.
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
Showing posts with label Rolfing®. Show all posts
Showing posts with label Rolfing®. Show all posts
Saturday, March 14, 2009
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.
STRUCTURAL AND MYOFASCIAL CONSIDERATIONS IN CERVICOGENIC PAIN
STRUCTURAL AND MYOFASCIAL CONSIDERATIONS IN CERVICOGENIC PAIN
Notes for the workshop presented at the AMT AGM, April 2008 & again at the AMT Annual Conference, October 2008.
Printed in the AMT Journal "In Good Hands", December 2008
©AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
Cervicogenic pain is pain that has its origin (genesis) in the neck. Soft tissue pain
in this region can be either local or referred, somatic, autonomic, visceral or neural in origin. In addition to local visceral structures, pain can also refer from viscera in the torso. The main considerations of this paper will be somatic pain from soft tissue structures, primarily the myofascia. Aside from direct trauma to the region, such as whiplash, myofascial dysfunction in the cervical region is generally secondary to structural imbalances below the level of the neck.
Many structures and tissues in the neck can be responsible for pain. Autonomic manifestations would include perturbation of the cervical sympathetic ganglia (just anterior to the vertebral bodies) such as could occur as a result of whiplash or prolonged forward head posture, where vertebral instability creates a cluster of symptoms, as in Barré-Lieou Syndrome (for example.) Somatic pain could originate in either bony tissue (such as facet joint referral)or the soft tissue.
STRUCTURAL CONSIDERATIONS
1. Gravity
“Posture is the distribution of body mass in relation to gravity over a base of support. The base of support includes all structures from the feet to the base of the skull.”
(Kuchera and Kuchera, 1997)
The prime structural consideration is our response to gravity. All posture can be viewed as our response to gravity and subsequent orientation to our environment. All life on Earth responds to the gravitational force of the planet: even birth can only occur in the appropriate gravitational field. While no doubt it may be possible to conceive in zero gravity on a space station, it is impossible to give birth out of Earth's gravitational field. NASA experiments using quails on the space station has proven this many times.
Form follows function: optimal alignment in gravity and to 3 dimensional space has resulted in a structure that has evolved to meet the demands of uprightness in gravity with minimal energy expenditure yet maximum efficiency in movement. Humans are fairly unique in the animal kingdom in that as a species we have evolved to stand and operate upright in gravity. This places unique stresses on our bodies. A snake, a quadruped (like the horse or dog) and another possible biped like the kangaroo will all respond to gravity differently from humans. Bears are another biped, but their response to gravity has resulted from different adaptations to the 3 dimensional environment.
To maintain our upright posture we need to be aligned around our centre of gravity (CoG) over 2 bases of support (the feet) and, from that place, move in, relate to and inter-act with the 3-dimensional space around us. While each of us is unique and our postural pattern can vary slightly from one individual to another, we all conform to major, common patterns that are determined by our form as a species and the relentlessness of the force of gravity on this planet operating upon us.
2. Tensegrity
Twentieth century architect, inventor and philosopher R. Buckminster- Fuller coined the term ‘tensegrity’ as a contraction of ‘tensional integrity’. He used the term to encapsulate the concept of a lightweight, integrated structure that gives great stability with the use of minimal material. A tensegrity structure thus maintains a synergy between balanced tension and compression forces. This means that any applied force can be met evenly by the structure, yielding without disturbing its internal equilibrium.
A tensegrity structure comprises two basic components:
• A compressive structure (such as posts, poles, struts or columns).
• A tensile structure (such as cables, wires, ropes, sheets).
There are some notable architectural examples - Centrepoint Tower and the Sydney Harbour Bridge are both tensegrity structures, In fact, any cantilever bridge or an old-fashioned airplane with struts and guy wires is a tensegrity structure. A tent is another basic example.
To be dynamic, animal bodies need to operate effectively in gravity by minimising the effect of their weight. The tensegrity relationship is one part of achieving this. Thus animals embody the characteristic unison of compressed and tensioned parts that defines a tensegrity structure. The skeleton of an animal is compressive, while the soft tissue, myo-fascial / tendinous and ligamentous structures are tensile.
3. The functional anatomy of the spine.
The human spine is a tensegrity structure. It consists of a series of rigid bones (compressive structures) interposed between deformable, fibro-cartilaginous intervertebral discs (tensile structures). The soft tissue muscles, fascia and ligaments connecting the bones are also tensile structures.
The spine has curves anterior (lordoses) or posterior (kyphoses) in the sagittal plane. Where there are kyphoses, there are bony structures such as the ribs and pelvis enclosing and protecting vital organs. There is also less mobility. Where there are lordoses, there are no bony enclosures and greater mobility.
These spinal curves have a definite relationship to our CoG, sometimes passing through it, sometimes behind it, sometimes anterior to it. Together with the tensegrity relationship within the spine, they allow the spine resilience in movement and stance.
The lordotic, cervical spine has the greatest mobility within the vertebral column. All mobility comes at the cost of stability and thus this region has a greater propensity for damage and soft tissue adaption / maladaption.
Functionally, the cervical spine has two divisions: the cranio-cervical (Occiput-C2)and the typical cervical (C3-C7) regions, with the C2/C3 motion segment constituting a transitional functional region.
The cranio-cervical region consists of the atlanto-occipital(C0/C1) and atlanto-axial(C1/C2) articulations, which together account for the greatest amount of saggital and transverse motion of any individual vertebrae in the whol spine. Think of the yes and no motions: the yes motion is saggital movement that occurs at C0/C1, while no is transverse movement occurring at C1/C2, the Atlas (C1) rotating around the peg (dens or odontoid process) of C2.
The C2/C3 articulation is functionally unique and quite important, providing the stable base to "anchor" the head and cervico-cranial region to the rest of the spine. The bony articulations of the superior aspect of C3 (large uncinate processes and large, uniquely inclined superior articlar processes) allows a deep, stable socket for articulation with the inferior aspect of C2. This enhanced stability is required to cope with the many muscles (from both above and below) that converge and articulate at this level, all of which play a role in anchoring the atlas.
C3- C7 for the most part conform functionally to the pattern of the rest of the spine below, apart from the following specifically local adaptations:
-bifid spinous processes that allow more muscular attachment sites, as well as preventing the 'kissing spines' effect in extension and thus allowing a safer, greater range of motion in extension.
- Transverse Processes (TPs) with two bony projections that allow two different muscular attachment sites: theanterior pedicles that projects laterally from the vertebral body and theposterior pedicle that projects laterally from the pedicles. A small strut of bone unites these two pedicles; together all three parts are referred to as the transverse process, though this is quite different structurally to TPs elsewhere in the spine.
- Within the transverse process there is the Transverse Foramen, through which the Vertebral Artery passes. This is clinically significant as a potential hazard in doing work on the cervical spine.
- Other clinically unique features worth considering are the orientation of the facets, which allow a large range of motion, the orientation of the pedicles which allows a large, triangular spinal canal, the uncinate processes, which minimize lateral motion and shear and thus protect the Vertebral Artery, and finally the shapeof the intervertebral foramen and the superior groove on the TP, that facilitates the exit of the spinal nerves in a unique way.
MYOFASCIAL CONSIDERATIONS
The myofascial and connective tissue network can be viewed as a tensegrity arrangement within the body. As mentioned in the above paragraph, it is the most mobile part of the axial skeleton; stability here is provided by appropriate relationships in the soft tissue. Like the mast of a sailing ship, the soft tissue of the shoulder girdle, ribs, lower vertebrae and manubrium that connects with the cervical spine, hyoid, mandible and cranium is like a tensegrity mast.
1. Fascia and connective tissue are highly plastic
Fascia is composed of about 30% collagen, 1% elastin and some reticulin fibres in a matrix of water-loving cells. Collagen is the netting that gives fascia its form - it is stronger than steel fibres of the same size. Fascia encloses every structure in the body and is the substance responsible for the form of the body.
It is also highly innervated with sensory nerves and can respond to neural inputs by contracting, relaxing, remodelling and changing its chemical makeup and ratios. When damaged, collagen frays and reconnects wherever it can. This is the basis of scar formation.
