tructural ntegration S ® I THE JOURNAL OF THE ROLF INSTITUTE JUNE 2010

TABLE OF CONTENTS

STRUCTURAL INTEGRATION: LETTERS 2 THE JOURNAL OF THE ROLF INSTITUTE® COLUMNS June 2010 Vol. 38, No. 1 Ask the Faculty: Working with a Valgus Leg Patt ern 3 Rolf Movement® Faculty Perspectives: 7 PUBLISHER Body Security: The Movement Brain Asks “Where Am I?” The Rolf Institute of ® Structural Integration CONSIDERING NERVES AND THE COLD LASER 5055 Chaparral Ct., Ste. 103 IN ROLFING® STRUCTURAL INTEGRATION Boulder, CO 80301 USA The Neurology of Posture 9 (303) 449-5903 An Interview with Don Hazen (303) 449-5978 Fax Jan Sultan (800) 530-8875 Gett ing a Handle on the Superfi cial Fascia 12 In Consideration of the Cutaneous Nerves EDITORIAL BOARD Stephen Evanko Craig Ellis Szaja Gott lieb Common Peripheral Nerve Entrapments and Syndromes 16 Anne F. Hoff , Editor-in-Chief Clay Cox Linda Loggins Practical Considerations for SI, Biased by the Nervous System 22 Heidi Massa Christoph Sommer Robert McWilliams, Managing Editor Deanna Melchynuk The Low-Level Cold Laser as an 26 John Schewe Adjunct to Rolfi ng® Structural Integration Dave Sheldon Mark Hutt on, Jeff rey Maitland, and Jonathan Martine

LAYOUT AND NEW CONSIDERATIONS OF ORAL STRUCTURES IN SI GRAPHIC DESIGN The Maxillae as the Inner Bridge Between 32 Susan Winter Neurocranium and Viscerocranium Peter Schwind Articles in Structural Integration: The Journal of The Rolf Institute® represent the Including the Stomatognathic System in Rolfi ng SI: 35 views and opinions of the authors and A Collaborative Experiment in Broadening Our Scope do not necessarily represent the offi cial A Collection organized by Pedro Prado and Heidi Massa positions or teachings of the Rolf Institute Including Functional Exercises in the 7th Hour of Structural Integration. The Rolf Institute By Beatriz Pacheco reserves the right, in its sole and absolute discretion, to accept or reject any article The Power of Working in the Stomatognathic System: for publication in Structural Integration: The NAPER Case Reports Journal of The Rolf Institute. By Rosângela Maria Baía, Beatriz Pacheco, Yahra Silveira Perdomo, Maria Beatriz Whitaker Structural Integration: The Journal of The Rolf Institute® (USPS 0005-122, ISSN 1538- Movement Strategies for the Stomatognathic System 3784) is published by the Rolf Institute, By Monica Caspari 5055 Chaparral Ct., Ste. 103, Boulder, CO 80301. Postage paid at Boulder, Colorado. POSTMASTER: Send address changes to REVIEWS Structural Integration: The Journal of The The Nature of Fascia DVD 47 Rolf Institute®, 5055 Chaparral Ct., Ste. Reviewed by Allan Kaplan 103, Boulder, CO 80301.

Copyright ©2010 Rolf Institute. All rights reserved. Duplication in whole or in part INSTITUTE NEWS in any form is prohibited without writt en Graduates 48 permission from the publisher.

“Rolfi ng®,” “Rolf Movement®,” and 2010 Class Schedule 48 “Rolfer™”are service marks of the Rolf Contacts inside back cover Institute of Structural Integration. LETTERS

capable of linear and sequential movement and there is no wish on our part to do away with that possibility. Some people used to Lett er to Authors of “A Rolfer’s™ Response to Gracovetsky” (December 2009 issue) think about light as having the properties of a wave. Others preferred the view of photon particles. Neither is the “truth,” yet the resolution of this confl ict brought about Dear Gael and David, Why are the diffi culties with your analogies quantum mechanics. important? Because the analogies fail Thank you for your article, “A Rolfer’s In fact this argument over the body has to support any supposed contradiction Response to Gracovetsky.” I agree been in the scientifi c world at least since between the “traditional, Western, linear, wholeheartedly with the point made in fi rst the 1800s. To refer to a recent book, The industrial-aged, two-dimensional” design part – that legs are important for walking Root of Thought by Andrew Koobs (Pearson of levers and pulleys and the “new, fl uid – and in the last part, which discusses the Education Inc. 2009), we fi nd this same and interactive” model with spirals, helices practical consequences. But, as a physicist, argument couched in the study of brain and tubes. As a scientist, in my view, there I must say a word about the middle part, function. Leaving the issue of spirals for is no such contradiction. Spirals, like levers, in which you argue that spirals and helices a moment, I think that this is the heart of are abstractions that simplify the reality of are favorite or superior designs of nature. the matt er: Golgi believed that the brain the natural world. Each of these abstractions In fact they are not; they are only two of worked like a net in which communication is useful to illustrate and conceptualize many natural designs, the favorite among and response was fl uid and simultaneous particular aspects of a complex reality, but which is more a matt er of taste than of fact. throughout the whole system. However, neither is itself reality. These models do not For example, my personal choice would be his colleague, Cajal, believed that the brain compete, and looking for spirals should not the sinus curve. was comprised of incremental cells and that prevent us from understanding what the information was conveyed sequentially. Although you look to various natural levers and masses are doing. There is plenty of evidence in the body that phenomena to support the superiority of I prefer to understand the unique both are true. My preference for the net the spiral and helical forms, the analogies contralateral patt ern of human gait through analogy is for the following reasons: do not quite work. For example: both models, and I’m proud to join Serge 1. Dr. Rolf based her theories of structural • Nothing we see in a spiral galaxy actually Gracovetsky in old-fashioned discussions integration on the holistic model of a web moves in spirals. All this stuff moves about levers, masses, and springs. I only or net. in ellipses. What appear to be spirals wish the Rolf Movement® Integration are actually regions in space where community had greater respect for and 2. We humans employ models in order intragalactic gas pressure is higher – understanding of Newton’s mechanics. to organize information. New models which is where stars are born. allow us to make new connections. Our, Why? Because at least concerning albeit poetic, model of natural walking • A hurricane is a catastrophic event very biomechanics I would like to see us gain has served me, my clients, and students far from the natural equilibrium, in the respect of the scientifi c community, and in organizing perception in a useful which the movement of air is generally I’m afraid that declaring a superior way of manner. I believe that the biomechanics either quasi-linear or chaotic. The jet thinking will not take us in that direction. of the helix have not yet been fully stream, for instance, moves almost Sincerely yours, appreciated in the scientifi c world, nor linearly. have they been applied to walking. Adjo Zorn, Ph.D., • Generally speaking, the motion of water Certifi ed Advanced Rolfer™, 3. The lever/pulley model tends to reduce is also either quasi-linear or chaotic. Rolf Movement® Practitioner the body into parts. A more fl uid model Water rarely moves in a spiral – unless holds new possibilities, not only for our you classify a turbulent vortex as a spiral. movement but for all healing. Response • Forms such as cochlea, DNA, and To follow are specific responses to Dear Adjo, perhaps seashells solve a distinct your points: problem: How to squeeze an immense Yes, all language is abstraction. The use As to the nature of water, new theories length into a small volume. of “spiral” was our best shot at fi nding of embryogenesis and books such as a word that invoked the many varied • A Chinese finger trap returns to its Water Sound and Image by Alexander curves, ellipses, and ovoid shapes that are original shape not so much because Lauterwasser (translated from the German observed in nature. Why? Because we are of its helix form as because of the by Gunter Maria Zielke and interpreted seeking a model of human movement that inherent elasticity of its materials: the by Jeff Volk. MACROmedia Publishing, is compatible with the rest of the animal original design of the material as living New Hampshire, USA, 2006) and Sensitive and natural world. vegetation was for its function as an Chaos by Theodor Schwenk (Rudolph elastic lever in an elastic framework. We are also seeking a model that allows Steiner press, 1st English Ed. 1965) make for and works with the most variety and a point that the movement of water is complexity of action. Of course we are highly ordered.

2 Structural Integration / June 2010 www.rolf.org LETTERS/COLUMNS

A hurricane is neither out of equilibrium a certain spring and spring back within our As much as I desire acceptance, nor is it a catastrophe until humans call form. The individual fi bers of the fi nger trap understanding, and elucidation from the it that for destroying their structures. are inherently not very stretchy for strength, scientifi c world, I cannot court its favor at Its overall movement pattern is helical much like collagen, and yet the shape of the price of my own vision. If Dr. Rolf had as seen when water goes down a drain. the counter-rotating helical construction waited to express her viewpoint until she Whenever moving forces come in contact allows the trap to shrink when lengthened was assured validation by the scientific with resistance they create chaotic eddies. or be bent in any direction and return to its world, we would not have the body of work So yes, the closeup view of a hurricane is original shape. Note: the spring of a metal that we all share. The diff erence between linear and chaotic, but the energy contained coil is due to the shape, not the elasticity of a mad or arrogant vision and a useful one in the storm system is dependent on the material. is not so much whether it is provable in its spiraling shape with a still “eye” at scientifi c terms, but whether it has relevance I am incredibly appreciative of those the fulcrum. and meaning to others. So, while I still seek members or our Rolfing® Structural to educate myself scientifi cally, I also apply The jet stream, another flowing Integration community who are well the diff erent models of walking to my own meteorological phenomenon, is hardly versed in scientifi c language and can act as experience. When it comes to movement, a linear. It is a consequence of atmospheric emissaries between their world and ours. theory has to work for my body in action. heating and planetary rotation, which As I am not of that ilk, I speak to my own So, I encourage anyone who is following meanders in helical “Rossby waves.” colleagues. To share a perspective with this discussion to include his or her own our community that has been developed As you say, the spiral is one of nature’s ways innate corporal wisdom on this subject. both from scientifi c infl uences and years of solving a serious space management of inquiry is not to brag of “superior Sincerely, problem. According to Bonnie Gintis, author thinking.” Our community fosters some of Engaging the Movement of Life, the spiral Gael Ohlgren, unusual sensibilities. Do you not think that is also one of nature’s solutions for energy Certifi ed Advanced Rolfer™ open dialogue can help our work evolve? storage. (See www.paxscientific.com/ (David Clark will address this more in an tech.html for a discussion of engineering Joining Serge Gracovetsky in his viewpoint upcoming article.) principles based on spirals and other may have improved his opinion of our wave forms.) community, but it did nothing to improve his opinion of Rolfing [SI]. He stated The Chinese finger trap was a teaching during his presentation that he has seen no analogy chosen to demonstrate that our scientifi c evidence for its viability. own construction is inherently elastic with

internally or externally rotated. Without going into the whole concept here, it is Ask the Faculty suffi cient to say that the externals would generally tend to valgus legs, and the Working with a Valgus Leg Patt ern internals varus. If you approach the leg patt ern in the context of the relation to the whole structure, then I have a lot of clients who exhibit a valgus leg patt ern. How much of this problem is typically you have a good chance of easing the Q due to the genetic structure and bony alignment, and how much is due to myofascial extreme expression of the pattern, and imbalance and faulty movement patt erns? Are women, who naturally have wider hips than men, lining the legs up under the body, so the more predisposed to problems of this type? What are the general considerations and goals in working knees can “track” more or less straight with these clients to help them achieve bett er structure and balance? ahead in walking and running. Tactically, the two types of legs will respond to a general approach through the Recipe, In my own process of learning the work but in fact each of the two polar types Ida Rolf created a system of values aft er my initial training, I began to suspect A needs a different approach to access to determine the relative spatial order of that Dr. Rolf had seen legs as generally the “lines of transmission” of weight the human body. These values give us a disorganized and had a broad template to and the corresponding musculofascial framework to make assessments about the “organize” them in the gravity template, development. The valgus patt ern, and its body-in-gravity (by means of a projection of but did not diff erentiate that into a typology correspondent, varus, are primarily genetic, a conceptual grid of vertical and horizontal of patt ern. In the early eighties, it occurred and not adaptive. You can see these patt erns lines), and the interrelationships of the to me that there were two general, or polar, come down family lines. The leg patt ern, major segments or components of the body types of posture and contour. These I called being part of a system-wide morphological in that gravitational grid. Dr. Rolf did not the Internal and External types, as each preference, cannot be taken as a local event discuss varus/valgus leg patt erns in her demonstrated a preference for organization in the legs. That is not to say that it cannot teaching or writing. around the vertical midline that was either be changed with our work. It is to say that

www.rolf.org Structural Integration / June 2010 3 COLUMNS it is not an isolated patt ern, out of context to When the varus or valgus patt ern is more the general postural preferences of the body. postural than structural, we will oft en see a leg in which the femur is relatively straight Valgus patt erns in the leg can have several (not twisted) but the whole leg is in external variations. As a baseline, consider that a rotation (valgus) or internal rotation (varus). relatively normal leg will have, as seen in This being more of a postural patt ern than Figure 1, the neck of the femur and an axis structural, it is much more accessible to through the femoral condyles relatively higher organization through education parallel. In neutral, and in motion, the knees and manipulation to bring the leg toward track (more or less) straight ahead. normal. In a genetically based patt ern, it requires system-wide intervention over time, plus an internal awareness in the individual, to bring lasting change. This asks for long-term intervention through manipulation, education, and consistent yoga-like movement work. Jan Sultan Advanced Rolfi ng® Instructor Figure 2: Valgus Legs A Working eff ectively with a client who Varus legs will have the relationship exhibits the valgus leg patt ern begins with between the neck of the femur and the determining whether the patt ern is actually condyles in a twist that brings the condyles problematic, as opposed to being a congruent into medial rotation in relation to the neck and functional manifestation of the general of the femur. That forces the leg to assume way in which the particular person adapts the classic “O” or bowlegged shape. to gravity Generally these people are faster oxidizers. One benefit of our Advanced Training Varus (see Figure 3) is a “bow-legged” is how it leads the practitioner to make condition or “A deviation from the fi ner and fi ner distinctions. For example, Figure 1: Normal Legs longitudinal alignment in which the while the patt ern is oft en a result of genetic part turns towards the midline” structure and bony alignment, it becomes In the valgus patt ern, that axis will have (Chambers Dictionary). problematic only when continuity of motion shift ed so that the femur (the bone itself) has is lost. When continuity of motion is not a twist down its length that puts the femoral present in the foreground, this discontinuity condyles in external rotation in relation to is the result of the myofascial imbalance the neck of the femur. This produces the and faulty movement patterns that we classic “X” or knock-kneed patt ern. This must address. twist can be mild to severe. This patt ern When Ida Rolf said “Gravity is the therapist,” is not dominant in females, but seems to she gave us an opportunity to refl ect on be distributed equally in the genders. The just how law-abiding structural integration relative width of the female pelvis may must be. According to Newton’s Universal dispose females to show more stress in the Law of Gravitation, each massive particle more extreme expressions of the patt ern. in the universe attracts every other Valgus is often associated with obesity, massive particle with a force directly which indicates that the shape of the legs proportional to the product of their masses may be the outward sign of system-wide and inversely proportional to the square preferences metabolically. Valgus people of the distance between them. Although are slower oxidizers as well! Valgus (see today’s physicists might describe gravity Figure 2) then is X-legged or “A deviation somewhat differently, Newton’s law from the longitudinal alignment of the body still works. in which the deformity turns away from the midline” (Chambers Dictionary). In distinguishing patt erns from problems, we should remember Wolff ’s Law: form follows function. Although we recognize the wide applicability of this abbreviated version, Figure 3: Varus Legs German anatomist and surgeon Julius Wolff (1836-1902) was talking about bone: every change in the form and function of a bone leads

4 Structural Integration / June 2010 www.rolf.org COLUMNS to changes in its internal architecture and in its • rotators external form. For me, the most useful model for • psoas major and minor A understanding valgus leg patt erns is Jan The way I typically begin my own sessions • sacrotuberous ligaments (to open narrow Sultan’s article on structural types. Sultan honors Wolff ’s Law: I try to feel beyond the ischial tuberosities) distinguishes two polar structural types soft tissue to the bony lay of the land. The based on pelvic inclination and femoral width of the hips (be they male or female) • obturator internus (to open the core) angle: the internal type, with varus legs is far less relevant to the valgus patt ern than When palpation reveals a lack of congruence etc.; and the external type, with valgus the relationship of the hips to each other; with respect to the genu valgum patt ern, legs. While any typology has limited to the sacrum and spine above; and to the the laws of Wolff and Davis still govern, application to reality, Sultan’s work helps femurs, legs, and feet below. My sense of particularly when we “hunt for the feel us think about femoral angle and whole the shape, contour, volume, and dimension of the tissue”4 and allow the palpation body structural preferences. Excluding of the osseous infrastructure informs my to inform our strategy. For example, as developmental anomalies, femoral angle strategy for intervention in the soft tissue. in the case of a recent client whose right is always infl uenced by the gravitational Whatever strategy is chosen, its femur was more externally rotated than preferences evidenced by the structure as a implementation will implicitly depend on his left , the planes through the greater and whole. For example, diminished amplitude Davis’ Law, which describes how soft tissue lesser trochanters were diagonal to a true of the spinal anterior/posterior curves forms in response to demands: ligaments coronal plane. This aff ected the extensor/ usually accompanies valgus leg patt erns. and other soft tissues, when placed under fl exor, front/back balance in the soft tissue Improving the bias toward valgus patt erns unremitt ing tension, elongate by the addition of throughout his structure. The structural in the legs will also involve improving new material. When remaining uninterrupted asymmetry in the pelvis and valgus leg anterior/posterior balance in the spine, in a lax state, they gradually shorten by the pattern was reflected functionally as a particularly in the neck. Additionally, and absorption of material. discontinuity of motion in his gait. Having more specifi cally, Sultan lays out the “lines honored Wolff ’s Law in order to feel the of transmission” in the legs that express Given the law of gravity, the laws pattern in the bones of the pelvis, the the soft-tissue strain patterns that hold concerning how the osseous and soft -tissue operation of Davis’ Law helped me to the valgus or varus patt ern in place. For components of living systems respond sense and release the soft -tissue restrictions a valgus patt ern, shortness in the lateral to the gravitational and other stresses infl uencing the patt ern. The result was a hamstrings is usually present. imposed upon them, and the intent of the dramatic increase in range of motion of Rolfer™ toward balance and integration, What is important here is to realize that the femur in the acetabulum, along with let’s see how we might address the valgus we are all living in patt erns of balance that the advent of anterior translation of the leg patt ern. have inherent biases. An external structure right ilium in walking. In other words, by will always have a tendency toward valgus If palpation reveals what Jan Sultan1 addressing the incongruence of the more patt erns in the legs, until the entire structure has described as the congruent genu externally rotated right femur to bring it evolves more toward neutral. This is only valgum patt ern2, consistent throughout the more toward neutral (i.e., symmetry with possible aft er the structure has achieved a structure, we fi nd the following: the other femur) and into congruence signifi cant degree of internal coherence or with the patt ern of his structure overall, • ilia tilted posterior on the axis through continuity “within its biased patt ern.” Most structural integration yielded greater acetabula of the structural problems dealt with early functional continuity. on in Rolfi ng Structural Integration have • primary and secondary curves of the Endnotes to do with confl icts within the inherent spine diminished structural patt ern of the client, i.e. high- 1. Based on Jan Sultan’s internal/external • ischial tuberosities narrow and iliac amplitude spinal curves and an anteriorly taxonomy. crest wide shifted pelvis with valgus legs would 2. In my twenty-three years of clinical represent a confl ict between the structural • femurs externally rotated relative to the practice, I have observed no gender-based patt ern in the spine and the legs. Clearing sagitt al plane correlation with respect to the genu valgum up the confl icts is the fi rst step in integration In working with a congruent valgus leg patt ern. and the foundation for any movement patt ern, Sultan3 suggests that work in the toward a more neutral structure. 3. Sultan, Jan, “Practical Exercises”; “X and following regions tends to bring the overall O Tactics”; “How to Work a Congruent X Hans Flury, in his article on pelvic structure to a higher level of order: Leg Patt ern.” Class handouts from Sultan’s inclination, and the recent work of Hubert • the high fi xed arch (use intra-articular Advanced Training, November 2005. Godard, both emphasize that the inclination stretching) of the pelvis has a strong and perhaps 4. Sutherland, William G., Contributions of determining eff ect on femoral angle. For • medial tibia (upper 1/3 to 2/5 of the Thought: The Collected Writings of William example, an anteriorly shift ed pelvis that is medial gastrocnemius and the deep Garner Sutherland, D.O., 2d ed. Portland, slightly posteriorly rotated will necessitate posterior compartment) OR: Rudra Press, 1998. external rotation of the femora, resulting • lateral hamstrings and the adductor/ Sally Klemm in a valgus patt ern in the legs. Correcting quadricep line of diff erentiation Advanced Rolfi ng Instructor the valgus pattern will always involve migrating the pelvis toward a more neutral • gluteals

www.rolf.org Structural Integration / June 2010 5 COLUMNS position which, of course, involves spinal Over the years I have had numerous femoris, lateral head of gastrocnemius, and curve preferences. In fact, if the upper Rolfing sessions as well as other types their fascial extensions. Sultan’s internal/ body’s center of gravity (G’ in Godard’s of bodywork (including a fair amount of external model would suggest working his system) moves posterior, the pelvis is excellent Feldenkrais work years ago), external “lines of transmission”: the septa of impelled to shift anteriorly and the femora along with a lifetime of yoga and t’ai chi the medial quadriceps, lateral hamstrings, to externally rotate. So, as Dr. Rolf said, it’s practice. I no longer have the exaggerated and postero-medial tibia. Classic Ten-Series a whole-body patt ern. look of the external body type that I showed work addresses a genu valgum patt ern in in my youth. I am still, and will always be, a each of the even-numbered sessions. Flury, Having said that, disruptions in normal core-bound external, but I no longer feel Goddard, Gaggini, Myers, and others have positioning of the ilia will infl uence femoral constrained by this patt ern. My knees do their own well-reasoned models too. angle. If one ilium is posteriorly and not exhibit the infamous X-leg patt ern, I inferiorly displaced with a slight out-fl are I’ve had good luck working to fi rst free have a slight lumbar lordosis, my scalenes (these confi gurations oft en go together), the obvious (visible or palpable) joint or no longer pull my head forward (a special the ipsilateral femur will externally rotate. soft -tissue restrictions. Then, in standing, thanks to Stacy Mills for that), and I actually we build the client’s awareness of aligned I always say the knee is the victim of what have a butt now. My overall structure has function via explorations in weight-bearing happens above and below. Hence, there moved toward a more neutral-looking type. and transmission through the hips, knees, can be distinct infl uences from the ankle I fi rmly believe that had I not embarked and feet. For example, I present a knee- that pull the knee into external rotation on this particular path, I would now, at bending/weight-bearing koan: how can and put the femur into a valgus bias. fi ft y-six, exhibit a much more exaggerated I bend my (valgus-tending) knees and Stabilization of any femoral patt ern will external body type. With eff ort, att ention, maintain even weight-bearing through always involve balance in the ankle and and intention, I have been able to free both my medial and lateral arches, without foot. The problems in the foot usually myself of my innate structural patt erns and pulling the knees apart or lett ing them fall involve slight displacements of the talus, inhabit a body I feel comfortable in and that together? If that seems impossible to the which then disrupts the normal distribution serves me well. client, oft en there’s more soft -tissue work to of weight anterior/posterior and medial/ John Schewe be done, or my instructions need to be even lateral in the foot. Fascial Anatomy Instructor simpler. Clients eventually get it, and this Michael Salveson serves as the beginning of a sense of support Advanced Rolfi ng Instructor and connection all the way up. A Valgus legs or knees is more common in women and, as you mention, is thought Til Luchau A I thought I would provide my outlook to be related to females’ wider hips (see Foundations of Rolfi ng SI Instructor on genu valgum patt erns (with apologies to www.asicsamerica.com/asicstech/ Jan Sultan if I have misinterpreted any of structural_diff erences.htm). This suggests his internal/external typology). that at least some of the contributing factors are structural or genetic (“nature”); Being an adherent of Sultan’s internal/ of course it is our Rolfing credo that external typology, and having used this way movement patterns and activities (and of assessing the body’s structure for almost other “nurture” factors, like Rolfi ng [SI]) twenty years now, it is my belief that any can mitigate (or exaggerate) this kind of deeply held structural patt ern has a genetic structural tendency. component – you are born either an internal or external and will carry that blueprint Is genu valgum due to osseous, myofascial, or throughout your life. I also feel that you are functional issues? I’m not sure these things not doomed to be trapped in that patt ern. can be teased apart in a causal sense since, I can present myself as a prime example. like nature and nurture, they’re reciprocally I was born an external with almost all of reinforcing. Chicken or egg? In terms of its requisite characteristics – fl at lumbars, practice-room strategy, these factors may out-fl ared hips (“apple butt ”), X-leg patt ern, not even need to be separated out, as we fl at occiput, and high, vaulted arches. I also see good results from both structural and had a slumped-shoulder posture with head functional work, and probably even bett er jutt ing forward that was not congruent with results when they’re combined. Sultan’s typical external type of shoulders It could be that you’re wondering about held back in a “military posture.” It turns how much change to expect, and how out, though, that this slumping of the upper best to proceed? Considerations: there pole was not due to my shoulders being are several sophisticated models for pulled forward and down by my pectorales understanding and working with leg minor (seen in a typical internal), but rather alignment. A simple bowstring analogy by shortened scalene muscles – a “core” would predict tighter longitudinal tissues shortening that is in agreement with the on the lateral leg that cross the knee: external type. iliotibial band, vastus lateralis, biceps

