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Contra Indications Article

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.”(5)

So what are considered Absolute Contra indications?

Absolute contraindications clearly are those when the application of technique compromises the safety of the client or the practitioner.

Fiona Rattray (2000) in Clinical Massage Therapy states: ‘….contraindications may be absolute; in other words, massage is an inappropriate method of treating a particular condition that affects the whole body or a part of the body.”(6)

Massage literature has an extensive laundry list of Absolutes, the problem as Batavia has stated is that some of the Absolutes can be relative. Some are myths, such as massage therapy will systemically metastasize all cancer, other make good sense, such as inappropriate deep friction applied to healing fractures or compromised soft-tissue.

Can Massage Spread Cancer?

No, it cannot. Massage of a solid tumor site should be avoided, but there is more to a person than a tumor site. An old myth warned that massage could, by raising general circulation, promote metastasis since tumor cells travel through blood and lymph channels.  We now recognize that movement and exercise raise circulation much more than a brief massage can, and that routine increases in circulation occur many times daily in response to metabolic demands of our tissues.  In fact, physical activity usually is encouraged in people with cancer; there is no reason to discourage massage or some form of skilled touch.  Massage is practiced widely at the Dana-Farber Cancer Institute, Memorial Sloan-Kettering, and growing numbers of hospitals around the country.  Metastasis is not a concern; instead, patients and researchers report countless benefits.
- Tracey Walton, Nationally Certified Massage Educator from Florida, USA (7)

Rattray looks at absolutes for general conditions and absolutes for local conditions.

• Absolute Contraindications for General Conditions (8)
• Acute conditions requiring first aid or medical attention, such as:
• Anaphylaxis shock
• Appendicitis
• Cerebrovascular accident CVA Stroke
• Diabetic coma or insulin shock
• Myocardial infarction
• Pneumothorax

Severe asthmatic attack
Acute seizure
Syncope (fainting)
Acute pneumonia
Advanced kidney, liver or advance respiratory failure
Diabetes with complications such as gangrene
Pregnancy with pre-eclampsia or eclampsia toxaemia
Hemophilia
Hemorrhage
Post CVA or heart attack where condition has not stabilized
Severe artherosclerosis
Severe undiagnosed headaches in those over 50 years of age
Severe unstable hypertension
Shock ( although there is controversy here)
Significant fever (38.5° C or 101.5° F)
Systemic, contagious or infectious condition
Clearly we would have little controversy with Rattray’s list.  Or this is from the CATCM – Canadian Association of Therapists in Complementary Medicine regarding Absolute Contraindications.(9)

Haemophilia:
Haemophiliacs people, possess not or few blood platelet which allow the coagulation of the blood during wound. Since massage can, occasionally, cause of micro muscular wounds (during kneadings for example) it is counter-indicated to make a massage. Even the lymphatic drainage which is however a light massage, which favors the movement of the lymph, can provoke haemorrhages.

Phlebitis:
The phlebitis is an inflammation of a vein (usually at the level of the legs). Massage can dislodge a bloody clot lodged in the affected vein, which could then lodge itself elsewhere in the organism (lung, brains). In the event of phlebitis, no massage, even of the non affected zones must be made. If the therapist suspects a phlebitis, he should redirect its client to the hospital immediately.

Fever:
Fever indicates that organism fights an infection. It is important to let the body do his work. Massage can provoke an increase of the body temperature, what should not be advised because body temperature is already too high. Moreover, massage could favor the movement of the infection in another zone of the body.

Little objection would be made with these lists, and when looking at the listed conditions, I would probably not treat most of them. I also do not contest the rationale that working on a client with a fever can cause harm, but where is the evidence to that effect? When is it appropriate to treat a person with a low grade fever? Or is it?

Absolute Contraindications to Local Conditions (10)

Let us proceed to look at Rattray list of absolute for local conditions.  Again, with most, no objections to her advisory, but there are grey areas. What about very gentle touch modalities such as Reiki, Therapeutic Touch or the technique I utilise, Two Pointing?

Massage therapy is not appropriate locally for the following conditions:

• Acute flare-up of inflammatory arthritidis, such as rheumatoid arthritis, systemic lupus erythematosus or ankylosing spondylitis.
• Acute neuritis, acute trigeminal neuralgia.
• Aneurisms deemed life-threatening- abdominal aorta depending upon location.
• Deep vein thrombosis, thrombophlebitis or arteritis.
• Ectopic pregnancy
• Esophageal varicosities
• Frostbite
• Local contagious condition
• Local irritable skin condition
• Malignancy if judged unstable
• Open wounds, sores or decubitis ulcers
• Pain syndromes such as causalgia or reflex sympathetic dystrophy.
• Radiation therapy
• Recent burn
• Sepsis
• Undiagnosed lump
• Varicosities (up to 24 post-treatment with saline injection)

Let us select reflex sympathetic dystrophy for an example

Ruth Werner in A Massage Therapist Guide to Pathology, comments on reflex sympathetic dystrophy: (p242)

“Most RSDS patients have little or no tolerance for touch of any kind, at least where the pain syndrome began.  Physical therapy is often recommended to keep affected joints moveable and functioning; massage may help to relieve some of the pain associated with this therapy. Massage within tolerance in other parts of the body may be welcome and supportive.”(11)

So are we to look at Fiona Rattray list and conclude we have an absolute contraindication for RSDS or we look to Ruth Werner’s version. This is the grey area massage therapists find when needing to determine a course of treatment for an individual with as serious a condition as RSDS. Physical therapy is recommended, but massage therapy is not? Remedial therapists in Australia are often trained extensively in Range of Motion assessment, testing and application, does this then imply that massage application is out, but those that practice massage and have skill in ROM can apply physical therapy principles? Relative or Absolute?

Contraindications: Debatable Arguments: “Massage Therapists Do Not Harm People”

Albert Schatz (2 February 1920 – 17 January 2005)

Toward the end of his life this dedicated scientist published a website dedicated to healing and the law pertaining to massage therapy. He had until his death in 2005, practiced his version of massage for over 20 years.  As a 23-year-old graduate student in 1943, Dr. Schatz discovered the antibiotic Streptomycin which was the first effective means of treating tuberculosis. This disease, also known as consumption and The Great White Plague, has killed more than a billion people during the last two centuries.

Dr. Schatz initiated the research which led to the discovery of Nystatin, an antibiotic which controls fungus and yeast infections. He has also done research with other infectious diseases, cancer, multiple sclerosis, atherosclerosis, the proteolysis-chelation theory of dental caries, fluoridation, the role of chelation in the formation and fertility of soils, and the use of garbage and soil to teach science, spiritual healing, and subtle energy.(12)

Schatz in his guest editorial article in Massage Magazine March/April 1998, spoke of why would massage therapists be regulated as an industry when there has been no evidence that massage causes harm.

Massage Law Newsletter, Vol. 5 No.1 1998

Schatz states, “The term contraindications refers to conditions which predispose people to harm by massage. Contraindications in and of themselves do not invariably cause harm. They are conditions for which massage may be potentially harmful.

This means that people with contraindications may or may not be harmed by massage. Moreover, if only one individual with a contra-indication is harmed by massage, that in and of itself does not necessarily mean that the contraindication was directly responsible for the harm. To establish a direct cause-effect relationship requires a significant number of cases of harm.(13)

Schatz in 1998, was in a spirited debate with Elizabeth Leach, Executive Director Ontario Massage Therapists Association, Toronto, Canada.

The core of Leach’s argument was this; “That massage therapy performed by massage therapists is quite safe. Massage therapy performed by unregulated individuals is not.’ (14) Massage Magazine September/October 1998, (75):8

Schatz response to Leach was, “Your Letter did not address the main point of my Guest Editorial because you did not present any well-documented evidence that massage therapists – unregulated or regulated – have actually harmed people. Instead, you focused on potential harm.

My more detailed report (in the Massage Law Newsletter. 5(2):1-12, 1998) expands my Guest Editorial. This report includes some of my research on harm over a period of several years. The title of the report is: Research shows that massage does not cause harm. Where adequate research was done, no harm was found and no state regulation was enacted. There”””””””””””””””””””””””””””””””’’s no need for state regulation to protect the public from harm, or for any other reason.(15)

Are we overly concerned about contraindications? What has evidenced based research shown to substantiate the ‘laundry lists’?  Is it more that we desire the government and public perception that we are a legitimate health care provider, and that we conform to standards and practices that are in line with our ethical principles?  Clearly we should have concern about contraindications, just as we have with sites of caution. However all conditions need to some degree be researched by the practitioner. The amount of training, your time in practice, the experience you have working with specific conditions all need to be considered when regarding whether or not to treat a condition listed as contra-indicated.

Relative Contraindications: Modifications to Treatment?

With many systemic conditions such as asthma or multiple sclerosis, we may not massage during the acute or flare-up stage but can apply treatment between flares or stages.

Batavia terms ‘relative contraindications’ as those that Rattray would view as the situation where you modify your treatment plan. Rattray calls these ‘treatment modifications.’ (16) p147

Modifications to treatment are necessary, whether a client has a condition that is contraindicated or not, the manual therapist is always adjusting and modifying treatment based on the previous results and feedback from the client. Assessment and palpatory literacy also determine with case history, the appropriateness of treatment.

Would you not assess if you found systemic contra-indications? Is assessment also contra-indicated? Again it would depend on what the assessment entailed. Orthopaedic physical assessment may or may not be appropriate. With pregnancy we modify for fundamental reasons, hormonal changes that release relaxin to relax pelvic ligaments, positional changes to accommodate supine hypotension and fetus growth.

With cardiovascular concerns such as thrombus or emboli, we might dislodge a clot and/or facilitate a life threatening situation.  Other modifications might be with hydrotherapy, where the application of heat to an already inflamed area will painfully congest the site further.

With Fibromyalgia, deep work is generally contraindicated due to pain amplification and sensitivity, yet deeper work can be applied as the pain sensitization changes.

Batavia makes a cogent statement: “Guidelines around contraindications should be consistent in the literature that supports a profession. Variation in these guidelines can lead to inconsistent treatment and a great deal of confusion in both academic and clinical settings. In addition it is important that there be adequate evidence to support the use of various contraindications as well. This is one area where the massage therapy profession is at a disadvantage because despite an increasing number of textbooks devoted to massage, there is still a lack of supporting evidence used for making many of these decisions about contraindications.”

As I consulted many of the standard texts in massage education, most were using a ‘laundry list’ format. The challenge as you review contraindications is to place the contraindication in context with the health history obtained from the client, decide on the severity of the condition and differential diagnosis, decide which modifications to treatment through the varying of technique, position, duration, depth, speed, autonomic nervous system response.

We are taught when in doubt, do not treat, this maxim is still appropriate. On the other hand, clear decision-making will aid you in stepping outside of fear to help make an informed decision regarding the treatment and welfare of your client.

