Notes made from a recording of the presentation made at the 2011 Soft Tissue Therapy Conference, Sydney.
©Colin Rossie, 2011. Not to be reproduced in any form without the express permission of Colin Rossie.
Contact:integratedbody@internode.on.net
There is much clinical anecdote about the effectiveness of manual treatment of scoliosis but minimal hard evidence or scientific research to validate manual therapy approaches.
Over the years the treatment of scoliosis by manual methods has received great attention in medical literature. From its inception in 1955 until the late 1980s, articles about the treatment of scoliosis often featured in the Australian Physiotherapists Association Journal. Individual physios still work with scoliosis, but exercise and manual therapy for scoliosis are now out of favour in physiotherapy. Recent physiotherapy journals and publications have become silent on the issue (with the possible exception of Josephine Key's and Shirley Sharmann's books.)
Many skilled Structural Integration practitioners offer courses on the manual treatment of scoliosis: Linda McClure, Robert Schleip, Til Luchau and Erik Dalton to name a few.
Various modalities, such as Alexander Technique, Orthobionomy, Visceral Manipulation, Onsen technique, Rolfing, Hellerwork and other forms of Structural Integration have protocols for working with scoliosis. In addition, books and DVDs on subjects like Yoga for Scoliosis and Pilates for Scoliosis have recently become big sellers on Amazon.
There has been a recent increase in journal articles discussing the manual therapy treatment of scoliosis, but still little solid research discussing methodologies or protocols or their effectiveness.
The Clinical Evidence Base
So …what does the current scientific evidence imply for manual treatment of scoliosis?
There have been two major recent systematic reviews discussing manual therapy treatment of scoliosis (Weiss, H. -R. and Goodall, D. 2008 and Romano, M. and Negrini, S. 2008).
Romano and Negrini had wide search criteria, including:
“in the term manual therapy all the manipulative and generally passive techniques performed by an external operator. In a more specific meaning, osteopathic, chiropractic and massage techniques have been considered as manipulative therapeutic methods.”
Romano and Negrini undertook a systematic search in Medline, Embassy, Canal, Cochrane Library and Pedro using the following terms: idiopathic scoliosis combined with chiropractic; manipulation; mobilisation; manual therapy; massage; osteopathy; and therapeutic manipulation. Inclusion criteria were any kind of research; diagnosis of AIS; patients treated exclusively by one of the treatment procedures accepted for the review (chiropractic manipulation, osteopathic techniques, massage); and outcome in Cobb degrees. Finding 145 texts, only 3 were considered relevant to the study. However, none of the 3 fitted all the inclusion criteria as they combined manual techniques with other treatment approaches. They concluded that there was a lack of serious scientific evidence for the efficacy of manual therapy treatment for idiopathic scoliosis.
In discussing the evidence, Weiss and Goodall noted that two distinct treatment approaches exist currently, each with their own cultures: a US/ UK/ Scandinavian one that emphasises surgery and bracing and a western and central European one which emphasises conservative treatment approaches such as manual therapy, exercise and monitoring.
They observed that no prospective controlled studies or RCT have been done on physiotherapy or manual therapy treatment for scoliosis but that several level III studies had been done, as well as two systematic reviews. The systematic reviews found little evidence for the use of physiotherapy whereas the level III studies described evidence for treatment. Several level II studies of bracing noted that, while there was some evidence for the effectiveness of bracing, the evidence had a wide and variable criteria, with weaknesses being the variability in brace type and the length of time worn each day and over what period of time.
Weiss and Goodall further observe that there are no prospective controlled study, RCT or meta-analysis comparing surgery to manual therapy or more conservative measures and note that “there is a substantial body of literature regarding complications following surgery”. They note that certain journals seem fixated on either surgical methods or bracing and publish poor quality papers advocating these, while ignoring or bypassing quality papers discussing more conservative measures. They conclude:
“there is evidence of a better scientific standard supporting conservative treatment for AIS, including in-patient rehabilitation and brace treatment. No evidence has been found in terms of prospective controlled studies to support surgical intervention. In the light of the unknown long-term effects of surgery, a RCT is long overdue, while to plan a RCT for conservative treatment options seems unethical when one considers the evidence for these treatment options already available. Even though there is evidence to support conservative treatments, this evidence is weak in number and length and further studies are warranted to extend the knowledge of such treatments.”
Their take away message is that surgery replaces one pathology (a rotated spine) with another (a stiff spine), with the possibility of increased complication and the need for further surgery, and that conservative treatment has well documented efficacy in both treatment outcomes and cost benefit.
Interestingly, the Scoliosis journal has since published a single case study that involves a massage therapist and an osteopath treating a single client over a number of years but the client has also concurrently tried physiotherapy and many different exercise systems during the same time period (Brooks et al. 2009.)
A recent paper (Weiss, 2012) discusses the current criteria for the physiotherapy approach to scoliosis------
(The scientifically validated evidence for this work is meagre, mainly because no one is doing the research. Research evidence for treatment of scoliosis by manual methods is almost non-existent. The several systematic reviews conclude that the anecdotal evidence is interesting and that further research needs to be done. Case studies are starting to be published outlining results but not methods.)
Other sources of research
Other sources of research include the online journal Scoliosis which publishes articles as they become available and the journal Spine, which is published fortnightly. The Journal of Bodywork and Movement Therapy, The Journal of Bone and Joint Surgery, The Annals of Internal Medicine and the Journal of Pediatric Orthopedics also occasionally feature relevant articles.
One particularly useful resource is the work of Katerina Schroth, a German physiotherapist active in the treatment of scoliosis since the 1920s. Her work has been continued by her daughter Kristina, also a physiotherapist, and has been described by her (Lehnert-Schroth The Schroth Method: Three-Dimensional Treatment for Scoliosis 2007.) While mainstream medicine and surgery was referring to scoliosis as a lateral curvature of the spine until the last 15 years, Schroth had been describing it as a 3 dimensional, body-wide, rotational pattern since the 1920s. Many of the manual therapy treatment protocols that are effective with scoliosis are based on principles that were first expounded by her, often many years in advance of mainstream thought on scoliosis: the idea of the pelvis having a profound effect on the measurement of Cobb angle and spinal rotation; the major concept of the trunk as a series of trapezoidal blocks stacked around the spine which become asymmetrical in 3 dimensions when in dysfunction; and the concepts of 3 and 4 rotations of the axial skeleton, among others, all owe their origin to her.
Absence of evidence or evidence of absence?
The hard evidence for the efficacy of manual therapy interventions for scoliosis is minimal. There is far more evidence for the efficacy of exercise interventions. Is this a classic instance of evidence of absence rather than absence of evidence, as Weiss and Goodall observed? Given the lack of evidence, how do manual practitioners formulate ideas regarding treatment? Anatomy is an imprecise science; most assessment techniques have limited efficacy; many of the techniques we use lack an evidence base and the reproducible techniques used in most studies for soft tissue and massage outcomes are effleurage, kneading, frictions, petrissage and tapotements.
However, we do get a lot of hints rather than direct indications for treatment methods - from that imprecise science of anatomy; from physiology; biomechanics; histology; extrapolation from various scientific laws; ideas and direction from some of the current pioneers outside the mainstream of science; extrapolating from journal articles (that possibly would stand up to rigourous scientific scrutiny) - some regarding conservative treatment (exercise) of scoliosis, others that discuss what impedes or enhances the results of spinal surgery for scoliosis; from published case studies and case series; from tradition; from clinical anecdote; and lastly and perhaps most profoundly, from the evidence of our clients’ responses. In this last respect, every clinician is a researcher.
Very little of the above is published in the reputable scientific journals. Most of it is what can be termed empirical evidence.
