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  • Ezekiel Biomechanics Group

Abstract and Figures

Tensegrity, a new System of mechanics, can be used to model biomechanical systems from viruses to vertebrates. Pelvic mechanics are readily understood using this System. Biomechanical dysfunction can also fit into the tensegrity model. When function, dysfunction and mechanics are combined into the same system we can obtain a more holistic concept of the various pelvic pain syndromes and how to best treat them.
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Third Interdisciplinary World Congress On Low Back & Pelvic Pain, Vienna, November 1998
Stephen M. Levin
Potomac Back Center
100 East Street SE
Vienna - VA – USA
Tensegrity, a new System of mechanics, can be used to model biomechanical systems from viruses to
vertebrates. Pelvic mechanics are readily understood using this System. Biomechanical dysfunction can also fit
into the tensegrity model. When function, dysfunction and mechanics are combined into the same system we
can obtain a more holistic concept of the various pelvic pain syndromes and how to best treat them.
Keywords: Tensegrity, biomechanics, pelvic pain, dynamical disease.
Tensegrity, the mechanical System of bicycle wheels,9 viruses," biologic cells," and many biologic multicellular
structures" is gaining scientific and lay acceptance as the "architecture of life". Scientific American, a science
news magazine with a worldwide circulation of over 600.000, features an article about `tensegrity'in its cover
story in January 1998.'° If we accept the tensegrity concept it will virtually turn biomechanics an its head and
require a paradigm shift in thinking. If we ignore tensegrity mechanics we are in peril of interpreting our clinical
and experimental observations using an outmoded model. We are in stage of biomechanies much akin to the
geocentric vs. heliocentric arguments in Copernicus' time. At the very least, we must test our theories in both
Systems and See which fits best, since, like the geocentric and heliocentric theories, tensegrity and classic
Newtonian biomechanics are mutually exclusive.
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In 1992 and again in 1995 World Congress an Low Back and Pelvic Pain the focus seemed to be the sacroiliac
joint, its mechanics and its role in generating pain. There are several references to joint injection as the `gold
Standard' for diagnosis and for treatment. This need to stress joint pathology is rooted in the Newtonian
concepts that the skeleton and its joints are the frame upon which the soft tissue hang, and the concept that
pathology is a function of anatomical disease or injury.
On the other hand, tensegrity stresses that the bones of the skeleton are but compression elements `floating' in a
highly structures, self generating, hierarchical, integrated tension network of soft tissues.'3." The ligaments,
muscles and fascia take an a whole new importance and joint mechanics becomes soft tissue mechanics. This is
consistent with the clinical observations of Mennell,'3 who stressed the play movement of joints as a necessary
dynamic function and Trave11` who focused an the imbalance of tension of the muscles and fascia as a source
of musculoskeletal pain and dysfunction. These works echoed the pioneering precepts of A.T. Still, Palmen and
others who focused an the dynamic aspects of the musculoskeletal System rather than the anatomical pathology
of the structures.
In 1988 the NY academy of Science, in conjunction with NIH held a conference `Perspectives in Biological
Dynamics and Theoretical Medicine' who's theme was `dynamical diseases'. To quote Fraiser "the motion of
Systems and not their anatomy frequently defines a disorder." At that conference it was pointed out that
`diseases' such as irritable bowel Syndrome, asthma, benign cardiac arrhythmia and the like, are not anatomic
pathological processes bat malfunctions of the rhythms of the systems. One of the defining characteristics of a
dynamical disease is that, unlike an anatomical pathologic disease, the healing process in nonlinear. Anatomical
healing has a prescribed, linear healing process. A cut will go through a recognized and clearly definable
process, fibroblastic proliferation, organization etc., That has a proscribed time sequence. Dynamical diseases
may suddenly convert and normalize. An asthma attach may suddenly cease and leave hardly a trace. Hives may
appear and disappear in seconds. A migraine headache may disappear as quickly as it started. Musculoskeletal
impairment that can suddenly revert to normal function alter manipulation, myofascial release or treatment of a
trigger point must surely be a dynamical disease, related to the rhythms of the system rather than anatomic
pathologic changes. It then may be deceiving to bank an uncovering anatomical pathologic processes in the Joint
of myofascial tissues in order to make a clinical diagnosis. This is particularly so since it is recognized that
many of these anatomical changes, such as those described in inter vertebral discs, may be no more than
incidental findings. As pointed out by Nachemson only 20% of patients with back pair have an anatomically
pathologic process as a possible cause of their pair.
