Originally published in the AMT Journal "In Good Hands", June 2009
© AMT 2009, © Colin Rossie 2009. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
In the last issue of In Good Hands, the contributions to the clinical perspectives article devoted to sciatica were so impressive that there seemed nothing of further significance that I could add. Jeff Murray mentioned the synergistic relationships of soft tissues in the pelvic girdle and the mechanics of force closure and form closure in pelvic and sacral function. He also discussed the role of stability versus strength in hip dysfunction. A few issues back (June 2008), there was a multi-contributor article on psoas function. From my perspective, there is a definite relationship between the two articles.
Although psoas isn’t always a first consideration in the treatment of sciatica, its dynamic relation to piriformis in stabilising the pelvic girdle should not be overlooked. These two muscles each cross the sacro-iliac and hip joints as ‘three-dimensional’ muscles and act synergistically to affect sacral biomechanics and stability as well as work to maintain the balanced position of the sacrum. I would like to add some other information on sciatica, and expand on that with some thoughts drawn from a Rolfing®/Structural Integration (SI) perspective.
On Sciatica: Historical Titbits, Description and Additional Considerations
The term sciatica was originally used in ancient times to describe any hip and buttock pain. From the mid 18th century, it has been used to describe pain in the buttock and posterior thigh originating from the sciatic nerve. ‘True’ sciatica was once thought of as a neuritis (inflammation) that occurred in untreated diabetes or severe alcoholism.(1) Now the term is commonly used to describe a neuralgia resulting from impingement of the sciatic nerve that results in pain, tenderness and paraesthesia, usually unilateral, in the buttock, posterior thigh and lower leg.(2,3) In addition to pain, gait can also be affected and in extreme cases, there can also be muscle wasting in the lower leg.
The sciatic nerve arises from L4–S3 nerve roots.(4) As Kerry Hage, Alan Ford and Jeff Murray all mentioned, pain can originate at the nerve roots, but it is useful to differentiate radicular the pain originating in nerve roots from neuralgia arising from the sciatic nerve. In the former, pain will be present in the lower back and maybe also in the buttock and thigh but not in the lower leg. In the latter, it will be absent in the lower back but present in the posterior thigh and below the knee. The distinction here is between central nerve root and peripheral nerve involvement. Bogduk argues, ‘the only pain that has ever been produced experimentally by stimulating nerve roots is shooting pain in a band-like distribution. There is no physiological evidence that constant, deep aching pain in the lower leg arises from nerve root irritation’.(5)
Anatomical and Functional Considerations
The sciatic nerve is the longest and widest peripheral nerve in the body. It exits from the greater sciatic foramen via the superior sciatic notch just anterior to the piriformis muscle and has peroneal and tibial portions. It supplies the hamstrings and adductor magnus, and its branches supply most of the lower leg. Also exiting the greater sciatic foramen are the inferior gluteal nerve, the posterior femoral cutaneous nerve, and the nerves supplying the other external rotators—basically, all the nerves that supply all the gluteal region and the posterior thigh and calf.
The piriformis muscle originates on the anterior surface of the sacrum and exits the inner pelvic bowl through the greater sciatic foramen to insert onto the upper border of the greater trochanter. It is a postural muscle, with type I fibres that shorten and tighten in response to overload. If these fibres become engorged and swollen in the limited space of the sciatic foramen, then piriformis will impinge on the sciatic nerve.
As Jeff noted, there is great anatomical variation in the relationship of the sciatic nerve to the piriformis muscle. In 85% of people both portions of the sciatic nerve pass anterior to the piriformis muscle; in 10% only the tibial portion is anterior to the piriformis, while the peroneal portion goes through the muscle; in 2–3% the peroneal portion starts superior and runs posterior to the muscle; and in 1% both portions travel together through the middle of the muscle belly.(6) If present, these structural anomalies could easily result in sciatic nerve impingement in the event of any myofascial dysfunction.
Travell and Simons note that, in addition to entrapment of the nerve by piriformis being responsible for sciatica, the referral pattern from active myofascial trigger points in piriformis mimics the pain pattern of sciatica. They also note that active trigger points in gluteus minimus and the anterior portion of gluteus medius can have similar referral patterns, which they term ‘pseudo sciatica’.(6)
Though frequently overlooked, the external rotators (piriformis, gemellus superior and inferior, obturator externus and internus and the quadratus femoris) are also postural extensors of the hip joint. When talking about hip extension, usually the hamstrings come to mind as the hip extensors. While that is undeniably their function, it is worth noting that as long muscles with a linear alignment of myosin and actin fibres that cross two joints, they are not the most efficient way to maintain upright stance at the hip joint. On the other hand, the external rotators, if thought of as short extensor muscles, are short, single-joint muscles responsible for form closure of the sacro-iliac articulation, thus bringing great postural stability to the pelvis.(7,8) Perhaps it would be useful to differentiate between femoral and coxal components of hip extension.(7)
There is a distinct relationship between the role of the hip external rotators—especially the piriformis—and the psoas. Both psoas and piriformis travel anteriorly, inferiorly and laterally from their origins to their insertions: the psoas from the anterior vertebral bodies of the lumbar spine to the lesser trochanter of the femur, the piriformis from the anterior surface of the sacrum to the upper border of the greater trochanter of the femur. The piriformi run primarily horizontally to their attachment, while the psoas run vertically.
If one considers the body from a tensegrity viewpoint, the psoas can be seen as a guy wire pulling the lumbar spine forward, countering the pull of the posterior guy wire of the lumbar erectors,(9) not only via the attachment of their deeper fibres to the lumbar spine,(5) but also through the thoraco-lumbar fascia.(10) Similarly, a fan around the hip consisting of the external rotators, gluteus minimus and the anterior fibres of gluteus medius can be seen as the tensegrity opposite of the iliacus in the ilium.
Piriformis is the tensegrity antagonist to the psoas around the sacro-iliac joint. An active psoas pulls the lumbar spine (and also indirectly the superior anterior surface of the sacrum) forward and down, affecting the position of the superior sacro-iliac joints, whereas the piriformis activates to counter this, bringing the anterior, inferior sacrum forward, thus creating a seesaw effect on the sacrum. The two muscles work together to allow optimal balance of the lumbosacral junction and the functioning of the inferior and superior SIJs around the body’s centre of gravity. This action balances the bones of the pelvis and ensures the congruence of the centre of gravity with the body’s centre of mass.
An Evolutionary Digression
It is worthwhile to digress slightly here and consider the hips from an evolutionary perspective. Over time, to accommodate the change to upright stance and bipedal gait, the hip girdle has changed shape and orientation. The direction of the ilia has changed. A deep iliac fossa has developed that allows a greater attachment area for the gluteus minimus, gluteus medius and external rotator muscles laterally and the iliacus medially. The ilia have twisted anteriorly to a more lateral and anterior orientation. Our nearest primate relatives have posterior facing ilia with small to non-existent iliac fossae. Their gluteus medius and minimus muscles extend the femur. In humans, these muscles abduct the femur at the hip joint in order to prevent a Trendelenberg gait. Moreover, the sacrum has increased in width and the complexity of its articulations in order to enhance stability. Consequently, the external rotators have taken on the extra functions of pelvic stabilisers and extensors.(11,12)
Rolfing®/ SI Definition and Perspective
SI, of which Rolfing®, Hellerwork and Tom Myers’ KMI (Kinesis Movement Integration) are probably the most commonly known varieties, is a specific body of work based on the teachings of Dr Ida Rolf (1896–1979).(13,14) The goal of the SI process is the optimal dynamic alignment of the body in relationship to gravity and the three-dimensional space around it (what a mouthful!). This most frequently occurs as an outcome-oriented process over ten or so sessions,(15) each session having a specific goal (see box). There is a long tradition and strong emphasis on the functional aspect of anatomy in the SI tradition, as witnessed not only in Ida Rolf’s only published work,(16) but also in such publications as Tom Myer’s Anatomy Trains(17) and the many research contributions made by SI practitioners to our current understanding of fascia.(18, 19, 20, 21, 22, 23, 24,25,26,27,28)
In the sciatica article, Jeff Murray stated that in hip dysfunction a tight piriformis might be all that provides stability to the pelvis and that to work initially to counter this could lead to even greater instability. I am in total agreement with him. Ida Rolf devoted a lot of her book to the role of the external rotators and the psoas around the pelvis.(16) In the classic SI process, work on the piriformis and other hip stabilisers is only commenced in the sixth session, once all the synergistic relationships in the hip girdle have been addressed in previous sessions. In SI, stability in the pelvis is addressed right from the first session, where the superficial gluteals are worked and balance between the hamstrings and quadriceps are themes.
This is ramped up in the third session, where attention is given to the TFL, ITB, gluteus medius anticus and fascial convergences at the trochanter, as well as the relationship of the pelvis to the ribs and the contra-lateral gluteus maximus/ latissimus dorsi relationship. The fourth session prepares for more thorough work on the pelvis, consisting of much work on the adductors, the lower insertion of the psoas and the ischial rami and tuberosities, sacrotuberous ligament and obturator membranes, and commences work with core activation and stability. Much of the moment work of this session focuses on synergistic, melodic relationships in the pelvic myofascia.
These themes continue into the fifth session, with work on the iliopsoas addressing issues of balance in the abdomen between the rectus and transversus and the rectus and psoas, as well as balance in contralateral gait - all in preparation for the sixth session. The later integration sessions are based on the relationship of upper and lower body to the pelvis (for a fuller description of the structural integration process, see Maupin 2005 and Myers 2004a, 2004b, 2004c.(29, 13, 15, 31),
Conclusion
I dislike the Cartesian view of the body as a ‘soft machine’ and am not fond of seeing it compared to inanimate objects such as machines or buildings. Living beings are far more complex and interesting than that. However, I will use two analogies to elucidate the ideas what I have attempted to express in this article.
If you compare the body to a carriage or chariot, the psoas can be thought of as the drawbar or pole and the piriformis as the axle attaching to it. The external rotators and the iliacus are the outer and inner spokes of the wheel. Maupin provides a distillation of the structural integration view when he says, ‘Much as the external rotators are the key to the sacrum, the piriformis is the key to the rotators’.(30) Further, from a tensegrity perspective, each of the spokes needs to be able to play their part in the balanced function of the wheel.(29,7) Thus, the two piriformi can be considered a prevertebral muscle axle, stretching from femur to femur. Their horizontal orientation and the psoas’ vertical orientation is responsible for the three-dimensional space in the area between the ribs and the legs. Together the piriformis and psoas support the lumbo-sacral junction—the central joint of the body—as well as hold the front of the spine back with the support of the legs.(30)
The sacrum itself is the keystone bone of the pelvis in both stance and movement. To continue with the architectural analogy, the pelvis is the arch spanning the columns of the legs, where they meet to support the vertebral column and the superstructure of the torso above. Pelvic floor muscles attach to its inferior aspect (the sacral apex); its superior aspect (the sacral base) provides the foundation for the vertebral column. Additionally, the sacrum is the body’s transverse centre of gravity.
Thus, the dynamic relationship between the piriformis and the psoas plays a crucial role in the efficient functioning of the sacrum. A properly functioning sacrum influences core tone and stabilisation. As the “keystone” of the body below the cranium, all structures (osseous and soft tissue) that attach to it are vital for optimally efficient upright stance.
References
(1) Cailliet R. Low back pain syndrome: 5th edition. Philadelphia: FA Davis Company, 1995.
(2) Lee D. The evolution of myths and facts regarding function and dysfunction of the pelvic girdle in Vleeming A, Mooney V, Stoeckart R.(eds) Movement, stability and lumbopelvic pain: 2nd edition. Churchill Livingstone, 2007.
(3) Willard FH. The muscular, ligamentous and neural structure of the lumbosacrum and its relationship to lower back pain in Vleeming A, Mooney V, Stoeckart R.(eds) Movement, stability and lumbopelvic pain: 2nd edition. Churchill Livingstone, 2007.
(4) Kendall F, McCreary E, Provance P, Rodgers M, Romani W. Muscles: testing and function, with posture and pain: 5th edition. Baltimore: Lippincott Williams and Wilkins, 2005.
(5) Bogduk N. 2005 Clinical anatomy of the lumbar spine and sacrum: 4th edition. Churchill Livingstone, 2005.
(6) Travell J, Simons D. Myofascial pain and dysfunction: the trigger point manual, vol 2: the lower extremities. Baltimore: Lippincott, Williams and Wilkins, 1983.
(7) Myers T. Extensor coxae brevis: treatment strategies for the deep lateral rotators in pelvic tilt in Beech M, Kemper P, Schumaker K.(eds) Missoula: IASI 2009 Yearbook of Structural Integration IASI, 2009.
(8) Richardson C, Hodges P, Hides J. Therapeutic exercise for the lumbopelvic stabilization: 2nd edition. Churchill Livingstone, 2004.
(9) DeRosa C, Porterfield J. Anatomical linkages and muscle slings of the lumbopelvic region in Vleeming, A, Mooney V, Stoeckart R.(eds) Movement, stability and lumbopelvic pain: 2nd edition. Churchill Livingstone , 2007.
(10) Gracovetsky S. 2007 Stability or controlled instability in Vleeming A, Mooney V, Stoeckart R.(eds) Movement, stability and lumbopelvic pain: 2nd edition. Churchill Livingstone, 2007.
(11) Lee D. The pelvic girdle: 3rd edition. Churchill Livingstone, 2004.
(12) Lovejoy CO. Evolution of the human lumbopelvic region and its relationship to some clinical deficits of the spine and pelvis in Vleeming A, Mooney V, Stoeckart R.(eds) Movement, stability and lumbopelvic pain: 2nd edition. Churchill Livingstone, 2007.
(13) Myers T. Structural integration: developments in Ida Rolf"s ‘recipe’: part 1. Journal of Bodywork and Movement Therapies 2004a;8(2):131–142.
(14) Smith J. Structural bodywork. Churchill Livingstone, 2005.
(15) Myers T. Structural integration: developments in Ida Rolf"s ‘recipe’: part 2. Journal of Bodywork and Movement Therapies 2004b;8(3):189–198.
(16) Rolf IP. Rolfing: re-establishing the natural alignment and Structural Integration of the human body for vitality and well-being. Rochester: Healing Arts Press, 1977.
(17) Myers T. Anatomy trains: 1st edition. Churchill Livingstone, 2001.
(18) Schleip R. Fascial plasticity—a new neurobiological explanation: part 1. Journal of Bodywork and Movement Therapies 2003a;7(1):11–19.
(19) Schleip R. Fascial plasticity—a new neurobiological explanation: Part 2" Journal of Bodywork and Movement Therapies 2003b;7(2):104–116.
(20) Schleip R, Klingler W, Lehmann-Horn F. Active fascial contractility: fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics. Medical Hypotheses 2005;65:273–277.
(21) Evanko S.P &Vogel,K.G. “Ultrastructure and proteoglycans composition in the developing fibrocartilagenous region of bovine tendon.” Matrix 1990 10: 420-36
(22) Evanko S.P &Vogel,K.G “Proteoglycan synthesis in the fetal tendon is differentially regulated by cyclic compression in vitro.” Arch Biochem Biophys 1992. 298: 303-12
(23) Robbins, J.R., Evanko S.P &Vogel,K.G “Mechanial Loading and TGF-beta regulate proteoglycans synthesis in tendon” Arch Biochem Biophys 1997 342:203-11
(24)Evanko S.P., Tammi, M.I., Tammi,R.H. & Wight, T.N. “Hylauron -dependant pericellular matrix" Adv Drug delivery Review 2007
(25) Chaudry, H.R. Schleip, R., Ji, Z., Bukiet, B., Maney, M. & Findley, T” Three Dimensional mathematical modelfor deformation of human fasciae in manual therapy” Journal of the American Osteopathic Association 2008,108: 379-90
(26) Evanko, S. “Extracellular matrix and the manipulation of Cells and Tissues.” IASI Yearbook 2009 61-68
(27) Cottingham, J.T, Porges,S.W. & Richmond, K. “Shifts in Pelvic Inclination Angle and Parasympathetic Tone Produced by Rolfing Stoft Tissue Manipulation.” Journal of the American Physical Therapy Association 1988 Vol 68 no9 1364-1370
28) Cottingham J. T, Porges,S.W. & Lyon, T. “Effects of Soft Tissue Mobilization (Rolfing Pelvic Lift) On Parasympathetic Tone in Two Age Groups.” Journal of the American Physical Therapy Association 1988 Vol 68 no3 352-357
(29) Myers T. Anatomy Trains: 2nd edition. Churchill Livingstone, 2008.
(30) Maupin E. A dynamic relation to gravity, vol 2—the ten sessions of Structural Integration. Dawn Eve Press, 2005.
(31) Myers T. Structural integration:developments in Ida Rolf"s ‘recipe’: part 3. Journal of Bodywork and Movement Therapies 2004c;8(4):249–264.
Also worth consulting for further elucidation would be the following websites:
http://www.anatomytrains.com/
http://www.somatics.de/
Tuesday, July 7, 2009
Saturday, March 14, 2009
AMT ETHICS WIKI CONTRIBUTIONS 1. Refusal of Treatment/ 2: Draping/ 3: Exceptions to Confidentiality/ 4.Advertising
.
1.REFUSAL OF TREATMENT
When is it appropriate to discontinue working with a client?
When the parameters of the therapeutic relationship have changed for the negative.
When the therapeutic relationship is damaged and beyond repair.
When it is no longer beneficial to either one of the two parties involved.
When there is the threat of physical harm or abuse.
When your client feels the need to test your boundaries e.g. keeping appointments, punctuality, seeking or giving inappropriate personal disclosure.
When the client inappropriately fulfills some social or emotional need of yours or theirs.
When they need work beyond your training or scope of practice.
When you feel in your gut that it isn't appropriate to continue working with them.
When you feel in your heart that it isn't appropriate to continue working with them.
When you know intellectually/ in your mind that it isn't appropriate to continue working with them.
When they have an unrealistic view of you or your work.
How do you approach discontinuing with a client/treatment?
If they test your boundaries, make them aware of it and inform them that if it continues the therapeutic relationship will be terminated.
In the case of immediate threat or abuse, their violating the therapeutic relationship or continually testing your boundaries after warning: inform them the therapeutic relationship is terminated and don't book them for any further sessions. If they've paid in advance return their money. Make it final, no need for further discussion.
If the parameters change for the negative or you are violating the therapeutic relationship or boundaries, seek supervision or mentoring and see what your supervisor/ mentor recommends. Act on it. If you feel it is particularly serious, delay your client's sessions until you have had supervision or have more clarity around the situation.
If it is training, scope of practice, minor boundary violations (i.e. their punctuality), the gut/ heart/ mind feeling or their unrealistic thinking/ expectations, explain that you feel your work isn't benefitting them or is inappropriate for them or that you simply can no longer work with them, but give them referrals to several other practitioners who you feel may be more appropriate to their situation. Explain it to them, terminate the relationship responsibly so that they don't feel "dumped" or left hanging.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
2.DRAPING
The most basic rule or guideline for draping is that it should always be done with the comfort, modesty and dignity of the client foremost in the practitioners mind. It should be done in such a way that:
1) The therapist has access to the relevant, targeted body part to be treated.
2) The client is comfortable with the draping procedure.
If their comfort means they wish to remain fully clothed, then so be it.
3) No more of the body is uncovered than is required.
4) Draping procedures and their rationale should be explained prior to the commencement of the session, and consent or permission sought.
5) If the draping is to be changed during the session, ensure permission has been granted for the new draping position before doing it. There should always be a therapeutic rationale for any change of draping.
The above applies to all passive massage. In more active bodywork or if movement therapy is involved, ensure that your client is wearing appropriately modest clothing that, while allowing you as the practitioner access or the ability to visually observe, THE CLIENT FEELS COMFORTABLE IN WEARING WITHOUT THEIR DIGNITY BEING IMPINGED.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
3. EXCEPTIONS TO CONFIDENTIALITY
Circumstances in which client confidentality can be breached:
1) Self harm: if there is a possibility the client may harm themself.
2) If there is the real possibility of specific harm to a specific other.