6 Structural Integration / June 2010 www.rolf.org COLUMNS

and clearly, the “movement brain” (those parts of the body that regulate movement), functions well. We move, stand, and interact, effi ciently and confi dently. There ® is fl ow. Rolf Movement Compared to other mammals, a human being has a more complex cortical brain. The cortical brain produces a secondary impulse Faculty Perspectives for security, and humans have developed this secondary impulse extensively. The cortical brain asks the question, “What is Body Security: The Movement Brain it?” (or “who is it?” or “when is it?”). This secondary question diff erentiates on the Asks “Where Am I?” basis of object identifi cation. Identifi cation By Kevin Frank, Certifi ed Advanced Rolfer™, involves past history and introduces the Rolf Movement® Instructor element of learning over time. In order to answer the question “what is it?,” the brain must use memory to match new Where is my up? Where is my down? How objects with something remembered. The A truism in the political world is does the diff erentiated space within and brain also looks to fi nd names for objects. that all politics is local. In the world of outside my body locate me and shape the All the objects and names that populate psychological security, it is fair to say sense of being here at this moment? Without our personal history are part of a narrative that all security is local. The topic of body location, our brain cannot meaningfully that lives in the imagination of time. We security begins by asking you to consider function. Without location, our body cannot build a narrative of our life that lives in your image of personal (local) security. choreograph movement and posture. the “what” part of our brain. We imagine the future with the what part of our brain. When you hear the word “security,” what To answer the “where am I?” question, This is part of being human. It serves us do you think of? A secure sense of family the body relies on the vestibular system in important ways. It off ers the capacity or relationship? Adequate employment? because it acts like a carpenter’s plumb to fi nd psychological security by sorting Money? Food? Shelter? Health? Youth? bob (pendulum) to tell the body where friend from foe, or by planning for the Beauty? All these aspects of security can, in “down” is; the body relies on stretch future. Sometimes, though, cortical activity fact, be part of one’s security. These forms receptors, pressure receptors, and other inhibits movement. of security represent a hedge against failure mechanoreceptors throughout the body. at some point in the future. These receptor organs tell the body about Our movement brain idea includes the its sense of weight and its relative position concept of the where (subcortical) aspect of To one degree or another, conventional in space. The body also listens for other our brain. The what aspect of the brain is forms of security dwell in the realm of time, types of sensory information, a sense of both helpful and not helpful to movement which is part of our cognitive imagination. being touched by the world: on the skin, brain function. In some instances, the This is not to diminish their importance. especially in hands and feet, through what aspect of the brain can interrupt the But it opens the door to consider other 2 the eyes, ears, nose, and skin. The body movement brain. Orientation to object dimensions of security, namely security that assembles its underlying security from all identifi cation, to personal narrative: all of belongs to the realm of space as opposed these sources. these are forms of orientation that locate us to time. Space, or spatial location, is the temporally (in time), rather than spatially. foundation on which cognitive reasoning, Our body security includes its sense of Temporal orientation can, through habit, and time and object recognition, depends. weight, volume, and body boundary, substitute for spatial orientation. One Remove our spatial security and the other supplied by proprioceptors, interoceptors, derives a sense of orientation from the 1 forms of security are not of much use. and touch receptors. Eyes and ears off er the story of one’s life, or from one’s calendar, sense of the space around one, the shape of Spatial security lies truly at the heart or by naming one’s familiar surroundings. it, the size of it, the density of it – and all of body security, and body security is Psychological security depends on a these senses answer the question “what is at the heart of structural integration. healthy narrative about personal history, the shape of my body and my surrounding Body security is a foundational issue for but our movement can become less skillful space?” The shape of the surrounding structural integration. Security underlies to the degree to which our what function space is an extension of one’s sense of body, availability to change. We resist change interrupts (dominates) where function in whether we are conscious of it or not. when we are afraid, no matt er how alluring movement. For example, if we focus on an the promise of improvement. What off ers This form of orientation – orientation to image of how we are supposed to move, or the kind of security that helps bodies to location – speaks directly to subcortical when we are supposed to move, this type consider new options? processes of the brain, and it is called (in of focus can limit the optimum flow of the neuroscience world) the “where” aspect movement. Structural integration rests on the of the brain. When the where aspect of philosophy that body security depends on One way to observe the “where and what” the brain gets this information directly the fundamental question, “Where Am I?” model in action is to observe how a person

www.rolf.org Structural Integration / June 2010 7 COLUMNS uses his/her eyes. We have two separate gaze sees the world in gray scale. Focused insists on locating itself because of a pathways that begin at the retina of the eye vision gathers information for object need for security at a biological level, but separate at the primary visual cortex recognition, and sees detail with acuity. It below the level of story. If we support in the back of the brain. One pathway is is color-aware and is usually slower than orientation with perceptive skills, the for peripheral vision and the other is for peripheral because it is linked to the activity movement brain makes coordinative focused vision. of cognition – making for more processing choices that are congruent with the goals of time in the brain. structural integration. Peripheral vision is “where” vision. It doesn’t mean looking out of the corner of the eye, (You can experiment to feel this shift in your Endnotes although peripheral vision has a broad fi eld own body. See if you can shift your att ention 1. At moments in which spatial location fails of view. It means the mode of sight in which between a mood of peripheral gaze and one us – such as in transition from anesthesia, the eyes connect to subcortical parts of the of focused gaze. In addition to att ending to during episodes of labyrinthitis, or other brain, to the where part of the brain. To see the diff erences mentioned above, you may neurological impairments that affect with peripheral vision means receptive fi nd peripheral gaze assisted by noticing a orientation – we realize directly our vision and links to weight orientation. The sense of weight in your body, or a sense of fundamental dependence on the basic sense experience is that the light and images come your volume or your skin boundary.) of up and down to organize perception of to you, land in you, and link to the feeling of People can use peripheral gaze and focused body and world. weight/volume sense in your body. gaze simultaneously. This is actually our 2. Working with thought processes is a Focused vision forms a separate pathway natural manner of function. In healthy necessary part of resolving movement from peripheral vision. Focused vision movement and perceptive activity, the issues. We must address psychological focuses. It can be focused on objects, colors, distinction between where and what meaning as part of the movement process. or details that one is looking at, or a focused outgrows its usefulness. In the experience of movement, however, gaze can be a vacant stare in which one It helps to gain skill in using and feeling perceptive skill involves abstaining from internally views a mental image, an image peripheral vision, and in feeling the shift cortical control of the body. Orientation to of the inside of one’s body, or a body part, or to focused gaze, so it becomes a distinct “where” is a skill that helps to do this. an image of how one looks in a movement, and recognizable experience. We perceive and so on. Focused vision speaks to the Resources the distinction in another when we know cortical aspect of our brain, the what aspect it in ourselves. Working on peripheral For a discussion of posture and perception, of orientation. vision is a form of “body building.” Skill at and the idea of the “movement brain,” see the We can use a peripheral gaze to “interrupt shift ing to peripheral vision is assisted by articles, “Posture and Perception” and “Body the interruption” that may occur from changing the orientation in other sensory as a Movement System” and other writings at over-dominance of the focused gaze. That channels such as hearing and touch. With www.resourcesinmovement.com. is, if cortical processes have compromised each sense we can practice finding the For conceptual and graphic representations movement response, we can release this two gravity orientations of each sense: of where and what vision, see Vision and inhibition with a peripheral gaze. For weight orientation for each sense and Art: The Biology of Seeing, by Margaret example, if one’s gaze is focused on a mental space orientation for each sense. (Practice Livingstone, Ph.D. (New York: Harry N. image of how to throw a ball, while actually with peripheral gaze also strengthens Abrams, 2002.) making a throw, the focused gaze can be the capacity to maintain robust sensory noticed by an observer. One will detect awareness while the eyes remain open.) Jacques Pailliard proposed this model “muscular focus” in doing the movement for many decades as a means of bridging A sense of feeling body location, feeling as well. Inviting the ball thrower to sense the world of cognitive psychology and the present location, supported by a space, not only with the eyes but with the neuroscience; for his precisely reasoned differentiation of the space within and whole body, may improve the person’s analysis of where and what aspects without is our natural state. Posture and coordination. In this example, movement of movement control, see the article coordination are indicators of the relative inhibition associated with what use of “Sensorimotor versus representational level of security in sensing location, as eyes (focused) is interrupted by a where framing of Body Space, A neural basis for a person’s restored body security is an use of eyes (peripheral). Where orientation a distinction between Body schema and expression of structural integration. restores through a shift in the mode of Body image” in V. Knockaert and H. De gaze. When we “feed” the movement In the simplicity of a body sensing its Preester (eds.) Body Image and Body Schema: brain with where information, the body location, we may notice something else as Interdisciplinary Perspectives (Amsterdam: oft en shows improvement in motor control well: an awareness of the present moment, John Benjamin, 2004). (coordination) – improved fl ow. a quality of relative quiet underlying the activities of life. Stillness manifests in the Peripheral gaze is quite specifi c in the types stability of orientation that isn’t built on of information it gathers: light and dark, the sense of time; mind noise is our mental outline, movement, shape, size, depth maneuvering around issues of security. perception, figure/ground separation. Peripheral gaze is fast because of its shorter Orientation is relevant to movement pathways to the subcortical aspects of the because the body makes orientation brain. It is also color blind – peripheral to “where am I?” a priority. Our body

8 Structural Integration / June 2010 www.rolf.org CONSIDERING NERVES AND THE COLD LASER

headaches to plantar fascitis. Infl ammation is the genesis of nerve arborization (growth of infl amed nerves) and neuropathic pain. Arborization: This is an absolutely key concept, and yet I doubt if there is much or The Neurology of Posture any clinical data to support its existence. It’s a well-known term in laboratory research into nerve behavior, but I’ve An Interview with Don Hazen never seen it used to refer to nerves in By Jan Sultan, Certifi ed Advanced Rolfer™ vivo. In the lab, inflamed nerves grow because infl ammatory neurotransmitt ers Note: Don Hazen was certifi ed as a Rolfer in 1978. He served on the Rolf Institute® of Structural cause the release of nerve growth factor Integration Board of Directors for six years, the Admissions Committ ee for six, and as a regional from local mast cells. I consistently fi nd chairperson forever (or so it seemed). He received his Doctor of Chiropractic Degree in 1994. infl amed nerves that have grown beyond Following his graduation he pursued his interest in the nervous system with 300 hours of their “usual” length – sometimes by several postdoctoral study in the chiropractic neurology diplomate program. He lives in the San Francisco feet. I constantly test my assumption East Bay with his wife Mollie, with whom he celebrates thirty years of marriage. Together they because it is such a novel idea; and, by share a mutual interest in photography and are working to create a business in photographic prints. extension, the arborized branch will not appear in an anatomy book. Arborization is an important concept because when a Jan Sultan: How did you fi rst become for the American Academy of Osteopathy growing nerve crosses a joint it is instantly interested in the nerve work? on peripheral and cranial nerves. I managed more vulnerable. Each joint it crosses to enroll. I discovered, to my surprise, that represents an additional demand for the Don Hazen: Probably my fi rst “niblet” nerves were palpable and that they were nerve to stretch. Additionally, joints are was Robert Becker’s Body Electric, which treatable. I wasn’t sure how I would use my typically sites for tethering because they opened the notion for me that more was new information in my Rolfi ng® practice— oft en sustain low-grade injuries and the happening than our models of neural except in those obvious cases where people resultant infl ammation. function explained. A decade later, in had pain from infl amed nerves. One of my chiropractic school there was a lot of Dorsal Root Refl ex: This is the process by fi rst clients [aft er the class] had a hallux buzz about a chiropractor and Ph.D. which neurogenic inflammation occurs rigidus (rigid first toe), which resolved neurophysiologist named Ted Carrick, who and is perpetuated. It’s important to the easily when I released the plantar nerve. I had developed an extraordinary technique understanding of the whole process, was hooked. for using ordinary environmental stimuli though not especially relevant to structural – light, sound, joint manipulation, etc. – to JS: What would you say are the problems. resolve severe neurological problems that fundamental concepts that underlie JS: What is the diff erence between nerves the medical neurologists were oft en unable working with nerves in a structural context? as transmitt ers and nerves as structural to handle. I studied his work over a period DH: Stretch and glide. Healthy nerves have elements? of four to fi ve years and several hundred a couple of properties that are essential to classroom hours. DH: Our everyday understanding of the normal movement: the ability to stretch and nervous system refl ects what I call the USB- The amount of study required to attain the ability to glide through surrounding cable model of neurology. Nerves hook up the level of mastery to use Carrick’s tissue. As joints approach their end ranges, various input and output devices to the work fulltime was beyond me, but I was stress is placed on the nerves that cross central processor. They even use binary profoundly infl uenced by his underlying them – the closer to the surface the more code. If we want to continue our analogy model: that imbalance in the fi ring rates the stress. To appreciate this, consider that to structural matters, you can think of of the brain’s hemispheres sometimes the path of a cutaneous nerve traveling over what happens when you go to move your produced pathological eff ects throughout the gluteus must stretch when the hip is in computer and the keyboard and printer the body. Applying this model led me fl exion compared to the sciatic nerve that USB-cables are under a large pile of books. to a greater understanding of structural runs beneath it. The mass of the gluteus The computer doesn’t budge. If a nerve imbalances that structural integration creates a greater arc. bundle is trapped in a pile of scar tissue, the (SI) practitioners face everyday. Things Tethering: This is oft en called “entrapment.” joint won’t bend and the limb won’t move. like pelvic rotations and many of the left - I like the term “tethering” because we’re right imbalances we fi nd are more easily We’ll have to leave our analogy to see often talking about relative restriction explained and reduced. Brain imbalance, the other structural eff ects on nerves. For of glide and the summation of several because of the complexities of cortical instance, certain nerves, when stimulated by restrictions. A nearby scar can impede a inhibition of motor output, causes muscles the CNS [central nervous system], produce nerve’s glide and can add to other sources on opposites sides of the body to be neurogenic inflammation, which, among restricting it. excited diff erentially. other things, causes nerves to be highly Inflammation: Neurogenic inflammation sensitized to stretching or compression. Then in 2004 I discovered, serendipitously, was fi rst examined in the ’80s and has been (Thankfully, USB cables don’t share that that Jean-Pierre Barral was teaching a class shown to have a role in everything from trait.) Stretching the infl amed nerve causes

www.rolf.org Structural Integration / June 2010 9 CONSIDERING NERVES AND THE COLD LASER pain, which makes you unconsciously of another molecule, which causes another what is commonly thought of as tight adjust your posture or your movement to cell to respond. hamstrings. It is more oft en a tight posterior minimize even slightly annoying input. femoral cutaneous nerve which has become The infl ammatory neurotransmitt er causes (It’s much more persuasive than an error tethered behind the knee. Where the an immune cell to release a molecule message on your screen.) nerve crosses the ishial tuberosity it gets (interleukin 2 beta, if you’re interested) compressed, generating pain. One of the In spite of the appearance that computer that vastly increases the sensitivity of all hallmarks of integration has to be joint cables seem to multiply, they don’t actually the nerve axons in the nerve bundle. All mobility. That hallmark is lost in a body grow. Inflamed nerves do. In growing the axons can now fi re more easily when with extensive neural infl ammation. longer, they oft en cross joints, which adds stretched or compressed, enabling you to to the possibility of stretching, pain and have more pain and increased spasm. JS: What are the properties of nerves that structural compensation. The joint fl exion you have found to be important enough JS: Why does it persist when no longer produces both stretching and compression, to devote your practice to studying them? necessary? which excites the axons in the nerve DH: This has been a process of “un- bundle; thereby generating pain, aberrant DH: Once nerve infl ammation gets started, covery.” The fi rst stage was surprise and sensation, and muscle spasm – hence it tends to be self-perpetuating unless it’s excitement to find the ease with which structural compensation. interrupted. The inflammatory process structure and function changed with work promotes pain, and pain causes more JS: What is the function of nerve on nerves. I set about to fi nd out the limits of infl ammation. Nice process. infl ammation? this way of working and would sometimes JS: What actually happens to an infl amed have three anatomy books on the stool next DH: Nerve infl ammation is an unfortunate nerve that makes it important to structural to me. Then I began to fi nd nerves that by-product of neurogenic infl ammation, integration? weren’t in the anatomy books and which which appears to have a function in the had even more profound effects. Large pinpoint delivery of pro-inflammatory DH: Nerves get inflamed all the time. diameter nerves began to show up in areas agents to an area of pain. But the same This usually resolves spontaneously. where no large nerves were listed. They neurotransmitt ers that initiate infl ammation On practically any client on any day, it’s would interconnect with other nerves in in the painful area also trigger an possible to fi nd nerves that are infl amed ways I hadn’t anticipated. infl ammatory response within the nerve and tender to palpation. The client may bundles themselves. That response is not not even be aware of the area until some I spent essentially two years evolving a so useful. Most of the literature deals more movement causes stretch or compression technique. I was aware that I was leaving with the undesirable eff ects – eff ects which that fi res the nerve. But here is one very behind the nuance and subtlety that I had include most of the major health threats innocuous piece in the puzzle of human learned in the previous twenty-fi ve years we face, not to mention the pain that is structure. Bodies try to minimize pain – as I struggled to get some mastery over produced. even pain which is below the threshold this unruly subject. I worried that I was of consciousness. becoming a technician – that nerves were JS: What is the physiology of nerve becoming my answer to every condition. infl ammation? At the most elementary level, this behavior is important in SI because it oft en leads to Slowly, I began to bring my earlier way of DH: Neurogenic inflammation – of compensatory patt erns. There’s more. As working back into my work with nerves. which “nerve infl ammation” is a subset infl amed nerves swell, they lose their ability In the process was a delightful “re-covery.” – is a process orchestrated by the central to stretch. This restricts the range of motion I’ve long had the ability to sense, with my nervous system as a response to prolonged at joints. While nerve fi bers themselves are own body, areas of difficulty in clients’ nociception (think pain input) from the microscopic, gel-fi lled tubules, each fi ber is bodies. They’ve mostly been vague and ill- peripheral nerves. You sprain your ankle. If loosely wrapped in fascia, and each bundle defi ned. Suddenly I noticed I was picking it doesn’t heal quickly, changes start to occur of nerves is sheathed in a denser, water- up sensations with much more clarity in your spinal cord, where nociceptors from tight fascial layer called the perineurium. and precision, and that I could tell before the ankle synapse with the nerves that carry The perineurial layer protects the nerve even touching the client which nerve was the signal to the brain. from ions, immune cells and organisms involved and how far it went. Perhaps These spinal-cord centers cause a signal that populate the extra-cellular matrix. It nerves have a more defi ned electromagnetic to be sent back down the fibers that also contains the infl ammatory fl uid. Under field. I don’t know, but it leads to brought the signal in. This is an example normal circumstances nerves stretch and surprising accuracy. of the dorsal root refl ex. The fi bers secrete glide through the muscles and around bone. I have little idea where this will lead. neurotransmitt ers in the tissue where the When infl amed they are limited. Therefore, After five years of immersion, I’m now signal originated, causing an infl ammatory the joints they cross are limited. looking to fi nd places of integration with response. That’s annoying enough, but But the biggest problem I encounter comes other modalities I’ve used, e.g. cranial the inflammatory neurotransmitter also from the fact that infl amed nerves grow and visceral work, and points of contact gets released in the nerve bundle itself. and then become tethered in scar tissue with the work of others, such as Peter This is nerve inflammation. In the way particularly in areas of high mechanical Schwind’s book.1 I am perpetually looking the body works, one molecule triggers a activity – like joints. Whenever nerves are for conditions where nerves are not the cellular response which causes the release tethered, the motion at the adjacent joints primary source of distortions. Thus far, then becomes restricted. An example is osseous malformations and traumatic and

10 Structural Integration / June 2010 www.rolf.org CONSIDERING NERVES AND THE COLD LASER surgical disruptions of the fascia seem to to say that clients don’t have pain around for creating change in Rolfi ng [SI] are the be the only ones. Even scars, where the the SI joint nor that sacral distortions aren’t habitat of important nerves. The TFL [tensor myofascial mobility has been compromised, problematic. Thus far, the distortions at the fascia lata] is home to the lateral femoral appear to have most of their eff ect because SI joint have been directly related to neural cutaneous nerve. The medial border of the of nerves that are entrapped. tension; and the pains more oft en are the ischial ramus houses the pudendal nerve, result of infl amed nerves descending from which is vitally important to pelvic fl oor JS: What is the value of symptom relief in the back. It used to be that I was working on tone and balance. The list goes on. the context of Rolfi ng [SI]? sacral problems several times a week, which I use the neural approach to accomplish DH: Here I will suggest that not only is the I would resolve with osseous manipulation. the goals of Rolfi ng [SI] as I’ve understood symptom no longer something to ignore, Sometimes the pain comes from dorsal them. I find I am much more effective the symptom becomes critical to the process sacral nerve roots, which are stretched by approaching the structure from the model of unraveling the biomechanics. I am also sacral malposition, but that malposition I’ve outlined in this interview than I was getting close to suggesting that chronic itself is relieved by addressing nerves that before I began this journey. Of course, I was pain generally is caused by, or related to, innervate pelvic fl oor muscles. never tested to see “how good a Rolfer” I infl amed nerves. I know! It sounds that I realize I haven’t quite answered the was before I started “nerve futzing” (as one way to me, too! question. The symptom isn’t important of my clients calls it), so this is a subjective This, of course, is an incredibly complex because it hurts – except, of course, to the perspective. question. We’ve been warned, over the years, owner of the body. It’s important because it For me this is not, in any sense, a “nerves about treating symptoms and “chasing the is indicative of an infl amed nerve, and the versus fascia” debate. Nerves live in the devil” and been admonished to “go where it infl amed nerve is typically also a tethered extracellular matrix. They are sheathed ain’t.” This makes perfect sense if the model nerve. The tethered nerve more than likely in several layers of fascia. Nerves, like you choose is one where symptoms are the has biomechanical sequellae – either by all the cells of the body, are in perpetual result of strains in the myofascial system. direct mechanical restriction of neurofascia, participation with the matrix. You mention Most likely they are sometimes. If the reign by fi ring motor neurons that excite muscles fascial differentiation in your question. of pain comes mainly from the strain, it is that cause the joint to fl ex, or by generating A large part of the neural work is to useful to look at the larger structure for pain, which causes avoidance behavior. diff erentiate neural fascia from surrounding biomechanical imbalance. The inflamed nerves, by themselves, myofascia, periosteum, peritoneum, and so If, however, the source of the symptom is the cause signifi cant postural distortions. I’ve on. That said I think that in the current same tissue as the biomechanical restriction, been working with a number of scoliosis fascination with fascia, some writers have we need to draw diff erent conclusions. Now suff erers. I’m perpetually surprised and assigned to fascia functions which may the symptom is a piece of information at delighted by the results of working only bett er belong to neural tissue. the same level of usefulness as the visible on nerves – in this case the dorsal rami of If you would like more detailed information, biomechanical imbalance is in the former individual vertebrae. The dorsal rami (the I recommend you visit my web site where system. In this model, what causes the pain tiny nerves that innervate the posterior I have several articles addressing these is the result of intraneural infl ammation area of the spine) at the apex of scoliotic subjects, at http://dhazen.com/Articles/ within a particular nerve bundle and the curves and at the transition of the curves are Aboutt heArticles.html. heightened sensitivity that infl ammation always “hot.” Reducing the infl ammation causes in axons within that bundle. If you in these tiny nerves aff ects the segment in a Endnotes follow the course of the nerve, you will way that it reduces the sidebend. Don’t ask 1. Schwind, Peter, Fascial and Membrane typically fi nd the nerve tethered at a joint me “how come?” Technique: A manual for comprehensive sometimes three joints removed from the JS: Traditional Rolfi ng [SI] is known as a treatment of the connective tissue system.” site of the pain. It is a nerve that has lost very direct method of intervention, stressing Edinburgh: Churchill Livingstone Elsevier, its ability to stretch and glide, and the pain fascial diff erentiation and education. Over 2006. comes from compression at the site of the the years, the system has been informed bony or ligamentous ridge, which causes by studies in parallel disciplines, like it to fi re. Accordingly, low back pains may craniosacral therapy, visceral manipulation, have their origin in a tethered nerve in the deepening understanding of biomechanics, knee or even the ankle. This inverts the and ligament function. Where does neural typical clinical relationship where injuries manipulation fit into the technologies in the back produce symptoms in the feet. that support the basic concepts and goals Obviously, these also occur though not of Rolfi ng [SI]? nearly as frequently. DH: As I approach it, I don’t think of neural Pelvic rotations and sacral misalignments work as a parallel discipline to Rolfi ng [SI]. also follow this patt ern. There are two or At times I think that what Rolfers have been three nerves that are always involved in doing over the years has been neural work pelvic distortions, and releasing them levels without being aware of it. I know I don’t the pelvis every time. I have not worked have widespread support in that point of with a single SI [sacroiliac] joint problem view. Many of the places that are popular since I began working this way. This is not

www.rolf.org Structural Integration / June 2010 11 CONSIDERING NERVES AND THE COLD LASER

nerve manipulation in the structural integration (SI) community. I’ll be forever grateful to Don for this new insight into the value of nerve work for Rolfi ng Structural Integration. For interesting reading on the subject, I recommend Don Hazen’s Getting a Handle on the website (www.dhazen.com), as well as Manual Therapy for the Peripheral Nerves by Jean-Pierre Barral and Alain Crobier.3 Superficial Fascial I also highly recommend taking a class in releasing entrapped nerves. I’m glad In Consideration of the Cutaneous Nerves to see there is growing recognition that mechanical irritation of the peripheral nerves, especially the cutaneous nerves, By Stephen Evanko, Ph.D, Certifi ed Advanced Rolfer™ is driving much of the infl ammation and subsequent pain, strain, joint restriction, and fi brosis in the body. Adding neurofascial the eye band, the chin band, the collar band, work to our repertoire is a notion whose A h, the superfi cial fascia. This thin layer the chest band, the umbilical band, the time has come for the Rolfi ng community of loose fatt y connective tissue underlies the inguinal band, and the groin band. These to embrace, and more discussion of the skin and binds it to the structures beneath. body straps were hardly discussed in most superfi cial layers can expand our abilities This layer also contains the cutaneous of my Rolfi ng® classes, with the wrist and to help our clients. Increased att ention to vessels and nerves, and is also called the ankle retinacula tending to get the most superfi cial fascia and neurofascial work hypodermis, subcutis, or tela subcutanea. airtime. These other body straps would has been an incredibly valuable addition While myofascia tends to get most of the seem to be relatively independent of the to my understanding, palpatory skills, press, I have recently been discovering how deeper myofascial anatomy of the body; and toolset, and has provided greater eff ective and dramatic structural change however, in practice lately, I fi nd them to possibilities for pain relief and structural can be evoked by contacting this upper zone be extremely important, and addressing the change in my clients than ever before. of the body, and the nerves therein, and thickened matrix just under the skin helps have come to realize how the superfi cial tremendously in resolving structural issues. One goal of neural mobilization is to fascia is largely underappreciated for its This is mostly due to the fact that many restore proper longitudinal and lateral role in aberrant structural and movement cutaneous nerves traverse these straps – glide of the peripheral nerve and its sheath patterns, as well as in pain generation. under and/or within the thickened tissue. where it becomes tethered in the fascia. In this paper, I would like to share some Therefore, the possibility of tethering of At the cellular level, substances released observations and experiences from my the nerves in these locations should always by mechanically or chemically irritated 4 recent focus on using the integument and be assessed. I know that my tendency had nerves can exacerbate the formation superfi cial fascia literally as a handle to always been to go for the deeper myofascia of myofibroblasts (cells that produce free nerves, access deeper tissues, and fi rst, oft en missing much of the important fibers in the myofascia in response to aid in restoring structural alignment in stuff in the fi rst available layer of the sleeve. inflammation), matrix stiffening, and my clients. I would also like to bring into fascial restrictions, as well as swelling A recent DVD by our colleague, Gil discussion some research fi ndings related to and edema that involve hyaluronan and Hedley, entirely devoted to the superfi cial the cell biology of the extracellular matrix, proteoglycan deposition in the tissue. The fascia,2 piqued my curiosity about this particularly hyaluronic acid (or hyaluronan) outgrowth of neurites (small neuronal layer even further. In it he shows the and proteoglycans, both of which are processes) underlies the phenomenon of incredible intricacy of the areolar tissue components of the ground substance and arborization of nerves (growth of small and the adipose layer – like a fl eecy set of are found in large quantities in the skin, the nerve branches) and may occur during pajamas under the skin. This pajama layer underlying layers, and within the nerves neurogenic infl ammation. Thus, there can can get twisted and saggy, or fi brous, thin themselves. My laboratory research over be a vicious cycle of infl ammation, fi brosis and dehydrated, thus trapping, tethering the years has focused on these components, and tissue contraction and hardening, more and pulling on the branching networks and there are a number of interesting nerve irritation, etc. Neurite outgrowth of the cutaneous nerves and, ultimately, fi ndings in this area that we may relate is infl uenced by hyaluronan and can be the deeper nerves, deeper fascia, and directly to our work as Rolfers as we explore blocked and/or guided by deposits of the joint capsules. We will see below how the superfi cial realms. chondroitin sulfate proteoglycans, which variability in the thickness and texture of interact with hyaluronan.5,6 For me, interest in the superfi cial fascia was the superfi cial fascia and overlying skin fi rst sparked through reading The Endless can give us clues about whether the nerves Figure 1 shows a cross section through a Web by Louis Schultz and Rosemary Feitis1 below or in the vicinity are infl amed or nerve. Manipulation of the epineurium and their fascinating description of the otherwise unhappy. of the larger peripheral nerves and various body retinacula – bands that run their smaller branches probably affects Don Hazen, Christoph Sommer, and horizontally around the body like retaining both the fibroblasts of the sheath and Jon Martine have been instrumental in belts holding in the soft tissue. These include the surrounding areolar tissue of the fostering the recent interest in peripheral

