ATMS Presentation at School of Integrated Body Therapy

Presenting at the School of Integrated Body Therapy Charmhaven, NSW 2002

S.I. Joint Dysfunction Treatment Protocols

Steven Goldstein explores sacroiliac joint dysfunction & low back pain.

We look at how to create a management plan based on this format, what assessment and special tests to form a working diagnosis, and utilize techniques drawn from direct and indirect myofascial release methods IFR/MFR, positional release technique PRT, muscle energy technique MET, mobilization techniques for the lumbar spine, pelvis and hip, trigger point and deep tissue massage.

To find out more about this DVD, please contact Steven Goldstein on +61 0402 068 658 or you can email at info@fascialrelease.com

To purchase DVD please click on link to Complimentary Health Seminars

http://www.comphs.com.au/

Clinical Approaches for Tension Head and Neck Pain

Steven Goldstein will discuss and demonstrate releases that address both a global and local perspectives for the anterior and posterior neck. Assessment includes OA Occipital Atlanto & AA Atlanto-Axial ROM, Special tests for tension headache.

Techniques will specifically address sub-occipital musculature: rectus capitis posterior major & minor, oblique capitis superior & inferior. Releases for the anterior throat region that includes Suprahyoid & Infrahyoid musculature will also be covered.

To find out more about this DVD, please contact Steven Goldstein on +61 0402 068 658 or alternatively you can contact him via email on info@fascialrelease.com

To purchase DVD please click on link to Complimentary Health Seminars

http://www.comphs.com.au/

Assessment and Treatment of Fibromyalgia

Fibromyalgia is a chronic syndrome, characterised by widespread body pain and pain at specific tender points. Patients can also exhibit a range of other symptoms including fatigue, sleep disturbance, muscle soreness and headache.

Join Steven Goldstein (ACNM lecturer) to distinguish how best we can manage clients suffering from this debilitating condition in line with the latest evidence-based research supporting the use of massage.

This DVD is available now, to enquire, please contact Steve Goldstein on +61 0402 068 658 or alternatively you can send an email to enquiry about this DVD here

To purchase DVD please click on link to Complimentary Health Seminars

http://www.comphs.com.au/

AAMT 5th National Conference Hobart

The AAMT 5th National Conference will be held in Hobart May 22 – 24 2009.

On behalf of the Australian Association of Massage Therapists (AAMT), it gives me great pleasure to invite you to
attend our 5th National Conference, held at the Wrest Point Convention Centre in Hobart Tasmania, 22-24 May 2009.

The theme for 2009 is focusing on core stability, including topics such as structural assessment for and injury due to lack of.

For 2009, the Bowen Therapists Federation of Australia is participating in collaboration with AAMT to present this
event to their membership, which reflects positively on our conference program by increasing the number of
opportunities for delegates to participate in afternoon breakout sessions.

Importantly, I would like to thank those who attended our 2008 national conference in Adelaide and took time to fill
out session feedback forms and rated the overall success of the conference. Once again, we have created a streamed
program, which will result in every delegate having an opportunity to be involved in a hands-on workshop on one of
the afternoons. Needless to say, workshop allocations are done on a first in first served basis so please register early
to avoid disappointment.
With a diversity of interest within the membership comes the challenging task of creating a program that caters
for everyone and I would like to extend my sincere thanks to this year’s Conference Committee and Chief Executive
Officer, Tricia Hughes for the discussion and program input which began soon after our Adelaide conference.
As with all past AAMT conferences, the Gala Dinner ticket is included and I strongly encourage you to attend this
important event, which includes a 3-course dinner and beverages. It is also the time to let your hair down and have
fun with like-minded people in our industry. Please note that there is no discount on conference fees for delegates
unable to attend our Gala Dinner, as we negotiate venue costs based on a variety of expenses and catering makes
up a large part of this.
Finally, I’d like to thank our sponsors and trade exhibitors for their generous support and we look forward to seeing
you at our 5th AAMT National Conference in Hobart.

David Sheehan Conference Organizer

To register your interest please visit the AAMT for a registration form: here

Costings and Policies

As of January 1st, 2011, the local Australian price structure for IFR Foundations, Levels or Advanced classes in Australian Dollars are as follows:

Costing Structure

IFR Foundations 3 Day	$625 Melbourne	$695 Interstate
IFR Intermediate 3 Day	$625 Melbourne	$695 Interstate
IFR Advanced 3 Day	$625 Melbourne	$695 Interstate
IFR Intensive 4 Day	$795 Melbourne	$850 Interstate
IFR Levels One thru Four 2 Day Workshop	$450 Melbourne	$495 Interstate
IFR Introductory One Day Workshop	$250 Melbourne	$275 Interstate

Discounts are available based on a guaranteed size of group, student or association affiliation.

This would be negotiated with Steven and the organizers.

In Melbourne

USA Prices differ than Australian prices.

Please Contact Steven for details

Shin Pain

anterior tibia

This was article published for the AAMT Australian Association of Massage Therapists March 2006 Journal.

One of the more perplexing areas of the body for a manual therapist to address is the lower leg, ankle and foot. With enormous potential for stress and dysfunction through the body’s handling of weight bearing and exertional activities, the lower leg compartment is often difficult to treat.

Shin pain is an extremely common complaint among any individuals who are active and athletic. Overuse injuries that cause shin pain such as tibial stress fracture, inflammatory shin splints, or compartment syndromes create clinical situations where you have to determine an accurate differential diagnosis, so that your assessment and the treatment choices are critical to your success. Often these overuse conditions co-exist, making diagnosis difficult.

Shin pain can present itself several ways in your practice. Three common varieties we may encounter for treatment are shin splints or medial tibial stress syndrome, tibial stress fracture and compartment syndrome.

“The pathophysiology of overuse injuries is local inflammatory response to stress. The cause are intrinsic (malalignment syndromes-muscle imbalance) or extrinsic (training error)”1 Management of Common Musculoskeletal Disorders 3rd Ed Hertling & Kessler p 419

From a clinical perspective, shin pain involves one or more of three pathological processes; bone stress, inflammation and raised intracompartmental pressure. 2 Clinical Sports Medicine, Bruker & Khan 2nd ed 2001 Chp 26 Shin Pain p508

1. Bone stress is a continuum of increased bone damage due to strain, stress reaction or fracture.
2. Inflammation develops at insertions of muscles, particularly tibialis posterior and soleus and the fascia to the medial border of the tibia.
3. The lower leg has a number of muscle compartments, each enveloped by a thick inelastic fascia. As a result of overuse and/or inflammation, these compartments may become swollen and painful..

Shin splints are a vague term widely used with a variety of definitions. Tibial Stress Syndrome (Shin Splints) is a common lower leg injury that affects many people involved in running sports. It is synonymous with anterior or medial tibial stress syndromes, tendoperiostitis, tibial periostitis, and tibialis tendinitis, all which denote varying degrees of soft tissue and osseous changes1.

It is an over-use injury and inflammatory condition of the tibia or fibula in which micro tears develop in the muscle’s myotendinous origin located along the bone shaft. The repetitive action of dorsiflexion/plantar flexion pulls the muscle away from its attachment on the bone causing periostitis2.

Shin splints are the name given to pain at the front of the lower leg. The most common cause is inflammation of the periostium of the tibia (sheath surrounding the bone). The injury is an overuse injury and can be caused by running on hard surfaces, running on tiptoes and sports where a lot of jumping is involved. If you over pronate then you are also more susceptible to this injury.

Signs and Symptoms for Shin Splint Pain include:

• Tenderness over the inside of the shin
• Lower leg pain
• Occasional edema or swelling.
• Lumps and bumps over the bone.
• Pain when the toes or foot are bent downwards in plantarflexion, and redness over the inside of the shin
• A gradual onset of pain on the inner lower third of the leg, with increased pain with weight bearing activities (running, jumping, etc.).
• Pain with activity that is usually alleviated with rest
• A “dull ache” that may disappear after a warm-up.

Anterolateral shin pain may occur secondary to heel contact on hard surfaces, or to wearing a shoe with a hard heel, or biomechanical abnormalities such as forefoot varus.

Posteromedial shin splints cause symptoms along the posteromedial border of the middle and lower tibia over the posterior compartment, which is appreciated during toe-off. Research has shown a strong positive correlation between excessive pronation and posterolateral shin splints.

Types of tibial stress syndrome

Medial Tibial Stress Syndrome involves the tibialis posterior muscle and often occurs in individuals who are moderately to severely pronated (collapsed medial arch or flat feet), thus placing tension on this posterior muscle and tendon.

Anterior Tibial Stress Syndrome involves the tibialis anterior muscle. This muscle is responsible for 80% of foot dorsi-flexion and acts as a strong decelerator for plantar flexion. Frequently, anterior shin splints arise in runners over-training on hills since both uphill and downhill running requires repetitive firing of the tibialis anterior muscle.

Symptoms are usually worse while running downhill as the tibialis anterior is responsible for slowing down the forefoot after heel strike (eccentric contraction)5. Consequently, a tight Achilles tendon may be found in this syndrome, resisting proper range for the tibialis anterior to function and leading to friction and inflammation.

It is synonymous with anterior or medial tibial stress syndromes, tendoperiostitis, tibial periostitis, and tibialis tendinitis, all of which denote varying degrees of soft tissue and osseous changes1. It is an over-use injury and inflammatory condition of the tibia or fibula in which micro tears develop in the muscle’s myotendinous origin located along the bone shaft. The repetitive action of dorsiflexion/plantar flexion pulls the muscle away from its attachment on the bone causing periostitis.

MTSS or tibial periositis (shin bone) presents exercise-induced pain localized to the distal posteromedial border of the tibia. Clinical distinction with shin splints is hazy, but MTSS is focal and painful. Pathophysiology is controversial, but is most likely periosteal inflammation at the origin of tibialis posterior or soleus

Medial Tibial Stress Syndrome MTSS is an irritation of the tibia (shin bone) at points where the Soleus and Tibialis Posterior muscles attach to it. It is caused by over-use in runners, with those who run on hard surfaces being particularly affected. However, there are a number of factors, such as altered foot, knee and hip posture, which can predispose a person to the syndrome.

Compartment syndrome is a serious, possible life threatening condition whereby trauma or hemorrhage causes swelling within a muscle compartment. It is defined as ‘an elevation of the interstitial pressure in a closed osseofascial compartment that results in micro vascular compromise’ (Mubarak and Hargens 1983).

The most common site of compartment syndrome is the lower leg (Abramowitz and Schepsis 1994), with the anterior compartment being the most frequently affected, followed by the lateral compartment and the deep posterior compartment.

Compartment syndromes arise when a muscle becomes too big for the sheath that surrounds it causing pain. The large superficial muscle on the outside of the shin is called the tibialis anterior and is surrounded by a sheath. This is called the anterior compartment of the lower leg. Compartment syndromes can be acute or chronic.

Acute anterior compartment syndrome can occur as result of an impact which causes bleeding within the compartment and therefore swelling.

A muscle tear which also causes bleeding or an over use injury which also causes swelling.

Symptoms include:
•    Sharp pain in the muscle on the outside of the lower leg, usually the result of a direct blow.
•    Weakness when trying to pull the foot upwards against resistance (dorsiflexing).
•    Swelling and tenderness over the tibialis anterior muscle and pain when the foot and toes are bent downwards

Tibial Stress Fractures

Stress fractures of the lower limbs account for more than 95% of all stress fractures in athletes. One half occurs in the tibia & fibula and is the result in fatigue failure within the bone, although surrounding muscle may fatigue first.
Increased or differing activity result in altered relationship of bone growth & repair. Wolff’s Law.