3) If there is current child abuse or the danger of abuse to children.
4) As required by a court order.
5) If the client is a minor or is of diminished mental capacity: disclosure can be made to the responsible parent, guardian or carer of the client. Due respect should still be shown for the clients privacy.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
4. ADVERTISING:
Therapists must not advertise or otherwise promote their services in a manner that:
is false, misleading or deceptive, or
is likely to mislead or deceive, or
creates, or is likely to create, an unjustified expectation of beneficial treatment.
creates, or is likely to create, false hope (e.g. massage cures cancer or other serious illnesses or the blatant, massage rids toxins).
Therapists should not advertise or promote services or modalities which they are not certified or qualified to perform. They should not advertise or promote services that are outside their scope of practice.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
1.REFUSAL OF TREATMENT
When is it appropriate to discontinue working with a client?
When the parameters of the therapeutic relationship have changed for the negative.
When the therapeutic relationship is damaged and beyond repair.
When it is no longer beneficial to either one of the two parties involved.
When there is the threat of physical harm or abuse.
When your client feels the need to test your boundaries e.g. keeping appointments, punctuality, seeking or giving inappropriate personal disclosure.
When the client inappropriately fulfills some social or emotional need of yours or theirs.
When they need work beyond your training or scope of practice.
When you feel in your gut that it isn't appropriate to continue working with them.
When you feel in your heart that it isn't appropriate to continue working with them.
When you know intellectually/ in your mind that it isn't appropriate to continue working with them.
When they have an unrealistic view of you or your work.
How do you approach discontinuing with a client/treatment?
If they test your boundaries, make them aware of it and inform them that if it continues the therapeutic relationship will be terminated.
In the case of immediate threat or abuse, their violating the therapeutic relationship or continually testing your boundaries after warning: inform them the therapeutic relationship is terminated and don't book them for any further sessions. If they've paid in advance return their money. Make it final, no need for further discussion.
If the parameters change for the negative or you are violating the therapeutic relationship or boundaries, seek supervision or mentoring and see what your supervisor/ mentor recommends. Act on it. If you feel it is particularly serious, delay your client's sessions until you have had supervision or have more clarity around the situation.
If it is training, scope of practice, minor boundary violations (i.e. their punctuality), the gut/ heart/ mind feeling or their unrealistic thinking/ expectations, explain that you feel your work isn't benefitting them or is inappropriate for them or that you simply can no longer work with them, but give them referrals to several other practitioners who you feel may be more appropriate to their situation. Explain it to them, terminate the relationship responsibly so that they don't feel "dumped" or left hanging.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
2.DRAPING
The most basic rule or guideline for draping is that it should always be done with the comfort, modesty and dignity of the client foremost in the practitioners mind. It should be done in such a way that:
1) The therapist has access to the relevant, targeted body part to be treated.
2) The client is comfortable with the draping procedure.
If their comfort means they wish to remain fully clothed, then so be it.
3) No more of the body is uncovered than is required.
4) Draping procedures and their rationale should be explained prior to the commencement of the session, and consent or permission sought.
5) If the draping is to be changed during the session, ensure permission has been granted for the new draping position before doing it. There should always be a therapeutic rationale for any change of draping.
The above applies to all passive massage. In more active bodywork or if movement therapy is involved, ensure that your client is wearing appropriately modest clothing that, while allowing you as the practitioner access or the ability to visually observe, THE CLIENT FEELS COMFORTABLE IN WEARING WITHOUT THEIR DIGNITY BEING IMPINGED.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
3. EXCEPTIONS TO CONFIDENTIALITY
Circumstances in which client confidentality can be breached:
1) Self harm: if there is a possibility the client may harm themself.
2) If there is the real possibility of specific harm to a specific other.
3) If there is current child abuse or the danger of abuse to children.
4) As required by a court order.
5) If the client is a minor or is of diminished mental capacity: disclosure can be made to the responsible parent, guardian or carer of the client. Due respect should still be shown for the clients privacy.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
4. ADVERTISING:
Therapists must not advertise or otherwise promote their services in a manner that:
is false, misleading or deceptive, or
is likely to mislead or deceive, or
creates, or is likely to create, an unjustified expectation of beneficial treatment.
creates, or is likely to create, false hope (e.g. massage cures cancer or other serious illnesses or the blatant, massage rids toxins).
Therapists should not advertise or promote services or modalities which they are not certified or qualified to perform. They should not advertise or promote services that are outside their scope of practice.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
POSTURE WORKSHOP DESCRIPTION
.
WAYS OF SEEING WAYS OF BEING:
POSTURE BEYOND THE PLUMBLINE.
Ask the average member of the public what posture is and the reply will probably involve all sorts of tales about how to hold the body, about ‘good’ and ‘bad’ posture. Often their emphasis will be on the "hold" part. Ask a bodyworker about posture and the reply may likely involve a description of an imaginary plumbline passing through an ideal, textbook alignment of the body. This view owes much to the pioneers of postural analysis, Henry and Florence Kendall. They identified an “ideal” posture and noted several “faulty” variant postures.
Put most simply, posture is how we hold the body, the positioning of body parts and attitude that allow us to respond to and interact with the environment we live in. There are efficient and inefficient ways to do this. Optimal posture is that which allows us to operate most efficiently in our environment. There are many definitions of posture and many different ways to view the body. My favourite definition is:
“Posture is distribution of body mass in relation to gravity over a base of support. The base of support includes all structures from the feet to the base of the skull.”
As bodyworkers we encounter postural dysfunction in our clients on a daily basis. Most of us are lucky if we have a good understanding of one model of viewing posture. However, there are many possibilities in viewing the body. Having more than one way of viewing bodies enhances our skill as clinicians, enabling us greater understanding of our clients and the ability to offer them a better service.
This workshop is a synthesis of knowledge gained through many years of training, study, experience, observation and enquiry. In it we will examine and discuss many different postural models, observe examples (both in photographs and fellow class members) and learn practical techniques for working with some of the patterns and ways of being we discuss.
It commences with examining the Kendall's classic view of the body as ideal alignment around a plumbline, and the “faulty’ postural variants they identified. We then discuss the role of gravity and Ida Rolf’s contributions to understanding posture; her initial view of segmental blocks stacked in gravity and its later ‘cubes in a sack’ & other variants. Following this we will investigate Sheldon’s typologies, discuss their evolution from their origin in psychology, then digress to look at the relationship of Sheldon’s typology to the Ayurvedic somatic typology.
Next is an in-depth study of Jan Sultan’s ‘internal / external’ model. Influenced by Rolfing and cranio-sacral therapy, it postulates there being several possible responses of the body to gravity. We will do some practical work around treating presentations of the internal/ external model. Hans Flury’s tilt and shift model, which views the body in terms of pelvis/ torso relationship, will also be introduced, as will Robert Schleip’s Flexor/ Extensor model, a refinement of the internal / external model, which also considers the primacy of primitive neural reflexes in motor co-ordination and posture.
Then we consider the evolutionary aspect of posture, how the pelvis has evolved and kyphosis and lordosis as components of mobility and protection in posture; where there are kyphoses, enclosing structures protect vital organs and the body is less mobile, where there are lordoses there is more movement but no bony, protective enclosure. This then leads to Hubert Godard's Tonic Function model of posture and concepts such as G & G1 and Michael Nebadon's Expansional Balance model, popularized by Ed Maupin. We may digress to discuss traditional oriental views of the body, such as charkas and meridians and relate this to the biomechanical model of G & G1. Throughout we will spend time in class observing each other’s posture to reinforce the concepts discussed.
Following from this we look at 'tensegrity' and explore at length Tom Myers "Anatomy Trains" view of the body. He conceives a series of myofascial meridians or slings as representing functional patterns determined by the continuous connections of the fascia. There will be an opportunity to swap work on each other, working two of the myofascial meridians.
Time permitting, there could be further discussion about Sheldon’s Typology and its Ayurvedic correlations, and pertinent treatment indications. As a final digression, we will briefly examine Alexander Lowen' and Stanley Keleman’s Bioenergetic view of the body, drawn from somatic psychotherapy.
© Colin Rossie 2007
WAYS OF SEEING WAYS OF BEING:
POSTURE BEYOND THE PLUMBLINE.
Ask the average member of the public what posture is and the reply will probably involve all sorts of tales about how to hold the body, about ‘good’ and ‘bad’ posture. Often their emphasis will be on the "hold" part. Ask a bodyworker about posture and the reply may likely involve a description of an imaginary plumbline passing through an ideal, textbook alignment of the body. This view owes much to the pioneers of postural analysis, Henry and Florence Kendall. They identified an “ideal” posture and noted several “faulty” variant postures.
Put most simply, posture is how we hold the body, the positioning of body parts and attitude that allow us to respond to and interact with the environment we live in. There are efficient and inefficient ways to do this. Optimal posture is that which allows us to operate most efficiently in our environment. There are many definitions of posture and many different ways to view the body. My favourite definition is:
“Posture is distribution of body mass in relation to gravity over a base of support. The base of support includes all structures from the feet to the base of the skull.”
As bodyworkers we encounter postural dysfunction in our clients on a daily basis. Most of us are lucky if we have a good understanding of one model of viewing posture. However, there are many possibilities in viewing the body. Having more than one way of viewing bodies enhances our skill as clinicians, enabling us greater understanding of our clients and the ability to offer them a better service.
This workshop is a synthesis of knowledge gained through many years of training, study, experience, observation and enquiry. In it we will examine and discuss many different postural models, observe examples (both in photographs and fellow class members) and learn practical techniques for working with some of the patterns and ways of being we discuss.
It commences with examining the Kendall's classic view of the body as ideal alignment around a plumbline, and the “faulty’ postural variants they identified. We then discuss the role of gravity and Ida Rolf’s contributions to understanding posture; her initial view of segmental blocks stacked in gravity and its later ‘cubes in a sack’ & other variants. Following this we will investigate Sheldon’s typologies, discuss their evolution from their origin in psychology, then digress to look at the relationship of Sheldon’s typology to the Ayurvedic somatic typology.
Next is an in-depth study of Jan Sultan’s ‘internal / external’ model. Influenced by Rolfing and cranio-sacral therapy, it postulates there being several possible responses of the body to gravity. We will do some practical work around treating presentations of the internal/ external model. Hans Flury’s tilt and shift model, which views the body in terms of pelvis/ torso relationship, will also be introduced, as will Robert Schleip’s Flexor/ Extensor model, a refinement of the internal / external model, which also considers the primacy of primitive neural reflexes in motor co-ordination and posture.
Then we consider the evolutionary aspect of posture, how the pelvis has evolved and kyphosis and lordosis as components of mobility and protection in posture; where there are kyphoses, enclosing structures protect vital organs and the body is less mobile, where there are lordoses there is more movement but no bony, protective enclosure. This then leads to Hubert Godard's Tonic Function model of posture and concepts such as G & G1 and Michael Nebadon's Expansional Balance model, popularized by Ed Maupin. We may digress to discuss traditional oriental views of the body, such as charkas and meridians and relate this to the biomechanical model of G & G1. Throughout we will spend time in class observing each other’s posture to reinforce the concepts discussed.
Following from this we look at 'tensegrity' and explore at length Tom Myers "Anatomy Trains" view of the body. He conceives a series of myofascial meridians or slings as representing functional patterns determined by the continuous connections of the fascia. There will be an opportunity to swap work on each other, working two of the myofascial meridians.
Time permitting, there could be further discussion about Sheldon’s Typology and its Ayurvedic correlations, and pertinent treatment indications. As a final digression, we will briefly examine Alexander Lowen' and Stanley Keleman’s Bioenergetic view of the body, drawn from somatic psychotherapy.
© Colin Rossie 2007
OBSERVATIONS ON CLIENTS W/ AUTISM & ASPERGER'S.
.
© Colin Rossie 2008. Not to be printed or used without permission of the copyright holder.
There is a world of difference between autism & Aspergers Syndrome (AS). What I write in the following article is from the coalface: over the last 9 years I have worked with people from both communities over a wide age range.
AS has a whole spectrum from mild to severe. I would differentiate it from autism, even though the DSM IV puts it into the autism range of disorders. My personal observation is that autistic people tend to look inward, minimize engagement with the external world and are easily stressed by it. Aspies will engage with the external world, but in a way reminiscent of children: great enthusiasm, but with the narrow focus of the special interests that takes their attention. They are interested in everything, but ESPECIALLY in their specific thing(s).
Because of both personal and clinical experience, I feel the DSM-IV's diagnostic criteria should be refined even further. It is commonly reported that in movement and coordination those with AS can be awkward, ungainly, clumsy, stiff & un-coordinated. While this is true of the majority, in my observation a sizeable percentage (maybe 20%) have an exceptional, almost unnatural, grace, coordination & balance in their movement. For example, from a Rolfing perspective, it is really difficult to pick if they internals or externals, G or G prime oriented. A deciding factor seems to be training early in life- particularly if it was dance, martial arts or yoga. Distance running also seems agreeable with them. Weights and gym work earlier in life do not seem to have the same effect.
Some symptoms often associated with autism spectrum & AS (ADD/ADHD/ lack of focus) may be secondary to not receiving appropriate support or to poor diet. They may be more of a misdiagnosis. AS clients could possibly become easily bored with routine if it does not support where their mind travels- for them, it is hard being a square peg in a round hole. Often the neurotypical world does not treat Aspergers as a unique variation of the human experience with equal validity, instead trying to make Aspies conform to behaviours and ways of being that, while those of the normal world, are foreign to their way of being: "notions not our own, nor suited to us". If being academically bored is not recognized it could lead to high school dropout; not being diagnosed can lead in extreme cases to violent behaviour (both physical &/or verbal) in social interactions, social and academic failure, drug & alcohol abuse, inability to form or maintain relationships and other self-destructive behaviours. Socially and emotionally, they are like children for life, needing a lot of hard work, nurture and support. If they receive this, they can blossom and their high intelligence and special talents can contribute positively to the world around them. To use a motor vehicle as an analogy, not all cylinders are firing emotionally, and those that are often do so inappropriately.
Clinical anecdote is no substitute for solid research, but it can inform the way we work & become the raw data for further hypotheses; what I write is based on observation of 40 plus clients over the last 9 years. I’d be interested to know the experiences and observations of other massage therapists and bodyworkers, what they think of what I relate and any further observation, experiences and thoughts that could contribute to this discussion.
Regarding autism:
Generally I find those with an autism diagnosis difficult to co-opt into the participation part of Rolfing, though this may apply across the spectrum of massage and bodywork. Depending on the degree of autism and age, their responses can range from:
• A lack of any sense of involvement (generally found in extreme autism and the very young, often clients 'sent' along by anxious parents/ caregivers), to
• Finding it a nice thing to look forward to but without true engagement (generally moderate autistics, adolescents & older children, curious adults), to
• Being obsessively engaged in Rolfing (no particular demographic- I have had a 9-year autistic boy who, after session one, read everything he could about Rolfing and wanted to come every day for 10 days! Others google more info than either you or I would know was out there); through to
• Anger (generally adults or those unhappy people "sent" by somebody for work).
Some fellow bodywork practitioners have noted that it can be a problem if their client has been "sent" for work (by a parent, caregiver or partner) and are unwillingly participants in the process. In my experience, it would be unlikely to get an autistic client otherwise- bodywork would not be on their horizon under normal circumstances.
As with any client, range & type of contact varies. In young children and those with extreme autism, I forgo the concept of a Rolfing series that aims for specific, sequential outcomes. Without trying to be prescriptive, I've found the following approachs generally work well: start with light contact that gradually increases compression/ pressure in one area without moving much or quickly. If I can engage the client, I will involve them in movement- not always easy. Set it up really well - explain and demonstrate what you want and encourage them gently. Applaud their efforts no matter how far removed it is from what you would have liked the outcome to be. Not having done much cranial training, I tend to refer all ages to the local osteopath, so they receive cranial work concurrent with my work.
My experience is that it is not unusual to see autistic clients only a few times; sometimes they or their caregiver/ partner opt entirely for cranial work, sometimes there is impatience that Rolfing is not a magical, quick- fix silver bullet with immediate results. Sometimes, especially if they’ve been 'sent' along, the client may want it to fail, so only come for one session. I've heard variations on the following after one session: "See! Happy now? I've done that Rolfing thing you wanted me to do!". Sometimes though, even if it is exceptionally gentle, the physical contact can be too much for them, too confronting.
Regarding Aspergers:
Aspergers clients, on the other hand, are usually entirely different. If they've been 'sent', the trick is to engage them. Once you've done that, they can be the most enthusiastic, compliant clients. If they have come of their own accord (movement and co ordination problems sometimes bring them, sometimes Rolfing has been casually mentioned to them and they've run with the recommendation), I generally find they have well researched not only Rolfing on google but also everything they can find about me before they arrive on the doorstep. They can be among the most enthusiastic clients, sometimes a little too enthusiastic. They can take you very literally- be prepared for the odd turn of phrase, the peculiar emphasis on words and patterns, the overdoing it, the enthusiasm that can seem bordering on mania. Once you have engaged them, they can talk endlessly about the minutiae of their responses to the work you undertake together.
I involve them in a lot of active movement participation while working their tissue in order to enhance their proprioception & coordination; also lots of basic, perceptual movement work lying supine, in sitting and off the table (both standing and lying on the floor). I also utilize props such as yoga blocks, Torson bolsters, Duradiscs and Swiss balls (both semi inflated as well as fully inflated) to introduce novelty to their sensory experience and engage them in different ways of thinking about how they use their body. I always introduce these new inputs gradually and explain fully what we are trying to achieve and why. Though their curiosity can be utilized in sessions, they can also be easily overloaded. Sometimes the unexpected, the change from routine, can disrupt their comfort zone, but if they can see the logic in what is being attempted they can usually embrace it with enthusiasm.
Because the bodywork experience can be quite profound for them, they may begin to regard you as their best friend for life. But AS clients can also be incredibly awkward socially and not forthcoming, so working with them involves treading a fine line: to engage them so they feel involved with the process without allowing the new best friend forever attitude (which erodes the therapeutic relationship). It is also possible to be bored to death by their enthusiasm.
Be aware of boundaries: sexual boundaries will not be the problem, time and appropriate disclosure will be. Friendships for them can be based on shared special interests rather than any deep amicability or compatibility. This friendship thing can be a steep learning curve for the therapist. No matter what their age, I find it helps me to think of dealing with a very precocious, curious child (think 8 year old) with the emotional volatility of the early teens thrown in, and all the obsessiveness that could be attendant upon those two ages. Another attitude I find useful to adopt I term “the distant relative”: politely engage them when they are there, no need to do so until they are back again.
Jum tungan, an Indonesian saying, "time is rubber", can typify their approach. Let them know at the start of the session what time you have to finish with them so they are aware of your boundaries. As clients they can often have no sense of time, being either late or extremely early. No strategy you may have in place for this will affect them profoundly; they seem impervious, so as a therapist you need to be tough. Never start the session earlier than the time you have scheduled it for. I sometimes use the strategy of telling them finish time is 15 minutes earlier- that way they can have their talking time and I can still keep on schedule. If they are enthusiastic about the work, they can talk to a (sometimes boring) standstill about it. Coincidentally, if they are enthusiastic about your work, they will talk to everyone about you, becoming a walking, talking advertisement for you. Of the 5 principles of Rolfing, always wholism, but in their case especially closure.
© Colin Rossie 2008. Not to be printed or used without permission of the copyright holder.
There is a world of difference between autism & Aspergers Syndrome (AS). What I write in the following article is from the coalface: over the last 9 years I have worked with people from both communities over a wide age range.
AS has a whole spectrum from mild to severe. I would differentiate it from autism, even though the DSM IV puts it into the autism range of disorders. My personal observation is that autistic people tend to look inward, minimize engagement with the external world and are easily stressed by it. Aspies will engage with the external world, but in a way reminiscent of children: great enthusiasm, but with the narrow focus of the special interests that takes their attention. They are interested in everything, but ESPECIALLY in their specific thing(s).
