Why Imaging May Be Keeping Us In Pain

Is It Helping or Harming?

By Kelly Clancy, OTR/L, CHT

June, 2019

In most parts of the western world, traditional allopathic medicine focuses on the treatment of specific sites of pain symptoms. The goal for the healthcare provider is to resolve this localized or regional pain or dysfunction based on the complaints and felt symptoms.

Depending upon this reductionistic approach, the diagnostic studies of specific parts of the body are ordered and examined. If an artifact is discovered on imaging, such as a bulging disc, torn rotator cuff, or frayed tendon it is deduced that it most likely must be the source of pain generation.

In many cases, localized interventions based on these radiologic or interventional test findings are executed, and the result is less than desired.  In more cases than we want to admit, especially in cases of chronic pain, the intervention does not produce the hoped upon resolution of symptoms or if it does, it lasts only for a brief reprieve with symptoms ultimately returning.

In this case, the patient is oftentimes hurried from healthcare provider to healthcare provider in pursuit to uncover other reductionistic answers or solutions to their complex and unique presentations.

Unfortunately these visits to multiple subspecialists often results in negative secondary effects of more invasive diagnostics or procedures such as surgery, which inadvertendly can create limiting scar tissue adherence, alteration of connective tissue balance, and further dysregulation of ANS functioning.
These interventional strategies end up creating further longer term negative effects on the stability and the balance of the individual’s structure and psyche.In physical medicine and rehabilitation for example, when a common conservative treatment regime is implemented such as localized injections, ultrasound, massage, stretching, or strengthening to localized areas of pain, these reductionistic attempts to remedy the pain often leads to temporary relief of symptoms but unfortunately, do not address the root cause of the symptoms.
If this conservative management protocol is not satisfactory, often surgical interventions are implemented to the specific dysfunctional region. It is not infrequent that a patient may undergo multiple surgeries, especially in areas like the upper extremity or the low back in the pursuit to “put out the fires” of complex multi-system symptoms.  Unfortunately, this approach is often met with limited success or in some cases a worsening of function.
Recent research on interventional treatments for low back pain, shoulder dysfunction, knee pain and other orthopaedic and neurologic conditions has increasingly demonstrated the ineffectiveness of these interventional approaches.
One example of this can be found in the work of Dr. Janna Friedly, a back specialist and assistant professor of rehabilitation medicine at the University of Washington, where she has demonstrated that injection therapy does not provide a long-term solution for low back pain:
‘But the benefits do not last, the latest science shows. In a commentary published in May in The Journal of the American Medical Association (JAMA), researchers from the Netherlands point out that there is almost no evidence that the shots ease most people’s pain long term, even after multiple injections. Other recent studies have concluded that injections also do not significantly reduce the likelihood of back surgery later. And in a particularly sobering study published in February, researchers found, to their surprise, that a small group of subjects with pinched nerves in their backs showed less improvement after injection therapy than a control group during a four-year follow-up period. Based on the available data, the JAMA authors conclude, doctors “should not” recommend injection therapy to their patients with chronic low back pain.The lack of alternative options that can be administered in a doctor’s office, however, is frustrating to physicians and their patients, says Dr. Friedly.
Doctors “want to be able to do something,” she says. (1)A 2015 study from the British Medical Journal examined the effectiveness of arthroscopic knee surgery for middle aged subjects with knee pain and or degenerative findings. They concluded that arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery.
Knee arthroscopy is associated with harms. Taken together, these findings do not support the practise of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis. (2)Another more recent study in 2017 published in Bone and Joint followed 90 subjects over a 10 year period and found that the patients who underwent operative treatment had a stronger belief in recovery, however their outcomes were no better than received with an exercise program. (3)
Fortunately pain science is rapidly helping us understand pain and the brain and it is changing our focus on structural artifacts as a determinant for invasive care. According to Howard Schubiner, the director of the Mind Body Medicine Center at Providence Hospital in Southfield, Michigan and a Clinical Professor at Wayne State University and Michigan State University School of Medicine, there are different types of pain related to chronic symptoms.
Inflammatory pain which can also be classified with and as nociceptive pain, neuropathic pain due to nerve damage and brain-induced pain, centralized, psychophysiologic, or psychosomatic pain.According to Schribener in his article entitled “Neural Pathway Pain, published in Practical Pain Management in volume 17, issue 10, a call for a more accurate diagnosis is warranted in these cases. He reports studies on imaging that can lead the healthcare provide and patient astray. “MRIs of pain-free 30-year-olds show degenerative disc disease in 50% of patients, and bulging discs in 40% of patients.
These statistics reach levels of 80% and 60%, respectively, in pain-free 50-year-olds, and are even higher in older patients. In the same article he goes onto to say that Imaging from MRI and functional MRI studies (fMRI) identify clear changes in the brains of individuals with chronic pain.Children who suffer from the consequences of parental divorce, drug abuse, neglect, or outright abuse have much higher rates of chronic pain (and other difficulties) later in life.
The experience of growing up feeling “unsafe” sensitizes the danger/alarm mechanism that may then be triggered later in life through stressful life events or physical injuries, such as a car accident or a surgical procedure. In these situations, the brain may construct pain as a protective mechanism. Specifically, the brain activates neural circuits or pathways of pain that create real pain in the
absence of tissue damage.
These pathways are, however, reversible due to the brain’s neuroplasticity”. (5)I would argue that our ‘maps’ need to be questioned. The biomechanical reductionist roadmap that leads us on a pain symptom chase is outdated and leads us down this path of overspending and prolonged suffering of both the patient and the healthcare system as a whole.
Our roadmaps need to be updated to include the latest research around connective tissue and the nervous system. It needs to be modified to include the psychoneuroimmunological in conjunction with the biotensegrity model in our attempts to treat the whole person.
Clinically we are seeing that approaches like Tensegrity Medicine that use these complex relational biology systems as roadmaps for both evaluation and treatment, are then able to implement treatment strategies that incorporate interoceptive awareness, somatic practices, dialogueing, and other bodymind approaches to the whole person.
When the whole person is examined and treated in this way, the root cause of the majority of chronic pain symptoms most often can be reversible.
(1)- Jama 313 (11), 1143-1153, 2015. 77, 2015. Noninvasive treatments for low back pain. R Chou, R Deyo, J Friedly , A Skelly, R Hashimoto, M Weimer, R Fu, .
(2) Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms BMJ 2015 ; 350 doi: https://doi.org/10.1136/bmj.h2747 (Published 16 June 2015) Cite this as: BMJ 2015;350:h2747
(3) Bone Joint J. 2017 Jun;99-B(6):Arthroscopic decompression rotator cuff tendinopahtyh799-805. doi: Ketola S 1, Lehtinen JT 2, Arnala I 3. 10.1302/0301-620X.99B6.BJJ-2016-0569.R1.
(4) December 2017 Volume 17, Issue #10 … – Practical Pain Managementhttps://www.practicalpainmanagement.com/issue/1710Volume 17 , Issue # 10 … A Model to Incorporate Functional Medicine into Chronic Pain Care … Neural Pathway Pain — A Call for More Accurate Diagnoses.
( 5) Clin J Pain. 2018 May;34(5):402-408. doi: 10.1097/AJP.0000000000000549. The Incidence of Adverse ChildhoodExperiences (ACEs) and Their Association With Pain-related and Psychosocial Impairment in Youth With Chronic Pain. Nelson S 1,2, Simons LE 3, Logan D 1,2.

