Journal of Bodywork & Movement Therapies (2016) 20, 784e799

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HYPOTHESIS The biomechanical model in manual therapy: Is there an ongoing crisis or just the need to revise the underlying concept and application? Christian Lunghi, DO, ND a,b, Paolo Tozzi, MSc Ost, DO, PT a,b,*, Giampiero Fusco, DO, PT a,b a School of Osteopathy C.R.O.M.O.N, Rome, Italy b C.O.ME. Collaboration, Pescara, Italy

Received 2 October 2015; received in revised form 4 January 2016; accepted 15 January 2016

KEYWORDS Summary Different approaches to body biomechanics are based on the classical concept of “ideal Biomechanical posture” which is regarded as the state where body mass is distributed in such a way that ligamen- model; tous tensions neutralize the force of gravity and muscles retain their normal tone, as result of the Osteopathy; integration of somatic components related to posture and balance mechanisms. When compro- Posture; mised, optimal posture can be restored through the balanced and effective use of musculoskeletal Manual therapy; components; however, various research findings and the opinion of experts in this field suggest a Fascia move away from the dogmas that have characterized the idea of health dependent on ideal posture, to promote instead dynamic approaches based on the interdependency of the body systems as well as on the full participation of the person in the healing process. Following these concepts, this article proposes a revised biomechanical model that sees posture as the temporary result of the in- dividual’s current ability to adapt to the existing allostatic load through the dynamic interaction of extero-proprio-interoceptive information integrated at a neuromyofascial level. Treatments using this revised model aim to restore the optimal posture available to the person in that particular given moment, through the efficient and balanced use of neuroemyofasciaeskeletal components in order to normalize aberrant postural responses, to promote interoceptive and proprioceptive integration and to optimize individual responses to the existingallostaticload.Thelatter is achieved via multi- modal programs of intervention, in a salutogenic approach that, from a traditional perspective, evolves on an anthropological basis, to thepointofcenteringitsworkontheperson. ª 2016 Elsevier Ltd. All rights reserved.

* Corresponding author. School of Osteopathy C.R.O.M.O.N, Rome, Italy. E-mail address: [email protected] (P. Tozzi). http://dx.doi.org/10.1016/j.jbmt.2016.01.004 1360-8592/ª 2016 Elsevier Ltd. All rights reserved. The biomechanical model in manual therapy 785

Introduction Therefore, it is necessary to consider holistic approaches aimed at integrating body structure and postural function, such as osteopathic manipulative treatment. Taking up the The classical biomechanical model (BMM) analyses the discussion in this regard, the authors of this article propose relationship between body behaviors and gravity, as well as a further step. The multifactorial nature of biomechanical the organization of static and kinetic chains in relation to adaptations cannot but lead the operator towards a global antigravity mechanisms, spinal and vestibular reflexes. approach that considers not only the assessment of the Efficient posture and good mobility of the entire musculo- integration between the structure of an area and its related skeletal system have always been the central focus of BMM. function, but also how this relationship might influence the In attempting to explain the emphasis in the approach of allostatic load of an individual, their personal adaptive A.T. Still (the founder of osteopathy) that was placed on capacity to the load, and how this is reflected on their the spine and locomotor system, Irvin Korr repeatedly posture. This includes the continuous postural response of referred to the musculoskeletal system indicating it as “the connective-fascial elements to internal and external stimuli primary machinery of life” (Korr, 1976), where causal fac- that the person is subjected to (Lunghi, 2015a), as well as tors and factors responsible for the maintenance of the possibility that an organism is well compensated from a different disease states can sometimes be established. In postural standpoint and adequately functioning, indepen- this sense, postural changes entail a substantial asymmetry dent of the asymmetry and adaptations which may be of body volumes and kinetic functions, with the consequent present. modification of body patterns, mediated by the sensory readjustment of specific neurophysiological mechanisms. Such postural changes may be found in the loss of harmo- Traditional view and critical review of the BMM nious relations between skeletal segments in three spatial planes as well as in modifications of articular mechanisms For some manual interventions such as osteopathy, the BMM and muscular synergies. This would cause changes in mus- considers the body as an integration of somatic components cle strength and load distribution on skeletal segments. In connected to posture and mechanisms for balance the therapeutic field, different disciplines have developed (E.C.O.P, 2011a). Stress, or imbalance of any kind within interventions of a biomechanical kind with the aim of this mechanism, will have an effect on dynamic function, dealing with possible deviations from the ideal posture. provoking a major expenditure of energy, altered proprio- This approach is historically rooted in the structural and ception, changes in articular structures, impediments to biomechanical aspects of the body and seems to be neurovascular function, as well as changes in metabolism attainable by the correct response to linear mechanisms of (Hruby, 1992). Treatments within this model aim to restore compression, counterweight, tension, effort and balance. optimum posture using efficient and balanced components However, osteopaths who, until a few years ago, while of the musculoskeletal system (Rogers et al., 2002). Perfect being anchored to the concept of the ideal posture, were posture was regarded as the state in which body mass is describing how difficult it was to detect in clinical reality, distributed in such a way so that the muscles maintain their now claim that a well compensated body, regardless of normal tone and ligamentous tensions neutralize the forces asymmetry and postural adaptations that may be present, of gravity (Kappler, 1982). In this regard, Kuchera (2003) might be considered as a balanced function (Kuchera, 2003, describes the osteopathic concept of ‘ideal posture’ as an 2010). optimal posture for a given individual in the attempt to In the light of these differences in interpretation and achieve and maintain a balanced configuration of the body implementation of the concept of human posture and with respect to the force of gravity. However, in spite of biomechanics, the authors intend to explore here whether, being anchored to the concept of the ‘ideal posture’, to what extent and how we should now move away from the Kuchera also reminds us how difficult it is to find it in concept of ideal posture. In recent years epistemological clinical reality. discussions have been initiated on the importance of oste- Osteopaths, chiropractors and many other manual opathic principles in defining the unique characteristics of therapists have given different explanations to malpositions osteopathy (Fryer, 2011). At the heart of these discussions, of body structures, thus developing different approaches to much attention has been placed on how some approaches, treatments. A recent current of thinking and modality of such as the biomechanical-postural-structural model, have intervention in the chiropractic field e Chiropractic been overvalued in the past and what now needs to be Biophysics (CPB) e proposes avoiding short treatment ses- changed (Lederman, 2011). In order to assess these argu- sions focused on the symptomatic area, while promoting ments with critical thought, in 2011 the Journal of Body- long-term therapeutic programs instead, with the objective work and Movement Therapy invited five leading experts of improving the general patient’s wellness as well as the from the world of manual medicine, osteopathy, chiro- balance of the individual’s posture (Harrison et al., 2000). practics and physiotherapy to a debate on the subject CPB is intended to be a systemic scientific model for the (Chaitow, 2011). In particular, they replied to the thesis global care of the individual and goes beyond the concept that, according to Lederman (2011), the use of manual of correcting a local subluxation. For instance, if the pa- techniques to readjust, correct and stabilize misaligned tient’s spinal curves are far from their ‘ideal’ balance, the structure cannot be justified. The experts argued that suggested treatment involves weekly-based sessions of without restoring postural balance, mobility, strength and ‘mirror image’ adjustments, neck and low-back extension resistance, normal functionality without pain may be much traction, and ‘mirror image’ exercises with the aim of more difficult to achieve through rehabilitation strategies. restoring the structure and function of spinal curves within 786 C. Lunghi et al.

