SCOLIOSIS: Perspectives influenced by the Rolfing® Paradigm.

By Colin Rossie.
Certified Rolfer®, Rolf Movement Practitioner.

First published in AMT Journal "In Good Hands", September 2006 & reprinted in ARM newsletter October, 2006. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.

Scoliosis, the abnormal lateral curvature of the spine, is a fairly common condition that frequently leads people to seek massage therapy. This can either be directly because of the visual aspect of the curvature (usually a case of aesthetics) or due to mechanical complications resulting from it.

Scoliosis can be either structural or functional. A functional scoliosis is generally acquired as the result of unbalanced usage, whereas a structural scoliosis means that the bony structure has changed. This can often have a congenital origin but can also be the result of prolonged functional changes affecting the structure. Structural scoliosis is statistically the more prevalent of the two; between 70-90% of these are “idiopathic”, so termed because the cause is unknown. Its highest prevalence is among teenage girls. Many pathological structural causes can contribute to scoliosis: congenital malformations of the spine (i.e. hemi-vertebra), poliomyelitis, skeletal dysplasias, spastic paralysis, hemi-pelvis and unequal leg length. Inequality of shoulder and hip levels are common symptoms. In addition to the visible curving of the spine there is also a rotational component.

Common wisdom in massage circles is that while functional scoliosis may respond to massage, structural scoliosis won’t. In my clinical experience, many people with structural scoliosis have responded well to the interventions of Rolfing Structural Integration.

Developed by Ida Rolf in the 1930s and 40s and originally called Structural Integration, Rolfing® is a ten-part process that works sequentially on the body to align it in gravity. It consists of deep tissue bodywork on the myo-fascia and gentle joint mobilizations combined with movement education. It is a process in which the client is an active participant. In the words of Rolfer Jeffrey Birch:

“Structural Integration is distinguished from other disciplines by its primary attention to gravity. Other bodywork systems seek tonal balance, energy balance, emotional balance … while Structural Integration attends to all these, its primary goal is to alter the structure of the human body so that instead of fighting gravity, one can use it as an energy source. After a complete series of 10 sessions, clients look taller and more balanced, and report that they not only feel lighter, but also physically uplifted. This lift is due to the client’s new relationship to gravity.”(1)

Its efficacy is well attested, not just by the many people who have received the work but also by many studies and research. Ida Rolf termed one component of the deep tissue bodywork "myo-fascial release". This work is closer to deep connective tissue massage than the gentle myo-fascial release popularised by John Barnes in the last 20 years. The Rolfing-style myofascial release is now often termed Direct Myofascial Technique (2,3) to distinguish it from the gentler Barnes style work. In Australia, this direct style of work has been popularised by Michael Stanborough (4) in his myo-fascial release workshops.

Another component of Rolfing is movement integration, a proprioceptive challenging of habitual and inefficient patterns of body use, which re-educates the client in more appropriate and energy efficient ways of operation. This quite directly affects the client's proprioception and co-ordination. Thus, in addition to considerations of gravity, this strong emphasis on the neurological aspect (5) of bodywork distinguishes Rolfing from many other bodywork modalities. This aspect of Rolfing is particularly useful in working with scoliosis clients.

Standard massage protocol for working with scoliosis (as I was taught in my TAFE training) is to assess the spine visually via the Adam’s Test, then to have the client prone and position their arms and legs to exaggerate the concave and convex curvatures of the spine. One then works cross fibre into the concavity/ies for 3-5 minutes, then reverses the position of the limbs and work the same side/s as before but this time longitudinally (6). This rather unsophisticated protocol can frequently have immediate results with functional scoliosis but achieves next to nothing with structural scoliosis and has very little long term, sustainable effect on a functional scoliosis. An understanding of the functional anatomy and kinematics of the spinal musculature as well as understanding the patho-mechanics of scoliosis can lead to more sophisticated, sustainable results.

Alternatives to the above protocol that enhance the sustainability of bodywork interventions follow:

Have the client seated on the table with their feet actively contacting the floor; work directly on the multifidi and rotatores. These muscles run between an inferior transverse process and a superior spinous process, laterally to medially. The furthest that the spine is laterally from the midline is considered the apex of the curve: apply direct myofascial technique to the multifidi and rotatores fibres superior to the apex on the concave side. Encourage the client’s active movement participation by having them side bend contra-laterally, away from the side you are working. With the same active movement, then work inferior to the apex on the convex side. You can assist their movement by introducing a gentle rotationary component: gently bring the shoulder on the convex side posteriorly as they side bend. Utilizing Muscle Energy Techniques to affect the rotationary component in this protocol can enhance the results.

Another consideration is working between the ribs on the lateral aspect of the torso furthest away from the spine. The ribs that originate from the concavity will be close together at the flank, so that it seems there is no space between them, whereas those on the convex side seem to be a greater distance apart. Have the client side-lying (and appropriately draped) with the ribs of the concave side facing up. Slowly and gently apply pressure to the intercostals between the close together ribs, travelling along the length of these "closed" ribs, not by pushing the tissue but by following any opening created by the client’s respiration. Repeat this several times, gradually allowing your work to become deeper as the client’s altering respiration allows greater opening in the area. The client’s active movement participation is their respiration. While on their side, work the serratus anterior: often on the gibbus (humped) side the scapula “wings” and the serratus anterior is hypertonic.

A frequent side effect of scoliosis is impaired respiration: long-term prognosis is that this will steadily worsen. Asymmetry of tonus is often present in pectoralis minor, the scalenes, serratus posterior superior and inferior as well as the intercostals; as well as being palpable this is usually visually observable. These muscles can be worked unilaterally on the involved side, again with the client’s active movement participation. Encouraging respiratory awareness with full breaths afterwards, as well as encouraging an element of “play” around respiratory possibilities, can enhance the scoliotic client’s breathing pattern and give them a sense of fuller, more balanced respiration.

