Terra Rosa E-magazine, Issue 16, July 2015 by Terra Rosa

www.terrarosa.com.au

Feature: BioTensegrity

Terra Rosa E-magazine, Issue No. 16, July 2015.

ontents BioTensegrity 2

The shape of nature—Graham Scarr

Biotensegrity, A Brief Historical Perspective—John Sharkey

BioTensegrity, Powering the fabric of human anatomy— John Sharkey & Joanne Avison

The Elastic Body, Introducing Biotensegrity as a model of Elastic Integrity in the moving body—Joanne Avison

Cover reproduced with kind permission from capacitor.org and the photographer RJ Muna (rjmuna.com).

Clinical Study 25

A randomized clinical trial of Structural Integration as an adjunct to outpatient rehabilitation for chronic low back pain: A summary— Eric Jacobson PhD, MPH

Practices & Techniques 31

The Price of Smart Phones: Ten common dysfunctional postures and injuries caused by smart phone use—Joe Muscolino

Putting the Maximus Back into Gluteus Maximus— John Gibbons

Perspectives 45

CORE Structural Integration and Myofascial Therapy: A lifetime of improving structure and function— George P. Kousaleos, LMT

Bringing Up Baby…. Bodywork grows-up from infancy to adolescent— Art Riggs

Research 56

Research Highlights

Pro iles 60

6 Questions to Joanne Avison

6 Questions to John Sharkey

Report 62

Fascial Fitness — Kati Cooper Terra Rosa E-mag 1

The Shape of Nature By Graham Scarr The natural world is full of shapes, from the smallest of crystals to the highest of mountains, and from simple molecular helixes to the complex spiralling of muscles and fascial sheets in the human body (Figure 1). Natural patterns and shapes have been generating wonder since at least the time of the ancient Greeks and caused much speculation in relation to living organisms, but most explanations have been (unfairly) relegated to the realm of the esoteric and fanciful. Modern anatomy has taken many centuries to accumulate a body of knowledge that is now unrivalled in any other sphere. It has classiied structures according to the thinking of the day and sought to 2 Terra Rosa E-mag

understand their functions using the latest technologies, but established conventions have allowed many inconsistencies to survive long past their sell by dates. Orthodox views of human movement, for example, are based on the mechanics of man-made machines described in the seventeenth century and have remained essentially unchanged ever since; but biology is not constrained by the rules of classical mechanics and there is now a better way of looking at functional anatomy. Whenever nature uses the same principle in a variety of different situations there is probably an underlying energetic advantage to its appearance, and biological

development and evolution will automatically favour those patterns and shapes that are the most ef icient in terms of stability, materials and mass. Even though they can appear to be rather complicated, at the most basic level all structures are the result of interactions between atomic forces, and the orderly arrangements that they settle into are governed by some basic rules of physics. Essentially, it is the fundamental and interrelated principles of geodesic geometry, close-packing and minimal-energy that lead to the formation of crystals and molecules, which thus become the physical representations of the invisible forces within them.

The Shape of Nature

Figure 1 Crystals and complex biological structures. a) luorite; b,c) iron pyrite; d) spinel; e) partial spirals of muscles and fascia in the human body. Figures b-e reproduced from Scarr 2014 Handspring.

Nature always does things in the simplest and most ef icient way possible and a proper understanding of this simplicity now provides a powerful means to relate complex patterns and shapes with functional anatomy. Albert Einstein emphasized that the laws of physics must be the same in every place, which means that even the most complex organism can be understood in terms of the same basic rules of construction. So, by simplifying these inter-atomic forces into those that attract and those that repel, and applying the principles described above, we now have a simple means to understand biological complexity at every size scale.

mechanical system that integrates them into a complete functional unit. It is a conceptual model that is causing a paradigm shift in biomechanical thinking and changing the way that we think about functional anatomy. Biotensegrity recognizes that the forces of attraction and repulsion at the molecular scale are comparable with those of tension and compression at higher size scales, and are easily modelled using cables and struts, respectively ( igure 2). It is a simple reevaluation of anatomy as a network of structures under tension and others that are compressed; parts that pull things together and others that keep them apart; basic physics!

Biotensegrity

Tensegrity con igurations are similar to biological structures in that they are strong, light in weight and resilient to the effects of damaging forces, yet can change shape with the minimum

Biotensegrity is a structural design principle in biology that describes a relationship between every part of an organism and the

of effort and return automatically to the same position of stable equilibrium. Their structural mechanics operate the same in any position, irrespective of the direction of gravity, and they have similar non-linear visco-elastic type properties that in luence movement. Each component part can be constructed from smaller ones within a hierarchy, with each level related to all the others so that the entire structure becomes united into a single functioning unit. The recognition of biotensegrity as a unifying structural principle in living organisms began in the mid 1970â&#x20AC;&#x2122;s with Stephen Levin (b. 1932), an orthopaedic surgeon who observed things at the operating table that could not be explained through orthodox biomechanical theory. He found that tightening up certain ligaments in the knee etc caused the bones to move apart, and that normal Terra Rosa E-mag 3

bones always had a slight spacing between them, but there was no known mechanism that could make this space possible; it was like the bones were ‘ loating’ in the soft tissues. Further research then uncovered a relatively little known structural principle called ‘tensegrity’ and a likely explanation for these indings. The term ‘tensegrity’ is a combination of the words tension and integrity and this structural system was irst recognized in 1948 by Kenneth Snelson (b. 1927), a young sculptor who continues to Figure 2 A tensegrity structure consisting of compressed struts ‘ loating’ within a network of tensioned cables. Reproduced from Scarr produce impressive works that he describes as “...unveil[ing] the 2014 Handspring. exquisite beauty of structure itself”. Tensegrity structures are structures, but because certain standings about functional anatoparticularly interesting because aspects are not transferable, Stemy. the struts remain isolated and do phen Levin introduced the term not compress each other at any A biotensegrity view of life biotensegrity to distinguish bepoint because they are suspended sweeps away the man-made contween these two ields. within the tension network. The straints of classical mechanics architect Buckminster Fuller Biotensegrity models emulate and re-establishes biology at its (1895-1983) recognized them as biology in ways that were inconvery core. It is based on the laws part of his theory of synergetics, ceivable in the past but it has tak- of physics irst, rather than the the study of nature’s coordinate en some time for the concept to arti icially contrived ones that system that considers that all nat- become widely accepted because have dominated biomechanics for ural structures are inherent disof its challenges to generally accenturies, and recognizes that the plays of the forces within them; cepted wisdom. Biotensegrity structure and behaviour of each and Donald Ingber, a cell bioloexplains how ‘joints’ can remain molecule, cell, tissue and organgist, has described the structural completely stable without overism must result from those same lattice (cytoskeleton) within cells stressing the soft tissues surrules. Both simple molecules and as a tensegrity structure that reg- rounding them and demonstrates complex structures result from ulates cell function. Mechanical that the spine is essentially a tenthe interactions of pure energy engineers also appreciate the dis- sioned structure that can function (forces), and although particular tinctive properties of tensegrity the same in any position, and con igurations dominate, they are structures and are producing rohow movement is controlled by not especially chosen by nature bots for use in the exploration of the very structure itself. It is atbut because their simplicity, ef ispace etc. Both biologists and entracting the attention of biolociency and stability favours them. gineers now recognize that the gists and hands-on therapists beThe real beauty of nature is that it simple principles of tensegrity cause it provides a better means does so much with so little. can be applied to understanding to visualize the mechanics of the the behaviour of more complex body in the light of new under4 Terra Rosa E-mag

The Shape of Nature Graham Scarr is a chartered biologist and osteopath, and has been researching the signi icance of natural patterns and shapes over many years. He has also developed new models that progress our understanding of the structurefunction relationship in human biology and published several papers on this subject in peerreviewed scienti ic journals. His fully illustrated book entitled â&#x20AC;&#x2DC;Biotensegrity: the structural basis of lifeâ&#x20AC;&#x2122; now brings all these indings together for the irst time. gscarr3@ntlworld.com This article was originally published in the the e-magazine Bare essentials 2014 issue 37 http:// bareessentialsmagazine.uber lip.com/i/437027/88 ) References Fuller, RB. 1975 Synergetics: explorations in the geometry of thinking. Macmillan.

Heartney, E. 2009 Kenneth Snelson: forces made visible. Hard Press Editions. Ingber, DE. 1998 The architecture of life. Scienti ic American (Jan), pp. 30-39. Levin, SM. www.biotensegrity.com

Scarr, G. 2014 Biotensegrity: the structural basis of life. Handspring Publishing.

This book brings all aspects of tensegrity/ biotensegrity together for the first time, from its discovery, the basic geometry, significance and anatomy to its assimilation into current biomechanical theory. Available at www.terrarosa.com.au

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A Brief Historical Perspective John Sharkey

Stephen Levin is the father of Biotensegrity. Dr Levin trained as an Orthopaedic and Spine Surgeon having formerly been a Clinical Associate Professor at Michigan State University and Howard University, Washington, D.C. He studied General Systems Theory with the distinguished biologist, Timothy Allen but is now retired from clinical practice. Following years of tirelessly working to seek appropriate focus of the biotensegrity model, it is currently enjoying growing acceptance and widespread academic approval. Work on biotensegrity started in the mid 1970s, when Levin, a young orthopaedic surgeon, was trying to understand what he was doing as a â&#x20AC;&#x2DC;body mechanicâ&#x20AC;&#x2122;. Medical education and surgical training, was to Levin the most anti-intellectual training experience outside of military combat training. Levin was of the opinion that like combat situations, life and limb are at stake and there is no room for learning from your mistakes, but only from the mistakes of others. Being overloaded with facts, given little time to think, too much to do, and little time to do it in original thought and experimentation was discouraged and usually punished rather than rewarded. It was only afterward, after all exams were completed, could one begin to think for oneself.

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Biotensegrity—A historical Perspective Having reached retirement from a distinguished career in clinical practice, Dr Levin finally had the time to do some thinking of his own. He hoped it was not too late. He was interested in spine mechanics and, after all, he should know something about spine mechanics since he spent so many years operating on the spine. What he had been taught during his residency training, by some of the top biomechanics people at the time, was the application of first year college physics to biologic structures and particularly how it applied to the human frame. This has been, and continues to be, the accepted mechanics since first described by Borelli, a mathematician and ‘renaissance man’, in 1680. Since that time little or nothing has changed. Levin was to find that the promotion of new ideas and new models that run contrary to the accepted way of thinking was to be no bed of roses. The accepted biomechanics for living tissue was based on Newtonian mechanics such as would be applied to a column or building built with rigid materials and standing in one place on solid ground. But Levin argued that humans, and all biologic structures, are mobile, omnidirectional, gravity independent structures built of ‘soft matter’, foams, colloids and emulsions, (Levin contended that bone and wood are stiff foams, structured more like Styrofoam), and mechanical laws as applied to these structures would be different. Over time Levin came to the conclusion that it is impossible to explain the mechanics of a dinosaur’s neck using standard Newtonian mechanics and so he walked a road less travelled. The road to the model of biotensegrity beckoned and became more compelling. Dr Levin lives outside of Washington, DC, and, in the mid 1970s in his efforts to better understand living mechanics he went to study the dinosaurs at the Smithsonian’s Natural History Museum. He could not accept the Borellian model, but could find no other suitable model to explain how the dinosaurs could hold up their long neck and tail. “There are no tail prints in the sands of time”, asserts Levin. Sitting on the mall in front of the museum, Levin looked across and could see the Needle Tower, a Kenneth Snelson sculpture, right across the mall at the Hirshhorn Museum. The forces that allowed the Snelson sculpture to exist, tension and compression, provided the missing link for Levin and the model of biotensegrity began, slowly, to emerge. Article (copyright Stephen Levin) and Images supplied with kind permission from Dr Stephen Levin.

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Introduction

many different movement modalities can be at odds with the basis of the anatomy, physiology and bioMassage therapy is recognised as the manual manip- mechanics in their training studio. ulation of the soft tissues namely muscles, connecNewtonian-based mechanics, using a post and beam tive tissue (fascia), tendons, ligaments and joints. With a clinically oriented bias massage helps allevi- construct, has allowed mankind to build amazing structures such as skyscrapers, bridges, airplanes ate the discomfort associated with daily living and automobiles. To provide stability and controlled strains and overuse issues leading to pain condimotion in any man made structure a pin joint must tions. To ensure high standards of education masbe employed to provide a rigid hinge (Fig. 1). This is sage schools have long included a complementary a lever system. In order for part A or B to move in a medical approach. This has led to massage schools syllabi content including modules on human anato- controlled manner a need exists for the addition of my and Newtonian based biomechanics. All this was an “engine” as a source of kinetic energy providing a in an effort to understand the mechanical structure- force to move one of the lever arms. This is how aufunction relationship. This lever based biomechanics tomobiles, trains and planes are constructed and it and one muscle one-movement philosophy has long all works very well. Transferring this post and beam, been at odds with what massage therapists intuitive- lever system to biological structures and cellular netly feel and clinically observe. The lever based biome- works (such as humans) seems to work, initially. chanics model promotes the existence of individual However thorough investigation and appropriate scrutiny reveals basic laws that call for new explaparts working independently under continuous nations and new models. BioTensegrity is the new gravitational compression. model of living motion, or biomotional experience. It In such a model the foot has little relation to the provides clear and concise explanations based on wrist, the sub occipital structures work autonomous- continuity, tension, compression and Mechnotransly with no concern for the sacrum and pain experiduction (Sharkey, 2008). These are congruent with enced in the shoulder would require massaging the the human experience of natural motion. shoulder and local soft tissues only. Many movement practitioners are also educated under these “laws” of biomechanics. As such the experience for teachers in 8 Terra Rosa E-mag

Image used courtesy of RJ Muna Pictures and Capacitor.

Powering the Fabric of Human Anatomy John Sharkey Joanne Avison

Biotensegrity—Powering the Fabric of Human Anatomy

Fig 1. This is the upper limb represented as a lever system where joint space (at the elbow) would require a pin for point A (shoulder) and point B ( ist) to move towards each other. There are no pin joints, or levers, in biologic forms. They can appear to make lever-like motions, however this is not the basis or the limit of their structure. Copyright: Joanne Avison

Massage therapy and movement nourishing our inner space Massage therapists work directly with the cellular network. So does the body in motion. Any movement practice, be it exercise protocols or Martial Arts invites us to work at the gross and cellular level. The cellular network is ubiquitous throughout nature and can be represented by foams and froth. Foams and froth can be seen everywhere. Take some water, soap, mix by shaking and you will get lots of “bubbles” making a wonderful froth. The froth on the top of your morning cappuccino (Fig. 2) is another great everyday example of a cellular network. It may even explain the irst basic cell 3000 million years ago. Look closely at the bubbles and you will notice they have a distinct number of sides, an innate and mobile geometry. Some will have three sides while others may have up to eight sides (polygonal). This arrangement can be seen everywhere in nature and is an essential aspect of the hierarchical organization of all biological organisms (Scarr, 2014, Avison. 2015)). It exists at the microscopic level such as looking at the arrangement of connective tissue (Fig. 3) to the macro level of skin markings on animals such as the Giraffe (Fig, 4). Molecules, cells, tissues, organs, and organisms are all constructed on these tensegrity principles of enclosed geometric structures within enclosed geometries. All are in fact tensegrities within tensegrities working collaboratively on a biologically hierarchical ba-

Fig. 2. The froth on the top of your morning coffee is an everyday example of a cellular network. (Image: Author’s own)

sis. Within these hierarchical biological tensegrity systems (BioTensegrity), the individual cells, which are self stressed (AKA Pre-stress), are poised and ready to receive mechanical signals that are then converted into biochemical expression, termed mechanotransduction (Ingber, 2008). The geometric patterns or organisations of the cellular network is even used to explain the anatomy of space. Astrophysicists call the distribution of galaxies the cosmic Terra Rosa E-mag 9

Fig. 3. Hierarchical organisation exists at the microscopic level such as looking at the arrangement of connective tissueâ&#x20AC;Ś (With kind permission of Dr J.C.GUIMBERTEAU and EndovivoProductions)

Fig. 4. Hierarchical organisation also exists at the macro level of skin markings on animals such as the Giraffe. Image by Shane McDermott Photography reproduced with his kind permission (www.wildearthilluminations.com)

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Biotensegrity—Powering the Fabric of Human Anatomy foam demonstrating a common fabric from Nano to Macro (smallest to biggest). The fabric of our inner space is made up of a continuum of soft matter comprising specialist tissue variations, all designed around these natural principles of biological structure. Variations range from blood cells to bones, digestive cells to autoimmune structures, mesentery, muscle, nerves and everything in between. In massage therapy we make contact with that inner cellular network by touching the outermost reaches of the same cellular network, the skin. In movement, we organise the outside via the inside and vice versa. While the topic of fascia in movement has been the focus of anatomical study in the last number of years the topic of continuity has taken second place. Fascia is the primary fabric providing continuous tension throughout the whole organism. Fascia is one of the specialties of our connective tissues including the bones (providing compressional forces) classically referred to as the skeletal system. A critical point to drive home at this juncture is that fascia and bones are not separate tissues. They are specialties existing in a continuum. They have different densities and speci ic organisations, however they form and evolve together embryologically and throughout life as a continuum. They may be distinct, offering different frequencies within the same force transmission system. However, all bodies, whether they are moving themselves or being moved by the massage or movement therapist, are changing and organising via these responsive and intimately related tissues that do not arise separately from each other. Tensegrity structures can include bridges and geodesic domes, which are non-living structures. (Fig. 5) BioTensegrity (Levin 1982) refers to living things. A tensegrity has no breath, no conscious driven electromagnetic activity, no original thought, no imagination, no love for music or prose. Tensegrity does not suffer pain. BioTensegrity can. Living cells and tissues share a common structural relationship with non-biological tensegrity structures. Each has two members namely tension and compression existing to provide structural integrity to the whole. Other differences include the fact that in non-living tensegrity structures these tensional and compressional members are connected. In BioTensegrity these members are not so much connected but are continuous. They change shape (and can change roles) depending on the forces acting upon them. They are shape shifting. In a tensegrity system, such as a bridge or a building, bolts, screws and

Fig. 5. This complex architecture forms a dome in the ancient Ulm Munster in Germany. Unlike living organisms, this has the attributes of a linear, non-biologic architecture which relies on speci ic ixed arrangements of compression structures. Geodesic Domes follow the rules of tension-compression architecture; incorporating mutually interdependent forces. (Image: Author’s own)

pins are required to join the members and ensure integrity. In biological tensegrities there is no need for screws, bolts, beams or gravity. There is no friction, no sliding. Tissues glide relative to one another, as there are no layers. They all exist as specialties along the living continuum. Tissues can resonate and respond to the forces around them and share properties such as the incorporation of polarity – innate to the tensioncompression design. The wholeness and integrity of that structural coherence relies upon the relationship and balance of these co-existing forces, united to form the whole structure. In other words, without such specialties – their integrity would be compromised. Thus there is a built-in mutual codependency from which comfort, ease and balanced motion or stability arise. When a client attends a massage clinic the focus for the therapist is to restore what has been lost, through pain or injury for example, when the balance of these forces has been compromised. In Terra Rosa E-mag 11

many cases what has been lost is structural integrity due to excessive tension and/or compression. A typical presentation seen in the clinic is rounded shoulders. In such a case it is obvious that excessive compression is being exerted anteriorly while excessive tension is experienced posteriorly. (This will appear as “shortening” at the front and “overly long” tissues at the back). Joint space becomes compromised, fascia thickens to support the new posture and bones and other soft tissues can drift out of alignment if such a situation perpetuates without attention. We might generally refer to such posture as a “compensatory pattern”. Forces may not be dealt with appropriately creating additional strain thus creating a downward spiral throughout the entire organism. The solution would be to restore balance between the forces of tension and compression. Treating the anterior chest and upper back may seem to be the order of the day however treating the person on the principles of BioTensegrity requires a whole body, whole person approach. While the treatment of local body parts is required this approach alone will seldom result in sustainable success. A combination of local changes and global reinforcement, with movement education can bring about a new soft tissue pattern that permits the whole structure to gradually change and sustain a more useful one; especially if it means less pain and the possibility of reversing the downward spiral to an upward one; bene iting the whole organism. In the BioTensegrity model strains are evenly distributed throughout the structure. When good tissues go bad the client will experience pain and changes in sensations at the weakest points in the structure. These points may be some distance from the source of the issue or the original insult. In the BioTensegrity model the harder soft matter (the skeletal tissues) act as spacers providing virtual space but real distance between the bones. Bones should never touch. In anatomy the ends of bone can be described as articulating surfaces but the truth is they are near frictionless. The upright human is not a stack of bones resting on top of another, despite the fact the spine, for example, is commonly described as the Spinal Column. If it really behaved as a column, then a small tilt would disrupt its structure and massage would destroy its structural integrity. Bones are suspended internally, loating in the sea of connective tissues that provides the nutrient tension all around them; emphasised by the surrounding skin. Bones provide the compressive energy and together with the fascia provide us with tensional integrity or lift. This is the reason humans don’t fall down or fall apart when they lie down and get up again. These are mutually co-dependent or inter-dependent forc12 Terra Rosa E-mag

es, giving rise to the ability to move around as humans and animals do; the way they do. BioTensegrity is an essential model for massage therapists and movement practitioners of every stripe. Understanding this model will provide you with the vocabulary and underlying logic of “body architecture” that forms the context of therapeutic bene its. BioTensegrity will add to your con idence and ability to achieve those therapeutic goals. A new era is dawning in our understanding of anatomy and living movement. That new anatomy and understanding of whole body structure is BioTensegrity.

