Bodywork Therapies – Self-repair and Adaptation
A fundamental truth should be kept in mind as we explore the many things that can go wrong with the biomechanics of the body: there is an inherent capacity for self-repair, constantly at work, whether this is in response to trauma (broken bones usually heal) or to chronic patterns of overuse and misuse.
If the causes can be reduced or removed and/or the structural integrity of the biomechanical (and, of course, the biochemical and psychological) components of the body can be improved, then self-regulation processes commonly ensure a return of normal function. Many of the symptoms we experience, unpleasant as they may be, should be understood as messages of recovery and repair- in-action – inflammation, for example, may be unpleasant, but without it tissue repair cannot take place.
Other symptoms, such as acute pain, may be understood as vital messages, warning us not to overuse a particular area because to do so would be to aggravate existing damage, or to create a worse situation.
By learning to understand and respect these messages, and to take appropriate action, we can enhance the healing process. Ignoring the symptom’s message can be disastrous. For example, inappropriate use of medication that is anti¬inflammatory and painkilling can lead to overuse and therefore aggravation of already damaged structures, creating a far worse state of affairs, and delaying recovery.
Does this mean that we should never use anti¬inflammatory or painkilling medication? No, but it does suggest that we should only do so if we intend to respect self-healing processes that are going on in the background. The therapeutic measures used for any condition should therefore strike the balance between helping the person to feel more comfortable, while not creating new problems, or retarding the potential for recovery.
The old saying, that there are only two certainties in life – death and taxes – can be accurately expanded to include adaptation. We adapt from the cradle to the grave. We adapt to both internal and external forces as we grow, mature, develop and interact with other people and the environment. We adapt to the things we do, the things that happen to us and to the characteristics with which we are born. We adapt physically, biochemically, emotionally and psychologically throughout life. And when we cannot adapt any more, problems become evident.
The pioneer researcher in this area was Hans Selye, a Canadian physiologist who identified adaptation as the main feature that characterises and influences our development. Maladaptation largely determines whether health is good or poor, and ultimately leads to our eventual collapse. On the larger stage, Selye noted that everything that calls for adaptation can be labelled as “stress”. By understanding stress in this way (i.e. as an adaptation demand) we can see that it only becomes harmful when we are unable to adapt to the stress factor – i.e. when our capacity for adaptation is overwhelmed.
“As the twig is bent …”
A simple analogy clarifies what happens when we adapt to the stresses of life, and how the body compensates to the adaptive demands placed on it.
If a living, flexible branch of a tree is bent, it will adapt to the forces applied to it until it cannot absorb any more tension, torsion or distortion – at which moment it breaks or splinters. However, if a milder force is repetitively applied, the living branch will adapt to match the “stress”, and will become permanently bent. The fact that it is no longer as nature designed it means that this particular bent twig, although well adapted to the stresses imposed on it, would be unable to perform the same functions that it could when it was straight. In general, adaptation occurs at the expense of the ability to function optimally. The new situation (bent) allows the young twig to survive, but removes some of its original potential.
Research into how blood vessel walls respond and adapt to the stresses imposed on them is an example of how the “bent twig’” analogy applies to the body. Blood vessel walls adapt to the structural strain (high blood pressure), bio¬chemical strain (high cholesterol) and psychological strain (hormonal instability caused by a hostile temperament) placed on them by hardening and narrowing. Gradually they become increasingly narrowed and inflexible and eventually the part of the body they supply simply does not receive enough oxygen and nutrients. Angina is the result of not enough oxygen and nutrients reaching the cardiac muscle, while if the coronary arteries block completely a heart attack will probably happen.
Doctors treat the problem by attempting to bring down blood pressure and blood fats with drugs and, if necessary, by replacing the furred-up artery with a vein from somewhere else in the body. In the long term, however, the best medical approach is to address all the structural, biochemical and psychological elements involved in high blood pressure and coronary artery disease in order to reduce the stresses that the blood vessels are being forced to adapt to. In some parts of the US, cardiac rehabilitation programmes follow up bypass surgery or a heart attack with diet, meditation, yoga and graduated exercise. Such programmes increase fitness and encourage psychological well-being, so improving the patient’s ability to cope with stress.
