What is fascia? And why is it so pivotal to pelvic health?
Grey’s Anatomy [3rd ed.] defines fascia as “connective tissue containing varying amounts of fat that separate, support, and interconnect organs and structures, enable movement of one structure relative to another, and allow the transit of vessels and nerves from one area to another. There are two general categories of fascia: superficial and deep… [fascia] often remains uninterrupted as a three-dimensional structure between tissues,” (p. 24-25).
However, defining it and truly understanding what it is are two different things entirely.
There are two well known names in the arena of fascial work that you have likely come across if you’ve expressed interest in this topic:
Jean-Pierre Barral, French physical therapist turned osteopath, and founder of The Barral Institute and developer of the technique called Visceral Manipulation; and
John F. Barnes, an American physical therapist who pioneered the Myofascial Release approach and founded MFR Treatment Centers and Seminars.
Now, while these two have held the reigns on the conceptualization of the fascial system in the past 50 years, I would wager to say that there is another name rising in the ranks of physical anatomy as it relates to fascia, and is worth introducing here – if you do not already know her by name:
Ramona Horton is an American physical therapist (DPT) who specializes in pelvic health. In 2020, she received the prestigious Academy of Pelvic Health Elizabeth Noble Award for her contributions to the field of pelvic health. She teaches various fascial specific courses for the Herman & Wallace Pelvic Rehab Institute, including:
Mobilization of the Myofascial Layer
Mobilization of Visceral Fascia: The Gastrointestinal System
Mobilization of Visceral Fascia: The Reproductive System of Men and Women
Mobilization of Visceral Fascia: The Urinary System
Let me just tell you, this woman is incredible. Not only is she brilliant, but she is hilarious, sassy, and has more balls (forgive me) than most men I know. Maybe it was her time in the U.S. Army that gave her all that gumption that she so clearly exudes (your guess is as good as mine). Still, the bottom line is – she is who I would recommend learning from if I were entering into the specific practice of pelvic health.
I had the honor of taking a course with her in 2016, well before I was emotionally committed to the idea of doing internal work in my therapeutic practice – but that gentle (not so gentle) nudge from my mentor (she just signed me up and made me go) put so many wheels into motion for me. Not only did Ramona fly across the entire country with a fetal pig cadaver in her carry on (yeah…) to show the extent of the mesentery and it’s attachment points, she launched into a lengthily lecture on the concept of fetal embryology that still has my head spinning some four years later.
As we learn more-and-more about this bizarrely delicate but enormously impactful structure, it’s essential to stay abreast of the changing literature, attitudes, and implications on the topic.
Our understanding of fascia is still evolving.
If you're reading this as an OT, and you gradated from an occupational therapy program around the same time that I did (2008), there’s a good chance that in the duration of your academic experience the word ‘fascia’ was seldom mentioned in any of your OT specific coursework. The exception to this being, perhaps, in the context of a cadaver lab where the large well documented lumbosacral fascial body is identified. As for the rest of the ‘fascia talk’…. it likely didn’t go into much detail.
In fact, when I was a new graduate and early practitioner, the whole idea of ‘fascia’ was rather… well… taboo. It was considered relatively ‘woo-woo,’ and those who were advocating for the integration of its consideration into mainstream practice were considered to be a bit ‘on the fringe.’ I quite distinctly recall (a very respectable and typically kind) colleague of mine saying to me one day (rather unkindly), “Oh my gosh, you’re going to end up being one of those weird myofascial therapists one day”… Well, yeah. I guess so.
But here’s the rub. It’s not considered to be so woo-woo anymore. Those days of ignorant categorization have pretty much dissolved. The presence of fascia in the human anatomy is pretty well accepted and articulated. Now, on that note, we are still a bit flummoxed at the extent of what it does, how it behaves, and what the extent of its involvement in our general health, stability, mobility, and nervous system regulation are.
If you are a practitioner in the biomechanical framework of occupational therapy, you may have heard about, sought information, or even integrated some techniques and practice philosophy of fascial mobilization into your therapeutic landscape. If not… well, you might want to consider it. Especially if you are practicing in the area of pelvic health.
