Originally published in the AMT Journal "In Good Hands", June 2009
© AMT 2009, © Colin Rossie 2009. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
In the last issue of In Good Hands, the contributions to the clinical perspectives article devoted to sciatica were so impressive that there seemed nothing of further significance that I could add. Jeff Murray mentioned the synergistic relationships of soft tissues in the pelvic girdle and the mechanics of force closure and form closure in pelvic and sacral function. He also discussed the role of stability versus strength in hip dysfunction. A few issues back (June 2008), there was a multi-contributor article on psoas function. From my perspective, there is a definite relationship between the two articles.
Although psoas isn’t always a first consideration in the treatment of sciatica, its dynamic relation to piriformis in stabilising the pelvic girdle should not be overlooked. These two muscles each cross the sacro-iliac and hip joints as ‘three-dimensional’ muscles and act synergistically to affect sacral biomechanics and stability as well as work to maintain the balanced position of the sacrum. I would like to add some other information on sciatica, and expand on that with some thoughts drawn from a Rolfing®/Structural Integration (SI) perspective.
On Sciatica: Historical Titbits, Description and Additional Considerations
The term sciatica was originally used in ancient times to describe any hip and buttock pain. From the mid 18th century, it has been used to describe pain in the buttock and posterior thigh originating from the sciatic nerve. ‘True’ sciatica was once thought of as a neuritis (inflammation) that occurred in untreated diabetes or severe alcoholism.(1) Now the term is commonly used to describe a neuralgia resulting from impingement of the sciatic nerve that results in pain, tenderness and paraesthesia, usually unilateral, in the buttock, posterior thigh and lower leg.(2,3) In addition to pain, gait can also be affected and in extreme cases, there can also be muscle wasting in the lower leg.
The sciatic nerve arises from L4–S3 nerve roots.(4) As Kerry Hage, Alan Ford and Jeff Murray all mentioned, pain can originate at the nerve roots, but it is useful to differentiate radicular the pain originating in nerve roots from neuralgia arising from the sciatic nerve. In the former, pain will be present in the lower back and maybe also in the buttock and thigh but not in the lower leg. In the latter, it will be absent in the lower back but present in the posterior thigh and below the knee. The distinction here is between central nerve root and peripheral nerve involvement. Bogduk argues, ‘the only pain that has ever been produced experimentally by stimulating nerve roots is shooting pain in a band-like distribution. There is no physiological evidence that constant, deep aching pain in the lower leg arises from nerve root irritation’.(5)
Anatomical and Functional Considerations
The sciatic nerve is the longest and widest peripheral nerve in the body. It exits from the greater sciatic foramen via the superior sciatic notch just anterior to the piriformis muscle and has peroneal and tibial portions. It supplies the hamstrings and adductor magnus, and its branches supply most of the lower leg. Also exiting the greater sciatic foramen are the inferior gluteal nerve, the posterior femoral cutaneous nerve, and the nerves supplying the other external rotators—basically, all the nerves that supply all the gluteal region and the posterior thigh and calf.
The piriformis muscle originates on the anterior surface of the sacrum and exits the inner pelvic bowl through the greater sciatic foramen to insert onto the upper border of the greater trochanter. It is a postural muscle, with type I fibres that shorten and tighten in response to overload. If these fibres become engorged and swollen in the limited space of the sciatic foramen, then piriformis will impinge on the sciatic nerve.
As Jeff noted, there is great anatomical variation in the relationship of the sciatic nerve to the piriformis muscle. In 85% of people both portions of the sciatic nerve pass anterior to the piriformis muscle; in 10% only the tibial portion is anterior to the piriformis, while the peroneal portion goes through the muscle; in 2–3% the peroneal portion starts superior and runs posterior to the muscle; and in 1% both portions travel together through the middle of the muscle belly.(6) If present, these structural anomalies could easily result in sciatic nerve impingement in the event of any myofascial dysfunction.
Travell and Simons note that, in addition to entrapment of the nerve by piriformis being responsible for sciatica, the referral pattern from active myofascial trigger points in piriformis mimics the pain pattern of sciatica. They also note that active trigger points in gluteus minimus and the anterior portion of gluteus medius can have similar referral patterns, which they term ‘pseudo sciatica’.(6)
Though frequently overlooked, the external rotators (piriformis, gemellus superior and inferior, obturator externus and internus and the quadratus femoris) are also postural extensors of the hip joint. When talking about hip extension, usually the hamstrings come to mind as the hip extensors. While that is undeniably their function, it is worth noting that as long muscles with a linear alignment of myosin and actin fibres that cross two joints, they are not the most efficient way to maintain upright stance at the hip joint. On the other hand, the external rotators, if thought of as short extensor muscles, are short, single-joint muscles responsible for form closure of the sacro-iliac articulation, thus bringing great postural stability to the pelvis.(7,8) Perhaps it would be useful to differentiate between femoral and coxal components of hip extension.(7)
There is a distinct relationship between the role of the hip external rotators—especially the piriformis—and the psoas. Both psoas and piriformis travel anteriorly, inferiorly and laterally from their origins to their insertions: the psoas from the anterior vertebral bodies of the lumbar spine to the lesser trochanter of the femur, the piriformis from the anterior surface of the sacrum to the upper border of the greater trochanter of the femur. The piriformi run primarily horizontally to their attachment, while the psoas run vertically.
If one considers the body from a tensegrity viewpoint, the psoas can be seen as a guy wire pulling the lumbar spine forward, countering the pull of the posterior guy wire of the lumbar erectors,(9) not only via the attachment of their deeper fibres to the lumbar spine,(5) but also through the thoraco-lumbar fascia.(10) Similarly, a fan around the hip consisting of the external rotators, gluteus minimus and the anterior fibres of gluteus medius can be seen as the tensegrity opposite of the iliacus in the ilium.
Piriformis is the tensegrity antagonist to the psoas around the sacro-iliac joint. An active psoas pulls the lumbar spine (and also indirectly the superior anterior surface of the sacrum) forward and down, affecting the position of the superior sacro-iliac joints, whereas the piriformis activates to counter this, bringing the anterior, inferior sacrum forward, thus creating a seesaw effect on the sacrum. The two muscles work together to allow optimal balance of the lumbosacral junction and the functioning of the inferior and superior SIJs around the body’s centre of gravity. This action balances the bones of the pelvis and ensures the congruence of the centre of gravity with the body’s centre of mass.
An Evolutionary Digression
It is worthwhile to digress slightly here and consider the hips from an evolutionary perspective. Over time, to accommodate the change to upright stance and bipedal gait, the hip girdle has changed shape and orientation. The direction of the ilia has changed. A deep iliac fossa has developed that allows a greater attachment area for the gluteus minimus, gluteus medius and external rotator muscles laterally and the iliacus medially. The ilia have twisted anteriorly to a more lateral and anterior orientation. Our nearest primate relatives have posterior facing ilia with small to non-existent iliac fossae. Their gluteus medius and minimus muscles extend the femur. In humans, these muscles abduct the femur at the hip joint in order to prevent a Trendelenberg gait. Moreover, the sacrum has increased in width and the complexity of its articulations in order to enhance stability. Consequently, the external rotators have taken on the extra functions of pelvic stabilisers and extensors.(11,12)
Rolfing®/ SI Definition and Perspective
SI, of which Rolfing®, Hellerwork and Tom Myers’ KMI (Kinesis Movement Integration) are probably the most commonly known varieties, is a specific body of work based on the teachings of Dr Ida Rolf (1896–1979).(13,14) The goal of the SI process is the optimal dynamic alignment of the body in relationship to gravity and the three-dimensional space around it (what a mouthful!). This most frequently occurs as an outcome-oriented process over ten or so sessions,(15) each session having a specific goal (see box). There is a long tradition and strong emphasis on the functional aspect of anatomy in the SI tradition, as witnessed not only in Ida Rolf’s only published work,(16) but also in such publications as Tom Myer’s Anatomy Trains(17) and the many research contributions made by SI practitioners to our current understanding of fascia.(18, 19, 20, 21, 22, 23, 24,25,26,27,28)
In the sciatica article, Jeff Murray stated that in hip dysfunction a tight piriformis might be all that provides stability to the pelvis and that to work initially to counter this could lead to even greater instability. I am in total agreement with him. Ida Rolf devoted a lot of her book to the role of the external rotators and the psoas around the pelvis.(16) In the classic SI process, work on the piriformis and other hip stabilisers is only commenced in the sixth session, once all the synergistic relationships in the hip girdle have been addressed in previous sessions. In SI, stability in the pelvis is addressed right from the first session, where the superficial gluteals are worked and balance between the hamstrings and quadriceps are themes.
This is ramped up in the third session, where attention is given to the TFL, ITB, gluteus medius anticus and fascial convergences at the trochanter, as well as the relationship of the pelvis to the ribs and the contra-lateral gluteus maximus/ latissimus dorsi relationship. The fourth session prepares for more thorough work on the pelvis, consisting of much work on the adductors, the lower insertion of the psoas and the ischial rami and tuberosities, sacrotuberous ligament and obturator membranes, and commences work with core activation and stability. Much of the moment work of this session focuses on synergistic, melodic relationships in the pelvic myofascia.
These themes continue into the fifth session, with work on the iliopsoas addressing issues of balance in the abdomen between the rectus and transversus and the rectus and psoas, as well as balance in contralateral gait - all in preparation for the sixth session. The later integration sessions are based on the relationship of upper and lower body to the pelvis (for a fuller description of the structural integration process, see Maupin 2005 and Myers 2004a, 2004b, 2004c.(29, 13, 15, 31),
Conclusion
I dislike the Cartesian view of the body as a ‘soft machine’ and am not fond of seeing it compared to inanimate objects such as machines or buildings. Living beings are far more complex and interesting than that. However, I will use two analogies to elucidate the ideas what I have attempted to express in this article.
If you compare the body to a carriage or chariot, the psoas can be thought of as the drawbar or pole and the piriformis as the axle attaching to it. The external rotators and the iliacus are the outer and inner spokes of the wheel. Maupin provides a distillation of the structural integration view when he says, ‘Much as the external rotators are the key to the sacrum, the piriformis is the key to the rotators’.(30) Further, from a tensegrity perspective, each of the spokes needs to be able to play their part in the balanced function of the wheel.(29,7) Thus, the two piriformi can be considered a prevertebral muscle axle, stretching from femur to femur. Their horizontal orientation and the psoas’ vertical orientation is responsible for the three-dimensional space in the area between the ribs and the legs. Together the piriformis and psoas support the lumbo-sacral junction—the central joint of the body—as well as hold the front of the spine back with the support of the legs.(30)
The sacrum itself is the keystone bone of the pelvis in both stance and movement. To continue with the architectural analogy, the pelvis is the arch spanning the columns of the legs, where they meet to support the vertebral column and the superstructure of the torso above. Pelvic floor muscles attach to its inferior aspect (the sacral apex); its superior aspect (the sacral base) provides the foundation for the vertebral column. Additionally, the sacrum is the body’s transverse centre of gravity.