Factors that influence the development of stress fractures include:
•    Repetitiveness of activities
•    Muscle forces acting across the bone.  Muscle force or torque may stress the bone if imbalances between antagonistic muscles exist.
•    Gradual Onset 2-3 weeks
•    Patient c/o Pain initially with activity
•    Relieves with rest
•    Next stage pain continues for hours, perhaps thru the night or worse at night suggests bone pain

Clinical exam reveals localized tenderness with or without swelling usually over the site of the fracture

Commonly known as ‘crescendo pain’

Stress fracture pain tends to build up gradually during the act of running, beginning as an annoying irritation and becoming a throbbing torment as an athlete continues to run(1).
There is usually little of the numbness, weakness, and swelling associated with compartment syndrome, and pain is usually not present to a significant degree when the athlete is at rest.

Sometimes, there is a specific point of tenderness in the lower leg, which is often felt on the inside of the calf when deep pressure is applied with the fingers.
Often, the bone will hurt when it is tapped near the damaged area, and occasionally a hard nodule will appear on the surface of the bone at the trouble site.

Clinical Heath History and Presenting Symptoms.

It is important to differentiate between symptoms that are presented to make an accurate assessment.

•    If the patient reports the pain improves after warming up and with continued exercise, then periosteal problems are most likely.

•    If the pain worsens with exercise and is accompanied by a feeling of tightness, then compartment syndrome may be present.  A pain that disappears relatively quickly with rest, and the presence of associated symptoms such as numbness, a ‘dead’ feeling in the leg or pins and needles in the foot indicates compartment syndrome

•    If jumping activities increases the pain, or if there is pain at rest or night ache, a stress fracture must be considered.

Treatment and Techniques:

Traditional Treatment for Anterior Shin Splints

With space available for this article we will address treatment of anterior shin splints. The most common treatment for shin splints is at least one week of rest. Ice packs or a light elastic bandage may also help minimize the pain, along with over-the-counter anti-inflammatory pain pills or creams. Shin splints eventually heal, but returning to a stressful activity too soon can cause them to flare up again quickly. This is why many doctors and coaches suggest a two to four week restriction on running after recovering from shin splints. Low impact cross training on bicycles or treadmills may be allowed, however.

Pain from anterior or medial tibial stress syndrome usually comes about with a delayed onset, often 24 hours after the primary bout of physical activity that initiated the problem. If the offending activities can be avoid, this may often be enough to alleviate the problem. 3(Orthopedic Massage, Theory & Technique, Whitney Lowe, Mosby 2003 p82)

With muscular overuse of this nature, massage and direct myofascial release often are modalities of choice. Anterior compartment tightness, the focus is upon tibialis anterior, (TA) which is a long fusiform shaped muscle, covered by strong fascia.  It gains it’s upper attachment from the deep surface of this strong fascia, and the upper two thirds of the lateral tibial surface and adjoining interosseous membrane and inserts through both the superior & inferior extensor retinacula to the medial side of the medial cuneiform bone and the base of the first metatarsal, the insertion reaching under both bones to blend with that of the peroneus longus. (Anatomy & Human Movement: Structure & Function, Palastanga, Field & Soames, Butterworth-Heinemann, 2000, p352)

Traditional massage approaches utilize longitudinal stripping with awareness of how attachment sites affect musculature tension. The amount of depth, force and pressure to be used is within patient tolerance levels. Often a deep tissue approach is ineffective, either due to pain, over or underpressure or myofascial resting tension that does not allow the tibialis anterior to relax. This is usually when the practitioner changes technique to use active engagement of the patient’s dorsiflexion/plantarflexion as the practitioner longitudinal strips the TA from insertion to origin. This tends to be more effective, but again often does not always lower the existing tension of the muscle.

This is when switching modalities using myofascial release is effective. Because the investment of fascia is three-dimensional running superficial to deep, treating the fascial anchoring sites are quite important. For the TA this includes all the superficial crural fascia and awareness of anterior crural intermuscular septum. The crural fascia anchors along the anteromedial tibia and the entire medial border of the fibula from fibular head to fibular malleolus.

Treatment for the superficial crural fascia can be quite straightforward. Many practitioners use direct myofascial release- MFR.

Michael Stansborough, Direct Release Myofascial Technique, p. 52 uses what he calls an Anterior Compartment Interosseous Membrame technique. 5

Patient: Sidelying with upper hip and knee flexed, support with pillow.

Therapist: Stands at foot of the table.

Contact: Use of an elbow with 90º flexion, begin at fibular malleolus. Glide proximally 2-3 inches at a time between tibia & fibula.  Superficial fascia can be treated more quickly-the interosseous membrame will respond to slow steady contact.  Encourage the client verbally to fully allow the weight of the leg into the table.

John Smith, Structural Bodywork, Elsevier Ltd., 2005, p.156 has a MFR Shin technique. 6

Patient: Supine, no bolster

Therapist: Use of a hand with fingers spread, octopus grip, for broad contact superiorly upper to mid anterior crural fascia. You can work on the flat of the tibia, with fingertips on the margins.  Inferior hand anchors reticulum.

Contact & Action: Ask for slow flexion-extension of the ankle

Treatment and Techniques: An Alternative Approach

Steven Goldstein’s Technique. 16

Borrowing from excellent structural integration practitioners such as Peter Schwind, Thomas Myers, Michael Stansborough & John Smith for direct MFR, I attempt to integrate indirect osteopathic technique such as positional release techniques from Lawrence Jones’ strain-counterstrain, joint play techniques from Andrew Noble, indirect two pointing from Michael Mann.

The key is to engage fascial receptor tonus by first stimulating the sensory receptors in the fascia. You achieve this by superficial (very light contact, minimal pressure) contact of the targeted soft-tissue you wish to change.

Patient: Supine with or without bolster

Therapist: Two pointing (Mann 1989) consists of wrapping both hands in a form-oriented approach. (Schwind 2006). Encircle the joint to relax receptor tonus then proceed with more direct MFR. Photos courtesy of Steven Goldstein Integrative Fascial Release Manual 2006

Contact & Action: Usually encasing the joint with both hands for 1-2 minutes with emphasis on static pressure at the hamstring insertions and gastrocnemius origins will also facilitate a golgi tendon organ response.

Apply to ankle joint in the same manner. Relax indirectly the retinaculum with specific focus on the talus bone.

Contact & Action: As tissue soften, engage the superficial fascia around the ankle and employ a superior shear lightly. Sustain with slight crowding of the talus into the tibia.

Because of the strong investment of fascia at the anterior talocrural joint it is important to assess joint play of the talus bone.

talar joint play

Joint Play for the Mortise. 15

The mortise is made up of the lower tibial condyle, tibial and fibular malleolus, which constitutes the superior aspect of the talus.

The joint play movement we are going to assess and treat is anteroposterior glide

Patient lies with hip, knee and ankle at 90º

Therapist:  grasps the patient’s lower leg around the ankle just above the malleoli with left hand, whilst with right hand grasp the dorsum of the foot, this being the stabilizing hand.

Contact & Action:  The mobilizing left hand then pulls forward and pushes back alternatively

The Subtalar 15

The joint play movement for this is called the rock of the talus on the calcaneus

Patient: sitting on the table with legs hanging over the edge.

Therapist: lateral to foot in crouched position. When applying this kind of joint play the ankle must be in long axis extension.

Contact & Action: Left hand pulls and pushes upwards and downwards while the calcaneus is stabilized producing posterior rock of the talus on the calcaneus.

Joint play as Technique

If you can reproduce this assessment then you can crowd or compress the joints into a closed-pack position, sustain light to moderate compression for 30 to 60 seconds, and usually a softening or release of the fibrous capsular tissue will occur. Mobilize as you crowd the joint and usually you will feel as ‘give’ to the hold and a breaking of adhesion. Reassess proximally and usually there is a considerable softening of the crural fascial sleeve.

References

1.    Hertling & Kessler , Management of Common Musculoskeletal Disorders 3rd Ed p 419

2.    Bruker & Khan, Clinical Sports Medicine, 2nd ed 2001 Chap. 26 Shin Pain p508

3.    Whitney Lowe, Orthopedic Massage, Theory & Technique, Mosby 2003 p82)

4.    Palastanga, Field & Soames, Anatomy & Human Movement: Structure & Function, Butterworth-Heinemann, 2000, p352)

5.    Michael Stansborough, Direct Release Myofascial Technique, p 52

6.    John Smith Structural Bodywork, Elsevier Ltd., 2005, p156 has a MFR Shin technique.

7.    Powerpoint:  Foot & Ankle: Researched and Written by Elizabeth Windham and Chris Watts. 2001

8.    Powerpoint: Greg Loomis ‘Compartment Syndrome’ 2003

9.    Powerpoint : Robin Ploeger, Ankle & Lower Leg Anatomy & Injuries, 1998

10.    PDF Download: Sharon Edwards Acute Compartment Syndrome, Emergency Nurse; 12:3, June 2004

11.    PDF Download: Matt Callison , Abstract: Journal of Chinese Medicine #70 October 2002, Article: Acupuncture & Tibial Stress Syndrome, pp54-57

12.    PDF Download: Richard Baxter, Medial Tibial Stress Syndrome: Shin Splints, 2006

13.    Peter Schwind, Fascial & Membrane Technique, Churchill-Livingstone, English Translation 2006

14.    Leon Chaitow & Judith Walker DeLany, Clinical Application of Neuromuscular Technique, Volume 2,The Lower Body, Chp 14, The Leg & Foot, pp501-507

15.    Andrew Noble: Joint Play: A Course in Synovial Joint Mobilization, Version 2.1, 1991

16.    Steven Goldstein: Integrative Fascial Release Course Manual, 2006

Emotionality

Emotional Release: A Grey Area in Massage

1.   How do we as therapists actually handle emotional releasing?
2.  What are the benefits and problems for the therapist and the client in doing so?
3.   What ethical questions do we need to consider?
4.   Is it appropriate for massage therapists to facilitate release?
5.   If so, what are our guidelines or parameters in doing so?

I have found that as manual soft-tissue specialists we have a great deal of skill in the clinical and technical aspects of massage therapy as befits are training, but have been woefully trained in dealing with the fundamentals of emotional discharge as Micheal Shea describes, “the often colourful displays of feeling, temperament and personality”. We find ourselves on a daily basis in the delivery of our ‘duty of care, the need to have skills that tests our empathy and compassion, and still reside within our scope of practice.

Unless you have a counselling background or are currently training in an advanced course of somatic psychotherapy or transpersonal psychology, or concurrently taking basic counselling classes, the parameters for dealing with a clients emotional upset can be daunting.

I have searched high and low in massage literature for help in navigating what I have always considered a grey area in our professional training.  Granted that many more contemporary massage training programs are recognizing the absolute need to equip students with these essential interpersonal skills, there seems to my mind still to be a huge gap in this training and scarce information in the general domain concerning it.

Clearly much of the skills needed to handle an emotional upset are commonsense like, compassion and empathy, good listening skills and a calm presence can be all that is needed to calm an emotional storm. But their also needs to a context about why the storm is appearing.  And yet we are not meant to be counselling clients, or are we?

Although it is not within the scope of this discussion to cover the many diverse schools of thought that constitute areas that contribute to how emotions constellate in the first place.  I will however attempt to allude to concepts that underpin emotional releasing.

Psychology has within it many substrata that reflect divergent views about how to approach conditions that affect the integrity of the mind and body.  Be it cognitive therapy or body-centred experiential psychotherapy, the concept and idea that the body and mind are one is widely held.  Body Mind has become a catch phrase word to describe the interconnectedness and inter-relatedness of the mind and body.

Stanley Keleman wrote a seminal work in the mid 1980’s that looked at Emotional Anatomy as a form of body mapping. He was an instrumental contributor in the 1960’s somatic psychology movement that evolved out of collaborative efforts at Esalen in Northern California.