"The evolutionary paradigm is necessary for the scientific study of macro and meta complexity, whereas the
Newtonian paradigm is only suitable for the limiting case of microcomplexity". William H. Weekes.
"Continued emphasis an generalities that cannot be transformed into meaningful specifics, as well as the
emphasis an specifics that cannot be transformed onto meaningful generalities, cannot be tolerated. " Hans
Christian van Baeyer.
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Biologic constructs are evolutionary, hierarchical structures, mechanically stable at each instant of development.
Each molecule, Organelle, cell, Organ and organism is structurally Sound, independent and also interdependent.
Tensegrity is an evolutionary System of micro to macro to meta structural development based an known and
accepted laws of physics as it applies to biology. If Standard post and beam Newtonian constructs were used to
model biologic structures then biologic tissues would exceed their known capacities. Using known
measurements and mathematical calculations based an Newtonian mechanics the human spine would buckle
with less than the weight of the head an top of it'6 and the vertebral bodies would crush under the leverage of a
fly rod held in the hand. Urinary bladders and pregnant uteri would burst when fall and, with each heartbeat,
arteries would lengthen enough to crowd the brain out of the skull. Animals larger than a lion would continually
break their bones and dinosaurs larger than an elephant would have crushed carrying their own weight.'° Since
biologic structures and organisms perform these tasks with apparent ease it seems logical to look at other models
to see if there is a better fit between what is calculated and what is observed. The `tensegrity' model of
continuous tension, discontinuous compression, first conceived by Snelson," and named and adapted by Fuller'
is a non Newtonian mechanical system that is to be gaining wider acceptance as the bases of the architecture of
Figure 1.
(a) Compressing a ring.
(b) A wagon wheel loads by compressing each rung in turn.
(c) A bicycle wheel loads by continuous tension of all the spokes at the same time.
The difference between Newtonian and Hookian post and beam mechanics and the mechanics of tensegrity is
the difference between the mechanics of a wagon wheel and a bicycle wheel. In a wagon wheel the load is
transferred through the structure by loading of directly connected compression elements. The weight of the
wagon presses an the axle which presses an the wheel hub which compresses the underlying spoke which, in
turn, compresses the rim of the wheel (fig. 1 b). In bicycle wheel mechanics the weight of the frame transfers to
the hub of the wheel which is hung in a tension network of wire spokes (fig. lc). There is continuous tension of
the spokes, which are pre stressed, but the compression elementsare discontinuous and do not compress one
another. The hub remains suspended in its tension network. Compression loads are distributed around the rim.
The compression elements behave in a counterintuitive way, not loading one another as in Newtonian construct
but loaded by the tension elements. The rim of the wheel is compressed by the distributed tension of the spokes.
The hub hangs from the spokes, which are always under tension, and the spoke under the hub is never
compressed. Compress structures unload into the tension network. Rather then the primary support elements of
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the system as they would be in a pillar of skyscraper Model the compression elements become secondary to the
tension support network. Fuller' calls these structures "tensegrity" structures as a contraction of "tension
intergrity". Other familiar tensegrity structures are the tennis racket that transmits the compression force of the
racket frame to the ball through the strings, snowshoes and the Buckminster Fuller geodesic domes. Tensegrity
structures transmit loads through tension and compression only. They are fully triangulated and, therefore, there
are no bending moments in these structures and no shear. If the front and rear hubs are linked to each other by
the frame we develop a hierarchical system where the load an the bicycle is suspended in a tension network. The
frame of a bicycle is suspended from the ground by the network of wire spokes of the two wheels. This works
even if we do "wheelees" (rear up an one wheel) and transfer the entire load to one wheel. Tensegrity can be
used to model biologic structures from viruses to vertebrates and their systems and subsystems.