Perhaps it is worth noting the changing paradigms in medical science at this point: in the mid-20th century, the dominant medical paradigm, called either the authority-based or eminence-based medicine paradigm, was guided mainly by a patho-physiologic rationale and by knowledge provided by respected authorities in that field. Around 30 years ago this was replaced by the evidence-based practice paradigm. The evidence-based paradigm has met with considerable resistance from the clinical field. The main criticisms revolve around over-reliance on research evidence at the expense of clinical expertise and experience and disregard for social context. This has led currently to a new approach, the evidence informed paradigm. This is inclusive of the evidence, but also recognizes clinical expertise, patient values and other contextual factors in the clinical practice. In it, the clinician takes the evidence of research into account when making a clinical decision in regard to patient management, but the evidence does not dictate the decision.
Most of the interventionist surgery and orthotic bracing is not evidence based but is from the authority, eminence based model. In the last few years this has changed, with much research being published. Unfortunately, it doesn’t stand up to the scrutiny of the evidence-based paradigm. The journal Scoliosis has been publishing many evidence-based articles in the last 10 years and recently has published a few articles written in the evidence informed paradigm. These recent articles have begun to consider exercise approaches from the evidence based paradigm and have been favourable, and manual therapy and exercise approaches to scoliosis from the evidence informed paradigm. Both these approaches were dismissed by the authority/ eminence paradigm. Interestingly, bracing and surgery approaches do not fare as well in the evidence based or evidence informed paradigms.
One scientific law useful when considering soft tissue treatment protocols is Wolff’s Law, which states that systems such as hard and soft tissues remodel in response to the loads placed on them, distorting in direct correlation to the amount of stress imposed upon them. Wolff formulated this law to describe osseous structure, metabolism and behaviour:
“every change in the form and the function of a bone leads to changes in its internal architecture and in its external form.”
Expand this beyond bone to embrace most connective tissue that contains collagen. Healthy connective tissue adapts to the loads and stresses placed on it, which determines its form and function (this is almost Davis’s Law, though that was formulated specifically for muscle but is probably applicable to all soft tissue as well.)
“One of the hallmarks of connective tissue, including fascia, is its mutability and remodeling in response to mechanical stress.”
Fascia
Like bone, fascia is subject to Wolff’s Law. It changes and remodels in response to the forces placed on it. Muscle fibres can contract and relax, unless in spasm. Fascia, on the other hand, can’t relax as readily and will respond to poor usage by remodelling negatively. This can be quite rapid - it doesn’t take much to change its length. However, this plasticity is also a blessing because it doesn’t take much for it to remodel positively as well.
Fascia / connective tissue can respond to the stress of chronic postural change in various ways:
1. Thickening
2. Shortening
3. Calcifying
4. Eroding
Chronic muscle shortening can easily be treated by Swedish/relaxation massage, stretch and trigger point type work. Prolonged muscle tightness or shortening if not addressed will manifest in changes in the fascia, and is beyond treatment by simple massage. This, primarily, is what we are working with in scoliosis: a long-term pattern that has led to the fascia and connective tissue being affected and subsequently remodelling (or modelling) in a less than optimal manner.
The role of Myofascia:
- Transmission/lines of force
- Continuity in kinetic chains
- Neuro-myofascial web –proprioception, mechanoception.
- containment of muscular structures
- transportation
- structural homeostasis & repair (fibrinogen)
How it can affect scoliosis:
• Asymmetrical growth or localised pinning of the structure blocks congruent development and the body is forced to react at the “pinned” block. As soft tissue, it is the fascia that responds to long-term change first, before the bone.
• Soft tissue shortening goes hand in hand with the spinal curvature; therefore straighten initially by lengthening the fascia. Unknown whether it is cause or effect but possibly irrelevant so treat anyway as it has an affect.
• Consider the curvature continuing into the neck/cervical spine and through into the cranium. Shortened sub-occipitals, TMJ dysfunction, dural changes, vestibular dysfunction – all manifestations of fascial continuity – as well as autonomic/ parasympathetic responses.
Various patterns are possible – always respond to the client and their specific situation rather than rigidly seeking patterns and following treatment protocols.
Jan Sultan’s Internal/External model
The internal / external theoretical model of the body, developed by Jan Sultan, postulates two tendencies in bodily presentation. Based upon his observations of how femoral retro- and ante-version led to two consistently different body patterns, Sultan originally considered aspects of limb (especially femoral) rotation as part of what drives this process, thereby giving a name to the model. The concept of two possible, different responses of the body to gravity means two different lines of force transmission in the body. This results in different muscular and fascial loads and thus differing, characteristic patterns of tonus.
The internal/external model is an empirical model of the body, yet to be scientifically validated. However, it has been used as a cornerstone for observing the body and posture for 25 years in the Structural Integration / Rolfing paradigm and is a particularly useful observation tool. Given that a significant proportion of claims in manual therapy are yet to be validated (even in fields that pride themselves on their evidence base, such as physiotherapy), it should not be dismissed out of hand as currently unproven for lack of hard evidence but viewed as a useful, empirical contribution toward understanding the body.
Some correlation can be found in Vladmir Janda’s stratification syndrome, which postulates that in some dysfunctions there are alternating strata of hypertrophic and weak muscle groups throughout the body, that these alternating sections can be to differ at each layer and even side to side. Balance (or the lack of it) is related directly to the feet.
Sultan’s contention is that we tend toward one or the other pattern and in my observations this holds true for people without scoliosis - the body is normally congruent bilaterally. In scoliosis, especially idiopathic scoliosis, there is bilateral incongruence: the body will be the opposite tendencies on each side at the same level.
Thus you will find, looking at the posture from the ground up, the arch of one foot will be planus, the other cavus; one foot will be subtalar varus (calcaneal varum), the other valgus (calcaneal valgum); Tibial varum (a common congenital osseous deformity in which the distal one-third of the leg is angled medially) is often present in one leg but not the other; one knee will be a little more valgus, the other slightly varus, one will have genu recurvatum while the other will display a normal configuration; one femur will be externally rotated (and often retroverted in the joint) and the other internally rotated (and anteverted.) One ilium will be in anterior tilt, the other posterior, one in outflare and the other in inflare. The sacrum articulates with the ilium and sacral position and biomechanics directly affects the lumbar spine, which sits on the sacrum superiorly. Depending upon which source you use, there are between 9-11 axiis of sacral motion - like a keystone, the position of the whole spine is directly affected by the sacrum’s orientation. No one axis acts alone in the sacrum, so the multi directional altered sacral position will affect vertebral rotation accordingly. The rotation of the vertebrae and the pulls from the pelvic soft tissue upward will affect the structure of the thoracic cage. The shape of the thorax along with the lines of force transmitted by soft tissue originating in the pelvis will affect scapular position, in turn affecting humeral rotation, length of arm bones, tone of connective tissue in the upper and lower arm and on into the wrists. With regard to the cranial vault, the roof of the mouth, the palatine bones will asymmetrical, usually reflecting the asymmetry of the diaphragm. The TMJ will be asymmetrical in shape and function.
So far this has been about appendicular relationships one side to the other. From here, in the axial skeleton, osseous changes come into play. The sacrum, vertebrae and ribs can be asymmetrical in shape one side to another. This is the result of the prolonged force of soft tissue pulling on the bone. It doesn’t start out that way, but it will rapidly develop like that. Asymmetrical pulls in a juvenile body increase with the adolescent growth spurts that accompany puberty; at the same time the bone is increasing in ossification.
Keeping the above in mind, over a period of time appropriate manual therapy on any connective tissue with a collagenous component (bone, ligament, tendon, various types of fascia, adipose tissue) will see the structure of the body change and adapt. This is the whole basis of Structural Integration (Rolfing©, Hellerwork©, Tom Myers’ Kinesis©, etc), myofascial release, deep tissue massage and connective tissue massage. If done with skill and intelligence, this can profoundly affect scoliosis.
