Graham Scarr Request copy

In: Pilat, A., (ed.)., Fascia: scientific advances; Proceedings of the 28th Jornadas de Fisioterapia Conference, March 1-3, Madrid: Escuela Universitaria de Fisioterapia de la Once; 2018:219-225.


Health care is something that many of us now take for granted because we are living in a time where our understanding of the aetiology, diagnosis and treatment of disease is rapidly expanding. Complex medical investigations and procedures have now become routine, and survival rates for previously untreatable conditions are rising. Our knowledge of genetics, intra-cellular mechanisms and molecular pathways is dramatically increasing, as is the role of the fascia and structural mechanics in general, yet research into each field is still often carried out in isolation from the others and remains subject to the political and economic fashions of the time. General attitudes to what we call ‘health and disease’ can also be considered flawed because, as will be suggested here, the body works in exactly the same way when it is ‘healthy’ as when it is ‘dysfunctioning’, and that what many people think is going on during the treatment process is actually quite different to the reality.

Everyone knows what a healthy body is, and what it is not, and popular culture and the standard medical system are keen to reinforce our illusions, because it is in their best interests to do so. National news headlines are quick to inform us about the latest ‘danger’ to our food and health while advertisers warn against using the ‘wrong’ face cream and shampoo and emphasize how their miracle pain-killer will resolve all our problems. Medical guidelines that standardize the patient’s condition into grades 1, 2 and 3 are also issued, and in so doing, develop a common terminology and treatment plan that enables efficacy to be quantified and value for money determined. Far from being a cynical view, the latter is an important communicative and administration strategy that provides valuable information to the practitioner, but how deeply does this categorization influence our therapeutic thinking?

On the one hand, we can think of a healthy body as one that moves easily, without pain, and enables us to do all the things we want to do with it. On the other hand we have dysfunction, injury and disease, but these words evoke images of harm, damage, abnormality and pathology and suggest that there must be something ‘wrong’ and that it needs ‘fixing’. Certainly from the patient/client’s point of view they are in pain or something is not working as well as they would like, and we need to have empathy and compassion for their situation, but a treatment approach that just fixes problems is missing something important because it sidesteps what is really going on and may not provide the best care for that person (Table 1).

A related article in this issue outlined the value of biotensegrity as a different way of understanding how the body works, and how it is based on the fundamental rules of physics first and from which everything else is derived.1 Where the same basic principles apply at every size scale from molecules to the complete organism and efficiently couple the architectural anatomy of bones, muscles and fascia etc into a unified motion system that operates with the minimum of effort.2,3 Essentially, it emphasizes that structure and function are inseparable and that any changes to one will inevitably affect the other – and every practitioner knows that – but sometimes it is easy to focus on one aspect and overlook another.

The dynamic body

The body is a dynamic system that is constantly changing and adapting itself to those changes over time. We can observe changes in breathing through the expansion and contraction of the ribcage, and listen to the heart as it changes shape and pumps blood around the body, both of which provide valuable clinical information. We know that bones are being continuously remodelled by the cells within them and in response to the forces imposed on them, through Wolff’s law.4 Our muscles tend to waste away if they are under-used, or become larger and stronger when exercised, and fascial tissues are constantly reorganizing themselves in response to the stresses imposed. Cells within the extracellular matrix are constantly changing shape and contributing to maintaining the structure, and molecules are continually moving from one place to another and interacting in complex ways that ultimately influence movement.5 So, while the patient lying in front of us may appear to be calm and still, we know that the tissues inside are constantly adapting to their ever-changing environment and part of a much more dynamic system than is often appreciated. Which then brings us to ask such questions as: why does biology behave in the way that it does and how does an understanding of that influence the way we approach treatment?

The fundamental rules of physics

Every system conforms to certain basic principles, or ‘rules of physics’, and the laws that we use to describe them are concise statements that summarize observations that are always the same. If the same thing happens over and over again, there is likely to be an underlying principle that causes this, and someone will eventually write it down as a law. But it is important to note that the laws are not the same as the principles but our best understanding of them; they become established by consensus and are open to revision, and there are lots of them.6 For example, the laws of thermodynamics were described in the nineteenth century and are now considered to apply to everything, everywhere in the universe – they describe fundamental physical principles that are true, absolute and predictable.7

The First law states that energy cannot be created or destroyed but only transformed from one state to another – the conservation of energy. The Second law indicates the direction that it always takes – from high to low – towards some minimal-energy state, yet can seem at odds with biology. Both these laws apply to systems that are in equilibrium (or close to), where the energy dissipates and becomes equally distributed, while living organisms are characterized by order and complexity. Their dynamics are in a constant state of flux and far from equilibrium (there is also a third law that applies to systems with temperatures close to Absolute zero but we will leave that one aside for now).