References

1.   Batavia, M. (2003). Contraindications for therapeutic massage: do sources agree? Journal of Bodywork and Movement Therapies, 8(1), 48-57.1
2. ibid Batavia
3. ibid Batavia
4. ibid Batavia
5. ibid Batavia
6. Rattray & Ludwig, 2000, Clinical Massage Therapy, Understanding, Assessing and Treating Over 70 Conditions, Talus Inc, 148
7. Cancer & Massage FAQ’s http://www.tracywalton.com/index.html
8. Rattray & Ludwig, 2000, Clinical Massage Therapy, Understanding, Assessing and Treating Over 70 Conditions, Talus Inc, 148
9. Jocelyn Vincent ACDMD, CATCM – Canadian Association of Therapists in Complementary Medicine, http://www.asscdm.com/index.htm
10. Rattray & Ludwig, 2000, Clinical Massage Therapy, Understanding, Assessing and Treating Over 70 Conditions, Talus Inc, 148
11. Ruth Werner, 2005 3rd Ed., A Massage Therapist Guide to Pathology, comments on reflex sympathetic dystrophy: (242)
12. http://en.wikipedia.org/wiki/Albert_Schatz
13. Albert Schatz, Guest Editorial, Massage Magazine March/April 1998, (72):7
14. Leach, E. Letters to the Editor, Massage Magazine September/October 1998, (75):8
15. Albert Schatz, An Open Letter to Elizabeth Leach, Massage Law Newsletter, Vol. 5 No.1 1998 http://www.healingandlaw.com/Massage_Law_Newsletter/massage_law_newsletter.html
16. Rattray & Ludwig, 2000, Clinical Massage Therapy, Understanding, Assessing and Treating Over 70 Conditions, Talus Inc, 148

NEW! Fascial Articulation Workshop NEW!

Fascial Articulations Concepts & Information

Fascial Articulations will be presented as a AAMT sponsored workshop for  AAMT Sydney-Post National Conference Workshop Monday May 24th, Cairns- Sunday July 25th,  Adelaide- Sunday August 8th & Hobart Sunday September 12th, 2010

A window of alternatives to the prevailing approach

This workshop has come about due to my attempt to present how I currently treat clients in my clinical practice.  As any practitioner can attest, the development of their skill and skill set evolves over time.  This process of learning takes the therapist along many avenues in their attempt to refine how to assess and deliver a consistent and quality outcome of manual therapy care.

The approach and style, the orientation of their understanding, and their passion for particular modalities, all create and embody the uniqueness and manner through which the artistic expression of the therapist shines forth.  My manner and expression has changed over time, and now the hybrid of my understanding allows me to enjoy and find playfulness in pursuit of passion and intuitiveness for soft-tissue dysfunction through the delivery of a variety of applications.

These applications consist of direct and indirect myofascial release, with an emphasis on autonomic expression that manipulates the sensory receptors of soft-tissue. I also learned from my studies and practice, that targeting muscles alone as the source of soft-tissue dysfunction will yield less than satisfactory results. This led me on a journey of investigating the nature of myofascial and from that, I now recognize clinically, as researchers have scientifically, that the myofascia is a dynamic partner in the tonality of the musculature.

What’s more interesting to my clinical experience is that the other main soft-tissue constituents; tendon, ligament and joint capsule, are all main contributors to the dynamic interplay of fibrosis, adhesion, congestion and excess tonality surrounding the musculature.

I tend to treat from a differing perspective. Whereas, most therapists assess and treat muscles at the beginning of a treatment, I employ most of my muscle applications towards the end of a treatment.  I’ll begin with assessment of the cardinal lines of myofascial tension (Myers 2000) and the high leverage points that anchor myofascial within the myofascial net (Schleip 2003).

The three main lines that correspond to main muscular and habitual patterns of motion that we all employ are:  sagittal which mediates flexion/extension, coronal/frontal which mediates abduction/adduction and horizontal/transverse which mediates rotation. Myers named these lines as SBL Superficial Back Line, SFL Superficial Front Line and LL lateral Line. The assessment of three cardinal lines ensure you a more global relaxation in the fascial tension and restoration of increase mobility corresponds along these lines.

Once I have assessed myofascial tension, I assess joint ROM from a fascial perspective. You may ask how can one assess from a myofascial perspective for ROM?  Essentially the distinct difference is not moving into the limit of anatomical integrity, instead the assessment of joint motion is confined to the level of first resistance. That is, where you feel the first tug, snag or glitch to the smoothness and quality of this motion. The reason is this will usually indicate the congestion of the connective tissue in the form of superficial fascia or fibrous connective tissue component as capsular or ligament restriction.

Remember myofascial surrounds each and every muscle group as a unit, muscle fibres and even muscle fascicles have a connective tissue wrapping. Therefore when you feel the first level of resistance you are keying into the first level of myofascial restriction that prohibits smooth joint motion.

I then move the joint through its muscular range but again feel the first level of restriction as it nears end feel.  Again the rationale is autonomic and neurological. When a therapist moves a muscle into its end range, and if restriction is present, the client will feel the pull or strain. When they feel the strain, they cannot help but to unconsciously guard or the very least, respond by flinching.

The guard response is what I’m attempting to avoid. Again if I can avoid any reactive distress by my passive range of motion assessment, I avoid moving the client back into a sympathetic state.  Micheal Shea (1995) is found of stating, and I quote; “all soft-tissue release is predicated on how the autonomic nervous system is discharging its impulses.”

The nervous system discharges, soft-tissue releases. You cannot accomplish soft-tissue change without a compliant nervous system.  That said, of course, if you are strategically deciding to assess ROM and need to employ a special test, say for example an anterior drawer test of the knee joint, you would use excessive force provocatively, as it is necessary to assess if anterior cruciate  ligaments are damaged.  This is referred to as a provocative test.  However, there is always a price to be paid from an autonomic or neurologic standpoint regarding excessive compressive force.  The body will always respond whether the practitioner is aware or unaware of this. You have chosen to over ride the ANS, by re-producing pain to substantiate your assessment or diagnosis. Once pain is provoked, the ability for the soft-tissue to change is diminished.  This is nervous system  Cause and Effect.  The sophistication of the central and autonomic nervous systems is a wonder to behold.

The other forgotten component in changing persistent and stubborn soft-tissue dysfunction is change to joint capsule and ligamentous structures. Although once considered inert and non-contractile structures, they are major contributors to the holding of tensional and tonal states of the muscles.  The sooner you understand that all the soft-tissue is in dynamic interplay, the better it is for you regarding your clinical outcomes.

Once assessment is complete, I initiate technique with the ANS autonomic nervous system in mind, to ‘settle the system’ by use of the gentle ‘Two Point’, this facilitates the ANS to enter into a parasympathetic state, with the lowering of high sympathetic tone (Shea 1995). The Two Point is applied either to transverse planes or the major peripheral joints, i.e. knee, ankle, shoulder, elbow or wrist.

This then leads me to address the quality and quantity of range regarding any involved joint by utilizing indirect technique approaches that are osteopathic in nature.  Among them is joint play, that is, combining accessory motion (anterior/posterior, lateral translation, distraction or rotational movements of approximated positions (close pack)), with crowding or approximation to the joint mechanoreceptors that facilitate a neurologic response of relaxation.

The other assessment component employed is the use of the assessment of ease or bind motion of the crowded joint by assessing the three planes of distortion within an ease or bind position.  This in osteopathic parlance is called stacking. Stacking is the engagement of two or more planes of distortion simultaneously to re-organize and transform congested soft-tissue.  It is a highly effective approach for changing proprioceptive mechanoreceptors in the joint capsule and surrounding ligamentous structures.

I address the musculature & joint restrictions by utilizing low load resistive (modified MET’s). This is directionally based rather than muscle specific. My intent is to target joint capsule, fibrous connective tissue responds well to low load resistives, thus joint capsule & ligaments respond to this type of technique.  Upon conclusion of all the above, I then address musculature. Clearly there are very appropriate times to address and release muscular hypertonicity straight way. My point is that when muscles are not responding or releasing, then you need to change your strategy and orientation.

FASCIAL PLANES OF DISTORTION

When palpating to distinguish the direction of a myofascial distortion, it is recommended that the therapist palpate the surface of the skin to determine the plane(s) of restriction. This method was first noted in osteopathic literature and is commonly held throughout all manual therapy disciplines.

The osteopathic concepts of ‘ease’ and ‘bind’ are assessed in two ways: either the direction of the restriction or barrier is palpated or the direction of the motion barrier or restriction is assess by PROM passive range of motion as a motion restriction. Ease is always away from the barrier or the greatest degree of movement. Bind is the barrier or where movement has the greatest degree of restriction

HOW TO LOCATE SUPERFICIAL FASCIA

Palpate the skin with your palm or fingertips in a manner that forms to the shape of the skin over the area you are palpating.  Do not tense your hand or forearm and your shoulders should be relaxed as you perform this assessment.

Next engage through the skin by increasing the depth of your pressure to the first layer of muscle, then back off. You should be between skin and muscle.  This is the space where superficial fascia resides. Palpation is to the first level or layer of restriction.

The skin should be assessed for its mobility.  Place your hands flat upon the surface of their skin and move the skin in all directions.  Ideally, the skin should move equally in all directions, except around tendinous insertions into osseous structures.  If it does not move well in a particular direction, this will indicate the underlying fascia is restricted.

If the skin does move in one particular plane of movement, say in a cephalic or sagittal direction, a myofascial technique can be applied in the direction of the restriction.

Skin adhesion is an indication of the ease or bind of the superficial fascia below it. You can easily assess fascial restriction by moving the skin over superficial fascial tissue. Assess the four cardinal directions by moving the skin proximal/distal medial/lateral or inferior/superior

DIRECT & INDIRECT TECHNIQUE: CONCEPTS OF EASE & BIND

The direction(s) the skin moves easily is called ‘ease’. The direction(s) that the skin resists moving is called ‘bind’. This is the method to assess planes of fascial distortion.

You engage bind by using a static compression of the skin into the superficial fascia and you will release the current assessed bind and create both a new ease and bind position.   If the skin moves easily in the area you are assessing, then you are probably able to use techniques that are more muscular oriented.  If however, the skin does not move easily, then in a general sense you are dealing with myofascial that needs to be released before you can achieve desired results from your muscular approaches.
This simple assessment can be utilized to assess superficial back and front line restrictions or lateral line restrictions. (Myers 2000) “Manual therapy comprises direct & indirect techniques.  Direct techniques load or bind tissue and structure. The tissue is moved towards a barrier on one or more planes.  The direction of displacement of the soft-tissue is in the least mobile, most restricted & most limited direction. Techniques are performed at or just before the barrier. The result is a change of the position of the barrier which will move closer to what would be the end of a more normal range of motion. For example, a direct approach might be employed to treat elbow flexion contracture with shortened and contracted biceps that limits elbow extension, a direct technique would be to move the elbow into extension. At the barrier, or just before the barrier at the interbarrier zone, a technique is performed with the result an increase in range of extension motion.

