The Fascial Continuum
Anyone who takes a class with me knows I often become obsessed with what I’ve learnt from my latest read—I will find a way to weave it into the session I’m teaching in some shape or form. Recently, I read a fabulous book by David Lesondak called Fascia: What it is and Why it Matters. I’ve long been interested in the subject of fascia, but what grabbed my attention about this book was Lesondak’s storytelling. He somehow manages to make the driest of subjects accessible and interesting, and his grasp of its history gives the reader context for why we see the world of anatomy as we do today. The book is full of quotations from brilliant minds that confirm Lesondak’s ideas, and he uses carefully chosen photos and illustrations to emphasise his points—one of these photos was the motivation for this blog.
This photo shows a plastination of the fascia of the lining of the heart with its connections to the diaphragm.
Dissection has long been a part of medical learning—the first documented dissections on the human body were in the third century. About ten years ago, I took a post-graduate diploma in clinical anatomy and spent six months learning to dissect the body. It is an excellent way to learn anatomy but has one great flaw—to identify structures, the fascia is removed. When I was studying the anatomy of the neck, I spent hours with my scalpel carefully removing fascia so that I could identify muscles, nerves and blood supply. In recent years there has been much talk about the importance of fascia in the functioning of our body and its connection to pain, yet it is hardly mentioned in medical textbooks and rarely appears in medical drawings. In 2018 the Fascia Research Society began a collaborative project with the Plastinarium and Body Worlds to plastinate ten fascial specimens. David Lesondak was one of the lucky dissectors who got to work on this project which was completed that year. The photo above shows one of the exhibits.
Fascia is connective tissue. It is the white tissue that surrounds a breast of chicken or a joint of beef. It covers every muscle fibre and creates a lining for groups of muscle fibres and for the groups of muscles themselves. It covers our nerves, organs and bones and connects our toes to our fingers. Imagine the fascia like the pith of an orange—the thick white pith covers the entire surface of the orange, but this pith then subdivides into the segments of the orange and then the individual juice sacs. Fascia connects one part of the body to another, and this is what is so clearly shown in Lesondak’s Photo.
If you look carefully at the photo, you can see the heart-shaped sac, or pericardium, at the centre (the heart has been removed so you can see the fascial envelope more clearly). At the bottom of the photo is a disc-shaped muscle. This is the diaphragm. I often compare it to a drum skin, as it is attached to the fascia on the inside lowest border of your rib cage, all the way around, just as a drum skin is attached to its rim. It will also have fascial attachments to the liver, which sits beneath it, and the lungs to each side of the heart. Again, in the exhibit, these have been removed to allow better definition of the pericardium and diaphragm.
What is illustrated so beautifully through this photo is the continuum of fascia from the major blood vessels through the pericardium and into the diaphragm. We tend to imagine the heart sitting in the middle of the rib cage, separate from other tissues, but this photo clearly shows this is not the case—it is firmly attached to the primary breathing muscle.
The breathing mechanics are pretty simple—it’s a matter of pressure equilibrium. The brain tells the body to inhale. The diaphragm and intercostal muscles contract, which widens our ribcage and pulls the diaphragm down into our abdominal cavity. This increases the space in our thoracic cavity. Because our lungs are attached to the rib cage via—you guessed it—fascia, the area in our lungs increases too. Air will always move from a region of high pressure to a region of lower pressure, and so air is dragged into our lungs.
We exhale because the diaphragm relaxes and the breathing muscles recoil. This decreases the space in the thoracic cavity, increasing the pressure inside the lungs and pushing the air out.
The Lungs and Diaphragm Massage the Heart.
We are taught in school that the heart pumps blood around the body so that oxygen and nutrients can be transported to tissues, waste products can be removed from tissues, and circulating immune cells can fight infection. An electrical impulse that fires 60 to 100 times per minute in normal conditions stimulates the heart into action. A foetal heartbeat can be detected in the foetus at about five weeks of development, and this heartbeat continues until the day we die. Life ends when the electrical impulse to the heart stops and isn’t restarted.
The founder of osteopathy, Dr Andrew Taylor Still, discussed the importance of a good blood supply. One of the first of his aphorisms I learnt when studying osteopathy was that the rule of the artery is supreme. Good health requires a good supply of blood to all our tissues, so any help that can be given to the heart will benefit our overall health.
The heart is assisted in its job in various ways; the elastic recoil of the artery walls pushes blood through these vessels, and valves in veins and the lymph system prevent backflow. Our muscular system also has elastic recoil, which squeezes fluid through the tissues—one of our greatest pumps is the working calf muscle which drives fluid from our feet back up to our heart.
Now, looking at this photo, you will see how the anatomy of our breathing apparatus also assists the heart in pumping. As we breathe in, the diaphragm descends. The diaphragm's fascial attachments to the heart's lining pull the heart down with the diaphragm. At the same time, the lungs expand three-dimensionally, pressing into the heart and exerting pressure on it. This changes the shape of the heart, increasing its length and decreasing its circumference. As we breathe out and the diaphragm elevates, the downward tension on the fascia is relieved. As the lungs deflate, the pressure on the heart reduces. This means that the heart is longer and thinner during inhalation and becomes shorter and fatter during exhalation. This continual change in pressure and shape assists the flow of blood.
Facia has been an important factor in osteopathic treatment for longer than in most other manual therapy or movement systems, and this photo perfectly illustrates why. The heart is connected to the diaphragm, which is connected to the spine, the liver, the psoas muscle, the ribcage, and so much more. In osteopathy, we are taught that the body is a whole and must be treated as such, and so we can’t treat the spine without considering the rest of the body. As the old spiritual song “Dem Bones” has it:
“Toe bone connected to the foot bone,
Foot bone connected to the heel bone,
Heel bone connected to the ankle bone,
Ankle bone connected to the leg bone,
Leg bone connected to the knee bone,
Knee bone connected to the thigh bone,
Thigh bone connected to the hip bone … etc.”