William Salvatore, D.C.

The “Tissue – Tensegrity” Matrix And Chronic Low Back Pain

Chiropractors primarily look at patient’s problems from a mechanical perspective. A classic chiropractic mechanical analogy is a pinched nerve (compressive neuropathology). Although chiropractors occasionally do treat compressive neuropathology, most chiropractors are aware that there are patients with compressive neuropathology that require a surgical decompression. Overall, compressive neuropathology is a rare clinical syndrome in chiropractic clinical practice. Most of the mechanical approach of chiropractic is not to “unpinch a pinched nerve.” Rather, the primary mechanical approach of chiropractic patient management is the improvement of the Tensegrity Matrix.

The human body is composed of four tissue types: epithelium, muscle, connective, and nerve. Everything in the body is made from these four basic tissues.

The connective tissue is found throughout the body. The great Canadian histologist, Arthur Ham (d.1992 at age 90), states (1):

“Connective tissue was given its name because it connects, and thus holds, the other tissues together.”

Connective tissue includes tissues that produce blood cells (hemopoietic tissue), the blood cells themselves, and the strong supporting types of connective tissue. The strong supporting types of connective tissues include, bone, cartilage, ligaments, tendons, fascia, etc.

The strong supporting types of connective tissues have two components:

• The living cells (like osteocytes, chondrocytes, fibroblasts, etc.).
• A non-living intercellular substance; this non-living intercellular substance is produced by the living cells.

The chief role of these living cells is to produce and maintain the intercellular substances.

Collagen is a protein. It is the primary protein produced as intercellular substance by the living cells of the strong supporting types of connective tissues. Collagen is the most abundant protein in our bodies. Most of the collagen in our bodies is produced by the fibroblasts.

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Rene Cailliet, MD, has had an accomplished life. Born in 1917 and still living at age 95, he helped pioneer the specialty of Physical Medicine and Rehabilitation during World War II. Dr. Cailliet served as a chairman of the Department of Physical Medicine and Rehabilitation at the University of Southern California. He is currently an emeritus professor of Physical Medicine and Rehabilitation at the medical school at the University of California, Los Angeles (UCLA). Dr. Cailliet has authored more than a dozen medical texts, and he has 49 articles in a PubMed database search of the National Library of Medicine (March 2012). Interestingly, his most recent PubMed indexed article was published in 2008, and is co-authored by chiropractors Deed and Don (d. 2011) Harrison (2).

In his 1987 book The Rejuvenation Strategies, Dr. Cailliet notes that, under a microscope, collagen produces a whole body lattice of fibers that appear as a grid (3):

Dr. Cailliet notes that ideally, at the contact points between these fibers they remain independent and glide on one another when moving. However, as a consequence of inflammation, trauma, or even inactivity, the points of intersection become fibrotic and “stick together,” resulting in “loss of flexibility.”

••••

In his 2000 book Energy Medicine, The Scientific Basis (4), James Oschman, PhD, notes that the cytoskeletons of all of the cells in the body are physically and mechanically linked to a collagenous connective tissue extracellular matrix. Proteins called “integrins” do this trans-cellular linking. The molecules that link the cell interior with the extracellular collagenous matrix are these integrins. Likewise, there is a physical mechanical link between the cellular cytoplasmic matrix and the nuclear envelope, nuclear matrix, and the DNA of the genes/chromosomes. This physical continuum, beginning with the skin and extending to the genetic material, can be affected physically as a consequence of postural distortions, injury, physical stress and scar tissue, resulting in alterations in expression of our genetic material. Dr. Oschman notes that this entire interconnected system is called the:

“connective tissue – cytoskeleton” matrix
or
the “tissue – tensegrity” matrix.

Our bodies behave as a tensegrity system. A tensegrity system is characterized by a series of continuous tensional networks. This means that the entire body is physically interconnected. A stress on one part of the system will spread to other parts of the system. This includes to the genome and its genetic expression. One can change the genomic expression of DNA by alterations of physical stress. All the components of our bodies, from the skin to the genome are physically and mechanically interlinked by a connective tissue collagenous matrix and integrins. Again, this is often referred to as the “tensegrity matrix.”