Psoas is almost always involved in scoliosis and given its origin on the lumbar vertebrae will affect spinal curvature. Asymmetry of the Anterior Superior Iliac Spine and the posterior iliac crest levels are often visible. Psoas is always unilaterally hypertonic in scoliosis, though this often doesn’t correlate with a positive Thomas Test. In addition to releasing the psoas, the quadratus lumborum of the same side should also be released.

In the cervical spine, consider the role the sub occipital muscles play in directing the senses through space: in scoliosis these muscles frequently work in a tonic manner, seeking to hold the head level as compensation, not always immediately obvious, for the lower curves. Rather than being the delicate proprioceptive muscles that fine-tune the direction of the senses, they become hypertonic, trying to fulfill a postural function. They are usually asymmetrically hypertonic, more noticeably on the side where the cranium tilts toward the shoulder. For any scoliosis treatment these important muscles need to be addressed.

The above is a far from exhaustive list; there are many other things that could be added- rhomboid, trapezius and latissimus hypertonicity, pelvis and core work, leg length inequality. Tom Myers’ spiral and functional lines offer further Rolfing perspectives on working with scoliosis (7) - this is only a brief article.

Finally, some other considerations, mainly about the neurological component of scoliosis. Multifidus fibres tend to be more fast-twitch than normal on the concave side of the apex (8). There are delayed (late) responses to stimuli in involved muscles in people with idiopathic scoliosis (20-243 milliseconds versus 5 milliseconds in normal subjects (9)). MRI studies have found abnormalities in the brainstem in a significant number of idiopathic scoliosis patients (10).

A noticeable neurological asymmetry is often present in idiopathic scoliosis. A lack of strength in resistance, especially to rotation, is present (11), and a lack of functional awareness in many parts of the body is present. I’ve heard various names applied to this: “neurological blind-spot”, “somatic amnesia”(12), “kinaesthetic dystonia”(13), and “proprioceptive inaccuracy”(14). In an article by Robert Schleip (15), there is reference to and subsequent lengthy discussion of a Dutch research effort by W. Keesen et al. ”Proprioceptive Accuracy in Idiopathic Scoliosis”(16). This article, complete with references, is available on Robert Schleip’s website: www.somatics.de.(17)

In brief, it discusses an experiment in proprioception among scoliotic subjects and states “a re-arrangement of the internal representation of the body has been proposed in these cases”(18). There is discussion about distortion of body image and body schema, and mentions anorexia as also being a distortion of body image/ body schema. It is about internal body perception: anorexics can’t view themselves, no matter how skinny, as anything other than fat. Similarly, idiopathic scoliosis subjects perceive and accept their body position as straight regardless of how off balance or distorted they are.

Here are two exercises I do with idiopathic scoliosis clients that are attempts to re-kindle proprioceptive awareness. The first is very simple: with the client seated, stand behind them with your hands either side of the spine. Get them to gently press their feet into the floor, asking them to observe what is and isn’t activating para-vertebrally (locating their proprioceptive blind spots). Then encourage them to activate the side that fires less, using your hands as reference. You can do the same thing with them standing, walking or rolling their spine forward and back (active flexion and extension).

The second is based on the experiment in the Keeson article: with my client seated and their eyes closed, have them raise their arms (to 90 degrees) and bring their pointed index fingers together. Generally they miss wildly. Then supportively hold their proprioceptive blind-spot/s on their back and repeat the exercise. Usually their index fingers touch first time. The purpose of both exercises is to give the client a sense of support where they can’t perceive it, and thus improved function.

I hope that some of the ideas and protocols discussed in this article can be useful in your future work with scoliosis clients.

1. Birch, J. “S.I.: Finding Balance” Massage & Bodywork April/ May 2001, p.22.
2. Stanborough, M. “Direct Myofascial Technique” Churchill Livingstone, 2004.
3. Smith, J. “Structural Bodywork” Churchill Livingstone, 2005.
4. For more information see: www.myo-fascial.com.au
5. Schleip, R. “Explorations of the Neuro-myofascial Net”, Journal of Bodywork and Movement Therapies 7(1), pp.11-17, 2003
6. Glazer, D.”TAFE Remedial Massage\Tspine- general treatment.doc” class notes, no date
7. Myers, T. “Anatomy Trains” Churchill Livingstone, 2001.
8. Schleip, R. “Scoliosis and Proprioception” Rolf Lines, Vol.xxviii, no.4, Fall 2000. Available on the www.somatics.de website, along with many other good articles on scoliosis.
9. Maguire et al. “Intraoperative Long-latency Reflex Activity in Idiopathic Scoliosis Demonstrates Abnormal Central Processing, a possible cause of idiopathic scoliosis” Spine, vol.18#12,1993, pp1621—26
10. Schleip, op.cit., 2000, p17.
11. Mooney,V. et al, ”Journal of Spinal Disorders” 13(2), pp.102- 107, quoted in Schleip, ibid, pp17-19
12. See Thomas Hanna “Somatics” Da Capo, 1988
13. See Tom Myers “Kinesthetic Dystonia” Journal of Bodywork and Movement Therapy 2(2), 2(3), 2(4), 3(1), 3(2). 1998- 1999
14. See Schleip op.cit 2000. Ortho-bionomy practitioners also refer to it as this.
15. Schleip op.cit 2000, pp.16-20
16. Keesen,W. et al. ”Proprioceptive Accuracy In Idiopathic Scoliosis” Spine 17(2), 1992, pp.149-155.
17. www.somatics.de
18. As reported in Schleip, op.cit., 2000 p.17

© Colin Rossie, August 2006