Living organisms are constantly taking in, storing and releasing energy to the environment as nutrients, heat, waste, forces and information, and it is the continuous dispersal of these resources towards some minimal-energy state that automatically drives or powers the system.8 However, their distribution through a highly ordered processing system that is constantly changing is something that is not easily accounted for by the first two laws.

Power drives everything that moves, lives and flows, and the natural engines that produce it depend on the continuous flow of resources through the system. One of the characteristics of life is the ability to transform the architecture of that flow in ways that enable the currents to move more easily, and this is now summarized as the Constructal law. Specifically: ‘for a finite-size flow system to persist in time (to live) it must evolve freely such that it provides greater access to its currents’, and this is often considered to be the fourth law of thermodynamics because of its fundamental nature.9,10

The architecture of flow

It is an inherent tendency of natural flow systems to change in ways that facilitate access to what flows, and the branching pattern of trees is an easy example (Figure 1). Here, the branches appear both above ground as well as below it, where the small roots collect water and minerals and transfer them to the larger roots, which then transfer them through the trunk, branches and twigs to the leaves; and the leaves photosynthesize and produce sugars that are collected by the twigs and passed through the branches and trunk to the roots; and these two different flow systems are constantly evolving as the tree grows and sustains itself throughout life.

In the same way, the flow of water through sand also forms these branching patterns, as do the dendrites that form as manganese chemicals diffuse across the surface of rock. Rivers carry huge amounts of water but often slow down as they reach the sea where they deposit their sand and silt and constrain the natural flow. As a consequence, river deltas with complex branching patterns can develop as a means of increasing the flow of water; and it is also common to talk about the arterial and respiratory ‘trees’ where these self-similar, fractal-like patterns frequently appear at different size scales within the human body.11

All these examples are architectural solutions to increasing flow within a constantly evolving system, with the particular patterns forming in response to the driving currents and local constraints in the environments through which they flow. Each one is a continuous, one-way process in time with the developing, dissipating flow-channels automatically following the path of least resistance and becoming established within an environment that is itself changing.

Such flow systems are apparent in every part of the body: from molecules that diffuse through a fluid environment and interact with each other in particular ways; to those that follow complex branching metabolic and signalling pathways; tubular fluid systems that carry blood and urine, etc; and structural anatomical entities that carry the forces of tension and compression and transform themselves in the process. Where the largest, stiffest structures carry the greatest forces and disperse them through many smaller ones, while others ‘collect’ the smaller forces and transfer them up through the heterarchy to the larger structures, and in ways that enable motion2. Here, the simplicity of these branching patterns is often hidden within the complex anatomical organization, but the forces within are still following the same principles of energy dispersion with the structures that carry them constantly adapting to the environment through which they flow. What we call tensegrity cables, struts and kinematic bars in a biological context are then the geometric, anatomical representations of these invisible forces and parts of a body-wide multi-scale architectural system that readily adapts to the forces that flow through it.12

The difference

So, return to our issue of health and disease, sustainability of flow is an over-riding factor in an organism’s existence and dependent on the architecture of a vast range of different flow-systems that emerge at every size-scale. Each one is unique, with all the different currents moving towards their own minimal-energy ‘sinks’ and feeding into each other in complex ways thus powering the overall dynamism that we recognize as life.13

The body is thus operating in exactly the same way when it is ‘healthy’ as when in it is ‘pathological’, in the sense that the physiology always follows the same basic principles and responds in the most energy-efficient ways that it can. Even though homeostasis is ‘built-in’ to the system, each process is following the path of least resistance and moving towards some minimal-energy state. The anatomy, architecture and tissue behaviour are different but the underlying principles that form them are exactly the same.


So, whether we have a cut finger, chronic arthritic joint or invasive cancer, the body is just operating within a different set of constraints and displaying a different pattern of behaviour, and it is us who really make the value judgement about ‘health’ and ‘disease’. For the patient who is need of help, however, it is the responsibility of the practitioner to understand the patient’s ‘problem’ and formulate a diagnosis and course of action, but treatment is more than just giving drugs, stretching muscles, repairing the structure or fixing problems. It is a physical, dynamic and interactive process that changes the tissue geometry, changes the architecture of these constantly evolving flow-systems at every size-scale, and the body’s self-organizing processes automatically respond to this in the most energy-efficient ways that they can and move the system towards a different state of ‘health’11.

The body does most of the work while the practitioner facilitates its dynamic transformations in the most appropriate way, and at a particular moment in time, and involves far more than just fixing problems.


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