Scoliosis as a body wide pattern
Nothing occurs in isolation in the body: scoliosis is a body-wide pattern, not restricted purely to the thoracic spine, even though this is where it is most visibly obvious. It is also where many traditional textbook definitions of scoliosis stop - tending to refer to scoliosis purely in terms of lateral curvature of the spine, though in the last 5 years most of the literature has started referring to it more accurately as a 3-dimensional rotationary pattern in the spine. Rotations in the thoracic spine do not occur independently of the function of the rest of the trunk but are intimately related to what occurs above and below in the cervical and lumbar spines.
I would like to emphasise what is written above again: the body wide pattern manifests in the girdles and limbs and in the axial skeleton - not just the spine but also the jaw, face, dentition, roof of the mouth and cranial vault above. The shoulder girdle is affected directly by thoracic rotations, continuing out to affect rotation in the upper limbs. Because it is a body-wide pattern, there is a need to work with the whole body, not just the spine.
Spinal rotation also affects rib shape. Thoracic shape affects the pathomechanics of the pleural viscera, and thus the potential impairment of respiratory and circulatory function makes this one of the sites of great physiological impact. The heart and lungs are the two most constant, mobile viscera in the body, both housed in the thorax, thus affecting the whole physiology of the body. Because of the need to accommodate the constant motion of these two organs, the thorax needs to be able to deform quite markedly while still providing protection for its enclosed viscera. Most movement in the body can be related to the respiratory function; indeed, many disciplines utilise this interface between breathing and movement. To work with scoliosis you need to work with the whole body, the whole broad canvas, to be truly effective.
Anecdotal observations re structural scoliosis (mainly idiopathic scoliosis):
There are two types of functional scoliosis: one that is due to asymmetrical muscle usage, the other is a spinal manifestation secondary to structural anomalies elsewhere in the body. It is relatively easy to work with asymmetrical muscle usage, but if it is secondary to something like leg length inequality, hemi vertebra, hemi pelvis or has a congenital cause, then manual therapy only offers symptomatic relief. These types of functional scolioses are tricky, because you don’t want to work to change function if this does not support the best possible functional pattern for the person; what you do has to be a considered, supportive response to their altered biomechanics. Consider if there is the need for orthotics –
The rotationary pattern is at its most aggressive around the adolescent growth spurt. Females are the gender most affected (10:1). The rotationary changes are at their most extreme one year before and one year after the onset of menstruation. During this time work done is basically that of a holding pattern. You will usually get no reversal of the rotation during this period of aggressive growth, but you can slow down what is termed “the natural progression” so that it doesn’t worsen. After the period of aggressive growth, while the client is still in their early adolescence, soft tissue work can have the effect of reversing the curve in about 60% of cases and of stabilizing it and preventing further progression in about a further 20% of cases. In the other 20% of cases it will progress; half of these will be relatively minor, possibly less than the natural progression, and the other half will progress markedly (in the range of natural progression.)
Though the most dramatic worsening of the visible rotation of AIS is during early puberty, generally the child isn’t in that much pain or discomfort. PAIN IS NOT AN ISSUE OR CONCERN FOR THE CLIENT - at this stage it is often more a case of aesthetics; the parents and doctors are generally more concerned. This is the time that parents are at their most vulnerable and when doctors are at their most insistent regarding the need for surgery. The progression is generally at its worst, but it stabilises a year after the onset of the period and only progresses slightly after that time. Two-dimensional x-rays measuring Cobb angle are the tool doctors generally use in discussing the severity of the curve. This is a little misleading, as it is a 3 dimensional condition that is primarily driven by rotation in the transverse plane. Recently technology has become available to measure this aspect of the condition and this may change the thinking around scoliosis. Of greater importance, though not often done as a test, is a bone scan of the carpal and metacarpal bones to determine the stage of ossification which would indicate whether surgery would be effective or not. This is rarely done.
General considerations for working with scoliosis
• Scoliosis is a 3-dimensional body-wide pattern. Think 3 dimensionally.
• Scoliosis is a whole body pattern, so you need to work with the whole body, not just the spine.
• Rotation is the driver of scoliosis (not just in the thoracic spine but across the whole body.)
• The severity of thoracic rotation is determined by the position of the pelvis. Level the pelvis first every session! Before assessing or treating the spine for rotations, correct sacral position in relation to the two ilia, and level the ilia left to right.
• Create connections with and gain support from the ground. Work from the ground up – every time you work with the client, bring their awareness to the feet and lower limbs as the base of support for the body and the axial line. Reignite their relationship to the ground before they leave.
• In all scoliosis it is the core that is primarily affected, specifically as it relates to the centre of gravity. Relate the work you do to this axial core. Emphasise the core and the relationship to Anticipatory Postural Activity.
• There is asymmetry of form, function and proprioception on opposite sides of the body at the same level in idiopathic scoliosis. Imbalance is one side to the other – therefore work unilaterally to induce more order and organisation on the side that is less organised and ordered, more random.
• To increase proprioception, work with the client seated, standing and moving in addition to lying on the table. Encourage them to explore what they can’t readily sense somatically. Utilise novelty in the attempt to stimulate neuroplasticity. (Try having them walk on the table!)
• Work relationships within the body: limbs to girdles; girdle to opposite girdle; lower girdles to axial line from the pelvis; upper girdle to axial line in the thorax; upper girdle to neck; cranium to spine, cranium to upper girdle.
• Think of scoliosis as a disturbance of perception, as a body image disturbance, similar to anorexia. No matter how skinny or on death’s doorstep, anorexics can’t perceive of themselves as anything other than overweight. Similarly, someone with scoliosis cannot perceive themself as anything other than straight and aligned, no matter how rotated or disordered their body pattern.
Specific considerations for working the scoliotic thoracic spine
• Think 3 dimensionally.
• Work superficial to deep.
• Know the anatomy of the region and physiological joint function of respiration – the reciprocal relationship of structure and respiration. Be aware of the continuity and relationship of muscles in both micro and macro structure and subsequently function.
• In the spinal component of rotation, the trunk (including shoulders and neck) can be divided into three segments:
1. Lumbar spine with pelvis
2. Thoracic spine with rib cage
3. Cervical spine with shoulders and head.
• The upper and lower two ribs function differently to ribs 3-10 of the thorax. The upper two are overlayed by the shoulder girdle and neck; the weight of the head is cantilevered off the spine as low at T5/6 (mid/apex of thorax to the cranial vault- scalenes are also important here). The lower two are the interface with the pelvis through quadratus lumborum, the posterior spinal muscles, the psoas and the thoraco lumbar fascia.
• The aim is to introduce physiologic movement to create adaptive possibility- encourage full respiration in all 3 dimensions across the whole thorax. Specific sections of the lung will be under-functioning.
• Though the rotations in the thorax are more obvious visually and in assessment, rotations of the pelvis affect the thorax more than thoracic rotation affects the pelvis. This pelvis driven pattern is more common than a thoracic one. Therefore, to get a true sense of the amount of thoracic rotation, ensure the client has level ilia around a normal, physiologically optimal, functioning sacrum. When the sacrum and ilium are in optimal position the amount of thoracic rotation will be less, and what there is will be a truer reflection of the rotationally status of the thorax.
• Rotation is the driver; therefore work the rotatores and multifidi to counter this.
• Lumbar or Thoraco-lumbar rotations tend to be more profound and drive the rotations in the thoracic spine. Thoracic rotations tend to be counter rotations to the initial lower rotation.
• Maintenance of the correct lumbar lordosis encourages appropriate thoracic kyphosis. An asymmetrical lumbar lordosis will be present before any thoracic manifestations.