Keleman’s underlying premise is their “exists a one to one correspondence between specific locales of pain and specific emotional states or purported physiological malfunctions. ´1

Keleman was fond of a Freudian quote, “that anatomy is destiny”.  “That anatomical process is a deep and powerful wisdom giving rise to internal feeling images. Outer body and inner organ shapes speak to us of cellular motility, as the organization and movement of the psyche and soul.  The feelings these shapes generate are the ground floor of brain programs, (of) consciousness, the way we think and feel.  Feeling is the glue that hold us together, yet they are based on anatomy.” 2.

There is another widely held belief system that the attitudinal and habitual sensory habits along with long held emotional states of consciousness form and determine body shape and tension. And established modalities such as Alexander Technique, Feldenkrais or Thomas Hanna’s Somatics long realized an important connection between sensory habits, posture and emotionality.

Micheal Shea an advanced certified rolfer, craniosacral therapist and Ph.D. in Somatic Psychology wrote a series of essays that constituted his myofascial release textbook.  One such article is on Working with Shock Psychology. Shea’s premise is often stated throughout his literature of how important it is as ‘body workers’ to recognize the huge contribution the autonomic nervous system plays in regulating the organism. Shea states, ‘what is often missing is observing the non-mechanical components of structure”. The way you in which you look at the non mechanical components of structure is by looking at the arousal states in the autonomic nervous system, and in particular how the sympathetic and parasympathetic nervous system discharge in rhythm with each other.  You look at how this ANS goes into flux and how it has balanced itself sympathetic dominance and parasympathetic depression.  You seek to see how the body can handle this charge or arousal.”

Shea believes that instead of observing the ANS we are always tracking the nervous system in any hands-on work that we do. You could facilitate the process through which the ANS contributes to self-healing and self-regulation of the organism.  How you do this is how you pace your work in terms of the level of input to your client.  Pacing means slowing down and taking a break every few minutes.  You cannot keep up constant input to the organism because you will overload the ANS. Most clients arrive already overloaded in their autonomic nervous system.  You can drive trauma deeper-first into the cardiovascular, and then the digestive system.  You may irritate pathology.  Shea believes you should allow two to three cycles of respiration between each application of a technique. Respiration is the glue between physical and emotional responsiveness of the organism. In this way of pacing we avoid re-traumatizing the patient and dissociating them. Shea conviction based on thirty years of experience is that trauma does not come out of the body.  You do not get rid of trauma. Shea believes trauma gets integrated. It gets integrated, organized and renegotiated to a higher or lower level of functioning depending on a number of factors. These factors are usually the environment the client comes from, the constellated aggregate of all the social and emotional experiences a person brings to the table. 3.

“We have a shunting mechanism in our autonomics. The level of input you give to the system reaches a given capacity and then the shunting moves into other systems of the body. We have a hierarchy within our systems, be them myofascial or any other system within the body can handle only so much energy.  Each system takes so much input and then places it somewhere else.  Using from the neuromuscular to the cardiovascular to the alimentary.  This is where stress goes.  Stress response goes into the visceral digestive system.  Then it shunts into the hypothalamus and into endocrine with elevated cortisol or adrenal. There is also a chronic disturbance of thermoregulatory and homeostatic mechanisms.

Emotional release becomes a complex phenomenon.

Although there is scant little information written by massage therapists about emotional releasing I found an article on Emotional Release During Bodywork Sessions by Micheal Santengelo, PhD, in the AMTA USA Massage Therapy Journal of Spring 1995.

His is the prevalent view I was taught when I went through my massage education in the United States in the mid 1980”s.

Santengelo posed a question to open his article, “bartenders, hair dressers and body workers.  What do those groups have in common?  Their clients share unsolicited details of their personal lives with them.  And of the three, body workers engage their clients on a most intimate level, the level of the body.  This contact can lead to revelations and often-traumatic secrets and events.  The responsibility of the client is that this material must be handled in such a way that does not compound the patient’s pain and that we offer a safe environment.

Santengelo contends that the soft-tissue specialist either tries to hard or enters areas for which he or she is not properly trained and prepared, can do more harm than good.

Clearly the concept of “cellular memory” and body memory are topics that engender discussion. We all hold to some degree an assumption that the body stores emotional conflict.  Often the patient is unaware of the connection between a bodily complaint and its emotional component.  So it comes as no surprise when emotional content comes unbidden when we are doing “routine” bodywork.  When this happens, our response can become very important.

There can be appropriate or inappropriate response to this event.  The first inappropriate response is any that carries anxiety or an overly reassuring tone.  Why?

Any discomfort you might feel about what is going on needs to be yours alone. When a patient is in a vulnerable position such as when emotional release is occurring, an accepting and non-judgemental atmosphere is essential.  The patients can construe any anxiety or discomfort you have as disapproval of their own experience.  It can also be seen as a lack of confidence or control.  And believe me when some is in an emotional storm the practitioner needs to hold the space.

The other inappropriate response, is an overly assured “It’s OK”.  The “it’s ok” response can be construed as dismissive as if you are not taking their experience seriously.  Any of these responses can lead the patient to repress the event or experience, feel guilty, or feel the need to care take the practitioner.

Another inappropriate response that may be just as damaging to the patient and is a more subtle and seductive response is the urge to do psychotherapy with the patient.  The urge is to explore the trauma or conflict, to help resolve the issues.  While this is often motivated by good intentions, it is fraught with problems.

For one you might need to ask the following questions.  Am I qualified to do this?  Do I want this responsibility?  Do I want the legal liability?  Whose needs am I serving here?  Shouldn’t we try to help when are help is needed?  Is it in the patient’s best interest for me to take this on?

Psychotherapy is more than just talking back and fort, offering solutions or making psychological interpretations.  It carries heavy responsibility and should not be taken lightly.  Those who have become mental health professionals have trod a long and hard road of training and experience.  Attempting to enter another’s psychological landscape without proper preparation invites trouble both for the manual therapist and the patient.

Nevertheless emotional release in the bodywork session does call for some response.  Santengelo coined his response a “psychological first aid”.

He quotes the AMA, American Medical Association definition of first aid as, “the immediate basic care given to someone who is injured or ill until professional help is available.”  Psychological first aid is exactly the same only in an emotional sense.  The aim is to provide immediate intervention to ease the crisis and get the individual to a qualified professional as soon as possible or reasonable.

Santengelo says, “Many emotional releases will require referral, while some will not.”  He believes any significant life event, such as rape child sexual or physical abuse, or severe guilt, grief, anxiety or depression, should be processed by the patient with a professional who specializes in working with peoples emotional problems.

Any emotional release should be met with caring, support and empathy.  It is important to let the situation run its course within a structure that the massage therapist provides.  He uses statements that are simply, ‘It looks or sounds like your crying.” This gives the patient an opportunity to respond or not.

Communication of caring and empathy through the tone of voice and touch establishes a safe place in which the patient can have the experience.  Do not force verbal interaction. Leave it up to the patient the choice whether to verbalize it or not.

When emotions surface and a client chooses to talk about or process them, be reflective, not interpretive.  Reflection involves extracting emotional content of a person’s statement and phrasing back a response.

Therapist: You sound like your crying

Patient: When you worked my lower back, my mother’s death flashed through my mind.  But that happened 17 years ago.
T: That must have been an upsetting time.
P: It happen so suddenly
T: You were taken by surprise
P: One day she was there, and the next day she was gone…. (Sobs)
T: There seems to be some grief still there.
P: Yes.  (Cries softly and gradually become silent.)

At a time like this resist the urge to pull more from a person.  We do not try to interpret the association between the mother and the lower back, nor is the timing of 17 years queried.

These are simple non-judgmental response.  Straightforward interactions like these can help the patient navigate through the experience.

Always give careful thought to whose needs are being served in the situation of emotional release.  Do not fall prey to the need to handle everything yourself, or to foster dependency in your patient.  No one can be expected to be competent in everything.

Usually calmness and support will be sufficient first aid when confronted with a patient emotional discharge.  However, marked disturbances should be addressed with a suggestion that the patient seek help from a mental health professional.

Santengelo emphatically stated that serious psychological problems are true ailments in themselves, as serious as physical ailments.  Ethical massage practitioners wouldn’t attempt to treat physical ills that they were not trained to treat, and so it must be for emotional problems.  If you have not been specifically trained and supervised in psychotherapy, attempting to resolve a patients problems is a betrayal of trust placed in you by those you work with, and can open you up to legal liability, among other problems.  Santengelo says these are very strong words and meant to be so.

He finishes with points for stimulating discussion:

• Refer whenever you encounter anything out of the ordinary. Don’t assume you can handle every situation alone
• Be reflective when emotions surface.  Spare interpretations and psychobabble
• Take responsibility regarding your patient emotional health seriously.
• You can show that you are caring and concerned by allowing honest ventilation of feelings, and by being present with the patient in their time of need.  It is a mistake to try to solve a patient problem for them.Remain calm when emotional material arises.  Don’t overstep your expertise, but don’t under rate either.  We are important people to our patients, they trust with their bodies as well as their emotions and spirits. This builds a position of trust from which to work from, and their state of mind will be influenced by our reactions to their emotional pain.  If you feel you are facing a true emotional emergency, let the authorities know immediately.
• Don’t diagnose unless you are qualified to do so.
• Be aware of patterns that certain patients display. Especially those who have cathartic experiences in most, but not all session are either practicing they’re acting talents or are seriously disturbed psychologically, or both.  Massage may be contra-indicated until the patient has some context of realization about those patterns.
• Obviously we get a certain amount of our needs met by our practice.  But beware that you wind up serving less noble needs in yourself such as the need to foster dependency or self-aggrandizement at the expense of your patient.  This betrays their trust, even if you are unaware of it.
• Seek consultations and liaisons with other mental health professionals.  You may need support in dealing with problem patients or about getting advice when to refer a patient to another professional.
• Know the differences between what the different mental health profession do and how to refer accordingly.

Get knowledgeable.  Take an introductory course in clinical psychology or basic counselling skills if you’re interested.  This gives you more skills and confidence in how to handle the emotional storms. 4.

I would like to take the rest of time to review an article you have in your hands by the founder of the Hakomi method, Ron Kurtz who has authored an important book called Body-Centred Psychotherapy.

You will see a similarity of information about how to handle emotional release when it spontaneously occurs in a session.  Interestingly enough, Santengelo did not use Kurtz as a reference.

Kurtz believes that whenever we touch a body, as does Micheal Shea, we are reorganizing structure and self-image of the patient.  Kurtz postulates that body and image are intimately connected and both are shaped by experience, and in the process of working with the body, especially deeper tissue work, you will evoke emotionally painful material.  There is no way to avoid it.

Kurtz follows four principles: first acknowledge the emotional issue.  Often a person’s self image is fixated in some way because emotions involved were not acknowledged.  They are buried…if you also do not acknowledge a person’s feelings, if you go on without noticing, without commenting, the silence can mean that they are unimportant, no good or unacceptable.  What happens if feelings are not acknowledged it leaves the patient with the choices of either burying the feelings or attempting to deal with them on their own.  Kurtz believes when people bury feelings, either the body structure drifts back to the position it was before you worked on them or the person compensates in some other way, psychologically or in behaviour.

So often you can make a statement that doesn’t analyse or interpret:  “Your sad”, “you sound like your crying”.  Your goal is to accept and notice what is going on.  Noticing and accepting makes people feel safe.  With safety and acknowledgement, the process can continue.  Kurtz states, “feeling emerge in small ways.  A little wetness around the eyes, a little redness around the nose, a little catches in the voice. These are important indicators that continue to allow acceptance.