Dr. Oschman explains how progressive changes in the function of the tensegrity matrix takes place because of the ways in which individuals use their bodies in relation to gravity, because of habits or injuries. These soft tissue changes provide a basis for the mechanically based restorative measures by chiropractors and others.

Dr. Oschman argues that the tensegrity matrix best serves physiology when it is flexible and balanced. This serves to reduce injury and enhance healing. He states:

“Tensegrity accounts for the ability of the body to absorb impacts without being damaged. Mechanical energy flows away from a site of impact through the tensegrous living matrix. The more flexible and balanced the network (the better the tensional network), the more readily it absorbs shocks and converts them to information rather than damage.”

“Tensegrity accounts for the fact that inflexibility or shortening in one tissue influences structure and movement in other parts.”

Dr. Oschman explains that the most significant influence on the tensegrity matrix is our alignment in the gravity field. He notes that gravity is the most potent physical influence in any human life. Simple mechanical calculations reveal that gravity gives rise to surprisingly large forces within the body as a consequence of levers that amplify the forces exerted on joints and other tissues.

The gravity system connects, via integrins, to the cytoskeleton of cells throughout the body. Therefore, an imbalance in one part of the body will affect the whole body.

Dr. Oschman states:

“Gravity pervades our bodies and our environment and affects our every activity. All of the structures around us - our homes, furniture, buildings, machinery, plant, and animal, - and our own bodies, are designed to function in a world dominated by gravity. The form of each bone, muscle, and sinew tells a story of its particular role in maintaining and moving the body in the gravitational field. Many of the injuries faced in the therapeutic setting are consequences of falling down, or of habitual movement patterns that strain tissues. Hence therapists of virtually every tradition can benefit from an appreciation of the ways in which gravity interacts with structures, energy flows, and emotions, and the clinical approaches that remedy ‘gravitational traumas.’”

“To introduce the therapeutic significance of gravity, we summarize the work of Joel E. Goldthwait and his colleagues at Harvard Medical School.”

“A surgeon in Boston and founder of the orthopaedic clinic at the General Hospital, Goldthwait developed a successful therapeutic approach to chronic disorders. The aim of his therapies was to get his patients to sit, stand, and move with their bodies in a more appropriate relationship with the vertical. After years of treating patients with chronic problems, he concluded that many of these problems arise because parts of the body become misaligned with respect to the vertical, and organ functions therefore become compromised.”

“Goldthwait's therapeutic approach was based in part on observations made while performing surgery on such patients. He noticed that abdominal nerves and blood vessels are under tension in individuals whose bodies are out of alignment. He also reported 'stretching and kinking' of the cerebral arteries and veins in those whose necks were bent. Various cardiac problems were correlated with 'faulty body mechanics' that distorted the chest cavity in a way that impaired circulatory efficiency. Goldthwait also documented with X-rays a build-up of calcium deposits around the vertebrae of individuals with chronic arthritis, and observed that these deposits can diminish when the individual acquires a more vertical stance. His therapeutic approach corrected many difficult problems without the use of drugs. He viewed the human body from a mechanical engineering perspective, in which alignment of parts is essential to reduce wear and stress. He pleaded with physicians to recognize and correct misalignments to prevent long-term harmful effects.”

Dr. Goldthwait pleaded for everyone to pay more attention to the way in which they hold and move their bodies in relation to the gravity field. He noted that misalignment of any part will affect the whole system, and that restoration of verticality is a way to address a wide variety of clinical problems. Optimal performance in a gravity field occurs only at a narrow peak of balance, and the slightest deviation reduces optimum efficiency. Altered posture in our gravity environment affects the tensegrity matrix continuum. This in turn influences physiology, pain perception, and health.

••••

Another champion of the concepts of the importance of mechanical influence on the physiology of the living matrix is Harvard’s Donald Ingber, MD, PhD. Dr. Ingber is from the Vascular Biology Program, Departments of Surgery and Pathology, Children's Hospital and Harvard Medical School. A check of the National Library of Medicine using the PubMed search engine finds 211 articles that have included Dr. Ingber as author (March 2012).

A relevant article by Dr. Ingber was published in the Annals of Medicine in 2003, and titled (5):

Mechanobiology and Diseases of Mechanotransduction

In this article, Dr. Ingber expresses his concern that contemporary medical practice focuses primarily on molecular genetics while largely ignoring the physical basis of disease. He notes that many of the problems that lead to pain and morbidity, and bring patients to the doctor's office, result from changes in tissue structure or mechanics. He stresses that mechanics should be integrated into understanding the molecular basis of disease.