Indirect techniques unload or ease the tissue or structure.  The tissue is moved away from the barrier on one or more planes. The direction of movement of the tissue is the most mobile, least restricted, least limited direction. The distortion is thereby exacerbated.  The problem is exaggerated. For example, with limited extension, there is relatively too much flexion. The problem could be described as excessive flexion. The treatment would be towards flexion.  The result is a ‘release’ phenomenon: the soft-tissues “let go” of tension in a tissue tension release.” (Giammatteo & Kain, Integrative Manual Therapy 2005 Vol.4, p70 North Atlantic Books)

MYOFASCIAL SLEEVE RESTRICTIONS

Myofascia behaves as a superficial wrapping as seen from Serge Paoletti’s anterior fascia of the low extremity.
Which brings me to assessment & palpation of fascial sleeves. Most practitioners are used to assessing rotation of the humerus or femur which determines movement at the shoulder or hip.
Another assessment that can be included is assessment of restriction of upper or lower extremity fascial sleeves. This is assessment is crucial to improving motion at the joint and for allowing the smoother movement of the muscle through its fascial sheath.

When addressing the scapular complex (GH joint, AC joint, SC joint & scapula-thoracic joints, humeral ulnar, radial ulnar, radial carpal), sleeve restrictions often will be the first restriction to release.  Since myofascial loves to be encased through fascial ‘grasps’, this simple static compressive technique can clear fascial tissue quite quickly.

• Assess which direction of rotational restriction is ease and which direction is bind.
• Engage myofascial by using a grasp and apply the twist in the direction of ease to unload the tissue, or bind to load the tissue.
• Usually the engagement of the superficial myofascial wrapping is enough to create a myofascial glide, usually within 10-30 seconds. However if this isn’t successful, then here are some points to consider:
• From a palpation standpoint you are pressing too hard
• You will need to engage a second plane of fascial distortion, which is to put a direction or vector on the myofascial by creating a ‘lateral shear’. Osteopaths call this ‘stacking’
• You may ask the client to use slight movement as you engage the myofascial, usually in a rotational direction.
• Micheal Stansborough and other direct myofascial release authors call this Active Movement Participation AMP.
• You will find once you’ve cleared a rotational distortion or restriction you will increase ROM at the joint and the clarity of the restriction will become more focal.
• Myofascial restrictions & distortions will obscure the ability to distinctly palpate the muscular structure beneath it.

Fibromyalgia:New Perspectives for the Manual Therapist



Introduction

By Steven Goldstein BHSc MST, BA Education

Fibromyalgia classically presents as wide spread musculoskeletal pain and we know that the origin of this pain is multifaceted and systemic.  Because of this, a more comprehensive understanding is required of you to be successful in your treatment options.  In this article I’m going to introduce the concept of ‘Central Sensitization’,  a fibromyalgia research blog, and the FIQ Fibromyalgia Impact Questionaire. All three of these components will give you a greater understanding of how to work with and treat your Fibromyalgia client.

There has been much written regarding Fibromyalgia and Massage Therapy, but a short review may be in order to the salient features of the syndrome.

Fibromyalgia FMS is a syndrome that is considered by many to be a chronic, culmative overload of the body’s coping and cushioning mechanisms (1. Gillick) in which on going residuals of macro-traumas (whiplash, system disorders, post traumatic stress syndrome, are perpetuated with numerous and cumulative micro-traumas (chronic sinusitis, repeated impact trauma, musculoskeletal dysfunction in the upper or lower extremities, positional sleep traumas) which sensitizes the central nervous system in such a manner as to amplify pain 24/7 and create pain from usually non-painful stimuli.

This is known as Hyperalgesia: the amplification of pain sensations and Allodynia: non-painful sensations such as touch, noise, vibration, lights or smells are painful.

Prevalence indicates usually affecting women over men by a 4/1 ratio, but Fibromyalgia can occur at any age. Although it usually manifests between the ages of 30 to 50. (Rattray p983)

There is an enormity of presenting symptoms with a wide range of variance as to fool the manual therapist, and probably the best source for the presenting symptoms would be to check out Dr. Devin Starlanyl’s website: http://homepages.sover.net/~devstar/.  I’ll cover presenting symptoms in a subsequent  article.

Central Sensitization

“Fibromyalgia (FM) pain is frequent in the general population but its pathogenesis is only poorly understood. Many recent studies have emphasized the role of central nervous system pain processing abnormalities in FM, including central sensitization and inadequate pain inhibition. However, increasing evidence points towards peripheral tissues as relevant contributors of painful impulse input that might either initiate or maintain central sensitization, or both.

It is well known that persistent or intense nociception can lead to neuroplastic changes in the spinal cord and brain, resulting in central sensitization and pain. This mechanism represents a hallmark of FM and many other chronic pain syndromes, including irritable bowel syndrome, temporomandibular disorder, migraine, and low back pain. Importantly, after central sensitization has been established only minimal nociceptive input is required for the maintenance of the chronic pain state.  Additional factors, including pain related negative affect and poor sleep have been shown to significantly contribute to clinical FM pain. Better understanding of these mechanisms and their relationship to central sensitization and clinical pain will provide new approaches for the prevention and treatment of FM and other chronic pain syndromes.”

Central sensitisation is defined as ‘‘an augmentation of responsiveness of central pain-signalling neurons to input from low-threshold mechanoreceptors’’ (Meyer et al.,1995). “While peripheral sensitisation is a local phenomenon, central sensitisation means that central pain processing pathways localised in the spinal cord and the brain are sensitised.”

The science is fascinating, but the clinical implications through the application of this understanding is essential.  An important and ongoing source of pain is required before the process of peripheral sensitisation can establish central sensitisation. Progression towards chronic widespread pain is associated with injuries to deep tissues which do not heal within several months (Vierck, 2006).

Consequently, appropriate and effective manual therapy in those with (sub)acute musculoskeletal disorders is important to prevent evolvement from an acute, localized musculoskeletal pain problem to complex clinical cases, characterised by chronic widespread pain and even symptoms outside the musculoskeletal system such as increased sensitivity to bright lights, auditory loudness, odours, and other sensory stimuli. Pain due to damage or inflammation of peripheral tissues is clearly capable of causing chronic widespread pain/FM (Clauw, 2007). 15-20% people with whiplash injuries develop chronic pain and disability (Spitzer et al., 1995; Radanov and Sturzenegger, 1996; Coˆ te´ et al., 2001). Regardless of whether FM is present in chronic whiplash, altered central pain processing and central sensitisation is evident (Curatolo et al., 2001; Sterling et al., 2002, 2003, 2006; Banic et al., 2004). Moreover, altered central pain processing rather than impaired motor control has been identified as one of the prime prognostic factors for developing chronic whiplash (Sterling et al., 2003, 2006).

Excerpted below from ‘From acute musculoskeletal pain to chronic widespread pain and fibromyalgia: Application of pain neurophysiology in manual therapy practice .’

Science Direct Manual Therapy 14 (2009) 3e12

Myofascial Treatment

“Anecdotally, muscles and fascia often become hypertonic and develop trigger points in people with chronic widespread pain/FM. Soft-tissue mobilisation is required to free up restrictions and restores local blood flow. However, it is important not to increase pain during treatment. The vicinity of myofascial trigger points differs from normal muscle tissue by its lower pH levels (i.e. more acid), increased levels of substance P, calcitonin gene-related peptide, tumour necrosis factor-a and interleukine-1b, each of which has its role in increasing pain sensitivity (Shah et al., 2005). Sensitised muscle nociceptors are more easily activated and may respond to normally innocuous and weak stimuli such as light pressure and muscle movement (Shah et al., 2005). Therefore, starting the soft-tissue mobilisation superficially with well-tolerated strokes along the length of the muscle fibres (referred to as ‘stripping’ in Benjamin and Tappan, 2005) and progressing towards deeper strokes that go perpendicular to the soft-tissue fibres is recommended Aggressive ways of treating trigger points (e.g. by using ischaemic pressure) are usually not well tolerated and therefore not recommended.”

The research is clearly demonstrating a lighter approach is needed when applying soft-tissue therapies with the sufferer of fibromyalgia.  We know from the studies of ‘facilitation’ with regard to active and latent trigger points, that once the dorsal horn of the spinal cord is switched on, it maintains its’ ‘facilitation’, with a low thresh hold  barrage of stimulus.

An awareness is needed of the mechanisms that activate the autonomic nervous system, such as ‘flight and fight’; and the de-activation of ‘high sympathetic tone’ (Shea 1995), so that the therapist modulates the ANS from a lower sympathetic state into a parasympathetic state which is demonstrated by ‘rest and repose’. With this type of client, modification of duration of treatment, amount of force or pressure and specific tissues totarget, i.e., myofascial tissue, are all essential to a greater degree of success through the cessation of the barrage of nocioceptive stimulus.

The clinical approach I utilize, uses a skill set that employs lighter touch, autonomic nervous system modulation, the use of mind-body techniques such as neuro-linguistic programming (NLP), awareness and imagery technique, along with low load resistive for targeting intrinsic ligament and axial spinal muscle groups, forms of applied kinesiology, reflexology; all have efficacy in the treatment application of the sufferer of fibromyalgia.

Finally remember you have to have a strong referral network due to the systemic nature of the presentation, that means you need to refer to qualified therapists who practice CAM therapies, including naturopaths, CAM therapy friendly allopath physicians, mind body therapists, rheumatologists, and cognitive therapists that deal with emotional and psychological issues that are part of the overall clinical picture.

Fibromyalgia Impact Questionnaire

A very important tool for the manual therapist in their treatment of Fibromyalgia is the FIQ or Fibromyalgia Questionaire.  This is the tool recognized for use in clinical trials around the world, and therefore is the major current tool to measure changeable outcomes for your client.

It was developed by Dr. Robert Bennett in the 1980’s in Portland Oregon in an attempt to capture the total spectrum of problems related to fibromyalgia and the responses to therapy. It was first published in 1991 and since that time has been extensively used as an index of therapeutic efficacy. Overall, it has been shown to have a credible construct validity, reliable test-retest characteristics and a good sensitivity in demonstrating therapeutic change. The original questionnaire was modified in 1997 and 2002, to reflect ongoing experience with the instrument and to clarify the scoring system. The latest version of the FIQ can be found at the web site of the Oregon Fibromyalgia Foundation (www.myalgia.com / F I Q / F I Q). The FIQ has now been translated into eight languages, and the translated versions have shown operating characteristics similar to the English version.