Kurtz’s second principle he believes the most important, “Feelings aren’t problems to be solved.” Feelings are just simply to be understood.  Kurtz believes if you try to solve problems, you are going off into the wrong direction, in fact, the same direction in which defence mechanisms tend. That is, the feeling is defended against because it is considered to be a problem and defence is the solution.  Essentially feelings are not accepted, they are handled.  If you get into problem solving, you get caught up in an active role, and lose the capacity to see and hear clearly. Problem solving can block intuitive kind of listening that would allow you to understand the person’s feelings. If you understand, then you can help the patient to understand.  You have to drop any problem-oriented way of thinking when you start working with people’s feelings. Help people process their emotions in such a way that they come to an understanding that is, they come to recognize some meaning in experience.

Kurtz’s third principle is for processing feelings is support spontaneous behaviour.  As Kurtz’s sees it, that’s all you have to do.  You’re just watching.  You notice spontaneous reactions to feelings and you support them.  Kurtz gives an example in his handout.

If someone starts crying on your table, they will either want to role away from you, so the head will start to turn away or they’ll start to manage the flow of feeling by tightening certain muscles.  The shoulders will come forward and up, the diaphragm and abdomen will tighten.  The person may try to close their knees.  All you have to do is to take over and help them do what their doing.  And since your only one person and can only do a few functions, you might for instance, put some towels or a pillow under their shoulders.  Take the effort out of any tightening their getting into, even if it’s defensive.  We’re not working against the defence system, were offering the kind of support they seem to spontaneously need.

The moment a person relaxes the muscles involved in managing the emotional expression, the feelings get more intense.  Kurtz believes that it is in this deeper experience that the meaning of the process can be found.  An example of how the head slumps forward with sadness, this puts the weight of the head on the back muscles and tends to restrict breathing in the upper chest.  As soon as you cradle the head and take it’s weight, the breathing deepens. With this relaxation more feeling comes into consciousness and the sadness is more clearly felt.  All this happens quite naturally.

The fourth and final principle that Kurtz examines is: go for meaning.  It’s not about attempting to get a bucket of tears out the person; it is a matter of how people organize their experience and how they organize the emotional flow of that experience.  Kurtz’s approach is to help the person stay with it long enough to examine where it comes from and what does it mean to them.  Sometimes, but not always, the experience involved something that happen a long time ago, even into childhood, and that something was beyond the understanding of the individual.  It is buried, the adult who could understand, never gets to.  If you never get a glimpse of it, you don’t discover in many ways, it is different from what you believed it was.  The emotional process may involve experiences that happened over and over again to a child, these, in turn, might have led the child to mobilize a particular self-image and to use the muscle system to express and maintain that self-image.  The way to meaning is, first to deep experience and, second, a questioning of that experience.  “What are you saying with your body when you tighten your chest and feel sad?”  Go for questions that ask a mind body interface.  “What does my hand seem to be saying to you?  Go for meaning of felt touch.  Meaning is in feelings and bodily experience.  Your questions aren’t invitations to speculate.  They direct the search for information about present experience. Even if the client doesn’t answer you, they may still realize something.

This concludes my presentation and I would like to open the floor up to discussion.

References

1.      Body mapping and Somatic Pain, Ray Bishop Ph.D. Advanced Certified Rolfer, and Website).
2.      Emotional Anatomy, Keleman, Stanley 1985, Centre Press, Berkeley, Calif, introduction xii.
3.      Working with Shock Psychology, Myofascial Release Textbook, Michael Shea, self published, Shea Educational Group 1995, pp. 77-78
4.      Emotional Release During Bodywork Sessions, Michael Santengelo, Massage Therapy Journal, Spring 1995 Vol. 34 No. 2 pp 83-91
5.      Dealing With Emotions, Ron Kurtz, lecture delivered to European Rolfing Association, Website www.somatics.de

Contra-Indications

Ruminations on Contra Indications

The Manual Therapists Dilemma-Do We Cause Harm?

Introduction:

As I researched for this article I found without surprise, larger issues were at play. Once on the side of regulation for our industry, now I have concern as to the efficacy of this road. What began as a simple article on contraindications turns out to be a journey in understanding the nature of our work and the decisions we are face every day regarding our practice. Steven Goldstein BSHSc MST MusculoSkeletal Therapy, ACNM Australian College of Natural Medicine, Chair National Education Subcommittee, AAMT Australian Association Massage Therapists.

One of the most basic considerations for manual therapist is to understand how and when to proceed with caution or not to treat at all. Our ‘duty of care’ requires that we recognize when a condition or situation presents itself that would make it unsafe for the client to receive our touch. Furthermore our care requires us to ‘do no harm’. And if indeed we proceed with a treatment and did not heed or understand the indications contrary to massage, we open ourselves up to malpractice and personal liability.

Contraindications provide a basic framework for understanding when, and under what circumstances, a particular therapeutic intervention is appropriate for treating the patient/client with minimal risk of injury. Therefore, contraindications serve as a guideline to help us determine if we should institute certain precautions in treatment, withhold treatment altogether, or recommend alternative treatments that would be more appropriate (Batavia 2003).(1)

Therapists understand that by modifying their depth of pressure, selecting techniques that are appropriate to the tissue type and the situation create efficacy in our treatment. We know a thorough case history is necessary, and to implement a treatment plan we must consider the clients medical history to ascertain if treatment is appropriate. Fundamentally we are always asking when can we and when can we not provide treatment. With serious medical conditions, we realize that we are obligated to modify our treatment by the site or area we touch, the position we need to place the client in to achieve desired results or the time frame we can work as in the stages of inflammatory response. And of course we have to know when not to treat a serious medical condition.

Traditionally contraindications have been categorized as total, local or site specific and/or medical. We were taught to pay attention to systemic or skin conditions that exhibited infectious or contagious symptoms, local traumas and injuries that showed the effects of partial tear, avulsions, lesions, fractures, breaks or punctures of soft-tissue structures, to name a few. Most traumas we understand are commonsense wise, and depending on the conventional wisdom of the time, many conditions are considered totally contraindicated.

I, for example, taught in 1986 could never treat acute injuries, or that cancer and pregnancy, erring on the side of safety, were totally contraindicated. By today standards this is not the case.

Problems with the Laundry List Approach:

One thing that can be stated with some certainty regarding contraindications is: ‘a blanket approach with absolutes will work but then we probably wouldn’t treat any of the relative contraindicated conditions’. An excellent resource for understanding how sources differ regarding contraindications is M. Batavia’s article (2003) Contraindications for therapeutic massage: do sources agree?, published in the Journal of Bodywork and Movement Therapies, 8(1), 48-57,

Batavia goes on to say: “Contraindications cited in these sources were classified as relative contraindications, absolute contraindications, precautions, or contraindications and precautions. A relative contraindication is a situation where massage should not be done in certain circumstances, but could be done in other circumstances. It also refers to what type of massage is being performed. For example, one type of massage might be contraindicated for a particular condition, but another type of massage might not be. An absolute contraindication is one where massage should not be done under any circumstances. A precaution is a situation where massage can be performed, but with particular precautions related to the pathology.”(2)

What is interesting about this article is Batavia found when purveying all the various physical therapy, manual therapy and massage texts he found a majority of the sources failed to cite specific references to support the position of the described contraindications and another 76% failed to offer alternative treatment strategies for those conditions that were considered precautions or contraindications. And half the sources he consulted failed to identify that more than 90% of the conditions have a precaution or contraindication associated with them. (3)

So how are we to reconcile this immense discrepancy and how do we as massage educators help students and practitioners navigate this difficult terrain?

Batavia goes on to say:, “While contraindications are a valuable guideline, to often they are misused and misunderstood in our educational programs. Many, if not most, massage therapy training programs are lacking in subject matter directly related to evaluating pain and injury conditions. In that situation contraindications are commonly used as a basic “laundry list” of situations or conditions to avoid when using massage.

The detriment to this approach is that frequently it is not spelled out there is a difference between relative and absolute contraindications. Without that distinction most of these conditions get lumped into absolute contraindications in an effort to err on the side of safety and precaution. While this does help the practitioner keep from providing treatment in a situation where it is not appropriate, it also dramatically limits the effectiveness of clinical work.”(4)

Batavia cites an example that an absolute contraindication is treatment for an inflamed area, when in actually it is a relative contraindication. He believes more clinical research is needed to validate contraindications listed in various sources, and we need to educate the educators, “we need better educational preparation of the faculty and instructors that are teaching from these materials as well. To some degree an absence of listed contraindications can be balanced by adequate knowledge of anatomy and physiology coupled with developed clinical reasoning skills.

Sciatica Approach

Basic Premise.

Integrative Fascial Release functions upon the basic premise, that “all soft-tissue release is based upon how the autonomic nervous system is discharging its impulses” (Michael Shea 1995). Accordingly, from this myofascial perspective, the autonomic nervous system is the primary mechanism that allows for the release of fascia.

Connective Tissue Properties

In addition to the autonomic nervous system premise we add therapeutic methods that affect the sol-gel relationship of the connective tissue ground substance. Utilizing thixotrophic effect (fascia becomes for fluid when it is stirred up, and more solid when it sits without being disturbed (Juhan 1987) & piezoelectric events (changing a mechanical force to electrical energy (Mark Barnes 1997), we have the basis for integrative and interactive change in the physiology and structure of the myofascial connective tissue.

Proprioception, Pain Receptors & the Autonomic Nervous System.

Maintaining the premise of the autonomic nervous system-soft-tissue relationship; then pain is considered an autonomic nervous system phenomenon. Pain triggers the neuromuscular system to maintain a sympathetic response. Shea postulates this as sympathetic tone.

Nociceptors register pain that become sensitised when chronically stimulated, leading to a drop in their threshold (Chaitow-DeLany 2000). With acute or chronic pain, soft-tissue dysfunction maintained by the ANS maintains high sympathetic tone. Once you intervene in the decrease of pain, even marginally, then soft-tissue will respond to manual pressure.

Fascia not only holds nociceptors but a host of other receptors. As excerpted from Clinical Application of Neuromuscular Techniques Volume One, (Chaitow-DeLany, Churchill-Livingston 2000); Bonica (1990) suggests that fascia is critically involved in proprioception, and that, after joint and muscle spindle imput is taken into account, the majority of remaining proprioception occurs in fascial sheaths (Chaitow-Delany 2000).

These receptors hold the key for stimulation of the autonomic nervous system. Once reflexively stimulated by manual pressure engaging superficial fascia, the receptors register within the ANS, thus relaxing and lowering sympathetic tone.

Parasympathetic response creates autonomic phenomenon that is visually discernible by manual engagement of the myofascia. It is in the threshold of parasympathetic that we can use indirect methods of myofascial release to lower pain, and neuromuscular and emotional holding patterns that facilitate soft-tissue response.

Myofascial Releasing Methods.

By employing three broad myofascial methods both directly, as manual pressure and movement, and indirectly, by nervous system response, we can affect soft-tissue dysfunction profoundly. This is the basis for how Integrative Fascial Release treats clinical soft-tissue dysfunction.

Two-pointing Technique with the Treatment of Sciatica.

With regard to treatment of sciatica, we have a variety of sciatic nerve dysfunctions; nerve root compression, disc protrusion and nerve impingement usually by contracted musculature (piriformis syndrome). Depending upon the severity of the symptoms, our first approach is the reduction of pain.

Integrative Fascial Release uses manual pressure engaging superficial fascia in the form of two-pointing. Two-pointing refers to the placement of hands usually beginning within the visceral seat of parasympathetic response, the abdomen and the pelvis.

By placing hands superiorly upon the abdomen and inferiorly on or around the sacrum, along with the engagement of the superficial layer of fascia, the autonomic nervous system responds with various autonomic phenomena to lower sympathetic tone and create a parasympathetic response.

Autonomic Nervous System Response

This response usually takes the form of fasciculation activity (trembling or twitch response), shaking, jerking, skin colour changes, clamminess, laughing, peristalsis (tummy rumbles and gurgles) and glazing or glassiness of the eyes; these are all signs of autonomic discharge. (Shea 1995)

Transverse Fascial Planes

Simultaneously two-pointing the abdomen allows reflexive relaxation to the deeper transverse fascial planes known as diaphragms. Relaxing deeper transverse planes allows for more consistent re-organization of fascial restrictions.

