Biotensegrity: Advancing Pain Diagnosis and Treatment by Rethinking Anatomy and Biomechanics
Regardless of specialty, clinicians need anatomic models as a context for the diagnosis and treatment of pain complaints. This chapter argues that the fundamental mis-framing of musculoskeletal anatomy has impeded our ability to diagnose and treat myofascial pain and traditional orthopedic pathologies. Biotensegrity theory and recent advances in fascial anatomy provide a context for understanding all other anatomic structures in new ways. This reframing of anatomy helps explain the persistence of myofascial pain and the effectiveness of alternative treatments, such as prolotherapy, manual fascial therapies, and manipulation. A detailed case example illustrates the clinical application of biotensegrity and dynamic ultrasound in the context of orthopedic injury and neuromuscular dysfunction.
MPS [myofascial pain syndrome] is actually a complex form of neuro- muscular dysfunction associated with functional deficits and broader symptomatology.
Jay Shah, et al.1
Myofascial Pain as an Introduction to Understanding Chronic Pain and Sports Injury
The “trigger point” has become common knowledge among pain sufferers and athletes; foam rollers and other devices for the self-treatment of trigger points are now present in most gyms and available at most big box stores. Chiropractors and physical therapists now commonly provide dry needling for symptomatic trigger points. So, what are these trigger points, and why are they so prevalent and persistent? To acknowledge the role of muscle and fascial elements in this pathology, the proper name is myofascial trigger points (MTrP). MTrPs are exquisitely tender nodules within a taut band of muscle which reproduce the patient’s symptoms with sustained pressure. They are associated with a twitch response when palpated in a “strumming” fashion, perpendicular to the muscle fibers. Active MTrPs correlate with spontaneously reported symptoms, while latent MTrPs do not produce spontaneous symptoms, though they may affect muscle function. The pain perceived can be local with specific referral patterns as outlined in The Trigger Point Manual.2 The myofascial pain syndrome (MPS) is a local or regional phenomenon of pain and other signs and symptoms, including autonomic symptoms, muscle stiffness, altered muscle control, and referred pain that can imitate radicular patterns. MPS is covered in Chapter 11 of this text, including mechanisms of central and peripheral sensitization. These important concepts help explain how a focal muscle pathology can spread via neurologic and inflammatory mechanisms. In a recent review article, the authors state “the development of successful treatment approaches depends upon identifying and targeting the underlying mechanisms of pain and dysfunction and addressing the perpetuating factors that maintain this common pain syndrome.”1 Yet, the etiology and perpetuating factors are often unclear. Perhaps, an overly mechanistic view of anatomy and biomechanics blurs our vision.
The eye sees only what the mind is prepared to comprehend.
Not All Feedback and Control Are Neurologic
In the research model of the decerebrate cat, scientists have explored the neurologic control of locomotion.4 The focus has been on the neurologic anatomy behind oscillating, controlled movement that is unconscious. With the cerebrum disconnected, a cat can walk, trot, and run if provided with external stimulus from a treadmill. A video of this model is available on YouTube.5 Whether trained in science or not, we tend to look at videos like this and wonder about the complex neurologic control that makes it possible. We are less likely to wonder about the complex myofascial anatomy that makes it possible.
In many ways, musculoskeletal anatomy is defined by the bones of our ancestors. This is what is left behind after life. Thousands of years of the collective unconscious have witnessed these bones and interpreted our form based on them. As an embryo, however, we have no bones. We are soft- bodied organisms, yet stable and capable of movement as seen in the mobility of both sperm and egg before they meet. Human anatomy began to be understood once dissection became culturally sanctioned. The reductionism of science involved cutting and separating structures so that the internal anatomy could be understood, surgeries developed, and suffering relieved. Our first imaging modality, X-ray, implies the obvious: the skeleton is the frame of our body. Muscles then are defined by where they originate and insert on bone. This allows us to picture shortening of a muscle and what that shortening would do to an adjacent joint. This model then becomes an unconscious visual pattern. The grasping of a weight or the process of locomotion involves the shortening of muscles to allow bending of joints and pulling of bones in a direction we desire. And biomechanics becomes a mapping of levers, joint angles, and force transfer controlled by neurologic signaling. Yet, our patients’ stories are always more than the sum of these parts.