“Pain Science”:A bias against Structural Integration

In this post I’m going to address what has been coined “pain science” and their particular beef with Structural Integration.  In the pain “science” circles, SI is commonly referred to as an “archaic narrative”.  I disagree.

Paul Ingraham is one of the leaders of the pain science movement and has a webpage at this address:
www.painscience.com

Paul Ingraham writing on Structural Integration:

“Biomechanical Bogeymen”
A great many of the massage modality empires are based on a basic guiding principle or school of thought I call “structuralism” — an excessive preoccupation with biomechanical and postural factors in pain problems, AKA the biomechanical bogeymen. Structuralist techniques are all fixated to some degree on straightening or improving your meat, because they believe that you are crooked or unbalanced in some way. This notion is easy to sell, but the entire school of thought has little merit. It is debatable at best — and debunked nonsense at worst. This is another topic I have covered in (great) detail in another article: Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain.

While I do find some merit in his complaints and critique with the structural approach, the bulk of his “evidence” against Structural Integration and what he calls “structuralism” is that MRI’s, CT scans and other imaging that show structural distortions do not necessarily correlate with pain.  MRI’s and other imaging routinely show structural distortions in people that are not painful to them.

Structural Integration, of course, is mostly preoccupied with a relationship between structure and function, … not pain.
In the domain of structure and function, there is a relationship between structural distortion that results in nerve compression and the loss of function.  This relationship is historically and medically demonstrable.  I go into great detail on my webpage:
http://www.therapeuticstructuralbodywork.com/theoretics.html

For an example of structural distortion and nerve compression at extreme, we can look at paralysis, an extreme form of spinal compression and distortion, which results in a complete loss of function. Amputation is also an extreme structural distortion which results in complete loss of function. Dislocations and bone breakage as well. All structural distortions have functional consequences.

Structural distortions which result in lesser degrees of nerve compression not surprisingly result in lesser degrees in loss of function. Here we are mostly talking about between bone compression. Sciatica, thoracic outlet, stenosis, and disc herniations resulting in the loss of nerve space are all medically proven and historically demonstrate a clear correlation in loss of function to innervated tissue due to neural compression.

Pain of course proves to be a bit more elusive, and a correlation between pain and structural distortion is admittedly not all that clear.  An explanatory reconciliation however may be arrived at.

PAIN and Structural Distortion:

Very few of us in SI have not encountered the client with acute nerve compression who’s back is “out”, i.e.: extreme spasms accompanied by extreme pain and limited mobility.  Many of us have experienced this type of pain ourselves, and for some of us, our own issues with neural compression and pain have driven us into this field.  For myself, I grew up with a scoliotic pattern, and my body started locking up on me when I was 13.  I have experienced neural pain for much of my life as well as loss of function, mobility, and profound shortness of breath diagnosed as adult asthma.  Dismissing connections between structural distortion and pain, for me seems ridiculous, but I can forgive their lack of perspective, and appreciate how structural distortion has shaped my own.

Again, the crux of the pain “science” argument against a correlation between structural distortion and pain is the existence of MRI’s and other imaging that shows routine structural distortions in people that do not register as pain.  Forgetting for a moment that a great many of the MRI’s and other imaging showing structural distortions most definitely DO register as pain, for which many millions of people seek surgical as well as alternative remedies, I will address in detail why some structural distortions DO NOT register as pain. The discussion, and critique of pain science, will be organized according to Paul’s own explanation of pain.

Paul writes:

Yes, but why does it hurt?Pain “demands an explanation,” wrote poet Ann Carson, but pain is weird. If you have chronic pain, it can be a huge help to understand things like the types of pain, or how insomnia makes pain so much worse, or the role of chronic low-grade inflammation. On the other hand, there’s a lot you don’t need to worry about, like your back being out of alignment and bad posture — both highly over-rated causes of pain. There are many more why it hurts topics.
…

I will now offer my own critique of the critiquers:

1.  “Pain is weird”.  Ok. Here Paul goes back to Freudian psychology to suggest that pain is IN the brain, that pain is a brain “thing”.  (To sum up Freud: unless your arm is hanging off, the pain is probably in your head.)  Despite accusations towards SI of “archaic narratives”, Paul, like Freud before him, basically cuts the head off of the whole of the nervous system and finds that pain is “generated” in the brain, thus may be “ungenerated” there as well...and a possible solution to pain is to “think it away” or “change your confidence”.  I personally do not find this compelling, starting with the partitioning of the nervous system.  Regardless, try thinking away cancer.  Not happening.  Think away a tumor?  Nope.  Nor can you think away a disc herniation or spondylolisthesis at L4 (See image below).  The Freudian approach is great for selling drugs, self-help books and snake oil, but that’s about it.  It is a profitable approach, not a comprehensive one.  

Paul also identifies a causal link between stress, “generated” in the brain, inflammation, and pain:

“Inflammation and stress:
There’s a well-known and strong link between chronic pain and stress. Exactly why is still surprisingly mysterious, and we still don’t actually know if stress causes chronic pain and other health problems. It’s possible that low-grade chronic inflammation is one specific way that stress can become painful (though it could still actually be a source of stress instead of the result).”
https://www.painscience.com/articles/inflammation-chronic-subtle-systemic.php


Somehow, Paul can never see the possibility that he’s got the link between chronic pain and stress thoroughly backwards: that it is often chronic pain that causes stress and not the other way around.  