Low Force-Long Duration

Since fascia is continuous and ubiquitous, along with its’ ability to respond to low-force and long duration stretch or compressive force (Leon Page 1950), it has the potential to alter the sol-gel relationship; thus relaxing and changing functional and structure dysfunction along with the reduction of pain.

Preparing the Area Indirectly

This greatly assists with any sciatica dysfunction. Thus preparing an area by the fascial use of two-pointing with upmost consideration given to autonomic phenomena, will allow for more rapid and speedy intervention with regard to a dysfunction like sciatica.

Two-pointing with Leverage Compression.

Two-pointing is just the first in a series of fascial techniques employed to work with sciatic conditions. Essentially determine whether stretch or compressive force technique is desirable, and then used in conjunction with movement techniques (usually passive positional release); one can reflexively relax the whole gluteal structure, thus employing deeper and effective muscular intervention. By considering the myofascial component, one can effectively treat sciatica-like dysfunction usually lowering pain significantly.

Preparing the Area.

After parasympathetic response is achieved, the soft-tissue is ready to be cued and facilitated towards release and movement. This can be achieved by using either ischemic direct pressure, stretch or compressive methods. In IFR we will use compressive methods, if possible, over stretching technique. The visceoelastic-plastic nature of the tissue allows for the reflexive phenomena of unwinding. If one attempts to exaggerate a distortion pattern instead of attempting to elongate or stretch, the nervous system response proprioceptively will be to “let go”, unwind and release. Thus achieving critical collangenous inter-fibre “space”.

Fascia as a Functional Joint.

Fascia is actually considered a “functional joint” (Oschman 1997). It allows for freedom of movement when properly relaxed. Creating space and support is the primary function of the fascia. Once a “slackening” is achieved within the “fascial sleeve”, the ability to facilitate muscular change is increased.

References

1. Jobs Body, a Handbook for Bodywork, Deane Juhan, Hill Press, Inc. NY. 1987 Chapter 3 pp 68-69
2. Myofascial Releasing, John Barnes, P.T. & Rehabilitation Services, Inc. 1990
3. Myofascial Release Textbook, Michael Shea, Ph.D Somatic Psychology, Self-Published, 1995 pp 45-56
4. Readings on the Scientific Basis of Bodywork, Energetic & Movement Therapies, James & Nora Oschman, Self-published Collection, 1997
5. Clinical Application of Neuromuscular Techniques Vol. One, Leon Chaitow & Judith Walker DeLany, Churchill Livingston, 2000, Chapter 3 pp 30-31

Posture Paper Article

Posture Paper for IRMA Institute of Registered Myotherapists

March 2004

I’ve been metaphorically all over the planet with this lecture, I’ve changed my mind literally a hundred times as to what I wish to talk about in this discussion about posture. I realized that there is a vastness to the information concerning the vagaries and varieties of approaches for correcting postural dysfunctions. So where does one begin?

I think one of the first considerations we have when dealing with postural dysfunction is to have an understanding as to why the posture of a particular individual is the way it is and what are factors affecting the individual to create the postural form we’re viewing.

So what I’ve decided to do is to take sort of a peripatetic path so to speak, looking at a variety of approaches that are decidedly alternative to the prevailing paradigm about posture.

So what is the prevailing paradigm of posture? The prevailing paradigm is typically one where we attempt to look at posture according to a vertical plumb line, with any asymmetry considered to be faulty posture and there is an attempt to usually strengthen weak musculature and to adjust and compensate the contracted musculature. We see postural distortion as primarily a muscular imbalance.

As an alternative I will to look at a models that recognize a gravitational approach. These include the views of Ida Rolf, Thomas Myers important Anatomy Trains approach, both, which include another interesting model called Tensegrity, and an authors from the Structural Integration community named Arline Newton, who speaks about Hubert Godard’s model of Tonic Function.

These approaches will take a brief view of how structure and function of the body interact with sensory perception and intrinsic movement regarding conscious and unconscious control of posture.

Ida Rolfs Approach

Ida Rolf (1896-1979) had a decidedly different view of structure and posture.

Rolf states, “…The first question is, what is structure? What is structure in anything? In humans, it is decidedly not posture, although most people seem to think the two words are synonymous. Etymologically speaking, the word posture contains an element of placement. The root of the word is the Latin, ponere, “to place”. The past participle, positum, means, “It has been placed”. Applied to humans, posture implies that something has been placed, or for the most part forced, into a space where properly and structurally it does not belong.”

”Shoulders back, guts in”, is a military adage. It means to force you to do what does not come naturally. The minute you force yourself to maintain a posture of this sort, you betray that all is not well with your world. You show the world that your structure and your posture are at war.

In any plane, physical or non-physical, structure implies relationship. Living bodies are such forceful and intimate expressions of vital energy or the lack thereof that the fact that they are also material manifestations in a three-dimensional world often disappears.

Balance reveals the flow of gravitational energy through the body. Asymmetry and randomness betray lack of support by the gravitational field. All these considerations are inherent in the word structure as it is applied to any three-dimensional system…. In no world can the flow of gravity reinforce imbalanced, asymmetric structure. Since it is segmented, the human unit is more plastic than an inorganic unit, and succumbs more quickly to the unequal torques of everyday life.” 1. (p30 Rolfing) But thanks to the same plasticity, it can be re-patterned.

Rolf viewed the basis of balance in the face of gravitational influence to be best dispersed by the soft-tissue fabric that disperses it-Fascia. Much her life was spent in the pursuit of researching and understanding the role fascia plays in the organization and maintenance of human uprightness.

The gravitational field of the earth is easily the most potent physical influence in any human life. When the human energy field and gravity are at war, needless to say gravity wins out every time. It may be friend and reinforce activity…or it may be foe and drag (a person) to physical destruction. Structure holds the key. 2(p30 Rolf)

Rolf was fond of the metaphor of building blocks. Her example was one of blocks encased in a very thin elastic sack. In this metaphor, the local variations on stretch in the sack serve as a measure of the strain and displacement of the weighted blocks. And when one block shows strain or distortion so will the others in corresponding relationship. It will do so until all blocks are aligned with its neighbour.

Since bodies are designed to contact the earth, of necessity they must stand on their feet and not be attached to the sky. So if you were to lift them by a skyhook and see their more slender straighter beauty, you must put them down again, and then stand them on the earth. Once down again, you would recognize no amount of lift is going to change the built-in structural compensations.

Gravity is with us from the time of our conception to the moment of death. 3(p70)

The inevitable action of gravity anywhere at any time on any soft pliable mass is to bring it nearer to a formless, chaotic, spherical unit. It acts to shorten, thicken and compress.

Flexors Flex-Extensors Extend

Rolf was found of a key concept: Her key to maintaining a balanced body is her concept of ‘when flexors flex, extensors extend.

“ In the conventions of physiology and kinesiology, the basic unit of movement is the paired flexor and extensor. The first member of the pair; which is the flexors, brings the ends of body parts closer together. The second of the pair separates the ends, (extends). A bent body is said to be in flexion; when straightened, it is in extension. Straightened past the vertical line, it is said to be hyper-extended. In as bending body, the flexors have been activated and have ‘flexed’, that is they have shortened and drawn the extremities together? But what of the extensors? When you bend your back, what does it look like? Does it lengthen or shorten? Does it pull into your shoulders? A basic test of body structure is its pattern of flexion. If the body is balanced, not only do the flexors flex, but the extensors simultaneously extend.”

All muscles are covered both individually and as a unit by continuous fascial coverings. In healthy posture this fascial covering has strength and flexibility in the form of deformation and recoil. Elasticity is its quality. “Shortening of a myofascial unit is as important and legitimate a function as lengthening, it is only chronic shortening that causes concern.”

Tensegrity

When we look at this concept of Ida Rolf saying that one of the basic tents for uprightness in the face of gravity is how the body is maintaining it’s balance between flexion and extension, she implies that the myofascial has an enormous structural and functional role to play. This fascia fabric is maintained by tension, and that tension is in relationship. Such a concept of this tensional relationship is the term ‘Tensegrity’, or tension integrity.

Tensegrity, is a term coined by architect/engineer Buckminster Fuller, that represents a system characterized by a discontinuous set of compressional elements (struts) which are held together, uprighted and/or moved by a continuous tensional network (Myers 1999, Oschman 1997).

Fuller, one of the most original thinkers of the 20th century, developed a system of geometry based on tetrahedral (four‑sided) shapes found in nature which maximizes strength while occupying minimal space (maximum stability with a minimum of materials) (Juhan 1987). From these concepts he designed the geodesic dome, including the US Pavilion at Expo ””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””67 in Montreal.

Tensegrity structures actually become stronger when they are stressed as the load applied is distributed not only to the area being directly loaded but also throughout the structure (Barnes 1990).

They employ both compressional and tensional elements. When applying the principles of Tensegrity to the human body, one can readily see the bones and intervertebral discs as the discontinuous compress ional units and the myofascial tissues (muscles, tendons, ligament, fascia and to some degree the discs) as the tensional elements. When load is applied (as in lifting) both the osseous and myofascial tissues distribute the stress incurred.

Of Tensegrity, Deanne Juhan from Jobs Body tells us:

Besides this hydrostatic pressure (which is exerted by every fascial compartment, not iust the outer wrapping), the connective tissue framework ‑ in conjunction with active muscles ‑ provides another kind of tensional force that is crucial to the upright structure of the skeleton.

We are not made up of stacks of building blocks resting securely upon one another, but rather of poles and guy‑wires, whose stability relies not upon flat stacked surfaces, but upon proper angles of the poles and balanced tensions on the wires … There is not a single horizontal surface anywhere in the skeleton that provides a stable base for anything to be stacked upon it.

Our design was not conceived by a stone‑mason, Weight applied to any bone would cause it to slide right off its joints if it were not for the tensional balances that hold it in place and controls its pivoting. Like the beams in a simple Tensegrity structure, our bones act more as spacers than as compress ional members, more weight is actually borne by the connective system of cables than by the bony beams.

Oschman (1997) concurs, adding another element:

Robbie (1977) reaches the remarkable conclusion that the soft tissues around the spine, when under appropriate tension, can actually lift each vertebra off the one below it. He views the spine as a Tensegrity mast.

The various ligaments form slings”””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””” that are capable of supporting the weight of the body without applying compressive forces to the vertebrae and intervertebral discs.

In other words, the vertebral column is not, as it is usually portrayed, a simple stack of blocks, each cushioned by an intervertebral disc.

Thomas Myers Anatomy Trains

Myers continues the same train of thought by using the metaphor of a brick wall for the old paradigm. The thought that the skeleton provides structural support is analogous to how we construct a wall of brick. One brick rest upon another, that rests upon another until you have several layers of interlacing brick. All support the weight above and transmit that weight through to the earth. Since they are subject to tensile forces as well, that is torque; they now are re-enforced with steel rods. The weight of the brick is minimal compared to the force of gravity through the structure.

Myers goes on to say, “The commonly held impression is that the skeleton is a continuous compress ional structure, like the brick wall; that the weight of the head rests on the 7th cervical, the head and thorax rest on the 5th lumbar and so down to the feet, which bears the whole weight of the body and then transmits that weight into the earth. Accordingly the muscles hang from this skeleton and move it around, the way the cables move a crane around. This mechanical model lends itself to the traditional picture of the actions of individual on the bones, the muscle drawing the two insertions closer together to each other and thus affects the skeletal superstructure. Forces in this model are localized. Something wrong locally, will not damage the entire structure. Most manipulative therapy works off this idea. Local treatment for local conditions.”