Fascia / connective tissue responds to the stress of chronic postural change by:
1. Thickening
2. Shortening
3. Calcifying
4. Eroding
Like bone, fascia is subject to Wolf’s Law: it changes and remodels in response to the forces placed on it. Muscle fibres can contract and relax, unless in spasm. Fascia, on the other hand, can’t relax as readily and will respond to poor usage by remodelling negatively. This can be quite rapid - it doesn’t take much to change its length. However, this plasticity is also a blessing because it doesn’t take much for it remodel to positively either.
Fascia is throughout what is commonly thought of as muscle. A piece of red meat trimmed of all its connective tissue (the white stuff) is approximately 50-60% muscle fibre and 40-50% fascia.
2. Cervical Fascial Anatomy
Once past the partly adipose superficial fascia, here are 4 major layers of deep fascia in the neck:
1. An outer, extrinsic, layer around the sleeve musculature
2. An Inner, intrinsic, deeper layer around the core musculature
3. A visceral layer around the oesophagus and the thyroid / parathyroids.
4. A meningeal layer around the spinal cord.
The Superficial Cervical Fascia is partly fascia and adipose tissue and is immediately under the dermis. It contains the platysma muscle. After the superficial fascia but before the epimysium of individual muscles lies the deep fascia. There are several layers of deep fascia in the neck:
• Deep Cervical Fascia around the whole neck, with an Investing Layer enclosing interiorly the trapezius and sternocleidomastoid.
• Prevertebral Fascia, superficial to longus colli and scalenes, it continues deep to the Investing Layer to enclose the deep posterior neck muscles.
• A Middle Layer that encloses the infra hyoids anteriorly.
• Visceral fascia that consists of:
a. The Pre Tracheal Fascia enclosing the cervical viscera anteriorly as well as the infra hyoids posteriorly, and
b. Retrovisceral Fascia, enclosing the viscera posteriorly.
The meninges can be viewed as neural fascia enclosing the spinal cord.
Individual muscles are covered with epimysium; perimysium encloses fascicles of muscle fibres and endomysium surrounds individual muscle fibres. These are morphologically no different to fascia. Where the muscle fibs finish, the fascia joins together and continues as the tendon. In other words, fascia is distributed throughout the entire structure.
3. Neuro-Fascial Considerations
As mentioned above, fascia is a heavily innervated material. For example, Golgi Tendon Organs only occur in fascia. As such, they can be found not only in the tendon but also throughout the fascia within the muscle belly. There are proprioceptors, chemoreceptors, mechanoreceptors and thermoreceptors in fascia. Once I would have added nociceptors here as well but recent reading has made me doubt the specific existence of nociceptors - nociception and pain may just be the response to threat or damage, a summation of responses to changes in temperature, ph, chemical environment and pressure. What I will say is that fascial, neural structures are sensory and capable of involvement in pain symptoms.
Proprioceptive feedback alters our cortical response which, in turn, alters our motor patterns … which will then alter structure and biomechanics. If this is prolonged, the fascia responds by changing its internal environment, creating thickenings and adhesions and increasing myofibroblast rather than fibroblast activity, which will further increase the contractile property of fascia.
Sympathetic nervous system activity (fight or flight responses) can shorten fascia. It’s not just prolonged physical overload that creates compromise but also constant low-level, psycho-emotional input: stress from the job/partner/children/bully/tax department/recent injury/that old pain that won’t go away etc. Fear and insecurity can lead to ANS sympathetic involvement as easily as other protective behaviour patterns, be they emotional in origin or physical in origin, such as muscle guarding around immediate physical pain.
Golgi Tendon Organs, Golgi receptors, Pacinian and Ruffini Corpuscles - all present in the fascia – will respond to appropriately to different types of manual therapy and can act to inhibit sympathetic activation of the fascial tonus.
4. Postural and phasic muscles
Structural modification, be it due to poor usage, muscle guarding around pain or sympathetic activation, can lead to an altered relationship to gravity. This can manifest in the muscle fibres as either hypertonicity, hypotonicity or muscle wasting, in the fascia as altered morphology anf tonus. Myofascial structures throughout the body can be divided into tonic or phasic, depending on muscle type and function.
Tonic or postural muscles are the anti-gravity muscles, working constantly to maintain upright stance. Postural muscles are fatigue resistant, Type 1 fibres. In dysfunction these will tend to shorten and can either tighten or weaken.
Phasic muscles are recruited only for specific movements, then rest and restore their energy levels. Phasic muscles are Type 2 fibres, which fatigue easily. Most type II fibres will tend to weaken without shortening in dysfunction
The following list is from Robert Schleip’s website www.somatics.de, a wonderful source of articles on structure and bodywork.
TONIC/ POSTURAL MUSCLES
Hamstrings
Iliopsoas
Rectus femoris
Tensor Fascia Latae
Triceps surae
Pectoralis Major (sternal; clavicular?)
Trapezius (ascending fibres)
Levator Scapulae
Erector Spinae (lumbar and cervical)
(thoracic?)
Quadratus Lumborum
Sartorius
Piriformis
Short Adductors (Magnus and Brevis)
Sternocleidomastoid
B. Brachii (?)
Flexors of hand (?)
Scalenii
PHASIC/ MOBILISER MUSCLES
Tibialis Anterior
Vastus Medialis and Lateralis
Gluteus (Maximus and Minimus)
Rhomboids
Trapezius (ascending and horizontal fibres)
Serratus Anterior
Long adductors
Short hand and foot muscles
Longus Colli and Capitus
Omohyoid (?)
Gluteus Minimus
Pectoralis Major (Costal attachments)
Gluteus Minumus
Triceps Brachii
Scalenii
Note that the scalenes appear in both lists. They are phasic muscles which, if put under the chronic stress of altered posture, become dysfunctional and adapt their fibre type to take on the characteristics of tonic/type 1 fibres.
The following list defines the features of the different fibre types (again from www.somatics.de):
TYPE I MUSCLE FIBRES
• Slow twitch
• Contract slowly
• Low stores of glycogen
• High concentrations of myoglobulin and mitochondria
• Fatigue slowly
• Mainly involved in postural and stabilising tasks
• Tonic or postural muscles
• Stress or dysfunction will lead to shortening
• When short/tight, may test either strong or weak
TYPE II MUSCLE FIBRES
• Fast twitch
• Rapid contraction
• Depending on sub-type, mitochondria and myoglobulin concentrations vary
• Generally fatigue rapidly
• Mainly involved in phasic activity
• Also referred to as phasic or mover muscles
• Stress or dysfunction will lead to weakening over their whole length
• Will always test as weak and without shortening
There are 3 subtypes of Type II muscles fibres:
TYPE IIa FIBRES
• “Fast twitch” or “fast white” fibres
• Contract more rapidly than type 1
• Are moderately resistant to fatigue
• High concentrations of mitochondria and myoglobulin compared to other type II fibres
TYPE IIb FIBRES
• “Fast twitch glycolytic” or “fast white”
• Less fatigue resistant
• Depend more on glycolytic sources of energy
• Low levels of mitochondria and myoglobulin
TYPE IIM FIBRES
• “Super fast” fibres
• Found mainly in the jaw muscles
• Depend on a unique myosin
• High glycogen content
• These last two properties differentiate it from other type II muscle fibres
5. The head as a level platform for the senses
The head is the platform for the senses. Due to the Ocular Righting Reflex, the eyes will always seek to look at a level horizon. This feature means that any damage, shortening or change in habitual pattern that occurs to alter the posture of the body will be allowed and compensated for (by involving other structures in the body) as long as the eyes can look at a level horizon. The vestibular system will accommodate the head in a different, dysfunctional position and alter the sense of balance and proprioception, thus perpetuating the new, dysfunctional pattern.
6. Upper Crossed Syndrome
Vladimir Janda’s ‘Crossed Syndromes’ are worth considering in treating the cervical region, specifically the Upper Crossed Syndrome:
• Hypertonic trapezius and levator scapula posteriorly, hypertonic pectoralis major anteriorly
• Hypotonic anterior deep neck flexors and rhomboids and serratus anterior
An appropriate treatment protocol could be to lengthen the upper trapezius, levator scapulae and pec major, accompanied by strengthening exercises and resisted movement for the anterior cervical musculature and rhomboid/ serratus sling.
7. Forward Head Posture
Forward head posture is a very common presentation, with myofascial compensations that are quite similar to upper crossed syndrome.