6 months to one year (and then to shift to a monthly-based Therefore the LAS represents the tissue response to a given maintenance program). A study from Paulk and Harrison stressor that surely prompts the local function to readapt to (2004) suggests that the CPB method can restore lumbar the new contextual request but also may promote a general lordosis and in some cases reduce symptoms in patients adaptation of the whole system (Chaitow, 2006). The suffering from chronic low back pain, following an accurate adaptation process allows us to understand the concept of analysis of postural deviations and a careful assessment of health in biological terms but also the concept of somatic the spinal curves. Furthermore, this approach has been dysfunction currently defined as “impaired or altered reported to be effective in normalizing cervical lordosis and function of related components of the somatic (body improving symptoms within a year during the follow-up framework) system” (E.C.O.P, 2011b) and classified with study of a 41 years old patient with syringomyelia (Haas the code M99.00 in the International Classification of Dis- et al., 2005). Despite further research being needed in ease, ICD-10 (2010). This is considered to be one of the this field, it is obvious that some authors within the chiro- main factors affecting the economy of the body and the practic community are shifting their therapeutic choice root of many disturbances even in remote areas from where from structural manipulation aimed to normalize a local the dysfunction is located; the normalization of which is subluxation towards a multimodal approach to posture considered central to restoring the normal mobility and based on the use of bioengineering principles and the function of the entire musculoskeletal system. Therefore human ability to maintain an erect posture in a painless and both the concepts of regional interdependence and somatic comfortable manner with low energy expenditure (Harrison dysfunction support the possibility that an altered muscu- et al., 2000). Harrison’s spinal model, in particular, is pro- loskeletal function may influence the impairments of other posed not only as a diagnostic but also as a predictive related body systems. In addition, despite the fact that the model for the development of back pain when the spinal treatment of the symptomatic area is considered as the curves lose their optimal geometrical relationship and primary objective of many therapeutic programs, in the functional balance. light of the concepts described above, it is necessary to The concept that an altered or impaired function in a apply different multimodal strategies which address the specific body region may potentially influence other areas functional interdependency of the body systems, especially or the posture itself is not a new topic in the manual in the case of a recurrent pain pattern that persists even therapy field. In 1955 Steindler proposed a mechanic after the intervention has been delivered in situ (Sueki bioengineering model that interprets the human body et al., 2013). Thus can the treatment of the body posture through a series of kinematic chains and interconnected be considered a valid intervention? Eyal Lederman, an junctions by means of which any movement can potentially osteopath and doctor of research, is one of the authors involve and influence the whole system (as for instance the critical of the BMM, which he has defined as the postural- dorsiflexion of the tibiotalar joint producing ascending structural-biomechanical model (PSB). Following Leder- biomechanical compensatory changes at the knee, hip and man’s reasoning, and the related debate, it is time to lay lumbar spine articular complexes). Nowadays, some au- the foundations for a new concept of BMM from a neuro- thors (Sueki et al., 2013) observe that most of the impair- myofascial and postural biotensegritive perspective. ments identified by manual therapists in their patients are not limited to the biomechanical system itself but include altered processes originating from the overload of other The JBMT debate on the BMM systems that, in turn, influence the musculoskeletal func- tion and clinical presentation. These considerations are Using back pain as an example, Lederman has stated that linked to the concept of ‘regional interdependence’ ac- the PSB model does not work, in that there is no demon- cording to which a dysfunctional unit in a system may strable or credible relation between back pain and postural deliver abnormal stresses to different segments in the same and biomechanical configurations. As a consequence, at- system or in other related systems, hence favoring the tempts to treat and normalize these configurations are establishment of new dysfunctions elsewhere (Erhard and meaningless and a waste of time and resources. Bowling, 1977). In other words, the aberrant mechanisms Lederman reports that manual therapists still cannot initiated and maintained by the primary dysfunctional area justify using manual techniques to readapt, correct, or may induce an allostatic response involving interdependent balance a misaligned structure (Lederman, 2011). The physiological processes of neural, somatic, visceral and suggestion is that a multi-disciplinary rehabilitative strat- biopsychosocial nature. Therefore, in the attempt to pre- egy, focusing on functional motor re-education, behavioral serve the state of health, we must rely on various adaptive methodologies and psychological, cognitive and therapeu- strategies of different kinds: physiological, cognitive, af- tic exercise approaches, is the best way to resolve and fective, psychosocial etc. (Bialosky et al., 2008). Selye prevent dysfunctions such as back pain. The effects of (1956) described the ‘local adaptation syndrome’ (LAS) as manual techniques are, in the best cases, short-lived and a chronic inflammatory reaction to stressful factors such as are largely redundant (Lederman, 2011). It can, however, chemical, physical, biological, environmental, psychologi- be argued that manual techniques permit the recovery of cal and emotional stimuli. The latter trigger a local tissue force and resistance, mobility and postural balance. This reactive response that may impair the blood flow and thus makes it easier to restore function without pain, through a accumulate metabolic wastes even causing changes of tis- multi-disciplinary rehabilitative strategy (Chaitow, 2011). sue texture. The stress load is a variable that moment by Lederman’s statements bring into question the methods of moment may lead the body either to adapt or to activate many manual therapists. He suggests an expansion of the the intrinsic self-regulatory and self-healing properties. PSB model, proposing individualized treatment for each The biomechanical model in manual therapy 787 