Several months ago I shared an article “The fall of the postural-structural-biomechanical model in manual and physical therapies; exemplified by lower back pain.” with about twenty of my colleague therapists and asked for their feedback and opinion. The reactions I received or the lack thereof actually surprised me.

For those of you who didn’t read the article in question, the text composed by Eyal Lederman questions, based on statistical analysis in regard to PSB factors and lower back pain, the validity of the often used and currently very popular postural-structural-biomechanical (PSB) model. According to Lederman the therapists applying the model falsely assume structural imbalances and asymmetries to be the cause of (lower back) pain. He thinks to prove this by sharing statistical research that fails to confirm a relationship between several postural-structural-biomechanical properties and (the occurrence of) lower back pain. While questioning the relationship between lower back pain and trunk asymmetries, low muscle strength, lumbar lordosis, disc degeneration, short (tight) hamstrings and psoas muscles he emphasizes the importance of what he refers to as the “biological reserve” (stress-resistance or adaptability as I prefer calling it).

To my surprise nearly all inquired colleagues – most of which look at their clients especially through a pair of PSB model glasses – regarded Lederman’s opinion simply as wrong or avoided discussing it all together. One often heard argument opposing Lederman’s ideas was, “I’ve applied the PSB model with success, which proves it does work therefore proving Lederman wrong.” Although understandable, this explanation doesn’t make much sense when thinking of the many influences (known and unknown) we exert during our treatment and exercise sessions and all that follows (known and unknown) in reaction to them. We can never say, beyond a doubt, what it is that makes our clients feel better. Unsettling as it might be, even the most knowledgeable therapists among us can merely make an educated guess, no more.

Only one colleague had the brightness of mind to imply that Lederman’s point of view was a righteous one. He argued that questioning the validity (or for that matter the existence) of one single, strongly distinct and fenced approach to all pain problems, and lower back pain in specific, was justified. There is after all far more to consider than only the postural-structural-biomechanical (postural, structural and biomechanical) variables of our clients suffering (lower back) pain. He concluded, “The PSB model is just a single approach to physical complaints, one of many.”

What struck me as odd is that of all inquired colleagues merely one thought to think of the complexity of (lower back) pain, all the possibly involved factors (known and unknown) and the possible solutions and/or remedies (known and unknown). Surely he could not be the only therapist realizing that no client is alike, pain comes in many different shapes and forms, is influenced by many internal and external factors and might therefore be approached from many different angles and eased in many different ways.

Although the reasons for the absence of an all encompassing answer from all my colleagues are likely manifold, I think I might have received more enlightening feedback if only Lederman would have reached a hand. Instead, he makes the same unfortunate mistake as those he tries to educate. By seemingly denying the possible use of the PSB model all together he displays a limited point of view equal to those who only work according to the very model he questions. I can’t help but think that his rather one-sided deliberation is probably not conducive to starting a useful discussion but instead shuts the door on exchanging thoughts. It would have been great if he’d have mentioned that, “although the PSB model might be effective at times – this despite the fact that certain statistics seem to prove otherwise – there is far more to consider, for example the biological reserve or stress-resistance of our clients”.

Be that as it may, I think the regrettable form in which Lederman shares his ideas does not excuse my colleagues from displaying an equally black and white train of thought – we should know better.

While I do not expect all of us to agree with every therapy philosophy, approach or technique I do feel we should at least acknowledge that there is more than we agree with, more than we know about, more than we (think we) understand and more than we are comfortable with. Just like stories, our clients and the pain they experience have many, many sides to them – as therapists maybe our thinking should be just as multifaceted.

© Willem Kramer for Willem Kramer, 2011. | Permalink | 2 comments | Add to del.icio.us digg
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For a better understanding please read “Physical Inter-Organ Connections” before reading this entry.

Either fixed and/or not fixed, all of our organs physically relate to their neighboring organs. Because they do, because they all connect and touch, they constantly exchange influence.

Without end (day and night) our muscles, bones, deep fasciae, nerves and other organs exchange mechanical force [?] and nerve impulses.

Externally and internally originating forces affecting our organs are passed to connecting organs and translated to afferent nerve impulses. Either obscure to us or noticeable, the afferent impulses are answered by efferent impulses, in turn generating obvious or subtle internally originating mechanical forces. The purpose of this continuous give and take between organs is generating motion, maintaining posture, providing joint stability, circulating blood, maintaining homeostasis, and so on.

Although the ongoing exchange pertains to all our body parts, not all of them trade the same kind of influence. Depending on which organs connect and how (fixed or not fixed), they trade only force, or trade force and nerve impulses.

Pendulum - Perpetuum Mobile

Healthy fixed-connections enable the inter-organ exchange of both force and nerve impulses. In regard to force, all organs with a fixed relationship partake in the force-shuffle. Ligaments and bones, joint capsules and ligament, bones and muscles, muscles and deep fascia; all fixed related organs exchange force. Even nerves, arteries and veins, and the organs they are bound with [?] participate in this ongoing correspondence of physical energy. Unlike all other securely anchored organs, the connecting peripheral nerves and muscles and peripheral nerves and blood vessels, exchange both force and nerve impulses [?]. The hamstring muscles and the sciatic nerve, for example, exchange both. Just like the femoral artery and the femoral nerve.

Healthy not-fixed-connections only exchange force. Unlike the fixed connections, however, they are designed to limit the inter-organ trade of shear and pull. The loose inter-organ bonds are perfectly suited to control the amount of force travelling between relating organs. The connection between the iliotibial band and the vastus lateralis muscle for example, is built to limit their correspondence. The same is true for all other not fixed bonds. The not fixed connections between organs and crossing peripheral nerves and blood vessels are designed to do the same. Also synovial joints, not fixed connections between individual bones, are assembled to control the exchange of force between relating parts.