In forward head posture, we can expect the following:
• The upper traps and levator scap are shortened. This creates an increased cervical lordosis.
• Activation of the Moro (startle) Reflex- increased ANS activity (fight or flight response) – cervical ganglions involved.
• TMJ involvement- retraction of mandible
• Jaw clenched or mouth open, possibly bruxism (grinding)
• The head will double in weight for every 2.5cm it is forward of the CoG, further increasing the load on the musculature (especially the sub occipitals).
The suboccipitals, which should delicately finetune the head’s position in space as the senses respond to stimuli, instead become postural in function.
The TMJ dysfunction affects the body globally by affecting the vestibular function and balance and thus our position space, leading the posterior neck muscles to further shorten and increase their dysfunctionality.
Conclusion
This article is an expansion from workshop notes; that workshop was primarily practical in content. Consequently, it is far from definitive. I have tended to discuss cervicogenic pain primarily in terms of local phenomena. Nothing, however, occurs in isolation in the body. A more global perspective would take into account that the neck is near the top of a chain that commences with the feet. Any other dysfunction in this chain will manifest sooner or later in the neck.
Viewing neck pain as a purely local phenomenon may mean overlooking the genesis of that pain elsewhere in the body. Trigger point pain is very much a local manifestation of a more global pattern. Many trigger points and acupoints correspond to where nerves pass through the fascia. These are very real to the client and offer fairly immediate pain relief when they are deactivated. But they are only a part of the problem. The trick is to make the client aware of what else is contributing and work to prevent recurrence. The body always seems to recruit strength over stability in dysfunction, whereas as the key to true rehabilitation is almost always enhancing stable function.
By way of a closing example, let’s consider Tom Myers’ ‘Anatomy Trains’ concept of the body. Perhaps we could view the involvement of the myofascial meridian or locomotor sling of the Superficial Back Line. The local manifestation of the global pattern could be neck pain or headache. But there will also be tight plantar fascia, perhaps with collapsed arches, genu recurvatum (knee hyperextension), anterior pelvic tilt, either hypo- or hyper- lordosis and definitely cervical hyperlordosis and forward head posture. Any of these more distal dysfunctions could be causing or contributing to the problem and would need addressing to resolve the cervicogenic pain. Or perhaps it could be an issue of core or pelvic stability; involving different myofascial slings again. Any treatment of a client should involve a comprehensive assessment and plan that considers the possibilities of the whole body presenting before you.
Bibliography
Butler D.S. and Mosley G.L. (2003) "Explain Pain" Noigroup Publications, Adelaide.
Chaitow, Leon (1988) "Soft Tissue Manipulation" Rochester, VT: Healing Arts Press, 26-27.
Chaitow, Leon & DeLany, Judith 2000 Clinical Application of Neuromuscular Techniques, Volume 1, The Upper Body Churchill Livingstone, Edinburgh.
Chaitow, Leon (2002) "Clinical Application of Neuromuscular Techniques, Volume 2, The Lower Body" Edinburgh Churchill Livingstone 21-94.
Kendall, F, McCreary, E and Provance, P (1993) "Muscle Testing and Function" Lippincott Williams and Wilkins, Baltimore.
Kuchera, M. and Kuchera, W. (1997) “General Postural Considerations” in Ward, R. "Foundations for Osteopathic Medicine", Lippincott Williams and Wilkins, Baltimore.
Levangie, P. K. & Norkin, C. M. 2005 Joint Structure & Function 4th Edition, FA Davis Company, Philadelphia PA.
Moseley, G.L. (2007) "Painful Yarns: Metaphors and Stories to Help Understand The Biology of Pain" Dancing Giraffe Press, Canberra.
Myers, Thomas W. (2002) "Anatomy Trains" London, UK: Churchill Livingstone, P.15.
Myers, Thomas W., http://www.anatomytrains.com, sighted 22/11/2008.
Paoletti, Serge (2006) "The Fasciae: Anatomy, Dysfunction and Treatment" Seattle, WA: Eastland Press, 138, 147-149.
Porterfield, J.A. & DeRosa, C. 1995 Mechanical Neck Pain: Perspectives in Functional Anatomy W.B. Saunders Co, Philadelphia PA.
Rolf. Ida P (1977) "Rolfing: Re–establishing the Natural Alignment and Structural Integration of the Human Body" Healing Arts Press, Rochester Vermont.
Schleip, R.; Klingler, W.; Lehmann-Horn, F. (2005) "Active fascial contractility: Fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics" Medical Hypotheses (Elsevier) 65: 273–277..
Schleip, R. (2003) "Fascial plasticity – a new neurobiological explanation: Part 1" Journal of Bodywork and Movement Therapies (Elsevier) 7 (1): 11–19.
Schleip, R. (2003) "Fascial plasticity – a new neurobiological explanation: Part 2" Journal of Bodywork and Movement Therapies (Elsevier) 7 (2): 104–116.
Schleip, R., http://www.somatics.de, sighted 22/11/2008.
.
Simons, D, Travell J, and Simons, P (1999) "Myofascial Pain and Dysfunction: the trigger Point Manual, Vol 1 Upper Half of Body" Lippincott, Williams and Wilkins, Baltimore.
Tomasek, J., Gabbiani, G., Hinz, B., Chaponnier, C., Brown, R. (2002) "Myofibroblasts and Mechanoregulation of Connective Tissue Remodelling" Molecular Cell Biology (Nature Publishing Group) 3: 350–352.
Notes for the workshop presented at the AMT AGM, April 2008 & again at the AMT Annual Conference, October 2008.
Printed in the AMT Journal "In Good Hands", December 2008
©AMT 2008, © Colin Rossie 2008. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
Cervicogenic pain is pain that has its origin (genesis) in the neck. Soft tissue pain
in this region can be either local or referred, somatic, autonomic, visceral or neural in origin. In addition to local visceral structures, pain can also refer from viscera in the torso. The main considerations of this paper will be somatic pain from soft tissue structures, primarily the myofascia. Aside from direct trauma to the region, such as whiplash, myofascial dysfunction in the cervical region is generally secondary to structural imbalances below the level of the neck.
Many structures and tissues in the neck can be responsible for pain. Autonomic manifestations would include perturbation of the cervical sympathetic ganglia (just anterior to the vertebral bodies) such as could occur as a result of whiplash or prolonged forward head posture, where vertebral instability creates a cluster of symptoms, as in Barré-Lieou Syndrome (for example.) Somatic pain could originate in either bony tissue (such as facet joint referral)or the soft tissue.
STRUCTURAL CONSIDERATIONS
1. Gravity
“Posture is the distribution of body mass in relation to gravity over a base of support. The base of support includes all structures from the feet to the base of the skull.”
(Kuchera and Kuchera, 1997)
The prime structural consideration is our response to gravity. All posture can be viewed as our response to gravity and subsequent orientation to our environment. All life on Earth responds to the gravitational force of the planet: even birth can only occur in the appropriate gravitational field. While no doubt it may be possible to conceive in zero gravity on a space station, it is impossible to give birth out of Earth's gravitational field. NASA experiments using quails on the space station has proven this many times.
Form follows function: optimal alignment in gravity and to 3 dimensional space has resulted in a structure that has evolved to meet the demands of uprightness in gravity with minimal energy expenditure yet maximum efficiency in movement. Humans are fairly unique in the animal kingdom in that as a species we have evolved to stand and operate upright in gravity. This places unique stresses on our bodies. A snake, a quadruped (like the horse or dog) and another possible biped like the kangaroo will all respond to gravity differently from humans. Bears are another biped, but their response to gravity has resulted from different adaptations to the 3 dimensional environment.
To maintain our upright posture we need to be aligned around our centre of gravity (CoG) over 2 bases of support (the feet) and, from that place, move in, relate to and inter-act with the 3-dimensional space around us. While each of us is unique and our postural pattern can vary slightly from one individual to another, we all conform to major, common patterns that are determined by our form as a species and the relentlessness of the force of gravity on this planet operating upon us.
2. Tensegrity
Twentieth century architect, inventor and philosopher R. Buckminster- Fuller coined the term ‘tensegrity’ as a contraction of ‘tensional integrity’. He used the term to encapsulate the concept of a lightweight, integrated structure that gives great stability with the use of minimal material. A tensegrity structure thus maintains a synergy between balanced tension and compression forces. This means that any applied force can be met evenly by the structure, yielding without disturbing its internal equilibrium.