Chronic pain can result in a loss of employment and income, as well as a potential but profound future loss of income, marital difficulties, sexual difficulties, loss of activity, loss of pleasure.  It sucks the joy out of life.  All of these are pretty potent mental stressors.  

Outside the realm of the brain and thoughts and into pure physicality, Paul graciously notes that chronic systemic physical inflammation may also cause stress.  However, he never quite addresses structural distortions creating a physical stress throughout the kinetic chain. Most every one of us in this field has seen or experienced how a severe fixation or problem at one vertebral joint can reverberate, stress, and impair the whole of the human, not just a part.  Quite simply, when a back or neck goes into extreme spasm, everything in the body gets stressed.  Physically, and mentally.
Does chronic pain cause stress?  Yes of course.

2.  How insomnia makes chronic pain so much worse.

Let’s reword this:  “How chronic pain makes insomnia so much worse”  


3.  The role of chronic low-grade inflammation (in pain).

Here Paul claims that pain may be caused by chronic low-grade inflammation, which is then caused by stress created by the brain or by poor diet.  To fix the problem, Paul suggests a change of diet as well as positive thoughts.

Let’s start with inflammation and what inflammation IS.
Inflammation is a key part of the healing process in the human body. And yes, pain typically accompanies inflammation. But what exactly is registering as pain? Is it an increase in white blood cell count? Fibroblast activity?

With inflammation comes a local change in fluid pressure.  It is this pressure that registers as pain.  Pressure, quite often = pain. Also known as “swelling”. From compartment syndrome to a sprained ankle, to a headache, to a zit, to migraines, to a bruise, to severe disc herniations; what always registers as pain in the human body is a change or distortion in internal fluid pressures. And our bodies are 60-65% fluid, and one big matrix of pressurized fascial membranes.  Layers.

Cognitively, we are exceedingly aware of changes in pressure, including external barometric pressure (grandma’s knees hurt when the storm is coming, diving, flying, the bends, etc).  Our internal pressures fluctuate constantly with changes in external pressure.  Similarly with mechanical pressures, we have extreme sensitivity - the slightest touch, or a whisper of wind - there is arguably nothing our neural system is more sensitive to than pressure change.

What is chiefly missing within the pain “science” model and rationale, along with current structural models, is the role of pressure, pressure balance and the compensatory process that accompanies changes in pressure, as well as the understanding that the neural system itself is a fluid, pressurized system; a system of tubes and hoses.  

When the bony borders of the neural system are distorted, fluid pressure within the neural system is distorted as well. Acutely, this is registered as pain. But once a pressure distortion exists within the neurological system, the system will immediately attempt to adjust and shift in order to mitigate and compensate to the problem -- ie: the compensatory process kicks in. As the body adjusts in gravity, the acute pressure distortion is alleviated at the site of initial distortion.  Pain diminishes, and measure of function returns, although never quite the same.  The initial distortion is now held throughout the whole.

Compensatory ability and the lack of…

The compensatory process requires the space to do so: i.e.: joint space in the spine and ribcage. Joint space translates into ease of movement and compensatory ability within the whole of the structure. With plentiful space, what initially registers as pain will quickly be alleviated through the compensatory process.  However, when joint space is limited is when the compensatory process becomes interrupted -- and acute pain quickly becomes something more akin to chronic pain.  The pain felt won’t necessarily be the place of initial structural distortion, it may also be where the body is trying to structurally compensate but cannot.  Or pain is felt where the body has already compensated and the compensation has now become more painful than the initial injury -- like a thoracic twist accompanying a pelvic twist, or a kyphosis with a lordosis.  Pain may be a question of decades of trauma’s and compensations, and compensations to those compensations.  Pain is weird?  No, pain is complicated.  Complex.

And...the older a person is, the more immobile, the more traumatized and distorted a body and a structure is, the less likely it will be able to successfully compensate to further distortions, or even surgical interventions trying to fix the pain problem.  

Ida Rolf designed the ten-series around the principle of “system adaptation”. System adaptation is another way of describing the body’s compensatory requirements. It basically means that in order to change a part, you must change the whole, and importantly, that a local problem in the body is also reflected in the whole.  Hence, ten sessions, addressing the whole, and not chasing the pain.  This is a wise approach, and easily adaptable to more specific yet comprehensive work with the spine -- something not very commonly done.  Not yet anyway...
…

Paul and I agree that SI hasn’t solved everything and I think that Paul makes some valid critiques of “structuralists” and SI, but here’s where he and I differ the most...  
Paul states:
“Posture, structure and biomechanics have had their day in the research sun; they have had their chance to make a difference. We’ve wrung almost as much explanatory power and clinical relevance out of that paradigm as we’re ever going to.”
https://www.painscience.com/articles/structuralism.php#sec_why

I sincerely disagree.
We have a lot more understanding to develop when it comes to things like biomechanics and the spine. We are barely scratching the surface.  The proverbial tip of the iceberg.  Sure we’ve looked at fascia and tensegrity, and we’ve looked at gravity, but there remains other incredibly important aspects of our context and makeup to consider...things like pressure and fluid dynamics.  Better techniques, more comprehensive models are within our grasp.

And clearly, there is also the other side of the spectrum: the idea that Ida solved it all and the ten series is ‘magic’.  That’s not accurate to say either.  But most of us fall somewhere in between; we do pretty good with this work but we’d like to do better, work smarter and understand more.   

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