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
Showing posts with label Structural Integration. Show all posts
Showing posts with label Structural Integration. Show all posts
Saturday, March 14, 2009
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.
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
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
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