A tensegrity structure comprises two basic components:
• A compressive structure (such as posts, poles, struts or columns).
• A tensile structure (such as cables, wires, ropes, sheets).
There are some notable architectural examples - Centrepoint Tower and the Sydney Harbour Bridge are both tensegrity structures, In fact, any cantilever bridge or an old-fashioned airplane with struts and guy wires is a tensegrity structure. A tent is another basic example.
To be dynamic, animal bodies need to operate effectively in gravity by minimising the effect of their weight. The tensegrity relationship is one part of achieving this. Thus animals embody the characteristic unison of compressed and tensioned parts that defines a tensegrity structure. The skeleton of an animal is compressive, while the soft tissue, myo-fascial / tendinous and ligamentous structures are tensile.
3. The functional anatomy of the spine.
The human spine is a tensegrity structure. It consists of a series of rigid bones (compressive structures) interposed between deformable, fibro-cartilaginous intervertebral discs (tensile structures). The soft tissue muscles, fascia and ligaments connecting the bones are also tensile structures.
The spine has curves anterior (lordoses) or posterior (kyphoses) in the sagittal plane. Where there are kyphoses, there are bony structures such as the ribs and pelvis enclosing and protecting vital organs. There is also less mobility. Where there are lordoses, there are no bony enclosures and greater mobility.
These spinal curves have a definite relationship to our CoG, sometimes passing through it, sometimes behind it, sometimes anterior to it. Together with the tensegrity relationship within the spine, they allow the spine resilience in movement and stance.
The lordotic, cervical spine has the greatest mobility within the vertebral column. All mobility comes at the cost of stability and thus this region has a greater propensity for damage and soft tissue adaption / maladaption.
Functionally, the cervical spine has two divisions: the cranio-cervical (Occiput-C2)and the typical cervical (C3-C7) regions, with the C2/C3 motion segment constituting a transitional functional region.
The cranio-cervical region consists of the atlanto-occipital(C0/C1) and atlanto-axial(C1/C2) articulations, which together account for the greatest amount of saggital and transverse motion of any individual vertebrae in the whol spine. Think of the yes and no motions: the yes motion is saggital movement that occurs at C0/C1, while no is transverse movement occurring at C1/C2, the Atlas (C1) rotating around the peg (dens or odontoid process) of C2.
The C2/C3 articulation is functionally unique and quite important, providing the stable base to "anchor" the head and cervico-cranial region to the rest of the spine. The bony articulations of the superior aspect of C3 (large uncinate processes and large, uniquely inclined superior articlar processes) allows a deep, stable socket for articulation with the inferior aspect of C2. This enhanced stability is required to cope with the many muscles (from both above and below) that converge and articulate at this level, all of which play a role in anchoring the atlas.
C3- C7 for the most part conform functionally to the pattern of the rest of the spine below, apart from the following specifically local adaptations:
-bifid spinous processes that allow more muscular attachment sites, as well as preventing the 'kissing spines' effect in extension and thus allowing a safer, greater range of motion in extension.
- Transverse Processes (TPs) with two bony projections that allow two different muscular attachment sites: theanterior pedicles that projects laterally from the vertebral body and theposterior pedicle that projects laterally from the pedicles. A small strut of bone unites these two pedicles; together all three parts are referred to as the transverse process, though this is quite different structurally to TPs elsewhere in the spine.
- Within the transverse process there is the Transverse Foramen, through which the Vertebral Artery passes. This is clinically significant as a potential hazard in doing work on the cervical spine.
- Other clinically unique features worth considering are the orientation of the facets, which allow a large range of motion, the orientation of the pedicles which allows a large, triangular spinal canal, the uncinate processes, which minimize lateral motion and shear and thus protect the Vertebral Artery, and finally the shapeof the intervertebral foramen and the superior groove on the TP, that facilitates the exit of the spinal nerves in a unique way.
MYOFASCIAL CONSIDERATIONS
The myofascial and connective tissue network can be viewed as a tensegrity arrangement within the body. As mentioned in the above paragraph, it is the most mobile part of the axial skeleton; stability here is provided by appropriate relationships in the soft tissue. Like the mast of a sailing ship, the soft tissue of the shoulder girdle, ribs, lower vertebrae and manubrium that connects with the cervical spine, hyoid, mandible and cranium is like a tensegrity mast.
1. Fascia and connective tissue are highly plastic
Fascia is composed of about 30% collagen, 1% elastin and some reticulin fibres in a matrix of water-loving cells. Collagen is the netting that gives fascia its form - it is stronger than steel fibres of the same size. Fascia encloses every structure in the body and is the substance responsible for the form of the body.
It is also highly innervated with sensory nerves and can respond to neural inputs by contracting, relaxing, remodelling and changing its chemical makeup and ratios. When damaged, collagen frays and reconnects wherever it can. This is the basis of scar formation.
Fascia / connective tissue responds to the stress of chronic postural change by:
1. Thickening
2. Shortening
3. Calcifying
4. Eroding
Like bone, fascia is subject to Wolf’s Law: it changes and remodels in response to the forces placed on it. Muscle fibres can contract and relax, unless in spasm. Fascia, on the other hand, can’t relax as readily and will respond to poor usage by remodelling negatively. This can be quite rapid - it doesn’t take much to change its length. However, this plasticity is also a blessing because it doesn’t take much for it remodel to positively either.
Fascia is throughout what is commonly thought of as muscle. A piece of red meat trimmed of all its connective tissue (the white stuff) is approximately 50-60% muscle fibre and 40-50% fascia.
2. Cervical Fascial Anatomy
Once past the partly adipose superficial fascia, here are 4 major layers of deep fascia in the neck:
1. An outer, extrinsic, layer around the sleeve musculature
2. An Inner, intrinsic, deeper layer around the core musculature
3. A visceral layer around the oesophagus and the thyroid / parathyroids.
4. A meningeal layer around the spinal cord.
The Superficial Cervical Fascia is partly fascia and adipose tissue and is immediately under the dermis. It contains the platysma muscle. After the superficial fascia but before the epimysium of individual muscles lies the deep fascia. There are several layers of deep fascia in the neck:
• Deep Cervical Fascia around the whole neck, with an Investing Layer enclosing interiorly the trapezius and sternocleidomastoid.
• Prevertebral Fascia, superficial to longus colli and scalenes, it continues deep to the Investing Layer to enclose the deep posterior neck muscles.
• A Middle Layer that encloses the infra hyoids anteriorly.
• Visceral fascia that consists of:
a. The Pre Tracheal Fascia enclosing the cervical viscera anteriorly as well as the infra hyoids posteriorly, and
b. Retrovisceral Fascia, enclosing the viscera posteriorly.
The meninges can be viewed as neural fascia enclosing the spinal cord.
Individual muscles are covered with epimysium; perimysium encloses fascicles of muscle fibres and endomysium surrounds individual muscle fibres. These are morphologically no different to fascia. Where the muscle fibs finish, the fascia joins together and continues as the tendon. In other words, fascia is distributed throughout the entire structure.
3. Neuro-Fascial Considerations
As mentioned above, fascia is a heavily innervated material. For example, Golgi Tendon Organs only occur in fascia. As such, they can be found not only in the tendon but also throughout the fascia within the muscle belly. There are proprioceptors, chemoreceptors, mechanoreceptors and thermoreceptors in fascia. Once I would have added nociceptors here as well but recent reading has made me doubt the specific existence of nociceptors - nociception and pain may just be the response to threat or damage, a summation of responses to changes in temperature, ph, chemical environment and pressure. What I will say is that fascial, neural structures are sensory and capable of involvement in pain symptoms.
Proprioceptive feedback alters our cortical response which, in turn, alters our motor patterns … which will then alter structure and biomechanics. If this is prolonged, the fascia responds by changing its internal environment, creating thickenings and adhesions and increasing myofibroblast rather than fibroblast activity, which will further increase the contractile property of fascia.
Sympathetic nervous system activity (fight or flight responses) can shorten fascia. It’s not just prolonged physical overload that creates compromise but also constant low-level, psycho-emotional input: stress from the job/partner/children/bully/tax department/recent injury/that old pain that won’t go away etc. Fear and insecurity can lead to ANS sympathetic involvement as easily as other protective behaviour patterns, be they emotional in origin or physical in origin, such as muscle guarding around immediate physical pain.