We now generally accept that the sacrum hangs from the ilea by its ligaments. A ligamentous tension system for
support and stability is consistent with the known anatomy. If we use a cycle wheel-tensegrity structure as our
model for the pelvis ring would be the rim and the sacrum would be the "hub" of the pelvis' (fig. 2). The mang
tension elements of ligaments and muscles attached to the sacrum stabilize it. The sacrum is suspended as a
compression element within the musculo-ligamentous envelope and transfers its loads through that tension
network. Even standing an one leg the sacrum would sit within its tension network, just as does the bicycle hub
when doing "wheelees". By changing the tension of the muscles or ligaments through their attached muscles as
the hamstrings the sacrum could piston or rotate but remain as part of the tensegrity network. This would
provide omnidirectional structural stability, independent of gravity, hierarchical, load distributing and allow
mobility as well as stability. The rim could distribute its load, rather than local loading. In a compressive loading
system with each step the heads of the femurs would smash into the soft concellous bone of the acetabulum. In a
tensegrity system the forces generated at the hip would not concentrate in the acetabulum but be efficiently
distributed throughout the pelvic bones and soft tissue. The sacrum would remain suspended in its soft tissue
envelope and transmit the loads above and the forced below through the pelvic ligaments and muscles.
In the tensegrity-pelvic wheel model the coccyx and lower sacrum takes an new importance. The coccyx no
longer can be considered a vestigial Organ but rather the hub of a dynamical structure. The coccyx and pelvic
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floor in which it floats, are important in upright stance, mechanical stability when Lifting, respiration,
ambulation, micturition, defecation, sexual function and parturition. The piriformis, obturator internus and
hamstrings muscles are part of the pelvic floor dynamics and important in upright stance, ambulating and lifting.
You cannot lift any significant weight without setting your pelvic diaphragm. The coccyx moves with each
breath and is integrated into all the pelvic visceral functions.
Gleuteus Maximus
Gleutus Minimus
Qudratus Lumborum
Tensor Fascia Latae
Pelvic Floor Myalgia
Levator Ani
Table 1.
Myofascial Pelvic Pain Syndromes
The various myofascial low back and pelvic pain syndromes are well described in the orthopedic, osteopathic,
physical medicine, proctologic and gynecologic (Table 1). Several articles have recognized the interrelationship
of these syndromes and the need for a multidisciplinary approach to diagnose and treat these syndromes. The
interrelationship of these conditions and treatment model is best understood when tensegrity is used as the
anatomic and dynamic model when evaluating and treating the many seemingly unrelated dynamic pelvic pain
syndromes. It seems clear that these are all different aspects of the Same 'dynamical disease' and they should be
evaluated and treated as the Same entity. There are many diagnostic tests described of pelvic floor related
problems, lumped together as myalgias of the pelvic floor but also including coccyx, sacroiliac, symphysis pubis
and even hip mechanics but the sine quo non is the diagnostic rectal and/or vaginal pelvic examinationi. There is
a very definable and discrete tender point, usually at the medial end of the sacrospinousligament as it attaches to
coccyx and lower sacrum that defines the patients pain. Pace and Nagle," looking for this tender point, state "an
examination for low back pain is incomplete unless a rectal or vaginal examination is performed" (italics Pace
and Nagle's). Wyant echoes these Sentiments and it is repeated in most of the other literature an this subject. It is
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my experience that when patients having the various pelvic pain syndromes are examined for this tender point
many of these seemingly separate conditions are linked through the pelvic wheel. Unfortunately this requisite
examination "is more honored in its breach than in its performance."