Thus, the dynamic relationship between the piriformis and the psoas plays a crucial role in the efficient functioning of the sacrum. A properly functioning sacrum influences core tone and stabilisation. As the “keystone” of the body below the cranium, all structures (osseous and soft tissue) that attach to it are vital for optimally efficient upright stance.
References
(1) Cailliet R. Low back pain syndrome: 5th edition. Philadelphia: FA Davis Company, 1995.
(2) Lee D. The evolution of myths and facts regarding function and dysfunction of the pelvic girdle in Vleeming A, Mooney V, Stoeckart R.(eds) Movement, stability and lumbopelvic pain: 2nd edition. Churchill Livingstone, 2007.
(3) Willard FH. The muscular, ligamentous and neural structure of the lumbosacrum and its relationship to lower back pain in Vleeming A, Mooney V, Stoeckart R.(eds) Movement, stability and lumbopelvic pain: 2nd edition. Churchill Livingstone, 2007.
(4) Kendall F, McCreary E, Provance P, Rodgers M, Romani W. Muscles: testing and function, with posture and pain: 5th edition. Baltimore: Lippincott Williams and Wilkins, 2005.
(5) Bogduk N. 2005 Clinical anatomy of the lumbar spine and sacrum: 4th edition. Churchill Livingstone, 2005.
(6) Travell J, Simons D. Myofascial pain and dysfunction: the trigger point manual, vol 2: the lower extremities. Baltimore: Lippincott, Williams and Wilkins, 1983.
(7) Myers T. Extensor coxae brevis: treatment strategies for the deep lateral rotators in pelvic tilt in Beech M, Kemper P, Schumaker K.(eds) Missoula: IASI 2009 Yearbook of Structural Integration IASI, 2009.
(8) Richardson C, Hodges P, Hides J. Therapeutic exercise for the lumbopelvic stabilization: 2nd edition. Churchill Livingstone, 2004.
(9) DeRosa C, Porterfield J. Anatomical linkages and muscle slings of the lumbopelvic region in Vleeming, A, Mooney V, Stoeckart R.(eds) Movement, stability and lumbopelvic pain: 2nd edition. Churchill Livingstone , 2007.
(10) Gracovetsky S. 2007 Stability or controlled instability in Vleeming A, Mooney V, Stoeckart R.(eds) Movement, stability and lumbopelvic pain: 2nd edition. Churchill Livingstone, 2007.
(11) Lee D. The pelvic girdle: 3rd edition. Churchill Livingstone, 2004.
(12) Lovejoy CO. Evolution of the human lumbopelvic region and its relationship to some clinical deficits of the spine and pelvis in Vleeming A, Mooney V, Stoeckart R.(eds) Movement, stability and lumbopelvic pain: 2nd edition. Churchill Livingstone, 2007.
(13) Myers T. Structural integration: developments in Ida Rolf"s ‘recipe’: part 1. Journal of Bodywork and Movement Therapies 2004a;8(2):131–142.
(14) Smith J. Structural bodywork. Churchill Livingstone, 2005.
(15) Myers T. Structural integration: developments in Ida Rolf"s ‘recipe’: part 2. Journal of Bodywork and Movement Therapies 2004b;8(3):189–198.
(16) Rolf IP. Rolfing: re-establishing the natural alignment and Structural Integration of the human body for vitality and well-being. Rochester: Healing Arts Press, 1977.
(17) Myers T. Anatomy trains: 1st edition. Churchill Livingstone, 2001.
(18) Schleip R. Fascial plasticity—a new neurobiological explanation: part 1. Journal of Bodywork and Movement Therapies 2003a;7(1):11–19.
(19) Schleip R. Fascial plasticity—a new neurobiological explanation: Part 2" Journal of Bodywork and Movement Therapies 2003b;7(2):104–116.
(20) Schleip R, Klingler W, Lehmann-Horn F. Active fascial contractility: fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics. Medical Hypotheses 2005;65:273–277.
(21) Evanko S.P &Vogel,K.G. “Ultrastructure and proteoglycans composition in the developing fibrocartilagenous region of bovine tendon.” Matrix 1990 10: 420-36
(22) Evanko S.P &Vogel,K.G “Proteoglycan synthesis in the fetal tendon is differentially regulated by cyclic compression in vitro.” Arch Biochem Biophys 1992. 298: 303-12
(23) Robbins, J.R., Evanko S.P &Vogel,K.G “Mechanial Loading and TGF-beta regulate proteoglycans synthesis in tendon” Arch Biochem Biophys 1997 342:203-11
(24)Evanko S.P., Tammi, M.I., Tammi,R.H. & Wight, T.N. “Hylauron -dependant pericellular matrix" Adv Drug delivery Review 2007
(25) Chaudry, H.R. Schleip, R., Ji, Z., Bukiet, B., Maney, M. & Findley, T” Three Dimensional mathematical modelfor deformation of human fasciae in manual therapy” Journal of the American Osteopathic Association 2008,108: 379-90
(26) Evanko, S. “Extracellular matrix and the manipulation of Cells and Tissues.” IASI Yearbook 2009 61-68
(27) Cottingham, J.T, Porges,S.W. & Richmond, K. “Shifts in Pelvic Inclination Angle and Parasympathetic Tone Produced by Rolfing Stoft Tissue Manipulation.” Journal of the American Physical Therapy Association 1988 Vol 68 no9 1364-1370
28) Cottingham J. T, Porges,S.W. & Lyon, T. “Effects of Soft Tissue Mobilization (Rolfing Pelvic Lift) On Parasympathetic Tone in Two Age Groups.” Journal of the American Physical Therapy Association 1988 Vol 68 no3 352-357
(29) Myers T. Anatomy Trains: 2nd edition. Churchill Livingstone, 2008.
(30) Maupin E. A dynamic relation to gravity, vol 2—the ten sessions of Structural Integration. Dawn Eve Press, 2005.
(31) Myers T. Structural integration:developments in Ida Rolf"s ‘recipe’: part 3. Journal of Bodywork and Movement Therapies 2004c;8(4):249–264.
Also worth consulting for further elucidation would be the following websites:
http://www.anatomytrains.com/
http://www.somatics.de/
Tuesday, July 7, 2009
Saturday, March 14, 2009
AMT ETHICS WIKI CONTRIBUTIONS 1. Refusal of Treatment/ 2: Draping/ 3: Exceptions to Confidentiality/ 4.Advertising
.
1.REFUSAL OF TREATMENT
When is it appropriate to discontinue working with a client?
When the parameters of the therapeutic relationship have changed for the negative.
When the therapeutic relationship is damaged and beyond repair.
When it is no longer beneficial to either one of the two parties involved.
When there is the threat of physical harm or abuse.
When your client feels the need to test your boundaries e.g. keeping appointments, punctuality, seeking or giving inappropriate personal disclosure.
When the client inappropriately fulfills some social or emotional need of yours or theirs.
When they need work beyond your training or scope of practice.
When you feel in your gut that it isn't appropriate to continue working with them.
When you feel in your heart that it isn't appropriate to continue working with them.
When you know intellectually/ in your mind that it isn't appropriate to continue working with them.
When they have an unrealistic view of you or your work.
How do you approach discontinuing with a client/treatment?
If they test your boundaries, make them aware of it and inform them that if it continues the therapeutic relationship will be terminated.
In the case of immediate threat or abuse, their violating the therapeutic relationship or continually testing your boundaries after warning: inform them the therapeutic relationship is terminated and don't book them for any further sessions. If they've paid in advance return their money. Make it final, no need for further discussion.
If the parameters change for the negative or you are violating the therapeutic relationship or boundaries, seek supervision or mentoring and see what your supervisor/ mentor recommends. Act on it. If you feel it is particularly serious, delay your client's sessions until you have had supervision or have more clarity around the situation.
If it is training, scope of practice, minor boundary violations (i.e. their punctuality), the gut/ heart/ mind feeling or their unrealistic thinking/ expectations, explain that you feel your work isn't benefitting them or is inappropriate for them or that you simply can no longer work with them, but give them referrals to several other practitioners who you feel may be more appropriate to their situation. Explain it to them, terminate the relationship responsibly so that they don't feel "dumped" or left hanging.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
2.DRAPING
The most basic rule or guideline for draping is that it should always be done with the comfort, modesty and dignity of the client foremost in the practitioners mind. It should be done in such a way that:
1) The therapist has access to the relevant, targeted body part to be treated.
2) The client is comfortable with the draping procedure.
If their comfort means they wish to remain fully clothed, then so be it.
3) No more of the body is uncovered than is required.
4) Draping procedures and their rationale should be explained prior to the commencement of the session, and consent or permission sought.
5) If the draping is to be changed during the session, ensure permission has been granted for the new draping position before doing it. There should always be a therapeutic rationale for any change of draping.
The above applies to all passive massage. In more active bodywork or if movement therapy is involved, ensure that your client is wearing appropriately modest clothing that, while allowing you as the practitioner access or the ability to visually observe, THE CLIENT FEELS COMFORTABLE IN WEARING WITHOUT THEIR DIGNITY BEING IMPINGED.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
3. EXCEPTIONS TO CONFIDENTIALITY
Circumstances in which client confidentality can be breached:
1) Self harm: if there is a possibility the client may harm themself.
2) If there is the real possibility of specific harm to a specific other.
3) If there is current child abuse or the danger of abuse to children.
4) As required by a court order.
5) If the client is a minor or is of diminished mental capacity: disclosure can be made to the responsible parent, guardian or carer of the client. Due respect should still be shown for the clients privacy.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
4. ADVERTISING:
Therapists must not advertise or otherwise promote their services in a manner that:
is false, misleading or deceptive, or
is likely to mislead or deceive, or
creates, or is likely to create, an unjustified expectation of beneficial treatment.
creates, or is likely to create, false hope (e.g. massage cures cancer or other serious illnesses or the blatant, massage rids toxins).
Therapists should not advertise or promote services or modalities which they are not certified or qualified to perform. They should not advertise or promote services that are outside their scope of practice.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
1.REFUSAL OF TREATMENT
When is it appropriate to discontinue working with a client?
When the parameters of the therapeutic relationship have changed for the negative.
When the therapeutic relationship is damaged and beyond repair.
When it is no longer beneficial to either one of the two parties involved.
When there is the threat of physical harm or abuse.
When your client feels the need to test your boundaries e.g. keeping appointments, punctuality, seeking or giving inappropriate personal disclosure.
When the client inappropriately fulfills some social or emotional need of yours or theirs.
When they need work beyond your training or scope of practice.
When you feel in your gut that it isn't appropriate to continue working with them.