Based on an intake questionnaire used in the OHSU Rheumatology Clinic and informal discussions with fibromyalgia patients, the initial version of the FIQ was developed in 1986. In particular, the functional component of the questionnaire was purposely biased to the use of large muscle groups rather than fine hand movements.

Make sure you download the questionnaire and thoroughly read the research behind the study, as it will allow you the insight about how the questions were formed and why they were asked. In particular the scoring is designed to target physical functioning versus physical impairment. The categories are such as to ascertain how ADL activities of Daily Living are affected.

Every client should be filling out this questionnaire and then you actually have the ‘research tool’ in your hand to validate and contribute to studies and findings from a research perspective.

FIBROMYALGIA IMPACT QUESTIONNAIRE (FIQ)

Name: _________________________________ Date:           /             /

Directions: For questions 1 through 11, please circle the number that best describes how you did overall for the past week. If you don””””””””””””””””””””””””””””””””t normally do something that is asked, cross the question out.

Always  Most  Occasionally Never

Were you able to :

1. Do shopping? ……………………………………………         0                  1                    2                3

2. Do laundry with a washer and dryer? ……..             0                   1                  2                 3

3. Prepare meals? …………………………………..              0                   1                  2                 3

4. Wash dishes/cooking utensils by hand?…..            0                   1                  2                   3

5. Vacuum a rug?…………………………………….             0                   1                  2                   3

6. Make beds? ………………………………………..              0                  1                  2                  3

7. Walk several blocks? …………………………..               0                   1                  2                  3

8. Visit friends or relatives? ………………………             0                   1                  2                  3

9. Do yard work?……………………………………..             0                   1                  2                 3

10. Drive a car? ………………………………………..           0                    1                2                  3

11. Climb stairs? ………………………………………             0                    1                2                  3

12. Of the 7 days in the past week, how many days did you feel good?
0      1      2      3      4      5      6      7
13. How many days last week did you miss work, including housework, because of fibromyalgia?
0      1      2      3      4       5      6      7

FIBROMYALGIA IMPACT QUESTIONNAIRE (FIQ) – page 2

Directions: For the remaining items, mark the point on the line that best indicates how you felt overall for the past week.

14. When you worked, how much did pain or other symptoms of your fibromyalgia interfere with your ability to do your work, including housework?

●___І ___І___І ___І___І ___І ___І ___І ___І___●

No problem with work            Great difficulty with work

15. How bad has your pain been?

●___І ___І___І ___І___І ___І ___І ___І ___І___●

No pain                                                           Very severe pain

16. How tired have you been?

●___І ___І___І ___І___І ___І ___І ___І ___І___●

No tiredness                                                              Very tired

17. How have you felt when you get up in the morning?

●___І ___І___І ___І___І ___І ___І ___І ___І___●

Awoke well rested                                    Awoke very tired

18. How bad has your stiffness been?

●___І ___І___І ___І___І ___І ___І ___І ___І___●

No stiffness                                                                   Very stiff

19. How nervous or anxious have you felt?

●___І ___І___І ___І___І ___І ___І ___І ___І___●

Not anxious                                                         Very anxious

20. How depressed or blue have you felt?

●___І ___І___І ___І___І ___І ___І ___І ___І___●

Not depressed                                               Very depressed

See Dr. Robert Bennett FIQ Abstract as a PDF file download for results of clinical study.

Robert Bennett, MD, FRCP, FACP, Professor of Medicine, Department of Medicine (OP09), Oregon Health and Science University, Portland, OR 97329, USA. E-mail: bennetrob1@comcast.net Clin Exp Rheumatol 2005; 23 (Suppl. 39):S154-S162.

© Copyright CLINICAL AND EXPERIMENTAL RHEUMATOLOGY 2005.

Current Clinical Studies

(from the The Fibromyalgia Research Blog http://www.blogcatalog.com/blogs/fibromyalgia-research-blog.html)

If your going to stay ahead of your contemporaries as a therapist, then you need to maintain and seek out current evidence based research about the condition you are specializing in. We live in an age of information overload, however that can be an advantage for the therapist if you can select material to wade through that is relavant to your interest. I subscribe through my email inbox, to numerous journals and blogs which automatically send me the latest research. Here are examples of studies from the Fibromyalgia Research Blog….

Sunday, December 21, 2008

Biochemical Basis of Myofascial Pain Syndrome

Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome is the title of an article published by members of the Rehabilitation Medicine Department of the National Institutes of Health (Bethesda, MD). The article “discusses muscle pain concepts in the context of myofascial pain syndrome (MPS) and summarizes microdialysis studies that have surveyed the biochemical basis of this musculoskeletal pain condition.” Myofascial pain condition is extremely common in fibromyalgia patients, though it is unclear whether MPS can cause fibromyalgia or vice versa.

The pathophysiology of MPS is “only beginning to be understood due to its enormous complexity.” It is considered to be characterized by the presence of myofascial trigger points (MTrPs), which should not be confused with fibromyalgia tender points. Myofascial trigger points are hyperirritable nodules located within a taut band of skeletal muscle. These bumps or bands can usually be felt through the skin. The authors of this article write that “MTrPs may be active (spontaneously painful and symptomatic) or latent (non-spontaneously painful).” Active trigger points can refer pain to other parts of the body as well as being painful to direct touch.

Painful MTrPs activate muscle nociceptors that, upon sustained noxious stimulation, initiate motor and sensory changes in the peripheral and central nervous systems. This process is called sensitization. The researchers sought to discover what influences this sensitization process using a microdialysis technique that was created in order to “quantitatively measure the biochemical milieu of skeletal muscle.”

They found significant biochemical differences between active and latent myofascial trigger points (MTrPs) as well as biochemical differences between healthy muscle tissue and muscle tissue afflicted with trigger points.

Sunday, December 21, 2008

40% of Patients with Cervical (Neck) Myofascial Pain Syndrome Also Have Fibromyalgia

A study from Selcuk University in Turkey (PMID: 19085177) recently analyzed the demographic features, clinical findings and functional status of a group of cervical (neck) myofascial pain syndrome patients. They evaluated the patients using the short form health survey (SF-36), pain and depression levels, patient demographics and physical examinations. They used the visual analog scale, Beck Depression Inventory, and medical history to evaluate the patients. A total of 82 patients had a diagnosis of cervical myofascial syndrome. Almost 88% of these patients were female, and they were around 37 years of age on average. 53.1% had trigger points in the trapezius muscle with high percentage of autonomic phenomena like skin reddening, lacrimation, tinnitus and vertigo. 58.5% of the series had suffered from former cervical trauma and 40.2% also had fibromyalgia syndrome and 18.5% had benign Joint hypermobility syndrome.

They concluded that younger female patients who present with autonomic system dysfunctions and early onset cervical spine injury should be “examined for cervical myofascial pain syndrome and also for fibromyalgia syndrome since this study demonstrated a high percentage of fibromyalgia syndrome in these patients.”

Sunday, November 08, 2009

Changes in Hippocampal Metabolites After Effective Fibromyalgia Treatment

The Clinical Journal of Pain just published a case study that evaluates the impact of fibromyalgia on hippocampal brain metabolite ratios. Researchers at the Department of Family Medicine, Anesthesiology and Psychiatry at Louisiana State University Biomedical Research Institute based this case study on the results of previous studies that used single voxel magnetic resonance spectroscopy (1H-MRS) to reveal an association between fibromyalgia and disruptions in hippocampal brain metabolite ratios in fibromyalgia patients with no psychiatric conditions. The hippocampus is an area of the brain located in the temporal lobes and near the amygdala. It is part of the limbic system and is involved in long-term memory (its the first area to be affected by Alzheimer Disease) as well as spatial navigation. It is extremely vulnerable to stress.

Exposure to stress is considered a risk factor for the development and exacerbation of fibromyalgia symptoms. Basic science has demonstrated the hippocampus to be exquisitely sensitive to the effects of stressful experience, which results in changes including alterations in metabolite content and frank atrophy.

The case study detailed in the report is of a 47-year old female fibromyalgia patient who, when evaluated, was shown to have a “profound depression of the ratio of N-acetylaspartate to creatine in her right hippocampus” when she participated in another study assessing brain metabolite disturbances in fibromyalgia. This irregularity had been diagnosed using single voxel proton magnetic resonance spectroscopy. The research team came up with an individualized treatment strategy based on the “physiological abnormalities associated with the disorder and symptoms that characterized the patients unique clinical profile.” What they discovered upon evaluating her after nine months of treatment was an “improvement in her clinical profile and normalization of the NAA/Cr ratio within her right hippocampus.” The researchers concluded that:

Therapeutic strategies aimed at demonstrable lesions associated with fibromyalgia appear to represent rational targets for pharmacological intervention. The rationale for development of novel pharmacotherapies for this unusual disorder is discussed.

Study Details: Clin J Pain. 2009 Nov-Dec;25(9):810-4. PMID: 19851163.

References

1. DR. John S. Gillick, How to Tame Fibromyalgia © 2001 This is the original paper presented for the first time at the American Occupational Health Conference on April 26, 2001 in San Francisco California by Dr. John Gillick of UCSD San Diego

2. Rattray F. & Ludwig L. Clinical Massage Therapy: Talus Inc. Toronto, Ontoario, Canada, 2000. Fibromalgia & Chronic Fatique Syndrome p 981

3. Science Direct: From acute musculoskeletal pain to chronic widespreadpain and fibromyalgia: Application of pain neurophysiology in manual therapy practice. Jo Nijs a,b,*, Boudewijn Van Houdenhove c
a Department of Human Physiology, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussels, Belgium b Division of Musculoskeletal Physiotherapy, Department of Health Care Sciences, University College Antwerp, Van Aertselaerstraat 31, B-2170 Merksem, Belgium c Faculty of Medicine, Katholieke Universiteit Leuven, Belgium Received 4 December 2007; accepted 9 March 2008

4. Benjamin PJ, Tappan FM. Tappan’s handbook of healing massage techniques. Classic, holistic, and emerging methods. New Jersey: Pearson Prentice Hall; 2005. p. 127.

5. Clauw DJ. Fibromyalgia: update on mechanisms and management. Journal of Clinical Rheumatology 2007;13:102e9.

6. Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, et al. Scientific monograph of the Quebec task force on whiplash-associated disorders: redefining ‘‘whiplash’’ and its management. Spine 1995;20:S1e73.

7. Sterling M, Treleaven J, Edwards S, Jull G. Pressure pain thresholds in chronic whiplash associated disorder: further evidence of altered central pain processing. Journal ofMusculoskeletal Pain 2002;10:69e81.

8. Shah JP, Philips TM, Danoff JV, Gerber LH. An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. Journal of Applied Physiology 2005; 99:1977e84.

9. Vierck CJ. Mechanisms underlying development of spatial distributed chronic pain (fibromyalgia). Pain 2006;124:242e63.

