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Looking beyond the horizon – The physics of anatomy and function -

Gracovetsky - Aug 2014

Research · October 2015

DOI: 10.13140/RG.2.1.3833.6725

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Looking beyond the horizon Page 1 of 8

Looking beyond the horizon – The physics of anatomy and function

Serge Gracovetsky, Ph.D.

Concordia University, Montréal, Québec, Canada
Email: gracovetsky@videotron.ca

Introduction

In the 1940’s Bartelink was commissioned by the German Air Defense to study the internal tissues forces
that pilots ejecting from the new military jets airplanes were subjected to with sometimes very deadly
consequences. During the course of his work, Bartelink proposed that the back muscles are the
predominant structure that would control the trunk during simple tasks such as weight lifting. This idea
was received with unabridged enthusiasm, and even to this day, many believe that this is the revealed
biomechanics’ gospel. That this concept survived for so long against the contradictions it generated is a
testimony to the unique ability of the art of medicine to keep an attractive idea alive in spite of a ruthless
experimental annihilation.

In the 1860’s, the Gray anatomy described the presence of a very strong collagenous structure (the
lumbodorsal fascia). For decades, no particular function was assigned to that important structure and its
role was not understood until the 1970’s when Harry Farfan (1975) was struck by the power difference
between the hip extensors and the erectores spinae. In truth Bartelink (1957) realized the discrepancy,
and proposed that the internal abdominal pressure (IAP) would rise to push up the diaphragm during the
lift. Very few went on to calculate the level of IAP needed to lift 200Kg and even less were troubled by the
fact that the calculated high pressure would result in having the hapless weightlifter explode during the
exercise. Since people do not routinely explode while lifting heavy loads, I thought that a better
explanation was needed.

Others noted that "comparative musculature anatomy between old world monkeys and modern humans
suggests the presence of relatively smaller, and potentially weaker, lumbar extensor musculature in
humans which may contribute to disuse atrophy of the lumbar extensors which, in turn, may explain the
consistent association of their deconditioning in LBP, and also predispose modern humans to the high
prevalence of LBP". In other words, it was easier to dump the observed anatomical differences between
species on a hypothetical pathological weakness of the human spine.

The hip extensors power cannot be transmitted to the upper extremities via the erectores because the
erectores are not large enough to do the job. In addition, even if they were, their anatomical positioning
would result in a compressive load that would crush the intervertebral joint. And instead of trying to
explain this paradox, the expedient thinking of the time was to arbitrarily decide that our anatomy was
deficient and responsible for the functional limitations leading to the dreadful low back pain. Many went so
far as to suggest that in a few millions years our spine would evolve to eliminate the deficient lordosis and
become straight: hence the label “spinal column”. The minor difficulty with that popular argument is that
monkeys already have a straight spine, and except for a few fortunate individuals especially in the field of
politics, it was not obvious to me that we are evolving towards a monkey’s stance. Again, a better
explanation was needed.

Farfan thought that the attachment of the fascia to the tip of the spinous processes would permit the
fascia to complement the erectores for an efficient transfer of loads, and speculated that the fascia would
supply what he termed the “missing moment”, that is the difference between what the hip extensors can
provide and what the erectores spinae can use. That difference is not trivial as it can reach 3 to 4 times
what the erectores can do.

In an elegant stroke, Farfan’s simple idea gave justice to the optimality of the human anatomy.
Unfortunately, his suggestion was met with ferocious opposition, mainly from fossilized researchers that
suddenly saw their pet theories being unceremoniously thrown out of the window. Farfan and I developed
a model (based on the anatomical work of the Australian anatomist Nicolai Bogduk - 1987) that
conceptually and numerically explained what was observed. The mathematical framework was the theory
Looking beyond the horizon Page 2 of 8

of optimum control that was just refined for the first flights to the moon. The theory expressed that the
force transfer throughout the spine will force a lordotic posture that will minimize and equalize the stress
at all intervertebral joints (Gracovetsky 1977, 1981, 2010). But a direct measurement was needed to
prove the validity of the approach. And so I decided in the 80’s to study the relationship between lordosis,
the angle of trunk flexion and the activity of the erectores. The protocol was as follows:

A string of skin markers is placed over the spine of a volunteer together with a set of EMG
surface electrodes at the L5 level. His lordosis (or, equivalently, the curvature of a line drawn on
the skin passing over the tips of the lumbar spinous processes) is measured simultaneously while
the EMG activity of multifidus at L5 which is integrated (IEMG) and displayed (Fig.1.1). The
technology that permits to assess the spine curvature using skin markers is described elsewhere
(Gracovetsky 2010 – User manual). From the tracking of the kinematics of the skin markers, an
estimate of the lumbosacral angle Ψ is obtained which is linearly related to the true lordosis Ψ*
(Fig 1.2).

The volunteer is then asked to maintain the same posture (that is, the same general angle of forward
flexion), but to first increase then decrease his lordosis by rotating his pelvis (nutation and counter
nutation). The corresponding IEMG and lumbosacral angle Ψ are recorded as function of lordosis
(Figs.1.1 & 1.2).

Fig.1.1 The Integrated EMG activity is

recorded bilaterally by superficial
electrodes placed 2 cm to the right and
left of the spinous process at L4.

The raw EMG signal is band filtered (5 Hz

to 300 Hz), digitized at 1kHz, rectified,
averaged and plotted. On this graph the
signals from the right and left electrode of
multifidus have been added.

The average levels corresponding to the

most comfortable posture: normal (c),
reduced (b) and increased (a) lordosis are
indicated by arrows.

The average of the EMG signal corresponding to the three basic lordosis position (normal, reduced and
increased lordosis) are labeled a, b and c. This data will form the basis for the construction of the curve in
Fig. 1.2 (left) and the surface shown in Figs. 1.3 & 1.4.

Fig.1.2 Left: Integrated EMG of

multifidus showing relative activity
versus lumbosacral angle
(lordosis). (a) for an increased
lordosis, (b) for a decreased
lordosis and (c) for the resting
upright lordosis.

Fig.1.2 Right: Definition of the true

lumbosacral angle Ψ* and its
estimate Ψ

This demonstrates experimentally that the most comfortable lordosis chosen by the subject corresponds
to the minimum IEMG of multifidus at L5. This experiment can be repeated with the volunteer assuming a
number of different angles of forward bending. For each angle of forward flexion, results obtained are
similar to those shown in Fig. 1.2 (left). When all the IEMG versus lumbosacral angle Ψ curves are
combined, the three-dimensional surface depicted in Fig.1.3 is obtained.
Looking beyond the horizon Page 3 of 8

Fig.1.3 Left: Assembly of the data collected in Fig. 1.2 (left) for four different angles of trunk flexion (in
degrees). The axis labelled lordosis is the lumbosacral angle measured from the position of skin markers
as shown in Fig 1.2 above and is expressed in degrees. The IEMG is in arbitrary units. The meaning of this
3D image is apparent when the IEMG valley is highlighted as in Fig. 1.3 right.

Fig.1.3 Right: When all individual curves are stacked together, a three-dimensional surface is obtained.
Notice that the subject’s preferred method of lordosis control for flexion-extension is in the bottom of the
valley. This is an illustration of the principle of optimality in which the subject selects the strategy that
minimizes his energy expenditure. Note the reduction in lordosis as the subject bends forward.

Clearly, flexion-extension in the sagittal plane is not executed arbitrarily. The volunteer adjusts his
lordosis according to the angle of forward flexion so that he remains at the bottom of the energy valley at
all times, by minimizing the activity of his multifidus. In fact, iliocostalis and longissimus lumborum exhibit
exactly the same behavior. The subject prefers to do his movement by using the minimum amount of
muscular energy or equivalently, the subject prefers to have the lumbodorsal fascia do the bulk of the
force transfer from the hip extensors to the upper extremities.