References 1. Levin, S. M., 1982. Continuous tension, discontinuous compression, a model for biomechanical support of the body. Bulletin of Structural Integration, Rolf Institute, Bolder:31-33. 2. Ingber DE. 2008. Tensegrity-based mechanosensing from macro to micro. Prog Biophys Mol Biol. 97(6 -3):163-179. 3. Scarr, G. M., 2014. Biotensegrity, The Structural Basis of Life. Handspring Publishing Ltd. ISBN: 9781909141216. 4. Sharkey, J. 2008 Concise Book of Neuromuscular Therapy. A Trigger Point Manual. Lotus Publishing and North Atlantic Press. 5. Avison, J. 2015. YOGA Fascia, Anatomy and Movement. Handspring Publishing Ltd. John Sharkey, Clinical Anatomist and Founder European Neuromuscular Therapy. MSc., Department of Clinical Sciences, University of Chester/NTC, Dublin , Ireland. E-mail address: john.sharkey@ntc.ie www.johnsharkeyevents.com Joanne Avison Professional Structural Integrator and Advanced Yoga Teacher (E-RYT500) KMI, CTK, IASI. Kinesis Myofascial Integration. E-mail address: jo@joanneavison.com www.joanneavison.com Read 6 Questions to John & Jo on page 60-61.

Maximise Oxygenation A N AT O M Y F O R T H E 2 1 S T C E N T U RY

BIOTENSEGRITY with John Sharkey Sydney, June 2016 Myofascial Trigger Points (MtPs) Versus Neuropathies A unique integrated neuromuscular approach for the treatment of unresolved pain due to MtPs or nerve insults. This is that one stop workshop that covers everything you need to know about identifying and treating Myofascial Trigger Points and nerve injury. David G Simons (Travel and Simons), the farther of Myofascial Trigger Points was mentor to John Sharkey and wrote the forward to Johnâ&#x20AC;&#x2122;s first book (a trigger point manual). Differentiating between neural generated pain and Myofascial Trigger Point pain is essential in providing the correct soft tissue interventions for successful therapeutic outcomes.

The Final Frontier Working within Endangerment sites, providing Manual and Movement Techniques to stay mobile and pain free. This informative workshop provides therapists with the necessary anatomical and palpatory excellence to expertly navigate the holy grails of the human body (endangerment sites). Providing safe neuromuscular techniques using digital applications guarantees effective therapeutic interventions for soft tissue based chronic pain conditions. Through your newfound anatomical knowledge and unique hands-on clinical pearls each learner will develop a greater appreciation of local and global anatomical connections.

The Theory of Everythingâ&#x20AC;&#x201D;BioTensegrity, anatomy for the 21st century This workshop is ideally suited to the advanced manual and movement therapist with appropriate clinical experience and a desire to take on fresh new ideas, new models and a new way of thinking. Therapists are warmly encouraged to demonstrate their current screening, assessments and therapeutic applications with John while he will provide feedback and suggestions offering a new vision supported by connective tissue techniques for successful manual and movement interventions for all participants. This workshop provides you, the chronic pain soldier the effective full body kinetic chain ammunition you need in the war on pain. John Sharkey MSc is a world renowned presenter and authority in the areas of bodywork and movement therapies. He is a Clinical Anatomist (BACA), Accredited Exercise Physiologist (BASES) and Founder of European Neuromuscular Therapy with more than 30 years of experience gained throughout his career working alongside his mentors and colleagues Leon Chaitow, David G. Simons, Stephen Levin MD, Prof. Kevin Sykes. John is recognised as a leading protagonist of BioTensegrity (providing new models and paradigm shifts concerning living movement and anatomy promoting therapeutic interventions for the reduction of chronic pain.

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For more information & Registration, visit www.terrarosa.com.au

The Elastic Body Introducing BioTensegrity as a model of Elastic Integrity in the moving body Joanne Avison

Fig. 1. Image used for the First BioTensegrity Summit in Washington DC; September 18th 2015. [biotensegritysummit.events.] and reproduced with kind permission from capacitor.org and the photographer RJ Muna (rjmuna.com).

Everyone has a motion pattern that we could call a movement signature. Working in yoga, or any movement modality, a teacher naturally develops a more re ined sense of people’s individual styles and movement expressions. Considering the fascial matrix as a dynamic, self-organising, BioTensegrity architecture can transform our ability to see how individuals develop their unique movement signatures within the protocol of a given class. Part of this includes recognising different fascial types and the value of elastic integrity. In this article it is viewed as an asset to 14 Terra Rosa E-mag

optimising any individual’s quality of movement. As well as shifting more popular ideas on ‘stretching’ for its own sake, the BioTensegrity model provides a valuable tool for recognising optimum movement patterns at the speed of motion. This discussion emphasises the general shift from seeing muscles as functional units, to understanding the fascial matrix (including muscles and bones) as a whole body architecture of soft tissues, morphologically unique to the selfmotivated individual moving it.

The Elastic Body

Fig. 2. The Elastic Body relies on different elements to ind Elastic Integrity for each individual movement signature; relating closely to the fascial body type.

Body-writing in Our Own Hand Flexibility and stretching tend to be held as the archetypal movement ‘celebrities’, particularly in yoga. Those with naturally bendy bodies can get top marks while the ‘stiff’ people, who feel they cannot stretch to twist and contort with ease, are often considered ‘not as good’ as their naturally lexible companions.

and overall tensional sogginess. This depends on the fascial body type of an individual and the way they “load” their tissues over time.1,2 Drawing from several different aspects of recent research, we might consider the two ends of a scale from strength to stretchiness, in natural tendencies of fascial body types. For example, a strong, ‘Viking type’3 body may tend towards strength and stiffness naturally. A bendy or sinewy, ‘jungle type’ body may err on the side of lexibility. Referring to the members of a movement classroom, the key is inding balance between the two extremes of the graph depending on their particular movement signature. The beneits of stretching or strengthening will be found in relatively opposite ways for each of these types, if the value of elastic integrity is to bring vitality to their very different signatures.

There is, however, a much more valuable and powerful distinction available, once we appreciate the myofascial body and its structure, as a whole dynamic anatomy of continuity. This distinction lies in recognising elasticity as paramount and understanding that for some individuals it is enhanced by stretching and for others it is the opposite. There are those that will increase their natural elastic integrity by stiffening the tissues. This makes sense if the foundations of BioTensegrity and the context it provides to describe human movement are de ined. This is as the basis of Elasticity as an Asset the collagen network of every human form: a matrix Identifying authentic elasticity is extremely valuable intimate to every tiny part of us, formed under tenas a teaching tool and an important ‘kinaesthetic dicsion since we began to self-assemble as embryos. tionary’ to expand and refer to. This is partly because of its global application in reading bodies accuEnergy Storage Capacity rately and partly because it makes sense of structurElasticity is the source (and containment and replenal integrity of the whole animated form. Elasticity ishment) of our energy storage capacity. Once we really means “resistance to deformation” and implies understand it – and there are a lot of misconceptions ef iciency of reformation. In other words; how do we around it – we have an immeasurably valuable rechange shape, respond appropriately and then resource for vitality. Really it comes down to an approstore optimum shape after doing so? The best way of priate balance between overall tensional stiffness obtaining structural integrity might include stretchTerra Rosa E-mag 15

ing and strengthening but such ef iciency and resilience (see Fig .1) is by no means limited to either. Elasticity emerges as the paramount asset to ef icient movement and poise in stillness. It refers to moment-by-moment changes locally and globally, while nourishing structural integrity over time. Exploring New Terms “It has been shown that fascial stiffness and elasticity play a signi icant role in many ballistic movements of the human body. First discovered by studies of the calf tissues of kangaroos, antelopes and later of horses, modern ultrasound studies have revealed that fascial recoil plays in fact a similarly impressive role in many of our human movements. How far you can throw a stone, how high you can jump, how long you can run, depends not only the contraction of your muscle ibres; it also depends to a large degree on how well the elastic recoil properties of your fascial network are supporting these movements.” Robert Schleip4 Robert Schleip refers in this quote to the elastic recoil properties of fascia in ballistic movements. However, if biotensegrity is the basis of the architecture of our collagen matrix, then it also has elas- Fig. 3. The Bendy Wendy body type, sketch reproduced with pertic integrity when we are still. We do not de late. mission from the author. The body bene its from the value of elasticity just as much when sitting on a meditation cushion or run ning a marathon: peak performance and peak ‘preThe useful schematic in Fig.2 is deceptively simple. formance’ are both animated by the same system. Balance and access come from the centre: it is a Understanding and recognising innate elasticity is question of ensuring balance of suitable stiffness, made more dif icult by the many different meanings which means suitable resistance to deformation and we have for the word ‘elasticity’ itself. There is a ef icient reformation. This is unique for each indigeneral perception that it is associated with stretch- vidual. In fact, ‘Bendy Wendy’ (see Fig. 3) may need iness and lexibility (the archetypal heroes in most more stiffness, not more stretching. yoga-based movement classes). The enemies in that The terminology needs some reframing and the idea environment might be seen as tension, stiffness, that yoga is synonymous with stretching might be a strain or stress. In the definition of elasticity howevdisservice to the potential power of its contribution er, it is the lack of suitable stiffness that can be a to elastic integrity. Elastic energy is very low-cost de icit to structural integrity. Despite the level to metabolically: it is the essence of healthy, vital which it is favoured in yoga teaching, stretching is movement. On or off the mat, we seek a signature just one aspect of a much broader picture: one that becomes clear if BioTensegrity principles are appre- our body signs with vitality whatever movements we are doing. Mixing modalities to bring this balciated. ance may be the most useful way to work and foster In order to see this as a general and global distincthis valuable asset of architectural integrity. In othtion for movement integrity and overall vitality er words, a balance between stretching-type move(including at rest) we can include four main attribments and those based upon resistance may hold a utes of elastic integrity (Fig. 2). key to elastic integrity. 16 Terra Rosa E-mag

The Elastic Body Elasticity can be considered as one side of a coin. The other side of that coin is stiffness. Stiffness is the resistance to deformation of a material. Elasticity is the efficiency of reformation. The literal definition is “stored energy capacity” which is a function of elasticity and stiffness in mutual balance. The amount of stored energy capacity is relative to the stiffness and elasticity of a material. On this basis, steel has higher energy storage capacity (elasticity) than rubber. A steel car spring has high stiffness, while a Slinky toy has low stiffness. Both have elasticity. The car spring (higher stiffness and elasticity) is better able to resist deformation and therefore to be supportive.

is a time-dependent way of regulating elastic ‘spring -back’. The internal tissues of the human body rely on this to change from one movement to another.

Poroelasticity is a feature of geology that is also relevant to the extracellular matrix.5 The combination of our tissues and contained fluids includes these characteristics as essential ingredients of our architectural form, from embryo to elder. They change constantly and yet remain in integrity, re-arranging as we do, movement-by-movement and moment-bymoment; inwardly and outwardly. This is what defines us as living forms and is re-defined by understanding the geometries of biologic forms, such as the full model of BioTensegrity represents on every scale. We are made up of various chambers in and Viscoelasticity. In liquids, this same principle is measured in viscosity (thickness). Honey is more around the Extra Cellular Matrix; holding together viscous than water because it resists deformation a variety of colloids, foams and emulsions of our inwhen you stir it. Water has relatively lower viscosity ternal chemistries and fluids. Thus a poroelastic asand is less resistant to deformation. Viscoelasticity pect of our internal “close packing” systems may be a acts as a ‘damper’ (i.e. such as would be placed on a valuable aspect of the BioTensegrity model. stiff car spring to modify the rate of elastic return). It

Fig. 4. “Tensegritoys” these tensegrity model toys were created by the Manhattan Toy Company in consultation with Tom Flemons of Intension Designs.6

Fig. 5. Suitable Stiffness: This tensegrity mast has no elasticated components. Nevertheless, it demonstrates high elasticity, because it has suitable stiffness. Model designed by Bruce Hamilton and constructed by the author.9

Suitable Stiffness as an Attribute of Biotensegrity

nal struts and the density of the external tensional elements that provides elasticity to the different aspects of our overall form. This can be demonstrated with the models in (Figs. 4 and 5).

Confusion about elasticity is also created by the use of elastic bands in building biotensegrity models. The distinction is between elasticity as a property of any material and ‘elasticated’ bands. Biotensegrity models are actually optimised using non-elasticated materials, to demonstrate strength and accurate examples of how collagen behaves in our body architecture. It is the sum of their combined tension– compression organisation combined in specific geometries, the balance between the length of the inter-

You may be able to see that the toy on the left is ‘soggy’: it has very low tension, or stiffness. The one on the right can bounce more. These are ‘Tensegritoys’7(Fig. 4) with elasticated tension members and ‘compression’ shafts made of wood, organised as one continuous structure. They are identical in size but the left-hand toy has lost its tensile integrity and is more collapsed. It has comparatively low stiffness. This does not represent lexibility, rather it shows lack of suf icient tensile integrity

The Middle Way

Terra Rosa E-mag 17

to hold itself up.8

While the tissue itself has recoil properties, a common misunderstanding is that the balance of elasIn these models, the ‘soggiest’ one (Fig.4) is the tin and collagen within the fascial ibres gives rise most stretched, which in this model makes it the to our elasticity. Elastin ibres can elongate up to weakest of the three. Stretching is an ingredient in 150% of their length and restore or reform. It is, in the recipe for structural integrity but only in balfact, one of the suite of tissues the body calls upon ance with suitable stiffness and depending, to some in wound healing.10 Suitable tensile properties in extent, on the movement signature of the individual. our tissues and their overall elastic integrity rely The mast, with no elasticated fabric, retains its elas- upon the stiffness of the collagen matrix, which is ticity when it is bounced, held out or up or hung upessentially low in deformation and relatively high side down. It is independent of gravity in that sense. in resistance to it (i.e. stiffness). (It stretches up to about 5% only.) This, in balance with our architecIt is the most balanced and resilient of the three models because it has the highest tensional integrity ture, creates overall energy storage capacity. If we were too “elasticated” we could not function: the and stiffness: it is by far the stiffest of the three. In this context, it is the guardian of the highest energy energy literally leaks. It can look like a soggy structure that needs strengthening, stiffening, or makstorage capacity. ing taut. A marquee is not a tensegrity structure as such, because it relies on being pinned by guy The mast in Fig 5 is made of guitar strings and hol11 low steel arrow shafts. It is exceptionally light and wires to the ground (we do not, even though we encloses a maximum of space with the fewest mate- are bound to return to it. We can move independently of gravity). However, a tent is a tensionrials. Any force applied to it can be seen and felt to compression model of sorts. Imagine using elastic be transmitted to varying amplitudes throughout guy wires and bendy tent poles. They would not the whole structure. This is a compelling model of “tension” or “stiffen” the fabric of the marquee sufbiological dynamic architecture, seen throughout iciently to take appropriate care of the internal the dynamic anatomy of living forms and their high- space or the external forces acting upon it. They ly ef icient ability to move around.12 It is a trianguwould have “low resistance to deformation”. This is the basic and simple way to begin understandlated structure (which provides some relative stability) and reveals a host of properties that we have ing our innate dependency on the logic of BioTensegrity as a powerful model of the architecture of throughout our tissues. It stands up, in all direcour living form. tions, by itself and, as a whole, it can bounce. It is also a model of a closed kinematic chain with multithreat to its structural integrity. In a cartwheel or a bar linkage and no levers.13 (See also Fig. 1 on page yoga pose with the spine parallel to the ground, the 9). bones would break apart if the spine followed the Whatever direction you pull or push this model in, rules of a stacked linear structure. It cannot be usethe structure gives, but naturally resists deforfully analysed on the basis of Newtonian physics mation which means it has high elasticity. Whether and laws of compression-based, hard matter organiyou pull, push, bend or twist, the architectural gesation. Human bodies do not conform to that logic. ometries naturally counter any movement by stiffOur various soft tissues (harder bones and softer ening the whole structure in resistance to defortissues around them of varying densities are all ‘soft mation. It then reforms immediately from defortissues’) conform to the very different laws of soft mation (within its resilience range) maintaining the matter. They are non-linear biologic structures. right internal spatial relationships. This relates to Once we place ourselves in a handstand, or pound our ability to perform postures or athletic feats, around a running track, bits of us don’t fall off!! As a without toppling body parts. If the human “spinal general rule, in healthy bodies, we restore our form column” really was a stacked vertical column, then soon after making shape changes. This makes us even a slight tilt, would destroy our structural integliving examples of how BioTensegrity principles rity. Columns are compression structures, like work as dynamic whole physiologies. stacked bricks in a house wall. They conform to the laws of ‘hard matter’ and non-biological linear orWhat this suggests is, effectively, the muscles can ganisation. If we change the angle of the ground or act more like brakes, while the tendinous tissues attempt to move the structure it poses a signi icant lengthen and shorten like springs. In terms of ap18 Terra Rosa E-mag

The Elastic Body

Fig.6 Images of research by Kawakami and colleagues (see note 13), after Schleip, showing the cooperation of muscles and fascial tissues. A is the classical view of the muscle moving with a relatively static tendon; B is the research result, showing the muscle acting more like a brake, while the tendon lengthens and contracts, acting more like a spring.