Food for Thought:
With the previous information in mind, what happens to its fixed relations when an organ goes through a character change, for example a change in tonus, pliability, length, etc?
And, what happens to its fixed relations when an organ passes on an abnormal amount of force or an abnormal number of nerve impulses?
And finally, what happens when a not fixed connection adheres and loses its mobility or range of movement?

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“The toe bone connected to the heel bone, the heel bone connected to the foot bone, the foot bone connected to the leg bone, the leg bone connected to the knee bone, the knee bone …”

Like the song “Dry Bones” by James Weldon Johnson implies, the bodies’ bones connect with one another. What James Johnson did not sing about is that not only bones but all our organs connect. Our arteries, bones, deep fasciae, ligaments, muscles, peripheral nerves, and all other organs physically connect to form the human body.

Although physical inter-organ connections have unique features based on which organs connect and where the connection is located in the body, we can divide them into two large groups; the physical fixed connections and the physical not fixed connections.

The fixed connections are, like their name implies, tightly anchored. They do not allow – or are not supposed to allow – any movement between connecting parts. To guarantee a strong link, the fixed connections are mainly established through the organ-unique connective tissues that invest and surround them. For example, the epineurium, perineurium and endoneurium of peripheral nerves are continuous with the meninges (the dura, arachnoid, and pia mater) surrounding the CNS. In the periphery, the nerves are anchored to the muscles through the “same” epineurium, perineurium and endoneurium. Bones and muscles also connect with one another. At a muscular attachment site, the bone’s periosteum is continuous with the epitenon and endotenon of the muscular tendon. For extra strength the tendon’s collagen bundles are anchored deep into the (cortical) bone. From a functional perspective, the fixed union – no freedom or slack between connecting parts whatsoever – is a requirement for health and proper function.

Opposed to the fixed links, the not fixed connections are not tightly anchored. They do allow – or are supposed to allow – at least some movement between connecting parts. The not fixed connections are generally established through interposed loose connective tissue. Arteries, veins and peripheral nerves, for example, loosely connect with muscles and the other organs they cross through a thin layer of loose connective tissue. Interposed loose connective tissue also ensures some movement between neighboring muscles. Of all not fixed connections only the bone-bone links (also known as synovial articulations or joints) are not established through loose connective tissue. Unlike other not fixed bonds these joints are established through interposed synovial fluid. From a functional perspective, the “free” or not fixed relationship – a certain degree of kinetic freedom or slack between connecting parts – is a requirement for health and proper function.

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Why is it necessary for a chiropractor, osteopath, physical therapist and manual therapist to know which muscles connect with the iliotibial tract, which blood vessels and nerves pass between and touch the hamstring muscles, which fascial septa connect with the fibula bone and which nerves and blood vessels connect with and “serve” the capsule of the talocrural joint?

Because connecting organs are essential for solving dysfunction, pain and injury!

Since muscles, deep fasciae, nerves and all other organs physically connect (either directly or indirectly) they have influence over each other. If the influence they have or pass on is “negative”, dysfunction, pain or injury can occur, spread and sustain.

By addressing the dysfunction, pain or injury relating organs with therapy and exercise we can turn their direct and indirect influence “neutral” and even “positive”. Doing so quickly resolves physical discomfort, promotes healing, prevents re-injury and helps increase performance.

For obvious reasons, knowing which organs connect with dysfunctional, painful or injured organs is important for deciding which organs to examine and, if necessary, treat and exercise. Without the use of a relational anatomy resource like Anatomy Links this becomes a daunting task.

Illustration: The biceps femoris (1) directly affects the fibula bone (2) and has an indirect effect on the anterior talofibular ligament.

Although the premise of the previous is well-known, simple and straight forward, the practical consequences are vast and therefore intimidating. Be that as it may, I sincerely hope it will not scare you off. For I am sure your soft tissue treatment results will improve drastically when you learn to take all connecting organs into account.

Rest assured, this anatomical point of view applies to all therapy and screening methods. It is not advanced nor does it require years of experience or an Einstein-like intellect. All that’s necessary is your expert precision and perseverance. Character traits I am sure all of you posses.

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The unique therapy we use at Veel Beter Fysiotherapie (transl. “Way Better Physical Therapy”) is exclusively developed for professional athletes.

Because of its intended clientele the therapy is solely aimed at results. Professional athletes are, after all, needed back in action as soon as possible and stronger than ever.

Now Veel Beter makes her unique approach and amazing results available to all her clients.

Because knowing what to treat and exercise is most important, we start with a thorough screening. With the support of an exceptional anatomy resource – developed by Willem Kramer, one of the co-owner of Veel Beter Fysiotherapie – we trace your pain or injury. All muscles, fasciae, nerves and other organs (body parts with a unique function) with a direct and indirect connection to your physical complaint(s) are examined and tested. The connecting organs found to have a negative influence over your pain or injury, are added to a so-called “To Treat list”.

In several treatment sessions, using unique hands-on treatment techniques and specific exercises, we switch the negative influences of the organs connecting with your pain or injury to positive. By turning the influences positive we clear out the road to recovery, allowing your body to heal in just days instead of weeks.

Because of our unique approach we might treat your hip after you sprain your ankle, your back when you suffer knee complaints or your abdominal region in case of neck pain. Your Veel Beter Therapist can explain and show you the intriguing inter-organ connections and influences.

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