Because of both personal and clinical experience, I feel the DSM-IV's diagnostic criteria should be refined even further. It is commonly reported that in movement and coordination those with AS can be awkward, ungainly, clumsy, stiff & un-coordinated. While this is true of the majority, in my observation a sizeable percentage (maybe 20%) have an exceptional, almost unnatural, grace, coordination & balance in their movement. For example, from a Rolfing perspective, it is really difficult to pick if they internals or externals, G or G prime oriented. A deciding factor seems to be training early in life- particularly if it was dance, martial arts or yoga. Distance running also seems agreeable with them. Weights and gym work earlier in life do not seem to have the same effect.
Some symptoms often associated with autism spectrum & AS (ADD/ADHD/ lack of focus) may be secondary to not receiving appropriate support or to poor diet. They may be more of a misdiagnosis. AS clients could possibly become easily bored with routine if it does not support where their mind travels- for them, it is hard being a square peg in a round hole. Often the neurotypical world does not treat Aspergers as a unique variation of the human experience with equal validity, instead trying to make Aspies conform to behaviours and ways of being that, while those of the normal world, are foreign to their way of being: "notions not our own, nor suited to us". If being academically bored is not recognized it could lead to high school dropout; not being diagnosed can lead in extreme cases to violent behaviour (both physical &/or verbal) in social interactions, social and academic failure, drug & alcohol abuse, inability to form or maintain relationships and other self-destructive behaviours. Socially and emotionally, they are like children for life, needing a lot of hard work, nurture and support. If they receive this, they can blossom and their high intelligence and special talents can contribute positively to the world around them. To use a motor vehicle as an analogy, not all cylinders are firing emotionally, and those that are often do so inappropriately.
Clinical anecdote is no substitute for solid research, but it can inform the way we work & become the raw data for further hypotheses; what I write is based on observation of 40 plus clients over the last 9 years. I’d be interested to know the experiences and observations of other massage therapists and bodyworkers, what they think of what I relate and any further observation, experiences and thoughts that could contribute to this discussion.
Regarding autism:
Generally I find those with an autism diagnosis difficult to co-opt into the participation part of Rolfing, though this may apply across the spectrum of massage and bodywork. Depending on the degree of autism and age, their responses can range from:
• A lack of any sense of involvement (generally found in extreme autism and the very young, often clients 'sent' along by anxious parents/ caregivers), to
• Finding it a nice thing to look forward to but without true engagement (generally moderate autistics, adolescents & older children, curious adults), to
• Being obsessively engaged in Rolfing (no particular demographic- I have had a 9-year autistic boy who, after session one, read everything he could about Rolfing and wanted to come every day for 10 days! Others google more info than either you or I would know was out there); through to
• Anger (generally adults or those unhappy people "sent" by somebody for work).
Some fellow bodywork practitioners have noted that it can be a problem if their client has been "sent" for work (by a parent, caregiver or partner) and are unwillingly participants in the process. In my experience, it would be unlikely to get an autistic client otherwise- bodywork would not be on their horizon under normal circumstances.
As with any client, range & type of contact varies. In young children and those with extreme autism, I forgo the concept of a Rolfing series that aims for specific, sequential outcomes. Without trying to be prescriptive, I've found the following approachs generally work well: start with light contact that gradually increases compression/ pressure in one area without moving much or quickly. If I can engage the client, I will involve them in movement- not always easy. Set it up really well - explain and demonstrate what you want and encourage them gently. Applaud their efforts no matter how far removed it is from what you would have liked the outcome to be. Not having done much cranial training, I tend to refer all ages to the local osteopath, so they receive cranial work concurrent with my work.
My experience is that it is not unusual to see autistic clients only a few times; sometimes they or their caregiver/ partner opt entirely for cranial work, sometimes there is impatience that Rolfing is not a magical, quick- fix silver bullet with immediate results. Sometimes, especially if they’ve been 'sent' along, the client may want it to fail, so only come for one session. I've heard variations on the following after one session: "See! Happy now? I've done that Rolfing thing you wanted me to do!". Sometimes though, even if it is exceptionally gentle, the physical contact can be too much for them, too confronting.
Regarding Aspergers:
Aspergers clients, on the other hand, are usually entirely different. If they've been 'sent', the trick is to engage them. Once you've done that, they can be the most enthusiastic, compliant clients. If they have come of their own accord (movement and co ordination problems sometimes bring them, sometimes Rolfing has been casually mentioned to them and they've run with the recommendation), I generally find they have well researched not only Rolfing on google but also everything they can find about me before they arrive on the doorstep. They can be among the most enthusiastic clients, sometimes a little too enthusiastic. They can take you very literally- be prepared for the odd turn of phrase, the peculiar emphasis on words and patterns, the overdoing it, the enthusiasm that can seem bordering on mania. Once you have engaged them, they can talk endlessly about the minutiae of their responses to the work you undertake together.
I involve them in a lot of active movement participation while working their tissue in order to enhance their proprioception & coordination; also lots of basic, perceptual movement work lying supine, in sitting and off the table (both standing and lying on the floor). I also utilize props such as yoga blocks, Torson bolsters, Duradiscs and Swiss balls (both semi inflated as well as fully inflated) to introduce novelty to their sensory experience and engage them in different ways of thinking about how they use their body. I always introduce these new inputs gradually and explain fully what we are trying to achieve and why. Though their curiosity can be utilized in sessions, they can also be easily overloaded. Sometimes the unexpected, the change from routine, can disrupt their comfort zone, but if they can see the logic in what is being attempted they can usually embrace it with enthusiasm.
Because the bodywork experience can be quite profound for them, they may begin to regard you as their best friend for life. But AS clients can also be incredibly awkward socially and not forthcoming, so working with them involves treading a fine line: to engage them so they feel involved with the process without allowing the new best friend forever attitude (which erodes the therapeutic relationship). It is also possible to be bored to death by their enthusiasm.
Be aware of boundaries: sexual boundaries will not be the problem, time and appropriate disclosure will be. Friendships for them can be based on shared special interests rather than any deep amicability or compatibility. This friendship thing can be a steep learning curve for the therapist. No matter what their age, I find it helps me to think of dealing with a very precocious, curious child (think 8 year old) with the emotional volatility of the early teens thrown in, and all the obsessiveness that could be attendant upon those two ages. Another attitude I find useful to adopt I term “the distant relative”: politely engage them when they are there, no need to do so until they are back again.
Jum tungan, an Indonesian saying, "time is rubber", can typify their approach. Let them know at the start of the session what time you have to finish with them so they are aware of your boundaries. As clients they can often have no sense of time, being either late or extremely early. No strategy you may have in place for this will affect them profoundly; they seem impervious, so as a therapist you need to be tough. Never start the session earlier than the time you have scheduled it for. I sometimes use the strategy of telling them finish time is 15 minutes earlier- that way they can have their talking time and I can still keep on schedule. If they are enthusiastic about the work, they can talk to a (sometimes boring) standstill about it. Coincidentally, if they are enthusiastic about your work, they will talk to everyone about you, becoming a walking, talking advertisement for you. Of the 5 principles of Rolfing, always wholism, but in their case especially closure.
ROTATOR CUFF TENDINITIS
Published in the AMT Journal "In Good Hands", September 2008
© AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
Clients with shoulder conditions often self diagnose and report having either frozen shoulder or “rotator cuff”, as though that in itself is the name of a disorder! Often GPs tell their patient that is what they have without even looking at them.
All joints are a compromise of stability versus mobility. In the case of the shoulder, the requirement for mobility has the upper hand (excuse the pun). The functioning of the shoulder requires it to be a highly mobile structure, especially at the Glenohumeral Joint (GHJ). The four muscles of the rotator cuff (Supraspinatus, Infraspinatus, Teres Minor and Subscapularis) attempt to give it greater stability. They enclose the joint capsule, their tendon fibres often blending with the joint capsule, acting as soft tissue stabilisers for the GHJ. The highly mobile nature of the shoulder means they are readily susceptible to injury.
Tendinitis is an acute inflammation, often a partial tear of the tendon. Tendinosis is a more chronic manifestation, being disorganised and chaotic scar tissue within the tendon, the result of poorly healed past injury and poorly formed collagen. In extreme cases, tendons can be quite calcific.
Physiology and assessment
Supraspinatus acts to initiate abduction. Infraspinatus and Teres Minor act to externally rotate the humerus; Subscapularis internally rotates the humerus. As noted earlier, all four muscles stabilise the humeral head in the glenoid fossa, both in static posture as the arms hang by the side and dynamically during gait and in using the upper limb for activities such as reaching, eating and bringing objects toward us.
The movements available at the GHJ are flexion/extension, abduction/adduction and internal/ external rotation. I would test all these to determine how the function is affected. Apley’s scratch test in its various stages covers all of these movements. Two tests that indicate general dysfunction in the rotator cuff complex are the Drop Arm test (also known as Codman’s test) and the Abrasion Sign 1,2 .
Many structures in the glenohumeral area can create pain (bursa, ligaments, nerves etc). With a client presenting with rotator cuff tendonitis or tendonosis, I would take a history, consider differential diagnoses and refer them to their medical practitioner for further testing if I sensed any red flags, had any doubts or felt further investigation or information was required.
Assuming that all red flags were addressed and it was safe to proceed with treatment, initially I would observe the client’s pain free active ROM then gently take them through passive ROM testing. I’d emphasise the need to do active ROM gently and would perform the passive ROM within their limit. The last thing l’d want is to further tear an already damaged tendon. For the same reason, any resisted testing should be done gently- if at all- with the emphasis on monitoring muscle function rather than opposing it. Avoid any extreme stretching with rotator cuff tendonitis. I would also avoid treatment techniques that involve an element of stretching, such as MET, CRAC or PNF. In the more chronic tendinosis scenario or in subacute tendinitis, these techniques could perhaps be used with appropriate care and caution. In partial or complete tears they should be avoided altogether.
After the initial health screen, questioning, ROM and special tests, I would then observe the client’s total posture, noting any left / right differences in the shoulder girdles and anything unusual in their thorax and torso that may be contributing to their presentation.
I have two approaches to working with clients. One I term ‘fix – it’, where I‘m working primarily with the local phenomena that clients present with on that day. The other is a more integrative approach, looking at the body globally and seeing local dysfunctions as part of that person’s totality- this approach heavily influenced by my training in Rolfing® Structural Integration (2,3,4). Often, when we’re training as Massage Therapists, we are taught to view the musculoskeletal system as the 435(6)- 650 (approx)(7) separate skeletal muscles that act in specific ways on the joints. From the structural integration perspective descended from Dr Rolf’s work, an inverse view can be taken – that there is one fascial continuity, muscles being spacers within the fascia (8).
Communicating openly with the client and sensing from the dialogue what they expect from the treatment and what will produce the best results given those expectations basically determines the direction I take (more fix-it or more integrative). As a conscientious practitioner, I would always do the best for my client by utilising every technique in my therapeutic toolbox that seems appropriate for them. What follows are descriptions of possible methods of treatment, however, nothing is intended as rigid or prescriptive. One should be responsive to the client as they present. I fiercely hate the concept of formulas when applied to the body. As an ex-chef I much prefer the metaphor of a recipe that is adaptable to the circumstances at hand.
Much of what follows is from a fix it perspective, as I feel Paul Doney has quite thoroughly addressed the wholistic perspective.
Remedial Treatment Perspective
In the acute phase, the treatment is protection, rest, ice, compression and elevation. Send the client to their doctor for testing.
In the subacute phase, the aim of the treatment is to decrease swelling, then work to bunch tissue into the area of injury to encourage collagen cross linkages and scar formation.
In the chronic phase, or if you are seeing the client for the first time, determine what rotator cuff muscles are involved. Palpate the myofascia to get a more discriminating sense of its condition, and to confirm or refute your observations. Deactivate any obvious, palpable trigger points that are present, then continue and deepen the palpation so that you are working the myofascia, using both the gentle Barnes style myofascial release and the more direct myofascial techniques popularly associated with Rolfing (9,10). This latter could take two forms, either ‘spots’ or ‘stripes’. ‘Spots’ involves palpating then holding one spot that feels restricted until the tissue changes texture and tension. ‘Stripes’ involves sinking into and then following a line of restriction within the myofascia, again sensing changes in texture and tension, similar to cold butter warming and giving way. One could use a variety of options as tools: the whole fingers, the whole palm, the finger pads, the thenar eminence, the heel of the hand, one or two fingers, the knuckles (either the proximal or the medial phalanges), the thumb pad, the distal phalanx of the thumb, and reinforced fingers.
Supraspinatus
Supraspinatus is the most commonly torn rotator cuff muscle. It initiates abduction and assists the middle deltoid in all abduction. However, it is nowhere near as strong as the middle deltoid. When in dysfunction, it can be active even with the arm just hanging by the side. The Painful Arc will be positive in the 85º -110º range, but I find this test moderately useless as it could also indicate other things, such as subacromial bursitis, calcium deposits etc. A positive Empty Can Test is an indicator of a supraspinatus tear. Various impingement tests (such as the Neer and the Hawkins–Kennedy)(1) also indicate supraspinatus involvement.
Initially I would primarily target the belly of the muscle, continuing carefully into the tendon. View the tendon as a continuation of the fascia past where the muscle fibres finish: once the myofascia has been suitably addressed start working the tendon more specifically. In chronic or calcific tendinitis and tendinosis, tendon damage and reduced function is present but without the inflammatory process to initiate the repair. Transverse frictions to the tendon induce controlled damage, re initiating the inflammatory response and renewing the ability for repair. It also encourages increased vascularity in otherwise vascularly undersupplied tissue. After working transverse, work along the line of pull of the structure with the intent of aligning the freshly redamaged tissue. Fibrinogen, the precursor to creating collagen fibres, realigns appropriately if encouraged in this way (11,12). I would be more circumspect with acute tendinitis and wait for the healing process to be under way before attempting transverse friction work. The two places on the tendon most prone to damage are the myotendinous junction (where the muscles cease within the connective tissue) and the tenoperiosteal junction where the tendon fibres insert into the periosteum of the bone.
All the techniques described above could be applied to the supraspinatus with the client seated or side lying. The U formed by the clavicle and spine of scapula is a good spot to access the supraspinatus tendon, especially its myotendinous junction. The tenoperiosteal junction of supraspinatus is on the humeral head; to access it in order to apply transverse frictions have the client side lying, involved side up, and passively extend the humerus, which moves the humeral head forward of the acromion allowing access to the tendon.
Subscapularis
If subscapularis requires work, I follow a similar protocol but with the client supine. Work the posterior aspect of the axilla, on the anterior surface of the scapula (just antero-medial to the lateral border of the scapula.) Commence by applying a discriminating palpation, identifying the condition of the tissue, deactivate trigger points if present, and continue that discriminating palpation to work on the totality of the myofascia using the myofascial methods outlined above. Have the client’s elbow flexed 90º and GHJ abducted 90º and externally rotated to allow greater access to the muscle. Ask for movement, getting them to abduct further by reaching away with their fingers and then move back to 90º with their elbow leading the way. The subscapularis tendon is on the lesser tubercle of the humerus: when working it, be sure that it is what you are on. If it moves in elbow flexion it is the long head of biceps brachii (a common mistake). Superiorly it attaches to the GHJ articular capsule; so again I emphasis the palpate / discriminate aspect of this work.
Infraspinatus
Infraspinatus rarely exhibits tendinitis, except as a result of impact injury. However, this muscle often has trigger points and the kind of chronic, fibrotic change associated with constant low-level stresses. This results from its stabilising role - when other rotator cuff muscles are damaged it becomes over-active.
To work supraspinatus, I have the client prone, GHJ abducted 90º and forearm dangling over the edge of the table (in more precise anatomical terms, the humerus is also partially externally rotated and elbow flexed 90º). Trigger points are almost always present so I deactivate them first. Then work, initially lightly with the finger pads, along the fibres from the medial scapula border to the insertion in the humerus. Have the client extend and flex the elbow joint as you pass along the muscle. You can gradually increase the depth of your work each pass and ask the client to increase the internal rotation of the humerus as they raise their forearm. Please note that increased depth does not necessarily equate with greater pressure, more a case of gently exploring and exploiting any opening that the tissue allows. With their elbow flexed, the client can also internally and externally rotate the humerus in an ever-increasing range as you work on them.
Teres Minor
When treating Teres Minor, I have the client side lying, arm abducted so that the upper arm rests on the side of the head. If the client’s ROM doesn’t allow this, have it rest on the table in front of them. Apply the same protocols as before, working along the muscle from origin to insertion. In my clinical experience, it is rarely a player in rotator cuff tendinitis but feels good to be worked. Damage is most likely in those who overdo weight training. (13)
The Integrative Perspective
From a global perspective, I would look at the position of the scapula and the forces operating on it. Pectoralis minor, serratus anterior, the rhomboids, coracobrachialis, levator scapulae and the trapezius all influence scapula position directly. Consider the myofascial sling created by the rhomboids and serratus anterior: the scapula can be viewed as a ‘sesamoid’ bone within this sling. Don’t overlook pectoralis minor: it affects scapula position and in my clinical experience is usually a major player in clients with rotator cuff tendinitis. Pectoralis major and latissimus dorsi also affect scapula position indirectly. Omohyoid and sub clavius can be bit players. The function of biceps brachii and attendant muscles coracobrachialis, brachialis and supinator, can affect glenohumeral function. Really obvious is the middle deltoid: its function is intimately tied to supraspinatus. Also, thoracic rotations are a major consideration in glenohumeral function: in scoliosis, for example, one scapula will be protracted, the other retracted; one in internal rotation, one external. Thus the forces operating on each shoulder complex will be different, which can either create or aggravate already existing tendinitis. Don’t forget the fascia, especially the clavi-pectoral fascia. Work around the clavicle generally can be helpful. Compensation is another factor: avoiding using the involved side will lead to overuse of the other side and the same condition manifesting. Also, remember that trigger points from the rotator cuff muscles can refer into the wrist and lead to a mistaken carpal tunnel diagnosis
1. Magee, D. J. “Orthopedic Physical Assessment” Saunders, 3rd edition 1997
2. Petty, N. & Moore, A. “Neuromusculoskeletal Examination & Assessment” Churchill Livingstone 1998
3. Sise, B. “The Rolfing Experience” Hohm Press 2005
4. Maupin, E. “A Dynamic Relation To Gravity, Volume 1: The Elements of Structural Integration” Maupin, self published, most recent edition 2006
5. Maupin, E. “A Dynamic Relation To Gravity, Volume 2: The Ten Sessions of Structural Integration.” Maupin, self published, most recent edition 2006
6. Gregor, R.J. ‘The structure & function of skeletal muscle’ in Rasch, P.J. “Kinesiology & Applied Anatomy” Lea & Febiger 7th edition, 1989
7. Tabners Medical Dictionary
8. Myers, T. “Anatomy Trains: Myofascial Meridians for Manual Therapists” Churchill Livingstone 2001
9. Smith, J. “Structural Bodywork” Churchill Livingstone 2005
10. Stanborough, M. “Direct Release Myofascial Technique” Churchill Livingstone 2004
11. Cantu, R. & Grodin, A. J. “Myofascial Manipulation” Aspen Publishers 1992
12. Various articles in Findley, T. W. & Schleip, R. “Fascia Research” Elsevier 2007
13. Simons, D. G., Travell, J.G. & Simons, L. S. “Myofascial Pain and Dysfunction: The Trigger Point Manual Volume 1 upper Half of Body” Williams & Wilkins 2nd Edition 1999
© AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
Clients with shoulder conditions often self diagnose and report having either frozen shoulder or “rotator cuff”, as though that in itself is the name of a disorder! Often GPs tell their patient that is what they have without even looking at them.
All joints are a compromise of stability versus mobility. In the case of the shoulder, the requirement for mobility has the upper hand (excuse the pun). The functioning of the shoulder requires it to be a highly mobile structure, especially at the Glenohumeral Joint (GHJ). The four muscles of the rotator cuff (Supraspinatus, Infraspinatus, Teres Minor and Subscapularis) attempt to give it greater stability. They enclose the joint capsule, their tendon fibres often blending with the joint capsule, acting as soft tissue stabilisers for the GHJ. The highly mobile nature of the shoulder means they are readily susceptible to injury.