case, based on the identification of the processes gener- 4. Lee (BSR, FCAMT, CGIMS) criticizes Lederman’s way of ated by the actual state of the patient. Subsequently approaching the BMM, in as far as lower back pain cannot “stimulation/signals/management/care that will support/ be classified from a single cause. The cause of back pain assist/facilitate change” must be provided (Lederman, must be found in a more global approach which also 2011). All this Lederman defines as “the process takes into consideration the clinical experience of op- approach”. This argument is in itself not controversial, in erators. In this pattern it is not possible to isolate a BMM that it suggests that passive manual treatments where the which would be the same for every patient with lower subject is not addressed cognitively, proprioceptively and back pain. Therefore, the BMM described by Lederman is interoceptively, are of little value in the process of healing not considered accurate or reliable. and recuperation. At the 7th Interdisciplinary Congress on 5. McGill (BPE, MSc, PhD), finally, strongly criticizes Low Back & Pelvic Pain in 2010 many lecturers echoed and Lederman’s BMM approach, in that back pain is a subject sustained Lederman’s position in many ways. There were so vast that it cannot be schematized into a protocol. also lecturers who proposed alternative ways of breaking Every individual will need a personalized therapeutic the impasse, as in the case of O’Sullivan who presented a approach. Studies by Lederman are therefore of little biopsychosocial approach to back pain, paying particular applicability in that they treat this subject from a attention to the mechanisms at the root of the changes that monodimensional perspective and do not take into can cause pain (O’Sullivan, 2010). The cognitive and re- consideration the actual evolution of back pain (from educational healing strategies O’Sullivan suggested are the dehydration of discs, to modifications in the func- less extreme than those of Lederman. tions of the articular facets and the consequent passage In order to critically evaluate these arguments, The of the transference of pain from disc to articular facet). Journal of Bodywork and Movement Therapy invited five The central sensitization will influence the connection authoritative world experts in manual medicine, osteop- between pain, mechanical and functional factors and athy, chiropractic and physiotherapy to respond to Leder- the correction necessary for the patient to finally reduce man’s thesis (Chaitow, 2011): the neuronal response. Thus the connection between pain and biomechanical factors is variable within the natural process of back pain. McGill observes that 1. Gary Fryer (PhD, BSc Ost, ND) states that although evi- Lederman had omitted particularly important research dence connecting posture with lower back pain is lack- cited in his article, particularly those which tend to ing, there exists a strong rationale explaining how favor a relation between a BMM and the probable posture can generate pain. An asymmetric posture can development of lower back pain, such as the neuro- create the overloading of ligaments and other struc- muscular asymmetry which anticipates an eventual tures, may contribute to the exhaustion of an in- episode of lower back pain. Lederman seems to have dividual’s reserve of energy, which translates into confronted the arguments without taking into consider- tension and pain. Fryer concludes by stating that the ation the multiple inherent aspects of back pain such as BMM was overvalued in the past, but that it is best to incorrect posture, the mechanism of therapeutic exer- consider the multi-dimensional nature of pain to estab- cise and its effectiveness, the kinematics of movement, lish a patient centered holistic approach. neurological function, the mechanism of pain, damage 2. John C. Hannon (DC) believes that the criticisms of to the spine, patient classification, the loading of tis- Lederman are too simplistic. He states that the psycho- sues, etc. logical aspect of the patient should be considered essential in the care of the individual. He reports the effectiveness Even though it seems the work was without rigor, this of traditional massage that is able to obtain immediate discussion can be the start of more accurate and spe- results on pain through the use of heated and padded ta- cific scientific research. These findings do not seem to bles, longer duration of treatment and the consequent have been conceived in relation to the clinical practice deeper relaxation of the patient. He believes that manual of manual therapists and osteopaths, still busy today therapy should not be based solely on the commitment of correcting misaligned or asymmetric structures. In spite the operator to make a diagnosis, but to unite the psy- of this, a more modern idea of “posture” can be iden- chological state of the patient to the treatment, thereby tified with the strategy adopted by the neuromyofascial combining art and technique to make each individual an system to react to the force of gravity and proprio- active and not a passive part of the treatment. ceptive and interoceptive afferent stress or allostatic 3. Irvin (DO) responds with a more complex postural load. pattern based on three fundamental systems: the feet, the sacrum, and the central nervous system (CNS). In the case of an imbalance in one of these three systems, a Innovation and current evidence on human modification of the entire posture with a resulting onset biomechanics and posture of pain may occur. It is not always possible to demon- strate a direct relationship between the BMM and the Man’s adaptation to the force of gravity and erect posture presence of pain, but tissue modifications which are a seems to be achieved through complex evolutionary consequence of incorrect posture can maintain or mechanisms in myofascial and skeletal tissue with the aggravate a pre-existing imbalance. The BMM is not purpose of improving stability with minimal energy expen- considered in decline, but thanks to study and research, diture (Zavarella et al., 2015). In the erect position, normal is in development, revision, and integration. muscle tone maintains the body standing with the minimum 788 C. Lunghi et al. of energetic expenditure (almost 7% more) compared to the the tension on the cellular membrane (Trotter, 1993). This supine position (Masi and Hannon, 2008), often for pro- assures that the principal stress vector on the cellular longed periods without causing fatigue. Modern research membrane will be tangential to the tension, minimizing the (Masi et al., 2010) suggests that human muscle tone at rest concentration of stress. is related to the passive or contracted musculoskeletal Thus, musculoskeletal tone at rest is an intrinsic visco- tissue. This would result from