When you feel in your heart that it isn't appropriate to continue working with them.
When you know intellectually/ in your mind that it isn't appropriate to continue working with them.
When they have an unrealistic view of you or your work.
How do you approach discontinuing with a client/treatment?
If they test your boundaries, make them aware of it and inform them that if it continues the therapeutic relationship will be terminated.
In the case of immediate threat or abuse, their violating the therapeutic relationship or continually testing your boundaries after warning: inform them the therapeutic relationship is terminated and don't book them for any further sessions. If they've paid in advance return their money. Make it final, no need for further discussion.
If the parameters change for the negative or you are violating the therapeutic relationship or boundaries, seek supervision or mentoring and see what your supervisor/ mentor recommends. Act on it. If you feel it is particularly serious, delay your client's sessions until you have had supervision or have more clarity around the situation.
If it is training, scope of practice, minor boundary violations (i.e. their punctuality), the gut/ heart/ mind feeling or their unrealistic thinking/ expectations, explain that you feel your work isn't benefitting them or is inappropriate for them or that you simply can no longer work with them, but give them referrals to several other practitioners who you feel may be more appropriate to their situation. Explain it to them, terminate the relationship responsibly so that they don't feel "dumped" or left hanging.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
2.DRAPING
The most basic rule or guideline for draping is that it should always be done with the comfort, modesty and dignity of the client foremost in the practitioners mind. It should be done in such a way that:
1) The therapist has access to the relevant, targeted body part to be treated.
2) The client is comfortable with the draping procedure.
If their comfort means they wish to remain fully clothed, then so be it.
3) No more of the body is uncovered than is required.
4) Draping procedures and their rationale should be explained prior to the commencement of the session, and consent or permission sought.
5) If the draping is to be changed during the session, ensure permission has been granted for the new draping position before doing it. There should always be a therapeutic rationale for any change of draping.
The above applies to all passive massage. In more active bodywork or if movement therapy is involved, ensure that your client is wearing appropriately modest clothing that, while allowing you as the practitioner access or the ability to visually observe, THE CLIENT FEELS COMFORTABLE IN WEARING WITHOUT THEIR DIGNITY BEING IMPINGED.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
3. EXCEPTIONS TO CONFIDENTIALITY
Circumstances in which client confidentality can be breached:
1) Self harm: if there is a possibility the client may harm themself.
2) If there is the real possibility of specific harm to a specific other.
3) If there is current child abuse or the danger of abuse to children.
4) As required by a court order.
5) If the client is a minor or is of diminished mental capacity: disclosure can be made to the responsible parent, guardian or carer of the client. Due respect should still be shown for the clients privacy.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
4. ADVERTISING:
Therapists must not advertise or otherwise promote their services in a manner that:
is false, misleading or deceptive, or
is likely to mislead or deceive, or
creates, or is likely to create, an unjustified expectation of beneficial treatment.
creates, or is likely to create, false hope (e.g. massage cures cancer or other serious illnesses or the blatant, massage rids toxins).
Therapists should not advertise or promote services or modalities which they are not certified or qualified to perform. They should not advertise or promote services that are outside their scope of practice.
An AMT Ethics wiki contribution,2008.
You too can contribute to the wiki: http://www.amt-ltd.org.au/wiki/
POSTURE WORKSHOP DESCRIPTION
.
WAYS OF SEEING WAYS OF BEING:
POSTURE BEYOND THE PLUMBLINE.
Ask the average member of the public what posture is and the reply will probably involve all sorts of tales about how to hold the body, about ‘good’ and ‘bad’ posture. Often their emphasis will be on the "hold" part. Ask a bodyworker about posture and the reply may likely involve a description of an imaginary plumbline passing through an ideal, textbook alignment of the body. This view owes much to the pioneers of postural analysis, Henry and Florence Kendall. They identified an “ideal” posture and noted several “faulty” variant postures.
Put most simply, posture is how we hold the body, the positioning of body parts and attitude that allow us to respond to and interact with the environment we live in. There are efficient and inefficient ways to do this. Optimal posture is that which allows us to operate most efficiently in our environment. There are many definitions of posture and many different ways to view the body. My favourite definition is:
“Posture is distribution of body mass in relation to gravity over a base of support. The base of support includes all structures from the feet to the base of the skull.”
As bodyworkers we encounter postural dysfunction in our clients on a daily basis. Most of us are lucky if we have a good understanding of one model of viewing posture. However, there are many possibilities in viewing the body. Having more than one way of viewing bodies enhances our skill as clinicians, enabling us greater understanding of our clients and the ability to offer them a better service.
This workshop is a synthesis of knowledge gained through many years of training, study, experience, observation and enquiry. In it we will examine and discuss many different postural models, observe examples (both in photographs and fellow class members) and learn practical techniques for working with some of the patterns and ways of being we discuss.
It commences with examining the Kendall's classic view of the body as ideal alignment around a plumbline, and the “faulty’ postural variants they identified. We then discuss the role of gravity and Ida Rolf’s contributions to understanding posture; her initial view of segmental blocks stacked in gravity and its later ‘cubes in a sack’ & other variants. Following this we will investigate Sheldon’s typologies, discuss their evolution from their origin in psychology, then digress to look at the relationship of Sheldon’s typology to the Ayurvedic somatic typology.
Next is an in-depth study of Jan Sultan’s ‘internal / external’ model. Influenced by Rolfing and cranio-sacral therapy, it postulates there being several possible responses of the body to gravity. We will do some practical work around treating presentations of the internal/ external model. Hans Flury’s tilt and shift model, which views the body in terms of pelvis/ torso relationship, will also be introduced, as will Robert Schleip’s Flexor/ Extensor model, a refinement of the internal / external model, which also considers the primacy of primitive neural reflexes in motor co-ordination and posture.
Then we consider the evolutionary aspect of posture, how the pelvis has evolved and kyphosis and lordosis as components of mobility and protection in posture; where there are kyphoses, enclosing structures protect vital organs and the body is less mobile, where there are lordoses there is more movement but no bony, protective enclosure. This then leads to Hubert Godard's Tonic Function model of posture and concepts such as G & G1 and Michael Nebadon's Expansional Balance model, popularized by Ed Maupin. We may digress to discuss traditional oriental views of the body, such as charkas and meridians and relate this to the biomechanical model of G & G1. Throughout we will spend time in class observing each other’s posture to reinforce the concepts discussed.
Following from this we look at 'tensegrity' and explore at length Tom Myers "Anatomy Trains" view of the body. He conceives a series of myofascial meridians or slings as representing functional patterns determined by the continuous connections of the fascia. There will be an opportunity to swap work on each other, working two of the myofascial meridians.
Time permitting, there could be further discussion about Sheldon’s Typology and its Ayurvedic correlations, and pertinent treatment indications. As a final digression, we will briefly examine Alexander Lowen' and Stanley Keleman’s Bioenergetic view of the body, drawn from somatic psychotherapy.
© Colin Rossie 2007
WAYS OF SEEING WAYS OF BEING:
POSTURE BEYOND THE PLUMBLINE.
Ask the average member of the public what posture is and the reply will probably involve all sorts of tales about how to hold the body, about ‘good’ and ‘bad’ posture. Often their emphasis will be on the "hold" part. Ask a bodyworker about posture and the reply may likely involve a description of an imaginary plumbline passing through an ideal, textbook alignment of the body. This view owes much to the pioneers of postural analysis, Henry and Florence Kendall. They identified an “ideal” posture and noted several “faulty” variant postures.
Put most simply, posture is how we hold the body, the positioning of body parts and attitude that allow us to respond to and interact with the environment we live in. There are efficient and inefficient ways to do this. Optimal posture is that which allows us to operate most efficiently in our environment. There are many definitions of posture and many different ways to view the body. My favourite definition is:
“Posture is distribution of body mass in relation to gravity over a base of support. The base of support includes all structures from the feet to the base of the skull.”
As bodyworkers we encounter postural dysfunction in our clients on a daily basis. Most of us are lucky if we have a good understanding of one model of viewing posture. However, there are many possibilities in viewing the body. Having more than one way of viewing bodies enhances our skill as clinicians, enabling us greater understanding of our clients and the ability to offer them a better service.
This workshop is a synthesis of knowledge gained through many years of training, study, experience, observation and enquiry. In it we will examine and discuss many different postural models, observe examples (both in photographs and fellow class members) and learn practical techniques for working with some of the patterns and ways of being we discuss.
It commences with examining the Kendall's classic view of the body as ideal alignment around a plumbline, and the “faulty’ postural variants they identified. We then discuss the role of gravity and Ida Rolf’s contributions to understanding posture; her initial view of segmental blocks stacked in gravity and its later ‘cubes in a sack’ & other variants. Following this we will investigate Sheldon’s typologies, discuss their evolution from their origin in psychology, then digress to look at the relationship of Sheldon’s typology to the Ayurvedic somatic typology.
Next is an in-depth study of Jan Sultan’s ‘internal / external’ model. Influenced by Rolfing and cranio-sacral therapy, it postulates there being several possible responses of the body to gravity. We will do some practical work around treating presentations of the internal/ external model. Hans Flury’s tilt and shift model, which views the body in terms of pelvis/ torso relationship, will also be introduced, as will Robert Schleip’s Flexor/ Extensor model, a refinement of the internal / external model, which also considers the primacy of primitive neural reflexes in motor co-ordination and posture.
Then we consider the evolutionary aspect of posture, how the pelvis has evolved and kyphosis and lordosis as components of mobility and protection in posture; where there are kyphoses, enclosing structures protect vital organs and the body is less mobile, where there are lordoses there is more movement but no bony, protective enclosure. This then leads to Hubert Godard's Tonic Function model of posture and concepts such as G & G1 and Michael Nebadon's Expansional Balance model, popularized by Ed Maupin. We may digress to discuss traditional oriental views of the body, such as charkas and meridians and relate this to the biomechanical model of G & G1. Throughout we will spend time in class observing each other’s posture to reinforce the concepts discussed.
Following from this we look at 'tensegrity' and explore at length Tom Myers "Anatomy Trains" view of the body. He conceives a series of myofascial meridians or slings as representing functional patterns determined by the continuous connections of the fascia. There will be an opportunity to swap work on each other, working two of the myofascial meridians.
Time permitting, there could be further discussion about Sheldon’s Typology and its Ayurvedic correlations, and pertinent treatment indications. As a final digression, we will briefly examine Alexander Lowen' and Stanley Keleman’s Bioenergetic view of the body, drawn from somatic psychotherapy.
© Colin Rossie 2007
OBSERVATIONS ON CLIENTS W/ AUTISM & ASPERGER'S.
.
© Colin Rossie 2008. Not to be printed or used without permission of the copyright holder.
There is a world of difference between autism & Aspergers Syndrome (AS). What I write in the following article is from the coalface: over the last 9 years I have worked with people from both communities over a wide age range.