Golgi Tendon Organs, Golgi receptors, Pacinian and Ruffini Corpuscles - all present in the fascia – will respond to appropriately to different types of manual therapy and can act to inhibit sympathetic activation of the fascial tonus.
4. Postural and phasic muscles
Structural modification, be it due to poor usage, muscle guarding around pain or sympathetic activation, can lead to an altered relationship to gravity. This can manifest in the muscle fibres as either hypertonicity, hypotonicity or muscle wasting, in the fascia as altered morphology anf tonus. Myofascial structures throughout the body can be divided into tonic or phasic, depending on muscle type and function.
Tonic or postural muscles are the anti-gravity muscles, working constantly to maintain upright stance. Postural muscles are fatigue resistant, Type 1 fibres. In dysfunction these will tend to shorten and can either tighten or weaken.
Phasic muscles are recruited only for specific movements, then rest and restore their energy levels. Phasic muscles are Type 2 fibres, which fatigue easily. Most type II fibres will tend to weaken without shortening in dysfunction
The following list is from Robert Schleip’s website www.somatics.de, a wonderful source of articles on structure and bodywork.
TONIC/ POSTURAL MUSCLES
Hamstrings
Iliopsoas
Rectus femoris
Tensor Fascia Latae
Triceps surae
Pectoralis Major (sternal; clavicular?)
Trapezius (ascending fibres)
Levator Scapulae
Erector Spinae (lumbar and cervical)
(thoracic?)
Quadratus Lumborum
Sartorius
Piriformis
Short Adductors (Magnus and Brevis)
Sternocleidomastoid
B. Brachii (?)
Flexors of hand (?)
Scalenii
PHASIC/ MOBILISER MUSCLES
Tibialis Anterior
Vastus Medialis and Lateralis
Gluteus (Maximus and Minimus)
Rhomboids
Trapezius (ascending and horizontal fibres)
Serratus Anterior
Long adductors
Short hand and foot muscles
Longus Colli and Capitus
Omohyoid (?)
Gluteus Minimus
Pectoralis Major (Costal attachments)
Gluteus Minumus
Triceps Brachii
Scalenii
Note that the scalenes appear in both lists. They are phasic muscles which, if put under the chronic stress of altered posture, become dysfunctional and adapt their fibre type to take on the characteristics of tonic/type 1 fibres.
The following list defines the features of the different fibre types (again from www.somatics.de):
TYPE I MUSCLE FIBRES
• Slow twitch
• Contract slowly
• Low stores of glycogen
• High concentrations of myoglobulin and mitochondria
• Fatigue slowly
• Mainly involved in postural and stabilising tasks
• Tonic or postural muscles
• Stress or dysfunction will lead to shortening
• When short/tight, may test either strong or weak
TYPE II MUSCLE FIBRES
• Fast twitch
• Rapid contraction
• Depending on sub-type, mitochondria and myoglobulin concentrations vary
• Generally fatigue rapidly
• Mainly involved in phasic activity
• Also referred to as phasic or mover muscles
• Stress or dysfunction will lead to weakening over their whole length
• Will always test as weak and without shortening
There are 3 subtypes of Type II muscles fibres:
TYPE IIa FIBRES
• “Fast twitch” or “fast white” fibres
• Contract more rapidly than type 1
• Are moderately resistant to fatigue
• High concentrations of mitochondria and myoglobulin compared to other type II fibres
TYPE IIb FIBRES
• “Fast twitch glycolytic” or “fast white”
• Less fatigue resistant
• Depend more on glycolytic sources of energy
• Low levels of mitochondria and myoglobulin
TYPE IIM FIBRES
• “Super fast” fibres
• Found mainly in the jaw muscles
• Depend on a unique myosin
• High glycogen content
• These last two properties differentiate it from other type II muscle fibres
5. The head as a level platform for the senses
The head is the platform for the senses. Due to the Ocular Righting Reflex, the eyes will always seek to look at a level horizon. This feature means that any damage, shortening or change in habitual pattern that occurs to alter the posture of the body will be allowed and compensated for (by involving other structures in the body) as long as the eyes can look at a level horizon. The vestibular system will accommodate the head in a different, dysfunctional position and alter the sense of balance and proprioception, thus perpetuating the new, dysfunctional pattern.
6. Upper Crossed Syndrome
Vladimir Janda’s ‘Crossed Syndromes’ are worth considering in treating the cervical region, specifically the Upper Crossed Syndrome:
• Hypertonic trapezius and levator scapula posteriorly, hypertonic pectoralis major anteriorly
• Hypotonic anterior deep neck flexors and rhomboids and serratus anterior
An appropriate treatment protocol could be to lengthen the upper trapezius, levator scapulae and pec major, accompanied by strengthening exercises and resisted movement for the anterior cervical musculature and rhomboid/ serratus sling.
7. Forward Head Posture
Forward head posture is a very common presentation, with myofascial compensations that are quite similar to upper crossed syndrome.
In forward head posture, we can expect the following:
• The upper traps and levator scap are shortened. This creates an increased cervical lordosis.
• Activation of the Moro (startle) Reflex- increased ANS activity (fight or flight response) – cervical ganglions involved.
• TMJ involvement- retraction of mandible
• Jaw clenched or mouth open, possibly bruxism (grinding)
• The head will double in weight for every 2.5cm it is forward of the CoG, further increasing the load on the musculature (especially the sub occipitals).
The suboccipitals, which should delicately finetune the head’s position in space as the senses respond to stimuli, instead become postural in function.
The TMJ dysfunction affects the body globally by affecting the vestibular function and balance and thus our position space, leading the posterior neck muscles to further shorten and increase their dysfunctionality.
Conclusion
This article is an expansion from workshop notes; that workshop was primarily practical in content. Consequently, it is far from definitive. I have tended to discuss cervicogenic pain primarily in terms of local phenomena. Nothing, however, occurs in isolation in the body. A more global perspective would take into account that the neck is near the top of a chain that commences with the feet. Any other dysfunction in this chain will manifest sooner or later in the neck.
Viewing neck pain as a purely local phenomenon may mean overlooking the genesis of that pain elsewhere in the body. Trigger point pain is very much a local manifestation of a more global pattern. Many trigger points and acupoints correspond to where nerves pass through the fascia. These are very real to the client and offer fairly immediate pain relief when they are deactivated. But they are only a part of the problem. The trick is to make the client aware of what else is contributing and work to prevent recurrence. The body always seems to recruit strength over stability in dysfunction, whereas as the key to true rehabilitation is almost always enhancing stable function.
By way of a closing example, let’s consider Tom Myers’ ‘Anatomy Trains’ concept of the body. Perhaps we could view the involvement of the myofascial meridian or locomotor sling of the Superficial Back Line. The local manifestation of the global pattern could be neck pain or headache. But there will also be tight plantar fascia, perhaps with collapsed arches, genu recurvatum (knee hyperextension), anterior pelvic tilt, either hypo- or hyper- lordosis and definitely cervical hyperlordosis and forward head posture. Any of these more distal dysfunctions could be causing or contributing to the problem and would need addressing to resolve the cervicogenic pain. Or perhaps it could be an issue of core or pelvic stability; involving different myofascial slings again. Any treatment of a client should involve a comprehensive assessment and plan that considers the possibilities of the whole body presenting before you.
Bibliography
Butler D.S. and Mosley G.L. (2003) "Explain Pain" Noigroup Publications, Adelaide.
Chaitow, Leon (1988) "Soft Tissue Manipulation" Rochester, VT: Healing Arts Press, 26-27.
Chaitow, Leon & DeLany, Judith 2000 Clinical Application of Neuromuscular Techniques, Volume 1, The Upper Body Churchill Livingstone, Edinburgh.
Chaitow, Leon (2002) "Clinical Application of Neuromuscular Techniques, Volume 2, The Lower Body" Edinburgh Churchill Livingstone 21-94.
Kendall, F, McCreary, E and Provance, P (1993) "Muscle Testing and Function" Lippincott Williams and Wilkins, Baltimore.
Kuchera, M. and Kuchera, W. (1997) “General Postural Considerations” in Ward, R. "Foundations for Osteopathic Medicine", Lippincott Williams and Wilkins, Baltimore.