It can be shown that when the muscular energy is minimized, the stress at the intervertebral joint is also
minimized thereby reducing the possibility of injury. This is what is meant by the optimization of spinal
resources predicted by the mathematical model proposed in 1977.

At that point it was reasonable to think that energy minimization was at least one desirable objective that
the evolutionary process would follow in the design of the animal.

But there were one more nagging unresolved problem that was, again, first pointed out by Farfan in 1969.

The human Gait.

After studying over 6,000 spine specimen, Farfan (1969) proposed that the existing pathological data was
consistent with the existence of two families of degenerative patterns. Each family behaves with its own
clinical manner and responds to its own different type of treatment. Specifically, the intervertebral joint
was mainly injured from excessive compression (compression injury) and/or excessive axial rotation
(torsional injury).

This is not a semantic philosophical argument to get another paper published in a journal. A compression
injury is a fracture of the cancellous bone of the vertebral endplates and as such heals relatively quickly.
Looking beyond the horizon Page 4 of 8

A torsional injury implicates the integrity of the collagenous structure of the annulus fibrosus and is quite
difficult to heal. Since both types of injury have a similar symptomatology, the clinician is confronted with
subjects that are able to repair themselves quickly while others become chronic. Hence the presence of
torsional anomalies in a LBP subject must be rapidly recognized. This is the perfect illustration where
treating symptoms can lead to clinical mistakes.

That proposal was immediately subjected to heavy bombardment by those who at the time believed in
good faith that a compression injury would damage the annulus fibrosus and start a cascade of events
leading to low back pain. The shells were essentially lobbed from Sweden where a brilliant man (Alf
Nachemson) decided in the 1960’s that excessive disk compression was the mother of all spinal
diseases. Never mind that a few years earlier Virgin (1951) demonstrated that an intervertebral joint in
which he drilled a large hole was as good at supporting compression as an intact disk. Never mind that in
the 1960’s, experiments conducted at the biomechanics laboratory of the Wright Patterson Air Force
Base in Ohio, subjected monkeys strapped to a chair to impacts forces of 120g’s (yes, one hundred and
twenty) on their buttocks. Upon impact, the (live and hapless) monkeys shrank by about half as their
vertebras were crushed, while their annulus fibrosus remained essentially intact. Never mind that in 1989
Sullivan shot down the back muscle theory etc... Farfan’s data was guilty of confusing many with
embarrassing facts and was therefore eagerly flushed out.

The resulting battle smoke could not hide a fundamental dilemma. On one hand, it was obvious to me
that Farfan was right in exposing the predominance of torsional anomalies in subjects with chronic LBP.
And that had nature given us a straight spine, that annoying torsional weakness would not be there and
the theory of Nachemson would have prevailed. And so for many years, at every conference, Farfan and
Nachemson slugged it out from their respective corners. But the success of the optimization procedure in
explaining the lordosis variation during flexion and recovery from flexion convinced me that nature would
not have permitted us to evolve with such a dangerous and potentially crippling design without a reason.

In other words, the risks represented by the possibility of torsional anomalies ought to be compensated by
a significant benefit for our species. And so the question was now to find what could be the significant
evolutionary benefit that justified our species taking the risk of a torsional injury in a way that merged the
significant work of Farfan and Nachemson, both rather strong willed individuals, but delightful companions
over a beer late at night in a Cambridge’s pub.

Human gait was the short answer. Note that there is a difference between bipedal locomotion (i.e.
dinosaurs and the like) and human gait. Human gait requires the spine to support both compression and
torsional forces. It is the need to exploit the earth gravitational forces, a constant resource all over the
planet, which shaped the anatomy of our bipedal species, and permitted Homo sapiens to colonize the
entire planet from his humble African origin. Bipedalism is widely spread across species, but the unique
feature and the extraordinary efficiency of our chosen locomotary mechanism dictated the need for axial
rotation while the spine is subjected to large compressive pulses. And that in turn neatly explained the
observed spinal pathology.

Simply put, human gait demands that the pelvis rotates in the horizontal plane. The problem is that there
are no muscles in the horizontal plane that can do that (Fig. 1.4).