10. The Fibromyalgia Impact Questionnaire (FIQ): a review of its development, current version, operating characteristics and uses. Robert Bennett, MD, FRCP, FACP, Professor of Medicine, Department of Medicine
(OP09), Oregon Health and Science University, Portland, OR 97329, USA.E-mail: bennetrob1@comcast.net
Clin Exp Rheumatol 2005; 23 (Suppl. 39): S154-S162.© Copyright CLINICAL AND EXPERIMENTAL RHEUMATOLOGY 2005.

11. Fibromyalgia Syndrome: An Overview: Susan Krsnich-Shriwise  Phys Ther. 1997;77:68-75.1

Posture:Alternatives to the Prevailing Paradigm

Posture: Alternatives to The Prevailing Paradigm

By Steven Goldstein, B.A. Education & B.Health Science MST Musculoskeletal Therapy

Abstract:

In this lecture series we will look at an overview of the modalities that can be alternatives to a standardize approach for postural assessment, that is an external orientation or what we term as an objective view that manual therapists take when assessing and intervening with postural dysfunctions.

In the first part of the series we will identify what has been the prevailing view of posture from teachings of mainstream perspectives and in the second and third parts of the series introduce to you differing viewpoints that hopefully will assist you in your practice.

Introduction

All you need do is type the word posture onto an internet search engine and in .11 seconds you have about 1,720,000 hits. And as you scan the dizzying array of responses, one can retrieve information about postural related aids and devices that include postural balls, ergonomic chairs, or find information all about posture; how to maintain correct posture when meditating or how to maintain a balanced and correct posture according to a variety of disciplines and modalities.

Some self-help manuals like Kit Laughlin’s have an integrated approach utilizing his background in yoga along with rehabilitation and sports exercise, dance, gymnastics and forms of martial arts he has been exposed to that assist in postural transformation. 1

Other sites prefer a health-oriented corporate workplace approach to helping employees become more productive by maintaining a conscious awareness of how they sit when performing various activities for their daily work regimen. And these tips include keeping your eyes level, shoulders level and not shrugged, elbows resting close to the torso, etc., all seemingly to take what appears to be a scientific physiotherapeutic approach to maintaining correct posture.

If one scans the responses further, there are aids to assist in assessing posture by the manual therapist and postural professional; these include a $349 USD Postural Evaluation Kit that will include a program for keeping postural records of your client, a plastic postural grid that can be suspended from the ceiling or wall, suspension cord and plumb bob for alignment.  If you so desire you can use a PALM device known as a palpation meter.

“This device combines the ease and proprioceptive of palpation with the objectivity and reliability of calliper and inclinometer measurements. The calliper determines the distance in centimetres between two palpating fingers. The inclinometer will give you accurate measurement in degrees between two palpating fingers.”

As manual therapists, how do we make sense of all this information? For one thing, all of the sites I viewed seemed to convey and portray a physical orientation of what correct posture is meant to be.  That is, assessing posture from an external point of view. Secondly, the sites describe how to counteract poor posture by re-educating one’s muscles utilizing movement in the form of specific exercises.

Are their any other approaches to normalizing posture and how do they compliment or conflict with a standardized approach that these sites convey?

Traditional Approaches to Postural And Musculoskeletal Dysfunction

Static Postural Images

If we peruse various massage anatomy and physiology texts or modality manuals, we find laid out for us a process and procedure that is taught and adhered to, based upon postural assessment or analysis; that is, a step by step procedure of looking at the structural landmarks of the body, both in weight-bearing and non weight-bearing positions.

That is usually an analysis of the body form from a static standing position. If we look to analyse the body in motion, we usually refer to it as ‘gait analysis’.  This is the logical and normal approach that is taken, it focuses our attention and awareness on our client when they present themselves for observation and assessment of postural considerations.

Ideal Postural Alignment

Faulty Postural Alignment

Muscle Testing and Function

Kendall and McCreary (1949), one of the bibles in the field for muscle testing and function have wonderfully dated black and white photographs of men and women in relation to a grid and plump line bob.  The photographs describe ideal plumb line and faulty plumb alignment.

Accordingly the authors state a premise about muscle function in relation to posture;

“posture is the composite of the positions of all the joints of the body at any given moment. If a position is habitual, there will be a correlation between alignment and muscle test findings.  If a reasonable assessment of a joint position is made, then an assessment also can be made regarding muscles in elongated positions and that are in shortened positions.  In faulty posture, those muscles in slightly shortened positions tend to be stronger, and those in slightly elongated positions tend to be weaker than the muscles that work in opposition to them.” 2

With this quote we have all the components for addressing physiologic functions that affect posture and the dysfunctions that occur.   We include joint play, movement, habituation (nervous system adaptation), agonist and antagonist muscle function, all of which can lead us into a discussion about sensory-motor nerve function.

So why is it we view postural dysfunction by the use of symmetrical comparison of bony landmarks and usually in context of muscle shortness and contracture?  Well for reason, it suits us to consider posture in the context of symmetry.  And if we can balance muscle groups there is a sense that posture can self-correct.

This is generally how manual therapists approach postural dysfunction. But is there more to postural dysfunction than asymmetry and muscle contracture? It is often more complicated and interesting than detailed extrinsic explanations.

Patterns of Musculoskeletal Dysfunction

Postural and tonic muscles and Janda’s syndrome patterns
Anatomic and physiologic responses to stress

No discussion on posture can occur without an understanding of the function of muscles.  .

One contributor to how muscle function in patterns has been a Czech researcher named Vladimir Janda.  He describes the patterns that affect posture by understanding the relationship between postural type 1 muscles and phasic type 2 muscles.  Predictable patterns emerge that he elaborates upon that he named Upper and Lower Crossed Syndromes.

Essentially postural or tonic muscles shorten while phasic often weaken.

Type 1 or Postural fibres contract slowly and are able to burn oxygen more efficiently than phasic muscles, which allows them to work slowly, and steadily over long periods of time. Over time with misuse and disuse, these muscles will shorten.  This is a clinically important distinction in tonic muscles response to stress. 3

Phasic or Type 2 fibres of which there are two main categories will weaken under prolonged stress and the fibres will tend to lengthen.

Type 2a fast-twitch fibres which contract more speedily than type 1 and are moderately resistant to fatigue with high concentration of mitochondria (the fuel-producing refineries of the cell) and myoglobulin (protein that speeds up the conversion of calcium ions) Usually used in walking and sprinting. 4

Type 2b fast-twitch glycolytic (uses blood sugar) are less fatigue resistant and depend on more glycolytic sources of energy. Usually used in strength training such as weight lifting.

Upper Crossed Syndrome

Involves the following imbalance:

Pectoralis Major and Minor    All tighten and shorten    Tonic or Postural Muscles
Upper Trapezius
Levator Scapulae
Sternocleidomastoid

While

Lower and Middle Trapezius    All Weaken            Phasic Muscles
Serratus Anterior
Rhomboid Major and Minor

When this occurs they alter the relative position of the head, neck and shoulders as follows:

1.    Occiput with C1 and C2 hyperextend with the head translating anteriorly
2.    The lower cervicales down to 4th thoracic are now stressed.
3.    Rotation and abduction of the scapula occur as the upper trapezius and levator scapulae become shortened and contracted.  This inhibits the lower trapezius and serratus anterior.
4.    As a result the scapula loses stability, which puts excess demand on the humerus now involving the levator scapulae, upper trapezius and supraspinatus to maintain functional efficiency.

Janda believed that by identifying the shortened structures and releasing these, they will improve overall function and posture.

Lower Crossed Syndrome

The lower-crossed syndrome involves the following imbalance:

Tonic or Postural Muscles
Iliopsoas, Rectus Femoris, Tensor Fascia Latae and Erector Spinae group

All tighten and shorten

While
Phasic Muscles
Abdominal and Gluteal    All weaken

Resulting in a reaction that tilts the pelvis forward on the frontal plane. Flexing the hip and exaggerating lumbar lordosis.  L5-S1 will have soft-tissue and joint distress with accompanying pain and irritation.

Also on the sagittal plane:

Quadratus Lumborum     Shortens

While

Gluteus Maximus and Medius    Weaken

With the instability of the lower cross, the sacroiliac joint becomes unstable and you start to find piriformis involvement.  Thus piriformis syndrome can be present.5

Many researchers have studied how muscle function affects posture.  The understanding of the body’s adaptability and how fibre types can change based upon the demands that function places upon structure has been a prevailing approach.

Anatomic and Physiologic Adaptations to Stress

Several authors continue the discussion of posture by viewing physiologic changes from factors that result in a complex sequence of events activated as a result of stress responses to soft-tissue structures. 6.

1.    Congenital and inborn factors
2.    Overuse, misuse and abuse
3.    Immobilization, disuse
4.    Postural stress
5.    Inappropriate breathing patterns
6.    Chronic negative emotional states such as depression and anxiety
7.    Reflexive influences (trigger points, facilitated segments)

Others view anatomic approaches

1.    Laxity of ligamentous structures
2.    Fascial tightness
3.    Muscle tonus
4.    Pelvic angle
5.    Joint position and mobility
6.    Neurologic outflow and inflow. 6

As a result of these types of factors a sequence of events can occur that have dramatic effect and consideration for the manual therapist.

The events are systemic and physiologic.  Without listing the complete list, here are the highlights:

•    ‘Something’ leads to increased muscular tone.
•    If increased tone is anything but short term you have metabolic waste build-up.
•    Increased tone means simultaneous local oxygen deficiency.
•    Ischemia, although not a producer of pain, is a major contributor of pain.
•    Increased muscle tone over long period leads to a degree of increased oedema.
•    All these factors, retention of waste/ischemia/oedema all contribute to creating pain.
•    Pain reinforces hypertonicity.
•    Inflammation may result.
•    Neurological reporting stations in these distressed tissues bombard the CNS with information regarding their status leading in time to a degree of neural sensitisation and hyperirritability and hyper activity.
•    Macrophages are activated, increased vascular and fibroblastic activity
•    Connective tissue production increases with cross linkage, leading to shortened fascia
•    Chronic muscular stress results in gradual development of hysteresis in which collagen fibres are rearranged to produce an altered structural pattern.
•    This results in tissues that are far more easily fatigued and prone to damage, if strained.
•    Since all fascia and other connective tissue is continuous throughout the body, any distortions that develop in one region can potentially cause fascial deformation elsewhere.
•    Hypertonicity in any one muscle will produce inhibition of its antagonists and aberrant behaviour in its synergists.
•    Energy wastage leads to unnecessarily sustained hypertonicity and an excessively active musculature leads to generalized fatigue and local energy crises, i.e. Trigger points.
•    These in turn create functional changes that affect respiratory function and body posture!  7

When we observe the posture of a client, we have in front of us a very complex picture.  We are in a sense seeing a current end product based upon a variety of factors that have caused the body form to be in the condition your presented with.