New Strategies: Elastic Integrity as a New Value A useful example of the paradigm shift between more classical notions and that of BioTensegrity as a biomechanical model, is in research on the Achilles tendon. Classical kinesiological models suggest that in jumping, for instance, the Achilles tendon is the strong, supportive, relatively less mobile binding, connecting the calf (gastrocnemius) muscle to the heel (calcaneus) at the back of the ankle joint. The ‘movement’ occurs at, or has been classically assigned to, the calf muscle (gastrocnemius), as it actively contracts and releases (i.e. based on the action classically assigned to that particular muscle). Using modern ultrasound equipment capable of measuring the muscles and the fascial tissues in vivo, however, researchers were surprised to discover that in oscillatory movement, the muscle ibres contract, or stiffen, almost isometrically (without changing length) and the Achilles tendon in fact acts like a strong elastic spring (Fig. 6).14 This would mean the muscle can act more like a brake on the spring-loaded recoil of the pre-tensioned Achilles, under such circumstances. This might suggest the muscles have a role in modifying or regulating stiffness and elasticity in appropriate length to tensional balance. plied BioTensegrity, the body-wide implications of this have global effects on organisation of the structure as a whole. In other words, the ‘muscle’ (which of course is a myofascial component of a global network or matrix of soft tissues) acts more like (in Dr. Stephen Levin’s words) a ‘turnbuckle’15 in the bodywide tensioned web. The internal compression members (bones) globally tension the external soft tissues surrounding them, which in turn compress the bones, which in turn tension the tissues and so on and on. Thus they are in a mutual balance that allows forces to be appropriately transmitted throughout the structure as a whole. This balance also preserves internal spaces; such as at the joints16 or through the neuro-vascular vessels. The more we look, the more examples of elastic integrity we ind in every aspect of the form and on every

scale. What this research all suggests is that we rely on elasticity perhaps more than we realise. The revelations about the fascial matrix are shifting the explanations we have for biomechanical function. They also raise many new questions and begin to make sense of why describing the experience of animating yoga postures in terms of levers, for example, is so awkward. According to Dr Levin “there are no levers in biologic systems. Anywhere.”17 Terra Rosa E-mag 19

The Elastic Body Joint Space Levers Levers are two-bar, open-chain linkage systems that do not explain our multi-joint and multi-directional abilities to move and balance. There are no pins at the joints, such as would be necessary in a two-bar (lever) open-chain system. “We maintain the joint space and its integrity through the omni-directionality of our living tissues, continuous from inger to toe, from side to side, front to back and top to bottom. This moves us from linear mechanics, hinge like joints and ‘one muscle works at a time’ mentality to a more global, continuous tensioned contractile fabric that facilitates closed chain kinematic linkages. A three bar linkage system would be too rigid and would not allow movement…. [suggesting that closed chain 4-bar and multi-bar linkages are the minimum]” John Sharkey18 How can this be applied? We are invited by various research into the fascial matrix19 to view the muscles (and any other components of our form) as part of the continuity of myofascial balance throughout the tensional web of our architecture, in multiple dimensions. The tissues clearly participate in the subtle translation and mediation of all types of movement. While this research focuses on different speci ic types of tendinous organisations, we must remember that the body itself does not go about getting agreement from each separate part. It organises and acts as an instinctive whole and the fascial matrix may be the uniting medium in which these specialisations occur. Anatomy Trains 20 encourages us to see the musclesin-fascia in longitudinal bands of continuity. This suggests both fascia (inclusive of tendons, ligaments and tendinous sheets) and muscle (in which it is profoundly invested) form integrating bands from head to toe.21 Whether you agree with the anatomical content of individual lines, slings or layers, Myers takes us towards an anatomical view of the body that endorses wholeness. He refers to the myofascial meridians as ‘lines of pull’, which is an important distinction in terms of elasticity. They are ‘pulled’ even when we are resting. The bones of our BioTensegrity architecture maintain them under tension. They have to have something to pull on! 20 Terra Rosa E-mag

Fig. 7. The so-called Super icial Back Line22 is a metaphor for continuity. It is not separate in the living body from the layer beneath or those either side of it. In a movement class we do not have time to assess muscle by muscle – nor does the body move that way.23

Fig. 7 shows the Super icial Back Line of Anatomy Trains (which includes the tissues of the foot, the Achilles, the calf and all the way up the hamstrings, erector spinae and over the back of the head to the bridge of the nose) can be shown to form a continuous layer and band, under tension. We have to expand our view to include the whole body to get a sense of why the bones play such an important role in creating suitable tensioning, or stiffness, in our tension–compression form. This is the quantum leap, from muscles as levers to muscles as moderators of stiffness and stretch. We might call them ‘tighteners’ or ‘modi iers’ in the weave of our three-dimensional architecture. When you tension an elastic band and stretch it, Fig. 8 you are sensing its resistance to deformation, that is, its stiffness. When you release it you are demonstrating its elasticity, that is, its ability to return, or reformation. Two important facts arise from doing this exercise, which are:(1) You need suf icient re-

The Elastic Body

Fig. 9. This puppy is using its whole body, from tail tip to nose tip to balance the overall structure. The BioTensegrity model explains this as a whole body architecture; expressing emergent properties to balance from moment to moment, as distinct from the more classical lever mechanics. (Reproduced with kind permission from Shane McDermott, www.wildearthilluminations.com)

Fig.8. An elastic band at non-tension (A), semi-tensioned or mid -point (B) and fully stretched (max-point) (C) (Reproduced with permission from the author)

sistance to deformation (stiffness), or the band is loppy and pulled out of shape too readily. (2) By fully releasing the band you do NOT demonstrate resting tension in the human body. It is the halfway point of the elastic band, the semi-tensioned stage B that demonstrates resting tension in the human body. We are ‘pre-stiffened’ or ‘pre-tensioned’ because we do not de late. We never experience the state represented by the elastic band at rest. We start at the second stage, the middle way, which is our default elasticity at rest and in stillness. Elasticity is an energy asset throughout many forms of our internal and locomotive structure, and many aspects of our architecture actually rely on it in health. “the visco-resilient nerves are under a constant internal tension. The strength of these forces is seen in ruptured nerves. Simply because of their tremendous elasticity, the two severed nerve stumps shorten by several millimeters. In repair procedures, the surgeon has to use a considerable amount of strength to bring the two nerve ends together again ... It is elasticity that allows nerves to adjust to the movement of a joint without loss of function.”24

The research that is accumulating on the study of biotensegrity is perhaps so compelling because in some aspects it suggests a scale-free explanation of our movements: from organelles within a cell, cells within an organ, vessels throughout the body and so on to include the whole organism. We recapitulate at the cellular level the same micro-patterns as whole bodies performing macro-movements, on a larger scale. This is also re lected in our personal evolution and development from embryo to elder. It is invariably on an individual basis as each person moves uniquely at any given moment in time: accumulating their own physical and emotional tendencies and gestures. “A recognised characteristic of connective tissue is its impressive adaptability. When regularly put under increasing physiological strain, it changes its architectural properties to meet the increasing demand.”25 Whichever way we do movements, exercises, yoga or other physical pursuits, we are looking for a place of elastic integrity, wherever we are (at the time) in terms of resting tension. While we are alive, we do not get to abstain from this choice. The ‘vote’ for inertia sets up its own strain (or lack of strain) patterns. The lack of strain allows for the sogginess we observe in the weaker of the two models in Fig. 4. What is also crucial is the timing of how our strain patterns are accumulated. The ‘myo’ part of Terra Rosa E-mag 21

the ‘myofascia’ (tensioned as it is by the bones) works in co-dependent relationship to modify stiffness and elasticity in balance. Each aspect can respond in different time frames. Summary and new considerations So how do we put all this together? Besides the knowledge we have for training and exercise, we uncover a body-wide explanation that includes using muscles for strength and tensioning, while beneiting from using tissues for stretch and lexibility. It begins to explain motion in 360 degrees with a whole range of variabilities. It also invites us to reconsider “stretching” or “stiffening” (e.g. through resistance) as better or worse forms of training the body. The relative value of either of these types of movements, resides in whether or not they work for the individual accumulating them in their tissues and to what degree. That is, what value do they have in the goal of optimising resilience and balance or poise for their unique elastic body? BioTensegrity raises many new questions as a model of human form and movement. It doesn’t it easily into the biomechanical models of disconnected parts that might be described as acting independently of one another. It also invites new semantic distinctions and connotations for words like ‘stiffness’, ‘tension’, ‘resistance’ and ‘strain’ and ‘stress’. We are called to rede ine stretching, for example 26,27,28, and review the context in which it is upheld and used in movement training. One of many dif iculties encountered in explaining the essential organisation of BioTensegrity, is the need to reside in paradox: that which connects (the fascial connective tissues) also disconnects (the membranes thereof). That which tensions also compresses. That which is under compression is simultaneously tensioning. In essence, the ability to fully appreciate the art of the Elastic Body is enhanced by understanding the science behind dynamic models such as BioTensegrity. It is a new science of Body Architecture and one that may transform the ability to learn, teach and express our movement signatures safely and with vitality. 22 Terra Rosa E-mag

Endnotes: 1 Schleip R. Schleip, D.G. Mü ller, ‘Training Principles for Fascial Connective Tissues: Scienti ic Foundation and Suggested Practical Applications”, Journal of Bodywork and Movement Therapies 17: 103–115; 2013 and Terra Rosa e-magazine No. 7, March 2011. 2 Joanne S Avison, YOGA Fascia, Anatomy and Movement,

Handspring Publishing 2015, Chapter 8, The Elastic Body 3 Joanne Avison, YOGA Fascia, Anatomy and Movement,

Handspring Publishing 2015, Chapter 13, Posture Pro iling 4 Robert Schleip, “Foreword”, in Luigi Stecco and Carla Stecco, Fascial Manipulation: Practical Part, English edition by Julie Ann Day, foreword by Robert Schleip, Piccin, Padua, 2009. 5 Leonid Blyum (http://blyum.com/). Private presenta-

tion at the Biotensegrity Interest Group (B.I.G.) Europe, Ghent, 2013

6 Tom Flemons made and sold toys designed on tensegri-

ty principles for many years. His “Skwish” toys were licensed to a local company to manufacture in 1987. Manhattan Toys subsequently bought that company and the licensing rights in 1995. 7Ibid. See also, for further reading: http://

www.intensiondesigns.com/bones_of_tensegrity.html 8 Note: For an example of insuf icient stiffness, this reference links to a ilm about a condition called “Swimmer puppy syndrome” : see YouTube references to Swimmer Puppy Syndrome: http://www.wimp.com/ puppytherapy/ for video 9 Bruce Hamilton’s designs can be seen at www.tensiondesigns.com. 10Adjo Zorn and Kai Hodeck; In: Erik Dalton’s The Dy-

namic Body, Freedom from Pain Institute, Oklahoma, 2011. 11 Bruce Hamilton’s designs can be seen at www.tensiondesigns.com. 13 Graham Scarr, www.tensegrityinbiology.co.uk, article:

“Geodesic”. See also: Biotensegrity: The Structural Basis of Life, Handspring Publishing Ltd., Pencaitland, 2014. 13 Joanne Avison, YOGA Fascia, Anatomy and Movement, Handspring Publishing 2015, Chapter 7. 14 Y. Kawakami, T. Muraoka, S. Ito, H. Kanehisa and T. Fukunaga,

“In vivo Muscle Fibre Behaviour During Counter-Movement Exercise in Humans Reveals a Signi icant Role for Tendon Elasticity”, Journal of Physiology 540: 635–646; 2002. 14 Stephen Levin, personal communication at the Bioten-

segrity Interest Group, Belgium, 2013; http:// www.biotensegrity.com/muscles_ at_rest.php; A.T. Masi and J.C. Hannon, “Human Resting Muscle Tone (HRMT): Narrative Introduction and Modern Concepts”, Journal of Bodywork and Movement Therapies 12(4): 320–332; 2008.

The Elastic Body 16John Sharkey, BioTensegrity. The fallacy of biomechan-

ics. Journal of Australian Association of Massage Therapists.Volume 14, issue 2 Winter 2015

theme see YOGA Fascia, Anatomy and Movement, Handspring Publishing 2015, Chapter 12, Yoga and Anatomy Trains

17 Stephen Levin: www.biotensegrity.com: Home Page and several articles under Papers: Tensegrity: The New Biomechanics.

24Jean-Pierre Barral and Alain Croibier, Manual Therapy for the Peripheral Nerves, Churchill Livingstone, Edinburgh, 2007.

18 John Sharkey, see article in this edition of Terra Rosa magazine “BioTensegrity” page 6-10.

25 Robert Schleip, Thomas W. Findley, Leon Chaitow and Peter A. Huijing, Fascia: The Tensional Network of the Human Body, Churchill Livingstone/Elsevier, Edinburgh, 2012.

19 Robert Schleip, Thomas W. Findley, Leon Chaitow and

Peter A. Huijing, Fascia: The Tensional Network of the Human Body, Churchill Livingstone/Elsevier, Edinburgh, 2012. 20 Thomas W. Myers, Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists, 2nd edition, Churchill Livingstone, Edinburgh, 2009. 21Joanne Avison, YOGA Fascia, Anatomy and Movement,

Handspring Publishing 2015, Chapter 12, Yoga and Anatomy Trains 22 Thomas W. Myers, Anatomy Trains: Myofascial Meridi-

ans for Manual and Movement Therapists, 2nd edition, Churchill Livingstone, Edinburgh, 2009. The Super icial Back Line 23 For a more detailed explanation expanding on this

26 Luiz Fernando Bertolucci , “Pandiculation: Nature’s

Way of Maintaining the Functional Integrity of the Myofascial System?”, Journal of Bodywork and Movement Therapies 15(3): 268–280; 2011. 27 Doug Richards, University of Toronto, Assistant Profes-

sor, Medical Director, David L. MacIntosh Sport Medicine Clinic. Also see www.youtube.com/watch? v=7qYYhkfu_vc for a 45 minute presentation by Doug Richards called “Stretching: The Truth”. 28For a more detailed explanation expanding on this theme and further reading references see YOGA Fascia, Anatomy and Movement, Handspring Publishing 2015, Chapter 4, Biotensegrity Structures and Chapter 8, The Elastic Body

YOGA: Fascia, Anatomy and Movement seeks to bridge the divide between the application of classical anatomy and real-life experiences of practicing and teaching yoga. Whatever your style of yoga, YOGA: Fascia, Anatomy and Movement makes sense of the experience of the moving body in and beyond the yoga classroom. It is a groundbreaking and invaluable resource in the contemporary art and science of yoga. The book is written in straightforward and accessible language, and is divided into three parts: • Part 1 examines recent research and the paradigm shift from the classical anatomy of the musculoskeletal system to the new perspective the fascia provides. • Part 2 applies this perspective to the practice of yoga with highly illustrated, clear descriptions of techniques and exercises. • Part 3 considers the metaphysical aspect of yoga and the hidden geometry of our biotensegrity architecture as a metaphor for consciousness. YOGA: Fascia, Anatomy and Movement is intended primarily for Yoga Teachers, but can be adapted for use with Pilates and all other movement training programs. It is also a resource for therapists working in the fields of sport, dance, and movement therapy as well as manual practitioners.

Available at www.terrarosa.com.au Terra Rosa E-mag 23

24 Terra Rosa E-mag

A randomized clinical trial of Structural Integration as an adjunct to outpatient rehabilitation for chronic low back pain: A summary By Eric Jacobson PhD, MPH Introduction

acupuncturists.[13]

Chronic low back pain is among the most burdensome of health problems in prevalence and cost of care.[1] It is the leading cause of years lived with disability worldwide and the most frequent cause of disability related loss in high-income countries.[2,3] Much of this economic burden is expended on costly surgical and rehabilitative services. Up to one third of acute low back pain cases may become chronic and lead to disability.[4] In a majority of chronic cases (estimated at 85– 95%) a definitive diagnosis, that is, infection, neoplasm, osteoporosis, arthritis, fracture, radiculopathy, or inflammatory rheumatic processes, is ruled out, and these are designated as chronic “uncomplicated,” “mechanical,” or “nonspecific” low back pain (CNSLBP).[5] There is no consensus on the optimal approach to the treatment of CNSLBP. Management typically includes some combination of analgesic or anti-inflammatory medication, directed therapeutic exercise, manipulation, cognitive-behavioural therapy, and patient education.[6] However, systematic reviews have generally concluded that the benefits of these approaches are limited and mostly short-lived. [7-11] A large survey in the United States found that 54% of patients with low back or neck pain used complementary therapies and that approximately one third of all visits to alternative care practices were for back or neck pain.[12] Low back pain has been reported to be the primary complaint in 40% of all visits to chiropractors, 20% to massage therapists, and 15% to

Structural Integration (SI) is increasingly turned to for the treatment of chronic musculoskeletal pain and disability. A few preliminary studies with small samples suggest possible effectiveness for musculoskeletal pain, but aside from a single case report, no clinical studies of SI for CNSLBP have appeared to date.[14] Studies of SI for musculoskeletal pain, and preliminary evidence regarding a number of hypothesized therapeutic mechanisms have been reviewed elsewhere.[15-17] SI treatment sometimes involves notable discomfort which has led to a reputation of being excessively painful and even to concerns as to its safety.[18] This has been a barrier to a more widespread adoption by conventional medical clinics, although SI was successfully incorporated into at least one.[15,19] Despite these concerns, published data on adverse events associated with SI are limited to a single case and a small prospective case series. [20,21] This study was designed to collect preliminary data on the feasibility, effectiveness, and adverse events associated with SI as an adjunct to outpatient rehabilitation (OR) versus OR alone for CNSLBP. The outcomes will inform our design of a more adequately powered clinical trial. We hypothesized that we could recruit and retain qualified participants who would comply with treatment and data collection, that a course of SI + OR would improve low back related pain and disability