12 Structural Integration / June 2010 www.rolf.org CONSIDERING NERVES AND THE COLD LASER

the hydrated quality of viscous matrix around the fibroblasts. the tissues following In a recent experiment, I found that an fascial manipulations. enzyme that degrades hyaluronic acid can This is also why joints change the appearance of a myofi broblastic get lubricated when we synovial cell to that of a normal-looking move them. When we fi broblast (unpublished observation). This touch tissues with the enzyme also caused cells to retract fine intention, pressure and microvillous protrusions, which they use to shear focused on this secrete the matrix and contact and pull on watery interface where each other. Thus, our manual interventions the cell membrane meets may be aff ecting myofi broblast formation the pericellular matrix, in part through the ground substance. I’m convinced it can Hyaluronan also has direct effects on allow tissue to release infl ammatory cells. We have recently found more easily and minimize that binding of hyaluronan can activate the cellular damage. At the immunosuppressive ability of a subset of very least, connecting T-lymphocytes called Tregs9, and this eff ect Figure 1: Histology of a nerve – cross-section more consciously with may underlie the benefits and growing showing various parts of a nerve. The arrow shows the matrix immediately popularity of hyaluronan as a supplement how nerve manipulation can create shear along the surrounding cells can be for joint pain. helpful in encouraging nerve bundles, thus affecting the fi broblasts in the Concerning the nerves themselves, tissue melting. In surrounding areolar tissue and in the perineurium. hyaluronan and associated proteoglycans addition, those seams of play important roles in the nerve sheath mesoneurial gliding structures, as well as areolar tissue between dense fi ber bundles as a lubricant for proper glide. Excess nociceptive endings (pain receptors) and are a good place to aim with fingertips amounts of this matrix could also act as a tiny neurites of the nervi nervorum.4 The or fi ngernails. kind of glue as part of the pathophysiology interface between the perineurium (the A litt le hyaluronic acid is probably a good of tethered nerves, which also includes connective tissue surrounding a single thing, but too much can be a problem. edema and thickening of the nerve sheath, fascicle of nerve fi bers) and the epineurial Under inflammatory conditions (and and thus more contractile, myofi broblast- interfascicular tissues would also be in certain cancers), more hyaluronan like cells. Hyaluronan is also found in aff ected. The connecting areolar tissues in and its fragments are produced, thus the endoneurium surrounding individual the superfi cial layers, as well as the dermis exacerbating the swelling in and around nerve fi bers, and associated chondroitin and lower layers of the epidermis, are inflamed nerves, joint rich in the watery, hyaluronan matrix that capsules, etc. In addition, serves as a lubricant for proper gliding hyaluronan also appears to that must take place in healthy tissues as be involved in the formation we move and stretch. Hyaluronan itself of myofi broblasts, and over- is a huge, water-loving and space-fi lling accumulation of hyaluronan molecule, capable of undergoing profound and proteoglycans during structural changes on a nanosecond time inflammation tends to scale. The ground substance, including precede fibrosis. Our hyaluronan and proteoglycans, represents laboratory and others8 that primitive binding and communication recently found that the material, the slimy biofi lm used by cells hyaluronan matrix produced when they fi rst started aggregating into under certain stimuli by multicellular organisms; in other words, the fi broblasts, adipocytes, and ground substance is alive and responsive. synovial cells can be quite A memorable film by Jean Claude sticky and binding, thereby Guimberteau, Strolling Under the Skin, trapping infl ammatory cells shows well the dynamic nature of the (see Figure 2). This is due, gliding mechanisms of skin and tendons, in large part, to an increase and the lubricating qualities of this watery in proteoglycans and cross- matrix. Research has shown that hyaluronan linking of the matrix, which in the pericellular matrix of fi broblasts may make it stiffer and more serve an antiadhesive function and aids viscous. In looking at these the cell when it releases tensional hold images, it is easy to imagine on a substrate under certain conditions.7 how manual therapies can Fibroblasts also respond to acute stretching potentially be very eff ective Figure 2: Hyaluronan and proteoglycan-rich by forming a pericellular matrix rich in at dislodging the stuck pericellular matrix of fi broblasts in the form of hyaluronan, and this may help explain infl ammatory cells and the sticky “cables” can trap infl ammatory lymphocytes.

www.rolf.org Structural Integration / June 2010 13 CONSIDERING NERVES AND THE COLD LASER sulfate proteoglycans are found specifi cally in the nodes of Ranvier.10 This suggests that the matrix may also play a role in nerve conduction. Working with Superfi cial Fascia/Nerves As we work in the superficial fascia, we can consciously connect with the pericellular matrix of the fibroblasts in the areolar tissue surrounding the nerve and in the sheath; and with infl ammatory cells, through pressure and shear, we can interact directly with this primitive communication medium of the body. As Hazen has pointed out (and I fi nd to be true), working with finger pads along tethered cutaneous nerves of the superfi cial Figure 3: The retinaculum roll. Manipulation of the entire retinaculum to restore fascia can be extremely eff ective at releasing lateral glide to the nerves and tendons crossing below. Similar broad-hand them and pumping the inflammatory techniques can be used to untwist the other body retinacula using the skin and exudate that fills the nerve sheath and superfi cial fascia as a handle. surrounding tissue into the lymphatic circulation (this fluid also contains the distribution as possible, fi rst pressurizing to thinning of the epidermis. It feels to pain mediator peptide, Substance P, engage the nerve endings and pericellular me like the superfi cial fascia has been infl ammatory cytokines – small proteins matrix of the cells in the appropriate layer, pulled into a somewhat corrugated that promote inflammation – as well and then listening for and coaxing the texture by the tension generated in the as the inflammatory cells themselves). release by creating shear of varying degrees nerve sheaths and surrounding areolar Neurofascial manipulations, especially at the dermis/superfi cial fascia interface: tissue, much like a drawstring in the those that produce some rolling and Pressurize, wait, listen, lift and shear. waistband of sweatpants (this analogy shearing along the nerve, probably break borrowed from Kirstin Schumaker11), up the viscous hyaluronan-rich matrix This technique is focused in areas of with the marks appearing along the and fine cellular processes around the clearly palpable tension in the cutaneous corrugations. This pulling can potentially epineurial fi broblasts. Neural mobilization nerve distribution where the fi nest nerve disrupt the normal relationships and techniques probably also affect the twigs and endings reach up to the surface communication between the fi broblasts microscopic neurites of the nervi nervorum mechanoreceptors and along the length in the dermis and the epidermal cells, as they arborize and potentially promote of the nerve itself. De-rotation of all the which has been shown in laboratory contraction of the tissues immediately retinacula of the wrist or ankle, and studies to cause dramatic changes in surrounding the nerve sheath. The nervi restoration of lateral glide to the nerves the epidermis. Examples of cutaneous nervorum monitor the tensional state of therein, can be accomplished using a nerves that may contribute to stretch the nerve (among other things), and release similar technique (see Figure 3). In addition, marks are the superior and middle of the nerve by manipulation may mediate working at proximal and distal locations cluneal nerves overlying the glutes, as the oft en rapid tissue soft ening, as well as of a nerve by tugging gently along its well as the iliohypogastric nerve, where some of the benefi cial eff ects of our work length at the level of the superfi cial fascia, it emerges above the iliac crest, and on the nervous system and surrounding as described by Barral and Crobier, is as it passes down behind the greater tissues. Robert Shleip gave a memorable also helpful. trochanter. As Hazen and others have presentation at the 2009 Rolf Institute® pointed out, these cutaneous nerves are Membership Conference in which he Surface Indicators very much involved in low back issues discussed a role for the mechanoreceptors, of Tethered Nerves and the pain that is oft en mistakenly such as the Ruffi ni corpuscles, in mediating In clinical practice, there are several att ributed to impingement of the sciatic tissue responses, as well as strategies noticeable visual and textural indicators nerve. I fi nd that stretch marks are nearly for releasing them, such as skin rolling. on the skin surface that can help us identify always present over the cluneal nerves This would also effectively release the potential tethering and/or irritation of the in such cases. With respect to the body finest nerve twigs reaching up to the cutaneous nerves directly below, due to retinacula, torque in either the inguinal surface endings or terminating in joint twists in the body retinacula or sagging of strap or the groin strap will tug on these capsule tissues. the superfi cial fascia that can be tugging on and other nerves, and should be checked. Recently, I have found that profound and a peripheral nerve. These include: • Cellulite – It seems to my touch and rapid large-scale releases and effective • Stretch marks – These represent, in eye that cellulite is due to tension along diff erentiation of layers can be achieved part, a loss of elastin and alterations the connective-tissue septa around and by using my hands like a suction cup, in collagen in the dermis along with between fat lobules as the superfi cial engaging as much of a cutaneous nerve

14 Structural Integration / June 2010 www.rolf.org CONSIDERING NERVES AND THE COLD LASER

fascia sags, and probably involves moles over the long thoracic nerve, 4. Sauer, S.K, G.M. Bove, B. Averbeck, tension along the sheaths of cutaneous serratus anterior, and in the axillary and P.W. Reeh, “Rat peripheral nerve nerves and nerve twigs. This tension region, where the chest band will bind components release calcitonin gene-related seems to cause the tissue to pucker and the nerve and plaster the latissimus peptide and prostaglandin E2 in response can involve the entire nerve distribution. dorsi against the ribs, i.e., Third-Hour to noxious stimuli: evidence that nervi Cellulite usually occurs on the back and territory. Addressing the long thoracic nervorum are nociceptors.” Neuroscience, sides of the legs, so examples of the nerve where it gets tethered under the 92:319-325, 1999. nerve fi elds involved are the posterior chest strap and/or arborizes down to the 5. Hynds, D.L. and D.M. Snow, “Neurite femoral cutaneous nerve (which should pelvis is crucial in helping to release a outgrowth inhibition by chondroitin sulfate be checked in the case of a posteriorly kyphotic patt ern. proteoglycan: stalling/stopping exceeds tilted innominate) and the lateral femoral turning in human neuroblastoma growth cutaneous nerve (which should be Concluding Remarks cones.” Experimental Neurology, 160:244- checked on the side of the anterior tilted In our quest to help clients release their 255, 1999. pelvis), as well as the obturator nerve. strain patt erns, fi nd tensional balance, and There are probably other examples as ease pain, it’s easy to dive directly into the 6. Yamada, H, B. Fredette, K. Shitara, well. Large-scale twists in the groin deeper myofascial layers, while ignoring or K. Hagihara, R. Miura, B. Ranscht, W.B. strap and the rest of the fascia lata, as unconsciously missing important structural Stallcup, and Y. Yamaguchi, “The brain well as the sagging in the overlying issues that are right on the surface. Sagging chondroitin sulfate proteoglycan brevican adipose layer, need to be addressed to and contortion of the superficial fascia associates with astrocytes ensheathing help smooth these areas and to free and happens in all of us. Like rumpled, twisted cerebellar glomeruli and inhibits neurite reposition these nerves more completely. pajamas, the superficial fascia can get outgrowth from granule neurons.” Journal An approach which seeks to lift the entire seriously distorted depending on how we of Neuroscience, 17:7784-7795, 1997. superfi cial fascia of the thigh upward sit, sleep, work at the computer, or play. 7. Evanko, S.P, M.I. Tammi, R.H. Tammi, works well to smooth this tissue out. Nerves crossing the body retinacula within and T.N. Wight, “Hyaluronan-dependent • Dry, taut skin, dry hair, and eczema the superfi cial layers are frequently the issue pericellular matrix.” Advanced Drug Delivery – Tight, dry skin around the forearm in many painful situations. Tethering of the Reviews, 59:1351–1365, 2007. and retinacula of the wrist involves the nerves in these locations should be checked 8. de la Mott e, C.A, V.C. Hascall, J. Drazba, radial, ulnar, and median nerves. As and, if found, released for more eff ective S.K. Bandyopadhyay, and S.A. Strong, mentioned above, I fi nd that imparting pain relief and more complete structural S.A, “Mononuclear leukocytes bind to a super-slow shearing action to untwist integration. Broad-hand techniques can be specific hyaluronan structures on colon the fl exor and extensor retinacula can used to untwist the body retinacula using mucosal smooth muscle cells treated be extremely eff ective for releasing the the skin and superfi cial fascia as a handle. with polyinosinic acid: polycytidylic acid: entire set of nerves crossing the wrist At the cellular level, focused intention on inter-alpha-trypsin inhibitor is crucial to or any other retinaculum (see Figure 3). connecting with the dynamic, vibrating structure and function.” American Journal In clients with extremely tight cranial pericellular matrix can help us accomplish of Pathology, 163:121-133, 2003. fascia, I look to release the occipital this goal. nerves, the auriculotemporal nerves, and Stephen Evanko, Ph.D, is a Certifi ed Advanced 9. Bollyky, P.L, J.D. Lord, S.A., Masewicz, supraorbital branches of the trigeminal Rolfer™ practicing in Seatt le. He also serves S.P. Evanko, J.H. Buckner, T.N. Wight, nerve, etc. Tightening along the eye part time as a Staff Scientist at The Benaroya and G.T. Nepom, “Cutting Edge: High band distorts and irritates these nerves. Research Institute, Seatt le, WA where he studies Molecular Weight Hyaluronan Promotes In addition, eczema, which is known to the biological properties of hyaluronic acid the Suppressive Effects of CD4+CD25+ have a neurogenic component, seems to and proteoglycans. Before that he conducted Regulatory T Cells.” The Journal of respond very well to release of bound biomechanical studies on tendons and Immunology, 179:744–747, 2007. cutaneous nerves. In my practice, this has fi brocartilage and the tissue response to cyclic 10. Melendez-Vasquez, C, D.J. Carey, included the saphenous nerve, as well as compression, and has published several peer- G. Zanazzi, O. Reizes, P. Maurel, and cutaneous nerves over the calves (sural reviewed papers on these topics. J.L. Salzer, “Differential Expression of n.), forearms, and triceps (radial n.). References Proteoglycans at Central and Peripheral • Moles, keratoses, and skin tags – Nodes of Ranvier.” GLIA 52:301–308, 2005. I suggest these as possibilities that 1. Schultz, L. and R. Feitis, R, The Endless 11. Schumaker, K, “Threads within the you can explore for any relation to the Web - Fascial Anatomy and Physical Reality. fabric.” Yearbook of Structural Integration, cutaneous nerves. I will often find a Berkeley, CA: North Atlantic Books, 1996. CITY: IASI, 2008. raised mole or keratosis-like lesion near 2. Hedley, G, The Integral Anatomy Series, a side-bent and rotated vertebra or other Vol. 1: Skin and Superficial Fascia. www. places where nerves feel arborized, integralanatomy.com, 2005. tethered, and perhaps overlapped with another nerve. There seems to be a 3. Barral, J.P., and A. Crobier, Manual pronounced unwinding in the superfi cial Therapy for the Peripheral Nerves. Edinburgh: tissues when I put my fi nger directly Churchill Livingstone Elsevier, 2005. on the mole. I have also noticed such

www.rolf.org Structural Integration / June 2010 15 CONSIDERING NERVES AND THE COLD LASER

distal from the suspected entrapment site. If it reproduces the client’s complaint of paresthesia and other sensor complaints, this is a positive on the test for Tinel’s sign.3 Understanding these fi ne points will help Common Peripheral the practitioner make an appropriate and accurate assessment. From the ideas put forth here, it becomes apparent that the Nerve Entrapments assessment of a neurological entrapment condition is one of exclusion: a process of ruling out factors in the case. and Syndromes There needs to be a working understanding of the diff erence between radicular issues By Clay Cox, Certifi ed Advanced Rolfer™ and issues of contractures. For example, some practitioners mistake a complaint of pain running down the back of the leg, Introduction mimics neuromusculoskeletal problems from the client’s butt ock to heel, as sciatic and to be in a professional position to refer pain, but the sciatic nerve only runs down In most health-care disciplines, the best out to the appropriate physician promptly. the back of the leg to the knee – from idea is to not treat pain complaints without there it travels around the lower leg. The a clear and accurate assessment of the The “red fl ags” of low back/lower extremity client’s issue may instead be a mechanical problem. The easiest way to arrive at an pain are: bilateral radicular pain, radicular condition of myofascial contracture of the accurate assessment is after a complete pain below the knee, a failed “toe walk” extensors. Continued questioning during case history has been taken and reviewed test, a failed “heel walk” test, and inability the case review and physical examination, and aft er a thorough physical examination to control the bowels/bladder. These with one focus being on the client’s exercise has been rendered. In any type of pain conditions are, for the vast majority of routines, may reveal more clues for a more management, if this explicit process is cases, strong indications for an immediate accurate assessment. followed, the risk to the client’s welfare allopathic referral. is minimized. There are four basic types of pain. Neurological entrapment more oft en than not refers to an area or region of localized Neurological entrapment symptoms are Neuropathic pain is the direct stimulation injury to a peripheral nerve. Exogenic due to nerve damage as a result of chronic of pain-sensitive neurons where the pain or endogenous trauma occurring at an mechanical compression. Most neurological is worse at night. Muscular pain is worse entrapment point causes biomechanical entrapments are classifi ed as syndromes. during the day when activity is increased. irritation and initiates an inflammatory It is common for this compression to occur Infl ammatory pain is worse fi rst thing in response; repetitive motion exacerbates in the body’s more narrow passages or in the morning and during activity. Lastly, this.4 The injury may be directly to a nerve tissues that have been compromised in mechanical pain increases during activity trunk or to the intrinsic blood supply of that some way. It is a biomechanical issue and and oft en eases at night with lying in bed 2 trunk. The results include swelling of the not an issue of pathology. in a certain position. nerve trunk, degenerative tissue change, Taber’s Cyclopedic Medical Dictionary1 defi nes Early on, you need to determine whether and fi nally fi brotic tissue replaces normal a “syndrome” as a group of symptoms, the client is in the appropriate offi ce, or tissue that has been injured. With both signs, laboratory fi ndings and physiological needs other medical care. General early time and repetitive movement, symptoms disturbances that are linked by a common screening questions while reviewing the become more apparent. anatomical, biochemical, or pathological client’s case history include: “Where is Peripheral nerves have to be able to move history. Syndromes that Rolfers most oft en your pain?” Is the pain easily pinpointed freely in relation to their surrounding hear about in their treatment rooms include or is it a diff use pain over an area? Does it tissues. Blood vessels have the necessary carpal tunnel syndrome (CTS), piriformis travel or extend from one place to another? inherent elasticity to stretch, say when an syndrome, and perhaps thoracic outlet We want to know whether the complaint extremity is moved. Nerves must be free syndrome. Less frequent diagnoses include is focal or radicular. In general, focal pain from their dorsal roots to termination points dorsal scapular entrapment, long thoracic issues are biomechanical in nature, and to slide within surrounding tissues. When entrapment, and pronator syndrome. radicular pain follows a [nerve] pathway in the body. Keep in mind, though, that this movement is restricted, you have a case 5 The primary purpose of this paper is to biomechanical pressure on a nerve can cause of neurological entrapment. present the clinical features of some of radicular symptoms. There are three types of neurological the more common mechanically induced entrapment: sensory, motor, and mixed. A neuropathies. This paper is not meant to A general physical examination technique prominent feature of sensory neurological be construed as a treatment guide or a for “Tinel’s sign” is oft en helpful in assessing entrapment is pain related to the nerve’s substitute for appropriate examination and/ the subjective complaint. A compromised distribution area. This pain may be or care. It is very important to recognize nerve becomes sensitive to mechanical perceived as sharp, burning, or any number the gross signs of a systemic disease that forces such as tapping, so you tap along the path of a peripheral nerve, proximal to of other related perceptions. Other sensory

16 Structural Integration / June 2010 www.rolf.org CONSIDERING NERVES AND THE COLD LASER experiences can include paresthesia and upper arm and ulnar nerve entrapment in TOS: vascular TOS can be either venous skin texture changes. Nerves where we the forearm are much less common.9 or arterial; neurologic TOS can be either commonly see sensory-based neurological “true TOS” (classic) or “nonspecific”; As detailed earlier, the pathological entrapments include the lateral femoral neurovascular TOS can be either “traumatic” process leads directly to focal peripheral cutaneous nerve, the saphenous nerve, and or “nonspecifi c.”11 neuropathy. The basic types of injuries interdigital nerves.6 are: laceration, crush, stretch, and rupture. In formal or true TOS, there are three Motor neurological entrapment pain Pressure on the nerve is the primary cause primary regions to pay att ention to early in is not as well localized or definable. It of most damage. Others types include the examination: the interscalene triangle, covers a wider area, and over time the chronic stretching and angulation, repeated the costoclavicular space, and the pectoralis aff ected musculature atrophies. Examples stretching and rubbing over a boney minor muscle insertion on the coracoid of nerves where this type of neurological surface, tumors, infections, and injections. process. In arterial TOS, swelling of the entrapment can occur are the deep branch Irradiation causes fi brosis in and around fi ngers or hand is apparent as a result of of ulnar nerve, the peroneal nerve, and the the nerve resulting in pressure. Exposure poststenotic dilation of the subclavian ilioinguinal nerve. to cold is also a basic injury type. artery. Venous TOS can be either acute or chronic. It presents with swelling of the arm The mixed entrapment patt ern presents a When clients learn that the symptoms they due to restriction of the subclavian vein.12 combination of vascular and motor nerve are suff ering from have an anatomical basis symptoms. Examples of mixed nerves that and that they can be alleviated, it is oft en When suspecting neurogenic phenomenon, can be aff ected in entrapments are the ulnar the case that they want some dramatic or true TOS, first exculpate the neck, nerve at the elbow, the peroneal nerve in intervention done as soon as possible (e.g., specifi cally the nerve roots of C5 throughT1, the lower leg, and the ilioinguinal nerve medication, surgery, hypnosis, physical looking for myofascial contracture patt erns, in the pelvis.7 therapy). The problem is that unless there is as well as reports on disc issues, boney a signifi cant vascular compromise or motor spurs, or other growths that could produce The common features found in neurological loss, most cases are best treated initially pressure on the nerve root. entrapment are as follows. The client will by conservative methods. [Allopaths treat report pain at rest as opposed to pain during When cervicogenic issues have ruled out symptoms that can be verifi ed objectively movement. Oft en, this pain will be reported (exculpated), look at the primary locations through standard orthopedic tests. as worse at night than during the day. of entrapment in this syndrome. The site Physicans are reimbursed for performing (We become more aware of these feelings to palpate is at the transverse processes of procedures (e.g., surgery, set broken bones, because we have less stimulus input at rest C7, oft en called the site of the cervical rib. suture a laceration). Without a diagnosis or before sleep.) Passive or active movement This is where the elongation of the process that requires allopathic intervention of of the aff ected area may exacerbate his/her becomes a catch point for the brachial some type, the patient is more often complaint. “Valleix’s phenomenon” may plexus and the median nerve. than not referred, with our or without be observed here: that is, both proximal as medications, to a physical therapist.] The next structure to look at is the anterior well as distal points along the nerve path scalene muscle (see Figure 1). When may be reported as tender or painful. An Neurological Entrapments contracted, it is possible for it to put enough example of this condition is in interdigital of the Median Nerve pressure posteriorly towards the medial neuroma causing pain that travels up the scalene to compress the median nerve sciatic nerve trunk into the lumbar region The median nerve has both motor and between the muscles. From there, follow of the spine. Observation of this event sensory fibers; thus, a compromise can the nerve under the clavicle, as ptosis of is common in neurological entrapment cause defi cits in both motor and sensory the clavicle can sometimes entrap the nerve syndromes where there are multiple experiences. Most of the sensory issues and against the fi rst rib, a set of conditions insults along a nerve path. Chiropractic will be perceived in the palms of the hands, oft en referred to as the “costoclavicular and scant allopathic literature citations since the vast majority of the sensory entrapment syndrome.”13 list this occurrence as the “double crush fi bers terminate in the palm. The motor syndrome” where the proximal component components innervate the fl exors of the Laterally, travel to the pectoralis minor of a nerve is injured, which predisposes the fi ngers and wrists, as well as a number region where the median nerve can be same nerve to a greater risk from a distal of muscles of the thumb. Weakness and trapped under a myofascial contracture of insult. For example, a patient with, say, a atrophy are the most observable signs of the pectoralis minor, thus pinned against 10 lower cervical radiculopathy may be more entrapment aff ecting the motor fi bers. the rib cage. Distally, at the elbow, the susceptible to a subsequent median or ulnar Thoracic Outlet Syndrome median nerve’s path is between the two nerve injury.8 heads of the pronator teres muscle – CTS One of the specific entrapments of the is frequently diagnosed when it is actually Here is a bit of an epidemiological median nerve is thoracic outlet syndrome “pronator syndrome” (same nerve, but perspective of various neurological (TOS). This patt ern encompasses a group a more proximal entrapment). Palpation entrapments: carpal tunnel syndrome is of maladies that involve the neurovascular will, more often than not, differentially four times more prevalent than ulnar nerve structures in the lower parts of the anterior diagnose the issue with a negative Tinnel’s entrapment at the elbow, which is twice as and middle scalene muscles, the first sign. Nocturnal symptoms are rare with this common as peroneal nerve entrapment at rib, the apex of the lung, the clavicle, the syndrome, sett ing it apart from true CTS. the knee. Radial nerve entrapment at the brachial plexus, and the subclavian artery and vein. There are three classifi cations of

www.rolf.org Structural Integration / June 2010 17 CONSIDERING NERVES AND THE COLD LASER

There can be confusion in the assessment not the clavicle also drops. When this of the common entrapments of the median occurs, we see in the postural degeneration Scalenus medius nerve. Severe CTS and true neurologic the opportunity for the brachial plexus to Scalenus anticus TOS both produce wasting of the thenar become compromised between the first eminence. Typical screening parameters are rib and the clavicle, as well as between the that the typical age and gender for true TOS pectoralis minor and the coracoid process.15 Brachial plexus is young to middle-aged females, where For clients who are obese, weight reduction Subclavian artery elderly men are more likely to develop helps improve posture and lessen the drag Subclavian vein CTS. Another parameter involves the on the shoulder girdle. First rib sensory abnormalities. With true TOS the aff ected regions are along the medial arm, Carpal Tunnel Syndrome forearm, and hand, while the median nerve True CTS is by far the most common distribution in the hand defi nes CTS. The neurological entrapment. Predispositions last parameter is whether or not there are include occupations that require repetitive associated neurological abnormalities in the movements of the hand and wrist, hand. With CTS there are no abnormalities advancing age, and obesity. The clinical in the ulnar nerve distribution areas; with feature of CTS is the reporting of nocturnal true TOS, there is weakness and wasting pain in the hand and fi ngers, which will of the ulnar-innervated intrinsic muscles oft en wake the client and is relieved by of the hand.14 shaking the hands. When you ask the client for the location of the pain, he/she reliably Many patients have the appropriate indicates the median nerve region of the diagnostic signs and symptoms but hand. In the later stages of this syndrome no evidence of an abnormal first rib the thenar eminence starts to atrophy.16 or abnormally long transverse cervical process, or any others static skeletal The major components that occupy the anomalies. These patients can oft en present carpal tunnel are nine digital fl exor tendons with poor posture and, in particular, ptosis and the median nerve (see Figures 2 and of the scapula on the involved side. The 3). The tunnel is a fi xed space. It cannot trapezius muscle is more oft en than not expand, so if the sheaths around the atrophic and weak, allowing the scapula to flexor tendons become inflamed and drop. Habitually poor posture, or overuse enlarged, neurological entrapment of the with some occupations of particular median nerve ensues. When the flexors muscles, can produce similar changes in and extensors are balanced and myofascial the scapula musculature. Anatomically, contractures are reduced, oft en so are CTS when the scapula drops, more oft en than symptoms as well.