Tendinitis is an acute inflammation, often a partial tear of the tendon. Tendinosis is a more chronic manifestation, being disorganised and chaotic scar tissue within the tendon, the result of poorly healed past injury and poorly formed collagen. In extreme cases, tendons can be quite calcific.
Physiology and assessment
Supraspinatus acts to initiate abduction. Infraspinatus and Teres Minor act to externally rotate the humerus; Subscapularis internally rotates the humerus. As noted earlier, all four muscles stabilise the humeral head in the glenoid fossa, both in static posture as the arms hang by the side and dynamically during gait and in using the upper limb for activities such as reaching, eating and bringing objects toward us.
The movements available at the GHJ are flexion/extension, abduction/adduction and internal/ external rotation. I would test all these to determine how the function is affected. Apley’s scratch test in its various stages covers all of these movements. Two tests that indicate general dysfunction in the rotator cuff complex are the Drop Arm test (also known as Codman’s test) and the Abrasion Sign 1,2 .
Many structures in the glenohumeral area can create pain (bursa, ligaments, nerves etc). With a client presenting with rotator cuff tendonitis or tendonosis, I would take a history, consider differential diagnoses and refer them to their medical practitioner for further testing if I sensed any red flags, had any doubts or felt further investigation or information was required.
Assuming that all red flags were addressed and it was safe to proceed with treatment, initially I would observe the client’s pain free active ROM then gently take them through passive ROM testing. I’d emphasise the need to do active ROM gently and would perform the passive ROM within their limit. The last thing l’d want is to further tear an already damaged tendon. For the same reason, any resisted testing should be done gently- if at all- with the emphasis on monitoring muscle function rather than opposing it. Avoid any extreme stretching with rotator cuff tendonitis. I would also avoid treatment techniques that involve an element of stretching, such as MET, CRAC or PNF. In the more chronic tendinosis scenario or in subacute tendinitis, these techniques could perhaps be used with appropriate care and caution. In partial or complete tears they should be avoided altogether.
After the initial health screen, questioning, ROM and special tests, I would then observe the client’s total posture, noting any left / right differences in the shoulder girdles and anything unusual in their thorax and torso that may be contributing to their presentation.
I have two approaches to working with clients. One I term ‘fix – it’, where I‘m working primarily with the local phenomena that clients present with on that day. The other is a more integrative approach, looking at the body globally and seeing local dysfunctions as part of that person’s totality- this approach heavily influenced by my training in Rolfing® Structural Integration (2,3,4). Often, when we’re training as Massage Therapists, we are taught to view the musculoskeletal system as the 435(6)- 650 (approx)(7) separate skeletal muscles that act in specific ways on the joints. From the structural integration perspective descended from Dr Rolf’s work, an inverse view can be taken – that there is one fascial continuity, muscles being spacers within the fascia (8).
Communicating openly with the client and sensing from the dialogue what they expect from the treatment and what will produce the best results given those expectations basically determines the direction I take (more fix-it or more integrative). As a conscientious practitioner, I would always do the best for my client by utilising every technique in my therapeutic toolbox that seems appropriate for them. What follows are descriptions of possible methods of treatment, however, nothing is intended as rigid or prescriptive. One should be responsive to the client as they present. I fiercely hate the concept of formulas when applied to the body. As an ex-chef I much prefer the metaphor of a recipe that is adaptable to the circumstances at hand.
Much of what follows is from a fix it perspective, as I feel Paul Doney has quite thoroughly addressed the wholistic perspective.
Remedial Treatment Perspective
In the acute phase, the treatment is protection, rest, ice, compression and elevation. Send the client to their doctor for testing.
In the subacute phase, the aim of the treatment is to decrease swelling, then work to bunch tissue into the area of injury to encourage collagen cross linkages and scar formation.
In the chronic phase, or if you are seeing the client for the first time, determine what rotator cuff muscles are involved. Palpate the myofascia to get a more discriminating sense of its condition, and to confirm or refute your observations. Deactivate any obvious, palpable trigger points that are present, then continue and deepen the palpation so that you are working the myofascia, using both the gentle Barnes style myofascial release and the more direct myofascial techniques popularly associated with Rolfing (9,10). This latter could take two forms, either ‘spots’ or ‘stripes’. ‘Spots’ involves palpating then holding one spot that feels restricted until the tissue changes texture and tension. ‘Stripes’ involves sinking into and then following a line of restriction within the myofascia, again sensing changes in texture and tension, similar to cold butter warming and giving way. One could use a variety of options as tools: the whole fingers, the whole palm, the finger pads, the thenar eminence, the heel of the hand, one or two fingers, the knuckles (either the proximal or the medial phalanges), the thumb pad, the distal phalanx of the thumb, and reinforced fingers.
Supraspinatus
Supraspinatus is the most commonly torn rotator cuff muscle. It initiates abduction and assists the middle deltoid in all abduction. However, it is nowhere near as strong as the middle deltoid. When in dysfunction, it can be active even with the arm just hanging by the side. The Painful Arc will be positive in the 85º -110º range, but I find this test moderately useless as it could also indicate other things, such as subacromial bursitis, calcium deposits etc. A positive Empty Can Test is an indicator of a supraspinatus tear. Various impingement tests (such as the Neer and the Hawkins–Kennedy)(1) also indicate supraspinatus involvement.
Initially I would primarily target the belly of the muscle, continuing carefully into the tendon. View the tendon as a continuation of the fascia past where the muscle fibres finish: once the myofascia has been suitably addressed start working the tendon more specifically. In chronic or calcific tendinitis and tendinosis, tendon damage and reduced function is present but without the inflammatory process to initiate the repair. Transverse frictions to the tendon induce controlled damage, re initiating the inflammatory response and renewing the ability for repair. It also encourages increased vascularity in otherwise vascularly undersupplied tissue. After working transverse, work along the line of pull of the structure with the intent of aligning the freshly redamaged tissue. Fibrinogen, the precursor to creating collagen fibres, realigns appropriately if encouraged in this way (11,12). I would be more circumspect with acute tendinitis and wait for the healing process to be under way before attempting transverse friction work. The two places on the tendon most prone to damage are the myotendinous junction (where the muscles cease within the connective tissue) and the tenoperiosteal junction where the tendon fibres insert into the periosteum of the bone.
All the techniques described above could be applied to the supraspinatus with the client seated or side lying. The U formed by the clavicle and spine of scapula is a good spot to access the supraspinatus tendon, especially its myotendinous junction. The tenoperiosteal junction of supraspinatus is on the humeral head; to access it in order to apply transverse frictions have the client side lying, involved side up, and passively extend the humerus, which moves the humeral head forward of the acromion allowing access to the tendon.
Subscapularis
If subscapularis requires work, I follow a similar protocol but with the client supine. Work the posterior aspect of the axilla, on the anterior surface of the scapula (just antero-medial to the lateral border of the scapula.) Commence by applying a discriminating palpation, identifying the condition of the tissue, deactivate trigger points if present, and continue that discriminating palpation to work on the totality of the myofascia using the myofascial methods outlined above. Have the client’s elbow flexed 90º and GHJ abducted 90º and externally rotated to allow greater access to the muscle. Ask for movement, getting them to abduct further by reaching away with their fingers and then move back to 90º with their elbow leading the way. The subscapularis tendon is on the lesser tubercle of the humerus: when working it, be sure that it is what you are on. If it moves in elbow flexion it is the long head of biceps brachii (a common mistake). Superiorly it attaches to the GHJ articular capsule; so again I emphasis the palpate / discriminate aspect of this work.
Infraspinatus
Infraspinatus rarely exhibits tendinitis, except as a result of impact injury. However, this muscle often has trigger points and the kind of chronic, fibrotic change associated with constant low-level stresses. This results from its stabilising role - when other rotator cuff muscles are damaged it becomes over-active.
To work supraspinatus, I have the client prone, GHJ abducted 90º and forearm dangling over the edge of the table (in more precise anatomical terms, the humerus is also partially externally rotated and elbow flexed 90º). Trigger points are almost always present so I deactivate them first. Then work, initially lightly with the finger pads, along the fibres from the medial scapula border to the insertion in the humerus. Have the client extend and flex the elbow joint as you pass along the muscle. You can gradually increase the depth of your work each pass and ask the client to increase the internal rotation of the humerus as they raise their forearm. Please note that increased depth does not necessarily equate with greater pressure, more a case of gently exploring and exploiting any opening that the tissue allows. With their elbow flexed, the client can also internally and externally rotate the humerus in an ever-increasing range as you work on them.
Teres Minor
When treating Teres Minor, I have the client side lying, arm abducted so that the upper arm rests on the side of the head. If the client’s ROM doesn’t allow this, have it rest on the table in front of them. Apply the same protocols as before, working along the muscle from origin to insertion. In my clinical experience, it is rarely a player in rotator cuff tendinitis but feels good to be worked. Damage is most likely in those who overdo weight training. (13)
The Integrative Perspective
From a global perspective, I would look at the position of the scapula and the forces operating on it. Pectoralis minor, serratus anterior, the rhomboids, coracobrachialis, levator scapulae and the trapezius all influence scapula position directly. Consider the myofascial sling created by the rhomboids and serratus anterior: the scapula can be viewed as a ‘sesamoid’ bone within this sling. Don’t overlook pectoralis minor: it affects scapula position and in my clinical experience is usually a major player in clients with rotator cuff tendinitis. Pectoralis major and latissimus dorsi also affect scapula position indirectly. Omohyoid and sub clavius can be bit players. The function of biceps brachii and attendant muscles coracobrachialis, brachialis and supinator, can affect glenohumeral function. Really obvious is the middle deltoid: its function is intimately tied to supraspinatus. Also, thoracic rotations are a major consideration in glenohumeral function: in scoliosis, for example, one scapula will be protracted, the other retracted; one in internal rotation, one external. Thus the forces operating on each shoulder complex will be different, which can either create or aggravate already existing tendinitis. Don’t forget the fascia, especially the clavi-pectoral fascia. Work around the clavicle generally can be helpful. Compensation is another factor: avoiding using the involved side will lead to overuse of the other side and the same condition manifesting. Also, remember that trigger points from the rotator cuff muscles can refer into the wrist and lead to a mistaken carpal tunnel diagnosis
1. Magee, D. J. “Orthopedic Physical Assessment” Saunders, 3rd edition 1997
2. Petty, N. & Moore, A. “Neuromusculoskeletal Examination & Assessment” Churchill Livingstone 1998
3. Sise, B. “The Rolfing Experience” Hohm Press 2005
4. Maupin, E. “A Dynamic Relation To Gravity, Volume 1: The Elements of Structural Integration” Maupin, self published, most recent edition 2006
5. Maupin, E. “A Dynamic Relation To Gravity, Volume 2: The Ten Sessions of Structural Integration.” Maupin, self published, most recent edition 2006
6. Gregor, R.J. ‘The structure & function of skeletal muscle’ in Rasch, P.J. “Kinesiology & Applied Anatomy” Lea & Febiger 7th edition, 1989
7. Tabners Medical Dictionary
8. Myers, T. “Anatomy Trains: Myofascial Meridians for Manual Therapists” Churchill Livingstone 2001
9. Smith, J. “Structural Bodywork” Churchill Livingstone 2005
10. Stanborough, M. “Direct Release Myofascial Technique” Churchill Livingstone 2004
11. Cantu, R. & Grodin, A. J. “Myofascial Manipulation” Aspen Publishers 1992
12. Various articles in Findley, T. W. & Schleip, R. “Fascia Research” Elsevier 2007
13. Simons, D. G., Travell, J.G. & Simons, L. S. “Myofascial Pain and Dysfunction: The Trigger Point Manual Volume 1 upper Half of Body” Williams & Wilkins 2nd Edition 1999
WORKING WITH WHIPLASH
AMT FORUM POST- WHIPLASH
© Colin Rossie 2007. Not to be printed or used without permission of the copyright holder.
Whiplash/ acceleration- deceleration injury has in turn acute, sub acute and chronic stages. Then there is WAD (Whiplash Associated Disorder), a long-term effect of severe, poorly or untreated whiplash.
In the acute phase (first few days post injury), if a client comes to see you then send them to their doctor to take care of them, do x-rays, ultasounds, scans etc.
In sub acute cases (3-14 days), only proceed if they have been seen by their doctor and have permission to receive manual treatment (i.e any swelling has abated and there have been radiological tests done.) At this stage, appropriate techniques for neck work may include: Strain/ counter strain or orthobionomy type work, lymphatic drainage, gentle PROM and possibly (as pain and swelling starts to subside) the gentle, Barnes style MFR. On other, non-cervical and non-cranial structures more robust work can be done, such as trigger point, MET and direct myofascial techniques. This can help relieve satellite and distal pain resulting from the injury.
In chronic whiplash, in addition to the above techniques mentioned for the neck, MET, trigger points and direct myofascial techniques can be added. Cranio- sacral techniques can be used at this stage as well. Special attention should be paid to the sub occipitals, especially Rectus Capitus Posterior major and minor. Often, Rectus Capitus Posterior minor is especially indicated: it partly attaches to the dura mater and this attachment is often partially torn in whiplash injuries. The nuchal ligament can also be torn.
Cross fibre frictions and deep tissue work for any local adhesions that result from the injury can be commenced after the 6-week phase.
Don't forget to start appropriate strengthening as part of rehabilitation. Also consider movement education, such as Feldenkrais or Rolf Movement, to retrain and enhance proprioception and co-ordination. There is always the possibility of autonomic involvement in whiplash, so these can also help with this.
Commonly affected structures to consider other than the sub occipitals include the longus colli, semispinalis, spinalis cap & cervicus, SCM, scalenes, infrahyoids, omohyoid, platysma, pec minor & subclavius myofascia and tendons. Also consider the major fascial sheaths in the neck (especially the pre vertebral), which also receive a lot of damage in whiplash. Facet joints are also often affected.
Remember that many neck muscles have insertions in the thoracic region, so working distally from the focus of the pain is also highly effective. Immediately I'm thinking of head & neck muscles with attachments on the scapulae, ribs and thoracic spine, but given the fascial and neural connections one should also consider the sacrum and on into connections in the lower limb. Interestingly, many clients with whiplash mention effects in the sacrum and pain radiating into the legs & feet! (Hardly surprising if one considers the RCP minor attachment to the dura mater being damaged in whiplash and the effect of this into the cauda equina and beyond.)
Any pre existing osseous conditions can be exacerbated by whiplash and become a source of further irritation. Gentle mobilisation of the cervical vertebrae should be included in any long-term treatment plan (assuming you are qualified to do these). In the acute and subacute phases don't do any mobilisations or craniosacral techniques such as CV4 or a cranial base release. These are great in the chronic phase but not in the acute or subacute phases.
Colin Rossie
Dip. Health Sc. (Massage Therapy)
Certified Rolfer™
Rolf Movement Practitioner
© Colin Rossie 2007. Not to be printed or used without permission of the copyright holder.
Whiplash/ acceleration- deceleration injury has in turn acute, sub acute and chronic stages. Then there is WAD (Whiplash Associated Disorder), a long-term effect of severe, poorly or untreated whiplash.
In the acute phase (first few days post injury), if a client comes to see you then send them to their doctor to take care of them, do x-rays, ultasounds, scans etc.
In sub acute cases (3-14 days), only proceed if they have been seen by their doctor and have permission to receive manual treatment (i.e any swelling has abated and there have been radiological tests done.) At this stage, appropriate techniques for neck work may include: Strain/ counter strain or orthobionomy type work, lymphatic drainage, gentle PROM and possibly (as pain and swelling starts to subside) the gentle, Barnes style MFR. On other, non-cervical and non-cranial structures more robust work can be done, such as trigger point, MET and direct myofascial techniques. This can help relieve satellite and distal pain resulting from the injury.
In chronic whiplash, in addition to the above techniques mentioned for the neck, MET, trigger points and direct myofascial techniques can be added. Cranio- sacral techniques can be used at this stage as well. Special attention should be paid to the sub occipitals, especially Rectus Capitus Posterior major and minor. Often, Rectus Capitus Posterior minor is especially indicated: it partly attaches to the dura mater and this attachment is often partially torn in whiplash injuries. The nuchal ligament can also be torn.
Cross fibre frictions and deep tissue work for any local adhesions that result from the injury can be commenced after the 6-week phase.
Don't forget to start appropriate strengthening as part of rehabilitation. Also consider movement education, such as Feldenkrais or Rolf Movement, to retrain and enhance proprioception and co-ordination. There is always the possibility of autonomic involvement in whiplash, so these can also help with this.
Commonly affected structures to consider other than the sub occipitals include the longus colli, semispinalis, spinalis cap & cervicus, SCM, scalenes, infrahyoids, omohyoid, platysma, pec minor & subclavius myofascia and tendons. Also consider the major fascial sheaths in the neck (especially the pre vertebral), which also receive a lot of damage in whiplash. Facet joints are also often affected.
Remember that many neck muscles have insertions in the thoracic region, so working distally from the focus of the pain is also highly effective. Immediately I'm thinking of head & neck muscles with attachments on the scapulae, ribs and thoracic spine, but given the fascial and neural connections one should also consider the sacrum and on into connections in the lower limb. Interestingly, many clients with whiplash mention effects in the sacrum and pain radiating into the legs & feet! (Hardly surprising if one considers the RCP minor attachment to the dura mater being damaged in whiplash and the effect of this into the cauda equina and beyond.)
Any pre existing osseous conditions can be exacerbated by whiplash and become a source of further irritation. Gentle mobilisation of the cervical vertebrae should be included in any long-term treatment plan (assuming you are qualified to do these). In the acute and subacute phases don't do any mobilisations or craniosacral techniques such as CV4 or a cranial base release. These are great in the chronic phase but not in the acute or subacute phases.
Colin Rossie
Dip. Health Sc. (Massage Therapy)
Certified Rolfer™
Rolf Movement Practitioner
VERTEBRAL ARTERY TEST (VAT)
Published in the AMT Journal "In Good Hands", September 2008
© AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
Over the years I have heard all sorts of stories about the efficacy and safety of the VAT. I've researched to find out all I can about it; some research indicates it's completely useless in indicating vertebral artery compromise. Nonetheless, I would do it each time before working on the cervical spine. In the absence of any alternative, I believe it's better to be safe than sorry.
I know at least two versions of it:
One is the cervical quadrant test, which involves, while the client is supine, bringing the head and neck into extension and side-flexion, and holding for 30 seconds,
The other is the deKleyn Nieuwenhuyse Test, which is similar: with the client supine, the practitioner passively brings the client's head into extension, then passively rotates the cervical spine instead of side-flexing it. This test is performed bilaterally.
There is also Hautant's Test, which tests for the same but in the seated position, as well as Barre's Test, which is the same thing but done in the standing position.
If dizziness, nausea, dipoplia or other vision disturbance, disorientation, ataxia, impairment of trigeminal sensation or nystagmus are provoked by any of these tests then your client is recording a positive: testing should cease immediately and they should be referred to their primary care physician.
I would recommend all practitioners familiarize themself with all of the above tests. These can all be found in a suitable examination and assessment text.(1,2)
After problems arising from it being done by a student in a college clinic, it is no longer taught at some massage training colleges. I think this attitude is a huge loss to massage or bodywork education. Perhaps the problem with the supine VAT arose through lack of supervision: perhaps it was over-enthusiasm, the student possibly applying, however slight, an over-pressure in the extension, the lateral flexion, or the rotation component of the testing. I've always performed these tests gently as passive tests, with no over pressure, and have never had a problem with a client, other than the occasional positive.
In my clinical experience, there has always been a higher incidence of clients recording a positive response to these tests than actually having vascular compromise. Often the problem is a middle ear/ balance issue. In any one year, I'll have at least ten clients test positive to the VAT. I always suggest they go to their doctor for further testing.
Half do, half don't. I rigourously follow up and encourage them to. In most cases it turns out that I am just being overly cautious - in the last ten years, most of those who have seen their doctors have had nothing wrong. A few have recorded high cholesterol levels; some have had vestibular compromise; one, a male amateur cricketer, 32 years old at the time, who otherwise seemed perfectly healthy, had a berry aneurysm; another, a yoga-practicing vegetarian in her late 40s, had an atheroma in her left carotid artery; and yet another had over the top hypertension. A client last year had a condition known as Cerebral Arterio Venous Malformation and after seeing her GP had immediate surgery with Dr Charlie Teo. None of these people would be walking on the planet today had they not been made aware of a possible problem via the VAT.