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significantly more than OR alone, and that SI could be delivered with acceptable levels of adverse events. Methods Institutional context: This study was conducted at the Motion Analysis Laboratory, Spaulding Rehabilitation Hospital, Partners HealthCare, LLC, Boston, and was approved by the Spaulding institutional review board. The study was registered with ClinicalTrials.gov (NCT01322399) prior to beginning the recruitment of participants. Design: Following screening, enrolment, and baseline data collection, participants were randomized in a 1:1 ratio to parallel treatment groups: OR alone versus SI + OR. Followup data were collected at 20 weeks after baseline. Subjects: We included men and women aged 18–65 living in the greater Boston area, with CNSLBP of ≥6 months duration which was not attributed to infection, neoplasm, severe radiculopathy (assessed by frequent severe pain radiating down a leg), fracture, or inflammatory rheumatic process, with a patient rated bothersomeness of pain on average over the preceding 6 months ≥3 on an 11-point ordinal verbal response scale (0=none, 10=worst imaginable), i.e. moderate to severe range. Prior arrangement to enter or having recently entered treatment at any Boston area outpatient rehabilitation clinic was also required. We excluded candidates for i) impaired hearing, speech, vision, or mobility; ii) current or anticipated receipt of payments from Worker’s Compensation or other disability insurance; iii) prior treatment with any type of SI; iv) plans to initiate additional treatment for back pain other than outpatient rehabilitation care during the period of the study; v) exclusions for safety; vi) exclusions for anticipated lack of therapeutic response; vii) conditions that might confound measures of balance and movement; viii) conditions that would confound data on inflammatory biomarkers; ix) any other condition that would impair the patient’s ability to complete the study. Sample Size: Using data from a clinical trial of massage and a meta-analysis of trials of balneotherapy, both for low back pain, a sample size of 40 was estimated as adequate to detect Minimal Clinically Important Differences (MCID) in pain and disability.[22,23] The sample was later increased to 46 to compensate for dropouts. Treatment: All participants were required to attend a recently arranged course of outpatient rehabilitation at any rehabilitation clinic in the Boston area. Typical courses of outpatient rehabilitation (OR) for CNSLBP employ varying combinations of analgesic and anti-inflammatory medication, joint manipulation, therapeutic exercise, cognitive behavioural treatment, and education. Participants were allowed 20 weeks to complete their course of OR. The number and frequency of treatments were determined by each participant and their therapist. Ten sessions conforming to the Rolf Ten Series protocol were provided free of charge to each participant assigned to the SI+OR group. SI treatments were provided by five therapists who met the criteria of graduation from the training

26 Terra Rosa E-mag

programs of the Rolf Institute® of Structural Integration,[24] the Guild for Structural Integration,[25] or Kinesis Myofascial Integration (KMI)[26]; a minimum of 10 years clinical practice of SI; and membership in the International Association of Structural Integrators®.[27] The KMI graduates agreed to provide the Rolf Ten Series instead of the twelve sessions taught by KMI, which include the Ten Series. Outcomes: The primary outcome of the study was pre-defined as a comparison across treatment groups of change between baseline and 20-week follow-up on a patient-rated visual analog scale (0–100 mm) of bothersomeness of pain on average over the preceding week (VAS Pain), anchored as 0=none, 100 mm=worst imaginable.[28] The secondary outcome was a comparison of changes in the total of the Roland-Morris Disability Questionnaire (RMDQ) over the same period.[29,30] Pre-defined exploratory outcomes included the Short Form 36 Health Survey (SF36),[31] the sum of days and half days disabled over the past week, and Global Satisfaction with Care. These questionnaires are all patient-completed and have been recommended for use together in low back pain trials.[32,33] All data were analysed on an intent-to-treat basis, i.e. the last available data for each dropout was substituted for their missing 20 week data. Because of our small sample size, the Wilcoxon rank sum test was specified to test the significance of between group differences in change scores. Adverse events were monitored through reports submitted by study staff and a biweekly Patient Questionnaire. We also recorded all elevations VAS Pain scores ≥30mm above baseline as adverse events. In addition we collected feasibility data on the demographic characteristics of unenrolled compared to enrolled candidates, compliance with assigned treatment, and dropouts. Results Recruitment, Enrollment, Treatment Compliance, and Dropouts: The study was conducted between April, 2011 and August, 2013. Enrolled compared to unenrolled candidates were approximately equivalent in gender, age and race. The demographic and prognostically relevant characteristics of the treatment groups were also acceptably similar at baseline. Attendance at OR treatments was unexpectedly low, but was not significantly different between treatment groups. In the SI+OR group, attendance at SI was almost perfect. The overall rate of dropout was 11%, which is within the range that has been recommended as a standard for assessing back pain trials, and was not significantly different between groups.[34] Outcomes: The median reductions in VAS Pain, the primary outcome, of −26 mm [Interquartile range −31.5, −3.0] in SI+OR compared to 0 mm [−24.5, 6.5] in OR alone were not significantly different (Wilcoxon rank sum 2-sided test p=0.075#) (Figure 1). However, the median reductions in RMDQ, the secondary outcome, of −2 points [−4.5, −1] in SI +OR compared to 0 [−2, 0] in OR alone, were significantly different (p= 0.007) (Figure 2). The between group difference in median change of two points is the smallest suggested absolute MCID for the RMDQ [37].

RCT: SI on Chronic Low Back Pain

Figure 1: Change in VAS (Visual Analog Scale) Pain by treatment group.

Figure 2: Change in Roland-Morris Disability Questionnaire (RMDQ) Pain by treatment group.

n=sample size; squares and circles represent the change score of individual subjects; Widest horizontal lines= median values; narrower horizontal lines=interquartile ranges

n=sample size; squares and circles represent the change score of individual subjects; Widest horizontal lines=median values; narrower horizontal lines=interquartile ranges

Other pre-specified outcomes which were different between treatment groups at a significance level of p<0.01 were the SF36 subscale for Bodily Pain, and Global Satisfaction with Care, each of which had greater improvement in SI+OR.[17]

related adverse events were not significantly different across groups, nor were the proportions for participants with any adverse event, whether study-related or not. The numbers of adverse events per participant were also compared across groups and found to be not significantly different. All studyrelated adverse events were rated as mild or moderate in seriousness, none were rated as severe, and none required medical treatment. The most endorsed types of study-related adverse events in both groups were sharp, burning, and aching pain, and the proportions of subjects with these were not significantly different across groups. The proportions of participants who endorsed the other most frequent types were compared across groups, and were significantly different only for a residual category of non-pain experiences that included time-limited sensations of heat, sweating, dizziness or spinning, reduced coordination or balance which were more frequent in SI+OR.

In an exploratory analysis that was not initially planned, we tabulated the number of participants with reductions in VAS Pain at 20 weeks that were minimal (10–20%), moderate (≥ 30%), and substantial (≥ 50%) relative to the baseline values, and also those with absolute reductions of 20 and 40 mm [52, 53]. We then compared the proportions of such responders versus non-responders at each level across groups. SI+OR had larger proportions of responders at the minimal and moderate levels at a p<0.05 level of significance. Differences all other levels were in favour of SI+OR but were nonsignificant. (Table 1) In a further exploratory analysis we constructed a linear mixed effects regression model of bi-weekly data on VAS Pain that had been collected on the Patient's Questionnaire. A total of 388 pain ratings were available with collection times ranging from 0 to 184 days and an average time from baseline to last observation of 137 days (19.6 weeks). The model that best fit that data had significant main effects for baseline VAS Pain, baseline RMDQ, between group difference at baseline , days since baseline, and the days-group interaction (i.e. the between-group difference in the rate of change per day). The days-group parameter, which represents the amount by which the rate of change for SI + OR differs from the rate of change for OR alone, was estimated as -0.14 mm/day, and was highly significant (p=0.0039). The negative value of this parameter indicates a greater rate of reduction in SI+OR compared to OR alone. Figure 3 displays the estimated marginal means and 95% confidence bands for the daysgroup interaction.

Two participants in SI+OR dropped out because of adverse events. The first reported an episode of “dread and worry” regarding their next treatment and subsequently dropped out, citing intolerance of the discomfort of SI treatment and a poor relationship with the SI therapist. The second dropped out subsequent to enrolment but prior to receiving any studyrelated treatment due to an exacerbation of a pre-existing medical condition. Discussion This was the first randomized trial to estimate the therapeutic effect of SI as an adjunct to OR for CNSLBP, and only the third clinical trial of SI for any medical condition.[35,36] It was also the first systematic study of adverse events associated with SI treatment, which were robustly monitored by both staff and participant reports and identified and rated using conservative criteria.

Adverse events: The proportions of subjects with study#p values referred to here and later quantify the probability that the between group difference detected does not reflect an actual difference between similarly defined groups in the larger population from which the study sample was drawn. The generally observed convention is that findings of between group difference with p<0.05 are "significant," but those was p>0.05 are “non-significant”. The threshold of 0.05 is arbitrary; and the validity of any particular p value depends on the assumption that the distribution of the data being tested in the larger population conforms to one of a few mathematically defined distributions, the most common of which is “normal distribution”.

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Table 1: VAS Pain responder analysis: responder/non-responder ratios compared across treatment groups . Pain Reduction

SI+UC (n=23)

UC alone (n=23)

RR (CI)

10-20%

17 (74%)

9 (39%)

1.89 (1.07-3.32)

0.036*

>30%

15 (65%)

7 (30%)

2.14 (1.08-4.26)

0.038*

>50%

12 (52%)

6 (26%)

2.00 (0.91-4.41)

0.130

>20 mm

12 (52%)

7 (30%)

1.71 (0.83-3.56)

0.231

>40 mm

5 (22%)

2 (9%)

2.50 (0.54-11.60)

0.414

n: sample size; RR: relative risk, the percentage for SI+UC divided by the percentage for UC alone; CI: 95% confidence intervals# for RR; 1. Fisher's exact 2-sided p value; * significant difference at p<0.05. Improvements in the primary outcome, VAS Pain, were not significantly different between treatment groups, but improvements in the secondary outcome, RMDQ, were significantly greater in SI+OR than in OR alone, with the difference between median change scores satisfying the lowest recommended absolute MCID.[37] Among pre-defined exploratory outcomes the SF36 subscale for Bodily Pain, and Global Satisfaction with Care both improved more in SI+OR than in OR alone. With respect to feasibility, we successfully recruited and enrolled a sample whose demographic characteristics did not differ significantly from those unenrolled. Randomization produced treatment groups that were acceptably equivalent on prognostically significant variables. Compliance with SI treatment was high, suggesting that any discomfort associated with it did not dissuade the majority of participants assigned to SI+OR from attending. Neither the incidence nor the seriousness of adverse events was significantly increased by the addition of SI to OR. Dropouts were within acceptable limits, and we found no evidence of crossover between treatment regimes. However, the length of time to recruit the cohort was unexpectedly long, and compliance with the requirement to receive OR treatment was unexpectedly low. Both would need to be remediated in a follow-up study. Limitations: Because this study assessed the effect of SI as an adjunct to OR compared to OR alone, its outcomes should not be taken to indicate the effect that SI alone might have on CNSLBP. The large number of exclusion criteria might have resulted in the enrolment of a sample that was not representative of the typical clinical population, and this might limit the generalizability of these results. It was not possible to blind participants or therapists to treatment assignment because of obvious differences between the experiences of SI and OR treatment. Effective maintenance of the initial blinding of investigators proved to be impossible due to limited administrative staffing, but the potentially biasing effect of this was mitigated by the fact that all outcomes were patient-rated. Compliance with the requirement to receive OR was unexpectedly low and might ##95%

Figure 3: VAS Pain marginal means by treatment group estimated by linear mixed model. Shaded areas are the 95% confidence intervals. have contributed to the median change scores of zero for both VAS Pain and RMDQ in the OR alone group. We did not directly monitor SI treatment sessions for fidelity to protocol, nor require the therapists to report their treatment interventions in detail. The additional 10 hours of hands-on treatment received in SI+OR might have contributed to the more favourable outcomes in that group compared to OR alone (Hawthorne effect). A placebo effect might also have contributed, because members of the SI+OR group were aware that they were receiving the treatment that was the object of our investigation (SI). The absence of follow-up at a longer duration is an additional limitation. Recommendations: A follow-up study should provide SI according to a specific treatment protocol such as the Rolf Ten Series, should use therapists who are adequately trained and experienced in whatever protocol is used, and should allow for the individualization of treatment strategies to reflect actual practice. The collection of information on the specific SI techniques employed in each treatment session would enable closer monitoring of the treatment protocol. At

confidence intervals represent the range of values within which the estimated value might vary for 95% of all possible samples that might be selected from the larger population. Like the p value, it assumes that the distribution of values in the larger population conforms to one of a few mathematically defined models.

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RCT: SI on Chronic Low Back Pain least a three-month follow-up should be included. We speculate that SI alone might be superior to outpatient rehabilitation alone and note that a direct comparison of the two could control for time, attention, and skin stimulation across treatment groups. Our positive outcome for greater reduction in disability in the SI+OR group suggests that hypothesized mechanisms for mediating a therapeutic effect of SI are also worthy of future investigation. Conclusions The outcomes of this study suggest that adding SI to outpatient rehabilitation for CNSLBP should not be expected to enhance reductions in patient-rated pain, but might enhance reductions in low back pain related disability at least for the short term and modestly increase patient satisfaction without significantly increasing the rates of adverse events. If these indications were confirmed by a more definitive study, that might support the recommendation of SI as an effective adjunct to outpatient rehabilitation for this condition. Data on enrolment, retention, data collection, and compliance with SI treatment suggest that a follow-up study is feasible. However, the study design should increase the efficiency of recruitment and improve compliance with OR. A more detailed report of this study is given in Jacobson et al. 2015 J Evid Based Complment Altern Med. 813418, which is publically available at www.hindawi.com/journals/ecam/ 2015/813418

Acknowledgements This study would not have been possible without the generous collaboration of Alec Meleger, Paolo Bonato, Peter Wayne, Helene Langevin, Ted Kaptchuk, and Roger Davis. Major study expenses and Dr. Jacobson’s effort were funded by a career development award from the National Center for Complementary and Integrative Health, National Institutes of Health (NCCIH/NIH, K01AT004916). Dr. Kaptchuk’s effort was supported by a mentorship award from NCCIH/ NIH (K24AT004095). Supplemental funding was provided by the Ida P. Rolf Research Foundation, Harvard Medical School, the Rolf Institute® of Structural Integration, Dean Rollings, and Hal and Sonya Milton. Administrative and technical support was generously provided by the Motion Analysis Laboratory, Spaulding Rehabilitation Hospital, Partners Healthcare, LLC, and by Harvard Medical School. We also thank the volunteers who served as independent monitor and on the data safety monitoring committee, and the SI practitioners: Lou Benson, Lisa Grey, Ellen Halpern, Tim Roode, and Garret Whitney.

The Author Eric Jacobson, PhD, MPH, investigates alternative medicine at Harvard Medical School. He was trained by Ida Rolf in 1974, completed advanced training with the Rolf Institute® in 2005, and has a private practice of Structural Integration in Boston.

References 1. Anderson, G. (1999). Epidemiological features of chronic low back pain. Lancet, 354(9178), 581-5. 2. Vos, T., Flaxman, A. D., Naghavi, M., Lozano, R., Michaud, C., et al. (2013). Years lived with disability (YLDs) for 1160 sequelae of 289 disease and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380, 2163-96. 3. Luo, X., Pietrobon, R., Sun, S. X., Liu, G. G., Hey, L. (2004). Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine, 29, 79-86. 4. Von Korff M., Saunders K. (1996). The course of back pain in primary care. Spine, 21(24), 2833-37. 5. Deyo R., Weinstein J. N. (2001). Low back pain. New England Journal of Medicine, 344(5), 363-70. 6. Dagenais S., Tricco A. A., Haldeman S. (2010). Synthesis of recommendations for the assessment and mangement of low back pain from recent clinical practice guidelines. Spine, 10(6), 514-29. 7. Lee, T. (2010). Pharmacologic treatment for low back pain: one component of pain care. Physical Medicine & Rehabilitation Clinics of North America, 21, 793-800. 8. Kuijpers, T., van MIddlekoop, M., Rubinstein, S. M., Ostelo, A., et al. (2011). A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low back pain. European Spine Journal, 20, 4050. 9. Stout. A. (2010). Epidural steroid injections for low back pain. Physical Medicine & Rehabilitation Clinics of North America, 21, 825-34. 10. van Tulder. M., Koes, B., Malmivaara, A. (2006). Outcome of non-invasive treament modalities on back pain: an evidence-based review. European Spine Journal, 15(Suppl 1), S64-81. 11. von Middlekoop, M., Rubinstein, S. M., Kuijpers, T., Verhagen, A. P., et al. (2011). A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. European Spine Journal, 20(19-309. 12. Wolsko, P. M., Eisenberg, D. M., Davis, R. B., Kessler, R., Phillips, R. S. (2003). Patterns and perceptions of care for treatment of back and neck pain: results of a national survey. Spine, 28(3), 292-97. 13. Cherkin, D., Deyo, R. A., Sherman, K. J., Hart, G. L., et al. (2002). Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. Journal of the American Board of Family Practice, 15(6), 463-72. 14. Cottingham, J. T., Maitland, J. (1997). A threeparadigm treatment model using soft tissue mobilization and

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guided movement-awareness techniques for a patient with chronic low back pain: a case study. Journal of Orthopaedic & Sports Physical Therapy, 26(3), 155-67. 15. Deutsch, J. E., Derr, L. L., Judd, P., Reuven, B. (2000). Treatment of chronic pain through the use of structural integration (rolfing). Orthopaedic Physical Therapy Clinics of North America, 9(3), 411-25.

March 1, 2015. 26. Kinesis Myofascial Integration. http:// www.anatomytrains.com/kmi, accessed March 1, 2015 27. International Association of Structural Integrators®. (2013). International Association of Structural Integrators® http://www.theiasi.net/home-header, accessed March 1, 2015.

16. James, H., Castaneda, L., Miller, M. E., Findley, T. (2009). Rolfing structural integration treatment of cervical spine dysfunction. Journal of Bodywork and Movement Therapies, 13(3), 229-38.

28. Dunn, K. M., Croft, P. R. (2005). Classification of low back pain in primary care: using "bothersomeness" to identify the most severe cases. Spine, 30(16), 1887-92.

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30. Roland, M., Fairbank, J. (2000). The Roland-Morris Disability Questionnaire and the Oswestery Disability Questionnaire. Spine, 25(3115-24),

19. Krotenberg, R. (2004). Alternative therapies join the mainstream. Focus on Rehabilitation. West Orange, NJ: Kessler Institute for Rehabilitation. Summer. July, 2004.

31. Ware, J. E., Sherbourne, C. D. (1992). The MOS 36item short-form health survey (SF-36): I. Conceptual framework and item selection. Medical Care, 30(6), 473-83.

20. Kerr, H. D. (1997). Urethral stent displacement associated with deep massage. Western Medical Journal, 96 (12), 57-58.

32. Deyo, R. A., Battie, M., Beurskens A. J., Bombarider C., P. et al. (1998). Outcome measures for low back pain research. a proposal for standardized use. Spine, 23(18), 2003-13.

21. Perry, J., Jones, M. H., Thomas, L. (1981). Functional evaluation of Rolfing in cerebral palsy. Developmental Medicine and Child Neurolology, 23(6), 717-729.

33. Bombardier C. (2000). Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations. Spine, 25(24), 3100-03.

22. Cherkin D. C., Eisenberg, E., Sherman, K. J., Barlow, W., et al. (2001). Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and selfcare education for chronic low back pain. Archives of Internal Medicine, 161(1081-88.

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35. Hansen, A., Price, K. S. , Feldman, H. M. Myofascial structural integration: a promising complementary therapy for young children with spastic cerebral palsy. Journal of Evidence Based Complmentary and Alternative Medicine, 17 (4), 131-35. 36. Stall, P., Teixeria, M. J. (2014). Fibromyalgia syndrome treated with the structural integration Rolfing® method. Rev Dor Sao Paulo, 15(4), 248-52. 37. Bombardier, C., Hayden J., Beaton, D. E. (2001). Minimal clinically important difference. low back pain. outcome measures. The Journal of Rheumatology, 28,431-38.