In agreement with Dr. Oschman above, Dr. Ingber describes the key roles that physical forces, extracellular matrix and cell structure play in the control of normal development, as well as in the maintenance of tissue form and function.

Dr. Ingber defines cellular mechanotransduction as the molecular mechanism by which cells sense and respond to mechanical stress. He notes that a wide range of diseases included within virtually all fields of medicine and surgery share a common feature: “their etiology or clinical presentation results from abnormal mechanotransduction.”

A central theme in Dr. Ingber’s discussion is that there are “mechanisms by which cells sense mechanical signals and convert them into a chemical or electrical response.” The molecules that mediate mechanotransduction are the extracellular matrix molecules, trans-membrane integrin receptors. The function of these molecules is modifiable with appropriate mechanical therapeutic intervention. This is relevant and important in chiropractic clinical practice.

Dr. Ingber makes these important points:

• “Mechanical forces are critical regulators of cellular biochemistry.”
• “There is a huge disconnect between ‘genome-age’ technologies and the reality of how diseases manifest themselves. From the time the first human looked, listened and felt for what is wrong with a sick friend, caregivers have recognized the undeniable physical basis of disease.”
• “In the current genome euphoria, there appears to be no place for ‘physicality’. This is especially worrisome given that abnormal cell and tissue responses to mechanical stress contribute to the etiology and clinical presentation of many important diseases, including asthma, osteoporosis, atherosclerosis, diabetes, stroke and heart failure.”
• There is a “strong mechanical basis for many generalized medical disabilities, such as lower back pain and irritable bowel syndrome, which are responsible for a major share of healthcare costs world-wide.”
• “In biology and medicine, we tend to focus on the importance of genes and chemical factors for control of tissue physiology and the development of disease, whereas we commonly ignore physical factors. This is interesting because it was common knowledge at the turn of the last century that mechanical forces are critical regulators in biology.”
• “These new insights into mechanobiology suggest that many ostensibly unrelated diseases may share a common dependence on abnormal mechanotransduction for their development or clinical presentation.”
• “Understanding of the relation between structure and function in living tissues and of fundamental mechanisms of cellular mechanotransduction may therefore lead to entirely new modes of therapeutic intervention.”
• “The therapeutic value of physical therapy, massage, and muscle stimulation is also well known.”

Dr. Ingber restates that tissues are composed of groups of living cells held together by an extracellular matrix which is primarily composed of a network of collagens. A summary of his article states:

“The current focus in medicine is on the genetic basis of disease. However, it is not necessary to correct the underlying genetic defect in order to treat clinically relevant symptoms or relieve the pain and morbidity of disease. Moreover, most of the clinical problems that bring a patient to the doctor's office result from changes in tissue structure and mechanics. Although these physical alterations have been commonly viewed as the end-result of the disease process, recent advances in mechanobiology suggest that abnormal cell and tissue responses to mechanical stress may actively contribute to the development of many diseases and ailments. Thus, it might be wise to search for a physical cause when chemical or molecular forms of investigation do not suffice.”

••••

Helene M. Langevin, MD, is a neurologist from the Department of Neurology, University of Vermont College of Medicine. In 2006 she published an article in the journal Medical Hypothesis, titled (6):

Connective tissue: A body-wide signaling network?

In this article, Dr. Langevin notes that connective tissue forms an anatomical network throughout the body that functions as a body-wide mechanosensitive signaling network. This connective tissue signaling network is affected by changes in movement and posture, and may be altered in pathological conditions (e.g. local decreased mobility due to injury or pain). Connective tissue thus functions as a whole body communication system. Since connective tissue is intimately associated with all other tissues (e.g. lung, intestine), connective tissue signaling may coherently influence (and be influenced by) the normal or pathological function of a wide variety of organ systems.