its intrinsic viscoelastic elastic tensile property, which expresses itself within the properties, which is the base level of passive muscle ten- kinematic chains of the body, organized tensegratively. sion and its resistance to passive stretch which contribute This function is inseparable from the corresponding fascial to the maintenance of postural stability. Myofascial tone is components and the tendino-ligamentous structures. In defined by Masi et al. (2010) as Human Resting Myofascial other words, the HRMT is a passive myofascial function, Tone or Tension (HRMT). Conversely, the co-contraction of which operates within the tensile network of tissues. This muscle is under active neuromotor control, which provides passive tension is independent from CNS activity, and is higher levels of tone for better stability. Functionally, the derived from the intrinsic molecular interaction of actin HRMT is integrated with other networks of passive tension, and myosin filaments in the repeating units of sarcomeres; such as fascial and ligamentous tissue to form a bio- however, muscular contractions activated by the CNS tensegritive system (Box 1). generate much more tension, and are transmitted by the Evidence suggests that the transmission of tension is a contractile elements of fascia (Masi and Hannon, 2008). basic property of the surface of muscle cells, and that the Nevertheless, myofascial tissue generates integrated layers specific morphologic junctions are the result of a dynamic and networks of passive and active tensile forces, which interaction between muscle cells and the tissues they provide stabilizing support and control for body movement adhere to (Trotter, 1993). The sites most studied in the (Box 2). transmission of tension are the distal portion of muscle fi- A complex analysis of HRMT is in the evolutionary phase bers, where in fact they are in contact with both connec- and has, through electromyography, identified silent signals tive and epithelial tissue. The morphological and molecular of lumbar muscles in an erect, relaxed position. The HRMT’s similarities of musculotendinous junctions in different ani- passive role in contributing to the maintenance of a bal- mals suggest that the challenge to create a strong adhesive ance posture is sustained by the biomechanical principles junction between muscle fiber and tissue with different of elasticity, tension, stress, rigidity, and myofascial ten- physical properties is essentially the same for all muscles. segrity. More research is necessary to determine the mo- In most animals, aside from phylum, the distal portion of lecular base of HRMT in sarcomeres, the transmission of muscle fiber is typically folded, producing a junctional tension between fascial elements which envelop the micro interface which significantly reduces the absolute value of and macro anatomical structures involved, and the way in which the “myofascia” help to maintain an efficient, pas- sive and balanced posture. Interestingly, a significant deficiency or excess of postural HRMT may lead to symp- Box 1. Biotensegrity and its implication in manual toms of musculoskeletal disturbances and pathologies. For therapy and research. instance, axial myofascial hypertonicity can be a predis- posing factor in ankylosing spondylitis (Masi et al., 2010). Through the principle of biotensegrity, the body is able This deforming, often progressive, condition leads to ri- to integrate different stimuli from mechanical forces, gidity and bony lesions localized at the osteotendinous which are distributed nonlinearly across the structure, junctions, with consequent excessive concentration and thus translated into biochemical signals, to finally transmission of force, up to tissue micro-lesions and mal- maintain the functional and structural integrity of the adaptive inflammatory reactions. system (Swanson, 2013; Chaitow, 2013). From mole- Considering such an evolution of the concept of posture cule to cell, and eventually to tissue and organ, the and biomechanics, and evaluating the role in which HRMT biotensegrity structure is, at each level, intimately can influence postural balance, we have encountered connected into a hierarchical organization. This helps several factors, each different yet intertwined. Each one of us understand how forces applied by a manual thera- these responses is significant in bringing about the final pist on the skin bring about responses either at a result; the storage, or memory, of responses in fascial tis- cellular level, arriving at changes in gene expression sue and the consequent individual postural patterns (Tozzi, (Maas and Sandercock, 2010), or at a global level, 2014). A dysfunctional tissue memory could therefore take leading to posturaladaptations(Cao et al., 2013). place during the infiltration of fibrous tissue and meshwork The principles of biotensegrity can thus be used to collagen in the nodal points of fascial bands, along with a bridge the divide between researchers and clinicians, progressive loss of elasticity. Alterations on the fascial level in addition to assisting research into the active related to architecture, contractility, viscoelasticity, fluid mechanisms of manipulative medicine. In fact, the dynamics, acid/alkaline balance, somatic and autonomic mechanotransduction, or rather the process of neuro-fascial interactions, metabolic, piezoelectric and converting mechanical energy into chemical energy epigenetic factors, can interact in the onset of somatic through specific cellular and molecular transmitters dysfunction, as suggested in the neuro-fasciagenic model could represent one of the mechanisms of (Tozzi, 2015b). It is proposed as a model unifying much interaction between manual intervention and tissue explored neurogenic aspects with mechanisms related to response (Tozzi, 2015a). the fascia underlying the genesis and maintenance of so- matic dysfunction (Fig. 1). Changes in the relation between The biomechanical model in manual therapy 789