Ulnar artery Flexor retinaculum Ulnar nerve Median nerve Flexor carpi ulnaris Flexor pollicis longus Figure 1: Anatomy of the thoracic Flexor digitorum outlet. A - right anterior view showing profundus Flexor digitorum nerve and artery passage through superfi cialis the interscalene triangle formed by Flexor carpi Pisiform radialis anterior and medial scalene and fi rst thoracic rib. B - the arrow shows a Digital synovial cervical rib attaching to the upper sheath surface of the fi rst thoracic rib, Scaphoid Triquetrium Hamate causing stenosis and poststenotic dilation of the subclavian artery (arterial TOS). C - the arrow shows Capitate a fi brous band, arising from the end of a rudimentary cervical rib and attaching to the upper surface of the fi rst thoracic rib, that stretches and angulates the T1 vertical ramus or the Figure 2: Carpal tunnel contents and bordering structures. proximal lower trunk of the brachial plexus, causing true neurologic TOS.

18 Structural Integration / June 2010 www.rolf.org CONSIDERING NERVES AND THE COLD LASER

Palmer digital functional understanding of the anatomy The existence of anterior scalene syndrome nerves will equip practitioners with the primary has been accepted based on anatomical tools necessary to reducing a number of evidence and clinical corroboration; it is clients’ suff ering (see Figure 4). shown to be a vascular type of syndrome.

Branches to lumbricals I and II

Flexor pollicis Common Brachial Plexus brevis, palmar Scalenus Medius superfi cial head digital Muscle Sc. Ant. Abudctor pollicis nerves brevis

Sc. Med. Palmar cutaneous branch of the Flexor median nerve retinaculum Median nerve Dorsal Scapular Nerve Rib Artery

Figure 3: The cutaneous and motor distribution of the median nerve in the hand. Brachial Plexus Tinel’s sign has been found to be 50%-75% accurate in predicting subjects who have been electro diagnostically confirmed with CTS. Traditional nonsurgical Scalenus Anticus Muscle treatments range from physician referral (to specialists such as neurologists and neurosurgeons), splinting, steroid injections Figure 4: The dorsal scapular nerve as it pierces the medial scalene. and nonsteroidal anti-infl ammatory drugs (NSAIDS). Initial treatment centers on the 1. The cervical intervertebral foramina are The scalene medius syndrome is primarily cause or exacerbation of the complaint. in the same plane as the anterior aspect of concerned with neurological issues. Splinting is the mainstream of conservative the medial scalene. The brachial plexus The course of this nerve after arising care with 14% reporting lasting relief from also occupies this position. symptoms and 58% reporting long-term from the superior and anterior aspect failure. Steroid injections yielded a 33% 2. There is a tall thin triangle formed by the of the fifth cervical dorsal root almost improvement average reported in seven anterior and medial scalene muscles. immediately passes directly through the studies between 1960 and 1984.17 medial scalene muscle. From there it travels 3. Within this triangle are the brachial inferoposterolaterally to its innervation plexus as well as the subclavian artery. Other conservative management point on the rhomboid muscle. approaches involve altering the ergonomic 4. The subclavian artery lies in the inferior loads or exposures that create or exacerbate The entrapment site is where the nerve and anterior aspect of this triangle, just CTS symptoms. Tasks involving excessive passes through the anterior aspect of the superior to the fi rst rib. wrist flexion, extension or deviation, medial scalene muscle. When entrapped, pinching, fi ne fi nger motion, and the use 5. This design allows the anterior scalene to the dorsal scapular nerve is “hung-up” of vibratory tools have been implicated. Job compress the brachial artery before it can at this point, thereby preventing the slack modifi cation, tools involved, job rotation, compress the brachial plexus, starting a required to compensate for necessary and and workstation modifi cation have all been pathological neurological process. common head and or arm motions. This found benefi cial to risk reduction.18 leaves a tensed nerve moving against taut 6. A change in the physical status of the muscle fi bers, which can initiate mechanical medial scalene can cause neurological Neurological Entrapment of irritation in the nerve for a neuropathy. the Dorsal Scapular Nerve19 diffi culties by displacing the brachial plexus. The dorsal scapular nerve is solely a Of the common entrapment syndromes, motor nerve; it does not have skin sensory 7. The dorsal scapular nerve arises from the most health-care workers are not components. The rhomboids and part of the superior aspect of the upper trunk of the particularly familiar with dorsal scapular levator scapulae receive their innervations brachial plexus and almost immediately entrapment. Yet in considering this from this nerve. In an active neuropathy, passes directly through the body of the syndrome, the important role of the dorsal pain is perceived in the scapular region; scapular nerves becomes apparent. A medial scalene muscle.

www.rolf.org Structural Integration / June 2010 19 CONSIDERING NERVES AND THE COLD LASER if the neuropathy is severe enough, there this area will produce an increase in focal on hard or angular surfaces or in peculiar/ will be atrophy and weakness in this group pain as well as radiation to the scapula and unusual positions. of muscles. down the forearm. Placing the client’s hand Staal, et al.23 found that a number of on top of his/her head will oft en relieve When the medial scalene is overactive and different scenarios of prolonged the pain, assisting in the confirmation the dorsal scapular nerve is entrapped compression in this region could elicit in diagnosis. via the traction process outlined above, neurological symptoms, such as sitt ing in irritation of that nerve occurs and scapular Neurological Entrapment an alcoholic and/or drug-induced stupor pain is perceived. If there is a cervical rib, of the Ulnar Nerve on the toilet, poor positioning during whether complete or otherwise, the inferior at the Elbow an anaesthetized surgical procedure, aspect of the brachial plexus angulates falling asleep in a crossed-legged posture. acutely over the rib and pain follows the Because of it position in the cubital tunnel, the There is even evidence of what is called ulnar nerve trunk distribution. ulnar nerve is very vulnerable to a repetitive “back-pocket sciatica” from sitt ing on an traction- and tension-induced stress patt ern overstuff ed wallet. Any review of the entrapment of the known as cubital tunnel syndrome.20 Staal, dorsal scapular nerve must include the et al. state that studies have shown that Piriformis Syndrome anomalous or cervical rib. This structure, 16% of the general population suff er from The sciatic nerve passes through the when present, is a congenital condition, a recurrent displacement of the ulnar nerve. greater sciatic notch, sometimes called the but is usually never an issue until the third They explain that when the elbow is fl exed “Gibraltar of the gluteus” along with the or fourth decade when entrapment most and extended repetitively a destructive piriformis muscle. The piriformis muscle oft en occurs. One explanation that comes cycle begins: stress, injury, infl ammation, has been shown to be comprised of two up frequently is a degradation of posture. and adhesions leading to progressive bellies in almost 20% of the population; Poor posture is oft en typifi ed by forward- compressive neuropathy. in up to 50% of the population, a synovial shoulder syndrome. This condition puts bursa exists between the piriformis tendon pressure on the base of cervical spine and Common etiologies include habitually and the bony material of the sciatic notch. leads toward forward-head syndrome as sleeping with the elbow flexed, work- There is also, a lot of variation in the size of well. This dynamic puts anterior pressure related repetitive fl exion/extension, and this muscle. Obviously, hypertrophy of the on the entire scalene group. Part of what over-stretching the arm in catching oneself piriformis muscle will result in a reduction happens here is that the medial scalene while falling. Congenital predispositions of space in the notch, increasing the risk while leaning anterior crimps the dorsal may increase the probability of incurring for sciatic nerve compression. Numerous scapular nerve at the entry point into the this insult. studies have shown that the bifurcation belly of this muscle. Not only is the nerve Clients with ulnar neuropathy at the elbow point of the sciatic nerve into its common entrapped at its entrance, but also restricted oft en present with paresthesia and pain in peroneal and tibial branches can occur all in function by an overly strained medial the ulnar nerve distribution patt ern of the along its path from the sciatic notch to the scalene. Now add this to the summation litt le fi nger and the lateral aspect of the popliteal fossa, with 28% bifurcating near of the eff ects of aging and repeated small ring fi nger.21 Symptoms are oft en without the lesser trochanter and 39% just above trauma and the case for dorsal scapular regard to origin of this condition (that is, the popliteal fossa.24 Of interest here is the nerve entrapment is made. clients may have subjective complaints that fact that this bifurcation can occur before The diagnosis of dorsal scapular entrapment are not easily explained by the diagnosis of the nerve reaches the piriformis muscle: in neuropathy is based on the complaint of ulnar neuropathy but can oft en be directly 12% of the population, the peroneal nerve pain along the medial border of the scapula related) and include an intermitt ent patt ern component passes through the piriformis, on the aff ected side. Oft en this symptom of numbness and tingling of the outer two and in a trace amount of cases it passes over is accompanied by diff use radicular pain digits. As the malady increases in severity, the muscle. Thus, the vast majority of the down the lateral aspect of the arm and it will generally exacerbate the level of time (87%), the sciatic nerve passes inferior forearm. If an injury is involved, it is more objective finding as well as subjective to the piriformis.25 than likely an indirect force such as a reporting. Simple elbow flexion will A fi rm diagnosis of piriformis syndrome sudden and violent head jarring. Most all aggravate all of the symptoms.22 should be arrived at only aft er there have patients are over thirty years of age when been strong objective signs that the sciatic there is no specifi c trauma. Onset is more Neurological Entrapment nerve is involved and not just gluteal oft en than not of a gradual nature. Almost of the Sciatic Nerve pain. The patient will usually present with always there will be a positive relationship Lower back pain coupled with lower lumbar-based radicular symptoms but between pain and head position or motion extremity pain is one of the most commonly without low-back pain. When there is a as opposed to arm position. reported neurological syndromes. Sites of low back pain complaint, more oft en than During the examination the head will oft en compression of the sciatic nerve include the not you are dealing with an L5-S1 radicular be carried stiffl y and sometimes listing to pelvis, the gluteal region, and the posterior complaint or discogenic referred pain.26 In the aff ected side. Pain will increase when aspect of the thigh. The most common piriformis syndrome cases there is more the head is rotated and laterally fl exed, entrapment site is the gluteal region, oft en more involvement of the peroneal either passively or actively. Significant because the nerve is relatively exposed nerve than the tibial. Complaints will be tenderness will be marked over the lower there. It is possible to compress the nerve along the path of the sciatic nerve, there will portion of the medial scalene. Pressure in by sitt ing for protracted periods of time be deep gluteal pain, and internal rotation

20 Structural Integration / June 2010 www.rolf.org CONSIDERING NERVES AND THE COLD LASER of the femur will result in exacerbated Assessment of this condition will be from a the assessment process is a process of focal gluteal pain as well as paresthesia reporting of either motor or sensory defi cits exclusions. The client’s own words and along top of lower leg and/or foot. The by the client. Examination may reveal a description of his/her complaint and pain complaints are exacerbated with foot-drop condition. Either the deep or suff ering are critical. What type of pain sitt ing or walking, and lessen when lying superfi cial branches may be involved in the is he/she describing? Where is it? What supine. Other differentiating symptoms compression. If there are complaints in the exacerbates or ameliorates the complaint? and signs are that there will be no pain region between the toes, the deep branch A careful examination of muscle weakness in the lumbosacral region. There will be is implicated. If there is only paresthesia (through tests such as heel walking, toe a peripheral instead of radicular nerve in or about the lateral aspect of the lower walking, medial and ulnar nerve testing) distribution patt ern. The piriformis will be leg, suspect the superfi cial branch of the is very important in fi nding out what has painful to palpate. Lastly, external femoral peroneal nerve. In severe cases, there may gone wrong and what direction treatment rotation will reduce the pain complaint.27 be radiation up to the sciatic axis.30 should take. For those who are obese, weight reduction helps improve posture Conclusion Peroneal and lesson the drag on the entire structure. Entrapment Syndrome In my eff ort to expose Rolfers to various Initially, the treatment plan should utilize topics in pain management, I spoken at A common entrapment in the lower leg is passive modalities and stretching daily for two annual meetings of the Rolf Institute®, the peroneal nerve being compromised in the fi rst week, tapering to three times a week printed two booklets, and published the region of the popliteal fossa and the for the next three to six weeks. At that point, several articles in Rolf Lines (now Structural promixal head of the fi bula. This nerve may a follow up physical examination should Integration). Here I am again. also be compressed as it winds around the indicate a change to active exercising. This proximal neck of the fi bula held against the The vast majority of Rolfers work on issues regime should be continued until no further bone in a fi brous tunnel (see Figure 5). This of pain every day of their practice. Many improvement is seen and a plateau reached is a common occurrence when one sits with of the referrals for Rolfing® Structural for a few weeks. one thigh crossed over the other.28 Integration are based specifically on a Treatment, in the pain management of search for pain relief. Very few clients biomechanical issues, should focus on approach the work for symptom control. Two aspects of the the improvement of their condition have to be addressed. First, posture alone. Training Common peroneal n. increase the space in the entrapment region at the various structural and reduce the neurovascular compression. integration schools Second – and probably most important is extensive. Before a Tendinous arch – correct the postural faults and poor body of the peroneus practitioner can bring a mechanics contributing the condition. This longus muscle “random body” out of is achieved through manual therapy to chaos and into a more include manipulations and mobilization ordered state in gravity, Site of entrapment emphasizing stretching and strengthening he/she must be well- of the compromised biomechanical system trained. Further extensive Deep branch of components. the peroneal n. training is required when one is involved in pain- An extensive allopathic approach to postural management work. impacts on neurological entrapments and Superfi cial branch of There is no question on ideas of correction is detailed in Allieu and the peroneal n. this matt er in reference to Mackinnon’s Nerve Compression Syndromes of osteopaths, naturopaths, the Upper Limb.31 Approaches from a Rolfer’s Figure 5: Compression of the common peroneal nerve or allopaths: extensive perspective, including interventions in the by the peroneus longus tendon involves both the training is the most context of the Rolfi ng ten-session series, are superfi cial and deep peroneal branches. important prerequisite formally addressed in the author’s earlier to treating. A Rolfer works.32, 33 (A bibliography of the author’s Frequently, a simple contusion or a chronic working on clients’ pain issues without writing also appears below.) compression of the peroneal nerve against formal and appropriate training specifi cally the fi bular head will set up this entrapment Endnotes in pain management makes it easier for the syndrome. A common phenomenon in client to adapt distortion more permanently. 1. Taber’s Cyclopedic Medical Dictionary. motor vehicle collisions is where the lateral It also seriously increases the possibility Philadelphia, PA: F.A. Davis Company, aspect of the knee comes into hard contact of mistreating or delaying appropriate 1985. with either the door panel or the center treatment for a client in need. console of the vehicle. A situation where the 2. Originally referenced from www. knee is resting against one of these vehicle The primary problem with neurological postgradmed.com.issues/1999/11_99/ components for period of time will result entrapment is not in the treatment but neuropathic.htm; regrett ably, the link no in compression of the peroneal nerve and in the assessment or diagnosis. What is longer appears valid to source this article. perhaps only a transient syndrome instead important is taking the history and detailing 3. Durrant, H. D. and J. M. True, Myelopathy, of chronic.29 the fi ndings of the examination. Therefore Radiculopathy, and Peripheral Entrapment

www.rolf.org Structural Integration / June 2010 21 CONSIDERING NERVES AND THE COLD LASER

Syndromes. Boca Raton, FL: CRC PRESS, 15. Novak, C.B., Chest Surg Clin North Am. 32. Cox, C., Four Chronic Pain Syndromes 2002, 10:282. 9:747-760. and the Basic Rolfing Series. Privately published,1989. 4. Kopell, H.P. and W.A.L. Thompson, 16. Omer, G.E. and M. Spinner, Management Peripheral Entrapment Neuropathies. of Peripheral Nerve Problems. Philadelphia, 33. Cox, C., Soft Tissue Management of Acute Baltimore, MD: William & Wilkins, 1963, PA: W.B. Saunders Company, 1998, 30:597. Physical Trauma. Privately published, 1988. 1:1. 17. Durrant, op. cit., 10:297. Clay Cox Bibliography 5. Staal, A., J. van Gijn, and F. Spaans, 18. Allieu and Mackinnon, op. cit., 3:50. 2009 “Temporomandibular Joint Mononeuropathies: Examination, Diagnosis Dysfunction: Overview, Diagnosis & and Treatment. London: W.B. Saunders, 19. Kopell, op. cit., 21:145-152. Treatment,” Third Revision. Missoula, MT: 1999, 1:1-2. 20. Staal, op. cit., 9:77. IASI 2009 Yearbook of Structural Integration. 6. Mendell, J.R., J.T. Kissel, and D.R. 21. Durrant, op. cit., 10:310 and 10:311. 2008 “Temporomandibular Joint Cornblath, Diagnosis and Management of Dysfunction: Overview, Diagnosis & Peripheral Nerve Disorders. New York, NY: 22. Kopell, op. cit., 21. Treatment,” revised edition. Structural Oxford University Press, 2001, Intro: 2. 23. Staal, op. cit., 121. Integration: The Journal of the Rolf Institute, 7. Ibid., Intro: 3. Vol. 36, No. 4. 24. Pecina, M.M., J. Krmpotic-Nemanic 8. Allieu, Y. and S.E. Mackinnon, Nerve and A.D. Markiewitz, Tunnel Syndromes: 2002 “Low Back Pain and Dysfunction.” Compression Syndromes of the Upper Limb. Peripheral Nerve Compression Syndromes. Structural Integration: The Journal of the Rolf London: Martin Dunitz, Ltd., 2002, 3:63. Boca Raton, FL: CRC Press, 1997:325. Institute, Vol. 30, No. 3. 9. Kopell, op. cit., 21:151. 25. Agur, A.M.R. and M.J Lee, Grant’s Atlas 2001 “Temporomandibular Joint of Anatomy. Baltimore, MD: Williams & Dysfunction: Overview, Diagnosis & 10. Lowe, W., “Essentials of Assessment,” Williams, 1991:281. Treatment.” Structural Integration: The from the newslett er Massage Today (www. Journal of the Rolf Institute, Vol. 29, No. 3. MassageToday.com), October 2004. 26. Yuen, E.C. and Y.T. So, “Sciatic Neurology.” Neurol.Clin., 1999, 17:617-631. 2000 “Contra-indicacao do Rolfi ng para 11. Stewart, J.D., Focal Peripheral Neuropathies, Pacientes com Cancer.” Rolfi ng Brasil, ano Third Ed. Philadelphia, PA: Lippincott, 27. Pecina, op. cit., 35:191. 1 numero 4, Novembro 2000. Williams & Wilkins, 2000, 7:133. 28. Rapoport, S., “Common Peripheral 1989 “Four Chronic Pain Syndromes and 12. Sanders, R.J. and C.E. Haug, Thoracic Nerve Injuries,” Hospital Med., 20(6), 35, the Basic Rolfi ng Series.” Private publication. Outlet Syndrome: A common sequela of neck 1984. injuries. Philadelphia, PA: L.B. Lippincott 1988 “Soft Tissue Management of Acute 29. Durrant, op. cit., 10:328. Company, 1991, 8:228. Physical Trauma.” Private publication. 13. Durrant, op. cit., 10:289. 30. Mendell, op. cit., 46. 14. Sanders, op. cit., 8:242. 31. Allieu, op. cit., 70.

Practical Considerations for Structural Integration, Biased by the Nervous System

By Christoph Sommer, H.P., Certifi ed Advanced Rolfer™, Rolfi ng® Instructor

of connectedness and differentiation that Look at the jellyfish, floating in its resembles our nervous system. nourishing environment – the sea – its fi ne In the following pages I want to emphasize tentacles united at the upper pole and webbed the value of certain selected peripheral into the space it encompasses. Contemplating nerves in relation to the Rolfing Ten it may give you a fl oating sensation, a sense

22 Structural Integration / June 2010 www.rolf.org CONSIDERING NERVES AND THE COLD LASER

Series so that we can avoid unrewarding Perineurium Together all these systems are sustained by responses in our structural integration (SI) intraneuronal pressure and distal tension. work. Diff erentiating our palpatory skills Imagine our jellyfi sh tentacles pressurized and therefore directly addressing nervous Myelinated nerve fi bers embedded in endoneurium from inside and able to resist external tissue is a valuable and recommended Endoneurium compression along their pathways within enterprise for your continuing education. Epineurium the body. I want to preface this article with some basic Figure 2: The nerve connective-tissue The distal tension of the peripheral nerves facts that will help you to comprehend the fi bres. and the vertical tension of the CNS results in biased point of view I wish to develop: a well-cushioned fl oating of the pons - spinal • The peripheral nerves approximate a cord tract, our internal jellyfi sh suspended • The epineurium internum ensures length of 100.000 km. in space and giving buoyancy to the system, the movement of the individual nerve which we SI practitioners recognize as lift • The central and peripheral nervous fascicles while adjusting to the movement and vitality (see Figures 3 & 4). systems (CNS, PNS) are composed of 14 of the extremities. billion nerve cells (14,000,000,000 / 149) • Nerves consist of 50%-90% connective with 1412 interconnections – numbers I tissue, depending on their location, and am unable to comprehend . . . . can elongate 8%- 20%. • A peripheral nerve consists of the cell body of the neuron, the dendrites, and the long axons. Motor and sensory fi bers are differentiated. The sympathetic The intercranial membranes may be compared to ganglia of the sympathetic trunk also a perforated three-dimensional trampoline which contain neurovisceral fi bers. overhangs the posterior cerebral fossa. • Most peripheral nerves consist of some type of myelin sheath encapsulating the nerve, and are then surrounded by connective-tissue sheaths (endo-, peri-, epi-, and mesoneurium). • Within the epineurium we fi nd blood vessels (vasa nervorum) supplying the needs of the nerve’s metabolism. • Within the epi-, peri-, and endoneurium we fi nd nerve fi bers (nervi nervorum), The neuraxis can be compared to a “bicephalic” consisting of sensory and sympathetic mushroom: the foot represents the PCT and the nerves perceiving and regulating the local two hats represent the cerebral hemisphere. nerve environment (see Figures 1 and 2).

