Fascia Myths and Fascia Facts

Have you noticed that the word “fascia” has become somewhat of a buzzword in the yoga world lately? There have been lots of articles written about this newly-appreciated bodily tissue (I myself have written two of them in the past few years!), and fascia has become a focus in many yoga classes - especially those that include rolling on self-massage tools like balls and foam rollers.

I understand this preoccupation with fascia, because it is a truly fascinating topic. Fascia is a type of connective tissue that forms a continuous body-wide web inside of us, surrounding and interpenetrating all of our muscles, bones, organs, nerves, and blood and lymph vessels. In fact, in addition to forming the architecture that weaves our inner structures together, our connective tissue system as a whole also absorbs and transmits force inside of us, working in conjunction with our muscular system to create smooth, efficient movement. Such insights have the power to expand the way we understand movement, which is very exciting!

In addition to these inherently interesting facts, there are other claims commonly made about fascia that are widely-believed, but reach a bit too far ahead of the research to be actually supported. Today I’d like to address a few of these specific claims in an attempt to encourage our yoga community to embrace a more science-based, productive dialog about the popular topic of fascia and the wonderful practices of massage and rolling.

 

MYTH #1: ROLLING ON BALLS AND OTHER MASSAGE TOOLS BREAKS DOWN FASCIAL ADHESIONS, KNOTS, AND SCAR TISSUE

Every massage therapist knows the experience of finding a tight spot in her client’s body, massaging it, and feeling it “release” or “relax” underneath her hands. It seems natural to assume that through her hands, she physically broke down a knot in her client’s fascia - and that through rolling on massage tools, we can do the same to ourselves too.

But one lesser-known fact about fascia is that its collagen fibers are literally as strong as steel. [Ref] To actually “break them up” would require so much force application that one’s body would sustain serious injury - this is not something that is achieved by a massage therapist’s hands or by a pair of massage balls.

Although you may feel a tight spot in your body change its texture after rolling or being massaged, this change was not due to the architecture of the fascia changing. For fascia to actually change its architecture, many, many inputs are required over a long time - collagen takes about three years in order to completely change and remodel. [Ref] Any instantaneous changes in tissue quality that you experience as the result of a massage are not the “breaking down” of adhesions, knots, or scar tissue - they are instead changes in tissue tone that are mediated by the nervous system. [Ref]

Once we understand that soft tissue treatments like massage and rolling work primarily via neurological communication instead of via physically breaking down adhesions, knots, and scar tissue, we might be encouraged to administer these treatments more gently than forcefully. When we roll and massage ourselves with deep, forceful pressure, this can often increase nervous system threat levels and sensitivity, which can be counterproductive to our efforts. Gentler, milder work is often more successful at decreasing threat levels and coaxing the nervous system to relax our tissues.

Massage and rolling on balls are undeniably wonderful, potent tools that help so many of us feel better in our bodies, but when we understand more about the mechanism for why they work, we will naturally be able to use them more wisely.

 

MYTH #2: WE FEEL PAIN IN OUR BODY BECAUSE OUR FASCIA IS FULL OF KNOTS, ADHESIONS, AND SCAR TISSUE

This is a very common belief, but it turns out that it is based on some inaccurate information about how pain works. I’ve written about the science of pain before [here and here], but one of the most foundational aspects of pain is that it is an output from the central nervous system, not an input from the periphery. It’s easy to be confused about this concept because when we feel pain, we feel it in a particular area of our body. It feels like the pain is in our tissues, and it’s our tissues that are therefore causing it. But the pain doesn’t actually reside in our tissues at all - it is 100% an experience that our nervous system has created for us to perceive - most likely to serve as some sort of protective signal.