The Price of Smart Phones Ten Common Dysfunctional Postures and Injuries caused by Smart Phone Use

By Joe Muscolino The introduction of any new technology often comes with unexpected consequences. This is certainly true with widespread use of the smart phone. Although it is a wonderful marvel of communication that allows us to be connected with our loved ones, friends, and business colleagues, as well as connect us to the internet and therefore the world around us, unfortunately it comes at a price. That price is the physical stress that it can place on our body. One only needs to go to a public place and observe others while using their smart phones. The odds are that we will see many dysfunctional postural patterns and future injuries in the making. However, most of these conditions can be avoided if we pay attention to our biomechanics as we hold and use the smart phone.

As therapists, it is important to be aware of these common conditions so that we can be prepared to assess for them, and if found, provide the appropriate clinical orthopedic work to ameliorate the condition. Being aware of these potential problems also arms us with the knowledge needed to be able to offer the client valuable postural advice about how to properly hold and use the smart phone so that the development of these problems can be avoided.

ter be described as repetitive overuse conditions. These conditions are therefore less posture related and more due to the chronic repetitive use of smart phones. However, even with repetitive overuse conditions, improving smart phone posture can help to minimize or avoid their onset. For these reasons, some suggested postures for smart phone use are offered at the end of this article.

Following are ten of the most common dysfunctional postural patterns and injuries that may occur with smart phone use. Some of these conditions are purely postural and can be avoided by improving the posture that is employed when using a smart phone. Other conditions may bet-

Golferâ&#x20AC;&#x2122;s elbow, also known as medial epicondylitis or medial epicondylosis, is a condition in which in lammation and/or degeneration of the common lexor tendon occurs, usually accompanied by hypertonicity of the bellies of the associated muscles. This condition is caused by over-

1. Golferâ&#x20AC;&#x2122;s Elbow

Terra Rosa E-mag 31

use of the muscles of the common lexor tendon that attaches to the medial epicondyle of the humerus. These muscles are the three muscles of the wrist lexor group ( lexor carpi radialis, palmaris longus, and lexor carpi ulnaris), the pronator teres, and the lexor digitorum super icialis. As a whole, these muscles do lexion of the wrist joint and the ingers; in other words, the joint actions necessary to grip and hold any object including a smart phone (Figure 1). Holding the smart Figure 1. Prolonged holding of a smart phone can lead to overuse, fatigue, phone occasionally for a few and dysfunction of the common flexor tendon. This condition is known as minutes at a time is not a probgolferâ&#x20AC;&#x2122;s elbow. lem. The problem occurs with overuse that requires prolonged isometric contraction of the associated musculature, leading to fatigue and eventual injury/ dysfunction of the common lexor tendon. The development of this condition is accelerated if the client grips the smart phone harder than necessary, thereby increasing the contraction strength and therefore stress upon the musculature and its common tendon.

2. Tennis Elbow Tennis elbow, also known as lateral epicondylitis or lateral epicondylosis, is a condition in which in lammation and/or degeneration of the common extensor tendon occurs, usually accompanied by hypertonicity of the bellies of the associated muscles. This condition is caused by overuse of the muscles of the common extensor tendon that attaches to the lateral epicondyle of the humerus. These muscles are the extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, and the extensor carpi ulnaris. As a group, these muscles do extension of the wrist joint and the ingers. It would seem that these muscles do not need to contract when gripping and holding a smart phone because this 32 Terra Rosa E-mag

Figure 2. Prolonged holding of a smart phone (or shown here as pen) can lead to overuse, fatigue, and dysfunction of the common extensor tendon. This condition is known as tennis elbow.

Figure 3. Crimping a smart phone between the shoulder and ear physically stresses muscles of scapular elevation.

The Price of Smart Phones activity requires contraction by lexion musculature, not extensor musculature. However, extensor musculature is needed to contract isometrically to stabilize the wrist joint and prevent it from lexing when the lexors digitorum super icialis and profundus muscles contract to lex the ingers. Most often, it is the extensor carpi radialis brevis that engages in this scenario (Figure 2). Therefore, holding a smart phone does physically stress musculature of the common extensor tendon and can contribute to tennis elbow. Occasional use is not a problem; like golfer’s elbow, tennis elbow is an overuse condition. Gripping the phone more forcefully than necessary will also increase the stress to the extensor musculature and therefore the likelihood that this condition will develop.

3. Uptight Shoulders Developing “uptight” elevated shoulders with a smart phone occurs when the phone is crimped (compressed) between the ear and shoulder, because this posture requires contraction of scapular elevation musculature to bring the shoulder up to hold the phone against the ear (Figure 3). Muscles of scapular elevation that are used/overused and likely to become fatigued, tight, and injured are the upper trapezius and levator scapulae. Crimping a phone also requires contraction of same-side lateral Figure 4. Holding the phone out in front of the body lexion musculature of the neck to help press the ear can overly stress, fatigue, and injure musculature of the anterior shoulder. downward against the phone and shoulder. This further requires contraction of, and therefore physically stresses, the upper trapezius and levator scapulae, as well as other muscles of lateral lexion. This anterior deltoid strain as well as strain of the upper problem is not new with smart phones. It was and trapezius and levator scapulae. still is common for people to crimp landline phones too. However, because smart phones are much smaller, the amount of muscular effort necessary to crimp a smart phone is greater than to crimp a land- 5. Rotator Cuff Strain/Tendinitis line phone. Holding a phone out in front of the body with humeral lexion can also stress and injure the rotator 4. Anterior Shoulder Strain cuff musculature. Whenever the arm is lifted upIt is common for people using a smart phone to hold ward in the air, whether it is up into lexion, extenthe phone in the air out in front of their body. The sion, abduction, or adduction, it is necessary for the dif iculty with this posture is that it requires isomet- rotator cuff musculature to contract to stabilize and ric contraction of the musculature of humeral lexhold the (proximal) head of the humerus down into ion at the glenohumeral joint to hold the arm out in the glenoid fossa as the distal end of the humerus the air. Foremost among these muscles is the anteri- raises (Figure 5). Overuse of this posture can, over or deltoid (Figure 4). Holding the arm out in lexion time, contribute to fatigue, tightening, and strain of also requires stabilization of the scapula, which rethe rotator cuff musculature, as well as tendinitis of quires contraction of and therefore stress to the up- the rotator cuff muscles. per trapezius. And if the person also adds in eleva tion of the shoulder girdle to hold the phone up higher, it places even greater stress on the upper trapezius, as well as the levator scapulae. Therefore, excessive engagement of this posture can lead to Terra Rosa E-mag 33

6. Rounded Shoulders Rounded shoulders is a postural distortion pattern in which the scapulae are protracted and the humeri are medially rotated. Therefore the shoulder girdles and arms are rounded in, hence the name. The client with rounded shoulders has scapular protractors (pectoralis minor and major) and humeral medial rotators (subscapularis, pectoralis major and teres major) that are locked short and tight, accompanied by scapular retractors (middle and lower trapezius and rhomboids) and humeral lateral rotators (teres minor and infraspinatus) that are weak and also likely locked long and tight. Using a smart phone often predisposes the client to this condition because so many people hold the Figure 5. Holding the arm out in front of the body can also physically smart phone down low in front of them (Figure 6). As with other over- stress, fatigue, and injure musculature of the rotator cuff group. use conditions, occasional rounded posture with a smart phone is not detrimental, but when this posture is assumed for long periods of time, the effects can become very chronic and severe.

7. Rounded Upper Back Rounded upper back is de ined as hyperkyphosis of the thoracic spine and almost always accompanies rounded shoulders. As the clientâ&#x20AC;&#x2122;s shoulder girdles and arms round and collapse forward and down, their thoracic spine also rounds and collapses into lexion, in other words, hyperkyphosis. As with rounded shoulders, rounded upper back is caused and/or exacerbated by prolonged use of the smart phone down in front of the body (see Figure 6).

8. Forward Neck Also accompanying rounded shoulder girdles and rounded upper back is forward head. When the thoracic spine is hyperkyphotic, the neck naturally projects forward with a hypolordotic lower cervical spine. The upper cervical spine then becomes hyperlordotic as a compensation to 34 Terra Rosa E-mag

Figure 6. Holding the smart phone down low in front predisposes the client to rounded shoulders characterized by protracted scapulae and medially rotated humeri, as well as rounded upper back, forward head, and rounded lower back.

The Price of Smart Phones

The 27 kg head Having the center of weight of the head forward of the trunk requires constant isometric contraction of the posterior cervical extensor musculature. How forceful the posterior cervical musculature must work is dependent upon the leverage force of the weight of the head. The average head weighs approximately 4-5 kg (10-12 pounds). However, as the head and neck are further lexed, the center of weight of the head moves increasingly anterior, increasing the leverage force of the weight of the head against which the cervical extensor musculature must work. It has been estimated that when the neck is lexed to 45 degrees, the head weighs the equivalent of 20 kg (45 pounds). And if the neck is lexed 60 degrees, the head weighs the equivalent of 27 kg (60 pounds)!

bring the eyes and ears back to level (see Figure 6). The posture of the head ends up being forward (protracted) with its center of weight anterior to the trunk and imbalanced over thin air; therefore, it should fall with gravity into lexion until the chin hits the chest. The only reason it does not is that the posterior cervical extensor musculature isometrically contracts to hold the head in this postural distortion pattern against the lexion force of gravity (Figure 7). Due to the prolonged isometric contraction of the posterior cervical musculature, it often fatigues, tightens, and becomes strained/injured and painful. Long-term chronic tightness of this musculature can also cause a tension pulling force (enthesopathy) upon its cranial attachments on the scalp, possibly resulting in tension headaches.

smart phone down low in front of the body, often in the lap. Over time, the assumption of this posture, as with all chronic postures, will result in locked short and locked long musculature, as well as fascial adhesions that will effectively â&#x20AC;&#x153;glueâ&#x20AC;? the tissues to become stuck in this posture. The

collapsed posture of rounded lower back usually couples with the collapsed postures of rounded upper back and rounded shoulders, as well as forward head posture (see Figure 6).

9. Rounded Lower Back Rounded lower back is becoming increasingly common as a postural distortion pattern. It involves excessive posterior tilt of the pelvis and either hypolordosis of the lumbar spine or an actual reversal of the lumbar spine into kyphosis. This condition is caused by collapsing the entire trunk forward, and in the context of smart phone use, occurs when using the

Figure 7. Forward head posture results in the centre of weight of the head being anterior to the trunk. This imbalance is compensated for by constant contraction of the posterior cervical extensor musculature.

Terra Rosa E-mag 35

10. Texting Thumb Texting thumb is the name given to irritation/in lammation/injury to the tendons of the thumb due to repetitive overuse when texting or otherwise using a smart phone. The strain to the thumb comes less from the pressing of the thumb against the phone that it does from the traveling of the thumb that is necessary to move from one area of the screen to another; although pressing harder would add to the physical stress. The muscles of the thumb can be divided into intrinsic and extrinsic groups. Intrinsic thumb muscles are wholly located within the hand; in other words they originate within the hand and insert onto the thumb. Extrinsic thumb muscles have their proximal attachment (origin) in the arm or forearm and then attach onto the thumb. The Figure 8. Texting thumb often involves overuse and injury to the tendons of the intrinsic thumb muscles are the ab- abductor pollicis longus and extensor pollicis brevis. ductor pollicis brevis, lexor pollicis brevis, opponens pollicis (all of the thenar group), and the adductor pollicis. The extrinsic muscles are the lexor pollicis longus, abductor pollicis longus, extensor pollicis brevis, and extensor pollicis longus. Although the tendons of any of the muscles of the thumb can be involved, the tendons, or more precisely the synovial sheathes of the tendons, of the abductor pollicis longus and extensor pollicis brevis are most commonly involved because the use of these muscles causes their tendons to rub against the styloid process of the radius (Figure 8). Tenosynovitis of these tendons is also known as de Quervainâ&#x20AC;&#x2122;s disease (or de Quervainâ&#x20AC;&#x2122;s stenosing tenosynovitis).

Suggested Smart Phone Postures Following are a few tips for posture when using a smart phone. Certainly, any static posture that is assumed for prolonged periods of time, even an ideal posture, can result in stiffness and excessive stress 36 Terra Rosa E-mag

The Price of Smart Phones

Locked Short and Locked Long There is an old saying that goes “There is no such thing as a bad posture, as long as you don’t get stuck in it.” This describes the idea that functionally being able to move in and out of any posture is ine. However, when a person continually/chronically assumes the same posture, the body’s tissues do tend to get stuck in it. Getting stuck can involve increased muscle baseline tone via the sliding ilament mechanism (termed adaptive shortening) as well as the formation of fascial adhesions. With any given posture, the myofascial soft tissues on one side of the joint are shortened and the myofascial soft tissues on the other side of the joint are lengthened. Therefore, we can describe the tissues on the short side of the posture as locked short, and the tissues on the long side as locked long. And because the length tension relationship curve (that describes the strength of a muscle at its various lengths) shows that both shorter and longer muscles tend to become weaker, the result is that we have tight and weak muscles on both sides of the joint, regardless of whether they are short or long.

Upper Crossed Syndrome The sum postural distortion pattern of rounded shoulders along with rounded upper back and forward head is often termed as the upper crossed syndrome. This name is used to describe the characteristic crossed pattern of overly facilitated / tight / locked short muscles with the overly inhibited / weak / locked long muscles.

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to the body. For this reason, it is wise to take a break from your smart phone every few minutes so that you can move and change your posture.

Tips for smart phone posture 1. Try to work with the phone at, or as close to eye level as possible; but it is important for your arm(s) to be supported (Figure 9A). 2. If present, perhaps you can lean your elbows on an armrest to support your arms. This might not quite bring the phone to eye level, but it will allow both hands to be free when writing/typing (Figure 9B). 3. Alternately, one elbow can be supported on an armrest with the other arm supported by your trunk. This will allow the phone to be held slightly higher and closer to eye level, but may cause you to lean your trunk toward the side of the armrest (Figure 9C). 4. If no armrest is present, then try to support your arms against your trunk (Figure 9D). This might slightly round the shoulders, but it does support the arms and it brings the phone up higher. 5. If one forearm can be held across your abdomen, then the other elbow can rest on it and this will bring the smart phone even higher and up to eye level. This is the best posture for your upper body. But because only one hand is free, this posture might not be best when typing but is recommended when reading (see Figure 9A). 6. Alternately, your elbows can be supported on your knees (Figures 9D and E). 7. Hold the phone gently. 8. When typing, tap the phone lightly.

Figure 9. Suggested postures for smart phone use.

This article was originally published in Massage Therapy Journal, Spring 2015 issue, reprinted with permission from American Massage Therapy Association.

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Terra Rosa e-magazine, No. 11

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Putting the Maximus Back into Gluteus Maximus By John Gibbons Physical therapists are what I call detectives: they possess some clues (patient’s history and symptoms), but they then have to take the patient through an elimination process (via a physical assessment) to hopefully ind out and identify the actual underlying cause of the symptoms. The purpose of this chapter is to brie ly explain about a patient who presented with pain in the left shoulder area, and to demonstrate that the possible cause of the problem can originate in an area that one might not consider in view of the patient’s presenting symptoms. This article hopefully demonstrates what Dr. Ida Rolf states—“Where you think the pain is, the problem is not.” I want to illustrate this statement from Dr. Rolf with a case study taken from my own physical therapy clinic at the University of Oxford. As I become more experienced, not only in lecturing physical therapy courses but also as a practicing sports osteopath in my own clinic, I am convinced that many issues which patients and athletes present with are purely symptoms rather than actual causes. The case study below is just a small snippet of the information that I provide in the Vital Glutes book. The information contained within the study is taken from a real case study patient who came to my clinic for a consultation. 40 Terra Rosa E-mag

Case Study The patient in question was a woman of 34 and a physical trainer for the Royal Air Force. She presented to the clinic with pain near the superior aspect of her left scapula ( igure 1.1). The pain would come on four miles into a run, forcing her to stop because it was so intense. The discomfort would then subside, but quickly return if she attempted to start running again. Running was the only activity that caused the pain. Her complaint had been ongoing for eight months, had worsened over the past three, and was starting to affect her work. There was no previous history or related trauma to trigger the complaint. After seeing different practitioners, who all focused their treatment on the upper trapezius, she visited an osteopath who treated her cervical spine and rib area. The treatments she had received were biased toward the application of soft tissue techniques to the affected area, namely the trapezius, levator scapulae, sternocleidomastoid (SCM), scalenes, and so on. The osteopath had also used manipulative techniques on the facet joints of her cervical spine— C4/5 and C5/6. Muscle energy techniques and trigger point releases were used in a localized area, which offered relief at the time but made no difference when she attempted to run more than four miles. She had not undergone any scans (e.g. MRI or x-ray).

The Vital Glutes Once a subjective history has been conducted, the physical therapist then proceeds to an objective assessment: this is where the therapist uses specialized techniques to assess the musculoskeletal system to come up with a thorough diagnosis. One of the speci ic techniques employed by the therapist can be simple range of motion (ROM) tests that are initially performed by the patient; these are known as active range of motion (AROM) tests. This assessment is generally followed by a series of passive range of motion (PROM) tests; these tests are normally performed on the patient by the therapist, and are commonly used to check the integrity of the affected joint. Resisted testing comes next: this type of speci ic movement tests the power and involvement of the contractile tissues, i.e. muscles and tendons. The physical therapist also uses palpatory awareness through their ingertips to decide on the condition of the affected tissues, and will generally include special tests to complement the diagnosis. The potential causes of my patient’s presenting pain are:  Referral pain from cervical facet C4/5 or C5/6. Figure 1. Diagram of painful area of the patient—left superior scapula.

 Protective spasm/strain of upper trapezius or

levator scapulae.  Dysfunction of the glenohumeral joint or even

the acromioclavicular joint (ACJ) or sternoclavicular joint (SCJ).

Assessment During a consultation (subjective history) the physical therapist will ask speci ic questions relating to the patient’s presenting pain so that a picture can be formed in their mind. This is a normal process in order for the physical therapist to come up with a hypothesis; this type of initial diagnosis will then help the therapist decide on what tissue(s) might be responsible for causing the client’s presenting pain/ symptoms. For the patient in question, the potential tissues responsible for the pain to her superior scapula are: 

Upper trapezius



Levator scapulae



Scalenes



Thoracic rib



Cervical rib (extra rib forming from the transverse process of C7)

 Intervertebral disc bulge of C4/5 or C5/6.  Elevated irst rib.  Cervical rib (extra rib from the transverse pro-

cess of C7).  Relative shortness/tightness of the scalenes.  Positional—due to upper crossed syndrome re-

lated to a forward head posture and rounded shoulders caused by tight pectorals and SCM, and possibly weak rhomboids and serratus anterior.  Upper lobe of left lung, referring to the trapezius.  Diaphragm—this is innervated by the phrenic

nerve, which originates from the level of C3–5 from the cervical spine; the dermatome from C3– 5 can cause a referred pattern of pain that can radiate to the area of the shoulder (dermatome is an area of skin that is supplied from a single nerve root). Terra Rosa E-mag 41

Figure 2. Form closure and force closure.

As you can see, there are many possible causes of the  patient’s presenting pain. This list is not exhaustive and highlights just some of the many avenues to con-  sider when confronted with a common complaint of “shoulder/trapezius pain.”

How does a weakness of the Gmax on the right side cause pain in the left trapezius?



What can be done to correct the issue?

Taking a Holistic Approach



What has happened to cause it in the irst place?