• There is often a loss of the thoracic kyphosis, which presents as an anterior/posterior flattening of the rib cage. Often the sternum is lower in relation to the thoracic spine than in non-scoliotic subjects. Work structurally to counter tissue restriction and functionally to enhance perception of the respiratory function.
• The Anatomy Trains arm lines, spiral lines and superficial back line directly affect the thoracic spine.
• Autonomic function is affected- between rib heads and transverse processes is a sympathetic nerve chain, therefore rib motion competence is vital to autonomic neural function.
• When working with the spine from skin to vertebra (surface to deep) there can be up to seven muscle layers that can affect the biomechanics of the spine and ribs. In functioning as a whole, these muscles can create different movements, opposite to each other, at the same level - each layer will need different things done to it.
• Each rib has four joints:
1. Sterno-chondral
2. Costo-chondral
3. Costo-transverse
4. Costo-vertebral
• Ribs 3-10 follow consistent rules
• R! -2
• R11-12
Relevant dissection observations (sample 7 bodies, 4 with scoliosis)
• 50% of serratus posterior muscle fibres continue to insert underneath the serratus anterior fibres. Serratus anterior could really be thought of as serratus anterior fibres interdigitating on top of serratus posterior fibres. It isn’t visually possible to discern where one starts and the other ends.
• There is no discernable difference where rhomboid minor ends and levator scapulae commences.
• The intertransversarii appear to be in three strips superior to inferior
• Levator costarum has superior and inferior portions. The superior portion is more tendinous and inserts into the rib at about 80˚, the inferior portion is more muscular and inserts primarily onto the muscle fibre of the external intercostals at the rib angles so that they seem like a continuation of the external intercostal fibres from the rib angle onto the transverse processes immediately superior to the intercostal region below the corresponding rib
• In subjects with scoliosis the levator costarum are hypertrophied and long on the convex side and hypertrophied and short on the concave side superior to the apex of the curve.
Spinal pathomechanics
- “very little is known about the details of how the loads are transmitted through the spine in three-dimensions.” (Stokes, 1996, 2000)
- “the vicious cycle hypothesis proposes that lateral spinal curvature produces asymmetrical loading of the skeletally immature spine, which in turn causes asymmetrical growth and hence progressive wedging deformity. Both discal and vertebral wedging contribute to a scoliosis curvature. The relative contributions of these two structures are not well-defined.” (Stokes, 2006)
There are currently several models posited for spinal pathomechanics. The experts are yet to achieve consensus on which is correct. This may be why there is so little validated research on manual therapy for scoliosis – no one seems entirely certain exactly what is going on.
Having said that, the model I tend to use is that of the transverse processes of the thoracic vertebrae rotating in the direction of the convexity of the curve. Thus, the spine side-bends to one side and rotates to the other. This means the anterior vertebral body rotates in the same direction as the TP. The ribs follow the transverse process: on the convex/ rotated side they present posteriorly, on the concave side they present anteriorly.
Technique Descriptions
Direct myofascial technique (myofascial release)
Direct myofasical technique is different to the slower, John Barnes-style MFR. It is the manual application of controlled mechanical stress to areas of restriction within the myofascia. This changes the mechanical properties of the fascia, allowing a new relationship between the previously restricted tissue and the surrounding tissue, in turn allowing new usage possibilities (i.e. lengthening; new, freer movement).
Choose appropriate tool: fingers, knuckles, soft fist, forearm. Then:
• Gently contact surface
• Sink to appropriate depth (INTENT)
• Contact appropriate level and apply gradual pressure to vector of force.
• Drift through tissue using bodyweight mindfully. Control by changing angle of application rather than amount of effort.
• Ask client for assisted movement.
• Be aware of your working posture; always maintain ease in your posture. This allows you to have greater responsiveness and sensitivity to your client. Don’t work with excessive pressure –your sensitivity decreases with too much force!
Active movement participation
Active motor learning is the fastest and most effective way for the nervous system to re-pattern. It involves the client more in the Rolfing process and increases proprioceptive input via kinetic activity and sensitivity. Active motor output decreases pain sensitivity and enhances the therapeutic effectiveness of interventions. As a movement education tool (i.e. homework), it educates the body to break habitual and limiting movement patterns by guiding it into new ones.
Indirect Myofascial Release (MFR)
Active Functional Technique (AFT)
Passive Functional Technique (PFT)
Dynamic Sensory Awareness (SA)
Muscle Energy Technique (MET)
Tri-Planar Fascial Loading (3PRFL) (AFL) (PFL)
Deep Transverse Frictions (DTF) and Cross Fibre Frictions (XFF)
Strain/ Counter-Strain (S/Cs)
C.R.A.C. & PNF Stretching
Trigger Point (TrP) and Direct Stretch
Acknowledgements
I would like to acknowledge the work of the many writers and teachers who have contributed to the knowledge I have and am able to present. Nothing I do is original; it is built on the shoulders of the giants who have preceded me. I would especially like to thank Dr Robert Schleip, Til Luchau, Jan Sultan, Judith Aston & Brian Linderoth, Ron Mariotti & Dee Ahern and for the classes of theirs I have attended; Robert Schlep, jan Sultan, Emmett Hutchins and Judith Aston for insights and several a-ha moments, and all the great trail-blazers - Ida Rolf, J.P. Barral & Katerina Schroth - whose original work has been the inspiration for this knowledge
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Newton, P., O’Brien, M., Shufflebarger, H. et al Idiopathic Scoliosis: The Harms Study Group Treatment Guide 2010 Thieme
Ni, Haijian MS; Zhu, Xiaodong MD; He, Shisheng MD; Yang, Changwei MD; Wang, Chuanfeng MS; Zhao, Yingchuan MS; Wu, Dajiang MS; Xu, Jin RN; Li, Ming MD An Increased Kyphosis of the Thoracolumbar Junction is Correlated to More Axial Vertebral Rotation in Thoracolumbar/Lumbar Adolescent Idiopathic Scoliosis Spine: 2010 - Volume 35 - Issue 23 - pp E1334-E1338
Pare, Stephen Internal/External: A Neglected Theory Rolf Lines/Structural Integration 2002 Vol 30 no 2 pp 18-19
Rolf I. P. Rolfing: Re-establishing the Natural Alignment and Structural Integration of the Human Body for Vitality and Well-being. 1977 Healing Arts Press, Rochester, VT
Rolf I. P. Rolfing and Physical Reality 1978 Healing Arts Press, Rochester, VT.
Saccucci M, Tettamanti L, Mummolo S, Polimeni A, Festa F, Salini V and Tecco S Scoliosis and dental occlusion: a review of the literature Scoliosis 2011 6:15 doi: 10.1186/1748-7161-6-15
Romano, M. and Negrini, S. 2008 Manual therapy as a conservative treatment for adolescent idiopathic scoliosis: a systematic review Scoliosis 3:2, 22 Jan 2008, available free online, through http://www.scoliosisjournal.com/ or via BioMed Central.)
Sahrmann, S. & Associates Movement System Impairment Syndromes of the Extremities, Cervical and Thoracic Spine 2011Mosby/ Elsevier, St Louis, MO
Schleip, R. Scoliosis and Proprioception Rolf Lines, Vol.xxviii, no.4, Fall 2000. Available on the www.somatics.de website, along with many other good articles on scoliosis.
Smith, J. Structural Bodywork 2005 Churchill Livingstone/Elsevier Edinburgh
Standring, S. (Editor) Gray’s Anatomy: The Anatomical Basis of Clinical Practice 40th Edition 2008, Churchill Livingstone/ Elsevier, Edinburgh
Stokes IAF, Spence H, Aronsson DD, Kilmer N: Mechanical modulation of vertebral body growth: implications for scoliosis progression. Spine 1996, 21(10): 1162-1167.