AS has a whole spectrum from mild to severe. I would differentiate it from autism, even though the DSM IV puts it into the autism range of disorders. My personal observation is that autistic people tend to look inward, minimize engagement with the external world and are easily stressed by it. Aspies will engage with the external world, but in a way reminiscent of children: great enthusiasm, but with the narrow focus of the special interests that takes their attention. They are interested in everything, but ESPECIALLY in their specific thing(s).
Because of both personal and clinical experience, I feel the DSM-IV's diagnostic criteria should be refined even further. It is commonly reported that in movement and coordination those with AS can be awkward, ungainly, clumsy, stiff & un-coordinated. While this is true of the majority, in my observation a sizeable percentage (maybe 20%) have an exceptional, almost unnatural, grace, coordination & balance in their movement. For example, from a Rolfing perspective, it is really difficult to pick if they internals or externals, G or G prime oriented. A deciding factor seems to be training early in life- particularly if it was dance, martial arts or yoga. Distance running also seems agreeable with them. Weights and gym work earlier in life do not seem to have the same effect.
Some symptoms often associated with autism spectrum & AS (ADD/ADHD/ lack of focus) may be secondary to not receiving appropriate support or to poor diet. They may be more of a misdiagnosis. AS clients could possibly become easily bored with routine if it does not support where their mind travels- for them, it is hard being a square peg in a round hole. Often the neurotypical world does not treat Aspergers as a unique variation of the human experience with equal validity, instead trying to make Aspies conform to behaviours and ways of being that, while those of the normal world, are foreign to their way of being: "notions not our own, nor suited to us". If being academically bored is not recognized it could lead to high school dropout; not being diagnosed can lead in extreme cases to violent behaviour (both physical &/or verbal) in social interactions, social and academic failure, drug & alcohol abuse, inability to form or maintain relationships and other self-destructive behaviours. Socially and emotionally, they are like children for life, needing a lot of hard work, nurture and support. If they receive this, they can blossom and their high intelligence and special talents can contribute positively to the world around them. To use a motor vehicle as an analogy, not all cylinders are firing emotionally, and those that are often do so inappropriately.
Clinical anecdote is no substitute for solid research, but it can inform the way we work & become the raw data for further hypotheses; what I write is based on observation of 40 plus clients over the last 9 years. I’d be interested to know the experiences and observations of other massage therapists and bodyworkers, what they think of what I relate and any further observation, experiences and thoughts that could contribute to this discussion.
Regarding autism:
Generally I find those with an autism diagnosis difficult to co-opt into the participation part of Rolfing, though this may apply across the spectrum of massage and bodywork. Depending on the degree of autism and age, their responses can range from:
• A lack of any sense of involvement (generally found in extreme autism and the very young, often clients 'sent' along by anxious parents/ caregivers), to
• Finding it a nice thing to look forward to but without true engagement (generally moderate autistics, adolescents & older children, curious adults), to
• Being obsessively engaged in Rolfing (no particular demographic- I have had a 9-year autistic boy who, after session one, read everything he could about Rolfing and wanted to come every day for 10 days! Others google more info than either you or I would know was out there); through to
• Anger (generally adults or those unhappy people "sent" by somebody for work).
Some fellow bodywork practitioners have noted that it can be a problem if their client has been "sent" for work (by a parent, caregiver or partner) and are unwillingly participants in the process. In my experience, it would be unlikely to get an autistic client otherwise- bodywork would not be on their horizon under normal circumstances.
As with any client, range & type of contact varies. In young children and those with extreme autism, I forgo the concept of a Rolfing series that aims for specific, sequential outcomes. Without trying to be prescriptive, I've found the following approachs generally work well: start with light contact that gradually increases compression/ pressure in one area without moving much or quickly. If I can engage the client, I will involve them in movement- not always easy. Set it up really well - explain and demonstrate what you want and encourage them gently. Applaud their efforts no matter how far removed it is from what you would have liked the outcome to be. Not having done much cranial training, I tend to refer all ages to the local osteopath, so they receive cranial work concurrent with my work.
My experience is that it is not unusual to see autistic clients only a few times; sometimes they or their caregiver/ partner opt entirely for cranial work, sometimes there is impatience that Rolfing is not a magical, quick- fix silver bullet with immediate results. Sometimes, especially if they’ve been 'sent' along, the client may want it to fail, so only come for one session. I've heard variations on the following after one session: "See! Happy now? I've done that Rolfing thing you wanted me to do!". Sometimes though, even if it is exceptionally gentle, the physical contact can be too much for them, too confronting.
Regarding Aspergers:
Aspergers clients, on the other hand, are usually entirely different. If they've been 'sent', the trick is to engage them. Once you've done that, they can be the most enthusiastic, compliant clients. If they have come of their own accord (movement and co ordination problems sometimes bring them, sometimes Rolfing has been casually mentioned to them and they've run with the recommendation), I generally find they have well researched not only Rolfing on google but also everything they can find about me before they arrive on the doorstep. They can be among the most enthusiastic clients, sometimes a little too enthusiastic. They can take you very literally- be prepared for the odd turn of phrase, the peculiar emphasis on words and patterns, the overdoing it, the enthusiasm that can seem bordering on mania. Once you have engaged them, they can talk endlessly about the minutiae of their responses to the work you undertake together.
I involve them in a lot of active movement participation while working their tissue in order to enhance their proprioception & coordination; also lots of basic, perceptual movement work lying supine, in sitting and off the table (both standing and lying on the floor). I also utilize props such as yoga blocks, Torson bolsters, Duradiscs and Swiss balls (both semi inflated as well as fully inflated) to introduce novelty to their sensory experience and engage them in different ways of thinking about how they use their body. I always introduce these new inputs gradually and explain fully what we are trying to achieve and why. Though their curiosity can be utilized in sessions, they can also be easily overloaded. Sometimes the unexpected, the change from routine, can disrupt their comfort zone, but if they can see the logic in what is being attempted they can usually embrace it with enthusiasm.
Because the bodywork experience can be quite profound for them, they may begin to regard you as their best friend for life. But AS clients can also be incredibly awkward socially and not forthcoming, so working with them involves treading a fine line: to engage them so they feel involved with the process without allowing the new best friend forever attitude (which erodes the therapeutic relationship). It is also possible to be bored to death by their enthusiasm.
Be aware of boundaries: sexual boundaries will not be the problem, time and appropriate disclosure will be. Friendships for them can be based on shared special interests rather than any deep amicability or compatibility. This friendship thing can be a steep learning curve for the therapist. No matter what their age, I find it helps me to think of dealing with a very precocious, curious child (think 8 year old) with the emotional volatility of the early teens thrown in, and all the obsessiveness that could be attendant upon those two ages. Another attitude I find useful to adopt I term “the distant relative”: politely engage them when they are there, no need to do so until they are back again.
Jum tungan, an Indonesian saying, "time is rubber", can typify their approach. Let them know at the start of the session what time you have to finish with them so they are aware of your boundaries. As clients they can often have no sense of time, being either late or extremely early. No strategy you may have in place for this will affect them profoundly; they seem impervious, so as a therapist you need to be tough. Never start the session earlier than the time you have scheduled it for. I sometimes use the strategy of telling them finish time is 15 minutes earlier- that way they can have their talking time and I can still keep on schedule. If they are enthusiastic about the work, they can talk to a (sometimes boring) standstill about it. Coincidentally, if they are enthusiastic about your work, they will talk to everyone about you, becoming a walking, talking advertisement for you. Of the 5 principles of Rolfing, always wholism, but in their case especially closure.
© Colin Rossie 2008. Not to be printed or used without permission of the copyright holder.
There is a world of difference between autism & Aspergers Syndrome (AS). What I write in the following article is from the coalface: over the last 9 years I have worked with people from both communities over a wide age range.
AS has a whole spectrum from mild to severe. I would differentiate it from autism, even though the DSM IV puts it into the autism range of disorders. My personal observation is that autistic people tend to look inward, minimize engagement with the external world and are easily stressed by it. Aspies will engage with the external world, but in a way reminiscent of children: great enthusiasm, but with the narrow focus of the special interests that takes their attention. They are interested in everything, but ESPECIALLY in their specific thing(s).
Because of both personal and clinical experience, I feel the DSM-IV's diagnostic criteria should be refined even further. It is commonly reported that in movement and coordination those with AS can be awkward, ungainly, clumsy, stiff & un-coordinated. While this is true of the majority, in my observation a sizeable percentage (maybe 20%) have an exceptional, almost unnatural, grace, coordination & balance in their movement. For example, from a Rolfing perspective, it is really difficult to pick if they internals or externals, G or G prime oriented. A deciding factor seems to be training early in life- particularly if it was dance, martial arts or yoga. Distance running also seems agreeable with them. Weights and gym work earlier in life do not seem to have the same effect.
Some symptoms often associated with autism spectrum & AS (ADD/ADHD/ lack of focus) may be secondary to not receiving appropriate support or to poor diet. They may be more of a misdiagnosis. AS clients could possibly become easily bored with routine if it does not support where their mind travels- for them, it is hard being a square peg in a round hole. Often the neurotypical world does not treat Aspergers as a unique variation of the human experience with equal validity, instead trying to make Aspies conform to behaviours and ways of being that, while those of the normal world, are foreign to their way of being: "notions not our own, nor suited to us". If being academically bored is not recognized it could lead to high school dropout; not being diagnosed can lead in extreme cases to violent behaviour (both physical &/or verbal) in social interactions, social and academic failure, drug & alcohol abuse, inability to form or maintain relationships and other self-destructive behaviours. Socially and emotionally, they are like children for life, needing a lot of hard work, nurture and support. If they receive this, they can blossom and their high intelligence and special talents can contribute positively to the world around them. To use a motor vehicle as an analogy, not all cylinders are firing emotionally, and those that are often do so inappropriately.
Clinical anecdote is no substitute for solid research, but it can inform the way we work & become the raw data for further hypotheses; what I write is based on observation of 40 plus clients over the last 9 years. I’d be interested to know the experiences and observations of other massage therapists and bodyworkers, what they think of what I relate and any further observation, experiences and thoughts that could contribute to this discussion.
Regarding autism:
Generally I find those with an autism diagnosis difficult to co-opt into the participation part of Rolfing, though this may apply across the spectrum of massage and bodywork. Depending on the degree of autism and age, their responses can range from:
• A lack of any sense of involvement (generally found in extreme autism and the very young, often clients 'sent' along by anxious parents/ caregivers), to
• Finding it a nice thing to look forward to but without true engagement (generally moderate autistics, adolescents & older children, curious adults), to
• Being obsessively engaged in Rolfing (no particular demographic- I have had a 9-year autistic boy who, after session one, read everything he could about Rolfing and wanted to come every day for 10 days! Others google more info than either you or I would know was out there); through to
• Anger (generally adults or those unhappy people "sent" by somebody for work).