Let’s now assess the case study patient globally rather than locally, remembering that the pain only comes on after running four miles.

Is there a link between the Gmax and the trapezius, and if so, how is this possible?

To answer these questions, we need to look at the functional anatomy of the Gmax, and the relationship of the Gmax to other anatomical structures, as deWhen I see a new patient for the irst time, no matter tailed in later chapters. what the presenting pain is, I normally assess the pelvis for position and movement, as I consider this area of the body in particular to be the “foundation” for everything that connects to it. I often ind in clinic that when I correct a dysfunctional pelvis, my client’s presenting symptoms tend to settle down. However, when I assessed this particular patient, I found her pelvis was level and moving correctly. I then went on to test the iring patterns of the gluteus maximus (referred to as the Gmax for the remainder of this book), which I often do with patients and athletes who participate in regular sporting activities. However, I only test the iring pattern sequence once I feel that the pelvis is in its correct position; the logic here is that you often get a positive result of the muscle mis iring when the pelvis is slightly out of position. With the patient in question, I found a bilateral weakness/mis iring of the Gmax, but the iring on the right side seemed a bit slower. As I had not found any dysfunction in the pelvis, I pursued this line of approach a little further. Before we continue I would like to pose a few questions for you to think about: 42 Terra Rosa E-mag

Figure 3—Ligaments of force closure.

The Vital Glutes irst need to consider two concepts—“form closure” and “force closure”—which are both associated with stability of the SIJ (see Figures 2 & 3). The shape of the sacrum—along with its ridges and grooves, and the fact that it is wedged between the ilia—helps to bring natural stability to the SIJ. This is known as form closure (Figure 3). If the articular surfaces of the sacrum and the ilia itted together with perfect form closure, mobility would be practically nonexistent. However, form closure of the SIJ is not perfect and movement is possible, which means stabilization during loading is required. This is achieved by increasing compression across the joint at the moment of loading; the surrounding ligaments, muscles, and fascia are responsible for this. The mechanism of compression of the SIJ by these additional forces is called force closure. When the body is working ef iciently, the forces between the innominates and the sacrum are adequately controlled, and loads can be transferred between the trunk, pelvis, and legs. So how do we link this to the patient’s complaint? In one of my previous articles (Gibbons 2008), about training the Oxford rowing team, I wrote about the posterior oblique “sling.” This structure directly links the right Gmax to the left latissimus dorsi via the thoracolumbar fascia (Figures 4 & 5). The latissimus dorsi has its insertion on the inner part of the humerus, and one of the functions of this muscle is to keep the scapula against the thoracic cage and aid in depression of the scapula. Piecing It All Together So what do we know? We know that the right side of the patient’s Gmax is slightly slower in terms of its iring pattern and that this muscle plays a role in the Figure 4. Muscle activation sequence. force closure process of the SIJ. This tells us that if the Gmax cannot perform this function of stabilizing Gmax Function the SIJ, then something else will assist in stabilizing The Gmax operates mainly as a powerful hip exten- the joint. The left latissimus dorsi is the synergist that helps stabilize the right Gmax and, more imsor and a lateral rotator, but it also plays a part in portantly, the SIJ. As the patient participates in runstabilizing the sacroiliac joint (SIJ) by helping it to ning, every time her right leg contacts the ground “force close” while going through the gait cycle. and goes through the gait cycle, the left latissimus Some of the Gmax muscular ibres attach to the dorsi is over-contracting. This causes the left scapula sacrotuberous ligament, which runs from the sacrum to depress, and the muscles that resist the downto the ischial tuberosity. This ligament has been ward depressive pull will be the upper trapezius and termed the key ligament in helping to stabilize the the levator scapulae. Subsequently, these muscles SIJ. To gain a better understanding of this action, we start to fatigue; for the patient in question, this ocTerra Rosa E-mag 43

Prognosis and Conclusion I advised the patient to abstain from running and to get her partner to assist in lengthening the iliopsoas, rectus femoris, and adductors twice a day. Strength exercises were also advised twice daily until the follow-on treatment (these exercises are discussed in later chapters). I reassessed her 10 days later and found normal iring of the Gmax on the hip extension iring pattern test, and a reduction in the tightness of the associated iliopsoas, rectus femoris, and adductors. Because of these positive results, I advised her to run as far as felt comfortable. I was not sure if my treatment was going to correct the problem, but she reported that she had no pain during or after a sixmile run. The patient is still pain free and continues to regularly use the Gmax strengthening exercises and the lengthening techniques for the tight muscles. This case study demonstrates that very often the underlying cause of a condition or problem may not be local to where the symptoms/pain presents, which means that all avenues need to be fully considered. I hope that the information from this study has intrigued you enough to continue reading, as the information presented is just a taster of what is to come in the following chapters. Remember, this book is what I call a jigsaw puzzle journey—if you stick with it, the picture will eventually become a lot clearer. Figure 5. Posterior oblique sling.

This article is an extract from The Vital Glutes by John Gibbons. Reproduced here courtesy of Lotus curs at approximately four miles, at which point she Publishing. feels pain in her left superior scapula. Treatment JOHN GIBBONS is a quali ied and registered osteopath You might think the easy way to treat the weakness with the British General Osteopathic Council, specialising in the assessment, treatment, and rehabilitation of in the Gmax is to simply prescribe strength-based exercises. However, in practice this is not always the sport-related injuries. Having lectured in the ields of correct solution, as sometimes the tighter antagonis- sports medicine and physical therapy for over twelve tic muscle is responsible for the apparent weakness. years, John delivers advanced therapy training to The muscle in this case is the iliopsoas (hip lexor), quali ied professionals within a variety of sports. and shortening of this can result in a weakness inhibition of the Gmax. My answer to this puzzle was to stretch the patient’s right iliopsoas muscle to see if it promoted the iring activation of the Gmax, while at the same time introducing strength exercises for the Gmax. All this will be explained in more detail in The Vital Glutes book, chapter ² .

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CORE Structural Integration and Myofascial Therapy: A Lifetime of Improving Structure and Function By George P. Kousaleos, LMT It is interesting that a cervical injury during a college rugby match lead me to my irst Swedish massage. After four weeks of treatment the massage therapist sent me to my irst Iyengar Hatha Yoga class, where I experienced more discomfort during exercise than I had ever felt in my lifetime. Six weeks later the Iyengar teacher gave me an article on Rol ing, and in a few short weeks I received my irst session of Structural Integration. Each step of the way I experienced signi icant improvement in decreasing my pain levels, improving my overall lexibility, and becoming more aware of my optimal physical alignment and balance. It took three years to realize that I was ready to change my life even further and started my training as a professional massage therapist and Structural Integration practitioner.

From the early 1980â&#x20AC;&#x2122;s I worked in New York City with leading ballet dancers, opera singers and classical musicians. They quickly appreciated the performance bene its of this precise work and cherished the added level of skill mastery they acquired through regular clinical treatment.

Later that decade I practiced and taught in Germany, applying this work to patients at a holistic centre for homeopathic medicine and psychiatry. Through various seminars I taught Myofascial Therapy to European massage therapists and physiotherapists in 13th Century Bavarian castles, on the Greek island of Santorini, in the oldest yoga school in Vienna, Austria and at the healing warm springs of Passau. I appreciated even more the effects of slow, powerful, and carefully orchestrated pressure that changed the pliFrom the earliest days of my study of the disciplines ability of even the densest tissues, the most hardened of bodies. of Structural Integration and Myofascial Therapy I was fascinated with the importance of recognizing After opening the CORE Institute in Tallahassee, the foundational relationships between structure Florida in 1990, and creating an entry level profesand function. Indeed, over many years and decades sional massage therapy program that included strucof practicing and teaching this incredible work, I tural and myofascial education, I looked for opportunever lost sight of those relationships that not only nities to help prepare my students for the day that improve structure and function, but increase neuroeach of them would embark on their professional somatic awareness and restore a sense of physical journey. I was thrilled when the British Olympic Asand mental con idence. sociation decided to hold their warm-weather prepaTerra Rosa E-mag 45

ration camps at Florida State University to prepare their athletes for the 1996 Atlanta Olympics. British Olympians from 13 sports received regular treatments from CORE students during three weeks of strenuous two-a-day practice sessions during the summers of ’95 and ’96. The Atlanta Olympics lead to my involvement as a Co -Director of the International Sports Massage Team of the 2004 Athens Olympics & Paralympics. One hundred and eighty therapists were chosen from 18 countries to provide therapeutic massage to over 15,000 athletes and coaches. Many athletes had never experienced massage therapy in their home country and relished at the improvement to form and function at the most meaningful time of their life. An Italian gymnast, who came to the clinic daily, won the gold medal in the horizontal bar in one the biggest upsets of the Athens Olympiad. The next day he came to the clinic to take photographs with the therapists who helped him prepare for his “lifetime moment”.

Last Fall I was honoured to travel to Sydney, Australia and teach leading sports therapists from all across Australia and New Zealand. Many of these therapists work in allied medical ields, including physiotherapy, podiatry and acupuncture. On the ninth and inal day of the intensive seminar we invited current and former professional and Olympic athletes to a special clinic. Each athlete responded favorably to their Later that decade I began teaching in England, Scot- sense of improvement from a 90-minute full body land and the Republic of Ireland from 2009 to 2011. session, with several emailing us later in the week with amazing stories of how their training had imMany of those students from London, Manchester, proved. The common theme we heard was “I feel Chelsea, Bath, York, Edinburgh, Aberdeen, Galway and Dublin assisted their Olympic teams at the 2012 more awareness of my body and how integrated my movements have become.” London Games. Each of them took their place with those who preceded them in offering a sports and I am more than satis ied that during the past four performance therapy that increased balance, respondecades I have represented one of the inest apsiveness, ease of movement, and kinaesthetic agility. proaches to structural and functional improvement At the same time I was engaged in creating Myofas- from the disciplines I studied 37 years ago. Each year cial Therapy protocols for the leading athletes of the I look forward to introducing this work to curious Florida State University Football Team. From 2011 and dedicated therapists who are searching for the to this day these athletes receive twice a week treat- keys to providing long-lasting health and wellness to those they serve each day. Each day I enjoy my cliniment from 10 CORE Institute graduates during the regular season as well as during all spring and sum- cal sessions with professional and amateur athletes mer training camps. During this time, soft-tissue in- who want to maintain elite athletic levels, with clients rehabbing from serious injuries and disease, juries decreased by 75% and FSU won three ACC and with those who simply yearn for a deeper sense Championships and the 2013 National Championship. Over 30 of these athletes are now playing in the of self. Each day I ind happiness. NFL, with many of them continuing their commitment to regular myofascial therapy.

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CORE MYOFASCIAL THERAPY with George Kousaleos Sydney, Brisbane Sept-Oct 2015 "George Kousaleos was one of the most influential people in the manual therapy profession on my career and my success. His amazing CORE Myofascial Therapy training should be the foundation of every manual therapist's practice. His incredible knowledge of the human body, his compassion, and his kind heart, make him one of my greatest mentors in the manual therapy” - James Waslaski LMT; Author & International Lecturer Integrated Manual Therapy & Orthopedic Massage CPT-

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George Kousaleos, LMT is the founder and director of the Core Institute, a school of massage therapy and structural bodywork in Tallahassee, FL. He is a graduate of Harvard University, and has practiced and taught Structural Integration, Myofascial Therapy and Sports Bodywork for the past 30 years. George has served as a member of the Florida Board of Massage Therapy and was CoDirector of the International Sports Massage Team for the 2004 Athens Olympics.

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Bringing Up Baby…. Bodywork Grows-up from Infancy to Adolescent By Art Riggs

A few months ago, some of us old-timers were reminiscing about the good, and not-quite-so-good, old days of massage and bodywork, and how the profession has evolved. I decided to contact three longtime bodywork luminaries to get a broad picture of how things were, where we are now, and where they think we are heading. Rick Garbowski is the co-owner of Georgia Massage School. He has trained more than 150 massage instructors, has been closely involved in the education of many thousands of students, and was a member of the Entry Level Analysis Project (ELAP) to provide a blueprint for consistent standards of training excellence. Tracy Walton is one of the foremost teachers of oncology massage and, among other contributions, author of Medical Conditions and Massage Therapy. I love that her background in the trenches of massage in both private practice and a spa setting bridges the sometimes-divisive dichotomy between “therapeutic” and “relaxation” massage. Thomas Myers is a world-renowned anatomist, writer, educator, and philosopher who describes himself as an expert in spatial medicine, as seen in his theories of organizing and integrating the body along fascial meridians in his modality Anatomy Trains and subsequent books and videos. 48 Terra Rosa E-mag

To some of the newer and (and perhaps younger) therapists out there, it may be dif icult to imagine that back in the Neanderthal 1980s, one could receive a diploma with slightly more than 100 hours of (often surprisingly good) training, using Anatomy Colouring Book as the gold textbook standard, and classes conducted without PowerPoint or threedimensional anatomical videos. Since the Internet was not in existence, to have a successful practice, a lot of work was needed in word-of-mouth promotion, lyers, and beating the pavement, sometimes offering free massage. Private business of ices were a rarity, and most depended upon a home or apartment with a less professional ambiance, sometimes offering such new age accoutrements as a lava lamp, incense burning in front of a bubbling fountain, and a boom box to play sitar music in the background. That said, there was excellent work being done, as evidenced by so many long-time experts who were drawn to the profession after experiencing massage. All of our experts agree that we have come a long way from the infancy of massage and that most of the changes could be considered an extremely beneicial evolution. However, few things in life are free, and along with all the progress, many of the changes have come at a cost, both to consumers and therapists.

The Growth of Bodywork

Probably the biggest change in massage is the respect bodywork now has as an extremely worthwhile part of a healthy life for our clients, and as a full- ledged profession rather than a fun hobby. When Myers changed his career path to massage, his family was disappointed and bemoaned “all that education wasted.” He feels the general perception was that massage was something old ladies did, or was for entertainment, titillation, or an expression of the alternative scene. With my own background in graduate study in both literature and exercise physiology, my abrupt march to the beat of a different drummer in my career path caused similar well-meaning concern for my wellbeing, if not my sanity, and reactions in the form of what Walton describes as raised eyebrows. Like Myers, however, when friends and family saw the happiness and ful ilment—as well as the inancial rewards—I got from my work, and the bene its to my clients, they quickly changed their views. Thirty- ive years ago, not only was the public unaware of the therapeutic and medicinal bene its of massage (partly because of the misperceptions that Myers mentions), but bodywork also faced downright hostility from ill-informed local governments and other therapeutic modalities who either feared competition or possibly felt it their duty to protect

the public’s health and morality. It was not easy to establish an above-board practice through of icial channels. Garbowski recounts that in Georgia the stiffest resistance came not from local of icials or concern over sexual massage, but from physical therapist organizations. In formulating licensing requirements in California, the chiropractic lobby attempted to prohibit massage therapists from ever moving limbs past the active range of motion—something that would have made it very dif icult for me to work on a favourite paraplegic client. Early in her practice, Walton was called to testify in support of allowing massage therapists to practice without a physician’s order—typical of the quagmire of local, state, and national licensing and regulation that is still not resolved today. Some therapists today are hesitant to provide massage to medically complex populations, such as people with cancer, without physician approval. Walton teaches MTs how to do the work safely and well, relying on their own reasoning rather than shifting responsibility to the client’s physician. She devotes a whole chapter of her book to effective communication with physicians when their involvement becomes necessary. In spite of the obstacles, it is dif icult to suppress a good thing for long, and public awareness moved Terra Rosa E-mag 49

massage to mainstream acceptance for both relaxation and therapeutic bene its. Now, of course, spas abound, massage is increasingly seen in hospital settings, and chiropractors regularly employ massage therapists in their of ices. Even physical therapists are now having massage therapists perform manual therapy on their patients. Massage is now considered a legitimate career. Just look at the name of an association in the USA: “Associated Bodywork & Massage Professionals.” Interestingly, as bodywork becomes mainstream, Myers notices a difference in the nature of today’s therapists. When he began, someone pursuing a career in massage had to be a bit of a rebel making an actual cultural choice. He feels most therapists had to be very strong in their commitment and willing to confront a somewhat condescending or adverse public opinion, but that many therapists today don’t have the same “verve” and drive to excel. Looking at massage as more of a trade rather than a craft or art, some are content to work for the security of meagre wages and poor working conditions that may cause injury and burnout. Rather than expressing their excellence, some therapists are hampered by assembly -line routines or rigid, unimaginative protocols of generic massage that shackle creativity and feelings of ful ilment. Many new therapists I speak with are unaware of their potential for inancial and emotional ful ilment if they challenge themselves and learn more sophisticated techniques. The success of our profession is much more than a word-of-mouth grass roots movement. Unlike in its infancy, massage now has an abundance of welldocumented studies demonstrating its therapeutic value. All of our experts agree this is good, but that many more studies need to be conducted. Myers especially mentions the increasing connection between physical therapy and bodywork and that as the two ields grow closer together, we will need more studies and veri ication.

formation in our work. She feels we need a “systematic parsing” of some of the old myths concerning massage and endorphins, cortisol, cancer, and immunity. She is preparing an eBook on this subject for the Massage Therapy Foundation. It will be offered along with other free resources for massage therapists on www.massagetherapyfoundation.org.

Effect of the Internet Our experts agree that the Internet may be the biggest in luence on the explosion of popularity of bodywork with the masses, both for marketing of private practice and also on continuing education training. In the 1970s and ’80s, the major marketing tools were word of mouth, lyers tacked on telephone poles or left at café s, and ads in local weekly counterculture newspapers. It generally was accepted that one had to work for three years to establish a full practice, so many supplemented their massage profession with other work, often relegating bodywork to an avocation and never making the leap to fulltime work. Now Yelp, LinkedIn, and other social media are a tremendous help and almost a necessity for a ledgling bodywork practice to hope to thrive. However, it takes more than an attractive website to be successful; Myers and Garbowski agree that many therapists inish school without suf icient training in marketing or running a business and don’t even consider the great rewards of a private practice.

In the old days, the slow progression of practice building not only allowed time to re ine biomechanics and tactile skills, but also gradually allowed the body to adapt to the physical stresses as one’s practice evolved. Nowadays, with the growing numbers of people looking to massage, one can get a job immediately out of school working ive days a week in a spa—essentially being thrown into a marathon race without a proper build-up of training. Every spa that brings me in for in-service trainings places injuConversely, Walton points out that many of our widely accepted claims about the effects of massage ry prevention as a high priority, and I see a large and unfortunate increase in massage injuries and burnare either not supported or are contradicted by research. We must come to accept newer, sturdier in- out. 50 Terra Rosa E-mag

The Growth of Bodywork The Internet has also revolutionized teaching. Before the advent of online training and the explosion of commercial video trainings, the only way to improve our skills was to take classes at schools. This was a huge obstacle to the progress of therapists living in out-of-the-way locations, depriving them of the excitement and ful ilment of growth. Now, with webinars, online continuing education trainings, and video instructional materials, fantastic information is available to virtually everyone, and our profession has greatly bene itted. Myers points out another advantage of video training that is helpful in his classes. Different folks learn at different rates, and being able to play back video demonstrations for clarity allows students to learn at a more profound level, or conversely, skip over material they are skilled in or which is not of interest. He often has students watch recorded lectures of anatomical or philosophical discourse on one of his favourite topics: evolution. This leaves more time in class for training in manual skills and more table supervision. A downside of this proliferation is that not all teaching is of the highest quality, and some therapists choose the most inexpensive and least challenging material simply to ful il yearly requirements for continuing education without the “verve” Myers speaks of to constantly improve in a profession they love. No matter how good the quality of distance instruction, there is no substitute for attending a class and seeing work performed in real time with a chance for questions and the all-important bene it of feeling the work in one’s own body and performing with personal supervision of the teacher. The Internet makes it easy to forego this important experience, and I highly recommend at least one hands-on class a year to jump-start your enthusiasm and broaden your horizons.