A Tensegrity structure still combines tension and compress ional members, but the compress ional members are islands, floating in a sea of continuous tension. The compress ional members push outwards against the tensional members that pull inwards. As long as the two sets of forces are balanced, the structure is stable.

The stability of a Tensegrity structure is, however generally less stiff but more resilient that the continuous compress ional structure. Load one corner of a Tensegrity structure and the whole structure will give a little to accommodate the load. Load it too much and the structure will eventually break-but not necessarily anywhere near where the load was placed.”

Thus this model of load in the face of gravity shows more resilience and actually is more stable the more it is loaded.

Using this model when faced with postural dysfunction and distortion, we can see how a localized injury can set into motion long-term strains in other parts of the body. Injury happens where it does because of inherent weakness or previous injury, not purely and always because of local strain. Discovering the pathways of strain and tension that affect the painful portion becomes a natural part of restoring ease and balance to the whole structure.

The skeleton is a continuous compression structure, eliminate the soft-tissue and watch the bones, which are not locked together, but perched on slippery cartilage surfaces, “clatter to the floor.”

If you wish to change the relationship among the bones, change the relationship through the soft-tissue and the bones will rearrange themselves.

So Myers looks at tension bands in a three-dimensional relationship of fascial organization. His fundamental bands follow superficial and deep lines of tension. To reorganize and correct postural distortions in the whole fabric, we can use Myers model to alleviate tension in these bands.

This is how I proceed when attempting to address postural distortions.

With the flexors flex and the extensors extend concept we can see the relevance of Thomas Myers Anatomy Trains.

Anatomy Trains

Two fundamental myofascial tension bands are known in Myers vernacular as the Superficial Back Line and Superficial Front Line. These correspond to the Flexion-Extension model that Ida Rolf is speaking about. It mediates movement around the sagittal plane.

Superficial Back Line SBL

The postural function of the back line SBL is to connect the entire posterior surface of the body from the bottom of the foot to the top of the head in two pieces, toes to knees, and knee to brows. When the knees are extended, as in standing, the SBL functions as one continuous line of integrated myofascial. Myers p61

This postural function demands very heavy bands and sheets of fascia, such as the Achilles tendon, hamstrings and sacrotuberous ligament, thoracolumbar fascia, and as Myers refers to the ’cables of the erector spinae’. The exception is at the knees, where flexion occurs in this line at the popliteal fossa. However once locked, the line assist the cruciate in maintaining postural integrity between the tibia and femur.

The Heel as an Arrow

Myers imagines the lower section of this fascial line as a bowstring, with the heel as an arrow. Seen from a Tensegrity prospective, the calcaneus is a compression strut that pushes the tensile tissues of the SBL out to create proper span from the back of the knees to the toes.

When this line gets chronically over shortened, it is capable of pushing the foot forward into the subtalar joint or bringing the tibia fibula complex posteriorly onto the talus.

Hamstrings and Sacrotuberous Ligament

Any reorganization along the SBL line of tension it will be necessary to assess and release tension to the hamstring attachments and sacrotuberous ligament as a continuation of several myofascial layers that proceeds through the occiput and over the head via the galeaponeurotica.

Myers looks at general movement considerations for the SBL line as general mobility and motility that allows the trunk and hip flexion with the knees extended ( take a bow) and to create trunk hyperextension, knee flexion and plantar flexion. Thus the various types of forward bends are good ways to stretch the line as a whole and note postural hyperextension as hypertonus or shortening of this line.

Superficial Front Line SFL

The postural function of the SFL is to balance the SBL and to provide tensile support from the top to lift those parts of the skeleton that extends forward of the gravity line: pubis, ribcage and face.

The SFL also maintains postural extension of the knee. The muscles and myofascia are what maintains and defends the soft and sensitive parts of the front of the body, especially the viscera.

This is what is called the AP balance or the anterior-posterior balance of the body. The SFL tends to shift down, whilst the SBL tends to shift up.

The overall movement function of this line is to create flexion of the trunk and hips, extension at the knee, and dorsiflexion at the foot.

Because this line needs to create often sudden and powerful flexion movements, it usually has a preponderance of fast twitch fibres. Myers states that the “interplay between the predominantly endurance oriented SBL and the quickly reactive SFL can be seen in the need for contraction in one line when the other is stretched.

Balance Between SBL & SFL

It is obvious to you that there is a dynamic interplay to balance the SBL & SFL, as they transverse the front and the back of the body. It is this interplay that Myers interjects that by how the fascial tension tends to shift down with the SBL we tend to get a “shifting up” with the SFL. This shifting tends to “lock short” the SBL and “lock long” the SFL.

A commonly observed pattern: the hamstrings and the muscles surrounding the sacrum become shortened and bunched, pushing the pelvis forward. The muscles on the front of the hip become tight as they are stretched and strain to contain the forward push.

It is important to make clinical distinctions between muscles that are tense because it is shortened, and a muscle that is tense because it is strained.

Tonic Function-Theory of Hubert Godard

Introduction

Much of what I intend to relate to you is excerpt from articles that can be obtained on the world wide web through the website of two advanced certified rolfers, Arline Newton and Kevin Frank, and also the excellent chapter in Deanne Juhan’s Job’s Body on Muscle As A Sense Organ.

Since I had the pleasure of attending a Body Wisdom Conference held on the Coramandel, North Island of New Zealand in February 2003, I was introduced to these concepts that were presented by Hubert Godard with regards to sensory habits and posture. He called the concepts ‘Tonic Function’. This has led me on a bit of meandering path through a host of informative approaches that constellate the theme of posture.

Kevin Frank’ begins his article with a discussion of Goodards work by considering what are the goals of Structural and Movement Integration. He believed that the stated goals should lead to optimum functioning. From the point of view of an athlete, or dancer or actor; optimal functioning should include being able to quickly adapt to changing needs in movement. It may include being able to jump with apparently no exertion. In performance we evaluate capacity of the performer to execute a move accurately, competently and aesthetically. In daily life, the goals may be more simple, to be free of pain, to move pleasurably and without strain, to recover quickly from exertion. In any of these examples, we as somatic therapists claim that an improvement in function is important and possible.

Frank goes on to state, “ we base improvement of function on certain principles that are not explicitly agreed upon, but generally include the following: minimum rigidity of the body, effectiveness of movement and appropriate strength, subtlety of locomotion (i.e. the kind of movement that is difficult to perceive exactly what muscles are performing the movement), contra-lateral spinal function in walking and free full breathing.”

So tonic function for posture as Frank implies, is the qualities of function that has at its core the capacity for successful fully flexible movement.

Arline Newton approaches Godard’s model of tonic function from another slant. Newton says that one of Ida Rolf’s key insights is that appropriate relationship with gravity is basic to our health as humans. In Newton’s article she looks at the premises through which all movement are based. These premises shape a lens through which we look at movement. These include a sense of the’ two directions’, the role of perception and a Neuro physiological basis for movement. This neurophysiologic base is what Frank and many talk when referring to stretch reflex, muscle spindle and Golgi tendon organs and alpha and gamma motor neurons.

Newton says, “From a structural point of view, the relationship with gravity is commonly described in terms of alignment. From a functional point of view, it is biomechanics of joint motion and the study of the impact of forces upon them.

Both perspectives carry a sort of objectification, a denial of human experience. When we feel pain in a particular area, we don’t immediately experience the muscle fibre contractions, or think of ourselves as a collection of neural impulses. Alignment and mechanics leave out what is happening to the Mind/Body connection.

The approach Newton takes is a called a phenomenological approach, that is the study of conscious and perceptual experience in subjective aspect. For a person who subscribes to this philosophy, one does not exist separately from the environment but is embedded in it.”

Newton spoke of a scientist named Edward Reed who took this perspective in the study of motor response. Reed observed that the study of movement typically takes place in a laboratory, under artificial conditions. Often the approach is to isolate specific movements, or isolate the action of a specific muscle. Reed concluded that movement studied outside of the context in which it occurs leads to very little that can be applied to in a rehabilitation setting.

Tonic Function

Both authors are talking about how function plays an enormous role in regards to posture.

Godard calls the body’s ability to organize itself in gravity “tonic function”.

Tonic function is considered fundamental. It is at the root of every action, even though we may not realize or think of it.

It takes place below the level of conscious awareness.

You are standing and you raise your arm, what is the first muscle to contract? Most will consider it is an arm or shoulder muscle, but the answer is the soleus, a muscle that is key to maintaining up rightness in gravity. Even before the intended movement occurs, the function is ensured.

Arline Newton eloquently states, “Like the air around us, our relationship with gravity is so basic, so fundamental, that we rarely think of it. Yet it underlies-sets the tone for-every one of our actions and behaviours.”

Thus tonic function or an individual’s tonic organization is what we are working with when we look at the body from a functional point of view.

Anatomically tonic function involves the parts of the body-that include the brain, nerve pathways, fascia, muscle spindles, Golgi tendon organs and tonic muscles, that all coordinate the body’s negotiations with gravity.

Uprightness & Gravity

For human beings, being in relationship with gravity, or how we remain upright or oriented, characterizes the human species. Physically we are formed to be upright, and this differentiation from other animals is what makes us unique as human beings. Thus our verticalility is a key to our humanness.

Erwin Strauss in his article on upright posture says, “Men and mice do not have the same environment, even if they share the same room. Environment is not a stage set with scenery as the one and the same for all actors that make their appearance upon it. Each species has its own environment. There is mutual interdependence between species and environment. The surrounding world is determined by the organization of the species in a process of selecting what is relevant to the function cycle of action and reaction. Upright posture pre-establishes a definite attitude toward the world; (as) it is a specific mode of being in the world.”

As humans, our relationship to gravity is so basic and it significantly and uniquely shapes our relationship to our environment.

Strauss pointed out that being upright is more than a simple mechanical problem. For human beings, “Upright posture is not confined to the technical problems of locomotion. It contains a psychological element.”

Thus Newton states, “For humans, being upright is a problem with significance, it has a symbolic dimension. Our language for one is fraught with metaphor, that link verticality with morality. To be upright and upstanding means to be good.

Because upright posture is the leitmotiv in formation of the human species, an individual who has lost or is deprived of the capacity to get up and keep him or her upright depends, for his or her survival, completely on the aid of others. Without their help, they are doomed to die. A biologically oriented psychology must notice that the upright posture is an indispensable condition for self-preservation.

So when we work in movement with a persons orienting system, their relationship with gravity, we are addressing one of the most fundamental aspects of what it means to be human.

Each individual must come to terms with gravity and uprightness.

Physiologically this happens through the development of the ability to control movement. The nerves and muscles that make up the tonic system, that register and respond to our changing relationship with gravity-these are the same pathways that fulfil this basic development function.

This theory is borne from the research of Judith Kestenberg, a psychoanalyst who is also trained in Laban movement. She describes the patterns of movement that develop through infancy. The simplest explanation for changes in muscle tension is the physiological interplay between agonists and antagonists muscle groups. A free flow of tension occurs when antagonists do not meet agonists with counteraction. The in movement, called bound flow of tension, occurs when antagonists contract along the agonist muscles.

Newborn infants toes stiffen periodically in bound flow. His legs fling and bicycle in spurts of free flow. As an influx of emerging free flow may bring his fist near his mouth, and the ensuing bound flow may enable him to hold there for a brief moment.

These, movements form the basis for interaction with the environment.

The shape of the body changes during movement. It grows, it shrinks, as does the simple configuration of the amoeba when it extends its pseudopodia and retracts them. We change are shape by al growing and shrinking when we inhale and exhale. We grow and shrink when we expel waste. We grow toward pleasant stimuli and shrink away form noxious…Growing and shrinking of the body shape are the basic elements of shape flow. They alternate periodically, this rhythmic alternation between growing and shrinking is a hallmark to high degree of self-regulation. It provides a structure for the organism’s interaction with the environment.

