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”””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””’’s 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 (it”””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””’’s the first area to be affected by Alzheimer”””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””’’s 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 patient”””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””””’’s 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

February 21st, 2010 in  Geelong, Victoria

Scheduled for Geelong, Victoria Sunday February 21st

Contact: Pippa Tuppen for registration & costs

Continuing Learning Officer AAMT
Level 6, 85 Queen Street,Melbourne  VIC  3000

Phone: 1300 138 872    fax:      03 9602 3088
Email: pippa@aamt.com.au Web: www.aamt.com.au

AAMT Sponsored IFR Introductory Workshop

February 27th, 2010 in Sydney, NSW

Scheduled for Sydney, NSW Saturday February 27th

Contact: Pippa Tuppen for registration & costs

Continuing Learning Officer AAMT
Level 6, 85 Queen Street,Melbourne  VIC  3000

Phone: 1300 138 872    fax:      03 9602 3088
Email: pippa@aamt.com.au Web: www.aamt.com.au

AAMT Sponsored IFR Introductory Workshop

February 28th, 2010 in Newcastle, NSW

Scheduled for Newcastle (Hunter), NSW Sunday February 28th, 2010

Contact: Pippa Tuppen for registration & costs

Continuing Learning Officer AAMT
Level 6, 85 Queen Street,Melbourne  VIC  3000

Phone: 1300 138 872    fax:      03 9602 3088
Email: pippa@aamt.com.au Web: www.aamt.com.au

IFR Foundations 3 Day Course Armidale, NSW

March 12-14th, 2010

Scheduled for Armidale, NSW March 12-14th, 2010

Cost: $625 includes morning & afternoon tea

Armidale Bowling Club, Armidale, NSW

Contact Katie Byrnes  0428 438 580

IFR Level 1 Melbourne Course

March 27-28th, 2010

Scheduled for: Melbourne, Victoria, Australia Date: March 27-28th, 2010

Cost: $425
Venue:
Melbourne High School-South Yarra Sports Centre
679 Chapel Street, South Yarra, Victoria

To register contact Steven Goldstein
Phone: 0402 068 658

AAMT Sponsored IFR Introductory Workshop

April 10th, 2010 Brisbane, Queensland

Scheduled for Brisbane, Queensland Saturday April 10th, 2010

Contact: Pippa Tuppen for registration & costs

Continuing Learning Officer AAMT
Level 6, 85 Queen Street,Melbourne  VIC  3000

Phone: 1300 138 872    fax:      03 9602 3088
Email: pippa@aamt.com.au Web: www.aamt.com.au

AAMT Sponsored IFR Introductory Workshop

April 11th, 2010 Gold Coast, Queensland

Scheduled for Gold Coast, Queensland, April 11th, 2010

Contact: Pippa Tuppen for registration & costs

Continuing Learning Officer AAMT
Level 6, 85 Queen Street,Melbourne  VIC  3000

Phone: 1300 138 872    fax:      03 9602 3088
Email: pippa@aamt.com.au Web: www.aamt.com.au

2010  IFR Foundations Queensland-NSW Course

April 16-18th, 2010

Scheduled for: Gold Coast-Kingscliffe, NSW  on April 16-18th, 2010

Cost: Early Bird Registration $575 before March 1st

After March 1st, $625 includes morning & afternoon tea

Venue: Cudgin Leagues Club, Wommin Bay Road Kingscliff, NSW

Local contact: Sonya Leslight  0412 588 709

To register contact Steven Goldstein 0402 068 658

Fibromyalgia Melbourne Course

May 1-2nd, 2010

Includes Fibromyalgia DVD & Manual

Scheduled for: Melbourne, Victoria, Australia Date: May 1-2nd, 2010

Cost: $475
Venue:
Melbourne High School-South Yarra Sports Centre
679 Chapel Street, South Yarra, Victoria

To register contact Steven Goldstein
Phone: 0402 068 658

AAMT Sponsored Sydney Post Conference

One Day Workshop: May 24th, 2010

IFR Fascial Articulations for the Shoulder & Pelvis

Scheduled for Sydney, NSW, Monday May 24th, 2010

Contact: Pippa Tuppen for registration & costs

Continuing Learning Officer AAMT
Level 6, 85 Queen Street,Melbourne  VIC  3000

Phone: 1300 138 872    fax:      03 9602 3088
Email: pippa@aamt.com.au Web: www.aamt.com.au