All those clients were thankful that such a thing was picked up. Several local doctors initially found it amusing that a massage therapist would write them a letter explaining their observations and refer clients to them. They now have a different attitude to professional massage therapy and bodywork. Though I tend to err excessively on the side of caution, these doctors are no longer surprised by such referrals and rather than dismiss them out of hand will consider my concerns, test their patient and respond to my concerns.
Now, a not so happy story. As a gift to her PA, one of my regular clients sent her to see me. The PA was in her late 20’s, classic “A” type, well organized, very bright, a fit, gym junkie. Her major complaint was “sore neck & shoulders”. The first thing I did in the session was a VAT. She came up positive so we calmly discussed what a positive result could mean and that before we could proceed with any work that I would need clearance from her doctor. I didn't work on her, and would not do so until I had the all clear. She didn’t return, and answered my queries about whether she had seen to it yet with a casual “I’ll get around to it one day”. Eight months later she died of a cerebral stroke while out running at 6 a.m.
1) Magee, D. J. “Orthopedic Physical Assessment” Saunders
2) Petty N.J. & Moore A.P. “Neuromusculoskeletal Examination & Assessment” Churchill Livingstone
© AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
Over the years I have heard all sorts of stories about the efficacy and safety of the VAT. I've researched to find out all I can about it; some research indicates it's completely useless in indicating vertebral artery compromise. Nonetheless, I would do it each time before working on the cervical spine. In the absence of any alternative, I believe it's better to be safe than sorry.
I know at least two versions of it:
One is the cervical quadrant test, which involves, while the client is supine, bringing the head and neck into extension and side-flexion, and holding for 30 seconds,
The other is the deKleyn Nieuwenhuyse Test, which is similar: with the client supine, the practitioner passively brings the client's head into extension, then passively rotates the cervical spine instead of side-flexing it. This test is performed bilaterally.
There is also Hautant's Test, which tests for the same but in the seated position, as well as Barre's Test, which is the same thing but done in the standing position.
If dizziness, nausea, dipoplia or other vision disturbance, disorientation, ataxia, impairment of trigeminal sensation or nystagmus are provoked by any of these tests then your client is recording a positive: testing should cease immediately and they should be referred to their primary care physician.
I would recommend all practitioners familiarize themself with all of the above tests. These can all be found in a suitable examination and assessment text.(1,2)
After problems arising from it being done by a student in a college clinic, it is no longer taught at some massage training colleges. I think this attitude is a huge loss to massage or bodywork education. Perhaps the problem with the supine VAT arose through lack of supervision: perhaps it was over-enthusiasm, the student possibly applying, however slight, an over-pressure in the extension, the lateral flexion, or the rotation component of the testing. I've always performed these tests gently as passive tests, with no over pressure, and have never had a problem with a client, other than the occasional positive.
In my clinical experience, there has always been a higher incidence of clients recording a positive response to these tests than actually having vascular compromise. Often the problem is a middle ear/ balance issue. In any one year, I'll have at least ten clients test positive to the VAT. I always suggest they go to their doctor for further testing.
Half do, half don't. I rigourously follow up and encourage them to. In most cases it turns out that I am just being overly cautious - in the last ten years, most of those who have seen their doctors have had nothing wrong. A few have recorded high cholesterol levels; some have had vestibular compromise; one, a male amateur cricketer, 32 years old at the time, who otherwise seemed perfectly healthy, had a berry aneurysm; another, a yoga-practicing vegetarian in her late 40s, had an atheroma in her left carotid artery; and yet another had over the top hypertension. A client last year had a condition known as Cerebral Arterio Venous Malformation and after seeing her GP had immediate surgery with Dr Charlie Teo. None of these people would be walking on the planet today had they not been made aware of a possible problem via the VAT.
All those clients were thankful that such a thing was picked up. Several local doctors initially found it amusing that a massage therapist would write them a letter explaining their observations and refer clients to them. They now have a different attitude to professional massage therapy and bodywork. Though I tend to err excessively on the side of caution, these doctors are no longer surprised by such referrals and rather than dismiss them out of hand will consider my concerns, test their patient and respond to my concerns.
Now, a not so happy story. As a gift to her PA, one of my regular clients sent her to see me. The PA was in her late 20’s, classic “A” type, well organized, very bright, a fit, gym junkie. Her major complaint was “sore neck & shoulders”. The first thing I did in the session was a VAT. She came up positive so we calmly discussed what a positive result could mean and that before we could proceed with any work that I would need clearance from her doctor. I didn't work on her, and would not do so until I had the all clear. She didn’t return, and answered my queries about whether she had seen to it yet with a casual “I’ll get around to it one day”. Eight months later she died of a cerebral stroke while out running at 6 a.m.
1) Magee, D. J. “Orthopedic Physical Assessment” Saunders
2) Petty N.J. & Moore A.P. “Neuromusculoskeletal Examination & Assessment” Churchill Livingstone
THE BASIC COST OF BEING A MASSAGE THERAPIST
Appeared in the AMT Journal "In Good Hands", June 2008.
© AMT 2008, © Colin Rossie 2008
So, now you are qualified. With a busy practice, you work many hours a week with clients- perhaps in a clinic with other therapists or perhaps by yourself in a clinic or from home. Perhaps you only do a few clients a week, again maybe from home: or you have retired from an active practice and do 1 or 2 people a week. These might be old clients, perhaps friends- maybe you charge them, maybe you don't. Another scenario is that you only do voluntary work: the local nursing home, community work, the local sports team- all free of charge, the pay off being pride in your work or a warm glow inside.
The income received may vary in all these scenarios, but in all of them can you really afford to be uninsured? The unequivocal answer to this is no!
If you are qualified and practicing any massage, regardless of whether you are being paid for it or not, whether you regard yourself as active or retired, you are liable for the consequences of your work. Thus you should carry insurance. Being a member of association makes insurance cheaper. If you are qualified and not in an association, insurance costs over a $1,000 more on a per annum basis.
In AMT there are 5 levels of membership. Which can get insurance?
For the sake of ease, I'll band these 5 levels into 3 categories, based on the options available for insurance.
These 3 categories are:
1. Auxiliary membership
2. Student membership
3. General and Senior Levels 1 & 2
The easiest to address is the Auxiliary category: insurance is unavailable to this category of membership.
The second category, Student members of AMT, can get insurance with OAMPS once they have completed the basic Swedish Massage section of their training. Depending on whether they are charging people or not and what amount of indemnity they want, insurance costs students between $127 - $253 per annum. Certain requirements must be met in the treatments they offer i.e. identifying their student status to clients. Given that students if they meet certain criteria can join AMT for free, this insurance cost represents a membership cost of as little $2.50 per week. This cost is only if they choose to take out insurance: otherwise, membership can cost students nothing.
Now for the third category: General, Senior level 1 & Senior Level 2 members. The following calculations represent the basic cost of membership per annum, thus the basic yearly cost of practicing Massage Therapy:
General Level membership:
Annual membership fee $150
Insurance-$1,000,000 $197
Cheapest CEU requirement (E.G) $120
TOTAL Per Annum $467
This, if you do your sums, works out to be just less than $9 a week. Though the CEU rates I quote represent the cheapest I could readily find, you could possibly fulfill your CEU requirements for less cost. (I'm not advocating "doing it on the cheap". Personally, I think you should never scrimp on the cost of good continuing education.) I have seen someone charge as little as $50 for an hour massage recently. More frequently I've seen $65 -$70 an hour as a basic, starting rate. If you are doing 8-9 hours paid massage work per annum, you can afford to cover this cost. If you accidentally do something to your client, or are sued for any reason, can you afford to have not met this cost? If you are doing 1 paid massage a week from home, you can easily afford $9 a week- and you get to keep your home if something you do makes the massage go awry.
Similarly, for Senior Level 1 the cost with $1,000,000 insurance is $9.75 a week. The sums are:
Senior Level 1
Annual membership fee $190
Insurance-$1,000,000 $197
Cheapest CEU requirement (E.G) $120
TOTAL Per Annum $507
Even with $2,000,0000 insurance, Senior Level 1 membership costs just $10.27 a week, or $534 per annum.
Lets go deluxe with Senior Level 2:
Annual membership fee $220
Insurance-$5,000,000 $264
Cheapest CEU requirement (E.G) $120
TOTAL Per Annum $604
This represents just $11.62 a week over a year for $5,000,000 insurance. For $1,000,000 insurance it would cost $10.33 a week ($537 p.a.), for $2,000,000 insurance the cost would be $10.85 a week ($564 p.a.) Of course, SL-2 members would most likely willingly pay a lot more for their CEUs.
Again, I emphasize that these are just the basic costs of your being able to practice massage therapy. Without paying these basic costs listed above you wont be able to practice as a massage therapist. Tables, oils etc, linen & rent are all in addition- none of these others matter if the basics aren't met.
© AMT 2008, © Colin Rossie 2008
So, now you are qualified. With a busy practice, you work many hours a week with clients- perhaps in a clinic with other therapists or perhaps by yourself in a clinic or from home. Perhaps you only do a few clients a week, again maybe from home: or you have retired from an active practice and do 1 or 2 people a week. These might be old clients, perhaps friends- maybe you charge them, maybe you don't. Another scenario is that you only do voluntary work: the local nursing home, community work, the local sports team- all free of charge, the pay off being pride in your work or a warm glow inside.
The income received may vary in all these scenarios, but in all of them can you really afford to be uninsured? The unequivocal answer to this is no!
If you are qualified and practicing any massage, regardless of whether you are being paid for it or not, whether you regard yourself as active or retired, you are liable for the consequences of your work. Thus you should carry insurance. Being a member of association makes insurance cheaper. If you are qualified and not in an association, insurance costs over a $1,000 more on a per annum basis.
In AMT there are 5 levels of membership. Which can get insurance?
For the sake of ease, I'll band these 5 levels into 3 categories, based on the options available for insurance.
These 3 categories are:
1. Auxiliary membership
2. Student membership
3. General and Senior Levels 1 & 2
The easiest to address is the Auxiliary category: insurance is unavailable to this category of membership.
The second category, Student members of AMT, can get insurance with OAMPS once they have completed the basic Swedish Massage section of their training. Depending on whether they are charging people or not and what amount of indemnity they want, insurance costs students between $127 - $253 per annum. Certain requirements must be met in the treatments they offer i.e. identifying their student status to clients. Given that students if they meet certain criteria can join AMT for free, this insurance cost represents a membership cost of as little $2.50 per week. This cost is only if they choose to take out insurance: otherwise, membership can cost students nothing.
Now for the third category: General, Senior level 1 & Senior Level 2 members. The following calculations represent the basic cost of membership per annum, thus the basic yearly cost of practicing Massage Therapy:
General Level membership:
Annual membership fee $150
Insurance-$1,000,000 $197
Cheapest CEU requirement (E.G) $120
TOTAL Per Annum $467
This, if you do your sums, works out to be just less than $9 a week. Though the CEU rates I quote represent the cheapest I could readily find, you could possibly fulfill your CEU requirements for less cost. (I'm not advocating "doing it on the cheap". Personally, I think you should never scrimp on the cost of good continuing education.) I have seen someone charge as little as $50 for an hour massage recently. More frequently I've seen $65 -$70 an hour as a basic, starting rate. If you are doing 8-9 hours paid massage work per annum, you can afford to cover this cost. If you accidentally do something to your client, or are sued for any reason, can you afford to have not met this cost? If you are doing 1 paid massage a week from home, you can easily afford $9 a week- and you get to keep your home if something you do makes the massage go awry.
Similarly, for Senior Level 1 the cost with $1,000,000 insurance is $9.75 a week. The sums are:
Senior Level 1
Annual membership fee $190
Insurance-$1,000,000 $197
Cheapest CEU requirement (E.G) $120
TOTAL Per Annum $507
Even with $2,000,0000 insurance, Senior Level 1 membership costs just $10.27 a week, or $534 per annum.
Lets go deluxe with Senior Level 2:
Annual membership fee $220
Insurance-$5,000,000 $264
Cheapest CEU requirement (E.G) $120
TOTAL Per Annum $604
This represents just $11.62 a week over a year for $5,000,000 insurance. For $1,000,000 insurance it would cost $10.33 a week ($537 p.a.), for $2,000,000 insurance the cost would be $10.85 a week ($564 p.a.) Of course, SL-2 members would most likely willingly pay a lot more for their CEUs.
Again, I emphasize that these are just the basic costs of your being able to practice massage therapy. Without paying these basic costs listed above you wont be able to practice as a massage therapist. Tables, oils etc, linen & rent are all in addition- none of these others matter if the basics aren't met.
STRUCTURAL AND MYOFASCIAL CONSIDERATIONS IN CERVICOGENIC PAIN
STRUCTURAL AND MYOFASCIAL CONSIDERATIONS IN CERVICOGENIC PAIN
Notes for the workshop presented at the AMT AGM, April 2008 & again at the AMT Annual Conference, October 2008.
Printed in the AMT Journal "In Good Hands", December 2008
©AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
Cervicogenic pain is pain that has its origin (genesis) in the neck. Soft tissue pain
in this region can be either local or referred, somatic, autonomic, visceral or neural in origin. In addition to local visceral structures, pain can also refer from viscera in the torso. The main considerations of this paper will be somatic pain from soft tissue structures, primarily the myofascia. Aside from direct trauma to the region, such as whiplash, myofascial dysfunction in the cervical region is generally secondary to structural imbalances below the level of the neck.
Many structures and tissues in the neck can be responsible for pain. Autonomic manifestations would include perturbation of the cervical sympathetic ganglia (just anterior to the vertebral bodies) such as could occur as a result of whiplash or prolonged forward head posture, where vertebral instability creates a cluster of symptoms, as in Barré-Lieou Syndrome (for example.) Somatic pain could originate in either bony tissue (such as facet joint referral)or the soft tissue.
STRUCTURAL CONSIDERATIONS
1. Gravity
“Posture is the distribution of body mass in relation to gravity over a base of support. The base of support includes all structures from the feet to the base of the skull.”
(Kuchera and Kuchera, 1997)
The prime structural consideration is our response to gravity. All posture can be viewed as our response to gravity and subsequent orientation to our environment. All life on Earth responds to the gravitational force of the planet: even birth can only occur in the appropriate gravitational field. While no doubt it may be possible to conceive in zero gravity on a space station, it is impossible to give birth out of Earth's gravitational field. NASA experiments using quails on the space station has proven this many times.
Form follows function: optimal alignment in gravity and to 3 dimensional space has resulted in a structure that has evolved to meet the demands of uprightness in gravity with minimal energy expenditure yet maximum efficiency in movement. Humans are fairly unique in the animal kingdom in that as a species we have evolved to stand and operate upright in gravity. This places unique stresses on our bodies. A snake, a quadruped (like the horse or dog) and another possible biped like the kangaroo will all respond to gravity differently from humans. Bears are another biped, but their response to gravity has resulted from different adaptations to the 3 dimensional environment.
To maintain our upright posture we need to be aligned around our centre of gravity (CoG) over 2 bases of support (the feet) and, from that place, move in, relate to and inter-act with the 3-dimensional space around us. While each of us is unique and our postural pattern can vary slightly from one individual to another, we all conform to major, common patterns that are determined by our form as a species and the relentlessness of the force of gravity on this planet operating upon us.
2. Tensegrity
Twentieth century architect, inventor and philosopher R. Buckminster- Fuller coined the term ‘tensegrity’ as a contraction of ‘tensional integrity’. He used the term to encapsulate the concept of a lightweight, integrated structure that gives great stability with the use of minimal material. A tensegrity structure thus maintains a synergy between balanced tension and compression forces. This means that any applied force can be met evenly by the structure, yielding without disturbing its internal equilibrium.
A tensegrity structure comprises two basic components:
• A compressive structure (such as posts, poles, struts or columns).
• A tensile structure (such as cables, wires, ropes, sheets).
There are some notable architectural examples - Centrepoint Tower and the Sydney Harbour Bridge are both tensegrity structures, In fact, any cantilever bridge or an old-fashioned airplane with struts and guy wires is a tensegrity structure. A tent is another basic example.
To be dynamic, animal bodies need to operate effectively in gravity by minimising the effect of their weight. The tensegrity relationship is one part of achieving this. Thus animals embody the characteristic unison of compressed and tensioned parts that defines a tensegrity structure. The skeleton of an animal is compressive, while the soft tissue, myo-fascial / tendinous and ligamentous structures are tensile.
3. The functional anatomy of the spine.
The human spine is a tensegrity structure. It consists of a series of rigid bones (compressive structures) interposed between deformable, fibro-cartilaginous intervertebral discs (tensile structures). The soft tissue muscles, fascia and ligaments connecting the bones are also tensile structures.
The spine has curves anterior (lordoses) or posterior (kyphoses) in the sagittal plane. Where there are kyphoses, there are bony structures such as the ribs and pelvis enclosing and protecting vital organs. There is also less mobility. Where there are lordoses, there are no bony enclosures and greater mobility.
These spinal curves have a definite relationship to our CoG, sometimes passing through it, sometimes behind it, sometimes anterior to it. Together with the tensegrity relationship within the spine, they allow the spine resilience in movement and stance.
The lordotic, cervical spine has the greatest mobility within the vertebral column. All mobility comes at the cost of stability and thus this region has a greater propensity for damage and soft tissue adaption / maladaption.
Functionally, the cervical spine has two divisions: the cranio-cervical (Occiput-C2)and the typical cervical (C3-C7) regions, with the C2/C3 motion segment constituting a transitional functional region.
The cranio-cervical region consists of the atlanto-occipital(C0/C1) and atlanto-axial(C1/C2) articulations, which together account for the greatest amount of saggital and transverse motion of any individual vertebrae in the whol spine. Think of the yes and no motions: the yes motion is saggital movement that occurs at C0/C1, while no is transverse movement occurring at C1/C2, the Atlas (C1) rotating around the peg (dens or odontoid process) of C2.
The C2/C3 articulation is functionally unique and quite important, providing the stable base to "anchor" the head and cervico-cranial region to the rest of the spine. The bony articulations of the superior aspect of C3 (large uncinate processes and large, uniquely inclined superior articlar processes) allows a deep, stable socket for articulation with the inferior aspect of C2. This enhanced stability is required to cope with the many muscles (from both above and below) that converge and articulate at this level, all of which play a role in anchoring the atlas.
C3- C7 for the most part conform functionally to the pattern of the rest of the spine below, apart from the following specifically local adaptations:
-bifid spinous processes that allow more muscular attachment sites, as well as preventing the 'kissing spines' effect in extension and thus allowing a safer, greater range of motion in extension.
- Transverse Processes (TPs) with two bony projections that allow two different muscular attachment sites: theanterior pedicles that projects laterally from the vertebral body and theposterior pedicle that projects laterally from the pedicles. A small strut of bone unites these two pedicles; together all three parts are referred to as the transverse process, though this is quite different structurally to TPs elsewhere in the spine.
- Within the transverse process there is the Transverse Foramen, through which the Vertebral Artery passes. This is clinically significant as a potential hazard in doing work on the cervical spine.
- Other clinically unique features worth considering are the orientation of the facets, which allow a large range of motion, the orientation of the pedicles which allows a large, triangular spinal canal, the uncinate processes, which minimize lateral motion and shear and thus protect the Vertebral Artery, and finally the shapeof the intervertebral foramen and the superior groove on the TP, that facilitates the exit of the spinal nerves in a unique way.
MYOFASCIAL CONSIDERATIONS
The myofascial and connective tissue network can be viewed as a tensegrity arrangement within the body. As mentioned in the above paragraph, it is the most mobile part of the axial skeleton; stability here is provided by appropriate relationships in the soft tissue. Like the mast of a sailing ship, the soft tissue of the shoulder girdle, ribs, lower vertebrae and manubrium that connects with the cervical spine, hyoid, mandible and cranium is like a tensegrity mast.