Some fellow bodywork practitioners have noted that it can be a problem if their client has been "sent" for work (by a parent, caregiver or partner) and are unwillingly participants in the process. In my experience, it would be unlikely to get an autistic client otherwise- bodywork would not be on their horizon under normal circumstances.
As with any client, range & type of contact varies. In young children and those with extreme autism, I forgo the concept of a Rolfing series that aims for specific, sequential outcomes. Without trying to be prescriptive, I've found the following approachs generally work well: start with light contact that gradually increases compression/ pressure in one area without moving much or quickly. If I can engage the client, I will involve them in movement- not always easy. Set it up really well - explain and demonstrate what you want and encourage them gently. Applaud their efforts no matter how far removed it is from what you would have liked the outcome to be. Not having done much cranial training, I tend to refer all ages to the local osteopath, so they receive cranial work concurrent with my work.
My experience is that it is not unusual to see autistic clients only a few times; sometimes they or their caregiver/ partner opt entirely for cranial work, sometimes there is impatience that Rolfing is not a magical, quick- fix silver bullet with immediate results. Sometimes, especially if they’ve been 'sent' along, the client may want it to fail, so only come for one session. I've heard variations on the following after one session: "See! Happy now? I've done that Rolfing thing you wanted me to do!". Sometimes though, even if it is exceptionally gentle, the physical contact can be too much for them, too confronting.
Regarding Aspergers:
Aspergers clients, on the other hand, are usually entirely different. If they've been 'sent', the trick is to engage them. Once you've done that, they can be the most enthusiastic, compliant clients. If they have come of their own accord (movement and co ordination problems sometimes bring them, sometimes Rolfing has been casually mentioned to them and they've run with the recommendation), I generally find they have well researched not only Rolfing on google but also everything they can find about me before they arrive on the doorstep. They can be among the most enthusiastic clients, sometimes a little too enthusiastic. They can take you very literally- be prepared for the odd turn of phrase, the peculiar emphasis on words and patterns, the overdoing it, the enthusiasm that can seem bordering on mania. Once you have engaged them, they can talk endlessly about the minutiae of their responses to the work you undertake together.
I involve them in a lot of active movement participation while working their tissue in order to enhance their proprioception & coordination; also lots of basic, perceptual movement work lying supine, in sitting and off the table (both standing and lying on the floor). I also utilize props such as yoga blocks, Torson bolsters, Duradiscs and Swiss balls (both semi inflated as well as fully inflated) to introduce novelty to their sensory experience and engage them in different ways of thinking about how they use their body. I always introduce these new inputs gradually and explain fully what we are trying to achieve and why. Though their curiosity can be utilized in sessions, they can also be easily overloaded. Sometimes the unexpected, the change from routine, can disrupt their comfort zone, but if they can see the logic in what is being attempted they can usually embrace it with enthusiasm.
Because the bodywork experience can be quite profound for them, they may begin to regard you as their best friend for life. But AS clients can also be incredibly awkward socially and not forthcoming, so working with them involves treading a fine line: to engage them so they feel involved with the process without allowing the new best friend forever attitude (which erodes the therapeutic relationship). It is also possible to be bored to death by their enthusiasm.
Be aware of boundaries: sexual boundaries will not be the problem, time and appropriate disclosure will be. Friendships for them can be based on shared special interests rather than any deep amicability or compatibility. This friendship thing can be a steep learning curve for the therapist. No matter what their age, I find it helps me to think of dealing with a very precocious, curious child (think 8 year old) with the emotional volatility of the early teens thrown in, and all the obsessiveness that could be attendant upon those two ages. Another attitude I find useful to adopt I term “the distant relative”: politely engage them when they are there, no need to do so until they are back again.
Jum tungan, an Indonesian saying, "time is rubber", can typify their approach. Let them know at the start of the session what time you have to finish with them so they are aware of your boundaries. As clients they can often have no sense of time, being either late or extremely early. No strategy you may have in place for this will affect them profoundly; they seem impervious, so as a therapist you need to be tough. Never start the session earlier than the time you have scheduled it for. I sometimes use the strategy of telling them finish time is 15 minutes earlier- that way they can have their talking time and I can still keep on schedule. If they are enthusiastic about the work, they can talk to a (sometimes boring) standstill about it. Coincidentally, if they are enthusiastic about your work, they will talk to everyone about you, becoming a walking, talking advertisement for you. Of the 5 principles of Rolfing, always wholism, but in their case especially closure.
ROTATOR CUFF TENDINITIS
Published in the AMT Journal "In Good Hands", September 2008
© AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
Clients with shoulder conditions often self diagnose and report having either frozen shoulder or “rotator cuff”, as though that in itself is the name of a disorder! Often GPs tell their patient that is what they have without even looking at them.
All joints are a compromise of stability versus mobility. In the case of the shoulder, the requirement for mobility has the upper hand (excuse the pun). The functioning of the shoulder requires it to be a highly mobile structure, especially at the Glenohumeral Joint (GHJ). The four muscles of the rotator cuff (Supraspinatus, Infraspinatus, Teres Minor and Subscapularis) attempt to give it greater stability. They enclose the joint capsule, their tendon fibres often blending with the joint capsule, acting as soft tissue stabilisers for the GHJ. The highly mobile nature of the shoulder means they are readily susceptible to injury.
Tendinitis is an acute inflammation, often a partial tear of the tendon. Tendinosis is a more chronic manifestation, being disorganised and chaotic scar tissue within the tendon, the result of poorly healed past injury and poorly formed collagen. In extreme cases, tendons can be quite calcific.
Physiology and assessment
Supraspinatus acts to initiate abduction. Infraspinatus and Teres Minor act to externally rotate the humerus; Subscapularis internally rotates the humerus. As noted earlier, all four muscles stabilise the humeral head in the glenoid fossa, both in static posture as the arms hang by the side and dynamically during gait and in using the upper limb for activities such as reaching, eating and bringing objects toward us.
The movements available at the GHJ are flexion/extension, abduction/adduction and internal/ external rotation. I would test all these to determine how the function is affected. Apley’s scratch test in its various stages covers all of these movements. Two tests that indicate general dysfunction in the rotator cuff complex are the Drop Arm test (also known as Codman’s test) and the Abrasion Sign 1,2 .
Many structures in the glenohumeral area can create pain (bursa, ligaments, nerves etc). With a client presenting with rotator cuff tendonitis or tendonosis, I would take a history, consider differential diagnoses and refer them to their medical practitioner for further testing if I sensed any red flags, had any doubts or felt further investigation or information was required.
Assuming that all red flags were addressed and it was safe to proceed with treatment, initially I would observe the client’s pain free active ROM then gently take them through passive ROM testing. I’d emphasise the need to do active ROM gently and would perform the passive ROM within their limit. The last thing l’d want is to further tear an already damaged tendon. For the same reason, any resisted testing should be done gently- if at all- with the emphasis on monitoring muscle function rather than opposing it. Avoid any extreme stretching with rotator cuff tendonitis. I would also avoid treatment techniques that involve an element of stretching, such as MET, CRAC or PNF. In the more chronic tendinosis scenario or in subacute tendinitis, these techniques could perhaps be used with appropriate care and caution. In partial or complete tears they should be avoided altogether.
After the initial health screen, questioning, ROM and special tests, I would then observe the client’s total posture, noting any left / right differences in the shoulder girdles and anything unusual in their thorax and torso that may be contributing to their presentation.
I have two approaches to working with clients. One I term ‘fix – it’, where I‘m working primarily with the local phenomena that clients present with on that day. The other is a more integrative approach, looking at the body globally and seeing local dysfunctions as part of that person’s totality- this approach heavily influenced by my training in Rolfing® Structural Integration (2,3,4). Often, when we’re training as Massage Therapists, we are taught to view the musculoskeletal system as the 435(6)- 650 (approx)(7) separate skeletal muscles that act in specific ways on the joints. From the structural integration perspective descended from Dr Rolf’s work, an inverse view can be taken – that there is one fascial continuity, muscles being spacers within the fascia (8).
Communicating openly with the client and sensing from the dialogue what they expect from the treatment and what will produce the best results given those expectations basically determines the direction I take (more fix-it or more integrative). As a conscientious practitioner, I would always do the best for my client by utilising every technique in my therapeutic toolbox that seems appropriate for them. What follows are descriptions of possible methods of treatment, however, nothing is intended as rigid or prescriptive. One should be responsive to the client as they present. I fiercely hate the concept of formulas when applied to the body. As an ex-chef I much prefer the metaphor of a recipe that is adaptable to the circumstances at hand.
Much of what follows is from a fix it perspective, as I feel Paul Doney has quite thoroughly addressed the wholistic perspective.
Remedial Treatment Perspective
In the acute phase, the treatment is protection, rest, ice, compression and elevation. Send the client to their doctor for testing.
In the subacute phase, the aim of the treatment is to decrease swelling, then work to bunch tissue into the area of injury to encourage collagen cross linkages and scar formation.
In the chronic phase, or if you are seeing the client for the first time, determine what rotator cuff muscles are involved. Palpate the myofascia to get a more discriminating sense of its condition, and to confirm or refute your observations. Deactivate any obvious, palpable trigger points that are present, then continue and deepen the palpation so that you are working the myofascia, using both the gentle Barnes style myofascial release and the more direct myofascial techniques popularly associated with Rolfing (9,10). This latter could take two forms, either ‘spots’ or ‘stripes’. ‘Spots’ involves palpating then holding one spot that feels restricted until the tissue changes texture and tension. ‘Stripes’ involves sinking into and then following a line of restriction within the myofascia, again sensing changes in texture and tension, similar to cold butter warming and giving way. One could use a variety of options as tools: the whole fingers, the whole palm, the finger pads, the thenar eminence, the heel of the hand, one or two fingers, the knuckles (either the proximal or the medial phalanges), the thumb pad, the distal phalanx of the thumb, and reinforced fingers.
Supraspinatus
Supraspinatus is the most commonly torn rotator cuff muscle. It initiates abduction and assists the middle deltoid in all abduction. However, it is nowhere near as strong as the middle deltoid. When in dysfunction, it can be active even with the arm just hanging by the side. The Painful Arc will be positive in the 85º -110º range, but I find this test moderately useless as it could also indicate other things, such as subacromial bursitis, calcium deposits etc. A positive Empty Can Test is an indicator of a supraspinatus tear. Various impingement tests (such as the Neer and the Hawkins–Kennedy)(1) also indicate supraspinatus involvement.