Stokes IAF: Hueter-Volkmann effect. In Etiology of Adolescent Idiopathic Scoliosis. State of the Art Reviews. Spine 2000, Volume14: 349-357. 9 Edited by: Burwell RG, Dangerfield PH, Lowe TG, Margulies JY.
Stokes IAF, Burwell, RG & Dangerfield, PH Biomechanical spinal growth cent scoliosis – a test of the 'vicious cycle' pathogenetic hypothesis: Summary of an electronic focus group debate of the IBSE Scoliosis 2006, 1:16doi: 10.1186/1748-7161-1-16
Sultan, J Towards a Structural Logic Notes on Structural
Integration, May 1986
Ward, R.C. (editor) Foundations for Osteopathic Medicine 2003 2nd edition, Lippincott Williams & Wilkins
Wisby-Roth, T. 3 Dimensional Assessment & Treatment of Cervical/ Thoracic Spine 2005-2010 Wisby-Roth Consulting
Weiss, H. -R. and Goodall, D. 2008 The treatment of adolescent idiopathic scoliosis (AIS) according to present evidence: a systemic review (European Journal of Physical and Rehabilitation Medicine 2008 44:177-93
Weiss, H. The method of Katharina Schroth - history, principles and current development Scoliosis 2011, 6:17
Weiss, H. Physical Therapy Intervention Studies on Idiopathic Scoliosis - Review with the focus on Inclusion Criteria Scoliosis 2012, 7:4 (25 January 2012)
Sunday, April 15, 2012
Thursday, February 25, 2010
Clinical Perspectives: Carpal Tunnel Syndrome A Remedial Massage Therapist’s Perspective
Originally appeared as a contribution to the " Clinical Perspectives: Carpal Tunnel Syndrome" article in the December 2009 edition of "In Good Hands" © Colin Rossie 2009/ AMT 2009. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
By Colin Rossie
Description
Carpal Tunnel Syndrome (CTS) is an occupational overuse syndrome of the wrist. The tunnel is formed by the carpal bones on the dorsal aspect and by the transverse carpal ligament (and to a lesser extent the flexor retinaculum) on the volar aspect of the wrist. The tendons of the wrist, finger flexor and thumb muscles pass through this tunnel along with the median nerve. The tendons can become inflamed and swell through overuse, thereby compressing the median nerve.
CTS is a mono-neuropathy in that only a single nerve is affected. Muscles that are affected would include the palmaris longus, flexors carpi radialis and ulnaris, flexors digitorum superficialis and profundus, and flexor pollicis longus.
Many references state that CTS is more prevalent in middle-aged females. This could perhaps be partially attributed to physiological changes occurring around menopause, but could also be the result of long-term keyboard use. In practice, I find the condition presenting in both genders, and across a wide range of ages and occupations. In addition to assembly line workers and keyboard operators, CTS also commonly affects any occupation where power or precision grip is constantly required such as musicians, waiting staff, chefs and drivers.
Initially, symptoms are low level and of insidious onset, starting with numbness and tingling in the thumb (I digit), index (II digit) and middle (III digit) fingers, the radial half of the ring finger (IV digit) and possibly the wrist, gradually becoming chronic.
After several months this becomes an acute pain in the wrist and forearm, described as “burning”, “itching” and “throbbing” by those with it. Clients will also report that their fingers feel swollen and numb, even though there will be no visible swelling. In fact, after prolonged periods the forearm muscles and fingers atrophy. Power and precision grips weaken, fine motor skills diminish and the ability to distinguish temperature variations can become difficult. Symptoms are not relieved by rest and actually worsen with sleep, especially where there is a tendency to clutch the hand and fingers in flexion.
Differential Diagnosis
Differential diagnosis would include medial epicondylitis, neuropathies of the ulnar and radial nerves, cervical radiculopathies, thoracic outlet syndrome, sub-acromial impingement, osteoarthritis of either the carpal bones, metacarpals or distal radius and ulna, and tenosynovitis. Also, active trigger points from the scalenes, infraspinatus, subscapularis, brachialis, supinator, pectoralis major and minor, serratus anterior, pronator teres, palmaris longus, flexors carpi ulnaris and radialis, and digitorum profundus and superficialis, adductor pollicis and opponens pollicis all refer pain in patterns that mimic CTS.
In closed kinetic chains, I believe that myofascial trigger points are tertiary considerations - more a symptom of stability and core dysfunction than a primary factor (essentially, they are a local symptom of a poor global relationship to gravity). However, in open kinetic chains such as the upper limb, trigger points play a more significant role as manifestations of purely local dysfunctions, occupying a more central role in the treatment protocols employed.
Assessment
Pain from the median nerve can originate anywhere along the length of the nerve, not just the carpal tunnel. Although symptoms may appear the same between individuals, the cause may be completely different. True CTS is over diagnosed, being a convenient catch-all for any wrist pain or pain of median nerve origin. Therefore accurate assessment is vital before commencing treatment.
What follows are assessment protocols I use and a brief rationale for their use. This is followed by a description of some treatment approaches, which would vary according to the specific findings of the assessment. Fuller descriptions of the tests can be found in the references provided. Kerry Hage has already described Tinel’s Sign and Phalen’s test in her contribution earlier in this article:
• Active Quick Test of the median nerve to determine that it is the median nerve involved (Butler, 2008, p34).
• Tinel’s Sign to determine median nerve involvement at the carpal tunnel (Magee, p441).
• Phalen’s Test (Magee, p442) to determine carpal tunnel involvement.
• Upper Limb Neurodynamic Test 1 (median nerve), another test to determine median nerve involvement (Butler, 2008, p35-6 and accompanying DVD).
• Upper Limb Neurodynamic Test 2 (median nerve), again to determine median nerve involvement (Butler, 2008, p37-8 and accompanying DVD).
• Adson’s Manoeuvre or Halstead Manoeuvre to determine whether thoracic outlet syndrome is involved in the wrist symptoms (Magee, p322),
• Apley’s Scratch Test to determine if there is gleno-humeral joint involvement (Magee, p254-255).
I would perform the following to rule out involvement of structures other than the median nerve and to determine what structures to work:
• Passive, active and resisted testing of elbow flexion/extension
• Passive, active and resisted testing of forearm supination/pronation
• Passive, active and resisted testing of wrist in flexion/extension, ulnar and radial deviation
• Passive, active and resisted testing of finger flexion/extension, abduction / adduction
Assessment of power and precision grip (Magee, p422) - in addition to determining how these are affected by the CT - is also a good pre- and post-session yardstick for both the client and practitioner.
Treatment
Commence by decreasing the hypertonicity of the myofascial structures of the forearm starting with gentle, myofascial release to the forearm flexors. Follow this with deep transverse frictions to the common flexor tendon, then deep connective tissue massage along the length of the muscles from the distal tendon at the wrist through to the epicondyles, and broadening, transverse compressions across the muscle fibres.
A good series of techniques similar to the above can be found at:
http://www.massagemag.com/Magazine/2004/issue107/assess107.5.php
Another good source of techniques that could be employed, along with excellent illustrations of the anatomy, can be found in Clay & Pounds ‘Basic Clinical Massage Therapy’. The technique illustrated for working with the Flexor Retinaculum is particularly useful. A word of caution though – unfortunately, the photo in the 1st edition of this book looks like the therapist is crushing the nerve. I’m sure this isn’t actually the case! Always keep in mind that your intent isn’t to crush the nerve (which would exacerbate the client’s symptoms) but to
a) free it from the surrounding structures that it might be adhered to
b) lengthen shortened structures that could be impinging it and
c) decrease the swelling of other soft tissue structures within the carpal tunnel that affect the nerve.
Next, deactivate trigger points that may be present in the forearm myofascia and tendons. Kerry Hage has already addressed this aspect in her contribution. If it is a genuine case of Carpal Tunnel Syndrome, there will likely be active TrPs in the shoulder girdle that will need deactivation as well.