Nerve fi ber bundle

Perineurium Endoneurium Arterial capillary (vas nervorum) Neurilemma

Arteriole

The entire device in place. The hats are on the trampoline, the foot passes through the perforation (homologous with the free edge of the after Breig tentorium cerebelli). Every mechanical stress on the foot of the mushroom involves the foot-hat Nervus nervorum juncture, the hats themselves, and the entire Total force concentrated on the upper part of the system of intracranial suspension and cushioning. PCT results from the individual forces caused by each nerve root during fl exion of the trunk. Epineurium Figures 4: The three-dimensional Figures 3: Traction forces on the trampoline. spinal cord. Figure 1: The nerve with its vascularization and the nervi nervorum.

www.rolf.org Structural Integration / June 2010 23 CONSIDERING NERVES AND THE COLD LASER

Practical tibio-talar glide, and diff erentiation between The Third Session – The Axillary Applications for SI the short and long fl exors of the toes. and Radial Nerve Let me take you through some general The medial and lateral plantar nerve (see The axillary nerve originates at the spinal considerations for myofascial interventions Figures 5 adn 6) sections of the tibial nerve nerve roots of C5/C6 and is a mixed before off ering a few examples of “how (a split of the sciatic nerve) are well covered motor and sensory nerve. It innervates the to” work structurally utilizing the primary by the plantar aponeurosis and the m. fl exor posterior aspect of the shoulder joint, the importance of the nervous system in digitorum brevis. deltoid and teres muscles, and the skin of regulating the body. Practical Recommendations: When working the shoulder (see Figure 7). Peripheral nerves are everywhere we touch the plantar fascia, focus on the medial aspect, Practical Recommendations: When working – the main branches are located in well- while considering the medial to lateral with a client in a sidelying position to access protected inter- and intra-muscular septa. direction to which the nerves orient. the posterior aspect of the shoulder, consider Nerves do not like compression! Always work the inferior border of the teres minor muscle to be a possible entrapment site for the in oblique angles (as we were all taught) Proper plantar and do not compress tissues onto the bone. digital nerves axillary nerve. Working the tissues in the direction of a medially rotated humerus will When working in the area of the large help to free a possible nerve entrapment. peripheral nerve branches, work in the distal direction, not proximally. Keep in mind that your strokes should follow the Superfi cial Common Deltoid mucle tissues and meander around a chosen branch to plantar anatomically meaningful direction, not interosseous digital Nerve of the teres muscles nerves minor muscle follow straight lines. When working near Deep Vessel branch nerves, make sure that you use fi nger pads (nerve) branch to Infraspinatus (not fi ngernails) or other soft surface tools. If interosseous muscle Vessel muscles branch you fi nd highly sensitive places in the body (artery) Axillary nerve (possibly caused by nerve irritation and the Lateral Medial infl ammatory processes involved), work plantar nerve plantar Axillary artery nerve Teres minor Nerve to proximal and distal to the “sensitive spot” muscle Skin abductor branch of in a light and slow viscoelastic manner until digiti minimi Tibial Teres major nerve muscle the axillary the “spot” diminishes in intensity. muscle Triceps nerve to the In the following, I will relate some local Lateral Medial brachii calcaneal calcaneal muscle shoulder goals within the structural series to the branch of branch of long head peripheral nerves that may be involved. sural nerve sural nerve These treatment ideas are based on the Figure 7: The axillary nerve Figure 5: The medial and lateral teachings of Jean-Pierre Barral, D.O. and innervating the posterior shoulder plantar nerve innervating the Alain Croibier, and their books (Trauma, joint capsule and the deltoid muscle. üplantar surface with about 8,000 Manual Therapy for the Peripheral Nerves, and Manual Therapy for the Cranial Nerves, nerve endings. all published by Churchill Livingstone - The Fourth and Fift h Sessions – Elsevier) and more than thirteen years of The Saphenous my personal experience with these tissues. and Obturator Nerves The following examples are meant to The obturator nerve originates at L2-L4. awaken your curiosity for further studies The nerve’s anterior branch travels in the in the realm of manual therapy for nerves. medial aspect of the psoas major muscle, Just as the Rolf Institute® is regarded as the surfaces at the level of the promontory and leader in the fi eld of structural integration, traverses the small pelvis. It exits through the Barral Institute is recommended for the obturator foramen and innervates the further diff erentiated studies in the realm adductors (motor), the anterior hip joint, of manual therapy for the nerves. the posteromedial knee joint and the skin The Second Session – the Medial on the lower medial thigh (sensory). and Lateral Plantar Nerves The saphenous branch of the femoral Each sole of the foot contains about 8,000 nerve also originates from L2-L4, travels peripheral (sensory and motor) nerve through the central part of psoas major endings with the function to perceive Figure 6: Work on the plantar fascia and surfaces on the lateral side where the “ground” and inform our “Triangle and the medial and lateral plantar the iliacus and psoas muscles meet. It of Perception” about where we stand. A nerve. You work distally and can use exits the pelvis next to the femoral artery, structural aim within the second session is active or passive toe extension. under the inguinal ligament, to travel a competent foot with balanced arches, good distally within the intermuscular septum

24 Structural Integration / June 2010 www.rolf.org CONSIDERING NERVES AND THE COLD LASER

of the quadriceps femoris and the adductor Working at the level of the adductor canal, compartment, which is covered by the make sure you contact the canal four to sartorius. The sensory and vasomotor five fingers above the knee joint on the saphenous nerve innervates the medial medial aspect of the vastus medialis, deep aspect of the knee joint and has anastomosis to the sartorius. Slacken the muscle tone with the obturator nerve at the level of the by fl exing the knee and stay light-handed adductor canal (see Figure 8). when working on the medial condyles of the tibia and femur. Working on the psoas major and iliacus, remember that the major nerves of the lumbar plexus run within Anterior Medial Lateral or on the anterior surface of the muscle Posterior belly. After having considered all other Vastus medialis precautions, work in a distal direction using Nerve of the muscle vastus medialis soft fi nger pads. muscle Sartorius muscle Saphenous muscle Figure 9: In the fi fth session, working Femoral the intermuscular septum under the artery sartorius in a distal direction you will Saphenous vein have an effect on the femoral nerve. Femoral Gracilis vein muscle External Iliacus vein Psoas mucle 4-5 fi ngers wide Iliacus Adductor muscle longus muscle Femoral nerve External Iliacus Branches artery to the sarorius muscle Saphenous vein Sartorius Figure 11: While working in the muscle Profunda femoral connective tissue between the psoas Branches artery Sartorius to the and iliacus muscle, maintain contact muscle rectus Femoral femoris vein with your cranial thumb and work muscle Femoral artery respectfully in a distal direction with Branches to the Adductor the inferior hand. This may affect the vastus longus muscle mediais lumbar plexus nerves. muscle Saphenous nerve Figure 8: The best acces to the Vastus mediais Nervus saphenus above the knee. muscle The Seventh Session – Brachial Rectus Plexus and Phrenic Nerve femoris Sartorius Practical Recommendations: Working muscle muscle In this article, I am not going to highlight (quadripceps below the inguinal ligament, slowly contact muscle) any of the cranial nerves that are within the tissues with your fi nger pads and induce the territory of the neurocranium or the tissue changes in a distal direction (see viscerocranium. I want to focus instead on Figures 9, 10 and 11). the anterior and medial scalenes, which surround the proximal section of the brachial plexus. In addition, the medial part of the anterior scalene is traversed by the phrenic Figure 10: The femoral nerve nerve, which innervates the diaphragm. between the fascia of psoas and iliacus muscle as well as in the space covered by the Sartorius.

www.rolf.org Structural Integration / June 2010 25 CONSIDERING NERVES AND THE COLD LASER

Verterbral artery to regain some distal gliding. The scalene will readjust its tone once the plexus is freely gliding under the clavicle and pectoralis minor. Vagus nerve Conclusion Cervical ganglia, Anterior scalene medium These are just a few practical suggestions of muscle how to enhance results in structural work by Vagus nerve (recurrent rami) including manual perception of the peripheral Phrenic nerve nerves. There are many more details to learn, Ganglia stellate Subclavian artery as there are many compression sites for Brachial plexus nerve tissue that lead to diff erent structural Pieura dome and symptomatic phenomena. Studying the nerves and the best entries for treatment is a worthwhile enterprise. By doing so, it will help to diff erentiate and evolve your palpatory skills and allow yet another level of manual communication between you and Figure 12: When working on the scalenius anterior consider the phrenico your client. nerve. When working on the brachial plexus (superior part) consider possible entrapments between anterior an medial scalenus muscle. Christoph Sommer, Heilpraktiker (H.P.), is on the Rolf Institute faculty, teaching in the Practical Recommendations: When working Between the anterior and medial scalenes, European Rolfing Association’s Modular the anterior scalenes, keep in mind that the the superior part of the brachial plexus is Training. He is also on the faculty of the Barral phrenic nerve travels on the anterior surface girded and can be entrapped, aff ecting all Institute. from the cranial to caudal aspect and from the brachial nerves and causing the arm and Note: Illustrations courtesy of Churchill lateral to medial (see Figure 12). If you can cervical spine to go into compensational Livingstone - Elsevier, Barral Institute USA; adjust to these angles while working and use patt erns. When working with the scalenes, photos courtesy of the author. soft , melting fi nger pads, you will be able pay att ention to the embedded brachial to infl uence the eff ects of the phrenic nerve plexus, contact it with a light touch with and see a change in your client’s breathing. your fi nger pads, and help the nerve plexus

in Structural Integration: The Journal of the Rolf Institute®, which articles suggest the The Low-Level Cold Laser primacy of the nervous system in Rolfi ng [SI] and suggest that perhaps we should be ® rethinking what it is we are actually doing as an Adjunct to Rolfing in our SI sessions. The authors are keenly aware that this new Structural Integration idea and technique is an uncomfortable fi t for practitioners who believe and desire to define our work by only those goals Looking Back and Looking Forward and objectives that can be achieved by exclusively manual means. We respect those By Certifi ed Advanced Rolfers™ Mark Hutton, beliefs and both appreciate and welcome Jeffrey Maitland Ph.D., and Jonathan Martine the rich diversity of tools, techniques, experiences, and opinions that make up the Rolfing community. However, the way to remove doubt and skepticism is the cold laser in the context of Rolfing Introduction through experience, and the vast majority of Structural Integration (SI) not only makes practitioners who are trained in this adjunct It has been over six years since Jeff Maitland the work more eff ective, but also makes ® technology can’t imagine ever going back to fi rst started using the Erchonia PL5000™ possible results normally beyond the reach a time when they did not use it. low-level cold laser as an adjunct to his of traditional Rolfi ng SI methods. work. When Jeff fi rst discovered the laser, he was amazed by the results and shared This article is about the use of the low Where Are We Now – some of what this remarkable machine level cold laser as an adjunct to Rolfi ng And How Did We Get Here? could do in “The Too Good to Be True Structural Integration. It incorporates and For several years now, the nature of 1 Machine.” What Jeff discovered then builds on new information, as well as ideas nervous system tissue and its impact remains true today: appropriate use of already set forth in several recent articles on our work has attracted the attention

26 Structural Integration / June 2010 www.rolf.org CONSIDERING NERVES AND THE COLD LASER of prominent persons in the SI fi eld. In components in movement. Mark and Jon optimum aff erent information to the brain. Christoph Sommer’s particularly eloquent were so impressed by the results they were This usually results in increased eff erent article, “A New Paradigm: On Nerve Tissue gett ing that they began to hold workshops activity, leading to increased stability and Treatment,”2 he discusses neurogenic in which they donated their time to teach strength in those joints. infl ammation and fascial restrictions, and the use of the laser to other Rolfers. As a predicts, “These developments (i.e., nerve result of those workshops, many Rolfers Neurogenic Infl ammation palpation and manipulation) represent the are now using lasers in their practices. At and Myofascial Restrictions next paradigm shift for our work.” Don this point, Mark has been using the laser for Our combined experience suggests that Hazen’s “Peripheral Nerve Work - Compare over three years (with over 6,000 hours of the myofascial restrictions and strains and Contrast,”3 while mainly a commentary laser use) and Jon for two years. associated with misalignment in gravity on Jean-Pierre Barral’s peripheral and can usually be traced to neurogenic cranial nerve work, is also a summary of How Does the Laser infl ammation or neurologic defi ciencies. his own survey of medical literature on Affect the Nervous System? Even the existence of so-called trigger neurogenic infl ammation and pioneering Perhaps the most important recent points and myofascial pain syndrome have neurology work by Australian physical insight about the nervous system is that been questioned, based on epistemological, therapists. In Pathophysiological Model for infl amed nerves can be found in myofascial clinical and pathophysiological evidence Chronic Low Back Pain Integrating Connective restrictions and strains. The implications suggesting that these phenomena might Tissue and Nervous System Mechanisms, for our work are staggering: to the extent be better understood and treated as Helene M. Langevin, M.D. and Karen J. that Rolfi ng [SI] cannot address infl amed secondary hyperalgesia of peripheral 13 Sherman, Ph.D. describe the relationship nerves, it cannot achieve full integration neuro-infl ammation origin. When nerves between the nervous system’s aff erentation of the body in gravity. Because we know become infl amed, they create restrictions by and connective-tissue remodeling as it that mesodermal structures are governed adhering to muscles, tendons, and ligaments. 4 relates to low-back pain. by the ectoderm,11 it is clear that to work Over time, more fascial restrictions occur, Nearly ten years ago, in an interview only with the connective and muscle causing a down-regulation of afferent published in Structural Integration, Erik tissues and ignore the role of the nervous activity, which, in turn, interferes with the Dalton discussed the omnipresence of system profoundly and tragically limits stabilizing function of the eff erent system. the nervous system in all soft tissues, the possibility for change. Our collective Joint stability is compromised, resulting in including ligaments, fasciae, joint capsules, experiences are clear that when certain a loss of continuity throughout the whole intervertebral discs, and tendons/muscles, neurological conditions are not addressed, body, with the appearance of joint fi xations as well as the net impact when aff erentation our ability to achieve structural integration and overall misalignment in gravity. through proprioception is compromised in gravity is limited. To the degree that myofascial restrictions to the extent efferent pathways are not Aff erentation are linked to neurogenic infl ammation,14 activated.5 In The Core as a Coordination, the structural work of Rolfi ng [SI] will be John Smith reviewed many of Godard’s We are indebted to Hazen, Allen, and compromised to the extent we cannot free observations on Australian research, which Barral for their groundbreaking work and our clients from neurogenic infl ammation. described the neuromuscular coordination writings about the role of neurophysiology Until the work of Barral, Hazen, and 12 required to achieve “core stabilization”; in structural integration. Allen says, Martine,15 we had no way to mitigate i.e., the optimal balance between tonic and “The entire experience of human existence neurogenic infl ammation. Mark’s discovery phasic or intrinsic and extrinsic muscles.6 is based upon joint mechanoreceptor was about how to address infl amed nerves In “The Confluence of Neuroscience stimulation as a result of joint movement, using the laser in conjunction with Rolfi ng and Structural Integration: A Discussion and joint movement is a result of muscle [SI]. In the authors’ experiences, this with Sandra Blakeslee,” Kevin Frank function. The ability to resist the Earth’s method is the quickest and most effi cient concludes, “In essence, our work may be gravitational fi eld is as a consequence of way to address what traditional Rolfi ng more about the body’s motor control than postural muscles, through cerebellar refl ex techniques oft en miss. See Figures 1 and 2. we previously thought.”7 Finally, Robert pathways. No function of human existence Schleip’s, “Fascial Plasticity – A New is independent of joint mechanoreceptor What the Laser Does potentiation.” Therefore, if afferent Neurobiological Explanation” (Parts 1 The low level cold laser is clinically information is not available, then the and 2, published in the Journal of Bodywork proven to increase two things: (1) cellular innate wisdom of the body will not order and Movement Therapies), identifies an energy production and regeneration 8 “eff erent” movement and joint stabilization explanation for neural control of fascia. (without the reciprocal release of free energy. Without eff erent movement energy, radicals or increase in inflammation), Building on the work of Jean-Pierre Barral there is no joint stability. Neurogenic 9 and (2) cellular communication. Cellular and Don Hazen , Mark Hutt on discovered infl ammations lead to decreased aff erent regeneration involves the physiology of how to use the laser in conjunction with nerve information as well as the fascial cell metabolism, mitochondria and the visceral touch to eff ectively and effi ciently restrictions that create malalignment and 10 synthesis of ATP.16 Cellular communication address nerve infl ammation. Meanwhile, efferent down regulation. Afferent loss involves the nervous system, phospholipid Jon Martine found a way to use the laser can occur due to disease, injury, posture, cell membrane and the integrin system.17 more quickly to stabilize and integrate surgery, and aging. tonic and phasic function as it relates to The biochemistry is complicated and the stabilizing the appendicular and axial By aligning joints and segments, we remove physiology even more so; but generally the physical and physiological blockages to the diff erent frequencies programmed into

www.rolf.org Structural Integration / June 2010 27 CONSIDERING NERVES AND THE COLD LASER

tool and the inclusion of the neural tissue in the conception of our work. The science of the low-level cold laser is well-established in peer-reviewed literature.21 We hope that someday the science and basis of SI is equally well established. Meanwhile, what follows is an outline of why and how we use the low level cold laser in the context of SI. Why We Use It: What We Have Learned By trial and error, accident and experiment, our use of the cold laser brought us the following insights, which ground our use of the laser as an adjunct to SI: 1. That the physiological and mechanical aspects of neurogenic inflammation might be the single most neglected factor in the understanding fascial restrictions, joint malalignment, subluxations, and lesions. 2. That the inability of the efferent nerves to fully fi re the muscles, which stabilize joints, might be the single most neglected reason why structural changes sometimes do not hold. 3. That the cooperative relationship between afferent and efferent nerve function might explain what actually happened under Dr. Rolf’s hands, and therefore might explain what she taught. 4. That the neurophysiology of afferent and efferent nerves, peripheral and cranial nerves, sympathetic and parasympathetic nerve balance, brain hemispheric balance, and various ailments and injuries actually infl uence, if not constrain, our ability to achieve the goals of structural integration. In our view, these discoveries and insights Figures 1 and 2: Jon Martine using the laser to reduce neurogenic are a logical extension, evolution, and infl ammation and release fascial strain. advancement of Rolf’s observation that “the study of nerves per se are not the province the laser’s diodes stimulate integrins – the This communication has been measured of structural integration. Our work deals photoreceptor cells on the phospholipid at the speed of light and is believed to link primarily with systems derived from the cell membrane – to produce a variety of changes in the mitochondria across all ten mesoderm.”22 Our purpose here is not to different enzyme cascades.18 The laser body systems – i.e., the muscular, skeletal, diverge from the fundamental tenets of SI, accomplishes these two broad tasks by endocrine, respiratory, etc., systems. but only to acknowledge new information varying the frequencies (Hz) to produce supporting the critical role of the nervous the desired results. Use of the Laser within the SI Paradigm system in respect to the behavior of To increase energy and regeneration, we use mesodermal tissues and to show how easy various frequencies to elicit a wide range In our clinical practices, the results we it is to incorporate this understanding into of changes, from reduced inflammation achieve using the laser in support of the our work using the laser. to increased stimulation of muscle spindle goals and objectives of SI are consistently We believe that it is a now possible to fibers.19 To increase communication, we greater than those we achieve without the leverage the unique paradigm of our work enhance transmission of information via laser. It is the extraordinary results the laser into a somatic practice that can call forth the three-dimension collagen fiber living- produces that compels us to teach, write the person’s innate blueprint of perfection at matrix that Dr. Oschman writes about.20 about, and urge consideration of this new

28 Structural Integration / June 2010 www.rolf.org CONSIDERING NERVES AND THE COLD LASER a life-transforming cellular level. This work reliable clinical data. We have chosen to use Healing and Repair requires the same discipline of a traditional the lowest-power laser on the market: the We believe that malalignment and Rolfi ng session or series – including that Erchonia Low Level Cold Laser, which has myofascial distortions are a function of the work be an extension of our heart a power output of 1/200th of a watt and a neurogenic infl ammation. Therefore, aft er and soul. wavelength of 635 nanometers (a nanometer testing has identifi ed the relevant issues is a billionth of a meter). It is the safest, On the one hand, with the laser it is not with form and function, we address all most-studied, and most-sophisticated only possible but common to achieve of the restrictions that stand in the way laser on the market. The wavelength has in each session what Michael Salveson of achieving the structural goals of the been proven in many clinical trials to calls unique states of consciousness. One particular session. In general we will spend pass through cell membranes without a innovative aspect of Rolf’s work was the from half to three quarters of the session single recorded instance of damage of any primacy of order and patt ern. According addressing these fascial restrictions. kind.24 It has also been cleared by the FDA to Salveson, explicit in Rolf’s work is for adjunctive use in various pain and the idea that “patterns of order in the Stabilization and Integration rehabilitative therapy. body” might be “constitutive of states Most sessions need an integrating piece at of consciousness”: “A Rolfing session Balance and Testing the end. With the laser, a common one is to that moves a person into alignment with address all the weak acting muscles crossing Most sessions begin with three to fi ve testing gravity is oft en accompanied by heightened the joints of greatest interest (i.e., either the protocols, the fi rst of which is designed to energetic, perceptual and intentional shoulder/neck complex or the pelvic girdle establish that applied kinesiology (AK) can or volitional awareness and control.” 23 and all joints below). When we use the laser be used to make further determinations. In Salveson goes on to say that how the parts to up-regulate the energy of the eff erent accordance with strict testing protocols,25 are related produces the desired results. motor neurons, the eff ect is dramatic: the we use the laser to address issues in the The good news is that with the laser we can client usually feels the internal strength brain, spine, organs, impingement sites, produce these results with more regularity that comes from muscles fully firing to and tissue memory to fi nd a strong muscle than without the laser. The energy from the stabilize key joints. Later in the series, we that is both testable and not switched. Next, laser lets the practitioner make changes oft en use Jon’s methods to integrate girdle we test hemispheric balance, looking for the and communicate them to every cell in the movements with the spine, in which the cerebellum or cortex that displays weak. body. As a result, patt erns of order come laser is set in a stand and directed to the The laser is used to correct the weakness directly from the mitochondrial energy and spine while a particular movement is and hemispheric balance is restored. mitochondrial DNA processes, where many practiced (see Figure 3). We can use this Third, we test the parasympathetic cranial believe a blueprint of perfection originates approach with clients on wobble boards or nerves (III, VII, IX and X). Using AK and and is instantaneously transformed across Bosu® balls, or performing movements of the laser, we work with weak-appearing all body parts and systems. particular interest. This work can take ten parasympathetic cranial nerves until they to twenty minutes. On the other hand, we have the dramatic exhibit strength. structural and functional changes that The fourth and fi ft h protocols are optional Examples come from the laser’s nearly instantaneous depending on the practitioner’s skill eff ect on neurogenic infl ammation (and We are confounded by how to express and the client’s needs. We primarily use resultant myofascial restrictions), cellular results, which as witnessed or felt, are so Liz Gaggini’s tilt and shift model, which infl ammation, nerve imbalance between remarkable that they seem exaggerated gives us a starting place to understand and among body systems, hemispheric – or even perhaps fabricated. Our clients malalignment, malfunction and course imbalance in the cortex/cerebellum control have had their “never-quite-resolved” of action. We then use AK as yet another of posture and movement, sympathetic issues addressed and resolved – sometimes way to verify the most neutral and original dominance and parasympathetic in a single session. Injuries that prevent patt ern of the client. depression, and loss of aff erent/eff erent normal session work can now be addressed, information and control. In our experience, Last, we will sometimes use an advanced resolved, and eliminated as obstacles these remarkable changes become routine technique called gait analysis to determine toward optimum form and function in a when the laser is used as an adjunct to whether or not the muscle-fi ring patt ern single session. When the laser is used at the Rolfi ng [SI]. has been altered such that key muscles outset for balance and structural testing, session benefi ts of healing and repair, and How We Use It: Strategies in a are fi ring when they should be inhibited. This is not a “walk while I watch you” stabilization and integration, are much Structural Integration Session assessment: it is a very sophisticated and greater than would otherwise be expected. We teach very specifi c ways to use the laser accurate test. We believe that a failed gait For example, one problem traditional in a Rolfi ng session. Typically, we use it for test or incorrect muscle firing sequence methods of Rolfing [SI] cannot easily three strategies: (1) balance and testing, (2) reveals the most fundamental and deepest address is hemispheric brain balance. To healing and repair, and (3) stabilization and cause of almost everything that appears in understand its importance for integration integration. Each strategy respects the time- our offi ce that seems resistant to holding in gravity, try this exercise: Stand with honored principles, goals and objectives change. Performing all of these tests takes your ankle bones and toes touching. Look governing each Rolfi ng session. only fi ve to seven minutes and they are straight ahead and then close your eyes. taught in our basic training. Notice what happens. Do you sway more Our choice of lasers is based on both safety to the left or more to the right? If you sway and the availability of substantial and

www.rolf.org Structural Integration / June 2010 29 CONSIDERING NERVES AND THE COLD LASER

most-eff ective currently available means through which to evoke these changes in the context of SI. Endnotes 1. Maitland, J., “The Too-Good to Be True Machine.” Structural Integration: The Journal of the Rolf Institute, June 2004. 2. Sommer, C., “A New Paradigm: On Nerve Tissue Treatment. Structural Integration: The Journal of the Rolf Institute, December 2006. 3. Hazen, D., DC, “Peripheral Nerve Work – Compare and Contrast. Structural Integration: The Journal of the Rolf Institute, March 2008. 4. Langevin, H.M., M.D. and J. Sherman. Pathophysiological Model for Chronic Low Back Pain Integrating Connective Tissue and Nervous System Mechanisms. Structural Integration: The Journal of the Rolf Institute, June 2007. Figures 3: Jon Martine using the laser to integrate girdle movement with the 5. “An Interview with Erik Dalton.” spine. (Note: The laser would normally be placed in a stand, but is held in this Structural Integration: The Journal of the Rolf photo by a workshop participant). Institute, Spring 2001, pp. 5-7. more to one side than another, the side it is present. Fortunately, the laser allows 6. Smith, J., “The Core as a Coordination.” of your cerebellum to which you sway is us to reset the conditions within thirty to Structural Integration: The Journal of the Rolf not summating properly, in which case sixty seconds. Institute. June 2008. you simply will not be able to maintain 7. Frank, K. A., Discussion with Sandra Conclusion a clear midline. Of course, the midline is Blakeslee. Structural Integration: The Journal a major axis of orientation for the human While the cold laser most certainly cannot of the Rolf Institute. June 2009. body and the bett er established it is, the accomplish the work of SI unless it is used 8. Schleip, R., “Fascial Plasticity – A New bett er organized the structure is. Continual by a competent structural integrator, it Neurobiological Explanation,” Parts 1 listing to one side progressively imbalances does allow the SI practitioner to achieve and 2. Journal of Bodywork and Movement the structure, and somatic dysfunctions results far greater than those achievable by Therapies, March and April 2003. get progressively worse. With the laser, traditional SI techniques. Conversely, the SI hemispheric imbalance can be corrected viewpoint and context seem to maximize 9. See http://dhazen.com/neuropages/ early in the series – in a matt er of seconds. the laser’s potential. nerv_struct.html. Another important function of the laser By our conservative estimate, Certified 10. As an acupuncture patient of Dr. Peter is its ability to reset neuro-muscular- Rolfers and Advanced Rolfers have Courtnage L.Ac. in Anchorage, Mark skeletal conditions. Accompanying pain, delivered between twenty and thirty thousand observed his combination of manual injury or poor posture are often what sessions of laser-assisted SI. Based on this manipulation techniques with a low- appear to be weak muscles. However, the collective experience, in addition to our level cold laser. In his own experiments, weakness is most oft en from nerves not extensive personal experience, we believe Mark discovered that nerve infl ammation conveying information to the muscles. that SI, as measured against some ideal disappeared signifi cantly faster under a When the problem is with the nerves, of neutral or optimal form and function combination of visceral palpation touch not the muscles, no amount of gym (or and innate perfection, is enhanced by and the laser than with either of them used home) strengthening exercises will restore appropriate changes to the nervous system. alone. This observation has been confi rmed proper function. Whatever caused the These changes address the structural through over 6,000 hours of laser use to physiological dysfunction, and whatever inefficiencies created by cellular and eliminate fascial restrictions caused by exercises the client does, the weak muscles neurogenic inflammation; the down- neurogenic infl ammation. will neither regain nor sustain their normal regulation of eff erent nerves that reduces 11. See http: //dhazen.com/neuropages/ strength until the relevant nerve/muscle muscle strength and destabilize joints; nerv_struct.html, “Report Overview, The complex is turned back on. Unfortunately, the brain hemispheric control of absolute Embryonic Background,” where Hazen because traditional Rolfi ng techniques do balance and centeredness; the balance of states, “What mesoderm structures exist not address this kind of weakness in the sympathetic and parasympathetic function; at that time (third and fourth week) are information system, any att empt to integrate and muscle-fi ring sequence malfunction. the person in gravity is compromised when We believe the cold laser is the single-