Initially I would primarily target the belly of the muscle, continuing carefully into the tendon. View the tendon as a continuation of the fascia past where the muscle fibres finish: once the myofascia has been suitably addressed start working the tendon more specifically. In chronic or calcific tendinitis and tendinosis, tendon damage and reduced function is present but without the inflammatory process to initiate the repair. Transverse frictions to the tendon induce controlled damage, re initiating the inflammatory response and renewing the ability for repair. It also encourages increased vascularity in otherwise vascularly undersupplied tissue. After working transverse, work along the line of pull of the structure with the intent of aligning the freshly redamaged tissue. Fibrinogen, the precursor to creating collagen fibres, realigns appropriately if encouraged in this way (11,12). I would be more circumspect with acute tendinitis and wait for the healing process to be under way before attempting transverse friction work. The two places on the tendon most prone to damage are the myotendinous junction (where the muscles cease within the connective tissue) and the tenoperiosteal junction where the tendon fibres insert into the periosteum of the bone.
All the techniques described above could be applied to the supraspinatus with the client seated or side lying. The U formed by the clavicle and spine of scapula is a good spot to access the supraspinatus tendon, especially its myotendinous junction. The tenoperiosteal junction of supraspinatus is on the humeral head; to access it in order to apply transverse frictions have the client side lying, involved side up, and passively extend the humerus, which moves the humeral head forward of the acromion allowing access to the tendon.
Subscapularis
If subscapularis requires work, I follow a similar protocol but with the client supine. Work the posterior aspect of the axilla, on the anterior surface of the scapula (just antero-medial to the lateral border of the scapula.) Commence by applying a discriminating palpation, identifying the condition of the tissue, deactivate trigger points if present, and continue that discriminating palpation to work on the totality of the myofascia using the myofascial methods outlined above. Have the client’s elbow flexed 90º and GHJ abducted 90º and externally rotated to allow greater access to the muscle. Ask for movement, getting them to abduct further by reaching away with their fingers and then move back to 90º with their elbow leading the way. The subscapularis tendon is on the lesser tubercle of the humerus: when working it, be sure that it is what you are on. If it moves in elbow flexion it is the long head of biceps brachii (a common mistake). Superiorly it attaches to the GHJ articular capsule; so again I emphasis the palpate / discriminate aspect of this work.
Infraspinatus
Infraspinatus rarely exhibits tendinitis, except as a result of impact injury. However, this muscle often has trigger points and the kind of chronic, fibrotic change associated with constant low-level stresses. This results from its stabilising role - when other rotator cuff muscles are damaged it becomes over-active.
To work supraspinatus, I have the client prone, GHJ abducted 90º and forearm dangling over the edge of the table (in more precise anatomical terms, the humerus is also partially externally rotated and elbow flexed 90º). Trigger points are almost always present so I deactivate them first. Then work, initially lightly with the finger pads, along the fibres from the medial scapula border to the insertion in the humerus. Have the client extend and flex the elbow joint as you pass along the muscle. You can gradually increase the depth of your work each pass and ask the client to increase the internal rotation of the humerus as they raise their forearm. Please note that increased depth does not necessarily equate with greater pressure, more a case of gently exploring and exploiting any opening that the tissue allows. With their elbow flexed, the client can also internally and externally rotate the humerus in an ever-increasing range as you work on them.
Teres Minor
When treating Teres Minor, I have the client side lying, arm abducted so that the upper arm rests on the side of the head. If the client’s ROM doesn’t allow this, have it rest on the table in front of them. Apply the same protocols as before, working along the muscle from origin to insertion. In my clinical experience, it is rarely a player in rotator cuff tendinitis but feels good to be worked. Damage is most likely in those who overdo weight training. (13)
The Integrative Perspective
From a global perspective, I would look at the position of the scapula and the forces operating on it. Pectoralis minor, serratus anterior, the rhomboids, coracobrachialis, levator scapulae and the trapezius all influence scapula position directly. Consider the myofascial sling created by the rhomboids and serratus anterior: the scapula can be viewed as a ‘sesamoid’ bone within this sling. Don’t overlook pectoralis minor: it affects scapula position and in my clinical experience is usually a major player in clients with rotator cuff tendinitis. Pectoralis major and latissimus dorsi also affect scapula position indirectly. Omohyoid and sub clavius can be bit players. The function of biceps brachii and attendant muscles coracobrachialis, brachialis and supinator, can affect glenohumeral function. Really obvious is the middle deltoid: its function is intimately tied to supraspinatus. Also, thoracic rotations are a major consideration in glenohumeral function: in scoliosis, for example, one scapula will be protracted, the other retracted; one in internal rotation, one external. Thus the forces operating on each shoulder complex will be different, which can either create or aggravate already existing tendinitis. Don’t forget the fascia, especially the clavi-pectoral fascia. Work around the clavicle generally can be helpful. Compensation is another factor: avoiding using the involved side will lead to overuse of the other side and the same condition manifesting. Also, remember that trigger points from the rotator cuff muscles can refer into the wrist and lead to a mistaken carpal tunnel diagnosis
1. Magee, D. J. “Orthopedic Physical Assessment” Saunders, 3rd edition 1997
2. Petty, N. & Moore, A. “Neuromusculoskeletal Examination & Assessment” Churchill Livingstone 1998
3. Sise, B. “The Rolfing Experience” Hohm Press 2005
4. Maupin, E. “A Dynamic Relation To Gravity, Volume 1: The Elements of Structural Integration” Maupin, self published, most recent edition 2006
5. Maupin, E. “A Dynamic Relation To Gravity, Volume 2: The Ten Sessions of Structural Integration.” Maupin, self published, most recent edition 2006
6. Gregor, R.J. ‘The structure & function of skeletal muscle’ in Rasch, P.J. “Kinesiology & Applied Anatomy” Lea & Febiger 7th edition, 1989
7. Tabners Medical Dictionary
8. Myers, T. “Anatomy Trains: Myofascial Meridians for Manual Therapists” Churchill Livingstone 2001
9. Smith, J. “Structural Bodywork” Churchill Livingstone 2005
10. Stanborough, M. “Direct Release Myofascial Technique” Churchill Livingstone 2004
11. Cantu, R. & Grodin, A. J. “Myofascial Manipulation” Aspen Publishers 1992
12. Various articles in Findley, T. W. & Schleip, R. “Fascia Research” Elsevier 2007
13. Simons, D. G., Travell, J.G. & Simons, L. S. “Myofascial Pain and Dysfunction: The Trigger Point Manual Volume 1 upper Half of Body” Williams & Wilkins 2nd Edition 1999
© AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
Clients with shoulder conditions often self diagnose and report having either frozen shoulder or “rotator cuff”, as though that in itself is the name of a disorder! Often GPs tell their patient that is what they have without even looking at them.
All joints are a compromise of stability versus mobility. In the case of the shoulder, the requirement for mobility has the upper hand (excuse the pun). The functioning of the shoulder requires it to be a highly mobile structure, especially at the Glenohumeral Joint (GHJ). The four muscles of the rotator cuff (Supraspinatus, Infraspinatus, Teres Minor and Subscapularis) attempt to give it greater stability. They enclose the joint capsule, their tendon fibres often blending with the joint capsule, acting as soft tissue stabilisers for the GHJ. The highly mobile nature of the shoulder means they are readily susceptible to injury.
Tendinitis is an acute inflammation, often a partial tear of the tendon. Tendinosis is a more chronic manifestation, being disorganised and chaotic scar tissue within the tendon, the result of poorly healed past injury and poorly formed collagen. In extreme cases, tendons can be quite calcific.
Physiology and assessment
Supraspinatus acts to initiate abduction. Infraspinatus and Teres Minor act to externally rotate the humerus; Subscapularis internally rotates the humerus. As noted earlier, all four muscles stabilise the humeral head in the glenoid fossa, both in static posture as the arms hang by the side and dynamically during gait and in using the upper limb for activities such as reaching, eating and bringing objects toward us.
The movements available at the GHJ are flexion/extension, abduction/adduction and internal/ external rotation. I would test all these to determine how the function is affected. Apley’s scratch test in its various stages covers all of these movements. Two tests that indicate general dysfunction in the rotator cuff complex are the Drop Arm test (also known as Codman’s test) and the Abrasion Sign 1,2 .
Many structures in the glenohumeral area can create pain (bursa, ligaments, nerves etc). With a client presenting with rotator cuff tendonitis or tendonosis, I would take a history, consider differential diagnoses and refer them to their medical practitioner for further testing if I sensed any red flags, had any doubts or felt further investigation or information was required.
Assuming that all red flags were addressed and it was safe to proceed with treatment, initially I would observe the client’s pain free active ROM then gently take them through passive ROM testing. I’d emphasise the need to do active ROM gently and would perform the passive ROM within their limit. The last thing l’d want is to further tear an already damaged tendon. For the same reason, any resisted testing should be done gently- if at all- with the emphasis on monitoring muscle function rather than opposing it. Avoid any extreme stretching with rotator cuff tendonitis. I would also avoid treatment techniques that involve an element of stretching, such as MET, CRAC or PNF. In the more chronic tendinosis scenario or in subacute tendinitis, these techniques could perhaps be used with appropriate care and caution. In partial or complete tears they should be avoided altogether.
After the initial health screen, questioning, ROM and special tests, I would then observe the client’s total posture, noting any left / right differences in the shoulder girdles and anything unusual in their thorax and torso that may be contributing to their presentation.
I have two approaches to working with clients. One I term ‘fix – it’, where I‘m working primarily with the local phenomena that clients present with on that day. The other is a more integrative approach, looking at the body globally and seeing local dysfunctions as part of that person’s totality- this approach heavily influenced by my training in Rolfing® Structural Integration (2,3,4). Often, when we’re training as Massage Therapists, we are taught to view the musculoskeletal system as the 435(6)- 650 (approx)(7) separate skeletal muscles that act in specific ways on the joints. From the structural integration perspective descended from Dr Rolf’s work, an inverse view can be taken – that there is one fascial continuity, muscles being spacers within the fascia (8).
Communicating openly with the client and sensing from the dialogue what they expect from the treatment and what will produce the best results given those expectations basically determines the direction I take (more fix-it or more integrative). As a conscientious practitioner, I would always do the best for my client by utilising every technique in my therapeutic toolbox that seems appropriate for them. What follows are descriptions of possible methods of treatment, however, nothing is intended as rigid or prescriptive. One should be responsive to the client as they present. I fiercely hate the concept of formulas when applied to the body. As an ex-chef I much prefer the metaphor of a recipe that is adaptable to the circumstances at hand.
Much of what follows is from a fix it perspective, as I feel Paul Doney has quite thoroughly addressed the wholistic perspective.
Remedial Treatment Perspective
In the acute phase, the treatment is protection, rest, ice, compression and elevation. Send the client to their doctor for testing.
In the subacute phase, the aim of the treatment is to decrease swelling, then work to bunch tissue into the area of injury to encourage collagen cross linkages and scar formation.