Once the condition is defined the treatment seems rather straightforward and simple. Theile described an intra
pelvic stretch technique, very similar to trigger point techniques described by Travell and Simons to treat this
condition and subsequent authors have confirmed a sixty to eighty percent success rate with these techniques
(with the usual modifications by various authors) since its first description in 1936. My experience has been the
same. These intra pelvic stretching techniques can be performed rectally or, in females, vaginally. The choice of
access depends an the particular structure being treated and therapists and patient choice. Wyant points out that
vaginal access is often easier and Travell and Simon" indicate that both vaginal and rectal access might be
necessary. Most. authors add stretching and strengthening exercise programs for the piriformis, pelvic floor and
associated hip and back muscles. These would make Sense, using the tensegrity model. In a bicycle wheel you
cannot adjust one spoke without having to adjust the others. In keeping with the concept ofdynamical diseases,
the improvement may often be sudden and dramatic. This is particularly true if it is a sudden, recent condition
causing the problem. As time goes an secondary mal adaptations usually occur and need to be treated as well.
That would be adjusting the other spokes an the tensegrity wheel. Theile used a series of treatments daily over
seven to ten days. Other authors have various modifications of the technique. At my facility the usual course of
treatment is three to six treatments over a two-month period with the last few treatments mostly fine-tuning.
There are flaw physical therapists an both sides of the Atlantic trained in these specific intra pelvic techniques
and appropriate exercises.
Additionally, injections into the various structures may be necessary for recalcitrant lesions or to facilitate the
stretching techniques. Injections into the posterior sacroiliac, iliolumbar, sacrospinous and sacrotulerous
ligaments, piriformis muscle and coccyx, either singly or in multiples, all have their proponents. I try to be
selective and treat only those structures that have specific tender points. Injections can be local anesthetics,
various steroids, prolotherapy compounds and other injectables depending an the experience of the practitioner.
When looking at musculoskeletal pelvic pain syndromes through newer and now accepted biomechanical and
clinical models we can reinterpret what is already known and observed clinically. We can make some scientific
sense of what appeared to be a confusing picture of disparate clinical entities. Much of the low back and pelvic
pain syndromes appear to be more a function of tissue and structure dynamics rather than anatomic pathologic
processes. MRls, x-ray studies, joint contrast injections and the like, are but single frames of a moving picture
and tell us little about the dynamics and functional rhythms of the musculoskeletal system. They must be
interpreted with caution. Clinical examination using time tested techniques still is the most valuable and
accurate method of assessing the dynamics of the musculoskeletal system and the clinician should not be
seduced by technology until it provides us with the musculoskeletal equivalent of an echo cardiogram. The
tender or trigger points studied by many clinicians over the years cannot be discounted as a valuable tool and
must be related to dynamical diseases of the musculoskeletal system. When evaluating a patient with pelvic pain
the examination is incomplete without an orthopedic pelvic and/or rectal examination to look for those tender
points. These tender points disappear when treatment is adequate and therefore are the hallmark of successful
treatment of these conditions. Any clinical study of painful pelvic lesions must include evaluation of these
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tender points in order to be of value.
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ResearchGate has not been able to resolve any citations for this publication.
The piriformis is a deep-seated muscle, most of its muscular portion being part of the dorsal wall of the pelvis. The lateral portion and its insertion is extra-pelvic and lies deep to the glutei. Like more superficially located and therefore more easily accessible skeletal muscles, the piriformis too can be the seat of trigger points, giving rise to symptoms indistinguishable from those of other causes of low backache, unless a deliberate search is made for the signs specific to the piriformis syndrome. Having made a presumptive diagnosis, confirmation is gained by palpating the muscle itself via rectum or vagina and reproducing the pain by digital pressure. If this test also is positive, the muscle is injected, the approach being either through the sciatic notch, from the perineum, or through the vagina. Immediate relief of pain is experienced after the solution of local anaesthetic and steroid has been deposited deep within the fleshy portion of the muscle.