30 Structural Integration / June 2010 www.rolf.org CONSIDERING NERVES AND THE COLD LASER primarily to support this neuron factory (a as a Medical Treatment Modality: Manual into the laser classifi cation of 3A, which is nervous system).” for Physicians, Dentists, Physiotherapists considered a non-signifi cant risk factor by and Veterinary Surgeons (Kuopio, Finland: the FDA.” 12. Allen, Michael D., DC, NMD, DAAPM, Art Urpo Ltd., 2003). Pöntinen is one of DIBAK, DACAN, DABCN, Chiropractic 25. Hawkins, D., Power versus Force. the original Scandinavian laser-therapy Neurologist. “The neurology of spinal Carlsbad, CA: Hay House, Inc., 2007. See pioneers, who presents the applications erection, research report from the Space Chapters 2 and 3. of low-level laser therapy for medical Shutt le Columbia.” biostimulation, pain relief and pre- and 13. Quintner, J.L. and M.L. Cohen, in post-operative care. Pöntinen provides “Referred Pain of Peripheral Nerve Origin: comprehensive theoretical and practical An Alternative to the “Myofascial Pain” information on how to apply low-level Errata – Construct,” cite epistemological, clinical laser therapy in the treatment of chronic “SourcePoint Therapy and Its and pathophysiological grounds that pain with focus on musckuloskeletal and Implications for Rolfi ng® Structural myofascial pain syndrome (i.e., trigger myofascial pain and dysfunction, vascular Integration” points) is invalid and that the phenomena disturbances, wound healing, and ulcer it purports to explain is bett er understood treatment. He gives a special att ention to In the final proofing of the article as secondary hyperalgesia of peripheral the role of soft lasers in acupuncture. “SourcePoint Therapy and Its neural origin. 1994. Clinical Journal of Pain, Implications for Rolfing® Structural 20. Oschman, J., Energy Medicine, The 10, 243-251. Integration” in the December 2009 issue Scientific Basis. Edinburgh: Churchill of Structural Integration: The Journal 14. Hazen, D., “The Neurology of Posture,” Livingstone, 2000. See Chapter 3 (The of the Rolf Institute®, editorial changes and “The Peripheral and Cranial Work of Circuitry of the Body) for research and were made that inadvertently changed Jean-Pierre Barral and its Relation to Pain, citations supporting the living matrix the meaning of the article. On page Neurogenic Infl ammation and Structure” at whereby trans-membrane linking 20, the fi rst paragraph to the section htt p://dhazen.com/neuropages/nerv_struct. molecules, or integrins, link intra- and Experiences with SourcePoint Therapy html. extra-cellular environments electrically incorrectly indicates that the author was and physically throughout the whole body. 15. Jon Martine has established beginning one of the case subjects. and advanced trainings devoted to the 21. Perform a Google® search on “low-level That paragraph should have read: palpation and identifi cation of infl amed cold laser” within PUBMED.COM for nerves that cause myofascial restrictions. hundreds of articles on this subject. “What follows are two accounts of See htt p://www.integrativehealthinc.com. SourcePoint Therapy, both from the 22. Rolf, I., Rolfi ng: The Integration of Human above-mentioned workshop. The fi rst 16. Karu, T., Ten Lectures on Basic Science Structures. Rochester, VT: Healing Arts is that of a man I will call ‘Mr. X,’ the of Laser Phototherapy, Laboratory of Laser Press, 1977. second that of a woman I will call Biology and Medicine, Institute on Laser 23. Salveson, M., “The Evocation of Unique ‘Ms. Y.’” and Informatic Technologies. Troitsk: States of Consciousness as a Consequence Russian Academy of Sciences, Moscow We apologize to the author for of Somatic Practices.” Structural Integration: Region, 2007, p. 120: “Free energy from misconstruing his meaning. The Journal of the Rolf Institute, June 2008. this redox chemistry is converted into In no way are we implying that Salveson an electrical potential across the inner endorses this article or the laser. We use mitochondrion, which ultimately drives this reference only out of a need to express the production of ATP. The laser stimulates a type of result found in our sessions, out of cytochrome c-oxidase as the central role in respect for his ideas, his stature as a student In Memoriam this bioenergetics equation.” of Dr. Rolf’s, and his long and distinguished Structural Integration: The Journal of the 17. Oschman, J.L., Energy Medicine in tenure on the Advanced Faculty of the Rolf Rolf Institute® notes the passing of the Therapeutics and Human Performance. Institute. following members and friends of our Cambridge: Elsevier Limited, 2003 (see 24. In the Preface to D.A. Chu’s Effi cacy community (in alphabetical order): Ch. 8, Introducing the Living Matrix). of the Low Level Laser (LLL) in Physical Kerry Haladae (aka Kerry Welch), former 18. These concepts are fully explained Therapy (Mckinney, Texas: Erchonia, 2010), (resigned 2003), Certified Advanced in Turner, J. and L. Hode, Laser Therapy: Erchonia President Steven Shanks reports: Rolfer™ Clinical Practices and Scientifi c Background. “Although the technology has become more Cambridge: Prima Books, 2002. sophisticated over time, the benefi ts of low- Brugh Joy, M.D., teacher, physician, level lasers or cold lasers has not changed healer, friend of Rolfing® Structural 19. Students in our laser trainings receive much and has been well-documented for Integration a manual with descriptions of possible wound healing, physical therapy, nerve changes and the specifi c frequencies and Jason Mixter, Certifi ed Advanced Rolfer regeneration, and pain management. In their protocol for each change. The laser fact, there are more than 2,000 published Tom West, Certifi ed Advanced Rolfer has the potential for a million different articles worldwide and not one reports frequencies. See also Professor Dr. Med. any negative side eff ects. This is one of Pekka Pöntinen’s The Low Level Laser Therapy the reasons why the Erchonia lasers fall

www.rolf.org Structural Integration / June 2010 31 NEW CONSIDERATIONS OF ORAL STRUCTURES

side of the back, giving only a litt le support to the back. Immediately with a shift to uprightness, the dynamic changed towards a balance of cavities, where each organ contributed with a limited range of motion during breathing to stabilize the diff erent The Maxillae as the spinal curvatures. At this moment of human evolution, the column of organs starts its Inner Bridge Between interplay with the vertebral column. At this time of beginning uprightness, the shape of the cranium also had to adapt Neurocranium and to the new dimensions of the brain. The head of the hominid ancestors and early hominids was dominated by a large and heavy mandible and dense construction in Viscerocranium the viscerocranium to be able to withstand enormous pressure in biting and chewing The Lightweight Construction of the activities. (We find similar structures still in primates whose diets require very Maxillae and Its Signifi cance for SI forceful biting and chewing.) In contrast, By Peter Schwind, Certifi ed Advanced Rolfer™, the head of the developing hominid biped Advanced Rolfi ng® Instructor had to meet diff erent challenges. While the neurocranium was expanding and taking Note: The author shared his view of the temporomandibular joint (TMJ) when interviewed by its place at the very top of the curvatures Christoph Sommer in “The Temporomandibular Joint in the Context of Structural Integration,” of the vertebral spine, the viscerocranium published in the December 2008 issue of Structural Integration: The Journal of the Rolf Institute. lost quite a bit of its former size and weight. Here he adds to that foundation. Schwind’s concept of the treatment of cranial strain has its base Diff erent functional demands allowed for in a long-term dialogue with Dr. med. Sebastian Schmidinger, a German dentist with extensive a change towards lightweight construction experience in the fi eld of oral surgery and implantology. Besides being an Advanced Rolfi ng of its most important parts, especially the Instructor, Schwind also teaches his concept of fascial and membrane technique for the Barral development of an extremely fi ne bone to Institute (www.barralinstitute.com), with special emphasis to the cranial system. This fall he will separate the cavities of the nose and mouth. start teaching his cranial concepts for the Barral Institute in Mexico, and in June he will be one of It is exciting to investigate the density of the key speakers at the annual meeting of the German Association of Oral Surgery and Implantology. all the cranial bones of the pre-hominids and compare them with the development of the hominid/human cranium. For the Introduction: feet. These developments have been time being we can only speculate about the Looking Back at the History considered and are well-documented in details of this process, which the French of the Human Cranium paleoanthropological research – work that scientist A. Dellatre called “L’hominisation was possible because there were enough du crane.”1 Certainly we would have to look While our ancestors were on their long fi ndings available that showed the shape at the role of the tongue in shaping the new trajectory from quadruped to biped, their and density of bones. maxillae as speech became an important musculoskeletal system had to go through Although there is no tangible record activity for our ancestors. And we would a tremendous change. Not only body available for soft tissues, it would be have to appreciate new relationships contour, but also the proportion of body interesting to risk some speculative follow- between teeth and maxillae as well as teeth segments and the size of muscles had to up on the connective-tissue changes that and mandible within the new shape of the fi nd a new order as the force of gravity likely accompanied changes to bones. We early hominid cranium. put a very diff erent demand on the body can also consider what it meant to the as a whole. This also required a new inner Differing Construction body’s cavities, how they had to relate system of organization. We can see, for diff erently to the vertebral spine and the Principles in the Human example, how ligamentous elements started back (with all its diff erent layers) as soon Mandible and Maxillae to replace muscular units inside the foot, as the hominid structure was on its way a process, a change that was necessary When we look at paired bones within one to uprightness. Here we would have to to allow further development of arches segment of the body we frequently fi nd one speculate about the very diff erent dynamics within the foot. And it can be observed at bone that has a “sister” or “brother” within of the respiratory diaphragm with the the level of the low leg that, as soon as our the same segment. One of them shows organs above and below it: as long as the ancestors started to stand and walk upright, more boney substance than the other, or is human animal had four legs to support its the tibia had to develop more strength and in some way more dense or more strongly movement, the diaphragm was separating develop more density of boney material developed. We fi nd this clearly in the distal two cavities that enveloped organs that in its upper part so that the full weight parts of the extremities, where paired were more or less hanging from the front of the body could be carried on only two bones serve together as a functional unit

32 Structural Integration / June 2010 www.rolf.org NEW CONSIDERATIONS OF ORAL STRUCTURES and develop in response to the repeated visible in white, while the cavities show in In Figure 2 we see how the teeth meet the transmission of force or to a more or less black and an irritated part of Schneider’s maxillae at the level of the second cervical permanent weight transmission. A simple membrane shows in grey within the sinus vertebra and the foramen magnum. It example, one mentioned earlier, is that the (visible on the upper right). We benefi t from documents the plane where the inferior move to a hominid bipedal stance required this kind of imaging system in the sense that border of the maxillae meets pressure much more development of the tibia, with we are able to clearly distinguish bony and from chewing. its new dense bony shape in contrast to the membranous structures. diameter and resilience of the fi bula. We fi nd this contrast also when we compare Anterior the boney substance of the mandible and maxillae. However, evolution arrived at an almost paradoxical situation with the construction principle of the bony units of mandible and maxillae. The mandible is connected to the neurocranium by a suspended hinge – it is literally hanging off the container of the brain. One would think that this adjunct to the container of the brain should be as light as possible, as the TMJ is (aft er the shoulder joint) one of the most mobile joints in the body. However, evolution has shown that the opposite works Maxillary Sinus Schneider’s Membrane well functionally. The head of Homo sapiens, elegantly replacing the earlier hominid head, maintains some of the heaviness of the Occiput mandible and shapes a new pair of maxillae out of extremely thin, fi ne bony elements. The roof of the mouth can have a very thin bony structure as it has developed into the form of an arch, a shape that almost perfectly Posterior distributes strong pressures. Dense bony substance had to be replaced by the economy Figure 1: Transverse cut through the living human cranium at the bottom of the of appropriate shape. maxillary sinuses. All images courtesy of Dr. Sebastian Schmidinger.

Collecting Empirical Data Anterior Using Digital Volume Tomography Models of the human skeleton may help communicate our view of the cranium, but even actual human bones, when they are from dead bodies, do not allow us to truly see and feel the differences that make a bone “lightweight” or “heavyweight” in its construction. We have to look inside the head of a living person to see what our “thinking fi ngers” are meant to sense.

Sebastian Schmidinger and I recently Alveolar Process Axis started to document the manifestation of of the Maxillae “lightweight construction” within the living organism using digital volume tomography. This kind of imaging system, which compared with conventional systems uses only a low percentage of radiation, allows us to get pictures of living bones, opening the door to very detailed documentation of diff erences in bone density and shape. Posterior Figure 1 shows the thin bony construction of the maxillary sinuses. The bones are Figure 2: Transverse cut through the cranium and upper cervical area at the level of the axis.

www.rolf.org Structural Integration / June 2010 33 NEW CONSIDERATIONS OF ORAL STRUCTURES

Superior very lightweight. Again we see the superior Lightweight bony margin of the sinus with a diameter Construction of less than a quarter of a millimeter. Also, of the we can recognize the very fi ne, delicate Maxillae structure of the bone separating sinus and Maxillary Sinus nasal cavity. Conclusion Schneider’s The separation of the viscerocranium Membrane Schneider’s into different cavities is essential for Membrane all mammals. Without this separation, enlarged by sucking, swallowing, and breathing would not have their necessary diff erentiation.2 Heavyweight infl amation Construction The primary function of the maxillae is to stabilize this necessary separation of of the Second Alveolar Process cavities. The bony maxillae act together Mandible Molars, with membranes to create a very stable upper & yet lightweight construction that can resist lower tremendous forces without undergoing deformation or fracture. In contrast to this, Inferior the thick bone of the mandible is easily deformed by mechanical impact. Figure 3: Frontal cut through the maxillary sinuses and – simultaneously – through the mandible at the level of the second molars. We see the maxillae and related membranes as an area of major importance, the inner bridge where the neurocranium and In Figure 3 we see what “lightweight The fi nal image, Figure 5, shows only one viscerocranium “articulate.” The author construction” means within a living maxillary sinus together with the nasal speculates that this inner bridge, with organism, as it can be clearly seen how thin cavity, adding to that what we could its potential for micromovement, is a the lateral bony margins of the maxillae already observe in Figure 3. We see that the keystone for structural integration (SI) of are. We are also able to recognize that the space of the cavities is maintained only by the neck and the craniosacral system as a superior part of the maxillae – the “roof bones that are extremely thin and by that whole when balanced in its relationship to of the mouth” – is formed of an arch of the neurocranium. extremely thin material (the bone here has a thickness of less than a quarter of a millimeter). In contrast to this we see the Superior density and thickness of the bony structure of the mandible. Remember that with this imaging system bone shows as white and empty cavities (filled with air) show as black. Thus, during chewing activity the mandible is pressing (through its teeth) with tremendous force against the upper teeth embedded in the alveoli of the maxillae. The Front Teeth force arrives through the alveoli directly onto the thin bony structures of the roof of the mouth. Note also that in this picture Axis we can see a diff erent spatial arrangement of Schneider’s membrane on either side of the maxillary sinuses. Plane of Occlusion Figure 4 shows the further bony connections of the maxillae to other bones above. From these relationships, we become Mandible aware of how forces are transmitted cranially through the maxillae to the Inferior bony elements surrounding the eye and cranioposteriorly towards the ear. Noting Figure 4: Sagittal cut through the cranium to illustrate the relationship between thin and thick bony (white) elements, we recognize the combination of lightweight the level of the second cervical vertebra and the alveolar level, as seen from a and heavyweight construction. different view in Figure 2.

34 Structural Integration / June 2010 www.rolf.org NEW CONSIDERATIONS OF ORAL STRUCTURES

Implications for SI Superior When I go through my notes taken more Maxillary Sinus than thirty years ago as a student during my fi rst Basic Training in Rolfi ng® Structural Integration, I fi nd plenty of reference to Lightweight the signifi cance of the roof of the mouth Construction for the concept of the seventh hour of the of the ten-session series. My fi rst instructor, John Maxillae Lodge, used to say, “touch the restricted half of the maxilla, and wait until it comes towards your fi nger.” Talking like that, he Schneider’s Alveolar Process gave a helpful metaphor for the indirect Membrane method we have to choose in this territory, before we change gears and use directive touch (i.e., whatever we want to make more mobile or more resilient within the adult First cranium, we fi rst have to follow into the Molars, restriction to its very end, and then support upper & lower Heavyweight the hidden potential of the system to fi nd Construction a larger range of motion and integration.) of the Unfortunately, as Rolfers we have not Mandible always traveled on this safe avenue. We sometimes tried to push things – structural Inferior relationships of the cranium – directly p “where they belong” without listening to Figure 5: Looking into details – frontal cut through one maxillary sinus and the tissues. That was not such a good idea, nasal cavity at the level of the fi rst molars. as some of us experienced personally. It is not surprising that so many SI practitioners seek an esoteric form when pursuing an interest in the cranial fi eld. However, it may be worthwhile to explore physics a Including the litt le bit more – and there really is a lot to be explored – before we venture into metaphysics. Stomatognathic System Endnotes ® 1. Dellatre, A., L´hominisation du crane. in Rolfing SI Paris: Editions du Centre National de la Recherché Scientifi que. 1960. A Collaborative Experiment 2. Schwind, Peter, Fascial and Membrane in Broadening Our Scope Technique. Edinburgh: Churchill Livingstone Elsevier, 2006, p.190. Compiled and translated by Certifi ed Advanced Rolfers™ Heidi Massa and Pedro Prado

Editor’s Note: The gathering of the selections that follow, as well as their development, organization, and translation from the Portuguese, is the joint eff ort of Heidi Massa and Pedro Prado.

Introduction time, several NAPER participants have been exploring this territory in their clinical The structural and functional importance of practices. NAPER1 is an organization of oral refl ex functions and their relationship Brazilian Rolfers™ operating out of the ® to Rolfing Structural Integration (SI), Brazilian Rolfi ng Association’s Sao Paulo both conceptually and practically, has headquarters, the mission of which includes been calling the att ention of practitioners clinical work, public outreach, mentoring, ® in Brazil. Rolf Institute Faculty member continuing education and research. Monica Caspari has done extensive research related to the jaw, tongue, and teeth, and Beatriz Pacheco (author of Including has developed structural and movement Functional Exercises in the Seventh Hour), protocols to address them. At the same who had studied with speech therapist www.rolf.org Structural Integration / June 2010 35 NEW CONSIDERATIONS OF ORAL STRUCTURES

Beatriz Padovan and M.D. physiologist Thus, we have hind legs (or fi ns, in the Carlos Douglas, experimented with oral Including Functional case of fi sh) posterior to the axis to push exercises in her NAPER Rolfi ng practice. the body forward (rear drive), and at the When she shared the results with other Exercises in the same time the mouth provides another NAPER members, they were also inspired Seventh Hour force in the opposite direction (front drive). to include the oral refl ex functions in their These forces combine to generate a sense thinking and practice, and began to observe By Beatriz Pacheco, Certifi ed Rolfer™, of push-pull – a functional opposition in their clients’ processes remarkable Rolf Movement® Practitioner shared throughout the vertebrate animal changes in structure, function, and quality family. In humans, however, there are other of life. This article1 highlights the four vegetative possibilities; we can move to wherever our oral refl ex functions – chewing, sucking, faces are directed. Over the years, NAPER has built a set of breathing and swallowing – as avenues of clinical practice and research protocols, approach to the work of the Seventh Hour. Based on these facts, as well as other and has organized a data bank, which An understanding of the movements, mechanical and neurological observations, now includes outcome information on bones, joints, and muscles employed in oral health professionals such as the processes of more than 1,000 clients. these functions provides both a reference orthodontists, phonoaudiologists, The prospect of gathering empirical data and an orientation to the structural work bucomaxillary specialists, and others on the use of exercises based on the oral of the Seventh Hour. I also seek to bring have a vision of bodily organization refl ex functions in the Rolfi ng context is a vision of bodily organization that based not on the support of the structure, ® exciting, indeed! enhances our sense of the involvement as in Rolfing Structural Integration, but rather on the reference point of the In this collection, we share Beatriz Pacheco’s of these functions, and also to show that mouth (the stomatognathic system). This summary of the oral reflex functions working functionally provides a resource concept of bodily organization is important and their anatomy and physiology; case preparatory to core opening, maintains the because it is the reference of many health studies and observations by Pacheco and gains of the structural work, and allows us professionals, including the followers her fellow NAPER practitioners Rosângela to organize the cervical and atlantooccipital of Sigmund Freud. In his theory of the Maria Baía, Yahra Silveira Perdomo and regions – all of this besides reducing our development of psychic structures, Freud Maria Beatriz Whitaker; and Monica clients’ discomforts. considered the “oral” stage to be the Caspari’s “Movement Strategies for the I will not explain the particulars of oral beginning of human psychic existence; at Stomatognathic System.” We hope it will exercises, but will highlight what they can that stage, we begin to move and to perceive inspire and encourage the international achieve. The information contained herein ourselves and the world through the mouth. community of Rolfers to include this is from notes of classes conducted in 2006 Besides, this view of bodily organization dimension in their view of our work. and 2007, and from interviews with oral enhances, reinforces and complements our Pedro Prado health specialists Beatriz Padovan and own as Rolfers. The typology of the oral Certifi ed Advanced Rolfer Carlos Douglas. health professions is well known to us, as Rolf Movement® Practitioner if they have arrived at the same place via a Introduction Advanced Rolfi ng Instructor diff erent route. Research Coordinator, NAPER, To think about oral functions, we must go For me on my path, this idea greatly Sao Paulo, Brazil back to the origins of animal structural enhances comprehension of how the organization. Unlike plants, which Heidi Massa axis functions and the question of developed photosynthesis as their means of Certifi ed Advanced Rolfer communication among the diaphragms. nourishment, animals developed nervous Rolf Movement Practitioner And, above all, it leads to a reassessment systems, which brought the possibility of of the importance of the muscles of voluntary movement in pursuit of food. Endnotes mastication, the temporomandibular In other words, feeding is the motive joint (TMJ) and the tongue – all of which 1. For background information on of locomotion. NAPER, see Matt oli, P., “Refl ections on are explored but litt le in Rolfi ng [SI] – for the São Paulo Ambulatory Project” (Rolf Following this idea, when we consider proper posture and structural function. We Lines, January 2001, pp. 5-7) and Prado, P., the dichotomy of form and function, we should also keep in mind the importance of “The São Paulo Ambulatory Project” (Rolf discover that each vertebrate animal has the study of function to the understanding Lines, January 2001, pp. 8-10.) an axis, one extremity of which is the entry of form, as well as its importance as a point for food, and the other of which reference for structural work. is the exit point for that which the body does not assimilate. Therefore, the mouth, Views of 7th Hour Work which is one extremity of the axis, is a We come to the Seventh Hour with the reference not only for locomotion but also objective of fi nding a position of equilibrium for vertebrate morphology generally. In for the head. This is a daunting task, as we fi sh, amphibians, reptiles, and quadrupeds, are seeking equilibrium over the vertebral where the axis is aligned horizontally in column for the cranial mass, which weighs relation to the center of gravity, we see the over fi ve kilograms. For something this mouth in front with respect to locomotion. heavy, we seek equilibrium of the occiput

36 Structural Integration / June 2010 www.rolf.org NEW CONSIDERATIONS OF ORAL STRUCTURES over the condyles of the atlas, which • forming facial expressions of the most highly innervated joints surround the dens of the axis. It is no • smiling and laughing in the body. As noted above, the TMJ accident that we have a veritable forest receives proprioceptive signals regarding So, we return to the question of proper of muscles that connect, stabilize, extend, bodily positions and movements so placement of the head over the spinal rotate and fl ex the head over the neck. that the position of the head may adjust column. We learn from the oral health appropriately. Because it is a paired joint, So, let’s consider the mobility of the head. profession that the position of the mandible the TMJ also registers any diff erence in the It is stimulated by the sense organs: determines the position of the head. The horizontal level of one condyle from that the eyes, nose, mouth, ears, and skin. three main muscle groups governing of the other, and transmits this information Embryologically, the mouth is the fi rst of mandibular position are: to the brain so that the body may adapt to these organs to form. Once the entry point • the muscles of mastication support the head. In addition to postural for food and the exit point for unassimilated information, the TMJ registers periodontal byproducts forms the axis around which • the suprahyoids (digastrics, stylohyoid, information concerning the consistency human structure is organized, we observe milohyoid, geniohyoid) of food, which indicates how much force in the embryological development that • the infrahyoids (sternohyoid, thyrohyoid, is needed to chew it and when to stop the gastrulation of the morula forms the omohyoid) chewing – or whether the food contains digestive tube, already rendering the mouth a bone or small stone harder than the both the superior reference of the axis and These muscle groups eff ect a dynamic in teeth themselves. the starting point for the embryological which the muscles of mastication act as diff erentiation of the endoderm, ectoderm, antagonists to the hyoid muscles. In the But in my opinion, the most important and mesoderm. Shortly aft er the digestive taxonomy of Tom Myers, the latt er are part point for structural integrators is the TMJ’s tube is formed, nerve tissue starts to form at of the deep anterior line, which penetrates intimate association with the thalamus its inferior portion and migrate toward the the thorax through the mediastinal fascia. gland, which is the center of the limbic mouth, where the central nervous system Their participation in the deep anterior line system. The limbic system coordinates will develop. makes them functional antagonists to the affects connected to the basic survival powerful muscles of mastication. mechanism of “fi ght or fl ight.” Whenever In humans, motor control begins at the the sympathetic branch of the autonomic mouth through sucking. The very first The muscles of mastication belong to the nervous system is activated, the trigeminal voluntary human movement is to suck erector group. In other words, they are nerve is also activated to prepare the the thumb, which activity begins in utero, antigravity muscles, and are among the mandibular system for att ack or defense. at the fourth month of gestation. This strongest in the entire body. No wonder, in thumb sucking is timed to the mother’s an evolutionary sense, we see that in most Thus, the entire mandibular system (nerves, heartbeat and coordinates the function non-human vertebrate species they are the bone, muscles. and teeth) is activated of the fetus’ hyoid muscles, which the principal mechanism of att ack and defense. involuntarily. As I see it, this is the principal newborn will need in order to suck at the justification for functional work with Accordingly: breast. Intrauterine thumb sucking also the four oral reflex functions (sucking, allows the fetus to ingest amniotic fl uid, • If the tension in the muscles of chewing, breathing, and swallowing): in which contains substances necessary for the mastication is greater than the tension our society, we are exposed to sympathetic maturation of its digestive and respiratory in the hyoids, then the head will be activation many times each day, which tracts. Because thumb sucking has a displaced backward and the axis will be powerfully reinforces existing neuromotor formative function, all fetuses exhibit this hyperextended posterior. patt erns aff ecting the cervical region, head behavior in utero. and throat. • If the tension in the muscles of mastication We must also keep in mind the percentage is less than the tension in the hyoids, then Working with the of the motor homunculus devoted to the the head will be displaced forward and Four Oral Refl ex Functions mouth: the mouth occupies 20% of the the axis will collapse forward. primary motor cortex. Let’s list some of the All four oral refl ex functions employ the mouth’s functions: • If the tension in the muscles of mastication same neuromuscular equipment. Because is unequal from one side to the other, the the functions are so interconnected, if we • sucking, chewing, breathing, swallowing axis will rotate. fi nd a dysfunction in one, we may be sure to • vocalization Of course, as with any typology, we fi nd altered function in the others, as well. • maintenance of mandibular position, encounter various combinations in between For this reason, Padovan cautions against which is a component of the upright the pure types. We must also remember that working with any one function in isolation posture that, if inhibited, will interfere the position of the mandible is determined from the others. with the upright posture by genetics, by the positions of the teeth, • yawning Chewing and by the way the person performs the • kissing various oral functions. Chewing combines mandibular movements • biting in three dimensions – front-to-back, side- • whistling The mandible is controlled by the TMJ, to-side, and top-to-bott om – resulting in • ejective behaviors, such as vomiting, which is a very special joint. It is the a helical motion. This happens so that choking, regurgitating, and belching only synovial joint of the face; it allows both sides of the array may work equally. • blowing motion along three vectors; and is one Chewing begins with a bite, aft er which

www.rolf.org Structural Integration / June 2010 37 NEW CONSIDERATIONS OF ORAL STRUCTURES the teeth chop and tear the food to the upright posture. A chronically resting unwinding of the fetal position and brings consistency of the alimentary bolus. At tongue begets hypotonic muscles of a tendency to lift up the superior portion any moment, one side is working, and the mastication and hypertonic hyoids, which of the thorax. This is true in adults and the other is poised to work. On the working bring the head forward and cause the thorax elderly, as well as in infants. The search side, the teeth are in contact with the food, to collapse over the abdomen. stimulates the achievement, the same as while on the other side they are not, and when the infant seeks its mother’s breast. The main sucking muscles are the there is space between the teeth. The two And, because there is no achievement infrahyoids and suprahyoids and the sides alternate their functions as the tongue without a “pull” in its direction, we see extrinsic muscles of the tongue, the intrinsic transports the alimentary bolus from one the dynamic of the opposing forces that muscles of the tongue being more important side to the other. If for some reason one of organize the axis, which begin to show for swallowing and speaking. the two sides works more than the other themselves in the earliest infancy. (unilateral mastication), over time the The intrinsics of the tongue are: Among adults and the elderly, practicing mandible will develop a rotational patt ern • the superior longitudinal muscle, which sucking recovers and organizes this action/ resulting in a fi xation in the direction of the shortens/broadens the tongue, and att itude, which is eff ectuated through the harder-working side. curves its tip and sides toward the roof deep musculature and not through the The main muscle group for chewing of the mouth to form a concave upper fascia. The action of the tongue pressing comprises the muscles of mastication: surface; upon the palate generates an impulse temporalis, medial and lateral pterygoids, in humans equivalent to the heliotropic • the inferior longitudinal muscle, which and masseter. The initial bite is eff ected by tendency in plants, and develops the sense shortens/broadens the tongue, and the temporalis, masseter, and pterygoids. of spatial orientation emphasized by the depresses its tip toward the fl oor of the The masseter maintains the mandible in the work of Hubert Godard. mouth to form a convex upper surface; closed position. The lateral pterygoid eff ects Sucking brings about nasal breathing. The the side-to-side component of chewing. • the transverse muscle, which lengthens/ combination of sucking and nasal breathing narrows the tongue; and These days, because our food is so soft , allows the infant to support its head and we chew ten times less than humans did • the vertical muscle, which fl att ens and establish motor control of its neck. They at the start of the twentieth century. As broadens the tongue. also permit the infant a greater experience we chew, we induce parasympathetic of motor coordination. Could it be that the The extrinsics of the tongue are: activation, and discharge and inhibit the coordination of sucking, swallowing, and activation of the trigeminal nerve. As the • styloglossus, which raises the tongue to breathing, in their three diff erent rhythms, mandible alternates between opening and the palate, brings it backward, and cups it; is the cradle of motor coordination? (See the closing, the sides of the mouth alternate thesis of Manoel Souza e Cunha at www. between working (biting) and balancing • genioglossus, the anterior fi bers of which fmh.utl.pt/mestradodc/a succao.doc.) the jaw. This activity equalizes the tonus reach the tongue out of the mouth, and Sucking protrudes the mandible, which of antagonist muscles. But we can also the posterior fi bers of which retract it; is retracted in the fetal position. This achieve comparable equalization of muscle • palatoglossus, which acts as a sphincter movement also disengages the sympathetic tonus through exercises designed for to isolate the oral cavity from the pharynx activation of the muscles of mastication. The that purpose. during swallowing and speaking; and rhythmic movement that sucking produces Masticatory Disturbances • hyoglossus, which depresses the tongue in the pharynx, which is connected to the cervical column at approximately C4, • unilateral mastication and brings its lateral borders towards the generates a vibration (like a cat’s purr) that • nail biting fl oor of the mouth. can either relax or tonify the cervical region. • bruxism The base of the tongue is formed by Sucking produces endorphins and engages According to Padovan, a child’s baby teeth extrinsics – the geinoglossus, palatoglossus, the hippocampus to produce the proteins begin to imprint the helical chewing patt ern hyloglussus, and chondroglossus, which BDNF (brain-derived neurotrophic factor) when the child is about three years old. This inset into the hyoid bone. In sucking, the and GDNF (glial cell-derived neurotrophic is the same time at which the child begins tongue undulates upon, puts pressure factor), which increase cerebral activity to display contralateral motion. It is also against, and opens the anterior portion and enhance the neural plasticity of the the time when the child begins to use the of the palate. The tongue is raised by the hippocampus in functions such as memory fi rst-person pronoun, “I”: “I want to eat,” styloglossus, which brings the tongue and imagination. Sucking is, therefore, instead of “want to eat.” Thus we see the toward the palate at the same time it brings highly recommended for the elderly. structural, functional, and psychobiological the hyoid bone superior in order to close the Sucking also stimulates the peristaltic realms fl owering simultaneously! larynx so that food and saliva may descend through the pharynx. For this function, activity of the digestive tract. Sucking the suprahyoids and infrahyoids act as In balancing the tonus of the hyoids, antagonists, raising and lowering the hyoid Working with sucking is essential because it is worth emphasizing the role of the bone. Working with sucking, we can bring sucking is the most comprehensive of the digastrics, which originate at the occiput the tonus of these muscles into equilibrium. reflexive/vegetative oral functions. The and insert into the mandible. The posterior pressure of the tongue against the palate, Seeking and finding the breast, which belly of the digastric functions like reins on along with nasal breathing, sustains the precede sucking, initiates and stimulates an a horse and has considerable infl uence on