In the chronic phase, or if you are seeing the client for the first time, determine what rotator cuff muscles are involved. Palpate the myofascia to get a more discriminating sense of its condition, and to confirm or refute your observations. Deactivate any obvious, palpable trigger points that are present, then continue and deepen the palpation so that you are working the myofascia, using both the gentle Barnes style myofascial release and the more direct myofascial techniques popularly associated with Rolfing (9,10). This latter could take two forms, either ‘spots’ or ‘stripes’. ‘Spots’ involves palpating then holding one spot that feels restricted until the tissue changes texture and tension. ‘Stripes’ involves sinking into and then following a line of restriction within the myofascia, again sensing changes in texture and tension, similar to cold butter warming and giving way. One could use a variety of options as tools: the whole fingers, the whole palm, the finger pads, the thenar eminence, the heel of the hand, one or two fingers, the knuckles (either the proximal or the medial phalanges), the thumb pad, the distal phalanx of the thumb, and reinforced fingers.
Supraspinatus
Supraspinatus is the most commonly torn rotator cuff muscle. It initiates abduction and assists the middle deltoid in all abduction. However, it is nowhere near as strong as the middle deltoid. When in dysfunction, it can be active even with the arm just hanging by the side. The Painful Arc will be positive in the 85º -110º range, but I find this test moderately useless as it could also indicate other things, such as subacromial bursitis, calcium deposits etc. A positive Empty Can Test is an indicator of a supraspinatus tear. Various impingement tests (such as the Neer and the Hawkins–Kennedy)(1) also indicate supraspinatus involvement.
Initially I would primarily target the belly of the muscle, continuing carefully into the tendon. View the tendon as a continuation of the fascia past where the muscle fibres finish: once the myofascia has been suitably addressed start working the tendon more specifically. In chronic or calcific tendinitis and tendinosis, tendon damage and reduced function is present but without the inflammatory process to initiate the repair. Transverse frictions to the tendon induce controlled damage, re initiating the inflammatory response and renewing the ability for repair. It also encourages increased vascularity in otherwise vascularly undersupplied tissue. After working transverse, work along the line of pull of the structure with the intent of aligning the freshly redamaged tissue. Fibrinogen, the precursor to creating collagen fibres, realigns appropriately if encouraged in this way (11,12). I would be more circumspect with acute tendinitis and wait for the healing process to be under way before attempting transverse friction work. The two places on the tendon most prone to damage are the myotendinous junction (where the muscles cease within the connective tissue) and the tenoperiosteal junction where the tendon fibres insert into the periosteum of the bone.
All the techniques described above could be applied to the supraspinatus with the client seated or side lying. The U formed by the clavicle and spine of scapula is a good spot to access the supraspinatus tendon, especially its myotendinous junction. The tenoperiosteal junction of supraspinatus is on the humeral head; to access it in order to apply transverse frictions have the client side lying, involved side up, and passively extend the humerus, which moves the humeral head forward of the acromion allowing access to the tendon.
Subscapularis
If subscapularis requires work, I follow a similar protocol but with the client supine. Work the posterior aspect of the axilla, on the anterior surface of the scapula (just antero-medial to the lateral border of the scapula.) Commence by applying a discriminating palpation, identifying the condition of the tissue, deactivate trigger points if present, and continue that discriminating palpation to work on the totality of the myofascia using the myofascial methods outlined above. Have the client’s elbow flexed 90º and GHJ abducted 90º and externally rotated to allow greater access to the muscle. Ask for movement, getting them to abduct further by reaching away with their fingers and then move back to 90º with their elbow leading the way. The subscapularis tendon is on the lesser tubercle of the humerus: when working it, be sure that it is what you are on. If it moves in elbow flexion it is the long head of biceps brachii (a common mistake). Superiorly it attaches to the GHJ articular capsule; so again I emphasis the palpate / discriminate aspect of this work.
Infraspinatus
Infraspinatus rarely exhibits tendinitis, except as a result of impact injury. However, this muscle often has trigger points and the kind of chronic, fibrotic change associated with constant low-level stresses. This results from its stabilising role - when other rotator cuff muscles are damaged it becomes over-active.
To work supraspinatus, I have the client prone, GHJ abducted 90º and forearm dangling over the edge of the table (in more precise anatomical terms, the humerus is also partially externally rotated and elbow flexed 90º). Trigger points are almost always present so I deactivate them first. Then work, initially lightly with the finger pads, along the fibres from the medial scapula border to the insertion in the humerus. Have the client extend and flex the elbow joint as you pass along the muscle. You can gradually increase the depth of your work each pass and ask the client to increase the internal rotation of the humerus as they raise their forearm. Please note that increased depth does not necessarily equate with greater pressure, more a case of gently exploring and exploiting any opening that the tissue allows. With their elbow flexed, the client can also internally and externally rotate the humerus in an ever-increasing range as you work on them.
Teres Minor
When treating Teres Minor, I have the client side lying, arm abducted so that the upper arm rests on the side of the head. If the client’s ROM doesn’t allow this, have it rest on the table in front of them. Apply the same protocols as before, working along the muscle from origin to insertion. In my clinical experience, it is rarely a player in rotator cuff tendinitis but feels good to be worked. Damage is most likely in those who overdo weight training. (13)
The Integrative Perspective
From a global perspective, I would look at the position of the scapula and the forces operating on it. Pectoralis minor, serratus anterior, the rhomboids, coracobrachialis, levator scapulae and the trapezius all influence scapula position directly. Consider the myofascial sling created by the rhomboids and serratus anterior: the scapula can be viewed as a ‘sesamoid’ bone within this sling. Don’t overlook pectoralis minor: it affects scapula position and in my clinical experience is usually a major player in clients with rotator cuff tendinitis. Pectoralis major and latissimus dorsi also affect scapula position indirectly. Omohyoid and sub clavius can be bit players. The function of biceps brachii and attendant muscles coracobrachialis, brachialis and supinator, can affect glenohumeral function. Really obvious is the middle deltoid: its function is intimately tied to supraspinatus. Also, thoracic rotations are a major consideration in glenohumeral function: in scoliosis, for example, one scapula will be protracted, the other retracted; one in internal rotation, one external. Thus the forces operating on each shoulder complex will be different, which can either create or aggravate already existing tendinitis. Don’t forget the fascia, especially the clavi-pectoral fascia. Work around the clavicle generally can be helpful. Compensation is another factor: avoiding using the involved side will lead to overuse of the other side and the same condition manifesting. Also, remember that trigger points from the rotator cuff muscles can refer into the wrist and lead to a mistaken carpal tunnel diagnosis
1. Magee, D. J. “Orthopedic Physical Assessment” Saunders, 3rd edition 1997
2. Petty, N. & Moore, A. “Neuromusculoskeletal Examination & Assessment” Churchill Livingstone 1998
3. Sise, B. “The Rolfing Experience” Hohm Press 2005
4. Maupin, E. “A Dynamic Relation To Gravity, Volume 1: The Elements of Structural Integration” Maupin, self published, most recent edition 2006
5. Maupin, E. “A Dynamic Relation To Gravity, Volume 2: The Ten Sessions of Structural Integration.” Maupin, self published, most recent edition 2006
6. Gregor, R.J. ‘The structure & function of skeletal muscle’ in Rasch, P.J. “Kinesiology & Applied Anatomy” Lea & Febiger 7th edition, 1989
7. Tabners Medical Dictionary
8. Myers, T. “Anatomy Trains: Myofascial Meridians for Manual Therapists” Churchill Livingstone 2001
9. Smith, J. “Structural Bodywork” Churchill Livingstone 2005
10. Stanborough, M. “Direct Release Myofascial Technique” Churchill Livingstone 2004
11. Cantu, R. & Grodin, A. J. “Myofascial Manipulation” Aspen Publishers 1992
12. Various articles in Findley, T. W. & Schleip, R. “Fascia Research” Elsevier 2007
13. Simons, D. G., Travell, J.G. & Simons, L. S. “Myofascial Pain and Dysfunction: The Trigger Point Manual Volume 1 upper Half of Body” Williams & Wilkins 2nd Edition 1999
WORKING WITH WHIPLASH
AMT FORUM POST- WHIPLASH
© Colin Rossie 2007. Not to be printed or used without permission of the copyright holder.
Whiplash/ acceleration- deceleration injury has in turn acute, sub acute and chronic stages. Then there is WAD (Whiplash Associated Disorder), a long-term effect of severe, poorly or untreated whiplash.
In the acute phase (first few days post injury), if a client comes to see you then send them to their doctor to take care of them, do x-rays, ultasounds, scans etc.
In sub acute cases (3-14 days), only proceed if they have been seen by their doctor and have permission to receive manual treatment (i.e any swelling has abated and there have been radiological tests done.) At this stage, appropriate techniques for neck work may include: Strain/ counter strain or orthobionomy type work, lymphatic drainage, gentle PROM and possibly (as pain and swelling starts to subside) the gentle, Barnes style MFR. On other, non-cervical and non-cranial structures more robust work can be done, such as trigger point, MET and direct myofascial techniques. This can help relieve satellite and distal pain resulting from the injury.
In chronic whiplash, in addition to the above techniques mentioned for the neck, MET, trigger points and direct myofascial techniques can be added. Cranio- sacral techniques can be used at this stage as well. Special attention should be paid to the sub occipitals, especially Rectus Capitus Posterior major and minor. Often, Rectus Capitus Posterior minor is especially indicated: it partly attaches to the dura mater and this attachment is often partially torn in whiplash injuries. The nuchal ligament can also be torn.
Cross fibre frictions and deep tissue work for any local adhesions that result from the injury can be commenced after the 6-week phase.
Don't forget to start appropriate strengthening as part of rehabilitation. Also consider movement education, such as Feldenkrais or Rolf Movement, to retrain and enhance proprioception and co-ordination. There is always the possibility of autonomic involvement in whiplash, so these can also help with this.
Commonly affected structures to consider other than the sub occipitals include the longus colli, semispinalis, spinalis cap & cervicus, SCM, scalenes, infrahyoids, omohyoid, platysma, pec minor & subclavius myofascia and tendons. Also consider the major fascial sheaths in the neck (especially the pre vertebral), which also receive a lot of damage in whiplash. Facet joints are also often affected.
Remember that many neck muscles have insertions in the thoracic region, so working distally from the focus of the pain is also highly effective. Immediately I'm thinking of head & neck muscles with attachments on the scapulae, ribs and thoracic spine, but given the fascial and neural connections one should also consider the sacrum and on into connections in the lower limb. Interestingly, many clients with whiplash mention effects in the sacrum and pain radiating into the legs & feet! (Hardly surprising if one considers the RCP minor attachment to the dura mater being damaged in whiplash and the effect of this into the cauda equina and beyond.)
Any pre existing osseous conditions can be exacerbated by whiplash and become a source of further irritation. Gentle mobilisation of the cervical vertebrae should be included in any long-term treatment plan (assuming you are qualified to do these). In the acute and subacute phases don't do any mobilisations or craniosacral techniques such as CV4 or a cranial base release. These are great in the chronic phase but not in the acute or subacute phases.