static and linear. Yet the operating assumption of many Box 2. The myofascial “skeleton” and its function in operators seems to be firmly tied to the classic BMM, even body movement and posture though this would not be accepted by many authors and theories, as anything more than a holistic idea. Passive myofascial tension, independent of CNS con- trol, furnishes a basic stabilizing component to aid and maintain a balanced posture. In this regard, Wood The proposed revision of the BMM Jones (1944a, 1944b) demonstrated that muscles and tendons, which find a diffuse insertion on the fascia, Principles and aims use these extended sheets as a homologous function as in the ectoskeleton of invertebrates. This refers to a The BMM frames the patient from a structural or mechan- skeleton of soft tissue for muscular insertions called ical perspective. The structural integrity and the function ‘ectoskeleton’. Tendon networks display a distinctive of the musculoskeletal system are interactive, interde- feature in the hands and feet. On the back of the pendent with neurological, circulatory, respiratory, meta- hand, for example, there is a series of flat extensor bolic and behavioral systems (Hruby, 1992). Fascia and tendons, which expand themselves from underneath connective tissue can serve as a unifying characteristic of the extensor retinaculi in the direction of the fingers. all these elements (Tozzi, 2015b), playing an integrative The tendons are connected to each other by highly role on mechanical forces throughout the whole body. Ac- variable fibrous bands known as “juncturae tendinum” cording to Zink and Lawson (1979), by exploring posture (von Schroeder and Botte, 1997). Together with the through myofascial patterns, the operator is able to discern tendons themselves, and their associated fascia, the signs of the functions and dysfunctions from an these fibrous bands contribute to the formation of a anatomical, physiological and psycho-social point of view. complex network of tendinous tissue on the back of In fact, the concept that the perception of the body, the hand, which was probably developed from one environment, emotions and psyche affects posture (Sypher, embryonal blastoma. The bands are probably 1960) is intrinsically related and integrated in the BMM important in the spacing of the extensor tendons, (Irvine, 1973). Individuals suffering from mood disorders channeling forces between them, and coordinating manifested rigid and imbalanced postural patterns. In the extension of the finger (von Schroeder and Botte, contrast, in a healthy individual, the posture tends to show 2001). This structure represents a key to the a soft quality and good body flexibility. This implies good extensor surface of the hand, thanks to its adaptability and homeostasis. The BMM assesses the indi- integrated function of the internal tendon network. vidual by taking into consideration that “the body is a unit” As such, any particular function and its single and that the adaptations are parts of a tensegrity system, in elements serve this primary role. Contemporary which a minimal change in any body region can cause global anatomists use the term ‘super tendons” to describe biomechanical changes, at both tensional and ergonomic anetworkoftendonsandcloselyrelatedstructures level. Biotensegrity is the ability of the musculoskeletal (articular capsules, tendon sheaths, pulleys, system to adapt itself to different elements of continuous retinacula, fat pads, and bursae) where the complex tension and discontinuous compression, in order to maxi- internal function is superior to each singular mize efficiency and comfort (Swanson, 2013). An imbalance structure (Benjamin et al., 2008). Recently, the in this relationship can influence the function of all other complex interaction of various digital tendons has physiological systems. In the same way, changes to postural been evaluated in the context of the co-evolution of mechanism and related connective tissue often influence the body and the brain, allowing the principle of “non vascular, lymphatic, neurological function, metabolic and neural somatic logic” to emerge, on the basis of behavioral responses, independently of etiology. This pro- cellular function (Valero-Cuevas et al., 2006). cess compromises the individual’s capacity to adapt to various stressors or to recover from injuries, and to prevent further damage. In the first place, posture can be considered as the result the connective structures and their functionality, also of the dynamic and constant interaction of two groups of detectable by palpation, would be the result of changes forces: the force of gravity and the force of the body’s involving the tissues from the cytoarchitecture as far as the reaction to the environment. A postural deterioration in- extracellular matrix, resulting in structural, chemical, hy- dicates the individual’s loss of ability to efficiently coun- drodynamic and bioelectrical repercussions over the whole teract gravity. Respecting the rules of economy, comfort fascial network of the body. This would require a tissue and pain, the “optimal posture” for a given individual at a adaptation to local stress through a global connective given chronobiological moment will be “the best attempt” reorganization (Tozzi, 2015b). Consequently, these changes that the body makes through the integration of sensory in myofascial tissue can alter the activity of the related information and the best distribution of body mass. This higher centers responsible for both proprioceptive and decreases muscular-postural energy expenditure and har- interoceptive sensorial integration, and motor and postural monizes the compressive forces on the weight-bearing control (Schabrun et al., 2013; Tsao et al., 2008). structures through a balanced ligamentous tension. If the Hence the evolution of a new concept of posture is body presents structural changes, the operator will identify emerging, leading to a revised concept of BMM, which if this change is subject to an increase in energy demand or transcends the idea that posture is solely compressive, obvious pain. In this case we can define the “postural 790 C. Lunghi et al.

Figure 1 The fasciagenic model of somatic dysfunction (Tozzi, 2015b): the diagram shows two main interacting fascial changes e structural and functional e that may underlie somatic dysfunction and account for its palpable features (tissue texture changes, asymmetry, restriction of motion, tenderness). They may occur through various types of interactions and under different kinds of influences. Several dysfunctional events may produce different forms of forces and responses in the fascia with consequent dysfunctional processes. imbalance” which stresses the soft tissues sensitive to pain selection (Selye, 1956; Schulkin, 2003). Adaptation is the and is affected by events and/or structural changes, such main element of stress response, by which a biological as somatic dysfunction. This will create a predisposition to mechanism restores balance and minimizes the effects of gravity-related tissue strain and pathophysiological re- variables, through the interdependence between structure sponses resulting in various symptoms such as fatigue, back and function. Therefore, posture can be interpreted as the pain, headaches, etc. (Irvine, 1973). temporary result of the individual’s current ability to adapt Secondly, the concept of posture needs to be integrated to the present allostatic load through the dynamic inter- within the whole context of the individual. In fact, action of extero-proprio-interoceptive information inte- remembering the unity of the body, this leads to an eval- grated at a neuromyofascial