We need to look beyond assessing and observing asymmetries or contracture of certain muscle groups. We need to take into account other considerations. These considerations are those that are directly linked with our internal sensory awareness and the physiologic changes that occur from an over stimulated and highly stressed nervous system.

Alternative Postural Influences

• Autonomic nervous system and soft-tissue release

• Alternative postural and autonomic influences:

• Sympathetic activation, habituation and response to stress

• Hans Selye’s theory

The Autonomic Nervous System

The autonomic nervous system ANS is best known for its regulation of the sympathetic SNS “flight or fight” response and the parasympathetic PNS “rest and repose” response.  The SNS and PNS work together to maintain homeostasis through a feedback loop system.  Excessive sympathetic “tone” (Shea 1996) or output causes most of the stress related disorders that physicians encounter.

What is important to manual therapists is the relationship the ANS has with soft-tissue release and postural dysfunction.

All soft tissue has sympathetic innervation.  There is virtually no parasympathetic innervation of your soft-tissue.  All of your cardiovascular system has a sympathetic nerve attached to it.  Therefore it is the regulator of your vasomotor system.  The rate and flow of blood is controlled by the SNS. So neuromuscular and cardiovascular systems are sympathetically regulated.

The vagus nerve, the 10th cranial nerve that innervates the head, neck, thorax and abdomen is a mixed sensory and motor nerve and has 75% control of your parasympathetic system, and has some control over the heart and viscera.  The parasympathetic part helps regulate the visceral system (digestive organs) and forms a link to your enteric (gut) nervous system.

The parasympathetic system is called the cranial-sacral system with the vagus nerve and in the pelvis the sacrococcygeal plexus. The sympathetic system is called the thoraco-lumbar based upon nerve root plexuses.

There is a tuning or mediation between the two systems.  Since the sympathetic is the highest consumer of energy in the body, producing more waste, and using more oxygen, it is considered the primary system of the body.  The viscera or enteric nervous system keeps digesting food and producing amino acids along with fatty acids and fuel for metabolism.  When we start to stress, abuse or misuse our bodies, not have proper exercise, all of this begins to tighten the soft-tissue. This in turn decreases activity of the viscera with much more over-stimulation of the neuromuscular system occurring.  Over time this imbalance becomes the General Adaptive Response (Seyle 1984).  Soft-tissue dysfunction becomes prominent, including ulcers, diarrhoea, irritable bowel syndrome, constipation, etc, and with continued habituation comes adaptation and comprising the immune system. 8

This has a profound effect on our soft-tissue and postural dysfunction.

Adaptation, Habituation and Response to Stress

Selye’s:

• General Adaptation Syndrome GAS

• Local Adaptation Syndrome LAS

At the heart of postural considerations is the important premise of habituation. A prominent theory introduced is based upon the research of Hans Selye (1956).  Selye has contributed in understanding how adaptation and habituation –GAS and LAS is in relationship to somatic and postural dysfunction.

” That musculoskeletal dysfunction is a result of adaptive demands exceeding the capacity to absorb the load, while attempting to maintain something approaching normal function.  Elastic limits may at times be exceeded, resulting in structural and functional modifications.  Assessing these dysfunctions patterns-making sense of what can be observed, palpated, demonstrated- allows for detection and guidance towards remedial action.”
The demands that lead to dysfunction can either be forceful, violent, single events or they can be cumulative influence of numerous minor events.  Each such event is a form of stress and provides its own load demand on the local area as well as the body as a whole
.
Selye called stress the ‘non-specific element’ in disease production. He described the general adaptation syndrome as being comprised of three distinct stages:

•    the alarm reaction when initial defence responses occur (‘flight or fight’)
•    the resistance (adaptation) phase
•    the exhaustion phase (when adaptation fails) where frank disease emerges.

GAS affects the organism as a whole whilst LAS Local Adaptation Syndrome goes through the same steps but ofcourse is local in its orientation.  Repetitive activities over long periods of time result in somatic and muscular adaptation that can result in chronic hypertrophy of specific muscle groups.  The same activity repeated over time sees the body respond to the demand by adapting to the needs placed upon it.  When the demands become excessive, that is usually when we see injury or postural dysfunction.  When an individual is acutely alarmed, stressed or aroused, homeostatic mechanisms are activated.  If the alarm status is prolonged or if adaptive demands are excessive, long-term chronic changes can occur and these are at the expense of optimal functional integrity.”

“ The results of repeated postural and traumatic insults over a lifetime, combined with somatic effects of emotional and psychological origin, will often present a confusing pattern of tense, shortened, bunched, fatigued and, ultimately, fibrous tissue.”  9

Part 2

Sensory Awareness and Movement Modalities

• Thomas Hanna and Somatics

• Moshe Feldenkrais

• F.Mathias Alexander

Thomas Hanna’s Somatics

Thomas Hanna (1928-1990) borrowed heavily from Hans Selyes, Moshe Feldenkrais and F.Mathias Alexander’s research to develop a modality that sought to counteract the habitual state of forgetfulness called sensory-motor amnesia.

Hanna goes on to say in his book on Somatics, “It is a memory loss of how certain muscle groups feel and how to control them.  And, because this occurs within the central nervous system, we are not aware of it, yet it affects us to our very core. The reflexes that cause sensory-motor amnesia are very specific.  There are three…named Red light reflex, Green light reflex and Trauma reflex.”

Red Light Reflex.  (Left)

Essentially Red Light reflex is associated with the abdominal muscles and what Hanna termed the Withdrawal Response.  It is associated with distressful events.  It is a protective response to negative events that threaten us.

From head to toe, the Red Light reflex involves the following movements:

Closing the eyes, tensing the jaw and face, pulling forward of the neck, lifting of the shoulders, flexing the elbows, clenching the fists, flattening the chest, tightening abdominal muscle, contracting the diaphragm and holding the breath, contracting perineum including sphincters of the anus and urethra, contracting gluteus minimus muscles to rotate thighs inward, thus feet are pigeon toed, adduction of the thighs, contraction of the hamstrings to bend knees, flexing and supinating the feet. (Each foot lifts and inverts, tilting up the arch) the sensory feedback of all these movements constitutes the subjective feeling of the Red Light Reflex: Fear.

Green Light Reflex (Right)

From head to toe, the green Light Reflex involves the following movements:

Opening the eyes, jaw and face, pulling backward of the neck, pulling downward of the shoulders, extending the elbows, opening of the hands, lifting the chest, lengthening the abdominal, relaxing the diaphragm and freeing breathing, relaxing anal and urethral sphincters in the perineum, contracting the gluteus medius muscle to rotate the thighs outward (feet are duck like), abduction of the thighs, contraction of the thigh extensors to straighten the knee to hyper-extension, extension and pronation of the feet.  The sensory feedback of all these movements constitutes the subjective feeling of the Green Light Reflex-Effort. 10

Trauma Reflex

The trauma reflex according to Hanna is a reaction of the sensory-motor system in response to pain.  It seemingly causes the body to tilt.  Hanna viewed scoliosis, as a sideways twisting that was a result to some trauma that has occurred sometime in a person’s life.  Triggered by an injury, a fall, severe damage to the body, surgery, and whiplash all cause a protective pattern around the site of the injury.

Hanna went on to create a series of Somatic exercises whose primary task is to focus your attention on the internal sensations of movement.  By paying attention, moving slowly and gently with the least possible effort, not forcing any movement, you can clear the brain to receive uncluttered sensory feedback, thus aiding in alleviating a variety of postural and somatic dysfunctions. 11.

The Feldenkrais Method

The Feldenkrais method is a system that approaches human development and the improvement of functioning through physical movement and directed touch. How we learn and form habits is of central importance in the practice of the Feldenkrais method.  Our posture and the ways that we move were learned, even if the learn is not conscious.  Thus, physical difficulties or limitations are seen from this perspective, as the result of either incomplete learning or trauma that can lead to dysfunctional habit patterns.  The Method utilizes functionally based variation, innovation, and differentiation in sensory motor activity to break down habitual patterns and allow new ways of thinking, feeling and action to emerge. 12

Some quotes from Moshe Feldenkrais (1904-1984), give a flavour of how posture is integrated in his approach.
“The way the mind and body are united has preoccupied human beings throughout the centuries. ‘A healthy mind in a healthy body’ and similar sayings show a conception of one kind of unity.[...]
I believe that the unity of mind and body is an objective reality. They are not just parts somehow related to each other, but an inseparable whole while functioning. A brain without a body could not think; at least, the continuing of mental functions is assured by corresponding motor functions.
[...]
There is little doubt in my mind that the motor function, and perhaps the muscles themselves, is part and parcel of our higher functions. This is not true only of those higher functions like singing, painting and loving, which are impossible without muscular activity, but also of thinking, recalling, remembering and feeling.
The advantage of approaching the unity of mental and muscular life through the body lies in the fact that the muscle expression is simpler because it is concrete and easier to locate. It is also incomparably easier to make a person aware of what is happening in the body; therefore the body approach yields faster and more direct results. On acting on the significant parts of the body, such as the eyes, the neck, the breath, or the pelvis, it is easy to effect striking changes of mood on the spot.
[...]
A person is made up of three entities: the nervous system, which is the core; the body – skeleton, viscera and muscles; and the environment, which is space, gravitation, and society. These three aspects, each with its material support and its activity, together give a working picture of a human being.
[...]
Individually acquired action (onto genic action) pertains to the senses. Such action can be altered or learned as one can become aware of the actual differences, such as the extent of the effort, its coordination in time, the body sensation, the spatial configuration of the body segments, the standing, the breathing, the wording, etc.
This kind of aware learning is complete when the new mode of action becomes automatic or even unconscious, as all habits do. The advantage of a habit acquired by awareness is that when it shows unfitness or maladjustment when confronted with reality, it easily provokes new awareness and so helps one to make a fresh and more efficient change.
My inmost belief is that, just as anatomy has helped us to get an intimate knowledge of the working of the body, and neuroanatomy an understanding of some activities of the psyche, so will understanding of the somatic aspects of consciousness enable us to know ourselves more intimately. 13.

Posture and Alexander Technique

It is a testament to the power of this method that it has endured the passage of time to still be extremely relevant and timely in a world out of touch with internal sensory awareness.
Born in Tasmania, F.M.Alexander (1869-1955) was a successful actor and reciter whose career was cut short by loss of voice during performances. With no help forthcoming from the medical profession, Alexander undertook an intensive examination of himself in action, convinced that the source of his voice problem lay in the way he used his body. A long period of research led him to discover certain principles affecting mind/body co-ordination applicable to every kind of physical activity.  With this knowledge he went on to cure his own voice problem and found hat he could also help others.