The clinical picture in and efficacy of physical treatment for pelvic floor myalgia were reviewed. The medical records of patients having a diagnosis of pyriformis syndrome, coccygodynia, levator ani spasm syndrome, proctalgia fugax, or rectal pain who had been seen at the Mayo Clinic and treated in the Department of Physical Medicine and Rehabilitation from 1970 through 1975 were retrieved. Adequate information and follow-up were available for 94 patients. Seventy-eight patients were women and 16 were men, whose ages ranged from 26 to 72 years. All patients had tenderness of the pelvic floor muscles on rectal examination. The most common associated findings were poor posture, deconditioned abdominal muscles, and generalized muscle attachment tenderness. The most effective therapeutic regimen was a combination of rectal diathermy, Thiele's massage, and relaxation exercises. Of the 94 patients, 30 had complete resolution of their symptoms, 19 had marked improvement, 17 had moderate improvement, and 14 had mild improvement. Only 14 patients had no change and 1 patient was worse after treatment.
Recent investigations have documented the importance of ruling out occult nongynecologic diagnoses such as myofascial syndrome, IBS, urethral syndrome, and psychogenic disorders in women with CPP and normal laparoscopy. In light of current data regarding the prevalence of nonsomatic and nongynecologic somatic pathology among patients with pelvalgia, it seems clear that "definitive" surgical therapy consisting of total abdominal hysterectomy and bilateral salpingo-oophorectomy is neither definitive nor indicated in the large majority of these cases.
A retrospective review of 1293 cases of low back pain treated over a 12-year period revealed that sacroiliac joint syndrome and posterior joint syndromes were the most common referred-pain syndromes, whereas herniated nucleus pulposus and lateral spinal stenosis were the most common nerve root compression lesions. Referred pain syndromes occur nearly twice as often and frequently mimic the clinical presentation of nerve root compression syndromes. Combined lesions occurred in 33.5% of cases. Lateral spinal stenosis and herniated nucleus pulposus coexisted in 17.7%. In 30% of the cases of spondylolisthesis, the radiographic findings were incidental and the source of pain was the sacroiliac joint. Distinguishing radicular from referred pain, recognition of coexisting lesions, and correlation of diagnostic imaging with the overall clinical presentation facilities formulation of a rational plan of therapy. The above-outlined approach to managing low back pain evolved over a 12-year period. Designed to establish a specific diagnosis, it should yield excellent or good results in 84% of patients.
Mechanical stresses were applied directly to cell surface receptors with a magnetic twisting device. The extracellular matrix receptor, integrin beta 1, induced focal adhesion formation and supported a force-dependent stiffening response, whereas nonadhesion receptors did not. The cytoskeletal stiffness (ratio of stress to strain) increased in direct proportion to the applied stress and required intact microtubules and intermediate filaments as well as microfilaments. Tensegrity models that incorporate mechanically interdependent struts and strings that reorient globally in response to a localized stress mimicked this response. These results suggest that integrins act as mechanoreceptors and transmit mechanical signals to the cytoskeleton. Mechanotransduction, in turn, may be mediated simultaneously at multiple locations inside the cell through force-induced rearrangements within a tensionally integrated cytoskeleton.
Musculoskeletal dysfunctions often contribute to the signs and symptoms of chronic pelvic pain and in many cases may be the primary cause. The traditional team approach to chronic pelvic pain has not, however, routinely included a practitioner skilled in musculoskeletal examination and treatment. Characteristics of musculoskeletal pain are reviewed as are specific dysfunctions commonly found to produce lower abdominal and pelvic floor pain. A screening examination is presented to assist the gynecologic physician in identifying patients who may benefit from physical therapy.