level. uation of the integration between structure and function to Zink proposed that myofascial compensation pivots on understand the connection between how two people who four anatomical ‘transitional areas’ (lumbopelvic, thor- have the same dysfunction can take different paths: acolumbar, cervicothoracic, craniocervical) that play a compensation/adaptation or failure/inability to adapt. The major role not only in defining the spinal curves, but also in human body is capable of adapting itself to several envi- compensating regional patterns, both during the periods of ronmental or internal changes. What does this mean in development and learning but also in adult life. The biological terms? Today allostasis seems the most precise concept of the common myofascial pattern is accepted in response, defined as the capacity of physiological systems osteopathy as it, thanks to palpatory tissue tests, and can to maintain stability by means of change and adaptation furnish “a quick look” at the interrelationships existing (Schulkin, 2003). It is a metasystem of regulation which between body, mind, spirit, and the allostatic load of a maintains the stability of essential systems for life (ho- person (Zink and Lawson, 1979). This compensatory myo- meostatic systems). The function of allostasis is the fascial pattern represents a useful, functional, and bene- consistence of systems through various homeostatic con- ficial response without manifesting evident symptoms on trols, but actually the “fitness” of the system in respect to the part of the musculoskeletal system, as in, for example, the environmental demands on the organism by natural the consequences deriving from allostatic overload, The biomechanical model in manual therapy 791 structural asymmetry, that of lower limb discrepancy and Table 1 Main features of the classic BMM and the revised its overuse. Postural imbalance, however, describes the BMM. same phenomenon with the difference that the changes of adaptation are dysfunctional, symptomatic, and therefore Classic BMM Revised BMM highlight the failure of homeostatic mechanisms. Concepts Perfect posture is Posture is an adap-   In discussing the modalities for applying the BMM, the regarded as the tive function of a authors therefore advance the following proposal: the state where body multifactorial na- multifactorial nature of the adaptations and biomechanical mass is distributed ture, an indicator of allostasis. The term posture has inherent ideas of move- in such a way that the individual adap- ment, fluidity, action and reaction, integration, reciprocity, the muscles retain tive capabilities in tensegrity, economy, self-organization, adaptation, their normal tone dealing with complexity, and multi-sensory experience. And this makes and ligamentous stressors of various it so “complex” that a systemic perspective is necessary to tensions neutralize origin and nature. It gain a comprehensive understanding. Furthermore, in the force of gravity. manifests through posture we find the same features that are found in com- Efficient posture variations that can  plex systems, such as the non-linear thermodynamics and permits good be “seen”, but “not the ecology of autopoietic systems (Zhang et al., 2014). mobility and perfor- predicted”, inde- This multifactorial nature requires a comprehensive mance of the pendent of asymme- approach that considers: musculoskeletal tries which may be system. present. 1. the evaluation of the integration between a structure Posture is seen from  and its related function, in order to observe to what a neuromyofascial extent this relationship could influence the allostatic perspective and in load of an individual as well as their ability to also adapt terms of bio- through postural reflexes; tensegrity. It is 2. the neuromyofascial component in the continuous identified through postural response to internal and external stimuli which the strategy adop- the body receives and integrates through the intero- ted by the neuro- ceptive and proprioceptive senses; myofascial system 3. the biopsychosocial influences on a given person at a aimed at reacting to given time, that makes the adaptive response much the forces of gravity more individual and unique. and to stimuli given by extero-proprio- From this follows the complexity with which this adap- interoceptive tation manifests itself, in a non-linear way, permutable, afferents, as well as unpredictable, but observable. This, today, according to to the allostatic load the authors, is the necessary revision to guarantee the of the individual. evolution and viability of BMM (Table 1). The complex Implications Body adaptation to The postural bal-   relationship between inputs (visual, vestibular, occlusal, the force of gravity ance is achieved and somatoemotional, proprioceptive) and outputs (postural and to the upright maintained through and adaptive compensation) manifests itself in the myo- posture is the result a dynamic tense- fascial tone (Masi and Hannon, 2008; Masi et al., 2010) in a of the integration of gritive relation be- perennial search for new dynamics of balance. The revised somatic components tween neuro- BMM thus proposes a posture to be read and not corrected, related to posture myofascial and interpreted and not judged. An ideal posture to be reached and balance mecha- skeletal components at all costs, therefore, does not exist. Instead a posture is nisms (receptors). aimed at improving an epiphenomenon: the efferent result (musculoskeletal) Stress or postural stability with the  of an underlying afferent complexity (neuromyofascial). imbalances can least possible The treatment possibilities offered by this proposed revised affect functional expenditure of BMM do not then work on the efferent reflex arc (motor), dynamics causing a energy. but on the afferent reflex arc (sensory), aiming to identify greater expenditure The muscular tone  and treat altered integrated somatic information that has of energy, impaired of the neuro- caused the postural alteration (Zavarella et al., 2015). proprioception, myofascial system For example, we can find a reduction of movement in an joint disorders and not only depends on ankle caused by post-surgical adhesions which, indepen- impediments to neuromotor control dent of the applied surgical procedure, may become neurovascular and but also on intrinsic traceable in the underlying levels (from skin to bone, from metabolic functions. viscoelastic charac- fascia to nervous tissue). The information coming from the teristics of muscular scarred area comes not only from the skin, but from any tissue at rest (HRMT) and all tissue involved in the trauma and the intervention. integrated into a The same changes will be observed in the efferent system (continued on next page) when the messages return to the ankle and motor system, 792 C. Lunghi et al.

