As fresh entrants in the realm of musculoskeletal health, it's natural for us to absorb established knowledge, sometimes without question. Throughout history, notions such as scar tissue and adhesions have been assigned blame for various musculoskeletal concerns. However, as we stride ahead in our understanding and research techniques, these long-standing convictions demand re-evaluation.
Article Index:
Introduction
As novices, we may be inadvertently influenced by more seasoned practitioners, who, owing to 'confirmation bias,' may steadfastly uphold these notions, favouring information that validates their existing beliefs while downplaying or overlooking contradictory evidence. Yet, there are also voices of dissent advocating a more balanced understanding.
Our journey begins by untangling two frequently misconstrued concepts: fascial adhesions and scar tissue. While both are acknowledged as key contributors to considerable dysfunction, their actual prevalence and impact are subjects of intense discussion within the Musculoskeletal (MSK) community.
To dispel the fog of confusion, 'fascial adhesions' and 'scar tissue' are not perfect replicas of each other, despite their everyday interchangeable use. Both are bodily responses to trauma or stress, yet they exhibit significant differences in their properties and effects.
The onus is on us to dive deep into these complexities. Comprehending these subtleties will help us understand how unchecked biases, specifically confirmation bias, can shape our diagnostic and therapeutic strategies, potentially influencing the quality of patient care.
Scar Tissue
Think of scar tissue as a type of natural band-aid of the body, a dense, fibrous substance developed to mend normal skin and tissue after harm or trauma. Scar tissue is a testament to the body's intrinsic healing prowess.
Fibroblasts, the architect cells behind scar tissue, weave collagen, providing a scaffold for the newly formed tissue. However, scar tissue doesn't quite match up to the original tissue in terms of flexibility and strength, and its contractile capacity often falls short. When it takes shape in or near joints, it can serve as an unwanted barrier, potentially causing restrictions in the range of motion.
Fascial Adhesions
Conversely, fascial adhesions point to specific instances where the fascia has become intertwined or fused.
Imagine fascia as a continuous web of connective tissue enclosing and infusing our muscles, bones, organs, nerves, and blood vessels. Under typical circumstances, these different layers of fascia enjoy the freedom to glide and shift against each other. However, these layers may stick together due to disturbances such as injury, inflammation, surgical interventions, periods of inactivity, or other factors, birthing what we call an adhesion. This undesirable union can trigger pain, diminished mobility, and various other complications.
Thus, while both fascial adhesions and scar tissue represent atypical unions between tissues, the distinguishing factor lies in the specific tissues involved and the circumstances under which they occur. Scar tissue symbolizes the body's attempt to substitute normal skin or tissue post-injury, whereas fascial adhesions represent the unintended fusion of different layers of fascia.
The Disputed Influence of Scar Tissue and Fascial Adhesions
Let's now set foot in the more disputed territories. In the diverse realm of medicine and therapeutic sciences, a contentious assertion often echoes the notion that a high degree of myofascial/MSK system dysfunctions can be attributed to scar tissue formation or fascial adhesions.
While this viewpoint captivates us with its straightforwardness, it perilously risks eclipsing the many intricate complexities embedded within human physiology. Our bodies, representing nature's marvels of biology, comprise countless interconnected systems. The myofascial network — an extensive tapestry of tissues spanning from head to toe — is no exception, as an array of physical, biochemical, and neural influences shapes it.
Undeniably, scar tissue and fascial adhesions are pervasive within the human body, springing from varied origins like injuries, inflammation, surgical interventions, or the relentless advance of natural aging. These fibrotic transformations can tweak the biomechanical functionality of the myofascial system, potentially leading to pain, reduced mobility, and functional deficits.
The Logic Flaw
Despite the prevalent conviction among some practitioners that scar tissue and adhesions are the primary culprits behind myofascial dysfunctions, empirical evidence reinforcing this belief is lacking. The existence of individuals with evident scar tissue or confirmed adhesions who are symptom-free indicates the presence of other contributing factors at play.
From my perspective, a pivotal element leading to this misconstruction can be pinned down to confirmation bias. This cognitive skew is an inclination to cling to entrenched beliefs in the face of contradicting evidence. This bias offers a convincing reason for perpetuating the scar tissue/adhesion viewpoint. Regrettably, this confirmation bias can potentially undercut the efficacy of treatment and obstruct the full resolution of a patient's condition. By identifying and mitigating the impact of this bias, practitioners can formulate more balanced evaluations and forge more cooperative, evidence-informed treatment strategies.