Levangie, P. K. & Norkin, C. M. 2005 Joint Structure & Function 4th Edition, FA Davis Company, Philadelphia PA.
Moseley, G.L. (2007) "Painful Yarns: Metaphors and Stories to Help Understand The Biology of Pain" Dancing Giraffe Press, Canberra.
Myers, Thomas W. (2002) "Anatomy Trains" London, UK: Churchill Livingstone, P.15.
Myers, Thomas W., http://www.anatomytrains.com, sighted 22/11/2008.
Paoletti, Serge (2006) "The Fasciae: Anatomy, Dysfunction and Treatment" Seattle, WA: Eastland Press, 138, 147-149.
Porterfield, J.A. & DeRosa, C. 1995 Mechanical Neck Pain: Perspectives in Functional Anatomy W.B. Saunders Co, Philadelphia PA.
Rolf. Ida P (1977) "Rolfing: Re–establishing the Natural Alignment and Structural Integration of the Human Body" Healing Arts Press, Rochester Vermont.
Schleip, R.; Klingler, W.; Lehmann-Horn, F. (2005) "Active fascial contractility: Fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics" Medical Hypotheses (Elsevier) 65: 273–277..
Schleip, R. (2003) "Fascial plasticity – a new neurobiological explanation: Part 1" Journal of Bodywork and Movement Therapies (Elsevier) 7 (1): 11–19.
Schleip, R. (2003) "Fascial plasticity – a new neurobiological explanation: Part 2" Journal of Bodywork and Movement Therapies (Elsevier) 7 (2): 104–116.
Schleip, R., http://www.somatics.de, sighted 22/11/2008.
.
Simons, D, Travell J, and Simons, P (1999) "Myofascial Pain and Dysfunction: the trigger Point Manual, Vol 1 Upper Half of Body" Lippincott, Williams and Wilkins, Baltimore.
Tomasek, J., Gabbiani, G., Hinz, B., Chaponnier, C., Brown, R. (2002) "Myofibroblasts and Mechanoregulation of Connective Tissue Remodelling" Molecular Cell Biology (Nature Publishing Group) 3: 350–352.
SCOLIOSIS: Perspectives influenced by the Rolfing® Paradigm.
By Colin Rossie.
Certified Rolfer®, Rolf Movement Practitioner.
First published in AMT Journal "In Good Hands", September 2006 & reprinted in ARM newsletter October, 2006. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
Scoliosis, the abnormal lateral curvature of the spine, is a fairly common condition that frequently leads people to seek massage therapy. This can either be directly because of the visual aspect of the curvature (usually a case of aesthetics) or due to mechanical complications resulting from it.
Scoliosis can be either structural or functional. A functional scoliosis is generally acquired as the result of unbalanced usage, whereas a structural scoliosis means that the bony structure has changed. This can often have a congenital origin but can also be the result of prolonged functional changes affecting the structure. Structural scoliosis is statistically the more prevalent of the two; between 70-90% of these are “idiopathic”, so termed because the cause is unknown. Its highest prevalence is among teenage girls. Many pathological structural causes can contribute to scoliosis: congenital malformations of the spine (i.e. hemi-vertebra), poliomyelitis, skeletal dysplasias, spastic paralysis, hemi-pelvis and unequal leg length. Inequality of shoulder and hip levels are common symptoms. In addition to the visible curving of the spine there is also a rotational component.
Common wisdom in massage circles is that while functional scoliosis may respond to massage, structural scoliosis won’t. In my clinical experience, many people with structural scoliosis have responded well to the interventions of Rolfing Structural Integration.
Developed by Ida Rolf in the 1930s and 40s and originally called Structural Integration, Rolfing® is a ten-part process that works sequentially on the body to align it in gravity. It consists of deep tissue bodywork on the myo-fascia and gentle joint mobilizations combined with movement education. It is a process in which the client is an active participant. In the words of Rolfer Jeffrey Birch:
“Structural Integration is distinguished from other disciplines by its primary attention to gravity. Other bodywork systems seek tonal balance, energy balance, emotional balance … while Structural Integration attends to all these, its primary goal is to alter the structure of the human body so that instead of fighting gravity, one can use it as an energy source. After a complete series of 10 sessions, clients look taller and more balanced, and report that they not only feel lighter, but also physically uplifted. This lift is due to the client’s new relationship to gravity.”(1)
Its efficacy is well attested, not just by the many people who have received the work but also by many studies and research. Ida Rolf termed one component of the deep tissue bodywork "myo-fascial release". This work is closer to deep connective tissue massage than the gentle myo-fascial release popularised by John Barnes in the last 20 years. The Rolfing-style myofascial release is now often termed Direct Myofascial Technique (2,3) to distinguish it from the gentler Barnes style work. In Australia, this direct style of work has been popularised by Michael Stanborough (4) in his myo-fascial release workshops.
Another component of Rolfing is movement integration, a proprioceptive challenging of habitual and inefficient patterns of body use, which re-educates the client in more appropriate and energy efficient ways of operation. This quite directly affects the client's proprioception and co-ordination. Thus, in addition to considerations of gravity, this strong emphasis on the neurological aspect (5) of bodywork distinguishes Rolfing from many other bodywork modalities. This aspect of Rolfing is particularly useful in working with scoliosis clients.
Standard massage protocol for working with scoliosis (as I was taught in my TAFE training) is to assess the spine visually via the Adam’s Test, then to have the client prone and position their arms and legs to exaggerate the concave and convex curvatures of the spine. One then works cross fibre into the concavity/ies for 3-5 minutes, then reverses the position of the limbs and work the same side/s as before but this time longitudinally (6). This rather unsophisticated protocol can frequently have immediate results with functional scoliosis but achieves next to nothing with structural scoliosis and has very little long term, sustainable effect on a functional scoliosis. An understanding of the functional anatomy and kinematics of the spinal musculature as well as understanding the patho-mechanics of scoliosis can lead to more sophisticated, sustainable results.
Alternatives to the above protocol that enhance the sustainability of bodywork interventions follow:
Have the client seated on the table with their feet actively contacting the floor; work directly on the multifidi and rotatores. These muscles run between an inferior transverse process and a superior spinous process, laterally to medially. The furthest that the spine is laterally from the midline is considered the apex of the curve: apply direct myofascial technique to the multifidi and rotatores fibres superior to the apex on the concave side. Encourage the client’s active movement participation by having them side bend contra-laterally, away from the side you are working. With the same active movement, then work inferior to the apex on the convex side. You can assist their movement by introducing a gentle rotationary component: gently bring the shoulder on the convex side posteriorly as they side bend. Utilizing Muscle Energy Techniques to affect the rotationary component in this protocol can enhance the results.
Another consideration is working between the ribs on the lateral aspect of the torso furthest away from the spine. The ribs that originate from the concavity will be close together at the flank, so that it seems there is no space between them, whereas those on the convex side seem to be a greater distance apart. Have the client side-lying (and appropriately draped) with the ribs of the concave side facing up. Slowly and gently apply pressure to the intercostals between the close together ribs, travelling along the length of these "closed" ribs, not by pushing the tissue but by following any opening created by the client’s respiration. Repeat this several times, gradually allowing your work to become deeper as the client’s altering respiration allows greater opening in the area. The client’s active movement participation is their respiration. While on their side, work the serratus anterior: often on the gibbus (humped) side the scapula “wings” and the serratus anterior is hypertonic.
A frequent side effect of scoliosis is impaired respiration: long-term prognosis is that this will steadily worsen. Asymmetry of tonus is often present in pectoralis minor, the scalenes, serratus posterior superior and inferior as well as the intercostals; as well as being palpable this is usually visually observable. These muscles can be worked unilaterally on the involved side, again with the client’s active movement participation. Encouraging respiratory awareness with full breaths afterwards, as well as encouraging an element of “play” around respiratory possibilities, can enhance the scoliotic client’s breathing pattern and give them a sense of fuller, more balanced respiration.
Psoas is almost always involved in scoliosis and given its origin on the lumbar vertebrae will affect spinal curvature. Asymmetry of the Anterior Superior Iliac Spine and the posterior iliac crest levels are often visible. Psoas is always unilaterally hypertonic in scoliosis, though this often doesn’t correlate with a positive Thomas Test. In addition to releasing the psoas, the quadratus lumborum of the same side should also be released.