Follow TrP deactivation with stretching and a ‘flushing’ effleurage, starting gently but with depth, gradually decreasing the depth and slowing the rate to create a flushing effect on any soft tissue swelling.
I would then use direct myofascial technique with active movement participation (DMFT w/AMP) to the forearm flexors and inter-osseous membrane (IOM) of the forearm.
For more information on this style of work, see Smith (2005), Stanborough (2004), Riggs (2007) and Schleip (www.somatics.de).
Many of the forearm flexor muscle fibres attach directly to the Inter-osseous membrane (IOM)of the forearm (Stecco 2004); working it can have a profound effect on CTS symptoms.
Have the client supine and their hand and forearm supinated, have them form a soft fist and flex the wrist. as you apply pressure to the appropriate depth at the wrist and move slowly up the forearm toward the common flexor tendon. At the same time, ask the client to slowly bring the wrist into extension, gradually opening the fingers so that at maximum wrist extension the fingers are fully extending as well (see photos 1-3). Work up the arm like this several times, paying attention to the feel of the tissue being worked. Also pay attention to the different slips of muscle/fascia you contact, always seeking to differentiate the tissue (see photo 4). To work in a second plane, have the client vary their movement by medially and laterally deviating their wrist. As the radius and ulna move you will affect the IOM, especially if you focus your intent on it.
Other techniques I might incorporate into a session for CTS could include:
• DMFT w/AMP to the forearm extensors, client supine, arm beside the torso again with the intention of affecting the IOM (see photo 5), this time from the dorsal side (client supine, forearm pronated). Ask for medial and lateral deviation of the wrist as you work the forearm (figure 1).
Again, to get a second plane of movement, request the client to slowly lift their hand up and down (extend and flex the wrist –figure 2). Alternatively, ask them to gradually press their palm into the table and slowly release it as you work on it.
Another variation would be to have the client anchor their hand by pressing their palm into the table and then actively move the elbow medially and laterally as you work the forearm distally to proximally (figure 3 – see Maupin, 2005, pp80-81).
• DMFT w/AMP to the palmar fascia. Client's forearm and hand supinated. Apply direct pressure to the client's palm with either your thumb or finger pads, and slowly work up the palm to past the wrist as the client flexes and extends their digits.
• DMFT w/AMP to the flexor retinaculum. With the client’s forearm supinated, I hold the outsides of the client’s hand with both my hands, thumbs on the centre of the flexor retinaculum. I ask the client to extend their wrist at the same time opening (abducting) their fingers as I slowly and deeply drag both thumbs out to the sides.
I may also perform a series of neural mobilisations for the median nerve. These are fully described in Butler (2000) pp314-325, (2008) pp41 -43, and Barral (2007), pp161- 169. They are also demonstrated in the relevant section of the DVD accompanying Butler (2008). These mobilisations can be used as pre- and post- assessment tools or at any stage during the treatment session.
If the client has tested positive to the median nerve tests, the nerve may be impinged at sites other than the carpal tunnel. Neural massage of the median nerve at more proximal locations might be required.
In the upper arm, the median nerve is about the width of a window sash cord and is on the medial aspect of the arm between the biceps brachii and triceps brachii. Here it can be easily palpated and treated for restrictions (Barral, p162 and figure 6.58), also at the ligament of Struthers in the elbow (Barral, p164 and figure 6.59, Hammer, p165), in the forearm (Barral, p165 and figure 6.60), at the wrist (Barral, p165-6 and figure 6.62) and in the hand. The intent of this style of work is to release the nerve from the surrounding structures it could be adhered to. Basically, it is working epineurium. Nerves themselves have the consistency of blancmange and the intent should not be to crush them.
Tom Myers discusses the arm in his ‘Anatomy Trains’ model of the body, according it 6 myofascial meridians. Of special note in terms of working with CTS in his myofascial meridians paradigm would be the Deep Front Arm Line, which roughly corresponds to the lung meridian in Traditional Chinese Medicine (Myers, 2009, pp151-155) and more importantly the Superficial Front Arm Line, which approximates the pericardium meridian in TCM (Myers, 2009, pp155-158). Myers’ model is worth consideration and further study if you are seeing a large number of CTS clients (Myers, 2009, pp 149-169).
Homework
Wearing a wrist splint to bed to prevent wrist and finger flexion during sleep is one option that will help prevent the nocturnal exacerbation of CTS. Stretching the forearm flexors in conjunction helps reduce symptoms and speeds recovery. Butler (2008) shows a series of exercises in both his book (pp 44- 48) and DVD. I play the relevant median nerve self-management section of the DVD to clients, who have found it particularly useful.
CTS shouldn’t be considered from just a local, remedial perspective but in the global context of the whole being. From a structural Integration perspective, this would involve the body’s relationship to its centre of gravity. Previous trauma or unbalanced, repetitive work habits affect this relationship. Poor posture will affect the brachial plexus, thoracic outlet and sub-acromial region. Re-education regarding seated posture, shoulder girdle and upper limb usage (relating these to the body’s centre of gravity) would be essential in this paradigm, as well as modifying the workstation layout to improve its ergonomic efficiency.
Acknowledgments
My sincere thanks to Ed Maupin for generously allowing me to re-print his diagrams from “A Dynamic Relationship to Gravity: Volume 1-The Elements of Structural Integration”. Thanks also to Tania Lambert for her photography.
Bibliography
Barral J.P. 2007 Manual Therapy for the Peripheral Nerves Churchill Livingstone/Elsevier Edinburgh
Butler, David, 2000 The Sensitive Nervous System Noigroup Publications Adelaide
Butler, David 2008 The Neurodynamic Techniques Noigroup Publications Adelaide
Clay, J.H. & Pounds, D.M. 2003 Basic Clinical Massage: Integrating Anatomy & Treatment 1st edition, Lippincott Williams & Wilkins, Baltimore MD
Hammer, Warren 1999 Functional Soft-Tissue Examination and Treatment by Manual Methods 2nd edition, Aspen Publications, Gaithersburg MD
Lowe, W. 2004 “Assess and Address: Carpal Tunnel Syndrome” in Massage Magazine, issue 107. Available online: http://www.massagemag.com/Magazine/2004/issue107/assess107.5.php
Magee D.G. 2008 Orthopedic Physical Assessment, 5th Edition, Saunders/Elsevier St Louis Missouri
Maupin, E 2005. A Dynamic Relation To Gravity, Vol 1—The Elements of Structural Integration. Dawn Eve Press
Myers, T.W. 2009 Anatomy Trains, Myofascial Meridians for Manual and Movement Therapists 2nd edition, Churchill Livingstone/Elsevier Edinburgh
Riggs, A 2007 Deep Tissue Massage: A Visual Guide to the Techniques Revised Edition, North Atlantic Books, Berkeley California
Schleip, R. Put more AMPs into your sessions: Advantages & Tips for Active Movement Participation (AMP) of the client during
the hands-on myofascial work sighted 10/9 2009 at www.somatics.de
Smith, J. 2005, Structural Bodywork Churchill Livingstone/Elsevier Edinburgh
Stanborough, M. 2004, Direct Release Myo-Fascial Technique Churchill Livingstone/Elsevier Edinburgh
Stecco, L 2004 Fascial Manipulation for Musculoskeletal Pain Piccin, Padova, Italy
Colin Rossie has over 25 years experience as a bodyworker—initially as a shiatsu practitioner, then as a remedial and sports massage therapist, before becoming a Certified Rolfer® and Rolf® Movement practitioner. His work is firmly grounded in a sound knowledge of anatomy and physiology and Western science. Colin also brings a strong awareness and exploratory approach to kinaesthetics when treating clients. He works mainly from his Lilyfield, Sydney clinic and occasionally in the Tweed Heads/Byron region.