38 Structural Integration / June 2010 www.rolf.org NEW CONSIDERATIONS OF ORAL STRUCTURES head position. We should also emphasize • sinusitis • drooling the importance of the omohyoid, which • apnea originates at the hyoid bone and inserts Conclusion Mouth breathing can also induce emotional into the shoulder blade. Contraction of the and behavior problems, such as: Working with the four vegetative oral refl ex omohyoid narrows the thoracic inlet and functions has greatly enhanced my own the superior portion of the thorax itself. • att ention and concentration defi cits comprehension of the structural, functional, • hyperactivity Sucking Disturbances and psychobiological dimensions of bodily • fatigue organization, as well as the interplay among • prolonged thumb-sucking • emotional lability those dimensions. Perceiving the eff ects of • use of pacifi ers • low libido the TMJ on the lateral line, diaphragms, Respiration Finally, aesthetic and functional changes shoulder girdle, thoracic inlet and spine from mouth breathing include: has given me a bett er understanding of Respiration begins at birth. If all goes well, the dysfunctions that can happen in those the baby begins to breathe through the • oval face shape areas. It seems to me that Rolfers often nose and activate the musculature of the • open mouth underestimate the enormous strength diaphragm. Because the mechanisms of • hypertonic orbicular muscles of the lips and reactive capacity of the muscles of respiration are well known among Rolfers, • narrowed nose mastication in all dimensions of being. I will not describe in detail the muscles • arched palate Understanding how the musculature of involved, the phases of respiration, or the • dento-facial deviations or deformations the stomatognathic system is involved basic respiratory dysfunctions (inspiration Swallowing in posture makes possible different fi x and expiration fi x) and their postural approaches, from specialized touches and muscular characteristics. We swallow between 500 and 1,500 times to differentiate these various muscles each day. Saliva, besides dissolving food, But I would like to highlight the importance and other structures to oral exercises. protects the esophagus from the gastric of nose breathing, in which the nose Approaches may be directed to primary juices produced by the stomach. Swallowing fi lters, humidifi es, and warms the air so mechanical patterns that have not fully takes place in four phases: that it reaches the lungs at 38°C (the air matured, or to dysfunctional patterns temperature determines the fl ow of blood • the anticipatory phase, in which the resulting from the mechanical activation in the lungs). Having entered through the tongue projects forward, of the limbic system. (Dysfunctions arising nose, the air passes under the sphenoid, from genetics or misaligned teeth are • the oral phase, in which the tongue which is warmed by the heat cerebral beyond the scope of these approaches.) undulates upon the palate, activity produces. Thus, as the air passes The results of the manipulation, amplifi ed from the nose into the nasopharynx, a heat • the pharyngeal phase, when the supra and by the oral exercises, made it possible for exchange takes place in which the air is infrahyoid muscles suspend the hyoid me to give clients tools that both allow warmed and the brain is cooled. Inadequate bone so that the larynx is closed, and them to discharge the limbic activation and cooling of the brain (having a “hot head”) reeducate their systems. • the esophageal phase, when saliva or can be responsible for hyperactivity, food passes into the esophagus. Seeing how opposing forces organize defi cits in att ention and concentration, and the axial complex is reinforced by an emotional lability. The main structures involved in understanding of the tongue’s role in this swallowing are: Without nose breathing, the cold and dynamic. It is very diffi cult for a mouth- unfi ltered air that reaches the lungs creates • the hyoid bone breather to maintain an erect posture an opening for respiratory disease. The because keeping the tongue on the fl oor • the tongue mucosa of the nose contains 20% of the of the mouth to permit airflow creates autonomic nervous system’s pathogen • the suprahyoids and infrahyoids, which excess tension in the infrahyoids. This is detection receptors. Finally, pheromones, raise and lower the hyoid bone described in studies by phonoaudiologists which stimulate sexual behavior, are and biomechanical engineers concerning registered by the osmaceptors near • the muscles posterior and extrinsic to the axial forces imposed by the tongue in the vomer. the tongue mouth breathing versus nose breathing, in premature infants, and in persons with Mouth breathing generally arises from – styloglossus, which raises and cups Down’s syndrome and cerebral palsy. Given diffi culties at the time of breast-feeding, as the tongue the need to objectively evaluate the power of it is during this time that nose breathing – hyoglossus, which depresses the tongue, the Biomechanical Engineering should be established. Oral health the tongue Group at the Federal University of Minas professionals have observed that many Gerais (State of Minas Gerais, Brazil) has problems accompany mouth breathing. – genioglossus, which projects devised an apparatus to measure the axial Health problems include: the tongue forward forces produced by the tongue. Disturbances from Mouth Breathing Swallowing Disturbances But, do the oral exercises allow us to make • allergies • atypical swallowing, which produces changes in well-established patterns? • enlarged tonsils excess saliva that can be expelled during It depends on the client’s age, as well • earaches speaking as on how regularly the client practices

www.rolf.org Structural Integration / June 2010 39 NEW CONSIDERATIONS OF ORAL STRUCTURES the exercises. And, more important than As early as the first session, I began achieving specifi c changes is the capacity manipulation of her head, neck, and TMJ. of the functional tools to bring about When Evanice arrived for her second maturation of the vegetative oral reflex session, she reported that following the functions, as well as the client’s cognizance fi rst session – for the fi rst time in years! – of them. And, according to both the work she had been free of pain for a substantial cited above and my own experience, the period of time. In the second session, we changes we can eff ect are signifi cant. introduced exercises for sucking, chewing, and swallowing, which Evanice was I could tell you about many clients instructed to perform twice daily. who, after practicing the oral exercises, feel bett er contact of their feet with the As the process continued, each week ground, have longer necks, and can sense brought notable improvements. By the time the mobility of the spine’s contralateral we came to the tenth session, Evanice was movement manifests itself. Some day I will practically pain-free. The arches of her feet prepare an article just to tell you about my were relaxed, she had recovered her “Line”, clients’ responses. and was well-organized. At the close of the intervention, her occlusion had improved I want to be clear that the objective of by a few millimeters, and the orthodontist my work with the four vegetative oral was then able to make further progress refl ex functions is the fundamental one of with her. integration of the body in gravity. I do not pretend that this work is a substitute for Ida Rosa: Reversing the the work of oral therapists. My intention is Before After Course of a Pathological to cooperate with them to open a new area Process of work for us. Actually, I believe there are Evanice: The Opportunity many things for us to discover through Practitioner: Beatriz Pacheco, Certifi ed Advanced these ideas. That is why I wanted to present for Interdisciplinary Rolfer, Rolf Movement Practitioner them to you: so that we can enrich our Cooperation Rosa, age sixty-fi ve, sought out Rolfi ng [SI] practices and the possibilities of helping Practitioner: Yahra Silveira Perdomo, Certifi ed to improve the mobility of her head, neck, our clients. ® Rolfer™, Rolf Movement Practitioner and arms, and also to relieve pain she felt Endnotes The client, Evanice, a nursing student along the back of her neck, in her arms, and twenty-fi ve years of age, was referred to at the back of her head. She suff ers from 1. This article was translated and adapted 1 NAPER by her orthodontist. At the time sclerodermata, as well as osteoarthritis in by Heidi Massa from Pacheco’s article on her hands. the same subject published in Rolfi ng Brasil, she fi rst visited the referring orthodontist, Vol. 9, No. 29 (July 2009). Evanice’s occlusion was open in excess Taking Tom Myers’ Anatomy Trains as a of one centimeter, and several other reference point, I saw that her deep front orthodontists had declined her case. line2 was quite short, especially on her A year of treatment with orthodontic right side. Her head inclined slightly to The Power of appliances had substantially reduced the left , which suggested a minor cervical the occlusion to 0.5 cm; however, the torsion. The hypertonicity of the muscles of Working in the eff ectiveness of the orthodontic treatment mastication seemed to spread throughout seemed to have reached its limit, and the the cervical musculature, and to induce Stomatognathic orthodontist could achieve no further hyperactivity in their antagonists, the progress. At that point, the orthodontist suprahyoids, and infrahyoids. And, one System referred Evanice for ten sessions of of the dangers of sclerodermata is that Rolfi ng [SI]. loss of esophageal mobility can impede NAPER Case Reports swallowing. When Evanice arrived at NAPER, her ribs By Yahra Silveira Perdomo, Beatriz and sternum were elevated and anterior; Key structural strategies were to open the Pacheco, Rosângela Maria Baía, Maria her upper thoracic spine was straight, with thoracic inlet, to differentiate the head Beatriz Whitaker a prominent seventh cervical vertebra; her from the neck, and to bring adequate medial arches were elevated; her head was muscle tonus to the visceral compartment In the cases reported below, the clients were anterior of her “Line”; her mandible was of the neck. These produced structural and ® treated with Rolfi ng Structural Integration protracted; and the muscles of mastication functional balance, manifest in a dialogue and Beatriz Padovan’s Neurofunctional were tight and shortened. The left side of between the muscles of mastication and the Reorganization (www.padovan.pro.br). In the her face appeared smaller than the right hyoids, which stimulates chewing, sucking, view of human functionality on which Padovan’s side. She suff ered jaw pain each morning, and swallowing. To advance these same work is based, organization of the mouth and the as well as low back pain. goals, I added to the Rolfi ng Recipe oral body are considered interdependent. exercises, to be practiced together with

40 Structural Integration / June 2010 www.rolf.org NEW CONSIDERATIONS OF ORAL STRUCTURES exercises in pushing the feet and legs into The Fourth Hour began with sucking the support of the table, ground or wall. exercises, together with motor exercises for the legs, which were made more At the outset, I advised Rosa that because challenging by adding the use of force the scleroderma had left her skin and during execution of the chewing, sucking, subcutaneous fascia more rigid than and swallowing exercises. To advance average, I would have to repeat sessions that her progress, I asked Rosa to do all of the addressed the particularly rigid territory exercises during the week at home. of the feet, the lateral line, and the thoracic inlet. I will highlight here how the work Rosa performed the exercises religiously diff ered from the classic Rolfi ng series. and began to feel the benefi ts. By mobilizing the muscles of mastication and the hyoids The Third Hour took place in two sessions. through the chewing, sucking, and In the fi rst, I worked to bring support to the swallowing exercises, Rosa was able to lateral line by addressing the fascia from avoid the accumulation of tension in the feet to the serratus anterior. Following those muscles. This, in turn, facilitated Padovan’s view of the interconnectedness the work by rendering more accessible not only these particular muscles, but also their counterparts at the pelvic and Before After respiratory diaphragms. When we began, the hypertonicity of Rosa’s Her obesity and lack of independence leave hyoids seemed to permeate her entire body. her depressed. She is afraid of falling. At Rolfi ng [SI] provided greater adaptability in 1.4 meters tall, she weighs ninety-two the rest of her body than in the hyoid region kilograms. She used to weigh 150 kg. itself, which tended to tighten rapidly. The Recently, she joined a senior citizens’ group, contraction of the hyoid region, which is and goes to a fi tness class once a week. typical in sclerodermata, puts the tonus of the She has never had any kind of massage or rest of the body at the mercy of the hyoids. I physical therapy – not even aft er the gastric myself believe that tension in the omohyoid reduction surgery. Surprisingly, she takes disorganized Rosa’s shoulder blades, which no medication other than muscle relaxants in turn aff ected her entire spine. as a last resort for her pain. She came to NAPER at my invitation to participate Aft er fi ft een sessions, Rosa reported that in our research, and to improve her her pain had diminished. The photos below balance. Her goals include greater personal show the changes in the mandible and independence through bett er movement. hyoid regions. Note the great diff erence in muscle tonus at the throat and jaw, as well We did thirteen Rolfi ng sessions, which as how the work aff ected the entire spine. included both structural and functional Before After work. We devoted three sessions to the Judith: Using Oral Seventh Hour territory. Now, she has lost Exercises to Restructure five kilograms, but it is clear she must of the organizations of the mouth and the Obesity lose more. She has tightened up two body, the lateral line should include the centimeters. Her clothes are loose, and the fascia of the temporalis muscle and the TMJ. Practitioner: Rosângela Maria Baía, Certifi ed doctor said that now is the right time for Under this view, the muscles of mastication Rolfer, Rolf Movement Practitioner the skin reduction surgery. It is scheduled are very important: as powerful, richly Judith, a woman sixty-two years of age, for January 2010. She has more movement innervated anti-gravity muscles, they have makes delicious sweets and savories, as in the girdles, spine and neck (which has the capacity to tighten the entire lateral line. well as knit and crocheted handicrafts. gott en longer). The right side of her body During the second session on the lateral Five years ago, she underwent gastric aligns with the left . Her bosom does not line, I initiated chewing exercises to be used reduction surgery, and she’s waiting to suff ocate her neck so much. aft er the manual work (which addressed have a second surgery to reduce excess She reports: “I don’t feel so many pains, the temporalis and cranial fascias, the TMJ skin. She is married, with two children and I can walk more lightly and evenly, not capsule and its ligaments, the insertion (delivered by cesarean section) and four like a warped wheel. I look bett er in clothes of the masseter on the mandible, and the grandchildren. Twenty years ago, she lost and shoes. My disposition is bett er. I get posterior belly of digastric). I did tracking her uterus to a tumor. She has an umbilical on and off the bus bett er. My self-esteem to lengthen the hyoids; diff erentiated the hernia. Her legs, which are heavy and is improving, and fi nally I’m going to get visceral compartment of the neck from the poorly articulated, hurt her. So do her knees the surgery I’ve been waiting for.” Older cervical spine; and worked the diaphragm, – especially the right one. Last year, she had people speak about their physical changes, starting at the costal arch. a steroid injection in her right knee. and Judith now takes greater care with her appearance. In the fi tness classes, she gets

www.rolf.org Structural Integration / June 2010 41 NEW CONSIDERATIONS OF ORAL STRUCTURES up and down on her own without help from that session I had taught her how even just Eventually, we stabilized the sacrum, pelvis, anyone. “I’ll continue to do all the exercises, breathing and relaxing her jaw tension legs and feet, as well as the contralaterality especially the mouth ones, and I think they made her gait less lumbering. Judith had achieved, using the foot-to- will help me control my weight.” head movements in a way that includes Before we did the second session, her all the joints, including the TMJ, and also Since the first session, we talked about weight went into the lateral arch on the using Thera-Bands® and unstable standing the digestive system, about its physiology left , and the space between the halux and surfaces such as wobble boards. We used and anatomy and its influences on the the second toe on the right. By the end of lots of accessories: balls and foam rollers to emotions. We worked with the mouth and the second session, aft er having practiced diminish the sense of weight, and breathing mandible starting in the fi rst session. In pushing toward the wall through her feet to allow a felt sense of expansion. Most of many sessions, we discussed obesity and without tension in her mouth or jaw, she all, we harnessed the capacity to project other digestive system pathologies such as came to feel more weight through the imaginary vectors; something she could anorexia, diets, exercises, self-discipline, middle of the third toe on her left foot. But – not yet do, she could imagine herself doing. self-esteem, and body image. Thinking aft er the Padovan-style oral work, she came along these lines, movement of the mouth to sense in walking the heel strike and toe Judith had her surgery January 27, 2010. It and the feet, in every session re-establishing (especially halux) push-off . She also sensed went well, and she has already lost eight this connection. transmission of weight through more of kilograms. “As soon as I began to walk, it each foot, and came to use all her toes more was lighter, diff erent. All my clothes are In the eighth session, to enhance the work of in the push-off when she had a greater sense loose, and my self-esteem is still improving. the Seventh Hour, we used Beatriz Padovan’s of her fi ft h toe beforehand. I consider it a victory, and bless you for your techniques, as adapted by Beatriz Pacheco. part in the eff ort. But now there are other Right then, we captured an amazing quality In the third, fourth, and fi ft h sessions, we parts of my body I want to change... My of support, which was maintained, above practiced the exercise of pushing toward the breasts are too large, and my legs are really all, by the client’s own discipline. At home, wall from her feet, and using the support gross! I still do the oral exercises with the she followed the recommendations and of her back to avoid straining her knees. sipping straw, and the pacifi er – and another did the oral exercises (to chase away the What also helped in various sessions was one the doctor gave me with a tube and temptation to eat), the respiratory exercises, the suggestion of seeking the horizontal line three litt le balls to increase my respiratory and the abdominal exercises especially with the mandible and the peripheral vision capacity. Once my work with you at NAPER to strengthen transversus abdominus. together, while at the same time releasing is finished, I’ll need some guidance to The core, which had gone flaccid, was the back of the neck – as if to release the neck work on bett er movement on my own.” I gathering strength. with the aid of vision and gravity. suggested to her that for the time being, Notes on the Process She arrived for the fourth session by herself she use the vectors of weight and direction – and had put her own socks and shoes in space to imagine herself doing whatever First Session: On the right, the knee, thigh on beforehand. During the fi ft h session, movements she wants to do. and foot are valgus and the whole leg is she felt the presence of backs of her knees: more forward. The lumbars are straight, “They grow!” she observed. As I worked Ana Maria: with kyphosis in the upper thoracics and with the multifidus in the sixth hour, The Stomatognathic lower cervicals forming a small dowager’s pulling the tissue on the left side, her left System as a Gateway to hump. Her neck is short. So is her breathing. hand fell asleep and her right femur ached Autonomic Re-regulation She seems only to inhale. Rapid and forceful because it was unwinding. With aligned movements. Lumbering gait. Fixed girdles. Practitioner: Beatriz Pacheco, Certified knee bends, we tracked between the ischial Arms imprisoned at the shoulders by Advanced Rolfer, Rolf Movement Practitioner tuberosities and the arches of the feet. We trapezius. To walk faster, she likes to fold also used a movement technique that works Ana, age forty-nine, a chemical engineer her arms and grip her elbows. She’s easily with tennis balls on the soles feet, with the who also owns a fashion clothing business, startled – as if assaulted, on the defensive goal of releasing the head, neck, mandible arrived with cervical pain and a sense that and reacting quickly. Really high tonus – and tongue. her left arm lacked support. She said she hypertonus in the abdomen. Supine, her couldn’t sleep, nor could she walk for more right side is higher, and her bosom rises The work followed Jan Sultan’s ideas – than a few minutes. She had already gone to suff ocate her neck. Standing, her head freeing the sacrum, upper ribs, triceps of to medical doctors, who had diagnosed turns to her left and inclines to her right, the the right arm and biceps of the left arm, and bursitis; however, she did not want to take retracted mandible pulling toward the back the scoliosis (lumbars rotated to the left , and anti-infl ammatory drugs any longer. of the neck and head. The mouth, small with thoracics to the right.) Pulling the tissue. tension and sadness, speaks pessimism, The cervicals are still buried in the fl esh of I could see that her left side was shorter embitt erment with pain and obesity. But the neck; the mandible pulls to the right to than the right, and that there was a despite the fragility she describes, she is counteract a rotation to the left . counterclockwise torsion to the left in her very communicative with respect to the spine. I could also see a diff erence between Next, with the use of Lael Keen’s functional aging process. the two sides of her face, the right side of techniques, the neck began to lengthen. which appeared larger. At the conclusion of the fi rst session (to When we arrived at Ida Rolf’s structural which her daughter had brought her) she Seventh Hour, Judith had already gained The fi rst session began with work in the couldn’t even manage to put her shoes contralaterality through the liberation of neck for the cranial and temporal fascia of and socks back on by herself. Still, during the girdles. the left side, which produced pain in Ana’s

