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 myo fascial release. Show all posts
Showing posts with label myo fascial release. Show all posts
Saturday, March 14, 2009
WORKING WITH WHIPLASH
AMT FORUM POST- WHIPLASH
© Colin Rossie 2007. Not to be printed or used without permission of the copyright holder.
Whiplash/ acceleration- deceleration injury has in turn acute, sub acute and chronic stages. Then there is WAD (Whiplash Associated Disorder), a long-term effect of severe, poorly or untreated whiplash.
In the acute phase (first few days post injury), if a client comes to see you then send them to their doctor to take care of them, do x-rays, ultasounds, scans etc.
In sub acute cases (3-14 days), only proceed if they have been seen by their doctor and have permission to receive manual treatment (i.e any swelling has abated and there have been radiological tests done.) At this stage, appropriate techniques for neck work may include: Strain/ counter strain or orthobionomy type work, lymphatic drainage, gentle PROM and possibly (as pain and swelling starts to subside) the gentle, Barnes style MFR. On other, non-cervical and non-cranial structures more robust work can be done, such as trigger point, MET and direct myofascial techniques. This can help relieve satellite and distal pain resulting from the injury.
In chronic whiplash, in addition to the above techniques mentioned for the neck, MET, trigger points and direct myofascial techniques can be added. Cranio- sacral techniques can be used at this stage as well. Special attention should be paid to the sub occipitals, especially Rectus Capitus Posterior major and minor. Often, Rectus Capitus Posterior minor is especially indicated: it partly attaches to the dura mater and this attachment is often partially torn in whiplash injuries. The nuchal ligament can also be torn.
Cross fibre frictions and deep tissue work for any local adhesions that result from the injury can be commenced after the 6-week phase.
Don't forget to start appropriate strengthening as part of rehabilitation. Also consider movement education, such as Feldenkrais or Rolf Movement, to retrain and enhance proprioception and co-ordination. There is always the possibility of autonomic involvement in whiplash, so these can also help with this.
Commonly affected structures to consider other than the sub occipitals include the longus colli, semispinalis, spinalis cap & cervicus, SCM, scalenes, infrahyoids, omohyoid, platysma, pec minor & subclavius myofascia and tendons. Also consider the major fascial sheaths in the neck (especially the pre vertebral), which also receive a lot of damage in whiplash. Facet joints are also often affected.
Remember that many neck muscles have insertions in the thoracic region, so working distally from the focus of the pain is also highly effective. Immediately I'm thinking of head & neck muscles with attachments on the scapulae, ribs and thoracic spine, but given the fascial and neural connections one should also consider the sacrum and on into connections in the lower limb. Interestingly, many clients with whiplash mention effects in the sacrum and pain radiating into the legs & feet! (Hardly surprising if one considers the RCP minor attachment to the dura mater being damaged in whiplash and the effect of this into the cauda equina and beyond.)
Any pre existing osseous conditions can be exacerbated by whiplash and become a source of further irritation. Gentle mobilisation of the cervical vertebrae should be included in any long-term treatment plan (assuming you are qualified to do these). In the acute and subacute phases don't do any mobilisations or craniosacral techniques such as CV4 or a cranial base release. These are great in the chronic phase but not in the acute or subacute phases.
Colin Rossie
Dip. Health Sc. (Massage Therapy)
Certified Rolfer™
Rolf Movement Practitioner
© Colin Rossie 2007. Not to be printed or used without permission of the copyright holder.
Whiplash/ acceleration- deceleration injury has in turn acute, sub acute and chronic stages. Then there is WAD (Whiplash Associated Disorder), a long-term effect of severe, poorly or untreated whiplash.
In the acute phase (first few days post injury), if a client comes to see you then send them to their doctor to take care of them, do x-rays, ultasounds, scans etc.
In sub acute cases (3-14 days), only proceed if they have been seen by their doctor and have permission to receive manual treatment (i.e any swelling has abated and there have been radiological tests done.) At this stage, appropriate techniques for neck work may include: Strain/ counter strain or orthobionomy type work, lymphatic drainage, gentle PROM and possibly (as pain and swelling starts to subside) the gentle, Barnes style MFR. On other, non-cervical and non-cranial structures more robust work can be done, such as trigger point, MET and direct myofascial techniques. This can help relieve satellite and distal pain resulting from the injury.
In chronic whiplash, in addition to the above techniques mentioned for the neck, MET, trigger points and direct myofascial techniques can be added. Cranio- sacral techniques can be used at this stage as well. Special attention should be paid to the sub occipitals, especially Rectus Capitus Posterior major and minor. Often, Rectus Capitus Posterior minor is especially indicated: it partly attaches to the dura mater and this attachment is often partially torn in whiplash injuries. The nuchal ligament can also be torn.
Cross fibre frictions and deep tissue work for any local adhesions that result from the injury can be commenced after the 6-week phase.
Don't forget to start appropriate strengthening as part of rehabilitation. Also consider movement education, such as Feldenkrais or Rolf Movement, to retrain and enhance proprioception and co-ordination. There is always the possibility of autonomic involvement in whiplash, so these can also help with this.
Commonly affected structures to consider other than the sub occipitals include the longus colli, semispinalis, spinalis cap & cervicus, SCM, scalenes, infrahyoids, omohyoid, platysma, pec minor & subclavius myofascia and tendons. Also consider the major fascial sheaths in the neck (especially the pre vertebral), which also receive a lot of damage in whiplash. Facet joints are also often affected.
Remember that many neck muscles have insertions in the thoracic region, so working distally from the focus of the pain is also highly effective. Immediately I'm thinking of head & neck muscles with attachments on the scapulae, ribs and thoracic spine, but given the fascial and neural connections one should also consider the sacrum and on into connections in the lower limb. Interestingly, many clients with whiplash mention effects in the sacrum and pain radiating into the legs & feet! (Hardly surprising if one considers the RCP minor attachment to the dura mater being damaged in whiplash and the effect of this into the cauda equina and beyond.)
Any pre existing osseous conditions can be exacerbated by whiplash and become a source of further irritation. Gentle mobilisation of the cervical vertebrae should be included in any long-term treatment plan (assuming you are qualified to do these). In the acute and subacute phases don't do any mobilisations or craniosacral techniques such as CV4 or a cranial base release. These are great in the chronic phase but not in the acute or subacute phases.
Colin Rossie
Dip. Health Sc. (Massage Therapy)
Certified Rolfer™
Rolf Movement Practitioner
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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