Godard suggests that tension flow and shape flow that are the basis of movement patterns are related to tonic function. For a baby learning to move and walk requires the development of the tonic system. Through learning to alternate bound flow from free flow, the baby develops control over movement that usually leads to the ability to stand.

Tonic Function, Communication, Expression & Movement

Newton looked at how Strauss and Kestenberg made the connection recognizing the meaning in movement.

“We learn from movement studies that there is not only a correspondence between specific drives and specific objects, but also a correspondence between certain feeling tones and modes of expressions. For instance, annoyance is expressed appropriately through the narrowing of the brow in frowning, while pleasure recognition broadens the face in smiling. The basic movement patterns and expressions allow a growing independence, which forms the basis for the ability to communicate.

Godard suggests that, “In the body, there is no difference between the gravity system and the expression system. They are inseparable. Whenever we work on tonic function, we inevitably work on expression”

Tonic muscles are postural muscles. These are the muscles primarily involved in maintaining the body’s upright stance.

Tonic muscles are differentiating from phasic muscles, which are the ones we use for large motor movement and short intense activity.

Physiologically there are several different ways to differentiate tonic muscles form phasic muscles. Tonic muscles have more red fibres, phasic have more white. Tonic muscles use oxygen more than sugar for fuel. While phasic are the opposite. Tonic muscles are more densely spindles and have a higher proportion of fascia. By these definitions, some examples of tonic muscles would be the soleus, hamstrings and erector spinae’s.

The large number of spindles in tonic muscles makes them an important sensory tool. The spindles send the sensory information back nervous system. The brain uses this information to set the tone of other muscles.

For phasic muscles to work, the postural muscles have to release, thereby, they control and shape movement.

The tonic muscles are like the reins directing the phasic muscles. The order in which tonic muscles release orchestrates the actions of other muscles. In walking, it is the initial release of the tonic back muscles that allow the movement forward, the hamstrings releasing allows the quadriceps to work and coordinate the movement of other leg muscles.

The subtlety of tonic muscles, the extent of their ability to contract and release appropriately, and the order of this interplay creates coordination, which Godard coined the ‘kinetic melody”, the synergy in space and time of all the muscles of the body. Coordination how everything works together is the basis for movement.

Through its role in coordination, the tonic system will be involved in expressing inhibition. If one part of me wants something, but I am blocked psychologically, the block will be expressed by a lack of subtly, or flexible response in tonic muscles.

The tonic system controls movement by appropriate alternation between tension and release. The inhibition will interfere with the timing of the tonic system, and therefore desired expression. To change a movement pattern may necessitate dealing with inhibition. If we only study movement and posture from the popular point of view of economy or efficiency, we may overlook the limitations in expression that may be the related issue that is preventing most economical or coordinated movement.

The tonic muscles play an important role in coordination. This has both a mechanical and symbolic aspect. The tonic system is linked with physical and psychological developmental history as well as a person’s expressiveness in the present. Newton surmises that it is no surprise that when we work with the tonic system we can have a deep psychological change as a by-product.

Tonic Function and the Two Directions

One of the foundations that Newton sees as core to understanding tonic function is the relationship of the two directions.

Remember the example of the conscious initiation of movement by raising the arm? The voluntary command is “lift the arm”. But experiments have revealed the pre-movement of the tonic system involves the soleus. The pre movement is not under conscious control. It cannot be accessed directly by the motor cortex, by voluntary commands. But it can be influenced by what Godard calls the sense of weight and there sense of orientations, the perceptual organization of an individual’s experience with gravity.

“In space, the root of a bean plant will grow every which way, but as it approaches the earth, the roots will grow down. The plant obeys the laws of gravity, but it will also obey the law of the sun. Attracted by the sun, the plant grows upwards. Newton aptly coins a phrase, by saying, “we could say that there is gravitropism and heliotropism, the two directions.

In order to move, the body as a whole or an individual muscle must have a point of support. Newton says that without falling to a typology, there seems to be a preference people exhibit for organizing themselves in gravity more in terms of one direction or the other; either using the earth, the downward direction as their primary support, or using the sky, upward direction.

The two directions can also be thought in terms of the sense of inside space of the body or more of an outside space or environment. The sense of the two directions according to Godard is one of the primary ways to work with tonic function.

The two directions are the symbol of gravity in experience. A pull downward and the resistance to that pull or a lifting. We can describe the sense of the two directions in anatomical terms, from an external observation: the two directions involve a sense of upward and downward lengthening of the spine,

Lift the AO junction (which is the organization of the suboccipital muscles) and an internal sense of weight of the sacrum. Or the body weight distributed on the soles of the feet. At an individual muscle level, it has to do with accessing both the proximal and distal attachment of a given muscle. The concept of the two directions is not intended to imply lengthening only; from down to up or up to down, the two directions allow both gathering-in, a building of pressure, as well as expansion or release.

These directions are a sensation: part of what Strauss would call a body scheme: “the body scheme is not so much a concept or image that a person has of his own body as it is an ensemble of directions and demarcations-directions in which we reach out toward the world and the demarcations that we encounter in contact with the world.

The body scheme is also experienced, therefore, as an I-World relation. Corresponding to our conation (purposeful action)- inclination, drive and desire, space itself loosed its static character, an opens endlessly before us. Expands or represses us.

What this is suggesting, is that the space of the body does not end with our skin. Rather, human beings project their sensory awareness out into the world, to include the space around them.

This perception or relationship with surrounding space will also shape our tonic organization. If we can get a sense of physical support through sensing the two directions in space beyond our body. Our system will no longer need to contract, as many muscles for stabilization and our movements will be freer and stronger.

Action of Perception

So Godard demonstrated a traditional Aikido experiment known as the unbend able arm. With your arm outstretched, hand resting on another’s shoulder, a person is asked to prevent his arm from bending. First with the intension of resisting the outside force as someone leans on it, and subsequently, using an image of energy flowing out through the fingers. Inevitably using an image, with the arm outstretched is much stronger, able to keep the arm from bending with ease. whereas when struggled against the opponent, it was the opponent who was stronger.

Electromyographgy shows in this instance, when a person struggles to keep the elbow joint straight with no sensation in the hand, they are contracting the biceps muscle as well as the triceps muscle-and in so doing, actually working against themselves.

When the subject is asked to image reaching their fingers through to the wall, the biceps remains released, quiet and free, only the triceps contracts. The result is the Unbend able arm.

So Newton goes on to say, “Physiologically and mechanically, one can explain the phenomenon in terms of stabilizer muscles, agonist and antagonist action. But what is more significant is that the perception of these directions that affect movement. The two directions according to Newton “are a perceptual event which profoundly affects motor patterns.” Thus meaning perception is action. Perception is a form of internationality, a movement in a direction. This ofcourse has had profound implications in movement education that, Alexander, Feldenkrais, Pilate’s and Continuum practitioners are all aware of.

Thus Newtons says Godard postulates that movement will be more efficient when we use the unconscious reptilian part of our brain as much as possible; that is allowing the stretch reflexes and gamma motor neuron loop to mediate the initiation of movement rather than using only alpha motor neurons and cortical control. This is the physiological underpinning of the quality of movement we describe as “intrinsic”, that is movement where there is no obvious unnecessary shortening, what Pilate’s refers to as the ‘core’ free during movement.

Interesting enough although the reptilian layer in the cerebellum is in charge of movement, reticular formation is also important in terms of the overall tone of the body. The network of cells dispersed throughout the medulla, the reticular formation is affected by the input of the senses and by the memories and emotions of the limbic system, and thus the reptilian layer has from above.

In practice, what Godard calls impression, sensory awareness, changing perception, will be able to have a profound effect on tonic organization? Since the reticular formation has a strong influence on general tonus of the body, the sensory impression has a powerful affect on reticular formation.

The perception of the two directions accesses a lower brain response that results in better coordination, more strength, a more adaptive response to movement requirements of a particular situation.

In movement work, practitioners are not asking: “how can I do this movement”, but “what prevent me?” Or by using the sense of two directions, it allows us to access the physiological effects that lead to appropriate tonic function. Consciously a willing movement triggers alpha motor neuron pathways that go directly from the cortex via the alpha motor neuron to the muscle. We want to allow the gamma motor loop that is governed by the sense of spatial, thus sensory to mediate the alpha firing.

The gamma group, which is older brain, more reptilian brain function. Asking “what prevents me, rather than triggering cortical alpha motor neurons, allows the cortex to play a more useful role in movement. Actively, the cortex can only slow down the firing level of the muscle spindle response. You cannot inhibit a reflex, but you can modulate it. Rather than getting in the way of the movement we seek, this way, it functions constructively by inhibiting the inhibition that is inhibiting the antagonist.

Evoking the two directions can lower the sensitivity of the stretch reflex to allow more freedom of movement. In a simple demonstration Godard asks someone to lift their leg, generally, the hamstrings restrict movement to 90 degrees of hip flexion. Then he supports the person at the waist-giving sense of the upward direction- and asks the person to feel the weight of the sacrum, thus eliciting the downward direction. the degree of flexion at the hip dramatically increases, until the leg is nearly perpendicular with the floor.. Eliciting the sense of two directions in the spine allows a change in the stretch reflex in the hamstrings, and the leg goes further before the reflex is triggered.

In walking, a sense of the two directions in the spine allows for the small muscles around the spine and the erector spinae, the tonic muscles, to release. These and especially the suboccipital also affect reticular formation. The release in the spine, the change in lumbar lordosis and its contralateral movement create a lengthening of the psoas which automatically triggers a stretch reflex response. Thus the spinal release initiates the basic movement of locomotion. As the psoas flexes the hip, the knee, foot and leg muscles must be free to let the movement occur, phasic muscles, action muscles must not be overly involved in maintaining posture.

Movement work can be understood as the work of organizing tonic function and the thorough use of the sense of directions, the involvement of the gamma loop and the stretch reflex.

Newton goes on to say, “When this occurs, locomotion can be supported by the gravity system. Walking becomes an easy coordinated activity.”

What Newton is conveying is that knowing “perception is an action” will directly influence our techniques. Understanding change in perception-in sensory awareness-evokes change in fundamental tonic response, we can work with dimension, eliciting sensation. We can work with the sense of the two directions in terms of balance between perception of both an internal sensory reality and the perception of the periphery, or the world outside of self.

Newton states, “We often find that the key to evoking intrinsic movement is not focusing the client’s attention inward on sensations in the body, but on the outside-the ground beneath their feet, the feel of the wind on their skin, the sounds and sights surrounding space.”

Working at the periphery, evoking sensation anywhere on the skin, in the palms of the hand and the soles of the feet is a direct link to the gamma loop- to movement less controlled by the cortex.

Movement in Situation

Newton states, “Understanding movement is inseparable from the situation has several implications for working in movement. It implies we cannot teach an ideal form or position. Appropriate movement means appropriate to a specific time and place, a particular situation. There cannot be a right position, what we can teach is adaptability, the sensitivity to respond to the moment at hand, the freedom to move that will allow this response. Trying to imitate a form will activate the alpha motor neuron loop at a cortical level, rather than the sensory activity of finding a way to move that will activate gamma motor loop.

Newton says that in order to give movement a context, rather than isolated movement patterns, we need to work with whole functions- what is termed “foundation movements”. These are learned subroutines that form the basis of actions. They have strong symbolic significance: To throw, to push, to cut, to show (point), to welcome, these are basic movements that also relate to physiological abilities to make contact and to separate.

For example, if you ask a client to push you. You can visually see and get a sense if the person is pushing himself or herself that is contracting or shortening, rather than pushing me, moving themselves away from me rather than me away from them. Or if they lose there centre in the push, going with me in the push versus separating. The movement of pushing is symbolic of saying no.

Rather than getting into the psychological aspect or history behind the movement dimension, we can continue to focus on the sense of the two directions, knowing that behaviour is being affected.