Colin Rossie
Dip. Health Sc. (Massage Therapy)
Certified Rolfer™
Rolf Movement Practitioner
© Colin Rossie 2007. Not to be printed or used without permission of the copyright holder.
Whiplash/ acceleration- deceleration injury has in turn acute, sub acute and chronic stages. Then there is WAD (Whiplash Associated Disorder), a long-term effect of severe, poorly or untreated whiplash.
In the acute phase (first few days post injury), if a client comes to see you then send them to their doctor to take care of them, do x-rays, ultasounds, scans etc.
In sub acute cases (3-14 days), only proceed if they have been seen by their doctor and have permission to receive manual treatment (i.e any swelling has abated and there have been radiological tests done.) At this stage, appropriate techniques for neck work may include: Strain/ counter strain or orthobionomy type work, lymphatic drainage, gentle PROM and possibly (as pain and swelling starts to subside) the gentle, Barnes style MFR. On other, non-cervical and non-cranial structures more robust work can be done, such as trigger point, MET and direct myofascial techniques. This can help relieve satellite and distal pain resulting from the injury.
In chronic whiplash, in addition to the above techniques mentioned for the neck, MET, trigger points and direct myofascial techniques can be added. Cranio- sacral techniques can be used at this stage as well. Special attention should be paid to the sub occipitals, especially Rectus Capitus Posterior major and minor. Often, Rectus Capitus Posterior minor is especially indicated: it partly attaches to the dura mater and this attachment is often partially torn in whiplash injuries. The nuchal ligament can also be torn.
Cross fibre frictions and deep tissue work for any local adhesions that result from the injury can be commenced after the 6-week phase.
Don't forget to start appropriate strengthening as part of rehabilitation. Also consider movement education, such as Feldenkrais or Rolf Movement, to retrain and enhance proprioception and co-ordination. There is always the possibility of autonomic involvement in whiplash, so these can also help with this.
Commonly affected structures to consider other than the sub occipitals include the longus colli, semispinalis, spinalis cap & cervicus, SCM, scalenes, infrahyoids, omohyoid, platysma, pec minor & subclavius myofascia and tendons. Also consider the major fascial sheaths in the neck (especially the pre vertebral), which also receive a lot of damage in whiplash. Facet joints are also often affected.
Remember that many neck muscles have insertions in the thoracic region, so working distally from the focus of the pain is also highly effective. Immediately I'm thinking of head & neck muscles with attachments on the scapulae, ribs and thoracic spine, but given the fascial and neural connections one should also consider the sacrum and on into connections in the lower limb. Interestingly, many clients with whiplash mention effects in the sacrum and pain radiating into the legs & feet! (Hardly surprising if one considers the RCP minor attachment to the dura mater being damaged in whiplash and the effect of this into the cauda equina and beyond.)
Any pre existing osseous conditions can be exacerbated by whiplash and become a source of further irritation. Gentle mobilisation of the cervical vertebrae should be included in any long-term treatment plan (assuming you are qualified to do these). In the acute and subacute phases don't do any mobilisations or craniosacral techniques such as CV4 or a cranial base release. These are great in the chronic phase but not in the acute or subacute phases.
Colin Rossie
Dip. Health Sc. (Massage Therapy)
Certified Rolfer™
Rolf Movement Practitioner
VERTEBRAL ARTERY TEST (VAT)
Published in the AMT Journal "In Good Hands", September 2008
© AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
Over the years I have heard all sorts of stories about the efficacy and safety of the VAT. I've researched to find out all I can about it; some research indicates it's completely useless in indicating vertebral artery compromise. Nonetheless, I would do it each time before working on the cervical spine. In the absence of any alternative, I believe it's better to be safe than sorry.
I know at least two versions of it:
One is the cervical quadrant test, which involves, while the client is supine, bringing the head and neck into extension and side-flexion, and holding for 30 seconds,
The other is the deKleyn Nieuwenhuyse Test, which is similar: with the client supine, the practitioner passively brings the client's head into extension, then passively rotates the cervical spine instead of side-flexing it. This test is performed bilaterally.
There is also Hautant's Test, which tests for the same but in the seated position, as well as Barre's Test, which is the same thing but done in the standing position.
If dizziness, nausea, dipoplia or other vision disturbance, disorientation, ataxia, impairment of trigeminal sensation or nystagmus are provoked by any of these tests then your client is recording a positive: testing should cease immediately and they should be referred to their primary care physician.
I would recommend all practitioners familiarize themself with all of the above tests. These can all be found in a suitable examination and assessment text.(1,2)
After problems arising from it being done by a student in a college clinic, it is no longer taught at some massage training colleges. I think this attitude is a huge loss to massage or bodywork education. Perhaps the problem with the supine VAT arose through lack of supervision: perhaps it was over-enthusiasm, the student possibly applying, however slight, an over-pressure in the extension, the lateral flexion, or the rotation component of the testing. I've always performed these tests gently as passive tests, with no over pressure, and have never had a problem with a client, other than the occasional positive.
In my clinical experience, there has always been a higher incidence of clients recording a positive response to these tests than actually having vascular compromise. Often the problem is a middle ear/ balance issue. In any one year, I'll have at least ten clients test positive to the VAT. I always suggest they go to their doctor for further testing.
Half do, half don't. I rigourously follow up and encourage them to. In most cases it turns out that I am just being overly cautious - in the last ten years, most of those who have seen their doctors have had nothing wrong. A few have recorded high cholesterol levels; some have had vestibular compromise; one, a male amateur cricketer, 32 years old at the time, who otherwise seemed perfectly healthy, had a berry aneurysm; another, a yoga-practicing vegetarian in her late 40s, had an atheroma in her left carotid artery; and yet another had over the top hypertension. A client last year had a condition known as Cerebral Arterio Venous Malformation and after seeing her GP had immediate surgery with Dr Charlie Teo. None of these people would be walking on the planet today had they not been made aware of a possible problem via the VAT.
All those clients were thankful that such a thing was picked up. Several local doctors initially found it amusing that a massage therapist would write them a letter explaining their observations and refer clients to them. They now have a different attitude to professional massage therapy and bodywork. Though I tend to err excessively on the side of caution, these doctors are no longer surprised by such referrals and rather than dismiss them out of hand will consider my concerns, test their patient and respond to my concerns.
Now, a not so happy story. As a gift to her PA, one of my regular clients sent her to see me. The PA was in her late 20’s, classic “A” type, well organized, very bright, a fit, gym junkie. Her major complaint was “sore neck & shoulders”. The first thing I did in the session was a VAT. She came up positive so we calmly discussed what a positive result could mean and that before we could proceed with any work that I would need clearance from her doctor. I didn't work on her, and would not do so until I had the all clear. She didn’t return, and answered my queries about whether she had seen to it yet with a casual “I’ll get around to it one day”. Eight months later she died of a cerebral stroke while out running at 6 a.m.
1) Magee, D. J. “Orthopedic Physical Assessment” Saunders
2) Petty N.J. & Moore A.P. “Neuromusculoskeletal Examination & Assessment” Churchill Livingstone
© AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
Over the years I have heard all sorts of stories about the efficacy and safety of the VAT. I've researched to find out all I can about it; some research indicates it's completely useless in indicating vertebral artery compromise. Nonetheless, I would do it each time before working on the cervical spine. In the absence of any alternative, I believe it's better to be safe than sorry.
I know at least two versions of it:
One is the cervical quadrant test, which involves, while the client is supine, bringing the head and neck into extension and side-flexion, and holding for 30 seconds,
The other is the deKleyn Nieuwenhuyse Test, which is similar: with the client supine, the practitioner passively brings the client's head into extension, then passively rotates the cervical spine instead of side-flexing it. This test is performed bilaterally.
There is also Hautant's Test, which tests for the same but in the seated position, as well as Barre's Test, which is the same thing but done in the standing position.
If dizziness, nausea, dipoplia or other vision disturbance, disorientation, ataxia, impairment of trigeminal sensation or nystagmus are provoked by any of these tests then your client is recording a positive: testing should cease immediately and they should be referred to their primary care physician.
I would recommend all practitioners familiarize themself with all of the above tests. These can all be found in a suitable examination and assessment text.(1,2)
After problems arising from it being done by a student in a college clinic, it is no longer taught at some massage training colleges. I think this attitude is a huge loss to massage or bodywork education. Perhaps the problem with the supine VAT arose through lack of supervision: perhaps it was over-enthusiasm, the student possibly applying, however slight, an over-pressure in the extension, the lateral flexion, or the rotation component of the testing. I've always performed these tests gently as passive tests, with no over pressure, and have never had a problem with a client, other than the occasional positive.
In my clinical experience, there has always been a higher incidence of clients recording a positive response to these tests than actually having vascular compromise. Often the problem is a middle ear/ balance issue. In any one year, I'll have at least ten clients test positive to the VAT. I always suggest they go to their doctor for further testing.
Half do, half don't. I rigourously follow up and encourage them to. In most cases it turns out that I am just being overly cautious - in the last ten years, most of those who have seen their doctors have had nothing wrong. A few have recorded high cholesterol levels; some have had vestibular compromise; one, a male amateur cricketer, 32 years old at the time, who otherwise seemed perfectly healthy, had a berry aneurysm; another, a yoga-practicing vegetarian in her late 40s, had an atheroma in her left carotid artery; and yet another had over the top hypertension. A client last year had a condition known as Cerebral Arterio Venous Malformation and after seeing her GP had immediate surgery with Dr Charlie Teo. None of these people would be walking on the planet today had they not been made aware of a possible problem via the VAT.
All those clients were thankful that such a thing was picked up. Several local doctors initially found it amusing that a massage therapist would write them a letter explaining their observations and refer clients to them. They now have a different attitude to professional massage therapy and bodywork. Though I tend to err excessively on the side of caution, these doctors are no longer surprised by such referrals and rather than dismiss them out of hand will consider my concerns, test their patient and respond to my concerns.
Now, a not so happy story. As a gift to her PA, one of my regular clients sent her to see me. The PA was in her late 20’s, classic “A” type, well organized, very bright, a fit, gym junkie. Her major complaint was “sore neck & shoulders”. The first thing I did in the session was a VAT. She came up positive so we calmly discussed what a positive result could mean and that before we could proceed with any work that I would need clearance from her doctor. I didn't work on her, and would not do so until I had the all clear. She didn’t return, and answered my queries about whether she had seen to it yet with a casual “I’ll get around to it one day”. Eight months later she died of a cerebral stroke while out running at 6 a.m.
1) Magee, D. J. “Orthopedic Physical Assessment” Saunders
2) Petty N.J. & Moore A.P. “Neuromusculoskeletal Examination & Assessment” Churchill Livingstone
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