PHOTO DESCRIPTIONS:
Photo 1 - DMFT of the forearm flexors & IOM using the proximal phalanges
Photo 2 - AMP: extending the wrist and fingers from a soft fist
Photo 3 - DMFT w/AMP of the forearm flexors & IOM using re-enforced fingers
Photo 4 - DMFT w/AMP of the forearm flexors & IOM using thumbs of both hands
Photo 5 - DMFT w/AMP of the forearm extensors using the palm
FIGURE DESCIPTIONS:
Figure 1 (©2005 Ed Maupin used with permission)
Figure 2 (©2005 Ed Maupin used with permission)
Figure 3 (©2005 Ed Maupin used with permission)
By Colin Rossie
Description
Carpal Tunnel Syndrome (CTS) is an occupational overuse syndrome of the wrist. The tunnel is formed by the carpal bones on the dorsal aspect and by the transverse carpal ligament (and to a lesser extent the flexor retinaculum) on the volar aspect of the wrist. The tendons of the wrist, finger flexor and thumb muscles pass through this tunnel along with the median nerve. The tendons can become inflamed and swell through overuse, thereby compressing the median nerve.
CTS is a mono-neuropathy in that only a single nerve is affected. Muscles that are affected would include the palmaris longus, flexors carpi radialis and ulnaris, flexors digitorum superficialis and profundus, and flexor pollicis longus.
Many references state that CTS is more prevalent in middle-aged females. This could perhaps be partially attributed to physiological changes occurring around menopause, but could also be the result of long-term keyboard use. In practice, I find the condition presenting in both genders, and across a wide range of ages and occupations. In addition to assembly line workers and keyboard operators, CTS also commonly affects any occupation where power or precision grip is constantly required such as musicians, waiting staff, chefs and drivers.
Initially, symptoms are low level and of insidious onset, starting with numbness and tingling in the thumb (I digit), index (II digit) and middle (III digit) fingers, the radial half of the ring finger (IV digit) and possibly the wrist, gradually becoming chronic.
After several months this becomes an acute pain in the wrist and forearm, described as “burning”, “itching” and “throbbing” by those with it. Clients will also report that their fingers feel swollen and numb, even though there will be no visible swelling. In fact, after prolonged periods the forearm muscles and fingers atrophy. Power and precision grips weaken, fine motor skills diminish and the ability to distinguish temperature variations can become difficult. Symptoms are not relieved by rest and actually worsen with sleep, especially where there is a tendency to clutch the hand and fingers in flexion.
Differential Diagnosis
Differential diagnosis would include medial epicondylitis, neuropathies of the ulnar and radial nerves, cervical radiculopathies, thoracic outlet syndrome, sub-acromial impingement, osteoarthritis of either the carpal bones, metacarpals or distal radius and ulna, and tenosynovitis. Also, active trigger points from the scalenes, infraspinatus, subscapularis, brachialis, supinator, pectoralis major and minor, serratus anterior, pronator teres, palmaris longus, flexors carpi ulnaris and radialis, and digitorum profundus and superficialis, adductor pollicis and opponens pollicis all refer pain in patterns that mimic CTS.
In closed kinetic chains, I believe that myofascial trigger points are tertiary considerations - more a symptom of stability and core dysfunction than a primary factor (essentially, they are a local symptom of a poor global relationship to gravity). However, in open kinetic chains such as the upper limb, trigger points play a more significant role as manifestations of purely local dysfunctions, occupying a more central role in the treatment protocols employed.
Assessment
Pain from the median nerve can originate anywhere along the length of the nerve, not just the carpal tunnel. Although symptoms may appear the same between individuals, the cause may be completely different. True CTS is over diagnosed, being a convenient catch-all for any wrist pain or pain of median nerve origin. Therefore accurate assessment is vital before commencing treatment.
What follows are assessment protocols I use and a brief rationale for their use. This is followed by a description of some treatment approaches, which would vary according to the specific findings of the assessment. Fuller descriptions of the tests can be found in the references provided. Kerry Hage has already described Tinel’s Sign and Phalen’s test in her contribution earlier in this article:
• Active Quick Test of the median nerve to determine that it is the median nerve involved (Butler, 2008, p34).
• Tinel’s Sign to determine median nerve involvement at the carpal tunnel (Magee, p441).
• Phalen’s Test (Magee, p442) to determine carpal tunnel involvement.
• Upper Limb Neurodynamic Test 1 (median nerve), another test to determine median nerve involvement (Butler, 2008, p35-6 and accompanying DVD).
• Upper Limb Neurodynamic Test 2 (median nerve), again to determine median nerve involvement (Butler, 2008, p37-8 and accompanying DVD).
• Adson’s Manoeuvre or Halstead Manoeuvre to determine whether thoracic outlet syndrome is involved in the wrist symptoms (Magee, p322),
• Apley’s Scratch Test to determine if there is gleno-humeral joint involvement (Magee, p254-255).
I would perform the following to rule out involvement of structures other than the median nerve and to determine what structures to work:
• Passive, active and resisted testing of elbow flexion/extension
• Passive, active and resisted testing of forearm supination/pronation
• Passive, active and resisted testing of wrist in flexion/extension, ulnar and radial deviation
• Passive, active and resisted testing of finger flexion/extension, abduction / adduction
Assessment of power and precision grip (Magee, p422) - in addition to determining how these are affected by the CT - is also a good pre- and post-session yardstick for both the client and practitioner.
Treatment
Commence by decreasing the hypertonicity of the myofascial structures of the forearm starting with gentle, myofascial release to the forearm flexors. Follow this with deep transverse frictions to the common flexor tendon, then deep connective tissue massage along the length of the muscles from the distal tendon at the wrist through to the epicondyles, and broadening, transverse compressions across the muscle fibres.
A good series of techniques similar to the above can be found at:
http://www.massagemag.com/Magazine/2004/issue107/assess107.5.php
Another good source of techniques that could be employed, along with excellent illustrations of the anatomy, can be found in Clay & Pounds ‘Basic Clinical Massage Therapy’. The technique illustrated for working with the Flexor Retinaculum is particularly useful. A word of caution though – unfortunately, the photo in the 1st edition of this book looks like the therapist is crushing the nerve. I’m sure this isn’t actually the case! Always keep in mind that your intent isn’t to crush the nerve (which would exacerbate the client’s symptoms) but to
a) free it from the surrounding structures that it might be adhered to
b) lengthen shortened structures that could be impinging it and
c) decrease the swelling of other soft tissue structures within the carpal tunnel that affect the nerve.
Next, deactivate trigger points that may be present in the forearm myofascia and tendons. Kerry Hage has already addressed this aspect in her contribution. If it is a genuine case of Carpal Tunnel Syndrome, there will likely be active TrPs in the shoulder girdle that will need deactivation as well.
Follow TrP deactivation with stretching and a ‘flushing’ effleurage, starting gently but with depth, gradually decreasing the depth and slowing the rate to create a flushing effect on any soft tissue swelling.
I would then use direct myofascial technique with active movement participation (DMFT w/AMP) to the forearm flexors and inter-osseous membrane (IOM) of the forearm.
For more information on this style of work, see Smith (2005), Stanborough (2004), Riggs (2007) and Schleip (www.somatics.de).
Many of the forearm flexor muscle fibres attach directly to the Inter-osseous membrane (IOM)of the forearm (Stecco 2004); working it can have a profound effect on CTS symptoms.