Unpacking Strengths and Weaknesses
Let's take a dive into the theories that surround the genesis of scar tissue and adhesions to cast a brighter light on these nuanced topics:
The Scar Tissue/Adhesion Perspective
At first glance, the scar tissue/adhesion theory in musculoskeletal disorders appears logical, drawing on biological foundations and clinical anecdotes. While this perspective, positing scar tissue and fascial adhesions as prime movers behind myofascial dysfunctions offers a compelling narrative, it is essential we delve deeper to untangle the true complexities of this theory and its flaws.
Biological Anchors: The creation of scar tissue and fascial adhesions is an evolutionary defence mechanism, a response to trauma, inflammation, or stress. This process can, without a doubt, alter the dance of the myofascial system's usual biomechanics. Scar tissue, inherently less supple and less competent than the original tissue, and fascial adhesions that impede the gliding of fascial layers, can introduce structural changes leading to discomfort, movement restrictions, and biomechanical shifts.
Clinical Anecdotes: It's an undeniable observation that a notable number of patients battling myofascial pain syndrome report substantial relief after receiving treatments targeted at dissolving scar tissue or liberating fascial adhesions. However, the true mechanics of whether these therapies function exactly as practitioners theorize is a subject worthy of a separate discussion.
The Prevalence of Triggers: When considering the factors leading to scar tissue or adhesions – like injuries, surgical procedures, inflammation, overuse, and the relentless progression of age – it seems plausible to link a substantial portion of myofascial dysfunctions to these causative components.
However, while these points offer logical pillars supporting the scar tissue/adhesion perspective, they do NOT stamp a seal of undeniable causation. The biological scaffolding and clinical evidence spotlight potential links, but they don't wipe clean the stage of other influential actors. Therefore, it's critical to shun the temptation of oversimplifying these multilayered issues and maintain an open mindset to a broad array of potential villains and heroes in the plot.
Drawbacks of the Scar Tissue/Adhesion Perspective
Now let's consider the flaws of this theory:
Oversimplification of Intricate Systems: The myofascial system's complexity is a vibrant symphony involving more than just the fascia and muscle tissue; it includes the nervous system, vascular system, immune system and a chorus of biochemical factors. By laying all myofascial dysfunctions at the door of scar tissue and adhesions, we risk a reductive narrative, potentially missing essential characters like neural tension or biochemical inflammation.
Absence of Ironclad Proof: While scar tissue and fascial adhesions might be frequent guests at the table of pain and dysfunction, their presence doesn't always result in symptomatic performance. It's not unheard of to find individuals with apparent scar tissue or diagnosed adhesions who live free of pain or functional limitations, suggesting these factors aren't the sole puppeteers of myofascial well-being.
Narrowed Therapeutic Lens: Concentrating our gaze only on scar tissue and adhesions might result in a blind spot toward other crucial elements of treatment, such as retraining the choreography of movement patterns, correcting the harmony of muscle balance, soothing neural tension, or addressing joint dysfunction. This myopic focus may leave us short of the optimal treatment outcomes we seek.
Confirmation Bias: As practitioners, our beliefs and past experiences can add color to our clinical canvas, leading us to favour certain perspectives. This is where the art of confirmation bias comes into play, influencing us to appreciate evidence that flatters our viewpoint and turn a blind eye to evidence that questions it. Numerous studies and case reports in the medical literature illustrate instances of confirmation bias leading to diagnostic errors or suboptimal treatment decisions in all professions.
In the context of the scar tissue/adhesion perspective, practitioners might be inclined to hold this view in high regard as it aligns with their experience or training, potentially missing other valid and beneficial techniques in the palette. Being alert to this bias can guide us toward a more balanced and comprehensive masterpiece of patient care.
Unveiling the Multitude of Causes
Within the complex orchestra that is the musculoskeletal system, the disharmony leading to dysfunction can arise from various sections, not solely limited to fascial adhesions and scar tissue. It's a matter of utmost significance to recognize and evaluate a multitude of etiological factors that could equally be the cause of musculoskeletal disorders. Consider the following factors:
Neuromuscular: Deviations in the neuromuscular system can sow the seeds of musculoskeletal imbalances, instigate a cascade of microtrauma, and set the stage for pathological tissue loading. Furthermore, neural tension where peripheral nerves are subjected to undue stretching or compression, can debut as mobility impairments.
Biochemical Shifts: The influence of localized or systemic inflammation can cue biochemical changes that sway the performance of the musculoskeletal system, leading to a score that includes nociception, edema, rigidity, and functional loss.
Articular Dysfunction: Disorders originating from the joint section are frequent composers of MSK pain and disability. Degenerative or inflammatory conditions like osteoarthritis, rheumatoid arthritis, gout, and systemic lupus erythematosus can choreograph a dance of articular dysfunction, resulting in a painful, inflamed, and motion-restricted performance.
Ergonomic and Lifestyle Factors: Muscle imbalances stemming from the strains of poor posture, unharmonious ergonomics, and physical inactivity can play a dissonant tune that impacts joint health and the holistic functionality of the musculoskeletal system, further amplifying the dysfunction.