The Big Business of Bodywork Myers and Garbowski concur on the huge effect of corporate takeover of the bodywork business. Both agree that this phenomenon is a natural economic

reality for something as bene icial and successful as massage. Garbowski bemoans the effects on education, while Myers regrets what he considers the inevitable “massage industry and franchising” drawing a different kind of individual and different working conditions now. The popularization of massage and large spas making massage available to the masses has been a phenomenal bene it in many ways. Large numbers of therapists who may not have the experience or interest in a private practice can ind rewarding employment; the downside is limited maximum income, often giving 50–70 percent of a reduced competitive spa marketplace fee to their employers. I hear of frequent injuries and burnout, and complaints from consumers that they ind it dif icult to get quality therapeutic work as some spas seem satis ied to offer cookie-cutter routines. Often, because of restrictions from corporate lawyers fearing litigation, some therapists shy away from needed work in areas such as the chest and anterior neck, abdomen, gluteals, adductors, and other important areas, or refrain from extremely useful side-lying work because they’re not comfortable with overly restrictive employer draping protocols. Garbowski points out that the single largest complaint from consumers in general is that their therapist didn’t listen to requests for speci ic areas needing work. When all of our experts and I began, there was a sort of Darwinian survival of the ittest for a successful practice. Of course, that still holds true, especially in private practice, but also in spa work— one therapist told me of always being booked more than two weeks in advance at a large corporate spa because she listens to clients and gives them what they want rather than just performing routines. However, I hear countless complaints about the inconsistency of spa massage and the perception that many therapists are satis ied just getting by with performing essentially the same massage on all clients. The popularity pendulum may be swinging back toward private bodywork practices, as I recently heard from three different therapists in private practice that new clients complained they “didn’t want a ‘spa’ massage.” Terra Rosa E-mag 51

Garbowski is happy that “massage franchises have driven the cost of massage services down dramatically, making massage affordable for the middleincome family. But this also has made it more dif icult for the small businessperson operating a private practice to compete.” Walton points out that comparing hourly wages of corporate employment to hourly rates in private practice can be misleading. There are a lot of non-paying promotional hours necessary for independent therapists, especially in building a ledgling practice. Maintaining a website (pretty much a necessity today), paying rent, doing laundry, and other expenses must be taken into consideration. Firm numbers on income, expenses, hours, bene its, and taxes in all massage settings are badly needed. These will enhance the dialogue in our profession about the viability, sustainability, and real work of massage therapy. Garbowski pulls no punches in saying that the explosive growth and increased pro its have led to a proliferation of large schools led by “investors with no experience in the industry (who) recognized the potential for pro it in the burgeoning massage market and stepped into a profession that had been led by individuals who cared more about their students, their clients, and the profession itself than their return on investment … degrading the overall quality of training and leading to an increase in the overall turnover rate in our profession.” I speak with educators offering advanced continuing education classes who comment that many of the newer students have no idea of their potential, having had unimaginative routines stressed in their trainings, sometimes just to qualify them to pass tests, or to prepare them for generic spa massage, even if that generalization may be unwarranted— excellent spa massage is, of course, available. Of course, there are excellent large school programs turning out highly skilled therapists, but I must agree with Garbowski on many of his points. Even the much-needed licensing requirements have a downside. Myers says, “Teaching to pass licensing tests is a very poor way to get across knowledge.” 52 Terra Rosa E-mag

The Great News with Education To me, the explosion of knowledge and teaching of more advanced therapeutic techniques is the most exciting and bene icial progress. In the ’70s and ’80s, most training was relaxation based, often for non-professionals. Myers is happy that there is much more diversity and clarity today, but still feels there is confusion between sensuality and sexuality that should be clari ied. I would add that excellent therapeutic work for serious conditions need not con lict with a comforting, even sensuous, experience. One of the nicest compliments I’ve received was from a woman with serious low-back pain that I was working deeply on who commented, “You have such a kind touch.” For someone in constant pain, a warm and nurturing touch can stimulate the parasympathetic nervous system for serious therapy. It is so good that we, for the most part, have escaped from the sexual stereotypes of the past; but as many therapists emphasize the therapeutic and medicinal bene its, I feel there can be an overreaction to the sexual stereotyping, which removes the very crucial nurturing aspects of touch. Some therapists become so clinical that they appear to mimic the cold and dispassionate demeanour that is so often a criticism of doctors’ or physical therapists’ ofices. I love that Walton teaches advanced clinical skills, but also emphasizes the personal warmth that distinguishes massage therapists from some of the stereotypes of strictly medical approaches. She adds, “I don’t like the dichotomy, especially the denigration of relaxation work from lots of ‘experts’ doing ‘serious’ work.” That said, the incredible gifts of therapeutic strategies from practitioners such as Ben Benjamin, Erik Dalton, Whitney Lowe, Til Luchau, Myers, Walton, and countless others were simply not in existence 40 years ago. There is no doubt that high-quality educational opportunities in many different modalities are exponentially more available in continuing education classes, videos, and webinars; and many more therapists today are more highly skilled than in the past, particularly in therapeutic bodywork.

The Growth of Bodywork Thankfully, the misinformed small local policing of our profession that Walton and Garbowski have commented on has diminished, and we are moving toward state and national certi ication, often based on our own professional licensing groups. Still, a multitude of problems remain with competing accreditation groups, con licting rules, spotty acceptance of continuing education classes, and online study, thus making it dif icult for therapists to begin practice or relocate. Some states, instead of examining therapeutic specialization, simply continue to require more and more hours, both in initial trainings and continuing education. For example, in California, a therapist’s rating is automatically upgraded from “practitioner” to “therapist” based on the number of educational hours, without consideration of what classes have been studied. Myers points out that more speci ic categories need to be delineated so consumers can choose appropriate treatment. Garbowski feels a tiered system would be helpful. There are pros and cons to a tiered system too complex to examine in detail in this article, but Walton feels that is not the answer. Certainly more study can imply greater skill, but not necessarily, and arbitrary boundaries that imply superior skill based solely on hours of study may be misleading. A problem with policing inside our profession is that some large schools, vying for more students and higher tuition fees, lobby certi ication groups to simply continue to require more hours. Many excellent smaller schools without a large population base to draw from have had to close. Already, many potentially excellent therapists are prevented from entry to our profession by massive hour requirements and expense. Much of the skill of any therapist is not quanti iable or measured simply by hours of study. Several famous teachers admit that they would probably not have entered the ield 30 years ago with such daunting requirements. Many argue that real skill can best be achieved by getting out and working with fewer initial hours; that practice on the public combined with continuing education workshops are a better answer, both for getting experience and to ind passion for areas

to specialize in. Great progress has been made since the accreditation chaos of 30 years ago, and it is hoped that Garbowski's and others’ work with ELAP will solve many of these issues and make life easier for both therapists and clients. The great news is that massage and bodywork has had phenomenal success in the last few decades and will continue to grow. As some problems are solved, new ones will undoubtedly spring up. For instance, will massage begin to be covered by health insurance? Myers feels this would expand the availability to a wide range of clientele. This plan works well in Canada, where all citizens are granted a certain number of massages per year with a minimum of red tape, simply having to submit a receipt from the sessions. With his interest in evolution, Myers has noticed changes in the structure of clients over the years just from the environmental changes in posture as we spend more time hunched over computers and commuting. I ind an increasing need for bodywork for the it generation who spend large amounts of time exercising in many forms, sometimes causing injuries from over-exercise—especially in the burgeoning market of extreme exercise classes with minimal supervision. For success in whatever venue we work, in the future, we need to adapt to the changing environment of new technology, business models, and evolving needs of our clientele, including an aging population.

The Tangibles Having the bene it of our longtime experts’ advice, I asked them what suggestions they would have for therapists. For his suggestions, I see a connection in Myers’s comments about the early confusion de ining massage and his desire for clarity in present-day therapists’ self-perception and self-de inition. One needs to decide just where one’s niche lies in the continuum of an art, a craft, a science, or a skill. Myers feels the divisiveness between different modalities is counterproductive. As a profession with so many different approaches, we need to make allies, not Terra Rosa E-mag 53

competitive separations. Walton emphasizes good body mechanics and to keep moving, relaxed, and breathing, and to explore different forms of movement training including dance and sports to shake things up and keep the body from resting on habit. Garbowski is in agreement, suggesting getting into the habit of stretching, strengthening, and continually perfecting your mechanics: “I have yet to meet a healthy massage therapist who does not enjoy what they do for a living.” Most importantly, he says, “Listen intently to your clients. Massage therapy is a customer service industry driven by repeat business and referrals from existing clients.” I would agree with all of our experts, particularly the suggestions to stay healthy in our physically demanding work with lexibility, strength, and using gravity and core energy rather than muscling. However, I would emphasize the mental and emotional aspects of our work to stay focused, interested, and passionate. Rather than resting on my laurels, I ind

I am learning and improving at bodywork as much now as in my early years. Make each client an experiment in learning and giving. Whether your stay in the bodywork profession is a transitory chapter or a lifelong profession, I urge you to make your work a creative art form. Be curious and continue to aspire to improve, and the work will always be exciting, fun, and rewarding. Art Riggs is a Certi ied Advanced Rolfer and massage therapist who’s been practicing bodywork since 1988. He sells myofascial release videos and manuals, and teaches continuing education courses worldwide. Riggs is the recipient of the 2012 Lifetime Achievement Award from the American Massage Conference. For more information about his work, visit www.deeptissuemassagemanual.com. This article was published in the March/April 2015 issue of Massage & Bodywork magazine and is reprinted here courtesy of Associated Bodywork & Massage Professionals (ABMP). You can also access it online at www.massageandbodyworkdigital.com/i/465652-march-april2015/76

Art Riggs’ Deep Tissue Massage : An Integrated Full Body Approach Coordinating Deep Tissue and Myofascial Release into a Fluid Bodywork Session This extensive new set (seven DVD’s totalling over 9 hours) was created by Art Riggs after countless requests from therapists who loved the first set, “Deep Tissue Massage and Myofascial Release” but were having trouble working the therapeutic philosophy and techniques into a fluid deep tissue massage, especially in a spa setting. Rather than discreet sections, we move from A to Z, covering the whole body in a common sequence of beginning in prone, moving to supine with a whole segment devoted to the important side-lying position. Available at www.terrarosa.com.au

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Functional Fascial Taping with Ron Alexander

“Evidence-Based Pain Relief” This workshop teaches a fast and simple way for clinicians to reduce pain, improve function, encourage normal movement patterns and rehabilitation of musculoskeletal pathologies in a pain-free environment. FFT has been shown to have a significant effect on Non-Specific Low Back Pain in a randomised double-blind PhD study. FFT is a non-invasive, immediate, functional and an objective way to decrease musculoskeletal pain.

Presenter: Ron Alexander—

A great way to encourage treatments

STT [Musculoskeletal], FFT Founder and Teacher

Gold Coast, 14-15 Nov 2015 Sydney, 21-22 Nov 2015 Adelaide, 28-29 Nov 2015 Register Now at: www.terrarosa.com.au

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Research Highlights Compiled By Jeff Tan Isometric contraction reduce tendon pain Researchers from Adelaide investigated heavy isometric quadriceps muscle contractions for their ability to induce immediate analgesia in 6 athletes with patellar tendon pain and used transcranial magnetic stimulation to look at the possible motor activation changes. First of all, they found that people with patellar tendon pain had HUGE amounts of cortical inhibition (as if their motor cortex was trying to limit the use of the quads). However, a single bout of heavy (70% MVC) isometrics reduced tendon pain pretty much instantly (and lasted at least 45 minutes), it also reduced the associated muscle inhibition, resulting in an increase in muscle strength. It wasnâ&#x20AC;&#x2122;t just about heavy load though as this cross over study also examined isotonic (concentric / eccentric) contractions and found no effect on inhibition, and that isometrics were superior for pain relief. Some key points: Tendons dislike compression so any isometric load should avoid compression, e.g. avoid compression of the Achilles insertion at the calcaneus in ankle dorsiflexion. Time under tension and load (i.e. weight) both seem to be important (based on pre-study pilot testing). Some people may need to start with below body weight loads (e.g. seated calf raise machine for an unloaded Achilles tendon) but the elite football player with Achilles pain will tolerate much greater load and will need greater than body weight. Time for the holds in the study was 45 seconds (five times) but may need some clinical tweaking if the muscle is shaking too much. Make sure the muscle is given complete recovery between holds when using isometrics for tendon analgesia â&#x20AC;&#x201C; we used two minutes. This is an extract from an article by Ebonie Rio published in BodyinMind Practice and research in Australian massage therapy Massage is the largest complementary medicine profession in Australia, in terms of public utilisation, practitioner distribution, and number of practitioners, and is being increasingly integrated into the Australian health care system. A research was taken to identify practice, research, and education characteristics among the Australian massage therapist workforce. 301 randomly selected members of the Association of Massage Therapists (Australia) completed a 15-item, cross-sectional telephone survey. The results showed that most respondents (73.8%) worked 20 hours per week or less practising massage,

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nearly half of all respondents (46.8%) treated fewer than 10 massage clients per week, and over threequarters (81.7%) of respondents were self-employed. Massage therapy was the sole source of income for just over half (55.0%) of the study respondents. Only 5.7% of respondents earned over the average wage ($50,000) through their massage activities. Nearly half of all respondents (43.3%) reported regularly exceeding their continuing professional education (CPE) quota mandated by their professional association. However, 21.1% reported struggling to achieve their CPE quota each year. Over one-third of respondents (35.6%) were not interested in acquiring further CPE points beyond minimum requirements. Respondents were significantly more likely to have an active approach to research if they had higher income ( p = .015). Multivariate analysis showed factors associated with access to CPE to be the only significant predictors for increased CPE. In conclusion, the massage profession in Australia remains largely part-time and practitioners earn less than the average Australian wage. The factors that underlie research and education involvement appear to be highly individualised and, therefore, policies targeting specific groups may be arbitrary and ineffective. The Full article is available here Prevalence of gluteus medius weakness in people with chronic low back pain Clinical observation suggests that hip abductor weakness is common in patients with low back pain (LBP). A study from University of Iowa compared the prevalence of hip abductor weakness in a clinical population with chronic non-specific LBP and a matched sample without LBP. One hundred fifty subjects with chronic non-specific LBP and a matched cohort of 75 control subjects were recruited. A standardized back and hip physical exam was performed. Specifically tensor fascia lata, gluteus medius, and gluteus maximus strength were assessed with manual muscle testing. Functional assessment of the hip abductors was performed with assessment for the presence of the Trendelenburg sign. Palpation examination of the back, gluteal and hip region was performed to try and reproduce the subject's pain complaint. The results showed that Gluteus medius is weaker in people with LBP compared to controls or the unaffected side. The Trendelenburg sign is more prevalent in subjects with LBP than controls. Furthermore there is more palpation tenderness over the gluteals, greater trochanter, and paraspinals in people with low back

Research Highlights pain compared to controls. The authors concluded that Gluteus medius weakness and gluteal muscle tenderness are common symptoms in people with chronic non-specific LBP. The research is published in European Journal of Spine Massage May Initiate Tendon Structural Changes Physical exercise is now a widely known and studied factor of the proper functioning of living organisms. Many questions remain unanswered concerning various aspects of the changes in the morphology of structures subjected to chronic physical exercise. To study the effect of massage on collagen fibres in tendon, scientists from Poland conduced an experiment on rats. This study was conducted on fifty Buffalo strain rats, randomly divided into two equal (experimental and control) groups. All animals were subjected to physical training on a running track for 10 weeks, whereas only in the experimental group, massage was additionally applied five-times per week.

40) over four weeks. MEASUREMENTS: The primary outcome was improvement in pain measured on a 100 mm visual analogue scale one week after cessation of treatment. Secondary outcomes were disability, active flexion, abduction and hand-behind-back range of motion. Measures were taken at baseline, one week after cessation of treatment and 12 weeks after cessation of treatment. RESULTS: The between groups difference in pain scores from the initial measures to 12 weeks after cessation of treatment demonstrated a small significant difference in favor of the exercise only group (mean difference 14.7 mm, p=0.042). There were no significant differences between groups for any other variable. LIMITATIONS: It was not possible to blind therapists or participants to group allocation. Diagnostic tests were not used on participants to determine specific shoulder pathology.

The results showed an increase in the percentage of collagen fibers in tendons with the smallest diameter (≤100 nm) was observed only in the experimental group in week 3, followed by a decrease in weeks 5 and 7. A subsequent repeated increase was observed in week 10 of the study. No significant differences were observed for either study group in the number of collagen fibers based on fiber diameter (101-200 nm, 201300 nm and 301-400 nm).

CONCLUSIONS:

The results of this preliminary study showed that longterm massage performed during running training may initiate for small structural changes in the rat tendon. The study was published in the journal in Vivo.

Gluteal Trigger Points Found in Most Lumbosacral Radiculopathy Cases

Effectiveness of Soft Tissue Massage for Nonspecific Shoulder Pain? BACKGROUND: Soft tissue massage and exercise are commonly used to treat episodes of shoulder pain. OBJECTIVE: To investigate the effects of soft tissue massage and exercise compared to exercise alone on pain, disability, and range of motion in patients with non-specific shoulder pain. DESIGN: Randomized controlled trial. SETTING: Public hospital physiotherapy clinics, Sydney, Australia. PATIENTS: Eighty participants aged 62.6 ± 1.4 yrs (mean ± SE) referred to physical therapy for non-specific shoulder pain.

The addition of soft tissue massage to an exercise program for the shoulder confers no additional benefit in pain, disability or range of motion or disability in patients with non-specific shoulder pain. Reference

Most patients with lumbosacral radiculopathy have gluteal trigger points (GTrP), according to new findings.The findings raise the possibility that treating these trigger points could help ease pain in these patients. Lumbosacral radiculopathy, or pain in the low back and legs due to damage to the intravertebral discs, is a frequent cause of lower back pain, Dr. Adelmanesh and his colleagues note in their report. Painful GTrP due to lumbosacral myofascial pain syndrome can mimic this type of pain, they add, and distinguishing between the two can be difficult. While Dr. Adelmanesh and his team note that they often observe GTrP in patients with lumbosacral radiculopathy, GTrP is not routinely evaluated in these patients. To better understand the relationship between these two pathologies, the researchers compared the prevalence of GTrP in patients with clinical, electromyographic, and magnetic resonance findings indicating lumbosacral radiculopathy with healthy controls. They screened 441 patients, 271 of whom met the study's inclusion criteria. Two-hundred seven (76.4%) had GTrP, versus three of the 152 healthy volunteers (1.9%). Among patients with one-sided pain, 74.6% had ipsilateral GTrP.

INTERVENTIONS:

The findings were published March 12 in the American Journal of Physical Medicine & Rehabilitation.