Table 1 (continued) Table 1 (continued) Classic BMM Revised BMM Classic BMM Revised BMM complex, passive “ideal posture”) of tensional meta- the individual in system composed of that given fascia, muscles, lig- moment; aments, capsules o Balancing aberrant and articular ele- postural ments. Excesses or responses;; reduction of HRMT o Favoring the inte- can lead to disorders gration of extero- and pathologies in intero- the musculoskeletal proprioceptive system. afferents; The minimum o Optimizing indi-  change in any part of vidual responses to the body may cause the existing allo- a global biomechan- static load through ical re-adaptation a salutogenic pro- that is both cess which in- ergonomic and volves the active tensional which may participation of influence the person in neurological, healthy daily ac- vascular and tivities and lymphatic functions lifestyle. as well as behavioral and metabolic responses, thus altering the global postural response. Along the path- independent of ways of various messages, a symptom can emerge, probably etiological factors. in the area least capable of “compliance” (Bordoni and Applications Analysis of the rela- Observation of   Zanier, 2013), as, for example, in the spinal control of tionship between posture by means of the ankle which can become symptomatic with relative body attitudes (body an assessment pro- hypertonia in the paraspinal muscles, painful to the touch. volumes) and the cess which considers When stimulated in this way, the sympathetic nervous force of gravity. the integration of system can produce local vasoconstriction of the ankle and Analysis of the or- related structures  again disturb the postural balance (Macefield, 2005; ganization of kine- and functions and Mouchnino and Blouin, 2013). Frequently, the patient de- matic and static how this relationship velops sensory symptoms, even in the case of a small, chains in relation to influences the allo- aesthetically acceptable scar, because the adhesion can antigravity mecha- static load and the create entrapment along the course of the nerve (such as nisms and spinal and individual’s adaptive the peroneal nerve, citing the ankle as an example). vestibular reflexes. capacity; postural Trapping will not only be of mechanical origin, but also in Tracing the loss of imbalances conse-  response to the afferent postural system which induces harmonious re- quently are identi- involuntary local and segmental contraction (Gilbey, 2007; lationships between fied by assessing Raju et al., 2012). As a result of the constant stimulation skeletal segments structural variations of the pain, the CNS and peripheral nervous system adapt causing alterations which increase the and change their structure, creating a vicious cycle in muscular strength energy requirements (Zwerver et al., 2013; Day et al., 2012). Even the visceral and load distribution of the body or nociceptive stimulus and the interoceptive protopathic on skeletal seg- cause/favour the pain, carried by the C fibers, produces the same effect, as ments on three onset of pain. the central sensitization is established at a subcortical level spatial planes. The neuro-muscolo-  (brainstem and/or spinal cord) and does not need to come Restoring optimal skeletal  to consciousness (Ja¨nig, 2013). The neurologists who work posture through the components, the on scar tissue with prolotherapy and neural therapy found balanced and effec- myofascial patterns the same mechanism of altered afferent information (field tive use of musculo- and transitional of interference) which can create the basis for more serious skeletal areas are used for: organic and postural disorders (Gary, 2011). Therefore components. o Restoring “optimal trauma, scarring and adhesions at any level from teeth to posture” (not feet can alter the dynamics of walking, chewing, and the The biomechanical model in manual therapy 793 proper distribution of load (Rowe et al., 2005; Skraba and research in this direction is still necessary (Posadzki et al., Greenwald, 1984; Harrison et al., 2005); as in the case of 2013). a scar on the elbow that can cause postural problems The postural evaluation process, should firstly inform related to the gait, cervical and lumbar pain (Bordoni and the operator if the patient is able to respond positively to Zanier, 2014). In addition, some authors, hypothesize that postural treatment in terms of time, cost and effective- the presence of a dysfunctional vertebra may develop pain, ness. Subsequently, it should inform the operator if the increased muscle tone and altered weight bearing with person’s posture: consequent postural changes, because of a dysfunctional autonomic efferent pathway, influenced by electrical and 1) plays a role in the revealed clinical picture; biochemical afferents (Brumagne et al., 2008; Shirzadi 2) represents a significant risk factor for current or future et al., 2013). Every tissue can potentially become a pain, dysfunction or disease; source of aberrant afferent stimuli that in turn can elicit 3) is the result and the best possible adaptation to autonomic efferent reflexes with consequent changes in pathogenic causes and damage on a neuromyofascial posture via the influence on myofascial bands (Kumka and level; Bonar, 2012; Benjamin, 2009) or myofascial tissue in gen- 4) is the manifestation of local, segmental and/or global eral, such as the subcutaneous, aponeurotic fascia, dura imbalances in the interdependent relationship between mater, perimuscular, perivascular and perinevrial fascia. In structure and function. addition, the fascial system of the limbs should be consid- ered as communicating with the whole body, in particular In the evaluation process (Fig. 2) the operator assesses through the thoracolumbar fascia (Benjamin, 2009). The global (myofascial compensatory patterns) and local (so- latter, if undergoing dysfunctional processes, causes matic dysfunction) tissue adaptability that are clinically arthrokinematic abnormalities to the back or shoulder re- relevant for postural adjustments. For this purpose, the gions (Willard et al., 2012). In fact, when the fascial tissue BMM implies: is not in its normal physiological condition, the fascial re- ceptors such as Pacini and free endings may become noci- 1. Enlistment of the person for manipulative treatment, ceptors and promote the onset of a symptomatic complex through a differential diagnosis and an objective evalu- (Benjamin, 2009; Kumka and Bonar, 2012). By applying this ation. This requires the operator to assess the underlying model in treatment, the neuromyofascia may be primarily causes of pathology in order to understand the influence involved and activated so that it can respond to postural that the disease has on energy levels and body me- realignment (Dunnington, 1964). The treatment of fascial chanics. Some diseases, in fact, can affect posture on compensation patterns, also thanks to interventions in specific levels and can have specific consequences. An transitional areas and the corresponding body diaphragms example would be a spondylolisthesis at L5-S1, which (pelvic/thoraco-abdominal/superior thoracic/tentorium) affects most of the sagittal plane, having the effect of has produced positive physiological changes in “healthy” anterior postural displacement, resulting in iliolumbar people, such as decreased respiratory and heart rate, in- strain, as well as aggravation of lower back pain and crease in tidal volume and decreased skin resistance nerve root compression. This kind of presentation could (Ortley et al., 1980). This approach may also be useful in lead to the referral of the person to their doctor (Tozzi, planning preventative treatment for a general population 2015c); not affected by a manifest disease or musculoskeletal dis- 2. Verification of the presence of postural compensation order, as in the case of the subjects enrolled in the study of and decompensation (Chaitow, 2009). In this phase, the McPartland et al. (2005), where cannabimimetic, anxio- operator observes the person to assess their individual lytic, sedative and analgesic effects were found. This study adaptive ability, through postural tissue responses suggests that osteopathic manipulative treatment, and, in (Lunghi, 2015c). Using a specific test of tissue prefer- particular, the work on fascial compensation patterns, can ence in terms of quality of motion for the four transi- be associated with and mediated by the endocannabinoid tional areas, Zink and Lawson (1979) argue that it is system. possible to classify myofascial patterns in a clinically useful way (Box 3);

The operator may proceed with more comprehensive Examples of the application of the revised BMM in screening tools which indicate current levels of function- evaluation and clinical decision making processes ality and can be also repeated to assess progress during treatment: The revised biomechanical viewpoint guides the operator in the evaluation of somatic dysfunctions related to the pa- tient’s posture, as well as in the treatment of structural, Crossed syndrome patterns: are indicators of relative vascular, neurological, metabolic and behavioral function  postural alignment (Frank et al., 2009)(Box 4); by re-informing the neuromyofascial component. The Assessment of the balance in monopodalic load with objective is to optimize the patient’s adaptive potential by  eyes open and closed (Box 5): this is a neurological restoring structural and functional integrity. Some evidence indication of the integration between exteroceptive and supports the possibility of improving dysfunctional postural interoceptive input, as well as of the efficiency of cen- patterns through osteopathic manipulative treatment tral processing and motor control (Bohannonn et al., (LeBauer et al., 2008; Brooks et al., 2009), although further 1984); 794 C. Lunghi et al.