In the cervical spine, consider the role the sub occipital muscles play in directing the senses through space: in scoliosis these muscles frequently work in a tonic manner, seeking to hold the head level as compensation, not always immediately obvious, for the lower curves. Rather than being the delicate proprioceptive muscles that fine-tune the direction of the senses, they become hypertonic, trying to fulfill a postural function. They are usually asymmetrically hypertonic, more noticeably on the side where the cranium tilts toward the shoulder. For any scoliosis treatment these important muscles need to be addressed.
The above is a far from exhaustive list; there are many other things that could be added- rhomboid, trapezius and latissimus hypertonicity, pelvis and core work, leg length inequality. Tom Myers’ spiral and functional lines offer further Rolfing perspectives on working with scoliosis (7) - this is only a brief article.
Finally, some other considerations, mainly about the neurological component of scoliosis. Multifidus fibres tend to be more fast-twitch than normal on the concave side of the apex (8). There are delayed (late) responses to stimuli in involved muscles in people with idiopathic scoliosis (20-243 milliseconds versus 5 milliseconds in normal subjects (9)). MRI studies have found abnormalities in the brainstem in a significant number of idiopathic scoliosis patients (10).
A noticeable neurological asymmetry is often present in idiopathic scoliosis. A lack of strength in resistance, especially to rotation, is present (11), and a lack of functional awareness in many parts of the body is present. I’ve heard various names applied to this: “neurological blind-spot”, “somatic amnesia”(12), “kinaesthetic dystonia”(13), and “proprioceptive inaccuracy”(14). In an article by Robert Schleip (15), there is reference to and subsequent lengthy discussion of a Dutch research effort by W. Keesen et al. ”Proprioceptive Accuracy in Idiopathic Scoliosis”(16). This article, complete with references, is available on Robert Schleip’s website: www.somatics.de.(17)
In brief, it discusses an experiment in proprioception among scoliotic subjects and states “a re-arrangement of the internal representation of the body has been proposed in these cases”(18). There is discussion about distortion of body image and body schema, and mentions anorexia as also being a distortion of body image/ body schema. It is about internal body perception: anorexics can’t view themselves, no matter how skinny, as anything other than fat. Similarly, idiopathic scoliosis subjects perceive and accept their body position as straight regardless of how off balance or distorted they are.
Here are two exercises I do with idiopathic scoliosis clients that are attempts to re-kindle proprioceptive awareness. The first is very simple: with the client seated, stand behind them with your hands either side of the spine. Get them to gently press their feet into the floor, asking them to observe what is and isn’t activating para-vertebrally (locating their proprioceptive blind spots). Then encourage them to activate the side that fires less, using your hands as reference. You can do the same thing with them standing, walking or rolling their spine forward and back (active flexion and extension).
The second is based on the experiment in the Keeson article: with my client seated and their eyes closed, have them raise their arms (to 90 degrees) and bring their pointed index fingers together. Generally they miss wildly. Then supportively hold their proprioceptive blind-spot/s on their back and repeat the exercise. Usually their index fingers touch first time. The purpose of both exercises is to give the client a sense of support where they can’t perceive it, and thus improved function.
I hope that some of the ideas and protocols discussed in this article can be useful in your future work with scoliosis clients.
1. Birch, J. “S.I.: Finding Balance” Massage & Bodywork April/ May 2001, p.22.
2. Stanborough, M. “Direct Myofascial Technique” Churchill Livingstone, 2004.
3. Smith, J. “Structural Bodywork” Churchill Livingstone, 2005.
4. For more information see: www.myo-fascial.com.au
5. Schleip, R. “Explorations of the Neuro-myofascial Net”, Journal of Bodywork and Movement Therapies 7(1), pp.11-17, 2003
6. Glazer, D.”TAFE Remedial Massage\Tspine- general treatment.doc” class notes, no date
7. Myers, T. “Anatomy Trains” Churchill Livingstone, 2001.
8. Schleip, R. “Scoliosis and Proprioception” Rolf Lines, Vol.xxviii, no.4, Fall 2000. Available on the www.somatics.de website, along with many other good articles on scoliosis.
9. Maguire et al. “Intraoperative Long-latency Reflex Activity in Idiopathic Scoliosis Demonstrates Abnormal Central Processing, a possible cause of idiopathic scoliosis” Spine, vol.18#12,1993, pp1621—26
10. Schleip, op.cit., 2000, p17.
11. Mooney,V. et al, ”Journal of Spinal Disorders” 13(2), pp.102- 107, quoted in Schleip, ibid, pp17-19
12. See Thomas Hanna “Somatics” Da Capo, 1988
13. See Tom Myers “Kinesthetic Dystonia” Journal of Bodywork and Movement Therapy 2(2), 2(3), 2(4), 3(1), 3(2). 1998- 1999
14. See Schleip op.cit 2000. Ortho-bionomy practitioners also refer to it as this.
15. Schleip op.cit 2000, pp.16-20
16. Keesen,W. et al. ”Proprioceptive Accuracy In Idiopathic Scoliosis” Spine 17(2), 1992, pp.149-155.
17. www.somatics.de
18. As reported in Schleip, op.cit., 2000 p.17
© Colin Rossie, August 2006
Certified Rolfer®, Rolf Movement Practitioner.
First published in AMT Journal "In Good Hands", September 2006 & reprinted in ARM newsletter October, 2006. Not to be printed or used without permission of the copyright holders and acknowledgement of original publication.
Scoliosis, the abnormal lateral curvature of the spine, is a fairly common condition that frequently leads people to seek massage therapy. This can either be directly because of the visual aspect of the curvature (usually a case of aesthetics) or due to mechanical complications resulting from it.
Scoliosis can be either structural or functional. A functional scoliosis is generally acquired as the result of unbalanced usage, whereas a structural scoliosis means that the bony structure has changed. This can often have a congenital origin but can also be the result of prolonged functional changes affecting the structure. Structural scoliosis is statistically the more prevalent of the two; between 70-90% of these are “idiopathic”, so termed because the cause is unknown. Its highest prevalence is among teenage girls. Many pathological structural causes can contribute to scoliosis: congenital malformations of the spine (i.e. hemi-vertebra), poliomyelitis, skeletal dysplasias, spastic paralysis, hemi-pelvis and unequal leg length. Inequality of shoulder and hip levels are common symptoms. In addition to the visible curving of the spine there is also a rotational component.
Common wisdom in massage circles is that while functional scoliosis may respond to massage, structural scoliosis won’t. In my clinical experience, many people with structural scoliosis have responded well to the interventions of Rolfing Structural Integration.
Developed by Ida Rolf in the 1930s and 40s and originally called Structural Integration, Rolfing® is a ten-part process that works sequentially on the body to align it in gravity. It consists of deep tissue bodywork on the myo-fascia and gentle joint mobilizations combined with movement education. It is a process in which the client is an active participant. In the words of Rolfer Jeffrey Birch:
“Structural Integration is distinguished from other disciplines by its primary attention to gravity. Other bodywork systems seek tonal balance, energy balance, emotional balance … while Structural Integration attends to all these, its primary goal is to alter the structure of the human body so that instead of fighting gravity, one can use it as an energy source. After a complete series of 10 sessions, clients look taller and more balanced, and report that they not only feel lighter, but also physically uplifted. This lift is due to the client’s new relationship to gravity.”(1)
Its efficacy is well attested, not just by the many people who have received the work but also by many studies and research. Ida Rolf termed one component of the deep tissue bodywork "myo-fascial release". This work is closer to deep connective tissue massage than the gentle myo-fascial release popularised by John Barnes in the last 20 years. The Rolfing-style myofascial release is now often termed Direct Myofascial Technique (2,3) to distinguish it from the gentler Barnes style work. In Australia, this direct style of work has been popularised by Michael Stanborough (4) in his myo-fascial release workshops.
Another component of Rolfing is movement integration, a proprioceptive challenging of habitual and inefficient patterns of body use, which re-educates the client in more appropriate and energy efficient ways of operation. This quite directly affects the client's proprioception and co-ordination. Thus, in addition to considerations of gravity, this strong emphasis on the neurological aspect (5) of bodywork distinguishes Rolfing from many other bodywork modalities. This aspect of Rolfing is particularly useful in working with scoliosis clients.