Fig.1.4 The fundamental issue in human

locomotion is to convert the axial pull of the hip
extensors into an axial torque driving the pelvis.

There are no muscles capable of direct axial

rotation of the pelvis. An indirect mechanism must
be found. This is where the earth gravitational
field, as a temporary storage element in the
transfer of energy from the extensors to the pelvis,
is so important for our species.
Looking beyond the horizon Page 5 of 8

The only source of energy is produced by the powerful hips extensors which are essentially perpendicular
to the horizontal plane. A direct action would therefore be very inefficient. How to convert efficiently the
axial pull of the hips extensors into an axial torque driving the pelvis is what the theory of the spinal
engine is all about (Fig.1.5). In short, there is a need to temporarily store the hip extensor’s muscle
energy in the gravitational field and recover that energy during heel strike.

The reader can convince himself of the role of gravity by trying to walk while his belly button is forced to
remain in the horizontal plane. Surprise: It is not possible to walk and run that way since the interaction
between the body and the gravitational field is prevented. This energy exchange is obvious in a runner
that actually fly in the air at each step forcing the center of gravity to move up and down and in so doing
betrays the exchanges between kinetic and potential energies. This is discussed at length in Gracovetsky
(2010 – Non Invasive Assessment..).

Fig. 1.5 The spinal engine theory proposes that the hip extensors lift the body in the
gravitational field thereby converting the chemical energy liberated by the muscles into
potential form in the earth gravitational field. This is particularly obvious when both feet are off
the ground, and it has been noted for a long time that the center of gravity oscillates up and
down during gait. During flight, the spine readjusts its geometry to prepare for landing. As the
trunk descents the potential energy is converted into kinetic energy. That kinetic energy is then
recovered at heel strike on the form of a pulse that can be quite high (up to 19 times the body
weight for runners in a 100 meter dash). The heel strike pulse then travels up the leg where it
is mechanically filtered to compensate for the uneven ground surface condition. The resulting
pulse emerging at the L5/S1 interface has the correct shape and timing that the spine can use
to control the pelvis.

And so over the years a generalized concept of spinal function emerged based upon the laws of physics
applicable to our home planet. It is hoped that formulating such an approach to normal function might
encourage others to formulate a similar approach to the rehabilitation of a subject having abnormal
function.

In short, the ultimate purpose of this chapter contribution is to encourage the structuring of manual
medicine within a generalized and a unified perspective defendable from a basic science point of view.
Indeed, it is becoming necessary to consider that the patient’s pathology is independent of the clinician’s
training and hence the current plethora of treatments (chiropractic, osteopathic, physical therapy, yoga
etc.) must have some fundamental parts in common.

In particular, it can be expected that the various treatment philosophies are not independent and that
some of the claimed differences might be simply a matter of semantics and communications. That could
be resolved by developing a common language acceptable to everyone. If history is an guide, this step
will probably be met with some resistance since not everyone might be willing to renounce to his/her
beliefs, even if there is no scientific basis for continuing to adhere to them.
Looking beyond the horizon Page 6 of 8

But the writing is on the wall. The payers of medical services let it be government or private insurance,
are asking proof that what is being billed and paid for is actually working. And so there is a need to devise
techniques to assess the efficacy of a rehabilitation procedure, in spite of the strenuous opposition of
many providers who are not anxious to see an independent third party looking over their shoulders. In fact
many argued that the relationship between patient and provider is so unique that no statistical blind study
can ever be designed to assess the magic of the art. This is not a constructive position since it stifles
innovation by pre-empting the badly needed research to move forward.

How to assess manual therapy

The purpose of medicine is to restore normal function in an impaired subject. But what is the normal
spinal function that must be restored? For example, no cardiologist would attempt to interfere with the
heart of his patient without first having done an electrocardiogram. Measuring the function of the organ is
the first step to any intervention. Strangely enough, this strategy is rarely applied to the mechanical
etiology of spinal disorders, and it is no wonder that the rehabilitation of subjects with LBP is mainly a
matter of trial an error.