A characteristic feature of the body’s musculoskeletal system is its ability to absorb the impact of external stresses and to spread the load of internal tensions without compromising the overall integrity of its structure. This flexible ability evolves from the quality known as tensegrity, which can be found in the structure of both the cell’s skeleton and the geodesic dome.
The word tensegrity was coined in 1961 by the visionary US architect Buckminster Fuller. He wanted to describe the stability that results from the interaction of rigid struts, flexible connecting fibres and filaments, and enclosed fluids under pressure. A suitable architectural example of tensegrity structure is the geodesic dome (left), which has no upright pillars.
General and local adaptation
Selye used the terms “general adaptation syndrome” and “local adaptation syndrome”. The former describes the effects of stress on the whole person and the latter the effects of stress on a local area, such as the shoulder. Each “syndrome” follows three stages: an initial alarm phase; a period of adjustment, compensation and adaptation, which might last for many years; and a stage of collapse, when adaptive capacity is exhausted.
Examples of local adaptation syndromes include the way specific muscles adapt to new patterns of use – as happens when you take on a new job that involves physical labour or a sustained posture. A general adaptation syndrome involves the whole body. Imagine, for instance, you were born at sea level and relocated to live at altitude. It would take months or years for your body to adapt to the different environmental situation. The changes necessary would involve your heart, lungs, circulation and general metabolic functioning.
Alarm and adjustment phases
Learning a new skill, such as playing tennis, places specific adaptive demands on the body. Generally, the exercise affects the whole body, bringing cardiovascular and muscular changes as the system learns to adapt to the new aerobic activity. Locally, the dominant hand, shoulder and arm has to perform unaccustomed activities, which initially might cause muscular discomfort. This is the “alarm” phase of the adaptation syndrome.
If you continue to play tennis, the initial symptoms (soreness, stiffness) tend to reduce, as the body adjusts to the new demands. However, if you play too much, or too often or for too long, the compensatory demands will become excessive and the adaptive capacity overwhelmed, causing symptoms that may be severe – for example, tennis elbow or repetitive strain injury.
Excessive training of young footballers, gymnasts and other athletes has been shown to produce major structural problems (including early arthritic changes), often ending careers before they begin. In these situations, it is a case of too much activity, for too long, too often and too soon for their immature bodies.
The adaptive demands of work and leisure activities, whether mountain climbing, gardening, gymnastics or watching TV on the sofa, affect us all in different ways. The differences depend on various factors: the type of body and constitution you are born with; the nature of your health history; how “fit” and supple you are (and what you do to maintain this); your age; and how efficiently and non- stressfully you have learned to use the primary machinery of life – the physical body.
The result is that some people adapt without problems to the demands placed upon them, but many do not.
In fact few people pass their entire working lives without discomfort and many others experience repetitive strains, aches and pains.
Some people also are born with so-called “inborn stressors” which create adaptive demands. For example, some people have one leg shorter than the other; others have one side of the pelvis that is smaller than the other, leading to a “tilt” of the pelvis and spinal strain; and some people have upper arms that are shorter than usual, which leads to increased sidebending when sitting, in order to gain support when resting on the arms of chair.
Finally, some people are hypermobile and have a tendency to possess lax ligaments (they are “double¬jointed”). This tendency causes muscles to overwork in order to protect the “loose” joints. Rehabilitation, learning new and better ways of doing things, and encouraging a more balanced state of the muscles, helps people to overcome such inbuilt problems.
