Under development is a new way of treating pelvic organ prolapse.
It is based on biotensegrity principles, and their application to the understanding of the mechanics and pathology of pelvic organ prolapse.
Biotensegrity is a model for explaining the structure of living organisms, which was put forward by Stephen Levin in 1981. It challenged the classic biomechanical model of anatomy, and explained how we move in such dynamic, energy efficient and multi – directional way. Levins papers can be found at www.biotensegrity.com
The classic biomechanical model of the body, used since 1680 is based on the principle that the bones are stacked on top of each other and that the body moves using lever and pulley mechanics, to pull rigid bones around joints. This is ‘continuous compression’ mechanics. However, it does not explain how complex multidirectional movement happens, nor how the body copes with the massive force loading which would occur through joints if they really were simple levers. It also fails to explain how we swim or do a handstand, or land from a jump without being crushed by huge compressive forces.
“While skyscrapers and bridges are relatively rigid and must be heavily reinforced against the effects of those stresses, living organisms are light and flexible, and can function the same in virtually any position, which means they probably use a different system of mechanics altogether.” Graham Scarr 2012
Tensegrity is an engineering principle used to create structures which hold themselves up against gravity through an interaction of tension and compression. It was first developed by Buckminster Fuller and Kenneth Snelson. Here are some examples of Kenneth Snelsons Tensegrity sculptures:
Biotensegrity is the idea that rather than muscles and fascia being draped over the skeleton, the bones and organs are suspended within the bodies web of fascia. Fascia surrounds and interpenetrates every single body part, every nerve, muscle and organ. It is continuous, 3 dimensional and tensional. It thickens to form tendons, ligaments and aponeurosis but acts as the global continuum of the body, holding everything together and in the right place, while also softening, lengthening and releasing, to expand the structure and allow movement.
“Movement is not bending of hinges, but expansion, repositioning and contraction of tensegrities.” Levin & Martin 2012
Key to this suspension-based structure is the principle of triangulation. Triangulation of form gives flexibility and stability at the same time. It means that the body is held together in balanced, dynamic but strong equilibrium.
Levin noted in in 2007 that if the human body followed the laws of classic mechanics, where rigidity is key for strength, that urinary bladders and pregnant uteri would burst when full. Thankfully our bodies do not appear to follow those laws.
According to biotensegrity principles, our organs are anchored in place, suspended within our abdominal and pelvic cavities by fascia, with enough flexibility to allow for good trunk and pelvic movement, and healthy organ function including pregnancy.
Work has been going on across the world to develop our understanding of biotensegrity and its role in physical pathology, and plenty of information about biotensegrity is readily available.
For example :
Graham Scarrs book ‘ Biotensegrity – the structural basis of life’
John Sharkeys papers, developed through is dissection work :
‘The fallacy of biomechanics 1’ & ‘The fallacy of biomechanics 2’
Jean – Claude Guimberteau’s video ‘strolling under the skin’ and his book ‘Architecture of Human Living Fascia.’
For more information about fascia generally, a good place to start would be David Lesondaks book ‘Fascia – what it is and why it matters.’ For a more in-depth read : ‘Fascia – the Tensional Network of the Human Body’ by Schleip, Findley, Chaitow and Huijing.
In biotensegrity structures, problems occur when a tension imbalance occurs, which disrupts the dynamic equilibrium, altering the geometry of the structure. These structures are inherently self suspending, defying gravity through the mechanics of triangulation and the interaction between compression and tension. Essentially the more rigid parts are suspended in the more elastic parts, which are tensionally balanced to give overall structural integrity which is strong yet mobile. So an increase in the tension of one part will cause a change in the local and global structural arrangement. This then impacts the ability of that structure to function as it should.
Over the last 4 decades, biotensegrity principles and their implications have been applied across numerous disciplines.
However, the mainstream understanding of pelvic organ prolapse is still one based on ‘continuous compression’ mechanics : i.e. that an organ slips or falls downwards due to weakness of structures underneath it. There are several anomalies with the use of that model to understand this condition:
1) Things don’t fall in the body. There is no other body part that we would ever consider to have ‘fallen down’ through the body.