Considering these diverse causes is akin to acknowledging all the instruments within our musculoskeletal symphony. By doing so, we can create a more harmonious therapeutic plan that caters to the intricate and holistic nature of the musculoskeletal system, helping us achieve optimal patient outcomes.
Conclusion Confirmation Bias 101
In my early years of practice, I too was swayed by the gravitational pull of observational biases propagated by seasoned practitioners. The allure of single-cause theories such as scar tissue and fascial adhesions held me captive for a while, their seductive simplicity clouding the multifaceted nature of our musculoskeletal systems. But as I navigated the intricate labyrinth of my profession over three decades, my lens broadened, my understanding deepened, and my practice evolved.
My path led me to appreciate the power of diversity — not merely in terms of varying diagnostic perspectives — but also in the wealth of therapeutic modalities at our disposal. Understanding the complexity of the musculoskeletal system and the many origins of dysfunction helped dissolve the narrow lens of confirmation bias that had once affected my approach.
I found the true power of an integrated, evidence-based practice within this harmonious diversity. The recognition and acceptance of this rich tapestry, encompassing multiple perspectives and procedures, have significantly improved my ability to navigate the terrain of musculoskeletal health.
In conclusion, I earnestly hope that we can collectively embrace the nuances and complexities that shape our practice by sharing this understanding. As we continue our journey, let's celebrate the symphony of perspectives, the power of diversity, and the continual evolution of knowledge. Together, let's create a future of musculoskeletal health that is as rich and varied as the patients we serve.
DR. BRIAN ABELSON DC. - The Author
Dr. Abelson's approach in musculoskeletal health care reflects a deep commitment to evidence-based practices and continuous learning. In his work at Kinetic Health in Calgary, Alberta, he focuses on integrating the latest research with a compassionate understanding of each patient's unique needs. As the developer of the Motion Specific Release (MSR) Treatment Systems, he views his role as both a practitioner and an educator, dedicated to sharing knowledge and techniques that can benefit the wider healthcare community. His ongoing efforts in teaching and practice aim to contribute positively to the field of musculoskeletal health, with a constant emphasis on patient-centered care and the collective advancement of treatment methods.
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References
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Guimberteau, J.C., & Armstrong, C. (2015). Architecture of Human Living Fascia. Handspring Publishing.
Huijing, P. A. (2007). Epimuscular myofascial force transmission: A historical review and implications for new research. International society of biomechanics Muybridge award lecture, Taipei, 2007. Journal of biomechanics, 42(1), 9-21.
Kumka, M., & Bonar, J. (2012). Fascia: a morphological description and classification system based on a literature review. The Journal of the Canadian Chiropractic Association, 56(3), 179.
Langevin, H. M., & Huijing, P. A. (2009). Communicative & integrative biology: Fascia Research - A Narrative Review. Journal of Bodywork and Movement Therapies, 13(3), 279–286.
Langevin, H. M., & Sherman, K. J. (2007). Pathophysiological model for chronic low back pain integrating connective tissue and nervous system mechanisms. Medical hypotheses, 68(1), 74-80.
Meltzer, K.R., & Standley, P.R. (2011). Modeled repetitive motion strain and indirect osteopathic manipulative techniques in regulation of human fibroblast proliferation and interleukin secretion. Journal of the American Osteopathic Association, 111(12), 622-632.
Schleip, R., Gabbiani, G., Wilke, J., Naylor, I., Hinz, B., Zorn, A., & Klingler, W. (2019). Fascia is able to actively contract and may thereby influence musculoskeletal dynamics: a histochemical and mechanographic investigation. Frontiers in physiology, 10, 336.
Schleip, R., Jäger, H., & Klingler, W. (2012). What is 'fascia'? A review of different nomenclatures. Journal of Bodywork and Movement Therapies, 16(4), 496-502.
Shah, J. P., & Gilliams, E. A. (2008). Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome. Journal of Bodywork and Movement Therapies, 12(4), 371–384.
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References for Confirmation Bias:
Confirmation Bias: A Ubiquitous Phenomenon in Many Guises by R. Nickerson. This paper reviews evidence of confirmation bias in a variety of contexts and discusses its utility or disutility. PDF
Confidence drives a neural confirmation bias by M. Rollwage, Alisa M. Loosen, T. Hauser, R. Moran, R. Dolan, S. Fleming. This paper explores how confidence in a decision leads to a modulation of post-decision neural processing, contributing to confirmation bias. PDF
What Is the Function of Confirmation Bias? by U. Peters. This paper proposes a new explanation for the evolution of confirmation bias, suggesting that it helps us influence people and social structures to match our beliefs about them. PDF
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