It was at this point that teaching his method became the main focus of his life.
Alexander arrived in England in 1904 and during the next 25 years built up a practice in London and the USA. He had many influential supporters among those were Sir Henry lrving, John Dewey, Aldous Huxley and Sir Stafford Cripps.
In 1931 he began training others to teach the Technique and continued to do so until his death at the age of 86.
Today the importance of Alexander’s discoveries is confirmed by the existence of a rapidly growing body of teachers of his method.

Quotations:

You come to learn to inhibit and to direct your activity.
You learn, first, to inhibit the habitual reaction to certain classes of stimuli, and second, to direct yourself consciously in such a way as to affect certain muscular pulls, which processes bring about a new reaction to these stimuli.’

Boiled down, it all comes to inhibiting a particular reaction to a given stimulus.
But no one will see it that way. They will see it as getting in and out of a chair the right way. It is nothing of the kind. It is that a pupil decides what he will or will not consent to do. They may teach you anatomy and physiology till they are black in the face – you will still have this to face, sticking to a decision against the habit of life.
There is no such thing as a right position, but there is such a thing as a right direction.

You can’t do something you don’t know, if you keep on doing what you do know.
Trying is only emphasizing the thing we know already Sensory appreciation conditions conception – you can’t know a thing by an instrument that’s wrong.
To know when we are wrong is all that we shall ever know in this world.

You are not here to do exercises or to learn to do something right, but to get able to meet a stimulus that always put you wrong and to learn to deal with it. 14

How does the Alexander Technique reduce stress?

F. M. Alexander identified the fact that most of us are in a perpetual state of “fight or flight syndrome”; also know as the startle response. If you have ever seen a newborn or young infant react to a loud, unexpected noise, you may recall their shoulders come up to their ears and their heads are pulled or fall back – they are clearly startled by the experience. In a few moments, as the event passes, they return to their prior state, which is relaxed, alert, and engaged.
As we grow up in our fast paced society, we face a constant onslaught of stressful events. We are in the process of recovery from one event when yet another stimulus hits our systems, and so we begin to function in a constant state of startle response. Because our nervous system adapts to the new level of stress, we cease to register it as too much and so never fully return to the easeful state of the newborn. Instead, we increase muscular effort throughout our lives. The analogy I use to describe this constant state of over-contraction is that of driving with the parking brake on. We use much more energy to perform simple activities than we actually need, which are a wasteful process.
F. M. Alexander’s recognition that his sensory feedback was unreliable gave him a window into changing his chronic overuse of muscle effort to a more efficient, appropriate level when accomplishing his activities. By learning to inhibit his startle response upon receiving stimulus, he was not only able to change muscle tension in his body; he was also able to change the biochemical messages being sent through his nervous system. What was once stressful when performed with the old habit patterns became easeful, poised and appropriate to the task at hand. This tool of inhibiting the old response is a skill that can be learned and enhanced with practice. This is how the Alexander Technique reduces psychophysical stress. 15

Part 3 Gravitational Orientations

• Rolfing

• Structural Integration: The Guild

• Structural Integration: The Institute

• Hubert Goodard and Tonic Function

Rolfing: Structural Integration

Structural Integration, the offspring of Ida Rolf, began by attempting to view the body three-dimensionally as an aggregate of blocks attempting to balance in the flow of gravitational energy. 16

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, 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 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 its lack 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.” 17.

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.

Schools of Gravitation Orientation

Ida Rolf’s influence in the realm of a broad worldwide movement along with the likes of Moshe Feldenkrais and Mathias Alexander has been significant. Be it those who have attempted to be the keeper of the realm such as her advocates in the Guild for Structural Integration whose mission is to keep intact the teachings and message Rolf promoted.

Her is an excerpt from the Guild’s website:

The Guild is dedicated to the traditional teachings of Dr. Ida P. Rolf. The product of her life’s work and teaching is the “Recipe”; a ten- session sequence of structural, fascial and educational goals which establishes order in human structures. Due to its efficacy in symptom alleviation, both physical and emotional, there is little doubt that the Recipe will survive in various forms as techniques; it is not certain that it can endure as art and craft without the special dedication of those individuals who are inspired by the potency of intention and wisdom of process concealed within. The Recipe is not technique. The Recipe is more than a discrete succession of myo-fascial goals and intentions. The Recipe is, rather, a process, based on a set of relationships, which establishes structural balance and order. These relationships are based upon sound theoretical physics as well as some traditional metaphysical hypotheses. Relationships belonging to the realm of art,  are non-linear. Technique is better suited to scientific and linear analysis. The Recipe, as taught in other schools, has been modified or, perhaps, specialized in several ways. Some of these modifications ignore the underlying priorities in Dr. Rolf’s teaching. The Guild is formed to insure that the Recipe does not lose its potency of intention, its expression as art, nor its comprehension as process

Dr. Rolf’s teaching emphasizes the concept of the personal line of vertical intention, the “Line.”
The Line passes through the centres of gravity of the body’s vertical blocks. The Line, in our concept of the Structurally Integrated human, does not pass through bone, except at the top of the head. In actual fact, this weight-bearing line does pass through bone in all but the most exceptional human structures. Indeed, it was Dr. Rolf’s observation that our species had not yet successfully completed its journey to uprightness. The Recipe is designed to offer personal assistance in this evolutionary voyage. The emergence of the unstressed vertical, the Line that passes only through soft tissue is evidence of progress toward this goal. The Line being defined as a set of theoretical points in space is not real, but experiential, and it can be, perhaps, must be, intentional. The horizon is the horizontal reference for the Line. The shoulder girdle and the pelvic girdle must contain true horizontal balance to define and support vertical extension. The Line goes through the top of the head and through the bottom of the feet to infinity. The Line forms a relationship between the field, which is man, and the field, which is earth, the field of gravity. The Line is transcendental, it relates the realm of material particles, of basic physics to the non-material, the world of energy fields. While Dr. Rolf’s metaphysical hypotheses concerning the Line are not original, her use of the Recipe as a tool for exploring them is unique. The idea of using a vertical line of extension to integrate one’s personal energy field with the energy field of the earth is a compelling idea with both practical and visionary implications. The Guild recognizes the singular importance of the Line as raison d’ etre for the recipe. We believe that effort to clarify and develop a clear sense of vertical extension should be a path for personal growth. And further, that instruction concerning the Line is an essential educational aspect of the practice of Structural Integration.

Whilst those that did not wish to remain true and in their words “static” to the teachings of Rolf, decided to evolve the teachings and continue the exploration of human uprightness that we refer to as posture along varying lines. 18

The Rolf Institute of Structural Integration excerpt about its ‘ raison d’etre’ has a similar flavour:

Rolfing® Structural Integration is named after Dr. Ida P. Rolf. She began her inquiry more than fifty years ago, devoting her energy to creating a holistic system of soft tissue manipulation and movement education that organized the whole body in gravity; she eventually named this system Structural Integration. She discovered that she could achieve remarkable changes in posture and structure by manipulating the body myofascial system.
“Rolfing” is the nickname that many clients and practitioners gave this work, and is now a registered service mark in 27 countries. Rolfing structural integration has an unequalled and unprecedented ability to dramatically alter a person”””””””””””””””’’s posture and structure. Professional athletes, dancers, children, business people, and people from all walks of life have benefited from Rolfing. People seek Rolfing as a way to ease pain and chronic stress, and improve performance in their professional and daily activities.

It is estimated that more than 1 million people have received Rolfing work.
Research has demonstrated that Rolfing creates a more efficient use of the muscles, allows the body to conserve energy, and creates more economical and refined patterns of movement. Research also shows that Rolfing significantly reduces chronic stress and changes in the body structure. For example, a study showed that Rolfing significantly reduced the spinal curvature of subjects with lordosis (sway back); it also showed that Rolfing enhances neurological functioning.  19

It is in this fertile ground of investigative bodywork that very interesting approaches to working with and treating postural dysfunctions are presented and practiced.  One such theory to postural dysfunction has come from the work of Hubert Goodard.

The Theory of Hubert Goodard

Course Notes From Body Wisdom Conference

I had the brief pleasure to attend one of Hubert Goodards mini workshops that he gave at the Body Wisdom Conference held at the Coramandel Peninsula in New Zealand in February 2003. I confess I was taken by his elegance and his approach to viewing posture.  One of the ideas that I came away with is how profound a person’s internal sensory awareness is to how people orient themselves in space.

Goodard had us become aware of both external awareness and breath along with internal awareness in breath.  He had us perform an exercise where you would coincide the rhythm of a persons breathing with very small movements of internal and external rotation of the lower legs.  Whilst the practitioner attempted to coincide that particular rhythm, the client would breathe in an external awareness and breathe out an internal awareness.  This awareness had interesting effects on various individuals.  Although all is anecdotal, I still found it interesting what other practitioners and body workers described as their experience.

Some reported an altered state of awareness (consciousness?); others found that at least temporarily there was improved mobility.  What is it that Goodard is trying convey and what to what end does it affect posture?

From the notes I took I will attempt to convey what he presented.

He entitled his lecture/workshop Posture, Breathing and Sensory Habits.  Goodard gave a historical perspective.  In our mind or head we have an internal awareness of how our body moves, a map so to speak that he labelled ‘schema’.  We also have a body image of ourselves that is internal in orientation but we can get a sense of when for instance, we look at ourselves in a mirror.

So we have a body image and we have the real body. The schema or map is our relationship with oriented space.

We have an ongoing relationship with our image, our map or schema and our real body.
That relationship is imposed upon our real body, or as Goodard referred to as the organic body.  Their exist a symbolic relationship we have with our organic body that includes our body image and our map.  We have opportunities to ‘touch’ this image and map which represents a potential for action.

And when we view postural dysfunction are we seeing our organic real body or our body image?

Goodard also look at breath as not belonging to the body but to the ‘relationship’ with the image and map.

So the schema then represents the ‘Where” we are, the ‘MAP”, in oriented space.
And where we are in our body. And where we are in the world. And where we are in our selves.

The body Image represents the ‘Who I Am”.

The schema or map is linked to our surroundings.

The first thing we do as human beings is grasping our orientation to that surrounding.  It is in our short-term memory at an unconscious level.  This is the proprioceptive activity versus the awareness of proprioceptive, this is our body image.  All of this proprioceptive activity, vision, sound, skin, inform the body schema and is completely linked to the surroundings.

He goes on the state that the Image of who I am can become disconnected from the surroundings.

He looked at long-term memory, the cortical, the word memory, this is the Who I am.
The who is connected with perceptual activity, with emotions (limbic system interface with the conscious and the unconscious) and with conceptual belief systems.

Goodard said the image of who I am is coming outside of ‘who I am’.  The feedback I receive from outside my self is how I build my body image.  He gave an example; we have a child without arms. The schema or map has no proprioception on the organic real body, but does have an image because of the reflection the child has of humanity with arms.