 Relational Anatomy

Why our understanding of anatomy is changing and how this impacts rehabilitation

By Kelly Clancy, OTR/L, CHT, LMT

March, 2019

It is time for us to revisit the biomechanical model. To understand why it is time to move beyond what has become the traditional approach to diagnosis and treatment, it helps to understand a bit of history.In 1680, Borelli’s biomechanical model extended the rigorous analytical methods developed by Galileo in the field of mechanics into biology, using principles of mechanics to explain the structure and function of

biological systems. This mechanistic approach emphasized the relevance of levers within and as part of the musculoskeletal system as a means to comprehend force generation.[1]

Because this conceptual model represented the physical structure and its function only, it excluded psychological and social factors, focusing exclusively on the physical features of force transmission in an attempt to understand movement. This model dominated in explanations and demonstrations of kinematics of the human body. Despite its limited scope, the biomechanical model remains one of the foundational principles in orthopedic and rehabilitation medicine.

Modern day practice of this model surmises that isolated joints, muscles, tendons, ligaments, and nerve structures operate as independent levers and pulleys, creating the main architectural framework for human movement and functioning-Man as machine. In adherence to this model, diagnostic rationale seeks to explain dysfunction of specific regions of the body based on the presupposed mechanical functioning or disruptions within this force generation and transmission model.

Utilizing this mechanical model in clinical practice, once the dysfunction is identified, specific targeted interventions such as localized manipulation, trigger point injections, and joint replacements, are applied. This myopic approach therefore creates subspecialty fields, where expertise is defined by a specific body part (e.g. hand therapy). These clinical specialists train and practice in their areas of specialty providing isolated therapeutic assessments and interventions which perpetuate the idea of the body parts as isolated, independent structures.

Anatomical dissection and labeling of parts is another form of reductionism and has been a means to describe the human form for over two millennia. Via the scalpel of the skillful dissector who determines where one structure stops and another begins, we have explained and constrained the human form into the biomechanical framework. Whom amongst us in the medical professions hasn’t spent countless hours in the anatomy lab, separating and isolating structures to reach the ultimate goal of labeling them as parts?

Using this approach, the exposing, separating and labeling of tissue, has unfortunately led to an artificial representation of the actual connectivity of our underlying structures necessary to truly understand functional movement. Due to the hydrophilic nature of the connective tissue system, the drying, preserving and processing of tissue in preparation for dissection limits our understanding of what the tissue actually looks like and, more importantly, moves like in living, functioning human beings.