42 Structural Integration / June 2010 www.rolf.org NEW CONSIDERATIONS OF ORAL STRUCTURES left arm. As I diff erentiated the bones of the in considerable pain. That day, we began wrist and opened the carpal tunnel area, with exercises to help Ana feel the power Movement Ana felt a small tremor through her arm. I of her connection to the ground. The pains asked her to wave “bye-bye” with her hand, departed and returned, but were not as bad. Strategies for the and waited a few minutes for the tremor Ana continued the chewing exercises; and Stomatognathic to pass. I explained to Ana that the tremor the whole-body exercises were made more was most likely a benefi cial discharge of the challenging with the sense of moving System autonomic nervous system (ANS), and that both homolaterally and contralaterally she should not be alarmed by it. Opening to induce communication between the the interosseus membrane of the forearm two asymmetrical sides of the body. By Monica Caspari, Certifi ed Advanced produced more ANS discharge, as did ® Throughout the process, the intensity of Rolfer™, Rolf Movement Practitioner, work in the temporals, as did work at the Rolfi ng® and Rolf Movement Instructor Ana’s pain diminished considerably, and left trochanter and in the left hamstrings. after seventeen sessions, the pain was finally banished through the structural Introduction order that had been established. In this case, As the Rolf Institute’s® Little Boy Logo mobilization of the TMJs and strengthening shows, structuralists tend to emphasize the of the muscles of mastication on the weaker role of the pelvis in postural organization. Yet side equalized the pressure the TMJ infants initiate the organization of verticality exerted upon the cervical spine. Reducing from G-prime (G’) – the upper center of the tension in the muscles of mastication gravity – fi rst by following caretakers with and corresponding corporal musculature the eyes, and then by raising the head and (pelvic and respiratory diaphragms and chest with the help of the hands and arms. It the lateral line) rendered the muscles of seems that the impetus for verticality starts at mastication more available to receive the the mouth, which is far more important for work. I believe it was the ANS discharge the organization of posture and movement via the tremors through the left arm during patt erns and the dynamics of reaching than various maneuvers that relieved the strain. we have recognized. I always contextualize the oral function work We have long known that balance is with the use of the feet: the feet push and the organized through the feet, eyes and mouth reaches. It is this dynamic of opposing vestibular system. Both tonic and phasic forces that establishes the functional axial muscles, the tonus of which continually organization of the vertebrates. adjusts to keep us erect, are regulated by Maria Fernanda: Letting Go . . . the vestibular apparatus and eyes, while the Before After feet infl uence the body’s organization in the Practitioner: Maria Beatriz Whitaker, Certifi ed sagitt al plane. However, we now know that We allowed all of these discharges complete Advanced Rolfer, Rolf Movement Practitioner the mandible, temporomandibular joint (TMJ) and the four oral refl ex functions themselves. Aft er the fi rst session, Ana’s pain Maria Fernanda, a young woman of twenty- (sucking, mastication, breathing, and was reduced for a few days, but returned. one, was reluctant to complete her Rolfi ng swallowing) are essential to the organization series, to disengage. She received twenty- At the second session, I asked her to bring of our balance and posture. an oral kit (a small kit containing tools three sessions. Only aft er we att ended to the for oral exercises, such as a whistle and a TMJ did she feel ready to end her treatment. The TMJ, one of the body’s most innervated joints and the only moving joint of the pacifi er). I fi nd these off ered for purchase Endnotes at speech therapy clinics where they give face, acts in three planes. The TMJ registers classes in the oral exercises. Ana did not 1. Sclerodermata is a skin disease information about body position and movement bring one until the fourth session. To be characterized by thickening and hardening in space, and its own position adjusts clear, I present the oral function work of the subcutaneous tissues, leading to a accordingly. Conversely, because the to the client as a method perfected over rigid and hidebound condition. receptors in the mandibular fossa of the thirty years by experts in speech therapy TMJ register the position of the condyles 2. Myers, T., Anatomy Trains. Edinburgh: and dentistry. I explain why I believe that of the mandible, it is sensitive to whether Churchill Livingstone, 2001. certain exercises will be benefi cial in the the plane on which they lie is other than client’s particular case. If the client agrees to horizontal; if so, aff erent signals from the do the exercises, I send the client to Beatriz TMJ signal the body to adapt in order to create Padovan’s clinic to purchase the kit and support for the head. Basically, the jaw aff ects other necessary materials. the spine and the spine aff ects the TMJ. I began the core opening and introduced The four oral reflex functions and the unilateral chewing exercises. The following position of the mandible (relative to the rest week, the pain did not return until the day of the standing posture) are interdependent before Ana’s next session – but she arrived and infl uence each other. The oral refl ex

www.rolf.org Structural Integration / June 2010 43 NEW CONSIDERATIONS OF ORAL STRUCTURES functions also infl uence the tonus of the the postural mechanism of the head opposite: think, just think, that your jaw tongue and performance of various other and the movements of the mandible are wants to go back, towards your throat, and oral functions, such as speaking. Because intertwined, whatever infl uences the latt er feel what happens to your breathing and all four oral refl ex functions employ some (e.g., cavities, missing teeth, misaligned the connection of the feet to the ground. of the same neuromotor components, a teeth) will aff ect the balance of the head Perhaps just imagining to project your jaw problem in any one of them manifests in on the neck. In that sense, the masticatory forward encouraged inhalation, while the the others. system is part of the postural system: opposite encouraged exhalation. In fact, we can encourage a client to inhale or exhale Taken together, the TMJ, the mouth, • The anterior and posterior muscle chains simply by slightly extending or fl exing the and those parts of the head, neck, and meet in the masticatory system, with the client’s head. upper thorax (muscles, bones, ligaments, mandible and tongue associated with fascia, and nerves) that control sucking, the anterior and the maxillae (via the The Second Hour’s work at the ligamentous biting, chewing, swallowing, are called the cranium) associated with the posterior; level of the feet and lower legs reaches stomatognathic system. up to the cranium, and thus affect the • Positioned along the brainstem are nuclei jaw. Exploration: Assume your habitual of the trigeminal nerve. Although this is Human Verticality standing posture and notice how your jaw primarily a sensory nerve, it does have Starts at the Mouth is, how it feels. Then release into your inner motor functions in respect to biting, arches, maybe even collapsing them, and Classically, the Seventh Hour is about chewing, and swallowing. putt ing the head on or fi nding the skyhook. feel the eff ect on your throat, jaw, tongue While in structural terms it concerns • The information transmitted by and neck. Next, observe the eff ect of resting the suboccipitals, in functional terms it these nuclei, as well as by other into your lateral arches. See how the neck concerns the senses – fi nding directions in afferent structures, influences tonic and jaw feel when you either hyperextend space, and reaching to do so. In that respect, postural balance. the knees or never really straighten them. What happens to the jaw when you activate the impetus for our verticality starts in utero, • Many studies have confirmed the the extensor digitorum muscle or shorten at the same time human motor control starts reciprocal influence between the the low back? with the mouth. In the fourth month of masticatory system, on the one hand, gestation, the human fetus performs its fi rst and the feet and eyes, on the other In the Third Hour, we infl uence the TMJ voluntary movement: sucking the thumb hand. Other studies have shown how through our organization of the G’/G and consequently swallowing amniotic the function of the masticatory system relationship, as well as the lateral neck fluid. This activity cause ingestion of is affected by muscle adjustments work. Exploration: Assume your habitual substances essential to the maturation of the triggered by exteroceptor activation standing posture and notice how your jaw digestive tube and lungs, and also prepares consequent to the presence of dermal and neck feel. Then change the relative the hyoid muscles for sucking at the breast, scar tissue in the cervical region; e.g., a position of G’ and G, taking G’ way behind which, in turn, rehearses the verticality to surgical scar can have an impact on the or way forward of G and feel what happens. come. In putt ing the head on, we implicate masticatory system. primal developmental events and engage As we open the mid-line of the legs in the enormous portion of the motor and In any event, whether the masticatory the Fourth Hour, we aff ect the jaw via the sensory homunculi devoted to the mouth. system is a regulator or a perturbator of pelvic fl oor, respiratory diaphragm, and the tonic postural system, we do know that thoracic inlet. Exploration: Standing or Exploration: Suck your thumb and notice imbalances in one aff ect the other. sitt ing, notice what you feel in your jaw. how it awakens the neck muscles and Then tighten the pelvic fl oor and notice evokes the up direction. To experience Experiencing the Jaw what happens. Next, reverse the sequence: the baby’s complex coordination among in the Context of clench your teeth and notice what happens sucking, swallowing, and breathing, get the Ten Series in your pelvic fl oor. two feet of IV tubing and place one end in a cup of water. Suck the water through the Though the jaw is addressed specifi cally in In the Fift h Hour, as we organize the legs other end and breathe through your nose in the Seventh Hour, we infl uence the jaw in with the pelvis, and through the pelvis to the intervals. Notice how this action evokes each session. the visceral space, the aff ect on the core influences the jaw. Exploration: From the up direction. In the First Hour, when we enhance the your habitual standing posture, rotate the orientation to space by diff erentiating the TMJ: The Fourth femurs medially and laterally and feel what arms and neck from the thorax and freeing happens to both the pelvic tilt and the jaw. Balance Factor the breathing, already we‘re aff ecting the And, as we organize the core by organizing jaw. Exploration: Sitting as before, try When you work in the neck your the abdominal wall, we aff ect the jaw and rotating your arms medially and laterally, fi ngers will be as close as possible to TMJ via the abdominal, thoracic and cranial and notice how the rotations aff ect your the control structures of the body than cavities. Exploration: Notice how your breathing and the sensations in your jaw. at any other moment. jaw feels when you are in your habitual Next – in the millisecond before you want standing posture. Completely release your Ida Rolf to inhale – think, just think, that your jaw abdominal wall and feel what happens. is seeking a direction in space (as if it The front of the head is heavier than the From there, activate your transversus were a drawer opening), and notice how back. For that reason alone, balancing the abdominus (TA) and feel. Next, release head on the neck is complex. But, because it feels to breathe like this. Then try the

44 Structural Integration / June 2010 www.rolf.org NEW CONSIDERATIONS OF ORAL STRUCTURES the TA, activate rectus abdominus (RA), • Sit at the computer, hands on the place, fi rst project the neck forward and feel and feel the changes in the TMJ/jaw. The keyboard, wrists straight – then dorsifl ex what happens to the lumbars, the sternum, exploration around the TA and RA becomes the wrists and the breathing. Second, take the neck clearer with sit-ups: without activating the back as if you wanted to make it a straight • Sit at the computer, hands on the TA, you’ll notice the strong shortening of continuation of the spine, and feel what keyboard – keep the fi ngers straight but the neck. But if you fi rst activate the TA happens to the spine, the distribution of palmar-fl ex the wrists and only then the RA, the neck will remain weight in the feet, and the breathing. movable and relatively free, and so will • Medially or laterally rotate the humeri, To balance the action of the posterior erector the jaw. or just pull the upper arms back; muscles with that of the hyoids, it helps As we organize the whole back of the body • Pull the shoulders up towards the ears to imagine that the face to belongs to the in the Sixth Hour, our work on the spine sternum, while the cranium belongs to the • Allow the arms to hang freely – then as a whole infl uences the jaw. Exploration: spine. Let’s work fi rst with the whole head, pronate and supinate the forearms Shorten your spinal erectors and feel what and then with the jaw specifi cally. happens in the jaw; next, see what happens • Stand in front of a very stable piece of Exploration: Sit slightly forward of your when you lengthen the front of your neck furniture and push it away as if you ischial tuberosities, feet connected to the and throat. Exploration: Stand, one leg in were reaching through it – then pull it ground, head suspended in space by the front of the other, (let’s say the right leg towards you dynamics of the senses, and the weight in front), feet pointing straight ahead, the of your head balanced between front and right arm bent at your back over the upper • Next time you drive, grasp the steering back in such a way that the cranium rests lumbars, and the left arm along the body. wheel hard on the spine and the face on the sternum. Reaching with the left arm down and then As Ida Rolf said, if the client is adequately Now, allow your whole neck and head to to the front and then up, while your feet prepared, the mouth will not be vulnerable; go forward and recheck all the landmarks: make the best possible contact with the but if the client is not prepared, the mouth what happened to the connection of your fl oor, ask then the ischial tuberosities to will be quite vulnerable, indeed. Therefore, feet with the fl oor, your up direction, your widen, and lower the torso toward the if the arms, hands and shoulders have not down direction, your breathing? Return to fl oor by fl exing at the hip hinge (not at the yet been adequately diff erentiated, they neutral, imagining your head suspended lumbars), reaching with the extended arm should be addressed before proceeding to from or reaching toward the ceiling. as far down as you can, feeling the jaw, the classical territory of the Seventh Hour. Without moving the neck or head, imagine and reaching towards the fl oor with the the cranium staying with the spine as the forefoot of the front foot and with the heel Jaw Movements Infl uence jaw goes forward. This overactivates longus of the back foot. To come back up, draw the Postural Mechanism colli and the hyoids, yielding considerable the ischial tuberosities closer together and of the Head throat tension that makes it hard to swallow. still reaching with the arm allow your body to come to standing while you take your The position of the mandible aff ects not just of the head, but the whole person. Changing Psychobiology: The Jaw in awareness to your jaw and notice what the Expression of Emotions happens there. Explore the same sequence the position of the mandible changes the again – but without activating the contact whole line, as well as how the person relates Smile from your cervicals. to the environment. The next exploration uses of the feet with the fl oor, or reaching with Vivian Jaye the arm/hand, or widening or narrowing movements of the mandible to help the client of the ischial tuberosities – and feel what become aware of head and neck position. Hubert Godard teaches that our spine gives happens to the jaw. Exploration: Stand, connect your feet to us the sense of self. Hugh Milne, however, teaches that the mandible is the bone most Finally, in the Seventh Hour, if we consider the ground, and fi nd the up direction and your Line. Notice your breathing and where associated with the person’s sense of who he the functional goals as well as the structural is. Because so much of our self-expression goals, we will infl uence the TMJ by taking your body weight rests in your feet. Leaving your cranium where it is, project your happens through the face, the jaw helps the arms and hands to a higher level of display many feelings. When we feel: integration. The functional goals include: chin forward. • aggressive, we protract the jaw to signal • freeing the vestibular system • What happens to the distribution of weight in the feet? our readiness to fi ght; • having the head leading the body • To the lumbar and cervical curves? • ambivalent, we hold the chin to prevent through the dynamics of the senses, with • To the sensations on your abdomen? the head from sending a signal we are the dynamics of the senses organizing • To the breathing? not clear about sending, such as a nod posture and movements) • To the Line as a whole? yes, when we want to agree but know we • having the spine free of interference from After returning to neutral, leave your need more information; the girdles and diaphragms. cranium where it is and pull your chin • bored or tired, we support the chin with toward you. Ask the same questions. Explore the following arm/hand cupped hands; movements, and notice what happens in Finally, in the seated position, place a thumb • defensive, the head tilts down (even the TMJ: under your chin, its tip touching the throat, more than in submission) and the eyes to hold the chin steady. Keeping the chin in • Clench your fi sts

www.rolf.org Structural Integration / June 2010 45 NEW CONSIDERATIONS OF ORAL STRUCTURES

are downcast (gestures of shyness and Functional Interventions of the crescent to the other, the cradling fl irting are similar); hand neither encouraging nor inhibiting The face is just the other side of the neck. the translation of the mandible. Are you • determined, we set the jaw against moving the lips more than the mandible? adversity; Ida Rolf Explore this movement daily, starting • defi ant, we jut the chin out; To embody Dr. Rolf’s observation, sit with one minute, and increasing the daily slightly forward of your ischial tuberosities, duration by one minute each week until you • intimidating, we project the head with “footy feet” on the fl oor and “handy reach the three to fi ve minutes. If the jaw forward, with eyes wide, teeth clenched hands” in your lap. Turn your head to either translates asymmetrically, have a competent and shoulders up; side and notice the quality of movement. dentist evaluate it. Next, instead of turning the head from the • contemptuous, we can “point” the jaw face (or the nose in front), turn it from an For the Depressors of the Mandible at someone (insulting, but more subtle imaginary nose in back. Notice that in the and less threatening than pointing with The depressors of the mandible open and fi rst action, when you turn to the left , it a fi nger); retract the mandible. Included in this group seems to turn from an imaginary axis close are the lateral pterygoid (also an auxiliary • self-protective or threatened, we retract to the left sternocleidomastoid (SCM), and of mastication) and the suprahyoids the chin in to protect both the chin and when you turn to the right, it seems to turn (digastrics, stylohyoid, mylohyoid, and the throat; from an imaginary axis close to the right geniohyoid). SCM; but, in the second action, the whole • submissive, we lower the head as we head seems to turn on a single axis that lines Before opening the mouth, stroke the retract the chin; up with the cervical spine, which is what mandible with the thumb, from the mastoid • tenacious, we dig in, clench the teeth, we want to evoke. Notice also that here a process to the tip of the chin, inviting grin and bear it; perceptual shift improves the coordination. something there to let go before opening the Perception is also key to the functional mouth. Or, cradle the mandible in the crescent • thoughtful, we tap the chin with our interventions described below. of the thumb and index/second fi ngers and fi ngers. invite the mandible to rest in your hand Rolf Movement Integration is helpful for Communicating through the jaw as much before opening the mouth. Both touches give stomatognathic system and TMJ problems as we do, we develop movement patt erns support for the temporalis to release and the only if the client has the discipline to work that can contribute to TMJ dysfunction suprahyoids to work more freely. with it daily. First, teach the client to keep and temporal region tension headaches, the upper and lower teeth separated, even For Flexibility and Strength of the Jaw which have repercussions throughout the as the lips are soft ly closed. Next, the tip body. Fortunately, movement patt erns of Work gently with isometric exercises. of the tongue should rest on the palate, the jaw can be addressed through Rolf First, place three fingers of each hand just behind the upper front teeth. This Movement education. Jaw tension is hard to along the sides of the mandible to off er a positioning alone is oft en enough to reduce control, but the fi rst step is to help the client bit of resistance to its reaching side-to-side TMJ tension by opening some space at recognize the context in which the TMJ/ movements. Next, place the fi ngers under the condyles. Persons with TMJ problems temporalis tension arises. Next, encourage the chin and let the mandible reach through should be educated not to chew gum or eat the client to acknowledge any feelings the fi ngers as the mouth opens. Start with hard things like beef jerky. The client should associated with the situation or events. one minute per day and gradually increase be educated to avoid collapsed standing Finally, identify the manner and sequence to three minutes. postures and poor sitt ing habits that throw in which client builds the tension patt ern. the head forward, as well as carrying heavy For the Temporals-Masseters-Chin Sitt ing quietly for ten or fi ft een minutes handbags on one shoulder and chewing on Cradle the mandible to guide its movement before bed time, contemplating the day one side only. gently forward, so that the lower teeth go and releasing the tension generated by the Exploratory Repatt erning anterior to the upper teeth. Start with one day’s stress, allows us gradually to release minute per day, and gradually work up accumulated jaw tension. While sitt ing in Exercises for the Jaw to three minutes. Take it easy: Overdoing the meditative att itude, the client can place For each of the following exercises, sit this exercise might leave you with a a pencil as a brace between the upper and slightly forward of the ischial tuberosities, sore temporalis! lower molars to encourage the jaw muscles feet on the fl oor, fi nding the down direction to relax. As the muscles lengthen over with the ischial tuberosities and the up For Increasing the time, the client can use two pencils taped direction with the top of the head. The TMJ Range of Motion together. Take care to increase the size of the back of the spine looks back and opens Slightly open the mouth, and place a thumb brace gradually, and to respect the average graciously towards the wall, even as its front under the upper front teeth and two fi ngers limit of how far the mouth can open (forty remains open. to sixty millimeters). of the other hand over the lower front For the Lateral Pterygoids teeth. Invite the jaw to remain passive as you gently open the mouth. Take care not Before a mirror, if possible, cradle the to put too much pressure on the teeth: the mandible in the crescent of the thumb and more gentle you are, the bett er and more index/second fi ngers. With teeth resting quickly this works. This is good for clients apart, translate the jaw from one side whose mouths barely open. Start with one

46 Structural Integration / June 2010 www.rolf.org REVIEWS minute per day and gradually work up to the mouth, taking care not to cut any curve. Seventh Hour. It enhances our ability to help three minutes. Start with one minute to one direction and our clients by facilitating their awareness of another minute in the reverse direction. existing patt erns, and by giving them self- For Coordinating the Three Planes Gradually increase to two minutes each side. help movement tools. It also opens the door of Movement of the TMJs for us to work cooperatively with holistically Draw imaginary fi gure eights with the tip of Conclusion oriented dentists and speech therapists. your chin. For this you’ll have to open and Bett er understanding of the stomatognathic close the mouth, and take it side-to-side. system as a whole, and of the jaw in particular, Draw two equal fi gures, one to each side of off ers a new and broader perspective on the

pressure; what we have here in Schleip’s The Nature of Fascia: Latest News coverage of matrix hydration gives the current thought that stands behind it. When the fascial ground substance is from Connective Tissue Research rehydrated, it becomes stronger and less ® stiff , and the mechanisms leading to this DVD by Robert Schleip, Ph.D., Rolfi ng Instructor are investigated. The phenomenon of tonus regulation is explored, focusing on the Reviewed by Allan Kaplan, Certifi ed Advanced Rolfer™ interaction between the nervous system and myofi broblasts existing within fascial tissues. I found that the segment on fascial The Nature of Fascia: Latest News from elastic recoil was a little too short, and Connective Tissue Research, a DVD would have cared for elaboration on these presentation of recent scientific fascial properties; while still quite interesting, this research, is a cogent eff ort on the behalf of section felt almost like an aft erthought, and longtime Rolfi ng® Structural Integration I did not feel it got the att ention the rest of instructor Robert Schleip. It is a thoughtfully the material did. laid out forty-minute lecture, complete with illustrations, in which he summarizes the All in all, I found The Nature of Fascia a very latest thoughts on the function of fascia. well-conceived and informative overview of Of particular interest to Rolfers and other fascia and its properties. Besides its review bodyworkers is Schleip’s explanation of of the current thought of fascial function, it the diff erent sensory properties of fascia is valuable to Rolfers and bodyworkers for and how these may be capitalized upon its guide to aff ecting the fascial body and by diff erent strategies of using hands-on stimulating specifi c eff ects. tissue manipulation and motion in diff erent Robert Schleip’s website, www.somatics.de/ pressures, directions, and locations relative nature_of_fascia.html, has information on to the fascial network. how to obtain the DVD, depending on what In a conversational yet authoritative part of the world you are ordering from. manner, Schleip fi rst gives a quick review of comprehensive, outlining the four types of Note: The disc plays without problem from fascial anatomy, noting that interest in fascia nerve cells that are found in fascia. Schleip computer DVD drives, but it may not be by the scientifi c community has escalated covers in detail the characteristics of Golgi, compatible with all external DVD players (the several-fold in the past few years, then Paccini, Ruffi ni, and interstitial nerve cells, DVD player must accept PAL as well as NTSC). launches into the meat of the matt er (so to describing their functions, locations, what speak) – fascial function. He explains that types of contact will aff ect them, and the fascia is involved in four diff erent activities best ways of stimulating their responses. It within the body: it acts as a sensory organ; was interesting to hear how one may aff ect it functions as a contractile organ associated particular sensory nerve endings by using with tonus regulation; it is responsive to a variety of types of contact in diff erent hydration changes of its matrix; and it has areas of the fascial body, each to particular, properties of elastic recoil. Schleip outlines specifi c eff ect. each of these aspects and relates them to bodywork applications, backing theory The remainder of Schleip’s discussion with descriptions of the experimental data concerns fascia’s participation in its other at hand and illustrating his points well. roles in matrix hydration, tonus regulation, and elastic recoil. As Rolfers, we have long Much of the discussion of fascia thereaft er heard the theories of the fascial states centers on its properties as a sensory of gel/sol and the associated effects of organ. I found this particular section

www.rolf.org Structural Integration / June 2010 47 INSTITUTE NEWS

Congratulations to the New Graduates

Japan – November 2009 Faculty: Monica Caspari (instructor), Pedro Prado(instructor), Yoshitaka Koda(Assistant), Paula Mattoli(Ethics Teacher) Students: Seiko Handa, Naoyoshi Hashimoto, Takeshi Hirahara, Yoshie Ishiwari, Naoko Ito, Seiji Kamimura, Hidenori Kato, Miho Kodama, Tsutomu Kuno, Akari Maeda, Mami Miyata, Yukiko Nitsu, Hirohisa Okawa, Kazuko Ozawa, Keiko Segami, Takanori Tachibana, Natsuko Tsuchiya, Kiyomi Uekusa USA – December 2009 Faculty: Jon Martine (instructor), Neal Anderson (Assistant), Courtney Cox (Assistant) Students: Adriane Anile, Jed Bentley, Kate Bradfi eld, Thomas Brown, Melanie Dail, Rachel Felson, Evan Goldfarb, Gregory Guillemette, Beatrice Hollinshead, Christopher Horan, Charles Hung, Kara Imle, Sherri Lachance, Shannon Middleton, Taizo Omuro, Elaine Rasher, Mark Read-Smith, Jeremy Rosenberg, David Sobel, Anne Wasielewski, Naomi Wright Europe – March 2010 Faculty: Pierpaola Volpones (Instructor), Jörg Ahrend-Löns (Assistant) Students: Christiane Antunes dias de Oliveira, Marlyse Baumann, Ea Nitsche Holm, Julia Isbarn, James McCormack, Kaori Nakamura, Susanne Noll, Katharina Saliger, Alexandra Schnaubelt, Simone Schumacher, Michael Seymour

2010 Class Schedule

BOULDER, COLORADO BROOKFIELD (MILWAUKEE), GERMANY WISCONSIN Phase I: Foundations of Rolfi ng® Basic Rolfi ng Training: Intensive Structural Integration Phase I: Advanced Foundations of Rolfi ng Structural Integration Phase 1: August 2 – 21, 2010 October 4 – November 15, 2010 Instructor: Paola Volpones, Konrad Obermeier, Coordinator: Suzanne Picard Sept 16-19 / Oct 14-17 / Nov 11-14, 2010 & Giovanni Felicioni Instructors: Michael Polon & Jon Martine Phase 2: October 4 – November 26, 2010 Phase I: Advanced Foundations of Instructor: Giovanni Felicioni Rolfi ng Structural Integration NORCROSS (ATLANTA), GEORGIA Phase 3: January 31 – March 24, 2011 July 18 – July 31, 2010 Instructor: Pedro Prado Instructor: John Schewe Unit I: Advanced Foundations of Rolfi ng Structural Integration Basic Rolfi ng Training: Modular November 28 – December 11, 2010 Instructor: TBA September 19 – October 2, 2010 Training begins in September 2010 Instructor: John Schewe Phase II: Embodiment of Rolfi ng & Rolf Movement® Integration JAPAN SAN DIEGO, CALIFORNIA August 23 – October 14, 2010 Unit I Instructor: TBA Unit I: Advanced Foundations of Rolfi ng Principles Instructor: Mary Bond Structural Integration August 2 – September 10, 2010 Instriuctor: Raquel Mott a Phase III: Clinical Application Oct 14-17 / Nov 5-7 / Dec 3-5, 2010 of Rolfi ng Theory Instructors: Michael Polon & Juan David Velez Unit II February 7 – April 1, 2011 August 2 – September 24, 2010 BRAZIL Instructor: Ray McCall Instriuctor: TBA Anatomy Instructor: John Schewe Unit III Unit III

CHARLES TOWN, October 4 – December 9, 2010 September 26 – November 18, 2011 WEST VIRGINIA Instructors: Pedro Prado, Paula Matt oli and Instriuctor: TBA Kevin Frank Rolf Movement Certifi cation SOUTH AFRICA July 19-25 / August 23-29 / October 5-12, 2010 UNIT I: September 13-30 & Instructors: Jane Harrington & October 11-28, 2010 Rebecca Carli-Mills UNIT II: April 4 – May 26, 2011 UNIT III: September 5 – October 27, 2011

48 Structural Integration / June 2010 www.rolf.org Contacts

OFFICERS & THE ROLF INSTITUTE® JAPANESE ROLFING BOARD OF DIRECTORS 5055 Chaparral Ct., Ste. 103 ASSOCIATION Boulder, CO 80301 Japanese Rolfi ng Association Hubert Ritt er (Europe/Chairperson) (303) 449-5903 Keij i Takada, Foreign Liaison +49-30-4435 7473 (800) 530-8875 Tokyo, Japan [email protected] (303) 449-5978 fax www.rolfi ng.or.jp www.rolf.org Peter Bolhuis (At-large/CFO) vice-chair@rolfi ng.or.jp [email protected] (303) 449-2800 [email protected] CANADIAN ROLFING ROLF INSTITUTE STAFF Audrey Chester-McMann (Eastern USA) Diana Yourell, Executive Director ASSOCIATION (443) 850-2728 Jim Jones, Director of Education Kai Devai, Administrator [email protected] Heidi Hauge, Membership 615 - 50 Governor’s Rd. Judy Jones, Clinic Coordinator Dundas, ONT L9H 5M3 Kevin McCoy (Faculty/Secretary) Gena Rauschke, Accountant Canada (862) 202-2222 Trace’ Scheidt, Admissions (416) 804-5973 [email protected] Susan Winter, Marketing & PR Fax: (905) 648-3743 www.rolfi ngcanada.org Marilyn Miller (Central USA) info@rolfi ngcanada.org (858) 451-2134 AUSTRALIAN GROUP [email protected] Marnie Fitzpatrick, Administrator 5055 Chaparral Ct., Ste. 103 Maria Helena Orlando (International/CID) Boulder, CO 80301 +55-11 3819-0153 (303) 449-5903 [email protected] (800) 530-8875 Jeff W. Ryder (Western USA) (303) 449-5978 fax (503) 250-3209 www.rolfi ng.org.au [email protected] info@rolfi ng.org.au Wanda Silva (At-large) BRAZILIAN ROLFING® (904) 294-3335 [email protected] ASSOCIATION Sybille Cavalcanti, Executive Director R. Cel. Arthur de Godoy, 83 EXECUTIVE COMMITTEE Vila Mariana Peter Bolhuis 04018-050-São Paulo-SP Kevin McCoy Brazil Hubert Ritt er +55-11-5574-5827 +55-11-5539-8075 fax EDUCATION EXECUTIVE www.rolfi ng.com.br COMMITTEE rolfi ng@rolfi ng.org.br Ellen Freed, Chairperson Duff y Allen EUROPEAN ROLFING Kevin McCoy ASSOCIATION E.V. Michael Polon Angelika Simon, Executive Director Ashuan Seow Martina Berger, Training Coordinator Russell Stolzoff Monika Lambacher, Sales and PR Nymphenburgerstr. 86 80636 Münch en Germany +49-89 54 37 09 40 +49-89 54 37 09 42 fax www.rolfi ng.org info@rolfi ng.org Non-Profi t Org. U.S. Postage PAID Boulder, CO OF STRUCTURAL INTEGRATION Permit No. 782 5055 Chaparral Ct., Ste. 103 Boulder, CO 80301