Adaptating to a deskbound occupation
The postural demands of working at a desk in front of a computer terminal for eight hours a day are likely to create adaptive stresses affecting the neck and back. Unless the seating and desk arrangements are ideal and the postural awareness is good, progressive changes occur in overused neck, shoulder and arm muscles. Other muscles will be underused, including the stabilisers of the shoulder blade and the low back, abdominal and leg muscles.
Progressive shortening of some muscles (hip flexors and the pectoral muscles in the upper chest) and weakness in others (abdominal muscles) lead to restrictions in overused joints and in static, underused joints. In the low back and neck, elbows and wrists, localised areas of sensitivity and pain (trigger points) develop, particularly in the overused, shortened muscles. Eventually, background discomfort, pain and restriction become constant, with occasional acute spells of pain whenever irritable muscles (especially in the low back and neck) get even more tense and cramped.
The solutions are obvious. They include: better seating posture and better use of the body, with particular attention to avoiding overuse; stretching and movement strategies to help compensate for being sedentary; and appropriate treatment and self-care to loosen and mobilise structures that have become tense and irritable.
When cells in part of a muscle persistently receive insufficient blood and therefore oxygen (often because of excessive tension in the muscle), they become irritable. This affects the local nerve supply, producing areas of over-sensitisation known as myofascial trigger points (“myo” relates to muscle and “fascial” to connective tissue).
As tension builds up around this zone, calcium enters the muscle cells, but they lack the energy to pump it out again. This sets up a vicious cycle in which the muscle cells cannot loosen up and the affected muscle cannot relax. A characteristically taut band forms in the muscle, which can be located by a fingertip pressure.
TRIGGER POINT PAIN
Quite commonly, a person with trigger- point pain has not found the tender spot responsible. Sometimes, though, they are aware of a sore point that, when pressed, causes pain that may radiate to other areas. This is characteristic of the pain. The trigger points can cause symptoms some distance away and they become more active when stress, of whatever type, affects the person as a whole.
Trigger points are a common feature of pain. According to leading pain researchers and renowned neurologists, Patrick Wall and Ronald Melzack, there are few, if any, chronic pain problems that do not have trigger-point activity as a major part of the picture. They may not always be a prime cause, but they are almost always a factor that helps to maintain the condition.
Trigger points become self-perpetuating (a cycle in which pain leads to increased muscle tension which leads to pain) and seldom disappear unless they are adequately treated, or unless the reason for their existence, such as overuse or misuse, is removed.
TRIGGER POINT FACTORS
The following factors tend to maintain and enhance trigger point activity:
• Nutritional deficiency (especially vitamin C, B-complex vitamins and iron).
• Hormonal imbalances (for example, low output of thyroid hormones and those imbalances that occur during the menopause or in premenstrual women).
• Persistent, low-grade infections (bacteria, viruses or yeast).
• Food intolerances (wheat and dairy in particular).
• Poor oxygenation of cells and tissues (aggravated by tension, stress, inactivity or poor respiration).
TREATING TRIGGER POINTS
Ways of treating and deactivating trigger points include acupuncture, local anaesthetic injections, direct manual pressure, stretching and ice massage. These treatments will succeed in the long term only if the causes of the trigger points are removed. If muscles are stressed for long periods they tend to undergo fibrotic changes, becoming more “stringy” and less elastic, and more prone to injury when asked to perform new tasks. Regular, moderate degrees of exercise, including stretching, can help to reduce this tendency.
Prolonged sitting results in unplanned adaptation. What happens, however, when adaptation is planned? When someone prepares for a marathon, for example, he or she does not start the process by running the full 26-plus miles! The person trains, gradually increasing the amounts of stress (running and fitness training) so that the body can adapt to the new needs – to be able to run non-stop for 2-3 hours without injury. The adaptation process develops new muscle tissue and changes in responses of the heart, lungs and the whole biochemistry of energy production, as well as psychological adaptation to the discipline of training.