Participants were randomly assigned to either a group that received soft tissue massage around the shoulder and exercises (n = 40) or an exercise only group (n =

The investigators also found that just one of the 14 patients with no pain, but leg weakness and parasthesias, had a positive GTrP, versus 82.5% of patients with right

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Research Highlights -sided pain and 79.5% of those with left-sided pain.

suboccipital area on the flexibility of the hamstring.

"Taken together, these findings support the clinical observation of the authors of this study that GTrPs are common among patients with radicular pain and that they are directly associated with this pain condition," Dr. Adelmanesh and his colleagues write.

Fifty persons with short hamstrings participated in this research. According to the results of the finger-floor distance (FFD) test, the subjects were allocated to SMI and SMFR groups of 25 subjects each.

The effect of stretching the plantar fascia on the flexibility of hamstring and lumbar spine

The SMI and SMFR techniques were applied to the groups. For the analysis, they used the FFD test and the straight leg raise (SLR) test for the flexibility of hamstring. The evaluator was blindfolded.

In the era of evidence-based, everything needs to be tested before it is proven. The superficial back line of Anatomy Trains suggested that muscles along this line is "connected". Last month we reported a study that "proves" myofascial release of the suboccipital muscle increases the flexibility of hamstring. And now another study needs to "prove" what is usually taught in a myofascial course, stretching the plantar fascia increase flexibility and range of movement along the superficial back line. The researchers deemed it is necessary to do an experiment as "To date there is no evidence to support the effect of bilateral self myofascial release on the plantar aspect of the feet to increase hamstring and lumbar spine flexibility." Twenty four healthy volunteers (8 men, 16 women; mean age 28 years ± 11.13). underwent screening to exclude hypermobility and were randomly allocated to an intervention (self myofascial release SMR) or control group (no therapy). Baseline and post intervention flexibility was assessed by a sit-and-reach test (SRT).

The results showed that In the SMI group, FFD, SLR, and PA were significantly changed after the intervention, and in the SMFR group, there was a significant change in SLR after the intervention. In a comparison between the groups, FFD was found to be significantly increased in the SMI group. The authors concluded that the application of the SMI and SMFR to persons with short hamstrings resulted in immediate increases in flexibility of the hamstring. However, the SMI technique was more effective. The full article can be accessed here Performance-enhancing Placebos

Performance-enhancing drugs can improve a runner’s best time – even when they haven’t taken them. A study examining the placebo effect found that endurance runners who thought they were injecting a fictional perforThe results showed that there was a significant increase in the intervention SRT outcome measurements mance-boosting drug called OxyRBX improved their race time even though they had taken only sacompared to the control group, with a large effect size. And thus concluded that "An immediate clinical benefit line.Investigators from the University of Glasgow told 15 of SMR on the flexibility of the hamstrings and lumbar endurance-trained club-level runners that they were spine was indicated" Therefore we can now say research being given a new performance enhancing drug called OxyRBX which was said to improve oxygen delivery to has proven it! This study was published in Journal of the muscles in a similar way to a hormone called recomBodywork and Movement Therapies binant human erythropoietin (r-HuEPO). The runners, who all had personal best times over 10km of 39.3 minutes on average, self-injected the saline placebo, thinking it to be OxyRBX, over seven days and 3km running performances in head-toShortening of the hamstring has a negative impact on head competitions were assessed.The runners improved the posture of the pelvic region. As Tom Mytheir race time by an average of 1.2% – a small but sigers superficial back line implies the hamstrings and nificant margin after taking the placebo.Participants suboccipital muscles are connected. reported reductions in physical effort, increased potenThe study investigated if the flexibility of the hamstring tial motivation and improved recovery after running can be increased by targeting the suboccipital muscles. following the saline injections.Dr Jason Gill of the Institute of Cardiovascular & Medical Sciences, said: The suboccipital muscle inhibition (SMI) technique is a “The change in performance was of clear sporting relemethod of relaxing the tension in the four muscles locat- vance, albeit smaller than the improvement that would be produced by r-HuEPO.“The placebo may work by ed between the occiput and axis, which regulates the reducing perception of effort and increasing potential upper cervical vertebra (rectus capitis posterior major, rectus capitis posterior minor, obliquus capitis inferior, motivation in line with a psychological expectation of performance.” The study is published on the jourand obliquus capitis superior) ; these muscles are known to be associated with regulating body posture as nal Medicine and Science in Sports and Exercise. well as rotation of the head. When the tone of suboccipital muscles falls, it has been reported that the tone of Duration and magnitude of myofascial release knee flexors such as the hamstrings also decreases due in 3-dimensional bioengineered tendons: effects to relaxation of the myofascia. on wound healing. The purpose of this study was to research the effect of To investigate the mechanism behind the effectiveness performing the suboccipital muscle inhibition (SMI) of myofascial release (MFR), researchers from the Deand self-myofascial release (SMFR) techniques in the partment of Basic Medical Sciences at the University of The immediate effects of application of the suboccipital muscle inhibition on short hamstring.

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Research Highlights Arizona College of Medicine in Phoenix led by Paul Standley evaluated effects of duration and magnitude of The rats were divided into the following three groups; MFR strain on wound healing in bioengineered tendons (1) normal controls, (2) rats with LC application (LC (BETs) in laboratory. group), and (3) rats undergoing MT after LC (LC + MT group). The bioengineered tendons (BETs) were cultured on a deformable matrix and then wounded with a steel cutAccording to the CE-TOFMS analysis, a total of 171 meting tip. Using vacuum pressure, they were then strained with a modelled MFR paradigm. The duration tabolites were detected among the three groups, and 19 of these metabolites were significant among the groups. of MFR dose consisted of a slow-loading strain that stretched the BETs 6% beyond their resting length, held Furthermore, the concentrations of eight metabolites, including branched-chain amino acids, carnitine, and them for 0, 1, 2, 3, 4, or 5 minutes, and then slowly remalic acid, were significantly different between the LC + leased them back to baseline. To assess the effects of MT and LC groups. MFR magnitude, the BETs were stretched to 0%, 3%, 6%, 9%, or 12% beyond resting length, held for 90 secThe results suggest that manual therapy (MT) signifionds, and then released back to baseline. Repeated cantly altered metabolite profiles in DOMS. According measures of BET width and the wound's area, shape, to the findings and previous data regarding metabolites and major and minor axes were quantified using miin mitochondrial metabolism, the ameliorative effects of croscopy over a 48-hour period. MT might be mediated partly through alterations in meThe results showed that an 11% and 12% reduction in tabolites associated with mitochondrial respiration. BET width were observed in groups with a 9% and Full article is available here 12% strain, respectively. In the 3% strain group, a statistically significant decrease in wound size was observed at 24 hours compared with 48 hours in the non- Role of psychosocial factors in the development strain, 6% strain, and 9% strain groups. Longer duration of multisite pain of MFR resulted in rapid decreases in wound size, which The November 2014 issue of Journal of Pain published were observed as early as 3 hours after strain. a research study on the role of psychosocial factors in the development of multisite pain. The researchers used The authors concluded that Wound healing is highly experimentally induced Delayed Onset Muscle Soreness dependent on the duration and magnitude of MFR (DOMS) to investigate the possibility that pre-existing strain, with a lower magnitude and longer duration psychosocial status could predict the likelihood that leading to the most improvement. The rapid change in wound area observed 3 hours after strain suggests that someone would develop multisite pain. this phenomenon is likely a result of the modification of 119 healthy university students completed questionthe existing matrix protein architecture. These data sug- naires to assess depression, fear of pain and catagest that MFR's effect on the extracellular matrix can strophic thinking, and then reported on their experience potentially promote wound healing. The implication of of pain on lifting a heavy canister. They reported pain this research suggest that 3 hours after a wound ocintensity on a numerical rating scale, and pain sites by curred, application of 6% stretch on the area for 90 sec- shading a body chart. They then performed a set of exeronds could enhance healing. cises designed to induce DOMS, and went home. The The study was published in The Journal of the American next day, they came back and repeated the lifting test Osteopathic Association and pain reports. The researchers investigated possible influences of genManual therapy ameliorates delayed-onset mus- der, depression, fear of pain and catastrophising on (a) cle soreness and alters muscle metabolites (in pain intensity and (b) number of pain sites. They found rats). that depression influenced neither pain outcome. Pain Delayed-onset muscle soreness (DOMS) can be induced intensity was affected by gender: women reported more pain sites than men (both before and after DOMS inducby lengthening contraction (LC); it can be characterized tion), and women had a greater increase in pain after by tenderness and movement-related pain in the exercised muscle. Manual therapy (MT), including compres- DOMS induction than men had. Pain intensity after DOMS induction was correlated with catastrophising sion of exercised muscles, is widely used as physical rescore. Fear of pain did not appear to modulate pain inhabilitation to reduce pain and promote functional recovery. Although MT is beneficial for reducing musculo- tensity. skeletal pain (i.e. DOMS), the physiological mechanisms The number of painful sites was greater after DOMS of MT remain unclear. There is still a debate whether induction in both men and women, and both fear of manual therapy can help with DOMS. pain and catastrophising appeared to separately influence the number of painful sites after DOMS induction. To study the physiological mechanism, researches from This study makes a notable contribution to what we Japan studied the effect of manual therapy in DOMS on know about psychosocial influences on multisite pain: it rats. tells us that fear of pain and catastrophic thinking patLC was applied to the rat gastrocnemius muscle under terns that exist before pain begins may predict how far anesthesia, which induced mechanical hyperalgesia 2-4 that pain will spread, but that depression may not play days after LC. MT (manual compression) ameliorated the same role. mechanical hyperalgesia. Then, they used capillary electrophoresis time-of-flight mass spectroscopy (CEFrom Body in Mind TOFMS) to investigate early effects of MT on the metabolite profiles of the muscle experiencing DOMS.

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6 Questions to John Sharkey 1. When and how did you decide to become a bodyworker? In the 1970’s I was very interested in the life's work of Bernarr Macfadden (August 16, 1868 – October 12, 1955). Macfadden was teacher of Stanley Lief, the person who coined the term ‘neuromuscular techniques’ and he was uncle to Leon Chaitow, one of my mentors. I was fascinated by Macfadden as he combined physical activity and soft tissue manipulation in an effort to reduce pain and return homeostasis. I did every course available to me in those halcyon days (and I am still a student). I met Leon Chaitow in the mid eighties (as a young boy I could never have imagined I would end up working with Leon and create a new link in such an historical chain) and the rest is history crowned with the development of our masters degree in Neuromuscular Therapy. 2. What do you ind most exciting about bodywork therapy? For me there is no black or white in bodywork. There is at times a touch of grey but it is mostly colourful. It works. It is simplistic in its application. It requires touching and to be touched. There is a famine of touch in the world. It has the potential to change lives. It changes lives. 3. What is your favourite bodywork book? I am forever reading books. Not the latest Tom Clancy or Paula Hawkins but anatomy, physiology and bodywork topics. The irst book my mother bought for me was an anatomy text book. I have a handful of prized possessions including the original Macfadden's Encyclopaedia of Physical Culture. Macfadden was the father of health related physical itness and he combined soft tissue manipulation with exercise. I was truly taken with that idea. How I came to own Macfadden’s Encyclopedia is a story in itself and if I was not the person I am such amazing occurrences in life could make me believe in destiny. 4. What is the most challenging part of your work? 60 Terra Rosa E-mag

From an educational and clinical point of view a challenging aspect for me has been to develop my vocabulary to ensure that I stay true to scienti ic facts without dumbing it down, which in my view would be a grave insult to everyone patients and students. My responsibilities include that I stay true to the science but avoid complicating the issues for therapists and patients alike. I need to have the ability to speak to and teach a wide variety of learners while facilitating a great educational experience. That involves translating the theory and models into clinical take-away applications. I need my patients to buy into the therapeutic interventions I provide and in that regard education and understanding is empowering and healing for them. 5. What advise you can give to fresh manual therapists who wish to make a career out of it? Make sure the people you choose as your tutors are accepted and recognised experts in education. These people need to know your scope of practice and must be up to date with all legal implications of the work you are doing. I appreciate that therapists can be frustrated with having to always provide evidence based, research supported therapeutic interventions. Keep in mind that if you ever had the misfortune to end up in a court of law the judge needs to know you are professional in your approach, that you follow accepted standards and guidelines and above all that you took reasonable care. Lastly realise that you will be a student for life. 6. How do you see the future of manual therapy? Populous Fads will come and go but most people will always appreciate hands-on applications when compared to the use of machine based modalities. Never underestimate the power of endocannabinoids. The endocannabinoid system helps to balance sympathetic tone and imparts anti-emetic and antihypertensive bene its, and favourably modulates stress in the HPA axis and all due to manual therapies. Manual therapy has a great future.

6 Questions to Joanne Avison 1. When and how did you decide to become a bodyworker? I became a Yoga Teacher after a back injury that meant I had dif iculty carrying my new-born son. I couldn’t understand why the so-called “anatomy & biomechanics” I was learning, (and the postures) appeared to show up uniquely in each person I taught. As an artist, I had been trained in life drawing to see form in a way that didn’t lend itself to being broken down into muscles and joints, as if the structure underneath a body at rest, or in motion, was a robotic, mechanical form. I met Tom Myers in 1998 (before he had completed Anatomy Trains), as a Yoga Teacher, and become fascinated by the idea of anatomical continuity. The inclusion of the fascial matrix in the suite of tissues that hold us together was a paradigm shift for me. I wanted to learn how to sense these forms through my hands and make sense of movement. It transformed my notions of adjustment too. 2. What do you ind most exciting about bodywork therapy? Discovering the language of bodies through touch. It awoke a level of sensory perception and communication between me and the person I was working with, that just seems to become more eloquent and articulate as time goes on. It is as if people “speak” or “write” their body story and its history in their tissues; the hands can be a medium of translation that eventually becomes luent enough to communicate in individual dialects. Every encounter is a new conversation for different possibilities; I love that. My hands become translators in a way. 3. What is your favourite bodywork book? The book that has given me the most inspiration and wisdom is The Unknown Leonardo, (Leonardo da Vinci) which is full of his exquisite drawings and insights into form and Sacred Geometry. The man was a genius, way ahead of his time. Every time I look into it, it gives me a view of human motion that teaches or inspires me. If you want something more obviously about body work, then Job’s Body, by

Dean Juhan and Awakening the Spine by Vanda Scaravelli. I know that’s three altogether; but they are each very important works to me. There are many others, my book shelves take up a huge amount of space in my home… 4. What is the most challenging part of your work? Taking care of myself as well as my clients! 5. What advise you can give to fresh manual therapists who wish to make a career out of it? Practice, practice and practice on everyone you can, while you take care of yourself doing so; and work gently and thoughtfully, even if you are doing some of the “stronger” therapies. It takes years to really let yourself work instinctively and you need to be patient with the time it takes for you to really dance with the modality you choose. Listen to yourself and don’t make a guru of your teachers. That doesn’t mean ignore them or deny them credit for your learning facility. However it does mean gathering all that you are taught and making it your own. What’s in your heart? 6. How do you see the future of manual therapy? I see it expanding into new paradigms as we begin to recognise how entirely essential appropriate touch is in everyone’s life. My prayer is that we are kind to ourselves and realise that very gentle treatment can be as valuable as strong treatment. I would also love to see more manual therapy options in Orthopaedic training. I think it would be extremely valuable if more Orthopaedic Surgeons recognise the value of manual interventions before surgery, wherever possible. I think that is a lost aspect that too few recognise, but maybe the tides are turning. Surgery can be exceptionally valuable of course; it saves lives. However there are many intelligent options in the broader reach of manual therapies that can prevent the need for surgeries in many cases; preserving the wholeness of the body. That could perhaps be given a higher value as manual therapy becomes more articulate and new models emerge. Terra Rosa E-mag 61

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Fascial Fitness Workshop with Daniela Meinl, Sydney Feb 2015 By Kati Cooper Fascial Fitness, the original connective tissue conditioning program, has been growing for several years. An ever increasing number of high profile sporting, fitness and therapeutic organizations are now using and incorporating the Fascial Fitness conditioning techniques into their assessment, movement and training regimes. Amongst these are the World Cup winning German Soccer Team and the Canadian Olympic Athletic team. The success of Fascial Fitness is largely based upon its ability to translate the latest scientific research and insights regarding the nature of fascia, into practical, safe, complementary and enjoyable training techniques. When the techniques are taught correctly, they help to enhance the elasticity, strength and performance of connective tissue and those collahydration; myofascial stretch and fascia as a sensory organ, in genous structures most prone to injury. more depth. She demonstrated and explained how the techThe cutting edge and complementary approach of the Fascial niques associated with each principle can help remodel and Fitness training program always attracts a wide range of very condition our fascia. Workshop participants were given time enthusiastic health and fitness professionals leading the way to listen, watch, ask questions, practice and play with the techin their fields, as well as individuals seeking personal fascial niques and feel how best to work their tissue. enlightenment. Attending the Introductory and Trainer workThis play took us outdoors to rediscover how our inner child shops with Dani in Sydney were pilates and yoga specialists, had explored and experimented with movement. Leaving fitness, martial art and dance instructors, physiotherapists adult inhibitions behind we hopped, wiggled, jumped, and chiropractors as well as remedial, somatic, bowen and skipped, swung, leapt, climbed, crab-walked, monkeyed, balstretch therapists of every description. Itâ&#x20AC;&#x2122;s great that such a anced, danced, somersaulted and cartwheeled our way diversity of skills and life experiences can connect with each through the beautiful gardens surrounding our venue. The other and their fascia, in this exploratory learning environsuccess of the Introductory program was such that those who ment. had attended did not want to leave and were wishing they had Early this year, Daniela Meinl. Master Trainer from Augsburg, signed up for the Trainer course. Germany travelled to Sydney and teach how to safely and efThe Trainer course revisited but expanded significantly on the fectively train our fabulous fascial network. Along with Dr Robert Schleip and Divo Mueller, who have previously taught scientific research underlying the four main Fascial Fitness in Australia, Dani is a highly experienced core member of the training principles. The potential trainers were given time to Fascial Fitness Organization, travelling Europe and the world revisit and clarify their understanding of these principles and then given instruction as to how to go about teaching the basic to share her knowledge and expertise. techniques for each of them. Additional techniques for each of After a brief history and review of the evolution of our under- the principles were demonstrated and practiced and particistanding of fascia, Dani gave us an introduction to the scienpants were encouraged to focus on how they would adapt tific research upon which the Fascial Fitness principles and these for themselves and others individual needs and capabilitechniques are based. Whilst energy, enthusiasm and concen- ties. We were also lucky enough to have Dr Robert Schleip tration were at their peak Dani demonstrated, talked, walked, beam in for a Tele-Lecture on the latest research news and to warmed, bounced and stretched us through a sample Fascial answer any questions. It was both a fascia changing and career Fitness routine. Everyone was encouraged to participate enhancing process for the participants. adapting the techniques to suit their ability as they tuned in and took care to listen to what their individual fascial network Kati Cooper, Assuage â&#x20AC;&#x201C; Fascial Release Therapy, Fascial Freedom â&#x20AC;&#x201C; Advanced Fascial Fitness Trainer was telling them. Over the next two days, Dani then revisited each of the Fascial Fitness theoretical principles: elastic rebound; release and

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