Standard massage protocol for working with scoliosis (as I was taught in my TAFE training) is to assess the spine visually via the Adam’s Test, then to have the client prone and position their arms and legs to exaggerate the concave and convex curvatures of the spine. One then works cross fibre into the concavity/ies for 3-5 minutes, then reverses the position of the limbs and work the same side/s as before but this time longitudinally (6). This rather unsophisticated protocol can frequently have immediate results with functional scoliosis but achieves next to nothing with structural scoliosis and has very little long term, sustainable effect on a functional scoliosis. An understanding of the functional anatomy and kinematics of the spinal musculature as well as understanding the patho-mechanics of scoliosis can lead to more sophisticated, sustainable results.
Alternatives to the above protocol that enhance the sustainability of bodywork interventions follow:
Have the client seated on the table with their feet actively contacting the floor; work directly on the multifidi and rotatores. These muscles run between an inferior transverse process and a superior spinous process, laterally to medially. The furthest that the spine is laterally from the midline is considered the apex of the curve: apply direct myofascial technique to the multifidi and rotatores fibres superior to the apex on the concave side. Encourage the client’s active movement participation by having them side bend contra-laterally, away from the side you are working. With the same active movement, then work inferior to the apex on the convex side. You can assist their movement by introducing a gentle rotationary component: gently bring the shoulder on the convex side posteriorly as they side bend. Utilizing Muscle Energy Techniques to affect the rotationary component in this protocol can enhance the results.
Another consideration is working between the ribs on the lateral aspect of the torso furthest away from the spine. The ribs that originate from the concavity will be close together at the flank, so that it seems there is no space between them, whereas those on the convex side seem to be a greater distance apart. Have the client side-lying (and appropriately draped) with the ribs of the concave side facing up. Slowly and gently apply pressure to the intercostals between the close together ribs, travelling along the length of these "closed" ribs, not by pushing the tissue but by following any opening created by the client’s respiration. Repeat this several times, gradually allowing your work to become deeper as the client’s altering respiration allows greater opening in the area. The client’s active movement participation is their respiration. While on their side, work the serratus anterior: often on the gibbus (humped) side the scapula “wings” and the serratus anterior is hypertonic.
A frequent side effect of scoliosis is impaired respiration: long-term prognosis is that this will steadily worsen. Asymmetry of tonus is often present in pectoralis minor, the scalenes, serratus posterior superior and inferior as well as the intercostals; as well as being palpable this is usually visually observable. These muscles can be worked unilaterally on the involved side, again with the client’s active movement participation. Encouraging respiratory awareness with full breaths afterwards, as well as encouraging an element of “play” around respiratory possibilities, can enhance the scoliotic client’s breathing pattern and give them a sense of fuller, more balanced respiration.
Psoas is almost always involved in scoliosis and given its origin on the lumbar vertebrae will affect spinal curvature. Asymmetry of the Anterior Superior Iliac Spine and the posterior iliac crest levels are often visible. Psoas is always unilaterally hypertonic in scoliosis, though this often doesn’t correlate with a positive Thomas Test. In addition to releasing the psoas, the quadratus lumborum of the same side should also be released.
In the cervical spine, consider the role the sub occipital muscles play in directing the senses through space: in scoliosis these muscles frequently work in a tonic manner, seeking to hold the head level as compensation, not always immediately obvious, for the lower curves. Rather than being the delicate proprioceptive muscles that fine-tune the direction of the senses, they become hypertonic, trying to fulfill a postural function. They are usually asymmetrically hypertonic, more noticeably on the side where the cranium tilts toward the shoulder. For any scoliosis treatment these important muscles need to be addressed.
The above is a far from exhaustive list; there are many other things that could be added- rhomboid, trapezius and latissimus hypertonicity, pelvis and core work, leg length inequality. Tom Myers’ spiral and functional lines offer further Rolfing perspectives on working with scoliosis (7) - this is only a brief article.
Finally, some other considerations, mainly about the neurological component of scoliosis. Multifidus fibres tend to be more fast-twitch than normal on the concave side of the apex (8). There are delayed (late) responses to stimuli in involved muscles in people with idiopathic scoliosis (20-243 milliseconds versus 5 milliseconds in normal subjects (9)). MRI studies have found abnormalities in the brainstem in a significant number of idiopathic scoliosis patients (10).
A noticeable neurological asymmetry is often present in idiopathic scoliosis. A lack of strength in resistance, especially to rotation, is present (11), and a lack of functional awareness in many parts of the body is present. I’ve heard various names applied to this: “neurological blind-spot”, “somatic amnesia”(12), “kinaesthetic dystonia”(13), and “proprioceptive inaccuracy”(14). In an article by Robert Schleip (15), there is reference to and subsequent lengthy discussion of a Dutch research effort by W. Keesen et al. ”Proprioceptive Accuracy in Idiopathic Scoliosis”(16). This article, complete with references, is available on Robert Schleip’s website: www.somatics.de.(17)
In brief, it discusses an experiment in proprioception among scoliotic subjects and states “a re-arrangement of the internal representation of the body has been proposed in these cases”(18). There is discussion about distortion of body image and body schema, and mentions anorexia as also being a distortion of body image/ body schema. It is about internal body perception: anorexics can’t view themselves, no matter how skinny, as anything other than fat. Similarly, idiopathic scoliosis subjects perceive and accept their body position as straight regardless of how off balance or distorted they are.
Here are two exercises I do with idiopathic scoliosis clients that are attempts to re-kindle proprioceptive awareness. The first is very simple: with the client seated, stand behind them with your hands either side of the spine. Get them to gently press their feet into the floor, asking them to observe what is and isn’t activating para-vertebrally (locating their proprioceptive blind spots). Then encourage them to activate the side that fires less, using your hands as reference. You can do the same thing with them standing, walking or rolling their spine forward and back (active flexion and extension).
The second is based on the experiment in the Keeson article: with my client seated and their eyes closed, have them raise their arms (to 90 degrees) and bring their pointed index fingers together. Generally they miss wildly. Then supportively hold their proprioceptive blind-spot/s on their back and repeat the exercise. Usually their index fingers touch first time. The purpose of both exercises is to give the client a sense of support where they can’t perceive it, and thus improved function.
I hope that some of the ideas and protocols discussed in this article can be useful in your future work with scoliosis clients.
1. Birch, J. “S.I.: Finding Balance” Massage & Bodywork April/ May 2001, p.22.
2. Stanborough, M. “Direct Myofascial Technique” Churchill Livingstone, 2004.
3. Smith, J. “Structural Bodywork” Churchill Livingstone, 2005.
4. For more information see: www.myo-fascial.com.au
5. Schleip, R. “Explorations of the Neuro-myofascial Net”, Journal of Bodywork and Movement Therapies 7(1), pp.11-17, 2003
6. Glazer, D.”TAFE Remedial Massage\Tspine- general treatment.doc” class notes, no date
7. Myers, T. “Anatomy Trains” Churchill Livingstone, 2001.
8. Schleip, R. “Scoliosis and Proprioception” Rolf Lines, Vol.xxviii, no.4, Fall 2000. Available on the www.somatics.de website, along with many other good articles on scoliosis.
9. Maguire et al. “Intraoperative Long-latency Reflex Activity in Idiopathic Scoliosis Demonstrates Abnormal Central Processing, a possible cause of idiopathic scoliosis” Spine, vol.18#12,1993, pp1621—26
10. Schleip, op.cit., 2000, p17.
11. Mooney,V. et al, ”Journal of Spinal Disorders” 13(2), pp.102- 107, quoted in Schleip, ibid, pp17-19
12. See Thomas Hanna “Somatics” Da Capo, 1988
13. See Tom Myers “Kinesthetic Dystonia” Journal of Bodywork and Movement Therapy 2(2), 2(3), 2(4), 3(1), 3(2). 1998- 1999
14. See Schleip op.cit 2000. Ortho-bionomy practitioners also refer to it as this.
15. Schleip op.cit 2000, pp.16-20
16. Keesen,W. et al. ”Proprioceptive Accuracy In Idiopathic Scoliosis” Spine 17(2), 1992, pp.149-155.
17. www.somatics.de
18. As reported in Schleip, op.cit., 2000 p.17
© Colin Rossie, August 2006
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