IFR Level 2 Melbourne Course

June 5-6th, 2010

Scheduled for: Melbourne, Victoria, Australia Date: June 5-6th, 2010

Cost: $425
Venue:
Melbourne High School-South Yarra Sports Centre
679 Chapel Street, South Yarra, Victoria

To register contact Steven Goldstein
Phone: 0402 068 658

Bodywork Professional Development of the UK Presents:

IFR Foundations Workshop-Edinburgh, Scotland

June 18-20th, 2010

Scheduled for  Edinburgh, Scotland: Napier University on June 18-20th, 2010

Contact Nicola Brooks T +44 (0)7526 925734

http://www.bodyworkcpd.co.uk/

info@bodyworkcpd.co.uk

Bodywork Professional Development of the UK Presents

IFR Foundations Workshop-London, England

June 25-27th, 2010

Venue: London, England: British School of Osteopathy

Contact Nicola Brooks T +44 (0)7526 925734

http://www.bodyworkcpd.co.uk/

info@bodyworkcpd.co.uk

AAMT Sponsored IFR Introductory Workshop

July 25th, 2010 Cairns, Queensland

Venue TBA

Contact: Pippa Tuppen for registration & costs

Continuing Learning Officer AAMT
Level 6, 85 Queen Street,Melbourne  VIC  3000

Phone: 1300 138 872    fax:      03 9602 3088
Email: pippa@aamt.com.au Web: www.aamt.com.au

AAMT Sponsored IFR Introductory Workshop

August 8th, 2010 Hobart, Tasmania

Venue TBA

Contact: Pippa Tuppen for registration & costs

Continuing Learning Officer AAMT
Level 6, 85 Queen Street,Melbourne  VIC  3000

Phone: 1300 138 872    fax:      03 9602 3088
Email: pippa@aamt.com.au Web: www.aamt.com.au

Fibromyalgia: Clinical Approaches for the Manual Therapist Sponsored by the Barlen Institute of Massage

October 16-17th, 2010 Central Washington State USA

Venue: Barlen Institute of Massage

201 N. Pine
Ellensburg, WA 98926

509.962.3535
info@barleninstitute.com
Fax 509.962.3185

IFR Foundations Workshop-Pacific Northwest USA

Cortiva Institute-Seattle

October 22-24th, 2010 Seattle, Washington

Venue Seattle, Washington: Cortiva Institute Seattle

Catherine (Weigel) North, LMP
Manager of Continuing Education
Cortiva Institute – Seattle
425 Pontius Ave. N. #100 . Seattle . WA . 98109
t 206-204-3143 (direct) f 206-282-9183
e cnorth@cortiva.com  http://www.cortiva.com

Small intimate class held in Calgary

Great Somatic Awareness! A pleasure to instruct….

Each Foundations class has a different flavour for an instructor…what I can say generally about Canadian practitioners that is different from their American or Australian counterparts, is that their somatic education  is much more institutionalized in the delivery of their underpining knowledge….NHP Canada fosters this and several of the provinces allow for much more somatic content and exploration…that said these participants in my workshops already understand indirect technique, energetic approaches and to a certain part somato-emotional release.  It is an honour and privilege to travel with these folks to interesting places and great heights….

Practicing Spinal Awareness Exercise

I was able to present at the 21st National NHP Canada conference my Fibromyalgia: Clinical Approaches to the Manual Therapist. What a great day! Particpants are practicing an imagery & intent exercise called spinal awareness float using an airbed. Again the quality of presence and somatic awareness was astounding. Luminous moments are the best way to describe the experience. I was astounded as much as the participants were by the results. Great tools to help the Fibomyalgia sufferer.

Also introduced was the Two Point technique & ””Fulcrum”” (Giammatteo) to use with those of great soft-tissue sensitivity.

Front row from left to right : Rowena Langdon, Linda Alexander

Back row from left to right: Linda Howard, Maria Arena, Kristie Melling, Katie Byrne, Steven, Sonya Leslight and Linsie Davies

IFR Level 1 Kingscliff NSW July 2009

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 m