The self is exproprioceptive.  The question of the interconnection between the two is of tremendous import.

We know that there is a strong mind-body link with belief systems.  If you think, conceptualise a problem, i.e. breast cancer, it can physically manifest.  And the person with breast cancer will see a retracting breast in their body image that can create reduction in a physical sense.

Goodard believes ‘conception’ changes ‘perception’. This has an emotional component along with it.  Our brain has a somatic sensory and motor map in the cerebral cortex.  When there is a loss of sensation, other parts of the brain take over and the area is ‘lost’ (Goodards words).

If we discuss exproprioceptive awareness we can include the sense of sight.  We have

GAZE 
Fovea Centralis (rod less area of the retina that affords acute vision) vs. Peripheral Vision

BODY IMAGE 
Fovea relates to the Cortex whilst the Peripheral is Subcortical

So essentially Goodard is saying that our ‘Where’, our schema or map is peripheral, subcortical and not attached to language.  The ‘where’ in seeing feeds the body schema.  So that Gaze is an interpretation.  When we look at ourselves in a mirror we see our ‘self’ but the point Goodard makes is we are seeing our body image.  He said to look as if seeing someone behind the mirror.  That is look for your image.

SIGHT is SCHEMA-MAP

GAZE is IMAGE

Goodard used an example of when we have surgery.  We have scar tissue.  The metaphor or image is the body still feels as if the knife is still in the body.  We need to rebuild where the wound is in the body image.

Finally he made a distinction between the GROUND and SPACE.  He said we tend to strongly organize and identify with either one or the other.

I would be disingenuous if I said I understood from my note taking that a Frenchman speaking English as a second language, I understood what he was attempting to convey!  In fact I had more questions than any clear understanding.  So it motivated me to search out a clearer understanding of his work.  That led me onto various Rolfing sites that helped somewhat with my lack of understanding about his theory. 20

What follows is from the work of two advanced certified rolfers who have studied with and written about Hubert Goodards work, Kevin Frank and Arline Newton.  What I have gleaned is articles that were published in the mid 1990’s in Rolf Lines, a research publication for Structural Integrationists.

Tonic Function: Basic Concepts in the Theory of Hubert Goodard

I will draw heavily on Arline Newton’s published work of Hubert Goodard theory that appeared in the March 1995 Rolf Lines publication.  You can read and/or download the complete article from www.resourcesinmovement.com/Articles.

The basic premise that Newton states about Goodard is a key insight of Rolfing in general, that we need to have an appropriate relationship with gravity that is basic to our health.  From a structural point of view, this relationship is commonly described in terms of alignment.  From a functional point of view, it is described in terms of biomechanics, studying the movement of various joints and the impact of forces upon them.  Newton goes on to state,” … that both perspectives carry a kind of objectification, a denial (or ignoring) of human experience….Alignment and mechanics leave out the effect of what is occurring in the mind/body of the individual involved.”

Newton says the consideration of experience is phenomenological. That is philosophers wanted to study the perceptual experience in a purely subjective aspect.  Not at all accepting a traditional division of subject and object.  From this perspective the body does not exist separately from the body as lived.  A person does not exist separately from the environment but is embedded in it.  We do not live in a vacuum, so therefore it behoves us not to study the human form as if we do.

Action Systems

Newton visited the work of Edward Reed, who studied motor responses.  He observed most studies took place in a laboratory under artificial conditions.  Often to isolate specific movements, that is studied outside of the context.  In fact all movement is takes place in context.  And to some extent we now study the body in context especially when assessing performance athletes.  Reed suggested the study of movement be taken in terms of functions-which he called action systems.  These included the locomotion system that we amble around in, the expressive system that allows us to look and listen, and the semantic system that lets us speak.  The concept allows movement to be studied in terms that make sense.  These are purposeful activities that cannot be reduced to the sum of individual motor units.  And it cannot be studied separately from the function.  We begin to acquaint behaviour with structure and function.

The fundamentals of these action systems are the activities of lying, sitting or standing.
These basic activities enable of to survive and thrive and have a viable relationship within the gravity field.

Tonic Function

Goodard calls the body’s ability to organize itself in gravity, ‘tonic function’.

Tonic function is fundamental, and is at the root of every action.  It is taking place below the level of conscious awareness.

The example Goodard and Newton describe is you are standing and are asked to raise your arm.  What is the first muscle to contract when performing that action?  Most will imagine arm or shoulder muscles, but in fact the answer is the soleus muscle.  It is a key muscle in maintaining uprightness in gravity.  “Even before the intended movement occurs, the gravitity function is ensured.”

Anatomically tonic function involves the part of the body- brain, nerve pathways, fascia, muscle spindles, Golgi tendon organs and tonic muscles- all functions to coordinate the body’s negotiation with gravity.  What Newton will describe is that an individual’s particular tonic organization cannot be adequately described without taking more than anatomy into consideration.  It cannot be re-educated without a broader vision.

Uprightness

For human beings, the relationship with gravity is expressed in how we stay upright, or oriented.  This is one of the essential aspects of our uniqueness as human beings.  If we are unable to maintain uprightness, it becomes more than a problem with standing.  It is the fundamental basis for our emotional and psychological orientation with the world.

Newton equates uprightness as having a symbolic dimension.  It is a problem with significance and meaning in life.  Our language metaphorically as with touch, reflects this orientation, as we link verticality with morality; an ‘upright individual’, or a person of ‘good standing’.

If as Newton quotes Erwin Strauss in an article entitled Upright Posture,” …because upright posture is the ‘leitmotiv’ in the formation of the human organism, an individual who has lost or is deprived of the capacity to get up and keep themselves upright, depends for his or her survival, completely on the aid of others.  Ultimately without their help the organism is doomed to die.  A biologically oriented psychology must not forget that upright posture is indispensable condition of man’s self-preservation.”

What Newton claims is that when we view posture from this perspective we are tapping into a “primordial, instinctive relationship that is so profound as to be almost invisible.”

Tonic Function and Individual Development

The key concept that Strauss continues to elaborate upon is that upright posture characterizes the human species.  “Every individual has to come to terms with gravity and their own unique uprightness.  Psychologically this comes with the development of the ability to control movement.”

Newton states,  “the nerves and muscles that make up the tonic system-that register and respond to our changing relationship with gravity-these are the very same pathways that will fulfil this basic developmental function.”

Their has been numerous research done on patterns of movement and childhood development.  Newton sites Judith Kestenberg, a psychoanalyst trained in Laban movement.  Kestenberg describes the patterns of movement developed in infancy.  “The simpliest explanation for changes in muscle tension is the physiological interplay between agonist and antagonist muscle groups.  A free flow of tension occurs when agonists are not met with counteraction by antagonists.  The constraint in movement called the bound flow of tension, occurs when antagonists contract along with agonists.
A newborn infants toes stiffen periodically in bound flow.  His/her legss fling and bicycle in spurts of free flow.  An influx of suddenly emrging free flow, may enable him/her to hold its fist there for a brief moment.”

These movements form the basis of interaction with the enviromewnt.

The shape of the body changes during movement.  As we inhale and exhsale, it changes shape. We grow with the ingestion of food, and shrink with the expelling of waste.  We grow toward pleasant stimuli and shrink away from noxious.  Growing and shrinking are the basic elements of shape flow.  They alternate periodically, this rythymic alternation…provides a structure for the organisms interaction with their environment.

Goodard believes that tension flow and shape flow are basis of movement patterns.

And he suggests these are related to the tonic system.

Tonic Function and Communication.

Newton continues the discussion by quoting the previous authors that “we learn from movement studies that their is not only a correspondence between specific drives and specific objects, but also a correspondence between certain feeling tones and modes of expression.”

When we become annoyed, we express that by a furrowing of our brows, while pleasure is recognized by others when we broaden our face when smiling.

References

1.    Laughlin, Kit 2004 website http://www.pandf.com.au/pages/articles/articles.html
2.    F.P. Kendall, McCreary E.K. 1983 3rd Ed. p 270.
3.    Frank, Kevin, March 1995 ‘Tonic Function’ ROLF LINES p.3
4.    Chaitow, Leon, De Lany Judith Walker, 2000 Clinical Application of Neuromuscular Technique, Vol 1 Chap 2 Muscles p 22, Juhan, Deanne, 1987 Job’s Body: A Handbook for Bodywork Chap 5 Muscle p 128, Tortora, Gerald, Grabowski, Sandra, 2003, Priniciples of Anatomy and Physiology 10th Ed. Chap 10 Muscle p296)
5.    Chaitow, Leon, De Lany Judith Walker, 2000 Clinical Application of Neuromuscular Technique, Vol 1 Chap 5 Patterns of Dysfunction, pp 55-57
6.    Chaitow, Leon, De Lany Judith Walker, 2000 Clinical Application of Neuromuscular Technique, Vol 1 Chap 4 Causes of Musculoskeletal Dysfunction pp 43-44, Magee, David J., 1992 Orthopaedic Physical Assessment, 2nd Ed. Chap 15 Assessment of Posture, p. 581
7.    Chaitow, Leon, De Lany Judith Walker, 2000 Clinical Application of Neuromuscular Technique, Vol 1 Chap 4 Causes of Musculoskeletal Dysfunction pp 44-45.
8.    Shea, Michael, 1995 Myofascial Release Textbook, Expression of the Autonomic Nervous System pp45-46
9.    Chaitow, Leon, De Lany Judith Walker, 2000 Clinical Application of Neuromuscular Technique, Vol 1 Chap 4 pp 44-45.
10.    Hanna, Thomas,1988  Smantics: Reawakening the Mind’s Control of Movement, Flexibility and Health. Chap 10 The Sum of Neuromuscular Stress p68)
11.    ibid. Chap 13 How to Give Yourself the Maximum Benefit of Somatic Exercise p 97
12.    Johnson Don Hanlon, 1997, Groundworks, Narratives of Embodiment: Editor, Elizabeth Beringer article pp 81-82.
13.    Dr Moshé Feldenkrais, Body and Mind (article), 1980
14.    Alexander Website
15.    Lieb, n. Brooke, 2001Certified Teacher of the Alexander Technique; Member, American Society for the Alexander Technique (AmSAT); Faculty Member, American Center for the Alexander Technique (ACAT); brookelieb@mindspring.com o www.brookelieb.com Alexander Technique
16.    Rolf, Ida P., 1977 Rolfing, The Integration of Human Structures, Chap 2 Roadmap to Structure p30)
17.    ibid.
18.    http://www.rolfguild.org/mission.html
19.    http://www.rolf.org 2000 the Rolf Institute, 205 Canyon Blvd., Boulder, CO 80302, USA
20.    Goldstein, Steven, 2003, Course Notes on Lecture-Demonstration by Hubert Goodard.  February 2003 at The Body Wisdom Conference, Waimana, Coromandel, New Zealand.

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/

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.