2) It does not explain prolapse related pain. If an organ had fallen and was sitting on the pelvic floor it would not be heavy enough to cause the pain that many women feel. A tension that builds up to the point of pulling on nearby structures would be able to cause that pain.
3) It does not explain why there is an associated back and hip stiffness alongside prolapse for many women. However, within a tension-based model, it’s easy to see how tight pelvic floor tissue can limit the range of motion of the buttocks, hips and the lumbar spine.
4) Pelvic floor weakness is the presumed cause, but as a postural muscle, how is it becoming so weak for so many women?
5) If weakness really is the cause, why does pelvic floor strength training fail to reduce the symptoms of prolapse for so many women? Furthermore why do some women report a worsening of their prolapse symptoms when they do repeated pelvic floor muscle contractions?
Childbirth is a major risk factor for prolapse. Up to 90% of women receive some kind of laceration (either a tear or an episiotomy) during childbirth, which causes scarring through the pelvic floor muscle.
Scarring is known to tighten up tissue and restrict normal fascial glide and stretch.
Pelvic floor scarring or tension prevents the muscles from being able to contract through their normal range of motion with normal levels of effort. But I believe that this is due to tension and restriction of those tissue, rather than weakness. This is in line with the work of pelvic physiotherapist Amy Stein.
Karel Lewit has done extensive research into scars and how they increase tissue resistance and stiffness. This is key for understanding how, for many women, scarring through their pelvic floor limits normal elasticity in the area, causing a drag on local tissues. Within the pelvis that stiffness and restriction affects the motility and position of the nearby organs. It has been observed repeatedly that a prolapsing organ has moved within the pelvis towards the side with the predominant pelvic floor scarring. It has also been noted that applying light pressure to the active scarring replicates the feeling of the prolapse. It is difficult to explain that as a weakness, but thinking of it as a tension makes total sense.
Not all prolapses are due to scarring, and not all women experiencing prolapse have had children, but pelvic tension can build up in other ways, for example poor movement patterns or injury to one of the lower limbs or through trauma related tension.
I have been treating prolapse by releasing pelvic floor tension and scarring with myofascial release since 2015, with excellent results. The majority of women experience significant relief from all of their prolapse symptoms, including bulging, heaviness, dragging, urinary leakage and difficulty defaecating, over the course of 6 to 8 sessions.
Work is continuing to develop a more detailed picture of how exactly pelvic floor scarring and tension is disrupting pelvic organ position. Collaboration with other professionals working this way is very welcome.
Pre and post treatment assessments include PFDI20 scores, a validated patient reported outcome measure for prolapse symptom measurement.
An initial hypothesis paper is through the peer review process and on route to publishing
Follow up data will be presented at physiotherapy U.K. conference 2019
An animation to describe common tensional pulls within the pelvic floor and their effect on the position of the pelvic organs is underway.
A training package is in its infancy. Any pelvic physiotherapists who would be interested in being trained, please do get in touch.
A note about prolapse surgery. Pelvic organ prolapse surgery is notoriously unsuccessful. In my opinion, the reason why traditional prolapse surgery outcomes are so poor is that they are acting to further tighten up structures which are already under strain. If the organ has been pulled in a downwards direction due to scarring, fixing it back up high in the pelvis cannot possibly last, the tension is too great. Does this also go some way to explain the pain and sexual dysfunction so many women experience post prolapse surgery? The mesh was used to further reinforce pelvic tissue, without taking into account tension in the area, and as we know that has gone on to cause huge problems for many women.
Within the understanding of the body as a a biotensegrity structure, where the organs are anchored in place, in dynamic equilibrium, there is no anatomical reason why organs would just fall. However, an increase in tissue tension causing a downward pull makes far more anatomical sense. Particularly when the prevalence of pelvic floor scarring is considered, and the way that active scars behave.