Just as we are not able to study movement in a vacuum, we are not able to work with movement without the understanding of the symbolic realm of the person will profoundly affect our work.

If we understand that movement takes place in relationship with the world outside, we will not just work with clients with their eyes closed sensing just the internal world. We will work with them in relationship. The ability to feel an external object, we develop sensation in the skin, the relation with other, without losing self.

Practicalities

Accordingly, the curves of the spine hold some keys for working with tonic function. Godard, asks, ”Where can you see tonic function? He sees it in the coordination of the three lordoses.

If we think of alignment of the body in terms of masses- pelvis, trunk, and head, we lose the quality of function through movement. Godard says you can be perfectly aligned, but perfectly dead in terms of movement. It is important to look at the motion, not so much the symmetry of the arranged horizontal masses which her terms ‘blocks’ of structure.

He says look to the lordoses. Anatomically, in front of C3, L3 and the knee, you have a bone: hyoid, the umbilicus ( it obviously isn’t a bone, but is an interworking of tissue almost bone-like) and the patella. All three have the same organization: rectus and obliques. The law of moving the three lordoses is the two directions.

The key point for the spinal lordoses will be the apices of the curves: C3 and L3. Eliciting movement at these points, or at the two ends-joints of the spine,

The atlanto-occipital and the lumbosacral, will allow the two directions of the spine.

What Godard is after, is movement at these areas by ‘letting-go’. It is the change or release in the area that results in movement and allows coordination. Functionally the knee acts as a third lordosis, and acts like the spinal lordoses.

The diaphragms

Rolfers, myofascial release and craniosacral practitioners have long held the importance of relaxing the horizontal transverse concave and convex planes known as diaphragms. Restriction in the diaphragms-respiratory and pelvic as well as the functional diaphragm of the palate-will interfere with the ability to elicit two-directional movement of the lordoses.

Goodard states, “the freedom of movement and coordination between areas of the spine and the diaphragms will be the basis of movement in the two directions that allows appropriate tonic organization.

Conclusion

What I’ve attempted to do is present differing awareness about the complexity and inter-relatedness of what affects posture.

If we think only in structural terms, and do not account for gravitational effect that is always present and responsible for much our postural condition, if we think in a paradigm that one discounts the dynamic role and relationship myofascial plays with human uprightness, if we perceive that all we need consider is a structural biomechanical model, we really never face the extraordinary complexity of why a person is in the postural form they present at that moment.

Tensegrity allows for us to think about structure quite differently. The skeleton is no longer the sole support of the musculature, but is in relationship with tensional myofascial as a dynamic compress ional unit that creates a separation of space by hydrostatic pressure.

Arline Newton has pointed out, that human experience in its entire internal and external dimension is respected. Mechanical models are simply inadequate descriptors of movement. Tonic function goes beyond postural negotiation, it has physiological and mechanical organization, but also perceptual and symbolic. They ignore the fundamental role of perception has in movement.

Posture is not static; it is the dynamic interplay of body mind organization in which emotion, experience, developmental and psychological manifestations are played out every living moment. And we are privileged to attempt to intervene and facilitate the dance of transformation with our client.

We must become educated to treating and work with our client dynamically. Making use of our space in the session. In stead of just treating in a supine or prone position, but using side-lying, or have the client sit up in verticality, or working with movement. And if we feel we are not inclined, or inadequate to the task, then finding appropriate referral or taking a class ourselves, to give us a better sense the role awareness through movement implies.

References

1. Frank, Kevin, March 1995 ‘Tonic Function’ ROLF LINES p.3
2. Newton, Arline March 1995 ””””””””””””””””””””””””””””””””Basic Concepts in the Theory of Hubert Godard””””””””””””””””””””””””””””””””, ROLF LINES PP33-43
3. Rolf, Ida P., 1977 Rolfing, The Integration of Human Structures, Chap 2 Roadmap to Structure p30)
4. Ibid.
5. http://www.rolfguild.org/mission.html
6. http://www.rolf.org 2000 the Rolf Institute, 205 Canyon Blvd., Boulder, CO 80302, USA
7. Goldstein, Steven, 2003, Course Notes on Lecture-Demonstration by Hubert Goodard. February 2003 at The Body Wisdom Conference, Waimana, Coramandel, New Zealand.

Favourite Links

This page will endeavor to link articles I have prepared or those that I””ve deemed of special interest. You””ll find they tend to be from the Rolfing community that encompasses Structural Integration material from the Rolf Institute or Guild.

Research tends to move laterally with awareness and consciousness about movement modalities and research from the likes of Hubert Goodard, Emile Conrad-Susan Harper /Continuum studies, or of interest from Somatics, Feldenkrais or Alexander methods.

I””ve listed links to interesting articles below.

*Must view set of articles

Kevin Frank & Arline Newton articles from Rolf Lines on Hubert Goodard theory of Tonic Function

http://www.resourcesinmovement.com/Archive.htm

Robert Schleips fine web site!

http://www.somatics.de/somatics.html

Emile Conrad and Susan Harpers Continuum
http://www.continuummovement.com/index2.html

Alexander Articles
http://www.ati-net.com/ati-artl.htm

http://www.alexanderschool.edu.au/article.htm

Thomas Hanna Somatics
http://www.somatics.com/hannart.htm

http://www.hannasomatics.com/articles/

NHP Canada National Conference

Presentation at the 21st NHP Canada National Conference
October 25th, 2009
Saskatoon, Saskatchewan, Canada

http://nhpcanada.org/pages/home/default.aspx

Clinical Approaches for the Manual Therapists

Sunday September 20th, 2009
One Day Workshop
Fibromyalgia: Clinical Approaches for the Manual Therapists

http://www.comphs.ca/

Fibromyalgia: Dr.John Gillick Article

Fibromyalgia Article: Dr John Gillick

Ultimate Cumulative Overload Syndrome

Foundation article on the basis of understanding for manual therapists as to how to understand and approach a client with fibromyalgia. The article by Dr.John Gillick was one of the clearest available to contextually understand the syndrome.

Article: UNDERSTANDING FIBROMYALGIA

How to Tame Fibromyalgia © 2001, John S. Gillick
Jgillick@simple-ergonomics.com

FIVE CONCEPTS
To understand Fibromyalgia (FM), it is necessary to understand:

I. Vulnerability; II. Cushion & Overload; III. Trigger & Enabler; IV. Active Fibromyalgia; and, V. Ownership

I. VULNERABILITY

There is an apparent increased vulnerability among certain persons toward development of fibromyalgia. Others, exposed to the same triggers, show no signs of the condition.
Vulnerability (predisposition) appears to be familial with women more vulnerable than men. However, with enough trauma, virtually anyone can develop fibromyalgia. There are not significant cultural, ethnic, geographic, or generational predisposes or protectors.

II. COPING, CUSHION, OVERLOAD, OVERWHELM

People have varying capacities to cope with or cushion ongoing stress and trauma. An intact, healthy capacity allows multi-task coping without exhaustion. Each individual has a limited capacity for trauma with which can be overwhelmed. When the coping mechanism are strained or maladaptive — during illness, severe mental stress, marked sleep depravation –capability (buffering, cushioning) is decreased and an individual can become chronically overwhelmed. Uninjured individuals, with normally resilient and untaxed restorative powers, continue to readily cope with the ongoing large and small traumas of daily life.

While some people can endure prolonged torture without “breaking,” others are more easily overwhelmed. When the micro-traumas of daily tasks cumulate and neuro-muscular restoration (coping) cannot keep pace, even tiny traumas become noxious and cause pain. There is hypersensitivity to the slightest noxious (“hyperalgesia”) with normally non-noxious stimuli perceived as pain (“allodynia”). This is pain amplification.

With coping mechanisms overwhelmed, “pain-begets-pain.” Neuro-physiological and pharmacological equivalent for diminished “coping”. Chronic pain researchers have shown reproducible neuro-anatomical and biochemical changes from induced chronic pain in the nervous systems of animal-model experimentation.

With chronic pain, there is on-going hyper-stimulation of the nociceptors, anti-nociceptors, and dorsal horn cells, resulting in dendritic nerve remodeling with inhibition of the normal thalamic down regulation of pain stimulus transmission.

The anti-nociceptive system is not allowed to recover, the inter-relationship between dorsal horn dendrites and the nociceptive and anti-nociceptive receptors doesn””t recover. There is nerve remodeling with dendritic new growth toward the thalamus. There is sympathetic nerve sprouting as well as crossing over of fibers between lamina in the spinal cord. Experimental over stimulation in animals can produce retrograde activation of nociceptors, nerve remodeling, dorsal horn hyper-excitability with the allodynia and hyperalgesia that is common to the chronic pain syndromes. This process can be halted and may be partially reversible.

III. TRIGGERS AND ENABLERS (T&Es)

Triggers. Fibromyalgia is started (triggered) by painful stimuli (traumas) which
overwhelm an individual”’’s physical and mental defenses or coping mechanisms.
In my view, fibromyalgia (FM) can be categorized by how it starts. “Secondary” FM (10-30%) has a rapid (within three months) onset associated with a specific traumatic episode or event (macro trauma).

“Delayed-secondary” FM: (20-30%) onsets six months to several years after a traumatic episode or disease that leaves an ongoing, chronic measurable residual (i.e., whiplash, chronic inter-vertebral disc syndrome, rotator cuff injury…).

“Primary” FM: (50% +/-) – also called “idiopathic” — has a gradual onset without
immediately obvious trigger(s). My experience suggests that multiple, chronic,
cumulative micro-traumas are its usual trigger(s).

Enablers. Once activated, the global condition of active FM is kept active by ongoing irritations or traumas, which I dub enablers. Enablers are usually multiple. They may be ongoing residuals of macro-trauma triggers (i.e., whiplash, coccydynea, systemic diseases) or ongoing (micro) traumas (i.e., chronic sinusitis, repeated impact trauma, musculoskeletal dysfunction in the upper or lower extremities, positional sleep traumas…).

IV. THE FIBROMYALGIA SYNDROME (FMS)
THE ULTIMATE CUMULATIVE TRAUMA OVERLOAD SYNDROME

Active Fibromyalgia is manifest or hypersensitive (“hyperalgesia”) widespread myalgia
with extreme sensitivity to the slightest noxious stimulus (“allodynia”). The FMS persists as a widespread neuro-muscular-spasm condition with “pain-begetting-pain.” Living with fibromyalgia is like living in a “pain-amplification-chamber.”

I prefer to use “pain amplification” to express hyperalgesia and allodynia. Fibromyalgia continues because of uninterrupted daily activity trauma amplification (DATA). Amplification of daily activities traumas continues to further injure and prevent recovery of the individual”’’s normal coping responses. The fibromyalgic is unable to adequately blunt or cope with even small daily traumas. Until the enablers and the triggers are corralled, the fibromyalgics diminished physical/ mental coping mechanism (thalamic down-regulation) is overwhelmed.

V. OWNERSHIP – RESPONSIBILITY

Control of fibromyalgia is dependent upon the individual, not the health professional.
Fibromyalgia cannot be turned off by some doctor, some special treatment, pill, diet or supplement from the outside. Tools for control are education (understanding), behavior modifications with removal of the T&E”’’s, adjunctive medications, physical modalities, and emotional support. These tools can be made available to the Fibromyalgic, however only the Fibromyalgic can elect whether to employ them.

Fibromyalgia can control the individual when it is hyper-active. It becomes a dominant factor that limits home and employment activities, etc.. .

Fibromyalgia may co-exist within the individual when the individual has some ownership of the condition and can temporarily “shut-down” the condition (the echo or amplification effect) by willpower and concentration.

The Fibromyalgic owns the condition when the individual can “turn-down,” then “turn-off” the condition by removing the triggers and the DATA — daily activity trauma amplifiers – that keep it active.