Why you ask? Well, simply stated, it’s just too intertwined with the entire anatomy to ignore. Especially when working with postpartum women. And that does not mean immediately postpartum. Any woman who has EVER been pregnant, or hand a vaginal or cesarean childbirth is likely living with some sort of fascial restriction that was introduced to her physical body during the time she spent growing, carrying, expanding for, and birthing her sweet bundle of joy.
Pregnancy puts enormous pressure upon the body. It smashes everything inside of our pelvic, abdominal, and even thoracic cavities upon and into one another. And (sometimes) things get stuck.
And what does this have to do with the fascia?
I explain fascia like this to most of my clients:
Have you ever peeled an orange? Once you get that thick, tough rind off of the outer layer, there’s still many layers of ‘membrane-like structure’ dividing the segments of the orange. Once you peel those apart, upon closer examination of each of the individual wedges of orange segment, you will see that there are even smaller layers of membranous barriers between the fibers.
Think of your body in a similar way. Beneath the skin, you have a larger layer of this fascia that has an unbroken chain that runs along both the front side of the body and the back, from the crown of the head to the tip of the big toe. But within the body, you also have other fascial boundaries that ‘encase’ the four vaults within the body: the pelvic cavity, the abdominal cavity, the thoracic cavity, the dorsal body cavity that is comprised of both the cranial cavity and the cavity that runs along the length of the spinal cord.
And within each of those fascia encased vaults, all of your organs that lie within have their own special-casing of fascia around them as well. Furthermore, all of the fibers of the organs and tissues have (you guessed it) more fascia between their layers.
Now, unlike the orange, the fascial layers of the human body are not holding structures rigidly in place as they are in the orange. Instead, all of those fascial planes allow the various surfaces of tissue, organ, vault, and casing to slip, slide, and glide along one another. This delicate connective tissue helps to promote fluid movement of structures. However, like fluids themselves, fascia has the potential to take a more solid (dense) form when compressed, impacted, traumatized, or immobilized.
A fascial adhesion has an enormous amount of tensile strength – imagine how strong (yet delicate) a spider’s web is. And, oddly enough, the fascia behaves much like this incredibly impressive comparison. Have you ever blasted a garden hose at a spider’s web? And it just laughs at you… unbroken, unblemished, and unwavering. And yet, what that forceful jet of water could not accomplish, a delicate swiping of the hand completely dismantles it.
Interestingly, fascia requires a similar frame of reference. You can’t blast at it. Fascia does not respond well to being dug at, ground down upon, scraped, or vigorously rubbed. It’s not a muscle. It’s something uniquely itself. And in the words of John F. Barnes – fascia has to melt. And that melt takes slow, continuous, gentle, hands-on pressure. You have to trick the nervous system.
If you’re interested in Barnes’ conceptualization of how fascia exists as a liquid-crystal matrix and how to elicit a piezoelectric effect, then I recommend this short read, Use Fascia as a Level: Myofascial Release to Address Pain and Dysfunction to spark some creative frameworking.
So what’s next for this area of practice?
Well, who knows. I do know this though, once you start working with this delicate structure… weird things might start happening with your clients. And when I say weird, what I mean is – unexpected. Sometimes those unexpected occurrences are incredible emotional breakthroughs. Sometimes they are a violent reliving of past trauma. Sometimes is just spontaneous twitching. It’s always different. But it’s also always uniquely necessary to the client. We (as a medical establishment) don’t know WHY exactly these patterns of behavior and emotional uprising occur during fascial treatments – but they do. A lot more seems to be going on than with other connective tissues in the body. And there is undoubtedly a large amount of speculation and assumption. But, alas, in our modern medical lexicon, we cannot say with certainty the exact pathway that is being acted upon.
However, if you want to have a fascinating conversation about this topic, Cranio-Sacral Therapists (CSTs) have been witnessing these effects for quite some time. And they certainly have a lot to say on the matter.
But we’ll save that conversation for a future date!
About the author:
Heather M. Truog, OTD is an American occupational therapist with over a decade of experience working with traumatic injuries and neuromuscular conditions. She has been utilizing the myofascial release (MFR) approach in her practice since 2010.
The content of this blog post is based largely upon anecdotal experience, personal insight, and a little bit of sass. It is intended to spark interest and shape perspective, not to endorse one method of treatment style over another. All therapists names mentioned within this article are acknowledged to be extraordinary visionaries in advancing this method of practice.