In truth, it is very difficult to assess a subject with LBP. A landmark study made in 1992 by the Quebec
workmen compensation board with the guidance of McGill and the University of Montreal demonstrated
that for benign LBP, the clinician does not have the ability to see beyond what the patient is willing to tell
him. In other words, the physical examination is ineffective. The sobering results can be found in
Gracovetsky 2010 (Noninvasive assessment of spinal function). As expected, a considerable amount of
ferocious and unsolicited criticism greeted the news.

But if the sensory equipment of the clinician does not permit an assessment, then to what extent
technology can assist the clinician to compensate for his natural limitations?

There is no magic bullet here. The days when all data (radiological, pain, clinical examination, etc.) is
integrated by a machine are still a long way off. But partial data can be generated which can be of
assistance in specific cases.

Before going into how it can be done, let us revisit the concept of normality as it applies to spinal function.
It is proposed that normality be defined by the ability of the musculo skeletal system to function at
minimum energy expenditure in such a way that the stress in all structures is as low as possible. That is
another way to express the fundamental idea of survival of the species brilliantly exposed by Darwin over
a century ago. This is also a very general concept applicable to many other biological systems. In short a
person is said to be normal if he/she is able to use his/her resources optimally.

Mathematics allows us to go one step further. To function at minimum energy expenditure demands a
very specific coordination between pelvis and spine so that muscles and fascias are able to complement
each other for the benefit of the whole musculo-skeletal system. A suitable motion analysis system will be
able to pick up that coordination, and a proper expert system will then interpret the objective kinematic
data into pathological findings digestible by the clinician in charge of rehabilitating the patient.

That is what has been done and described in Gracovetsky 2010 (User’s manual and noninvasive
assessment..). To illustrate the application of the technology consider the changes in the spine function of
a subject that has been manipulated by a physical therapist. The experiment consisted in measuring the
estimated motion of the lumbar intervertebral joints before and just after (20 minutes) a single
manipulation. The results are given in Fig. 1.6
Looking beyond the horizon Page 7 of 8

Fig. 1.6 The Z-score of the estimated motion of the intervertebral joints from T12/L1 to L5/S1 is plotted
versus the angle of trunk flexion. The shaded zone is the (+/-)2 standard deviations zone of normality.
The subject has a normal function for all joints before the manipulation in spite of complaints of pain. The
dotted line is the pre-manipulation response done for zero and nine lbs. Less than 20 minutes after a
physical therapist applied his manipulation, the subject was measured again (red continuous line) for
both zero and nine lbs. lift. The subject felt better and demonstrated a minor improvement at the L 3/4
joints level. Left. Overlay of the before and after manipulation data for the zero pounds lift. Right –
Overlay of the before and after manipulation data for the nine pounds lift.

Since the system can detect changes after one manipulation, it should be possible to measure the
changes after a longer period of repeated manipulations. This experiment was done by tracking the
functional changes of 100 consecutive patients over a 60 weeks period while they were enrolled in a
rehabilitation program following complaints of LBP. The results are in Fig 1.7.

Fig. 1.7 Variation in functionality

for 100 subjects followed for over
a year after their entry into a
rehabilitation program for LBP.
Note that about 80% of the
subjects are functionally normal
to begin with and remain
essentially normal (unchanged)
during the treatment. The
remaining 20% of the subjects
enter the program as functionally
abnormal and have various
degree of improvement over time.

This limited experiment shows that the measure for the success of a rehabilitation program is not a simple
matter of physical performance. It also raises the issue of determining what are the ingredients benefiting
the patients, including the impact of the so called placebo effect.
 Looking beyond the horizon Page 8 of 8

Conclusion

This short essay is an attempt to explain the though process that guided us in the study of the function of
the human spine. We have proposed a unified theory that could be generalized to the entire musculo
skeletal system. In so doing we developed some equipment that lead to a technique to assess that
function and hence to a possible method for assessing the benefits of rehabilitation.

References

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