Today’s progressive scientists studying connective tissue are beginning to advocate for a change in this way of examining the body. The modus of anatomy training in most major educational institutions, however, has remained traditionally oriented-one of the study of parts and separation.

Over the last few decades, the fascial system has been increasingly recognized as an important system for understanding mechanical force generation. For instance, connective tissue studies are confirming that the endo-/peri-/epimysium which surrounds and permeates our muscles and muscle fibers are responsible for up to half of the force transmission, greatly augmenting the muscle/tendon attachments that previously were thought to be the sole driver in movement and propulsion.[2]

‘The fascial system is made up of a three-dimensional continuum of soft, collagen containing, loose and dense fibrous connective tissues that permeates the body. It incorporates elements such as adipose tissue, adventitiae and neurovascular sheaths, aponeuroses, deep and superficial fasciae, epineurium, joint capsules, ligaments, membranes, meninges, myofascial expansions, periostea, retinacula, septa, tendons, visceral fasciae, and all the intramuscular and intermuscular connective tissues including endo-/peri-/epimysium. The fascial system surrounds, interweaves between, and penetrates all organs, muscles, bones and nerve fibers, endowing the body with a functional structure and providing an environment that enables all body systems to operate in an integrated manner’.[3]

Despite centuries of neglect, it has become hard to ignore the fascial systems continuous global and three dimensional properties. The health or potential dysfunction of this system would most certainly have a broad influence on global structures of the body, including the nervous,lymphatic, circulatory, and the endocrine systems.

A 2018 study published in Scientific Reports by Neil Thiese described the loose connective tissue as the Interstitium. Some in the media described this as a ‘discovery of a new organ’. This study observed the macroscopically visible spaces within tissues via focal microscopy — noting the dynamically compressible and distensible sinuses through which interstitial fluid flows around the body. Thies stated that the findings of this study necessitated reconsideration of what we understand as the normal functional activities of different organs. He describes how these observed anatomic structures are potentially important in cancer metastasis, edema, fibrosis, and mechanical functioning of many or all tissues and organs.[4]

Fascial and biotensegrity researchers understand and have been studying this fibrous web of tissue for sometime and noting that it is directly connected to the skin layer and penetrates down to the cellular level. The collagen and elastin fibers within this connective tissue give fascia its shape and structure. The fibers are lined up based on the directional lines of force generation within the body. Repetitive motion, overuse, and injury can cause the fibers to become disorganized and dense, preventing smooth coordinated movement. For example, if your hamstrings are tight, it might not be because they are over contracted or short – it may be the fascial fibers are constricted and imbalanced in the particular lines of pull within the connective myokinetic chain of which the hamstring is part or in its neighboring structures which may be influencing the glide of the localized structures. This restriction may have a negative effect on the muscle receptors ability to fire correctly, which would then limit the concentric and eccentric motor control. The resultant effect could be limitations in range of motion, strength or global restriction in motor planning and functional coordination.

The biomechanics of fascial organization have been mapped through fresh tissue dissection and eloquently described through the writings of Carla Stecco, John Sharkey and other fascial anatomists. This scientific understanding of the three dimensional connections supports the modern theory of biotensegrity that is gaining traction in the movement and manual therapy world. Biotensegrity, a term coined by orthopedic manual therapy world. Biotensegrity, a term coined by orthopedic surgeon Stephen Levin, MD, is used to apply the force vector concept, tensegrity, to biology. According to biotensegrity, only tension and compression elements in tensegrity systems comprise biological organisms. There are no shears, bending moments or levers, just simple tension and compression, in a self-organizing, hierarchical, load distributing, low energy consuming structure.{5}

This way of understanding the human body can be applied to practical rehabilitation goals, aiming to create symmetrical compression and distraction balance throughout the bodywide system. Three dimensional balance allows the joints, muscles, tendons, venous and arterial flow, nerves, and lymph and fluid flow to operate optimally and maintain homeostasis. With Thiele’s new imaging research on the interstitium along with neo-anatomical research with fresh connective tissue, we may better be able to advance our understanding of this continuous network. Rejecting the simplistic and reductionistic biomechanical model while embracing the more complex and elegant bioetensegrity model opens the door for new diagnostics and treatment interventions in clinical practice.

[1] Pope MH. Giovanni Alfonso Borelli–the father of biomechanics. Spine. 2005;30(20):2350-5.
[2] https://www.researchgate.net/publication/320742664_Fascia_- _The_unsung_hero_of_spine_biomechanics [accessed Jan 22 2018] [3] Adstrum S, Hedley G, Schleip R, Stecco C, Yucesoy CA. Defining the fascial system. J Bodyw Mov Ther. 2017;21(1):173-177.
[4] Theise ND. Structure and Distribution of an Unrecognized Interstitium in Human Tissues. Scientific Reports. 2018;8:4947.

{5}https://www.biotensegrity.com Dr. Stephen Levin’s website

(This is an excerpt from Kelly’s upcoming book on Tensegrity Medicine- A treatment approach addressing the whole person – body, mind and spirit in traditional medicine).

copyright kellyclancy 2019