Have the client supine and their hand and forearm supinated, have them form a soft fist and flex the wrist. as you apply pressure to the appropriate depth at the wrist and move slowly up the forearm toward the common flexor tendon. At the same time, ask the client to slowly bring the wrist into extension, gradually opening the fingers so that at maximum wrist extension the fingers are fully extending as well (see photos 1-3). Work up the arm like this several times, paying attention to the feel of the tissue being worked. Also pay attention to the different slips of muscle/fascia you contact, always seeking to differentiate the tissue (see photo 4). To work in a second plane, have the client vary their movement by medially and laterally deviating their wrist. As the radius and ulna move you will affect the IOM, especially if you focus your intent on it.
Other techniques I might incorporate into a session for CTS could include:
• DMFT w/AMP to the forearm extensors, client supine, arm beside the torso again with the intention of affecting the IOM (see photo 5), this time from the dorsal side (client supine, forearm pronated). Ask for medial and lateral deviation of the wrist as you work the forearm (figure 1).
Again, to get a second plane of movement, request the client to slowly lift their hand up and down (extend and flex the wrist –figure 2). Alternatively, ask them to gradually press their palm into the table and slowly release it as you work on it.
Another variation would be to have the client anchor their hand by pressing their palm into the table and then actively move the elbow medially and laterally as you work the forearm distally to proximally (figure 3 – see Maupin, 2005, pp80-81).
• DMFT w/AMP to the palmar fascia. Client's forearm and hand supinated. Apply direct pressure to the client's palm with either your thumb or finger pads, and slowly work up the palm to past the wrist as the client flexes and extends their digits.
• DMFT w/AMP to the flexor retinaculum. With the client’s forearm supinated, I hold the outsides of the client’s hand with both my hands, thumbs on the centre of the flexor retinaculum. I ask the client to extend their wrist at the same time opening (abducting) their fingers as I slowly and deeply drag both thumbs out to the sides.
I may also perform a series of neural mobilisations for the median nerve. These are fully described in Butler (2000) pp314-325, (2008) pp41 -43, and Barral (2007), pp161- 169. They are also demonstrated in the relevant section of the DVD accompanying Butler (2008). These mobilisations can be used as pre- and post- assessment tools or at any stage during the treatment session.
If the client has tested positive to the median nerve tests, the nerve may be impinged at sites other than the carpal tunnel. Neural massage of the median nerve at more proximal locations might be required.
In the upper arm, the median nerve is about the width of a window sash cord and is on the medial aspect of the arm between the biceps brachii and triceps brachii. Here it can be easily palpated and treated for restrictions (Barral, p162 and figure 6.58), also at the ligament of Struthers in the elbow (Barral, p164 and figure 6.59, Hammer, p165), in the forearm (Barral, p165 and figure 6.60), at the wrist (Barral, p165-6 and figure 6.62) and in the hand. The intent of this style of work is to release the nerve from the surrounding structures it could be adhered to. Basically, it is working epineurium. Nerves themselves have the consistency of blancmange and the intent should not be to crush them.
Tom Myers discusses the arm in his ‘Anatomy Trains’ model of the body, according it 6 myofascial meridians. Of special note in terms of working with CTS in his myofascial meridians paradigm would be the Deep Front Arm Line, which roughly corresponds to the lung meridian in Traditional Chinese Medicine (Myers, 2009, pp151-155) and more importantly the Superficial Front Arm Line, which approximates the pericardium meridian in TCM (Myers, 2009, pp155-158). Myers’ model is worth consideration and further study if you are seeing a large number of CTS clients (Myers, 2009, pp 149-169).
Homework
Wearing a wrist splint to bed to prevent wrist and finger flexion during sleep is one option that will help prevent the nocturnal exacerbation of CTS. Stretching the forearm flexors in conjunction helps reduce symptoms and speeds recovery. Butler (2008) shows a series of exercises in both his book (pp 44- 48) and DVD. I play the relevant median nerve self-management section of the DVD to clients, who have found it particularly useful.
CTS shouldn’t be considered from just a local, remedial perspective but in the global context of the whole being. From a structural Integration perspective, this would involve the body’s relationship to its centre of gravity. Previous trauma or unbalanced, repetitive work habits affect this relationship. Poor posture will affect the brachial plexus, thoracic outlet and sub-acromial region. Re-education regarding seated posture, shoulder girdle and upper limb usage (relating these to the body’s centre of gravity) would be essential in this paradigm, as well as modifying the workstation layout to improve its ergonomic efficiency.
Acknowledgments
My sincere thanks to Ed Maupin for generously allowing me to re-print his diagrams from “A Dynamic Relationship to Gravity: Volume 1-The Elements of Structural Integration”. Thanks also to Tania Lambert for her photography.
Bibliography
Barral J.P. 2007 Manual Therapy for the Peripheral Nerves Churchill Livingstone/Elsevier Edinburgh
Butler, David, 2000 The Sensitive Nervous System Noigroup Publications Adelaide
Butler, David 2008 The Neurodynamic Techniques Noigroup Publications Adelaide
Clay, J.H. & Pounds, D.M. 2003 Basic Clinical Massage: Integrating Anatomy & Treatment 1st edition, Lippincott Williams & Wilkins, Baltimore MD
Hammer, Warren 1999 Functional Soft-Tissue Examination and Treatment by Manual Methods 2nd edition, Aspen Publications, Gaithersburg MD
Lowe, W. 2004 “Assess and Address: Carpal Tunnel Syndrome” in Massage Magazine, issue 107. Available online: http://www.massagemag.com/Magazine/2004/issue107/assess107.5.php
Magee D.G. 2008 Orthopedic Physical Assessment, 5th Edition, Saunders/Elsevier St Louis Missouri
Maupin, E 2005. A Dynamic Relation To Gravity, Vol 1—The Elements of Structural Integration. Dawn Eve Press
Myers, T.W. 2009 Anatomy Trains, Myofascial Meridians for Manual and Movement Therapists 2nd edition, Churchill Livingstone/Elsevier Edinburgh
Riggs, A 2007 Deep Tissue Massage: A Visual Guide to the Techniques Revised Edition, North Atlantic Books, Berkeley California
Schleip, R. Put more AMPs into your sessions: Advantages & Tips for Active Movement Participation (AMP) of the client during
the hands-on myofascial work sighted 10/9 2009 at www.somatics.de
Smith, J. 2005, Structural Bodywork Churchill Livingstone/Elsevier Edinburgh
Stanborough, M. 2004, Direct Release Myo-Fascial Technique Churchill Livingstone/Elsevier Edinburgh
Stecco, L 2004 Fascial Manipulation for Musculoskeletal Pain Piccin, Padova, Italy
Colin Rossie has over 25 years experience as a bodyworker—initially as a shiatsu practitioner, then as a remedial and sports massage therapist, before becoming a Certified Rolfer® and Rolf® Movement practitioner. His work is firmly grounded in a sound knowledge of anatomy and physiology and Western science. Colin also brings a strong awareness and exploratory approach to kinaesthetics when treating clients. He works mainly from his Lilyfield, Sydney clinic and occasionally in the Tweed Heads/Byron region.
PHOTO DESCRIPTIONS:
Photo 1 - DMFT of the forearm flexors & IOM using the proximal phalanges
Photo 2 - AMP: extending the wrist and fingers from a soft fist
Photo 3 - DMFT w/AMP of the forearm flexors & IOM using re-enforced fingers
Photo 4 - DMFT w/AMP of the forearm flexors & IOM using thumbs of both hands
Photo 5 - DMFT w/AMP of the forearm extensors using the palm
FIGURE DESCIPTIONS:
Figure 1 (©2005 Ed Maupin used with permission)
Figure 2 (©2005 Ed Maupin used with permission)
Figure 3 (©2005 Ed Maupin used with permission)
Tuesday, July 7, 2009
PSOAS, PIRIFORMIS AND SCIATICA: A Response to the Clinical Perspectives Article on Sciatica from a Structural Integration/ Rolfing® Perspective.
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/
© 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/
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.
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