Because pain is an output and not an input, adhesions, knots, and scar tissues - which are located in the periphery of our body (if they exist at all - but that’s a whole other topic!) - are not actually capable of creating pain. This concept might be tough to grasp, especially because we know that a massage therapist can touch a certain “knotty-feeling” spot on our body and it might feel tender or painful. But the pain you feel there was not created by the knot - it was created by your brain and experienced in that spot. Additionally, we know that we can have other painful-to-the-touch places in our body that do not actually correspond with a “knot” or tight spot that resides there. The flesh in those painful spots instead feels smooth and knot-free. And there are probably quite a few other locations in your body that definitely feel “knotty”-like when palpated, but are not associated with pain at all. [Ref]

As it turns out, pain and tissue quality are separate entities that sometimes overlap, but oftentimes do not. While it's easy to believe that all tight spots underneath our skin are problematic, the truth is that many of them are probably just normal, healthy variations in our tissue texture. And pain, regardless of where it is felt in the body, has less to do with knots, adhesions, and scar tissue, and more to do with a nervous system that has been sensitized around a particular area. This is a helpful, progressive change in perspective because the less that we pathologize the physical feel of "tightness" and "knottiness" in our tissues, the less likely we are to create nocebos for ourselves or our yoga students and massage clients. (A nocebo is a negative expectation of an otherwise harmless event or action that causes negative consequences like pain.)

 

MYTH #3: OUR FASCIA CAN BECOME DEHYDRATED AND ROLLING ON MASSAGE TOOLS HELPS TO RE-HYDRATE IT

This is an absolutely appealing and intuitive idea, but to the best of my knowledge, we don’t have research that supports this claim. Part of the problem lies in a lack of specificity for how this proposed dehydration/rehydration process would work.

An artist's depiction of connective tissue.

An artist's depiction of connective tissue.

In simple terms, our connective tissue is made up of cells, collagen fibers, and a non-living gelatinous matrix called ground substance. When the claim is made that fascia can be dehydrated, I believe the notion is that its ground substance is dehydrated.

It’s unclear to me how it could be determined that someone’s ground substance is dehydrated, however - can you tell by looking at someone from the outside? Maybe by looking at their skin? Can you tell because they feel pain somewhere? (As we mentioned earlier, pain and tissue quality are poorly correlated.)

Even if there was a reliable way to assess fascial dehydration, it is unclear to me how a massage or rolling on balls or other tools would hydrate it. The ground substance of connective tissue definitely has some water content, but how would the pressure from rolling change this water content? (Water that you drink goes through different channels in your body than water in your ground substance, so that's a different type of hydration than fascial hydration.) Does rolling add new water to fascia (how?), or does it move already-existing water from another part of the body to the deydrated one? If rolling did increase water content, wouldn’t everyone’s glutes be extra hydrated and especially healthy because so many of us squash them with pressure by sitting on them for hours every day?

Most of us believe this hydration claim because we heard it from someone knowledgeable like a smart yoga instructor or an experienced bodywork teacher. But if we actually look to connective tissue biology for some factual basis to the claim, we find that there is little support there. It may be true that massage can hydrate our dehydrated fascia, but research has not yet demonstrated this in a clear way. I believe we would do more of a service to our yoga community by waiting to make claims like this until science begins to produce some solid evidence for them.

 

In summary, fascia is an incredibly fascinating tissue of the body for an abundance of reasons. But we will better serve ourselves and our students if we shed some of our language about fascia that implies that it is full of painful adhesions and scar tissue that need to be broken down and hydrated. Additionally, massage therapy and self-massage tools like balls and foam rollers are absolutely wonderful, helpful practices that offer great results for so many people. But when we recognize and teach an awareness of the often-overlooked role that the nervous system plays in many of these massage benefits, we will be able to utilize these tools even more powerfully for ourselves and our students and clients.

 

(If you're interested in exploring these ideas further, you might appreciate this video from Quinn Henoch, Doctor of Physical Therapy:)

Can A Simple Sitting Test Predict Your Mortality? I Have My Doubts!

You may have heard about the Sitting-Rising Test for Mortality. This test is said to predict your mortality based on how well you perform the task of sitting down onto the floor and rising back up to standing. I’ve seen news articles and video segments about this test passed around an abundance of times on social media with headlines like “Simple Sitting Test Predicts How Long You’ll Live” and “The Exercise That Predicts Your DEATH”. (Scary!)

Now I am definitely a proponent of the importance of skill in functional movements like sitting and rising from the floor, and I teach yoga and movement with this as a guiding principle. But I was curious about the bold claims and dire warnings I was seeing associated with this sitting-rising test, and I also didn’t love the idea of someone scoring a point or two below perfect on the test and then worrying that certain death was nearly upon them. I decided to examine the original research study on the sitting-rising test to find out what the researchers actually did and what their results truly suggested. I discovered that the research does show that this test can be a helpful assessment tool for a small percentage of the population (namely elderly people), but that the study’s results have been largely misinterpreted by news articles and the health and fitness world in general.