1. Fascia and connective tissue are highly plastic
Fascia is composed of about 30% collagen, 1% elastin and some reticulin fibres in a matrix of water-loving cells. Collagen is the netting that gives fascia its form - it is stronger than steel fibres of the same size. Fascia encloses every structure in the body and is the substance responsible for the form of the body.
It is also highly innervated with sensory nerves and can respond to neural inputs by contracting, relaxing, remodelling and changing its chemical makeup and ratios. When damaged, collagen frays and reconnects wherever it can. This is the basis of scar formation.
Fascia / connective tissue responds to the stress of chronic postural change by:
1. Thickening
2. Shortening
3. Calcifying
4. Eroding
Like bone, fascia is subject to Wolf’s Law: it changes and remodels in response to the forces placed on it. Muscle fibres can contract and relax, unless in spasm. Fascia, on the other hand, can’t relax as readily and will respond to poor usage by remodelling negatively. This can be quite rapid - it doesn’t take much to change its length. However, this plasticity is also a blessing because it doesn’t take much for it remodel to positively either.
Fascia is throughout what is commonly thought of as muscle. A piece of red meat trimmed of all its connective tissue (the white stuff) is approximately 50-60% muscle fibre and 40-50% fascia.
2. Cervical Fascial Anatomy
Once past the partly adipose superficial fascia, here are 4 major layers of deep fascia in the neck:
1. An outer, extrinsic, layer around the sleeve musculature
2. An Inner, intrinsic, deeper layer around the core musculature
3. A visceral layer around the oesophagus and the thyroid / parathyroids.
4. A meningeal layer around the spinal cord.
The Superficial Cervical Fascia is partly fascia and adipose tissue and is immediately under the dermis. It contains the platysma muscle. After the superficial fascia but before the epimysium of individual muscles lies the deep fascia. There are several layers of deep fascia in the neck:
• Deep Cervical Fascia around the whole neck, with an Investing Layer enclosing interiorly the trapezius and sternocleidomastoid.
• Prevertebral Fascia, superficial to longus colli and scalenes, it continues deep to the Investing Layer to enclose the deep posterior neck muscles.
• A Middle Layer that encloses the infra hyoids anteriorly.
• Visceral fascia that consists of:
a. The Pre Tracheal Fascia enclosing the cervical viscera anteriorly as well as the infra hyoids posteriorly, and
b. Retrovisceral Fascia, enclosing the viscera posteriorly.
The meninges can be viewed as neural fascia enclosing the spinal cord.
Individual muscles are covered with epimysium; perimysium encloses fascicles of muscle fibres and endomysium surrounds individual muscle fibres. These are morphologically no different to fascia. Where the muscle fibs finish, the fascia joins together and continues as the tendon. In other words, fascia is distributed throughout the entire structure.
3. Neuro-Fascial Considerations
As mentioned above, fascia is a heavily innervated material. For example, Golgi Tendon Organs only occur in fascia. As such, they can be found not only in the tendon but also throughout the fascia within the muscle belly. There are proprioceptors, chemoreceptors, mechanoreceptors and thermoreceptors in fascia. Once I would have added nociceptors here as well but recent reading has made me doubt the specific existence of nociceptors - nociception and pain may just be the response to threat or damage, a summation of responses to changes in temperature, ph, chemical environment and pressure. What I will say is that fascial, neural structures are sensory and capable of involvement in pain symptoms.
Proprioceptive feedback alters our cortical response which, in turn, alters our motor patterns … which will then alter structure and biomechanics. If this is prolonged, the fascia responds by changing its internal environment, creating thickenings and adhesions and increasing myofibroblast rather than fibroblast activity, which will further increase the contractile property of fascia.
Sympathetic nervous system activity (fight or flight responses) can shorten fascia. It’s not just prolonged physical overload that creates compromise but also constant low-level, psycho-emotional input: stress from the job/partner/children/bully/tax department/recent injury/that old pain that won’t go away etc. Fear and insecurity can lead to ANS sympathetic involvement as easily as other protective behaviour patterns, be they emotional in origin or physical in origin, such as muscle guarding around immediate physical pain.
Golgi Tendon Organs, Golgi receptors, Pacinian and Ruffini Corpuscles - all present in the fascia – will respond to appropriately to different types of manual therapy and can act to inhibit sympathetic activation of the fascial tonus.
4. Postural and phasic muscles
Structural modification, be it due to poor usage, muscle guarding around pain or sympathetic activation, can lead to an altered relationship to gravity. This can manifest in the muscle fibres as either hypertonicity, hypotonicity or muscle wasting, in the fascia as altered morphology anf tonus. Myofascial structures throughout the body can be divided into tonic or phasic, depending on muscle type and function.
Tonic or postural muscles are the anti-gravity muscles, working constantly to maintain upright stance. Postural muscles are fatigue resistant, Type 1 fibres. In dysfunction these will tend to shorten and can either tighten or weaken.
Phasic muscles are recruited only for specific movements, then rest and restore their energy levels. Phasic muscles are Type 2 fibres, which fatigue easily. Most type II fibres will tend to weaken without shortening in dysfunction
The following list is from Robert Schleip’s website www.somatics.de, a wonderful source of articles on structure and bodywork.
TONIC/ POSTURAL MUSCLES
Hamstrings
Iliopsoas
Rectus femoris
Tensor Fascia Latae
Triceps surae
Pectoralis Major (sternal; clavicular?)
Trapezius (ascending fibres)
Levator Scapulae
Erector Spinae (lumbar and cervical)
(thoracic?)
Quadratus Lumborum
Sartorius
Piriformis
Short Adductors (Magnus and Brevis)
Sternocleidomastoid
B. Brachii (?)
Flexors of hand (?)
Scalenii
PHASIC/ MOBILISER MUSCLES
Tibialis Anterior
Vastus Medialis and Lateralis
Gluteus (Maximus and Minimus)
Rhomboids
Trapezius (ascending and horizontal fibres)
Serratus Anterior
Long adductors
Short hand and foot muscles
Longus Colli and Capitus
Omohyoid (?)
Gluteus Minimus
Pectoralis Major (Costal attachments)
Gluteus Minumus
Triceps Brachii
Scalenii
Note that the scalenes appear in both lists. They are phasic muscles which, if put under the chronic stress of altered posture, become dysfunctional and adapt their fibre type to take on the characteristics of tonic/type 1 fibres.
The following list defines the features of the different fibre types (again from www.somatics.de):
TYPE I MUSCLE FIBRES
• Slow twitch
• Contract slowly
• Low stores of glycogen
• High concentrations of myoglobulin and mitochondria
• Fatigue slowly
• Mainly involved in postural and stabilising tasks
• Tonic or postural muscles
• Stress or dysfunction will lead to shortening
• When short/tight, may test either strong or weak
TYPE II MUSCLE FIBRES
• Fast twitch
• Rapid contraction
• Depending on sub-type, mitochondria and myoglobulin concentrations vary
• Generally fatigue rapidly
• Mainly involved in phasic activity
• Also referred to as phasic or mover muscles
• Stress or dysfunction will lead to weakening over their whole length
• Will always test as weak and without shortening
There are 3 subtypes of Type II muscles fibres:
TYPE IIa FIBRES
• “Fast twitch” or “fast white” fibres
• Contract more rapidly than type 1
• Are moderately resistant to fatigue
• High concentrations of mitochondria and myoglobulin compared to other type II fibres
TYPE IIb FIBRES
• “Fast twitch glycolytic” or “fast white”
• Less fatigue resistant
• Depend more on glycolytic sources of energy
• Low levels of mitochondria and myoglobulin
TYPE IIM FIBRES
• “Super fast” fibres
• Found mainly in the jaw muscles
• Depend on a unique myosin
• High glycogen content
• These last two properties differentiate it from other type II muscle fibres
5. The head as a level platform for the senses
The head is the platform for the senses. Due to the Ocular Righting Reflex, the eyes will always seek to look at a level horizon. This feature means that any damage, shortening or change in habitual pattern that occurs to alter the posture of the body will be allowed and compensated for (by involving other structures in the body) as long as the eyes can look at a level horizon. The vestibular system will accommodate the head in a different, dysfunctional position and alter the sense of balance and proprioception, thus perpetuating the new, dysfunctional pattern.
6. Upper Crossed Syndrome
Vladimir Janda’s ‘Crossed Syndromes’ are worth considering in treating the cervical region, specifically the Upper Crossed Syndrome:
• Hypertonic trapezius and levator scapula posteriorly, hypertonic pectoralis major anteriorly
• Hypotonic anterior deep neck flexors and rhomboids and serratus anterior
An appropriate treatment protocol could be to lengthen the upper trapezius, levator scapulae and pec major, accompanied by strengthening exercises and resisted movement for the anterior cervical musculature and rhomboid/ serratus sling.
7. Forward Head Posture
Forward head posture is a very common presentation, with myofascial compensations that are quite similar to upper crossed syndrome.
In forward head posture, we can expect the following:
• The upper traps and levator scap are shortened. This creates an increased cervical lordosis.
• Activation of the Moro (startle) Reflex- increased ANS activity (fight or flight response) – cervical ganglions involved.
• TMJ involvement- retraction of mandible
• Jaw clenched or mouth open, possibly bruxism (grinding)
• The head will double in weight for every 2.5cm it is forward of the CoG, further increasing the load on the musculature (especially the sub occipitals).
The suboccipitals, which should delicately finetune the head’s position in space as the senses respond to stimuli, instead become postural in function.
The TMJ dysfunction affects the body globally by affecting the vestibular function and balance and thus our position space, leading the posterior neck muscles to further shorten and increase their dysfunctionality.
Conclusion
This article is an expansion from workshop notes; that workshop was primarily practical in content. Consequently, it is far from definitive. I have tended to discuss cervicogenic pain primarily in terms of local phenomena. Nothing, however, occurs in isolation in the body. A more global perspective would take into account that the neck is near the top of a chain that commences with the feet. Any other dysfunction in this chain will manifest sooner or later in the neck.
Viewing neck pain as a purely local phenomenon may mean overlooking the genesis of that pain elsewhere in the body. Trigger point pain is very much a local manifestation of a more global pattern. Many trigger points and acupoints correspond to where nerves pass through the fascia. These are very real to the client and offer fairly immediate pain relief when they are deactivated. But they are only a part of the problem. The trick is to make the client aware of what else is contributing and work to prevent recurrence. The body always seems to recruit strength over stability in dysfunction, whereas as the key to true rehabilitation is almost always enhancing stable function.
By way of a closing example, let’s consider Tom Myers’ ‘Anatomy Trains’ concept of the body. Perhaps we could view the involvement of the myofascial meridian or locomotor sling of the Superficial Back Line. The local manifestation of the global pattern could be neck pain or headache. But there will also be tight plantar fascia, perhaps with collapsed arches, genu recurvatum (knee hyperextension), anterior pelvic tilt, either hypo- or hyper- lordosis and definitely cervical hyperlordosis and forward head posture. Any of these more distal dysfunctions could be causing or contributing to the problem and would need addressing to resolve the cervicogenic pain. Or perhaps it could be an issue of core or pelvic stability; involving different myofascial slings again. Any treatment of a client should involve a comprehensive assessment and plan that considers the possibilities of the whole body presenting before you.
Bibliography
Butler D.S. and Mosley G.L. (2003) "Explain Pain" Noigroup Publications, Adelaide.
Chaitow, Leon (1988) "Soft Tissue Manipulation" Rochester, VT: Healing Arts Press, 26-27.
Chaitow, Leon & DeLany, Judith 2000 Clinical Application of Neuromuscular Techniques, Volume 1, The Upper Body Churchill Livingstone, Edinburgh.
Chaitow, Leon (2002) "Clinical Application of Neuromuscular Techniques, Volume 2, The Lower Body" Edinburgh Churchill Livingstone 21-94.
Kendall, F, McCreary, E and Provance, P (1993) "Muscle Testing and Function" Lippincott Williams and Wilkins, Baltimore.
Kuchera, M. and Kuchera, W. (1997) “General Postural Considerations” in Ward, R. "Foundations for Osteopathic Medicine", Lippincott Williams and Wilkins, Baltimore.
Levangie, P. K. & Norkin, C. M. 2005 Joint Structure & Function 4th Edition, FA Davis Company, Philadelphia PA.
Moseley, G.L. (2007) "Painful Yarns: Metaphors and Stories to Help Understand The Biology of Pain" Dancing Giraffe Press, Canberra.
Myers, Thomas W. (2002) "Anatomy Trains" London, UK: Churchill Livingstone, P.15.
Myers, Thomas W., http://www.anatomytrains.com, sighted 22/11/2008.
Paoletti, Serge (2006) "The Fasciae: Anatomy, Dysfunction and Treatment" Seattle, WA: Eastland Press, 138, 147-149.
Porterfield, J.A. & DeRosa, C. 1995 Mechanical Neck Pain: Perspectives in Functional Anatomy W.B. Saunders Co, Philadelphia PA.
Rolf. Ida P (1977) "Rolfing: Re–establishing the Natural Alignment and Structural Integration of the Human Body" Healing Arts Press, Rochester Vermont.
Schleip, R.; Klingler, W.; Lehmann-Horn, F. (2005) "Active fascial contractility: Fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics" Medical Hypotheses (Elsevier) 65: 273–277..
Schleip, R. (2003) "Fascial plasticity – a new neurobiological explanation: Part 1" Journal of Bodywork and Movement Therapies (Elsevier) 7 (1): 11–19.
Schleip, R. (2003) "Fascial plasticity – a new neurobiological explanation: Part 2" Journal of Bodywork and Movement Therapies (Elsevier) 7 (2): 104–116.
Schleip, R., http://www.somatics.de, sighted 22/11/2008.
.
Simons, D, Travell J, and Simons, P (1999) "Myofascial Pain and Dysfunction: the trigger Point Manual, Vol 1 Upper Half of Body" Lippincott, Williams and Wilkins, Baltimore.
Tomasek, J., Gabbiani, G., Hinz, B., Chaponnier, C., Brown, R. (2002) "Myofibroblasts and Mechanoregulation of Connective Tissue Remodelling" Molecular Cell Biology (Nature Publishing Group) 3: 350–352.
Notes for the workshop presented at the AMT AGM, April 2008 & again at the AMT Annual Conference, October 2008.
Printed in the AMT Journal "In Good Hands", December 2008
©AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
Cervicogenic pain is pain that has its origin (genesis) in the neck. Soft tissue pain
in this region can be either local or referred, somatic, autonomic, visceral or neural in origin. In addition to local visceral structures, pain can also refer from viscera in the torso. The main considerations of this paper will be somatic pain from soft tissue structures, primarily the myofascia. Aside from direct trauma to the region, such as whiplash, myofascial dysfunction in the cervical region is generally secondary to structural imbalances below the level of the neck.
Many structures and tissues in the neck can be responsible for pain. Autonomic manifestations would include perturbation of the cervical sympathetic ganglia (just anterior to the vertebral bodies) such as could occur as a result of whiplash or prolonged forward head posture, where vertebral instability creates a cluster of symptoms, as in Barré-Lieou Syndrome (for example.) Somatic pain could originate in either bony tissue (such as facet joint referral)or the soft tissue.
STRUCTURAL CONSIDERATIONS
1. Gravity
“Posture is the distribution of body mass in relation to gravity over a base of support. The base of support includes all structures from the feet to the base of the skull.”
(Kuchera and Kuchera, 1997)
The prime structural consideration is our response to gravity. All posture can be viewed as our response to gravity and subsequent orientation to our environment. All life on Earth responds to the gravitational force of the planet: even birth can only occur in the appropriate gravitational field. While no doubt it may be possible to conceive in zero gravity on a space station, it is impossible to give birth out of Earth's gravitational field. NASA experiments using quails on the space station has proven this many times.
Form follows function: optimal alignment in gravity and to 3 dimensional space has resulted in a structure that has evolved to meet the demands of uprightness in gravity with minimal energy expenditure yet maximum efficiency in movement. Humans are fairly unique in the animal kingdom in that as a species we have evolved to stand and operate upright in gravity. This places unique stresses on our bodies. A snake, a quadruped (like the horse or dog) and another possible biped like the kangaroo will all respond to gravity differently from humans. Bears are another biped, but their response to gravity has resulted from different adaptations to the 3 dimensional environment.
To maintain our upright posture we need to be aligned around our centre of gravity (CoG) over 2 bases of support (the feet) and, from that place, move in, relate to and inter-act with the 3-dimensional space around us. While each of us is unique and our postural pattern can vary slightly from one individual to another, we all conform to major, common patterns that are determined by our form as a species and the relentlessness of the force of gravity on this planet operating upon us.
2. Tensegrity
Twentieth century architect, inventor and philosopher R. Buckminster- Fuller coined the term ‘tensegrity’ as a contraction of ‘tensional integrity’. He used the term to encapsulate the concept of a lightweight, integrated structure that gives great stability with the use of minimal material. A tensegrity structure thus maintains a synergy between balanced tension and compression forces. This means that any applied force can be met evenly by the structure, yielding without disturbing its internal equilibrium.
A tensegrity structure comprises two basic components:
• A compressive structure (such as posts, poles, struts or columns).
• A tensile structure (such as cables, wires, ropes, sheets).
There are some notable architectural examples - Centrepoint Tower and the Sydney Harbour Bridge are both tensegrity structures, In fact, any cantilever bridge or an old-fashioned airplane with struts and guy wires is a tensegrity structure. A tent is another basic example.
To be dynamic, animal bodies need to operate effectively in gravity by minimising the effect of their weight. The tensegrity relationship is one part of achieving this. Thus animals embody the characteristic unison of compressed and tensioned parts that defines a tensegrity structure. The skeleton of an animal is compressive, while the soft tissue, myo-fascial / tendinous and ligamentous structures are tensile.
3. The functional anatomy of the spine.
The human spine is a tensegrity structure. It consists of a series of rigid bones (compressive structures) interposed between deformable, fibro-cartilaginous intervertebral discs (tensile structures). The soft tissue muscles, fascia and ligaments connecting the bones are also tensile structures.
The spine has curves anterior (lordoses) or posterior (kyphoses) in the sagittal plane. Where there are kyphoses, there are bony structures such as the ribs and pelvis enclosing and protecting vital organs. There is also less mobility. Where there are lordoses, there are no bony enclosures and greater mobility.
These spinal curves have a definite relationship to our CoG, sometimes passing through it, sometimes behind it, sometimes anterior to it. Together with the tensegrity relationship within the spine, they allow the spine resilience in movement and stance.
The lordotic, cervical spine has the greatest mobility within the vertebral column. All mobility comes at the cost of stability and thus this region has a greater propensity for damage and soft tissue adaption / maladaption.
Functionally, the cervical spine has two divisions: the cranio-cervical (Occiput-C2)and the typical cervical (C3-C7) regions, with the C2/C3 motion segment constituting a transitional functional region.
The cranio-cervical region consists of the atlanto-occipital(C0/C1) and atlanto-axial(C1/C2) articulations, which together account for the greatest amount of saggital and transverse motion of any individual vertebrae in the whol spine. Think of the yes and no motions: the yes motion is saggital movement that occurs at C0/C1, while no is transverse movement occurring at C1/C2, the Atlas (C1) rotating around the peg (dens or odontoid process) of C2.
The C2/C3 articulation is functionally unique and quite important, providing the stable base to "anchor" the head and cervico-cranial region to the rest of the spine. The bony articulations of the superior aspect of C3 (large uncinate processes and large, uniquely inclined superior articlar processes) allows a deep, stable socket for articulation with the inferior aspect of C2. This enhanced stability is required to cope with the many muscles (from both above and below) that converge and articulate at this level, all of which play a role in anchoring the atlas.
C3- C7 for the most part conform functionally to the pattern of the rest of the spine below, apart from the following specifically local adaptations:
-bifid spinous processes that allow more muscular attachment sites, as well as preventing the 'kissing spines' effect in extension and thus allowing a safer, greater range of motion in extension.