Dr. Langevin notes that the musculoskeletal system does not physiologically function in isolation from the rest of the body, and that the musculoskeletal tissues (bones, muscles, cartilage, tendons) are strongly associated with posture and movement. Dr. Langevin makes these important points:

• “Connective tissue not only forms a continuous network surrounding and infiltrating all muscles, but also permeates all other tissues and organs.”
• “Since connective tissue plays an intimate role in the function of all other tissues, a complex connective tissue network system integrating whole body mechanical forces may coherently influence the function of all other physiological systems.”
• Local connective tissue fibrosis following an injury may affect both electrical conductivity as well as fibroblast-to-fibroblast communication. Therefore, local pathology can affect whole-body connective tissue signaling.
• “Understanding the temporal and spatial dynamics of connective tissue bioelectrical, cellular and tissue plasticity responses, as well as their interactions with other tissues, may be key to understanding how pathological changes in one part of the body may cause a cascade of “remote” effects in seemingly unrelated areas and organ systems.”

Importantly, Dr. Langevin describes how the connective tissue matrix will adversely remodel when subjected to chronic stresses, postural distortions, injury, etc. Similarly, therapeutic improvements in posture, motion and fibrosis will improve the structure of the connective tissue matrix, improving whole body physiology. This therapeutic remodeling can take place over a period of days, weeks or months.

••••

Dr. Langevin added to her 2006 article in Medical Hypothesis the following year, 2007, with an article titled (7):

Pathophysiological Model for Chronic Low Back Pain
Integrating Connective Tissue and Nervous System Mechanisms

In this article, Dr. Langevin and colleague propose an etiology for chronic low back pain, and a plausible biological clinical approach that should improve clinical outcomes. Their model stems from Dr. Langevin’s prior work (2006) which indicated that adverse connective tissue remodeling leads to inflammation, nervous system sensitization and further decreased mobility. The decrease in movement leads to an increase in chronic low back pain. Specifically, she states:

“The integration of connective tissue and nervous system plasticity into the model of chronic LBP will potentially illuminate the mechanisms of a variety of treatments that may reverse these abnormalities by applying mechanical forces to soft tissues (e.g. physical therapy, massage, chiropractic manipulation, acupuncture), by changing specific movement patterns (e.g. movement therapies, yoga) or more generally by increasing activity levels (e.g. recreational exercise).”

Chronic low back pain may be caused by pathological connective tissue fibrosis, which causes adverse changes in movement. This is well documented in ligaments and joint capsules. This pathological connective tissue fibrosis is plastic and can therefore be remodeled. However, the remodeling must take place over time. Non-invasive measures of connective tissue remodeling may eventually become important tools to evaluate and follow patients with chronic LBP in clinical practice.

In this study, Dr. Langevin notes that adverse connective tissue remodeling cannot be imaged with X-ray, CT, MRI. She claims that this is why the association between such imaging and patient symptoms “has been consistently weak, and up to 85% of patients with low back pain cannot be given a precise pathoanatomical diagnosis using these methods.”

One of the proven strategies to successfully improve the clinical outcomes in those with chronic low back pain is to avoid rest and to resume physical activity as soon as possible. Dr. Langevin notes that this approach would facilitate the remodeling of the connective tissue matrix. Specifically, Dr. Langevin makes these comments:

“We hypothesize that connective tissue remodeling occurs in chronic LBP as a result of emotional, behavioral and motor dysfunction.”

“We further hypothesize that increased connective tissue stiffness due to fibrosis is an important link in the pathogenic mechanism leading to chronicity of pain, fear-avoidance and further movement impairment.”

“Abnormal movement patterns can have important influences on the connective tissues that surround and infiltrate muscles.”

“A hallmark of connective tissue is its plasticity or ‘remodeling’ in response to varying levels of mechanical stress.”

“Both increased stress due to overuse, repetitive movement and/or hypermobility, and decreased stress due to immobilization or hypomobility can cause changes in connective tissue.”

“A consistent absence of stress, on the other hand, leads to connective tissue atrophy, architectural disorganization, fibrosis, adhesions and contractures.”

“Fibrosis can be the direct result of hypomobility or the indirect result of hypermobility via injury and inflammation.”

“Connective tissue fibrosis is detrimental, as it leads to increased tissue stiffness and further movement impairment.”