 

WHAT IS THE SITTING-RISING TEST?

For those not familiar with the sitting-rising test, it’s very simple to perform. From standing, lower yourself into a seat on the floor and then rise back up again to standing, using the minimum amount of support that you can (i.e. try not to use your hands or knees to help you.) You’re awarded 5 points if you can sit down without support and 5 more points if you can stand without support for a total possible score of 10. For each hand, knee, or other form of support that you use on the way down and up, 1 point is deducted from your score.

According to the study, lower sitting-rising scores were associated with higher mortality among its subjects. This seems quite suggestive on the surface, but let’s examine a few details about the study that are often overlooked in news and media reports.

 

1) The title of the study, “Ability to sit and rise from the floor as a predictor of all-cause mortality”, is very easy to misinterpret. To most of us, the term “all-cause mortality” is foreboding and seems to suggest that if you score lower on the test, you have an increased risk of dying from all possible causes - i.e. cancer, heart disease, stroke, diabetes, etc. How worrisome indeed! But what this term truly means is that the researchers did not control for type of mortality in their study because they did not know how their subjects died. This is actually the exact opposite of the way that most readers would interpret the meaning of the title.

Because the study did not control for type of mortality, and because the sitting-rising test assesses musculoskeletal health qualities like balance and strength, the most likely explanation for the deaths reported was that they were from falls. Therefore a lower score on the sitting-rising test probably does not suggest that you might die sooner from cancer, heart disease, diabetes, or a host of other frightening possibilities. A lower score instead probably simply suggests that you lack balance and strength skills, which indicates that you’re more likely to take a fall. We know that falls are an unfortunately common cause of death among older populations, which leads us right into the next point:
 

2) The majority of people who received low scores on the sitting-rising test were between the ages of 76-80. And the study itself also only looked at people between the ages of 51-80. This means that the sitting-rising test was most meaningful for elderly people (and again, this could be explained in large part because of the high incidence of falling as a cause of death among the elderly.) This also means that despite news reports that this “simple test predicts how long you’ll live”, if you are younger than 51 years of age, the results of this study do not actually apply to you.
 

3) The study showed no difference in mortality between those who scored an 8, 9, and a 10 on the test. This means that if you use one hand for support on the way down to your seat and one hand on the way back up (a score of 8), your mortality risk is no different from someone who uses no support at all and scores a perfect 10. This seems counterintuitive and is not the way the sitting-rising test is generally presented to us in the health and fitness world. We are usually told that using one or two hands and knees is significantly worse than using no hands or knees at all. But this is a misinterpretation of what the study found.
 

4) The magnitude of the effect becomes most worrisome at scores lower than 6 (using 5 or more hands and knees), and is largest with a score of 3 or less (7 or more hands and knees). And because the majority of people who received these low scores were elderly, the effect is really much more relevant for this age demographic (and is likely explained by falls.) This isn’t to say that this test is meaningless for people in their early 50’s. But in all likelihood, if a 51-year old has to use 7 or more hands and knees to lower to the floor and rise back up (just picture for a moment what that would like), this is probably indicative of obesity or some other fairly obvious health factor that is impeding their function and affecting their mortality that this study did not control for. (While the researchers did control for body mass index, this is not the same as controlling for obesity.)

 

In conclusion, I definitely believe there is value in learning to sit and stand with as little support as possible, and I do teach this skill in my yoga and movement classes. But unless better research comes out in the future, I would hesitate to suggest based on this study that people should assess their own mortality by using the “sitting-rising test”. I believe that doing so could cultivate unnecessary fear, stress, and discouragement in people who don’t score a perfect 10, and it could also encourage a false sense of security in people who do. This test appears to be statistically significant for elderly people only, and even then, the mortality likelihood predicted could be driven entirely by falls. The “sitting-rising” test is probably best utilized by medical doctors as a general screening tool for their patients in combination with other routine health assessments like measuring blood pressure and taking pulses.