- Transverse Processes (TPs) with two bony projections that allow two different muscular attachment sites: theanterior pedicles that projects laterally from the vertebral body and theposterior pedicle that projects laterally from the pedicles. A small strut of bone unites these two pedicles; together all three parts are referred to as the transverse process, though this is quite different structurally to TPs elsewhere in the spine.
- Within the transverse process there is the Transverse Foramen, through which the Vertebral Artery passes. This is clinically significant as a potential hazard in doing work on the cervical spine.
- Other clinically unique features worth considering are the orientation of the facets, which allow a large range of motion, the orientation of the pedicles which allows a large, triangular spinal canal, the uncinate processes, which minimize lateral motion and shear and thus protect the Vertebral Artery, and finally the shapeof the intervertebral foramen and the superior groove on the TP, that facilitates the exit of the spinal nerves in a unique way.
MYOFASCIAL CONSIDERATIONS
The myofascial and connective tissue network can be viewed as a tensegrity arrangement within the body. As mentioned in the above paragraph, it is the most mobile part of the axial skeleton; stability here is provided by appropriate relationships in the soft tissue. Like the mast of a sailing ship, the soft tissue of the shoulder girdle, ribs, lower vertebrae and manubrium that connects with the cervical spine, hyoid, mandible and cranium is like a tensegrity mast.
1. Fascia and connective tissue are highly plastic
Fascia is composed of about 30% collagen, 1% elastin and some reticulin fibres in a matrix of water-loving cells. Collagen is the netting that gives fascia its form - it is stronger than steel fibres of the same size. Fascia encloses every structure in the body and is the substance responsible for the form of the body.
It is also highly innervated with sensory nerves and can respond to neural inputs by contracting, relaxing, remodelling and changing its chemical makeup and ratios. When damaged, collagen frays and reconnects wherever it can. This is the basis of scar formation.
Fascia / connective tissue responds to the stress of chronic postural change by:
1. Thickening
2. Shortening
3. Calcifying
4. Eroding
Like bone, fascia is subject to Wolf’s Law: it changes and remodels in response to the forces placed on it. Muscle fibres can contract and relax, unless in spasm. Fascia, on the other hand, can’t relax as readily and will respond to poor usage by remodelling negatively. This can be quite rapid - it doesn’t take much to change its length. However, this plasticity is also a blessing because it doesn’t take much for it remodel to positively either.
Fascia is throughout what is commonly thought of as muscle. A piece of red meat trimmed of all its connective tissue (the white stuff) is approximately 50-60% muscle fibre and 40-50% fascia.
2. Cervical Fascial Anatomy
Once past the partly adipose superficial fascia, here are 4 major layers of deep fascia in the neck:
1. An outer, extrinsic, layer around the sleeve musculature
2. An Inner, intrinsic, deeper layer around the core musculature
3. A visceral layer around the oesophagus and the thyroid / parathyroids.
4. A meningeal layer around the spinal cord.
The Superficial Cervical Fascia is partly fascia and adipose tissue and is immediately under the dermis. It contains the platysma muscle. After the superficial fascia but before the epimysium of individual muscles lies the deep fascia. There are several layers of deep fascia in the neck:
• Deep Cervical Fascia around the whole neck, with an Investing Layer enclosing interiorly the trapezius and sternocleidomastoid.
• Prevertebral Fascia, superficial to longus colli and scalenes, it continues deep to the Investing Layer to enclose the deep posterior neck muscles.
• A Middle Layer that encloses the infra hyoids anteriorly.
• Visceral fascia that consists of:
a. The Pre Tracheal Fascia enclosing the cervical viscera anteriorly as well as the infra hyoids posteriorly, and
b. Retrovisceral Fascia, enclosing the viscera posteriorly.
The meninges can be viewed as neural fascia enclosing the spinal cord.
Individual muscles are covered with epimysium; perimysium encloses fascicles of muscle fibres and endomysium surrounds individual muscle fibres. These are morphologically no different to fascia. Where the muscle fibs finish, the fascia joins together and continues as the tendon. In other words, fascia is distributed throughout the entire structure.
3. Neuro-Fascial Considerations
As mentioned above, fascia is a heavily innervated material. For example, Golgi Tendon Organs only occur in fascia. As such, they can be found not only in the tendon but also throughout the fascia within the muscle belly. There are proprioceptors, chemoreceptors, mechanoreceptors and thermoreceptors in fascia. Once I would have added nociceptors here as well but recent reading has made me doubt the specific existence of nociceptors - nociception and pain may just be the response to threat or damage, a summation of responses to changes in temperature, ph, chemical environment and pressure. What I will say is that fascial, neural structures are sensory and capable of involvement in pain symptoms.
Proprioceptive feedback alters our cortical response which, in turn, alters our motor patterns … which will then alter structure and biomechanics. If this is prolonged, the fascia responds by changing its internal environment, creating thickenings and adhesions and increasing myofibroblast rather than fibroblast activity, which will further increase the contractile property of fascia.
Sympathetic nervous system activity (fight or flight responses) can shorten fascia. It’s not just prolonged physical overload that creates compromise but also constant low-level, psycho-emotional input: stress from the job/partner/children/bully/tax department/recent injury/that old pain that won’t go away etc. Fear and insecurity can lead to ANS sympathetic involvement as easily as other protective behaviour patterns, be they emotional in origin or physical in origin, such as muscle guarding around immediate physical pain.
Golgi Tendon Organs, Golgi receptors, Pacinian and Ruffini Corpuscles - all present in the fascia – will respond to appropriately to different types of manual therapy and can act to inhibit sympathetic activation of the fascial tonus.
4. Postural and phasic muscles
Structural modification, be it due to poor usage, muscle guarding around pain or sympathetic activation, can lead to an altered relationship to gravity. This can manifest in the muscle fibres as either hypertonicity, hypotonicity or muscle wasting, in the fascia as altered morphology anf tonus. Myofascial structures throughout the body can be divided into tonic or phasic, depending on muscle type and function.
Tonic or postural muscles are the anti-gravity muscles, working constantly to maintain upright stance. Postural muscles are fatigue resistant, Type 1 fibres. In dysfunction these will tend to shorten and can either tighten or weaken.
Phasic muscles are recruited only for specific movements, then rest and restore their energy levels. Phasic muscles are Type 2 fibres, which fatigue easily. Most type II fibres will tend to weaken without shortening in dysfunction
The following list is from Robert Schleip’s website www.somatics.de, a wonderful source of articles on structure and bodywork.
TONIC/ POSTURAL MUSCLES
Hamstrings
Iliopsoas
Rectus femoris
Tensor Fascia Latae
Triceps surae
Pectoralis Major (sternal; clavicular?)
Trapezius (ascending fibres)
Levator Scapulae
Erector Spinae (lumbar and cervical)
(thoracic?)
Quadratus Lumborum
Sartorius
Piriformis
Short Adductors (Magnus and Brevis)
Sternocleidomastoid
B. Brachii (?)
Flexors of hand (?)
Scalenii
PHASIC/ MOBILISER MUSCLES
Tibialis Anterior
Vastus Medialis and Lateralis
Gluteus (Maximus and Minimus)
Rhomboids
Trapezius (ascending and horizontal fibres)
Serratus Anterior
Long adductors
Short hand and foot muscles
Longus Colli and Capitus
Omohyoid (?)
Gluteus Minimus
Pectoralis Major (Costal attachments)
Gluteus Minumus
Triceps Brachii
Scalenii
Note that the scalenes appear in both lists. They are phasic muscles which, if put under the chronic stress of altered posture, become dysfunctional and adapt their fibre type to take on the characteristics of tonic/type 1 fibres.
The following list defines the features of the different fibre types (again from www.somatics.de):
TYPE I MUSCLE FIBRES
• Slow twitch
• Contract slowly
• Low stores of glycogen
• High concentrations of myoglobulin and mitochondria
• Fatigue slowly
• Mainly involved in postural and stabilising tasks
• Tonic or postural muscles
• Stress or dysfunction will lead to shortening
• When short/tight, may test either strong or weak
TYPE II MUSCLE FIBRES
• Fast twitch
• Rapid contraction
• Depending on sub-type, mitochondria and myoglobulin concentrations vary
• Generally fatigue rapidly
• Mainly involved in phasic activity
• Also referred to as phasic or mover muscles
• Stress or dysfunction will lead to weakening over their whole length
• Will always test as weak and without shortening
There are 3 subtypes of Type II muscles fibres:
TYPE IIa FIBRES
• “Fast twitch” or “fast white” fibres
• Contract more rapidly than type 1
• Are moderately resistant to fatigue
• High concentrations of mitochondria and myoglobulin compared to other type II fibres
TYPE IIb FIBRES
• “Fast twitch glycolytic” or “fast white”
• Less fatigue resistant
• Depend more on glycolytic sources of energy
• Low levels of mitochondria and myoglobulin
TYPE IIM FIBRES
• “Super fast” fibres
• Found mainly in the jaw muscles
• Depend on a unique myosin
• High glycogen content
• These last two properties differentiate it from other type II muscle fibres
5. The head as a level platform for the senses
The head is the platform for the senses. Due to the Ocular Righting Reflex, the eyes will always seek to look at a level horizon. This feature means that any damage, shortening or change in habitual pattern that occurs to alter the posture of the body will be allowed and compensated for (by involving other structures in the body) as long as the eyes can look at a level horizon. The vestibular system will accommodate the head in a different, dysfunctional position and alter the sense of balance and proprioception, thus perpetuating the new, dysfunctional pattern.
6. Upper Crossed Syndrome
Vladimir Janda’s ‘Crossed Syndromes’ are worth considering in treating the cervical region, specifically the Upper Crossed Syndrome:
• Hypertonic trapezius and levator scapula posteriorly, hypertonic pectoralis major anteriorly
• Hypotonic anterior deep neck flexors and rhomboids and serratus anterior
An appropriate treatment protocol could be to lengthen the upper trapezius, levator scapulae and pec major, accompanied by strengthening exercises and resisted movement for the anterior cervical musculature and rhomboid/ serratus sling.
7. Forward Head Posture
Forward head posture is a very common presentation, with myofascial compensations that are quite similar to upper crossed syndrome.
In forward head posture, we can expect the following:
• The upper traps and levator scap are shortened. This creates an increased cervical lordosis.
• Activation of the Moro (startle) Reflex- increased ANS activity (fight or flight response) – cervical ganglions involved.
• TMJ involvement- retraction of mandible
• Jaw clenched or mouth open, possibly bruxism (grinding)
• The head will double in weight for every 2.5cm it is forward of the CoG, further increasing the load on the musculature (especially the sub occipitals).
The suboccipitals, which should delicately finetune the head’s position in space as the senses respond to stimuli, instead become postural in function.
The TMJ dysfunction affects the body globally by affecting the vestibular function and balance and thus our position space, leading the posterior neck muscles to further shorten and increase their dysfunctionality.
Conclusion
This article is an expansion from workshop notes; that workshop was primarily practical in content. Consequently, it is far from definitive. I have tended to discuss cervicogenic pain primarily in terms of local phenomena. Nothing, however, occurs in isolation in the body. A more global perspective would take into account that the neck is near the top of a chain that commences with the feet. Any other dysfunction in this chain will manifest sooner or later in the neck.
Viewing neck pain as a purely local phenomenon may mean overlooking the genesis of that pain elsewhere in the body. Trigger point pain is very much a local manifestation of a more global pattern. Many trigger points and acupoints correspond to where nerves pass through the fascia. These are very real to the client and offer fairly immediate pain relief when they are deactivated. But they are only a part of the problem. The trick is to make the client aware of what else is contributing and work to prevent recurrence. The body always seems to recruit strength over stability in dysfunction, whereas as the key to true rehabilitation is almost always enhancing stable function.
By way of a closing example, let’s consider Tom Myers’ ‘Anatomy Trains’ concept of the body. Perhaps we could view the involvement of the myofascial meridian or locomotor sling of the Superficial Back Line. The local manifestation of the global pattern could be neck pain or headache. But there will also be tight plantar fascia, perhaps with collapsed arches, genu recurvatum (knee hyperextension), anterior pelvic tilt, either hypo- or hyper- lordosis and definitely cervical hyperlordosis and forward head posture. Any of these more distal dysfunctions could be causing or contributing to the problem and would need addressing to resolve the cervicogenic pain. Or perhaps it could be an issue of core or pelvic stability; involving different myofascial slings again. Any treatment of a client should involve a comprehensive assessment and plan that considers the possibilities of the whole body presenting before you.
Bibliography
Butler D.S. and Mosley G.L. (2003) "Explain Pain" Noigroup Publications, Adelaide.
Chaitow, Leon (1988) "Soft Tissue Manipulation" Rochester, VT: Healing Arts Press, 26-27.
Chaitow, Leon & DeLany, Judith 2000 Clinical Application of Neuromuscular Techniques, Volume 1, The Upper Body Churchill Livingstone, Edinburgh.
Chaitow, Leon (2002) "Clinical Application of Neuromuscular Techniques, Volume 2, The Lower Body" Edinburgh Churchill Livingstone 21-94.
Kendall, F, McCreary, E and Provance, P (1993) "Muscle Testing and Function" Lippincott Williams and Wilkins, Baltimore.
Kuchera, M. and Kuchera, W. (1997) “General Postural Considerations” in Ward, R. "Foundations for Osteopathic Medicine", Lippincott Williams and Wilkins, Baltimore.
Levangie, P. K. & Norkin, C. M. 2005 Joint Structure & Function 4th Edition, FA Davis Company, Philadelphia PA.
Moseley, G.L. (2007) "Painful Yarns: Metaphors and Stories to Help Understand The Biology of Pain" Dancing Giraffe Press, Canberra.
Myers, Thomas W. (2002) "Anatomy Trains" London, UK: Churchill Livingstone, P.15.
Myers, Thomas W., http://www.anatomytrains.com, sighted 22/11/2008.
Paoletti, Serge (2006) "The Fasciae: Anatomy, Dysfunction and Treatment" Seattle, WA: Eastland Press, 138, 147-149.
Porterfield, J.A. & DeRosa, C. 1995 Mechanical Neck Pain: Perspectives in Functional Anatomy W.B. Saunders Co, Philadelphia PA.
Rolf. Ida P (1977) "Rolfing: Re–establishing the Natural Alignment and Structural Integration of the Human Body" Healing Arts Press, Rochester Vermont.
Schleip, R.; Klingler, W.; Lehmann-Horn, F. (2005) "Active fascial contractility: Fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics" Medical Hypotheses (Elsevier) 65: 273–277..
Schleip, R. (2003) "Fascial plasticity – a new neurobiological explanation: Part 1" Journal of Bodywork and Movement Therapies (Elsevier) 7 (1): 11–19.
Schleip, R. (2003) "Fascial plasticity – a new neurobiological explanation: Part 2" Journal of Bodywork and Movement Therapies (Elsevier) 7 (2): 104–116.
Schleip, R., http://www.somatics.de, sighted 22/11/2008.
.
Simons, D, Travell J, and Simons, P (1999) "Myofascial Pain and Dysfunction: the trigger Point Manual, Vol 1 Upper Half of Body" Lippincott, Williams and Wilkins, Baltimore.
Tomasek, J., Gabbiani, G., Hinz, B., Chaponnier, C., Brown, R. (2002) "Myofibroblasts and Mechanoregulation of Connective Tissue Remodelling" Molecular Cell Biology (Nature Publishing Group) 3: 350–352.
INTERVIEW of COLIN ROSSIE by Rebecca Barnett for "IN GOOD HANDS", December 2007
© AMT 2007.Not to be printed or used without permission of the copyright holder and acknowledgement of original publication.
RB: You’ve just recently spent a month in the States. Tell us about what you did over there.
CR: I attended a scoliosis workshop run in Boulder by the Rolf Institute, went to the 3-day American Massage Therapy Association (AMTA) conference in Cincinnati (preceded by a 2-day pre-conference workshop on Sports and Structural Integration), then a 2-day Tom Myers workshop in Boston, the 2 day Fascia Research Congress, the 2 day International Association of Structural Integrators’ (IASI) Symposium which followed that, then lastly a 3-day workshop with Kevin Frank on Tonic Function in a beautiful lakeside setting in New Hampshire, which was about the core and how to utilise it in bodywork.
RB: So at what point during this trip did your brain explode?
CR: Probably at the end of the first day of the Fascia Research Conference. It started at 6.30 a.m., with non-stop lectures until 8.30 in the evening. At 7.30 p.m. I went to see a lecture by Dr J C Giumberteau, a French hand specialist who does microscopies under the skin before he does his operations … so he’s done all these fabulous electron microscopies of the structure and movement of the fascia. The film he did, ‘Strolling Under the Skin”, is quite amazing- it’s available in both French and English. I understand it will be available soon from Tom Myers website (www.anatomytrains.com). I especially recall in vivo images of the fascia in the forearm during flexion and extension of the fingers. He’s also written a book with the same title in French; but the microscopy photos & film of fascia are breath taking. I think his stuff will truly revolutionize the way we as bodyworkers will view the body. One couldn't help but be awed.
Anyway, I saw his movie at lunchtime, thought it was one of the most wonderful things on the body that I’ve seen. So excitedly, I made my way to his lecture at 7.30 in the evening. Bear in mind, I'd been up since 5.00 a.m. and despite over a week in the US, was still suffering the effects of the timr difference. The voice over in the English version of the movie is this very plummy Brit accent. Unlike the voice-over, Dr Giumberteau speaks with a very thick French accent, which, being so tired, I was finding difficult to comprehend. I was like an over tired child; I couldn’t focus my attention, my eyelids started drooping, but I was desperately trying to stay conscious and take it all in. Probably a little bit of jet lag happening there as well. I would start to nod off and roll my head forward, then jerk my neck back violently. I couldn’t concentrate and knew at that stage I was fried – exhausted, in overload, had taken up too much information.
RB: Most of us have heard of Tom Myers. Tell us about the workshop with him.
CR: It was a workshop on working the head, neck and jaw. I do a lot of the work he was presenting as part of my Rolfing practice, so technique wise not a lot of it was new for me. But its always good to re-visit what you've learnt anew and viewing a master of one's field at work. Tom Myers has a very eloquent way of presenting. He's also done a lot of interesting dissection work in the last few years as research for his myofascial meridians theory- he used the results of this as an adjunct to teaching. It was well worth seeing- he'll probably be including the results of the dissections in the next edition of "Anatomy Trains". He’s revised his theories a bit and come up with some new ideas and perpectives, which should appear in that new version.
A lot of the workshop was revision but it was good revisiting the concept of working with 4 layers of fascia - a superficial layer around the sleeve musculature; a deeper layer around the core musculature; a layer around the viscera, which in the head and neck is the oesophagus and thyroid and so on; and finally a neural layer in the meninges.
RB: Moving right along, can you give us some concept of the scale of the AMTA conference?
CR:It was huge! I’m not exactly sure of the numbers but probably somewhere over a 1000 or so attendees and probably around 50 or 60 exhibitors. The theme of the conference was ‘Creating Connections in Cincinnati’. It was very show biz, razz-a-matazz: stage-managed to the nth degree, big smiles held a long time for the cameras etcetra.
Networking to my mind is normally a bit of a dirty word because it implies people trying to sell you things! But here networking was all about creating connections and building relationships- with fellow therapists, within our community in the industry, the wider community we exist in that is our practice and clients, and massage as a valid health & wellness practice in society; creating connections between different modalities, creating connections between the executive, regional committees and the membership, and between the local committees and members of the different regions.
RB: With that volume of people, though, it must be quite hard to create connections between the executive and the membership?
CR: Bear in mind that in addition to their national executive, there are 50 different state executives, each of which had several representatives at the conference. I managed to circulate and meet with a huge number of the ordinary delegates- Americans are really warm people, and being very obviously an Australian visitor helped in that regard - a lot of hospitality and warmth was extended. There was a lot of curiosity about Australia generally and massage therapy here. As AMT's rep and a guest, I also had contact with the AMTA national executive and many representatives from the individual state executives. There were also Massage Research Foundation dinners and parties and other dos; something different on every night after the conference day sessions, for 5 days!
Because I was going to the conference on behalf of AMT, I chose to do two ethics workshops that I felt would help with the work AMT is planning to do over the next few years in getting our protocol and scope of practice documents set up and developing the ethics sub-committee.