Therapeutically, Dr. Langevin makes a number of suggestions that are consistent with chiropractic clinical practice, including:

“In addition to its role in the pathological consequences of immobility and injury, the dynamic and potentially reversible nature of connective tissue plasticity may be key to the beneficial effects of widely used physical therapy techniques as well as ‘alternative’ treatments involving external application of mechanical forces (e.g. massage, chiropractic manipulation, acupuncture), changes in specific movement patterns (e.g. movement therapies, tai chi, yoga) or more general changes in activity levels (e.g. increased recreational exercise).”

“Manual or movement-based treatments have the advantage of not causing drug-induced side effects (e.g. gastritis, sedation).”

A “carefully applied direct tissue stretch may be necessary in cases of long standing hypomobility with pronounced fibrosis and stiffness.”

“The model presented in this paper predicts that beneficial connective tissue remodeling can result from a variety of therapeutic interventions.”

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Summary

Dr. Arthur Ham notes that collagenous connective tissue is found throughout the body.

Dr. Rene Cailliet notes that the collagenous connective tissue matrix is arranged in a grid-like pattern. When functioning normally, the fibers of the grid slide over each other during stress and motion. However, when chronically stressed, inflamed or traumatized the collagenous matrix becomes fibrotic, which impairs motion.

Dr. James Oschman refers to the collagenous connective tissue matrix as the tensegrity matrix. He notes that the matrix confers optimum physiology when it is flexible and balanced. He notes that the matrix becomes pathological as a consequence of alterations of the manner in which we live, exist and function in a gravity environment. He further notes that our physiology and function is improved when we improve our alignment with respects to gravity.

Dr. Donald Ingber, like Dr. James Oschman, refers to the collagenous connective tissue matrix as the tensegrity matrix. Dr. Ingber notes that abnormal mechanical stresses in the matrix are linked to a wide range of diseases included within virtually all fields of healthcare. He notes that there are mechanisms by which cells sense mechanical signals and convert them into a chemical or electrical response that influence function and health. He stresses that there is a physical basis for many diseases and symptoms, and that applied mechanics should not be forgotten by mainstream medical practice.

Dr. Helene Langevin notes that the collagenous soft tissue matrix functions as a body-wide mechanosensitive signaling network. This body-wide mechanosensitive signaling network is capable of influencing the normal or pathological function of a wide variety of musculoskeletal organ systems. She notes that many things can adversely influence the integrity of the matrix, including postural stresses, emotional stresses, inflammation, trauma, etc. Long-standing mechanical problems cause a remodeling of the matrix which in turn further adversely influences function and physiology. Dr. Langevin notes that applied mechanical forces can reverse and remodel the matrix, improving function, physiology, and associated symptoms. The mechanical approaches she advocates for this purpose include physical therapy, massage, chiropractic manipulation, acupuncture, movement therapies, yoga, and exercise. Each of these are commonly used in today’s chiropractic clinical practice.

Chiropractic is not primarily the “unpinching” of a nerve. Rather it involves a series of techniques, exercises, tissue work, ergonomics, etc. that are designed to improve the way in which our patients live, exist, and function in a gravity environment. This in turn remodels adverse changes in the collagenous connective matrix, improving many aspects of function, physiology, and pain. Because this remodeling occurs over a period of time, it is not uncommon for the chiropractor to recommend a program of treatment that extends for a period of weeks to months.

References:

• Ham AW; Histology; seventh edition; Lippincott; 1974.
• Harrison DE, Janik TJ, Cailliet R, Harrison DD, Normand MC, Perron DL, Oalkey PA; Upright static pelvic posture as rotations and translations in 3-dimensional from three 2-dimensional digital images: validation of a computerized analysis. Journal of Manipulative and Physiological Therapeutics; February 2008; 31(2):137-45.
• Cailliet R, Gross L, The Rejuvenation Strategy, Pocket Books, 1987.
• Oschman J; Energy Medicine, The Scientific Basis, Churchill Livingstone, 2000.
• Ingber DE; Mechanobiology and Diseases of Mechanotransduction; Annals of Medicine; 2003;35(8), pp.564-77.
• Langevin HM; Connective tissue: A body-wide signaling network?; Medical Hypotheses; Volume 66, Issue 6, June 2006, pp. 1074-1077.
• Langevin HM, Sherman KJ; Pathophysiological Model for Chronic Low Back Pain: Integrating Connective Tissue and Nervous System Mechanisms; Medical Hypotheses; Volume 68, Issue 1, January 2007, pp. 74-80.