This same process of adaptation occurs in all sports, whether weightlifting or mountain climbing. Planned adaptation (training), therefore, is designed to allow us to do things – and to do them more efficiently – than before. However, just as the “bent twig” on the growing plant would be unable to perform the tasks of a straight twig, so the trained marathon runner could not become a sprinter. Once the body has become specialised to suit one type of sport, it is difficult to adapt to a completely different one.
Factors leading to breakdown
Adaptation leads to specialisation, limiting the potential for further adaptation. This fact is critical to understanding many of the sudden pain events that occur in life. When body structures are unprepared for, or incapable of meeting unexpected demands, such as lifting, stretching or moving suddenly, then tissues fail. Strain occurs and pain and spasm is a frequent consequence.
The limit to how much adaptation is possible is called the point of adaptive exhaustion or breakdown and is brought about by age and condition (of the person or body structure), as well as the kind and duration of stresses to which the person has had to adapt. The addition of a new adaptive demand may also be involved.
One of Selye’s great discoveries was that multiple minor stresses have the same cumulative effect on the immune system and general health as one major stressful event. It is therefore extremely important to realise that adaptation is not just a response to external mechanical loads, but also a response to many internal biomechanical, biochemical, emotional and psychological stresses.
Breakdown can cause severe biomechanical symptoms, often involving spinal, pelvic or other joints: slipped discs, nerve impingement, inflamed tissues or other forms of dysfunction, decompensation or maladaptation. Along with actual injuries caused by trauma, falls, etc, these are the problems that keep manipulation therapists busy, as they try in their different ways to restore functionality. However, their efforts will be in vain if the adaptive load that produced the problem is not modified or avoided.
Causes of injuries
Many adaptive changes happen because of overuse, misuse, abuse and disuse. The sorts of problem that arise through sudden or long-term adaptation are often remediable or reversible. Treatment and self-help methods deal with the mechanical and structural changes, the functional changes or both.
Repetitive movements, habitual postures or breathing excessively use certain muscles over and over again. This leads to slow adaptation through multiple changes in the soft tissues and joints. These secondary changes produce new adaptive demands due to muscular irritation and tightness, leading to discomfort, pain and the formation of trigger points. In breathing pattern disorders there is constant overuse of particular breathing muscles.
People regularly misuse their musculoskeletal framework when sitting or standing. A slumped, or an excessively “military”, posture are two examples. Using the wrong size or design of objects, such as chairs, sports equipment, shoes and musical instruments, can all create distress in the musculoskeletal system. The mechanical strains and stresses of misuse lead to a chain reaction of secondary changes, causing pain, tension and trigger points.
Injuries, such as whiplash, sporting injuries (torn muscle, broken bone) and surgery can produce scar tissue and changed patterns of use. Over time, such chronic soft- tissue changes, plus joint degeneration and disc narrowing, produce pain and another round of compensation by the rest of the body. Whiplash injuries can apparently sensitise the central nervous system, and set in train the onset of bodywide pain syndromes, such as fibromyalgia.
Lack of exercise, immobilisation, protective non-use of an area (as in a fracture, arthritis or a disc problem) and sedentary occupations all lead to underuse of parts of the body and the progressive weakness of disused muscles.
Remedies for overuse, misuse, abuse and disuse
Problems caused by overuse and misuse are clearly avoidable and are often remedied by a simple change of habits. Learning to use the body more efficiently and less stressfully is a matter of re-education and retraining, often accompanied by some form of manual treatment. These include osteopathy, chiropractic, physiotherapy, occupational therapy, massage therapy (including tuina, shiatsu, Ayurvedic massage and Thai massage) and the Alexander technique. Yoga, t’ai chi, Pilates and athletic training can be useful in rehabilitation, too. Conditions that result from abuse may require similar rehabilitation approaches, but are more likely to require more manual and other therapeutic interventions. The after-effects of disuse also require rehabilitation. If muscles have been disused as a result of an injury, surgical operation, stroke or other event, very specialised occupational therapy, physiotherapy or athletic training may be necessary to coax the muscles back into normal working order.