covering certain body parts. His view can be explained by a passage in a British edition of Gray's Anatomy: "The advent of tissue fixatives, and especially formalin, which preserve and accentuate areolar tissue, was a great stimulus to the regional naming of fasciae; and the habit of attaching a specific local term to any aggregation of connective tissue, sizable enough to dissect, is still current, though perhaps on the wane."[1,p.490]
This passage means, of course, that when chemicals became available that preserve and stain "loose" or "areolar" connective tissue (the most pervasive of all body tissues), anatomists were able to clearly identify connective tissue at different anatomical sites. As anatomists identified the connective tissue in each body site, which they called fascia, they gave the tissue a unique. Hence, the index of most any anatomy textbook will list many different such names. For example, in my Grant's Atlas of Anatomy,[2] the author lists under the term "fascia" close to fifty specific fascial tissues. He lists "lumbar fascia," "renal fascia," "thoracolumbar fascia," "thenar fascia," "fascia of penis," "fascia of popliteus," and so on.
Instructors trained in basic science Ph.D. programs are likely to conform to the tradition of anatomists, who are basic scientists. So, the instructors may define fascia in a strict sense—as the loose connective tissue in specific body sites, identified and named by anatomists. However, as Warwick and Williams wrote in 1973, this practice is "perhaps on the wane."[1,p.490] Certainly the practice has completely waned among myofascial practitioners and their clinical teachers.
Barnes, others, and I have long taught that fascia is a web-like, loose connective tissue that covers and supports practically every structure in the body. According to this view, if every type of body tissue except fascia magically disappeared, we'd still see a representation of the human body. The representation would be spectral-like: a white, gossamer semblance of the former human being. We'd also see some body areas that were more densely white than others. In some areas, these more densely white areas would appear almost like plastic. These more dense areas would be anatomical sites where fibroblasts increased their output of collagen due to (1) biomechanical stress lines, trauma, chronic stress, and/or immobility. We myofascial practitioners often refer to these dense areas as "fascial adhesions."
For several reasons, I believe our use of the term fascia is justified. First, those of us doing myofascial therapies need a term that succinctly expresses "muscle" and its "loose (areolar) connective tissue." Our need has a practical basis. When muscle is adversely affected in some way, so is its fascia; when fascia is adversely affected, so is the muscle it ensheaths. And when we treat the adversely affected tissues, we're simultaneously and invariably treating both muscle and its fascia. It's impossible not to. So, when we use the term "myofascial," we do so partly as a convenience, since it succinctly refers to muscle and its connective tissue as <<a combined functional unit.>> And speaking of convenience: Saying and writing "myofascial therapy" is less cumbersome than "muscle and loose (areolar) connective tissue therapy." This latter term might crowd one's business card.
I think our use of the term fascia is also justified for another reasons: the fact that the use is consistent with definitions of many anatomists. For example, Warwick and Williams wrote, "‘Fascia' is a term so wide and elastic in usage that it signifies little more than a collection of connective tissue large enough to be described by the unaided eye." These authors describe fascia as a "less specialized connective tissues permeating all regions of the body, not only as the microscopic areolar component between, for example, the fibers of muscle, nerves, and tendons, but also in larger macroscopic accumulations between whole muscles, viscera, and other large structures." They explain: "The arrangement of such connective tissue is highly variable. As a result of dissection, it appears as condensations on the surfaces of muscles, etc. and is hence spoken of as <<investing>> fascia . . ."[1,p.490]
In the classic Gray's Anatomy, the authors wrote: "‘Fascia' is the term used in gross anatomy for all the fibrous connective structures not otherwise specifically named. It varies in thickness and density according to functional demands, and is usually in the form of membranous sheets."[3,p.270]
And in Cunningham's Textbook of Anatomy, the author referred to "compact layers of interlacing collagen fibers," explaining: "This is the deep ‘fascia' which invests the entire body and sends sheets inwards between the various organs to surround them with a sheath of greater or lesser density which, because it is felted, is equally strong in all directions. It therefore produces structures such as the epimysium and peritendineum (within which each muscle and tendon respectively slides), the epineurium which confers on peripheral nerves their great strength, and the tough fibrous capsules of such organs as the kidneys and testes."[4,p.8]
Some will argue that the myofascial practitioner's use of the term "fascia" is wrong. Regardless, this use of the term—by teachers such as Barnes, others, and me, and by tens of thousands of myofascial practitioners—is now the vernacular among clinicians. I sympathize that this circumstance vexes purists, such as Ph.D.s trained in traditional basic science programs. And I have no argument against their more restrictive use of the term—as long as it doesn't confuse their students destined to practice myofascial therapies. However, life may be easier for those instructors if they roll with the terminological wave, for it appears to be a juggernaut, and as such, isn't likely to stop.
.
References
1. Warwick, R., and Williams, P.L.: Gray's Anatomy: 35th British Edition. Philadelphia, W.B. Saunders Co., 1973.
2. Grant, J.C.B.: An Atlas of Anatomy. Baltimore, Williams & Wilkins Co., 1972.
3. Gray, H. and Goss, C.M.: Gray's Anatomy: Anatomy of the Human Body. Philadelphia, Lea & Febiger, 1973.
4. Romanes, G.J.: Cunninghams's Textbook of Anatomy, 11th edition. London, Oxford University Press, 1972.
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