Robert King, a well-known sports massage therapy pioneer in the States, presented one ethics workshop, “Know Thyself”. The session consisted of discussing the AMTA’s and the NCBTMB’s Code of Ethics and Standards of Practice documents, the requirements and necessity of professional ethics, our personal ethics and the importance of self-evaluation and self-examination. We filled in self evaluation forms, discussed steps and strategies to resolve ethical problems and then broke into groups of 10 or so to work through a series of ethical dilemma scenarios. Each group then presented their findings back to the whole class for discussion.
I also attended a workshop with Diane M. Polseno, “Everyday Ethics”. She is a well-known educator in the States. Her session focused on the pitfalls one can fall into as a therapist, focusing on issues like therapeutic relationship and professional boundaries, navigating the common grey areas we can be faced with as a professional. Putting it into the wider context of beliefs and society. It gave me fuel for thought personally; both workshops gave me ideas for developing another Ethics Module for AMT in the future.
RB: In the States, they have a compulsory Ethics requirement as part of their continuing education, don’t they?
CR: Yes. They have a rolling system of continuing education accreditation - within a 4-year period you have to get 400 points of which 35 have to be Ethics, 35 self-care, 35 business & practice management and so on. Basically, you need to do a day of Ethics continuing education every 4 years minimum. There is the same requirement for hands-on techniques, business practice, research, self-care etc - all built into their continuing education system. In that way, their continuing education system is more broad-based than ours. Here one can focus narrowly on one strand in professional development and neglect a broader based approach.
RB: So tell us about the Fascia Research Congress. What kind of people did that event attract?
CR: It was primarily aimed at the Structural Integration community - it sold out very rapidly to that community – there were also a lot of chiropractors acupuncturists and osteopaths in attendance; also a huge number of people from the massage therapy community.
Attendance wise, I think there were about 400 plus people in the main auditorium and another 700 in other rooms in the centre watching proceedings on video screens.
RB: In terms of the clinical application for Massage Therapists specifically, is there anything you can share?
CR: The information given out at the conference was astounding. It reinforced a lot of what I’d been taught but also gave me many new perspectives.
The whole concept that underlies trigger point work, deep connective tissue work, deep tissue massage, transverse frictions, both direct and gentle myofascial release… basically, all work with the properties of fascia. Working with the fascia underlies all those approaches. What this conference did was present all the current knowledge in its breadth, scope and diversity as well as present the latest research, most of which was really cutting edge.
Often we tend to think of fascia from the point of view of the thixotropic model - being something we need to work into gradually so that it begins to change its state from a solid to a liquid. But the reality of the fascia is that it is a heavily innervated substance. The Golgi Tendon Organs (that we generally tend to think of as being purely in the tendon) are throughout the whole epimysium, perimysium and endomysium. We tend to think about fascia as the wrapping around muscle and the wrapping around muscle compartments and wrapping around the entire limb, and several different layers of fascia from the skin coming down through the superficial fascia. There is this superficial, foamy, “fairy floss” of collagen fibres that connects the subcutaneous superficial fatty layer to the superficial deep fascia; this "fairy floss" is all pervasive, sort of extra to the fascia between every layer of it. Then the more superficial deep fasciae, such as the ITB of the fascia lata and the thoraco-lumbar fascia, are very dense, fibrous structures with major stabilizing roles. I found the presentations on fibroblast & myoflbroblast activity and formation enlightening - how the forces that act on the fascia can change what cells are formed. I dare say that that is something we in the bodywork field will be hearing a lot more about.
There were presentations on the microscopic aspect of fascia. The cross linkages in the collagen look like a Tibetan bridge - a polysaccharide tetrahedron, one person described it as! Again, I’ll mention Dr Giumberteau’s film here- these wonderful, moist, rope bridge-like cross linkages that glide, slide and deform in tensegrity forms are truly wondrous to observe.
The forces that act on fascia are quite astounding. Fascia doesn’t just work along the lines of pull of the muscle but can also work in different directions and through gradual pressure can lengthen and deform in any direction. Its all reminiscent of a kind of fluid, trabeculae arrangement. The work on smooth muscle-like contractility in fascia is also quite groundbreaking.
Dr Serge Gracovetsky, a Quebecois Canadian, was a very informative and the most entertaining presenter. He gave a historical review of his research and the different models that have been used over time to explain things like intra abdominal pressure and mechanical forces on the body in lifting, on the role of the thoraco-lumbar fascia as well as a summary of his most recent research work on its role in biomechanics, intra abdominal pressure and gait. Referring to the lengthy opposition his research received before it was widely accepted, he came up with one of the great quotes of the conference; “Medicine is perhaps the only discipline in which an attractive idea can survive experimental annihilation.”
There were also presentations on mechanoregulation and mechanotransduction, fascial regulation of tonus, pain, gross and microscopic anatomy, physiology, biomechanics, as well as presentations by acupuncture researchers (effective acupuncture affects the fascial system: most acupoints correspond to major indurations in the fascia).
Of course, there were quite a few presentations on tensegrity and the physical/ structural/ engineering aspects of fascia, which as you know are particular hobby horses of mine, so I won't wax too lyrical about those lest I bore everyone. You are best seeing those on the DVD.
I’d thoroughly recommend viewing a re-screening of the Congress proceedings when it comes to your capital city! Obviously there’s one being run at RMIT in Melbourne but that will be over by the time this journal is published. AMT are considering running a replay in Sydney, so keep an eye out for that.
Better ask me another question or else I'll talk fascia all day!
RB: Now, some AMT members will be aware of the work of Ruth Werner from the pathology module that we’ve had for several years. I understand you did a workshop with Ruth?
CR: Yeah, as part of the AMTA conference breakouts. She presented a session on Pathology for Psychiatric Disorders. Ruth is a wonderful teacher, very knowledgeable, with a warm personality. She made very complex and difficult material into something very simple and easy to understand. I suppose that’s what comes from having a massage therapist present pathology – it’s done from the perspective of our industry. She is truly passionate about her subject, and well researched. All this stuff that could potentially be very dry was bought alive in a way that spoke to working therapists.
RB: Were there other presenters you saw at that conference?
CR: I also did a workshop with Leon Chaitow later that day. It was a real “auditorium experience”. There were about 200 people in the room so it was a demonstration rather than a hands-on session. He would make a few statements, then quote the research he had to back them up. Towards the end of the three hours, he demonstrated a few techniques on stage. It was simultaneously filmed and presented on a screen, but the camera angles were bad so weren't sure precisely what was going on, so it was a little disappointing, especially as we didn’t get the chance to practice on each other and experience the work. I’ve heard others say that when he presents to smaller numbers, he’s really enjoyable, so I look forward to possibly experiencing this on another occasion.
I did a movement workshop with Betsy Wetzig, which, as a movement practitioner, appealed to me. This was in AMTA's self care category.
Another interesting character I encountered was George Kousaleos, a structural integrator from the CORE Institute. He did a sports and performance seminar as a pre-conference workshop in Cincinatti. George popped up everywhere over the next fortnight at the other conferences I attended. He’s also another one who’s passionate and enthusiastic about the work he teaches. He was teaching over 100 people in the room with two assistants, and all the attendees were fully engaged. George was quite active at the other conferences and avidly networked everywhere he went.
I also encountered Richard Rossiter – now there’s a character! He’s a certified Advanced Rolfer who has developed a really interesting approach to treating pain and stretching. He has a really populist approach to bodywork. He’s taken his work to the factories, where he thinks nothing of treating 100 people in a day. He teaches workshop in his methods, both to the average punter and to therapists. I’d love to see him present his work out here – it’s really quite unique. All things being equal and if enough interest is shown I'd love to sponsor some of his workshops here.
Both these characters I also encountered at the IASI Conference in Boston
RB: Tell us about a bit about that.
RB: You’ve just recently spent a month in the States. Tell us about what you did over there.
CR: I attended a scoliosis workshop run in Boulder by the Rolf Institute, went to the 3-day American Massage Therapy Association (AMTA) conference in Cincinnati (preceded by a 2-day pre-conference workshop on Sports and Structural Integration), then a 2-day Tom Myers workshop in Boston, the 2 day Fascia Research Congress, the 2 day International Association of Structural Integrators’ (IASI) Symposium which followed that, then lastly a 3-day workshop with Kevin Frank on Tonic Function in a beautiful lakeside setting in New Hampshire, which was about the core and how to utilise it in bodywork.
RB: So at what point during this trip did your brain explode?
CR: Probably at the end of the first day of the Fascia Research Conference. It started at 6.30 a.m., with non-stop lectures until 8.30 in the evening. At 7.30 p.m. I went to see a lecture by Dr J C Giumberteau, a French hand specialist who does microscopies under the skin before he does his operations … so he’s done all these fabulous electron microscopies of the structure and movement of the fascia. The film he did, ‘Strolling Under the Skin”, is quite amazing- it’s available in both French and English. I understand it will be available soon from Tom Myers website (www.anatomytrains.com). I especially recall in vivo images of the fascia in the forearm during flexion and extension of the fingers. He’s also written a book with the same title in French; but the microscopy photos & film of fascia are breath taking. I think his stuff will truly revolutionize the way we as bodyworkers will view the body. One couldn't help but be awed.
Anyway, I saw his movie at lunchtime, thought it was one of the most wonderful things on the body that I’ve seen. So excitedly, I made my way to his lecture at 7.30 in the evening. Bear in mind, I'd been up since 5.00 a.m. and despite over a week in the US, was still suffering the effects of the timr difference. The voice over in the English version of the movie is this very plummy Brit accent. Unlike the voice-over, Dr Giumberteau speaks with a very thick French accent, which, being so tired, I was finding difficult to comprehend. I was like an over tired child; I couldn’t focus my attention, my eyelids started drooping, but I was desperately trying to stay conscious and take it all in. Probably a little bit of jet lag happening there as well. I would start to nod off and roll my head forward, then jerk my neck back violently. I couldn’t concentrate and knew at that stage I was fried – exhausted, in overload, had taken up too much information.
RB: Most of us have heard of Tom Myers. Tell us about the workshop with him.
CR: It was a workshop on working the head, neck and jaw. I do a lot of the work he was presenting as part of my Rolfing practice, so technique wise not a lot of it was new for me. But its always good to re-visit what you've learnt anew and viewing a master of one's field at work. Tom Myers has a very eloquent way of presenting. He's also done a lot of interesting dissection work in the last few years as research for his myofascial meridians theory- he used the results of this as an adjunct to teaching. It was well worth seeing- he'll probably be including the results of the dissections in the next edition of "Anatomy Trains". He’s revised his theories a bit and come up with some new ideas and perpectives, which should appear in that new version.
A lot of the workshop was revision but it was good revisiting the concept of working with 4 layers of fascia - a superficial layer around the sleeve musculature; a deeper layer around the core musculature; a layer around the viscera, which in the head and neck is the oesophagus and thyroid and so on; and finally a neural layer in the meninges.
RB: Moving right along, can you give us some concept of the scale of the AMTA conference?
CR:It was huge! I’m not exactly sure of the numbers but probably somewhere over a 1000 or so attendees and probably around 50 or 60 exhibitors. The theme of the conference was ‘Creating Connections in Cincinnati’. It was very show biz, razz-a-matazz: stage-managed to the nth degree, big smiles held a long time for the cameras etcetra.
Networking to my mind is normally a bit of a dirty word because it implies people trying to sell you things! But here networking was all about creating connections and building relationships- with fellow therapists, within our community in the industry, the wider community we exist in that is our practice and clients, and massage as a valid health & wellness practice in society; creating connections between different modalities, creating connections between the executive, regional committees and the membership, and between the local committees and members of the different regions.
RB: With that volume of people, though, it must be quite hard to create connections between the executive and the membership?
CR: Bear in mind that in addition to their national executive, there are 50 different state executives, each of which had several representatives at the conference. I managed to circulate and meet with a huge number of the ordinary delegates- Americans are really warm people, and being very obviously an Australian visitor helped in that regard - a lot of hospitality and warmth was extended. There was a lot of curiosity about Australia generally and massage therapy here. As AMT's rep and a guest, I also had contact with the AMTA national executive and many representatives from the individual state executives. There were also Massage Research Foundation dinners and parties and other dos; something different on every night after the conference day sessions, for 5 days!
Because I was going to the conference on behalf of AMT, I chose to do two ethics workshops that I felt would help with the work AMT is planning to do over the next few years in getting our protocol and scope of practice documents set up and developing the ethics sub-committee.
Robert King, a well-known sports massage therapy pioneer in the States, presented one ethics workshop, “Know Thyself”. The session consisted of discussing the AMTA’s and the NCBTMB’s Code of Ethics and Standards of Practice documents, the requirements and necessity of professional ethics, our personal ethics and the importance of self-evaluation and self-examination. We filled in self evaluation forms, discussed steps and strategies to resolve ethical problems and then broke into groups of 10 or so to work through a series of ethical dilemma scenarios. Each group then presented their findings back to the whole class for discussion.
I also attended a workshop with Diane M. Polseno, “Everyday Ethics”. She is a well-known educator in the States. Her session focused on the pitfalls one can fall into as a therapist, focusing on issues like therapeutic relationship and professional boundaries, navigating the common grey areas we can be faced with as a professional. Putting it into the wider context of beliefs and society. It gave me fuel for thought personally; both workshops gave me ideas for developing another Ethics Module for AMT in the future.
RB: In the States, they have a compulsory Ethics requirement as part of their continuing education, don’t they?
CR: Yes. They have a rolling system of continuing education accreditation - within a 4-year period you have to get 400 points of which 35 have to be Ethics, 35 self-care, 35 business & practice management and so on. Basically, you need to do a day of Ethics continuing education every 4 years minimum. There is the same requirement for hands-on techniques, business practice, research, self-care etc - all built into their continuing education system. In that way, their continuing education system is more broad-based than ours. Here one can focus narrowly on one strand in professional development and neglect a broader based approach.
RB: So tell us about the Fascia Research Congress. What kind of people did that event attract?
CR: It was primarily aimed at the Structural Integration community - it sold out very rapidly to that community – there were also a lot of chiropractors acupuncturists and osteopaths in attendance; also a huge number of people from the massage therapy community.
Attendance wise, I think there were about 400 plus people in the main auditorium and another 700 in other rooms in the centre watching proceedings on video screens.
RB: In terms of the clinical application for Massage Therapists specifically, is there anything you can share?
CR: The information given out at the conference was astounding. It reinforced a lot of what I’d been taught but also gave me many new perspectives.
The whole concept that underlies trigger point work, deep connective tissue work, deep tissue massage, transverse frictions, both direct and gentle myofascial release… basically, all work with the properties of fascia. Working with the fascia underlies all those approaches. What this conference did was present all the current knowledge in its breadth, scope and diversity as well as present the latest research, most of which was really cutting edge.
Often we tend to think of fascia from the point of view of the thixotropic model - being something we need to work into gradually so that it begins to change its state from a solid to a liquid. But the reality of the fascia is that it is a heavily innervated substance. The Golgi Tendon Organs (that we generally tend to think of as being purely in the tendon) are throughout the whole epimysium, perimysium and endomysium. We tend to think about fascia as the wrapping around muscle and the wrapping around muscle compartments and wrapping around the entire limb, and several different layers of fascia from the skin coming down through the superficial fascia. There is this superficial, foamy, “fairy floss” of collagen fibres that connects the subcutaneous superficial fatty layer to the superficial deep fascia; this "fairy floss" is all pervasive, sort of extra to the fascia between every layer of it. Then the more superficial deep fasciae, such as the ITB of the fascia lata and the thoraco-lumbar fascia, are very dense, fibrous structures with major stabilizing roles. I found the presentations on fibroblast & myoflbroblast activity and formation enlightening - how the forces that act on the fascia can change what cells are formed. I dare say that that is something we in the bodywork field will be hearing a lot more about.
There were presentations on the microscopic aspect of fascia. The cross linkages in the collagen look like a Tibetan bridge - a polysaccharide tetrahedron, one person described it as! Again, I’ll mention Dr Giumberteau’s film here- these wonderful, moist, rope bridge-like cross linkages that glide, slide and deform in tensegrity forms are truly wondrous to observe.
The forces that act on fascia are quite astounding. Fascia doesn’t just work along the lines of pull of the muscle but can also work in different directions and through gradual pressure can lengthen and deform in any direction. Its all reminiscent of a kind of fluid, trabeculae arrangement. The work on smooth muscle-like contractility in fascia is also quite groundbreaking.
Dr Serge Gracovetsky, a Quebecois Canadian, was a very informative and the most entertaining presenter. He gave a historical review of his research and the different models that have been used over time to explain things like intra abdominal pressure and mechanical forces on the body in lifting, on the role of the thoraco-lumbar fascia as well as a summary of his most recent research work on its role in biomechanics, intra abdominal pressure and gait. Referring to the lengthy opposition his research received before it was widely accepted, he came up with one of the great quotes of the conference; “Medicine is perhaps the only discipline in which an attractive idea can survive experimental annihilation.”
There were also presentations on mechanoregulation and mechanotransduction, fascial regulation of tonus, pain, gross and microscopic anatomy, physiology, biomechanics, as well as presentations by acupuncture researchers (effective acupuncture affects the fascial system: most acupoints correspond to major indurations in the fascia).
Of course, there were quite a few presentations on tensegrity and the physical/ structural/ engineering aspects of fascia, which as you know are particular hobby horses of mine, so I won't wax too lyrical about those lest I bore everyone. You are best seeing those on the DVD.
I’d thoroughly recommend viewing a re-screening of the Congress proceedings when it comes to your capital city! Obviously there’s one being run at RMIT in Melbourne but that will be over by the time this journal is published. AMT are considering running a replay in Sydney, so keep an eye out for that.
Better ask me another question or else I'll talk fascia all day!
RB: Now, some AMT members will be aware of the work of Ruth Werner from the pathology module that we’ve had for several years. I understand you did a workshop with Ruth?
CR: Yeah, as part of the AMTA conference breakouts. She presented a session on Pathology for Psychiatric Disorders. Ruth is a wonderful teacher, very knowledgeable, with a warm personality. She made very complex and difficult material into something very simple and easy to understand. I suppose that’s what comes from having a massage therapist present pathology – it’s done from the perspective of our industry. She is truly passionate about her subject, and well researched. All this stuff that could potentially be very dry was bought alive in a way that spoke to working therapists.
RB: Were there other presenters you saw at that conference?
CR: I also did a workshop with Leon Chaitow later that day. It was a real “auditorium experience”. There were about 200 people in the room so it was a demonstration rather than a hands-on session. He would make a few statements, then quote the research he had to back them up. Towards the end of the three hours, he demonstrated a few techniques on stage. It was simultaneously filmed and presented on a screen, but the camera angles were bad so weren't sure precisely what was going on, so it was a little disappointing, especially as we didn’t get the chance to practice on each other and experience the work. I’ve heard others say that when he presents to smaller numbers, he’s really enjoyable, so I look forward to possibly experiencing this on another occasion.
I did a movement workshop with Betsy Wetzig, which, as a movement practitioner, appealed to me. This was in AMTA's self care category.
Another interesting character I encountered was George Kousaleos, a structural integrator from the CORE Institute. He did a sports and performance seminar as a pre-conference workshop in Cincinatti. George popped up everywhere over the next fortnight at the other conferences I attended. He’s also another one who’s passionate and enthusiastic about the work he teaches. He was teaching over 100 people in the room with two assistants, and all the attendees were fully engaged. George was quite active at the other conferences and avidly networked everywhere he went.
I also encountered Richard Rossiter – now there’s a character! He’s a certified Advanced Rolfer who has developed a really interesting approach to treating pain and stretching. He has a really populist approach to bodywork. He’s taken his work to the factories, where he thinks nothing of treating 100 people in a day. He teaches workshop in his methods, both to the average punter and to therapists. I’d love to see him present his work out here – it’s really quite unique. All things being equal and if enough interest is shown I'd love to sponsor some of his workshops here.
Both these characters I also encountered at the IASI Conference in Boston
RB: Tell us about a bit about that.
Subscribe to:
Posts (Atom)