Figure 2 Evaluation and clinical decision processes of the revised biomechanical model: the operator finalizes a clear picture of the global and biomechanical postural condition of the patient through the application of a process of evaluation and selection of the most appropriate therapeutic approach.

Assessment of core stability (Norris, 1999; Chaitow, (E.C.O.P, 2011b). However, somatic dysfunction is  2009): indicator of the relative importance of muscles nowadays described as a manifestation of ‘local adap- (transversus abdominis, obliques, diaphragm, erector tation syndrome’, or a mechanico-physiological somatic spinae, multifidus, etc.) that protect the spine. For response with the purpose of reacting, adapting to instance, the ability and coordination of the patient in exogenous and endogenous stresses which may be acting maintaining the lumbar spine stable during the phase of upon us (Fusco, 2015). Tissue reactions would allow the loading allows an assessment of the core stability. In a survival or the optimal function at a given context of the bent limbs test the patient, in supine position with the individual through the modification of four main pa- knees and hips also flexed, places a hand between the rameters: change in tissue texture, positional or func- lumbar region of the spine and the supporting surface. tional asymmetry, reduction of range and/or quality of Once becoming aware of the pressure of the column on movement, and tenderness or sensitivity to palpation supporting surface, the patient is asked to bring the (usually referred to by the acronym TART). navel towards the spine by contracting the transverse 4. Application of the inhibition test muscles of the abdomen and the multifidus muscles. The patient is then encouraged to gradually extend a leg, The assessment can identify different somatic dysfunc- sliding their heel along the supporting surface. If the tions, when the severity, the accessibility, the clinical eccentric contraction of flexors of the hip exceeds the relevance of the subject to the disorder is needed to be stability of the pelvis, an increased lumbar lordosis will understood. This can be determined by the detection of manifest before the limb is completely extended, indi- one or more of the qualitative parameters of the TART cating insufficient core stability. acronym in the dysfunctional area, but also from the 3. Verification, by both local and global testing, of the anamnesis, and the outcome of specific tests, including the presence of somatic dysfunction, that is an altered inhibition test. It consists in the application of manual interrelationship between structure and function vectorial induction stimuli for a few seconds on an area of affecting joint or soft tissue (viscera, connective tissue, somatic dysfunction, while the immediate response is muscles), with an influence on the postural pattern evaluated at a distance on another dysfunctional area, The biomechanical model in manual therapy 795

Box 3. Zink myofascial patterns (Lunghi, 2015c). Box 4. Crossed syndrome patterns (Chaitow, 2009). Relative postural alignment indicators that occur with: Ideal fascial patterns (craniocervical/cervicothora-  cic/thoracolumbar/lumbosacral transitional areas - Upper crossed syndrome, which concerns the short- show a minimal alternating preference for ening and tightening of the pectoralis major and sidebending-rotation): minimum load adaptation pectoralis minor muscles, the upper trapezius, the transferred to other regions, the condition of tissues elevator scapulae, erector spinae and sub-occipital that can also indicate the capacity of the individual muscles, as well as the lengthening and weakening to maintain the alternation of homeostatic/allo- of the deep flexors of the neck, the serratus, middle static processes; and inferior trapezius muscles. These functional Compensated fascial patterns (craniocervical/cer- changes favor conditions of cervico-thoraco-brachial  vicothoracic/thoracolumbar/lumbosacral transi- pain; tional areas show a clear alternating preference for - Lower crossed syndrome, which indicates muscle sidebending-rotation): which alternate direction tension in the quadratus lumborum, psoas, lumbar from one area to another and usually with some kind erector spinae, hamstrings, tensor fasciae latae and of adaptation. This tissue aspect can be an indicator piriformis muscles, which is associated with a of a compensated allostatic state; lengthening of the gluteal and abdominal muscles. Uncompensated fascial patterns (craniocervical/ This can induce a combination of lumbopelvic  cervicothoracic/thoracolumbar/lumbosacral transi- stresses which can lead to conditions of lower back tional areas present with a non-alternating prefer- pain. ence for sidebending-rotation): which do not alternate, and which are usually a result of an allo- The operator proceeds with palpation of the areas static overload, or a macro trauma or repeated affected by the functional changes described above, microtraumas. A condition that exceeds the capacity after requesting active movements of the patient, to of the individual to cope with adversity; a condition evaluate the sequence of activation of different of allostatic overload which corresponds to the muscles of the limb. For example, hip abduction phase of resistance or exhaustion in the theory of movements may be requested to verify if this move- the ‘general adaptation syndrome’ of Selye. It is ment takes place using the ideal sequence of when the allostatic load is superimposed on excep- contraction (tensor fasciae latae, gluteus medius, and tional or unforeseen disorders, resulting in an un- after 20e25 of abduction the quadratus lumborum), necessary and harmful overload. or if hyperactivity is manifested (e.g. tensor fasciae latae and quadratus lumborum which would denote a weakening of the gluteus medius). and/or on a compensation pattern, and/or on a related function (e.g. postural control). So, for example, the temporary inhibition of a disturbing influence in dysfunc- with respect to the dysfunctional somatic structure. A tional tissue, by a slight manual pressure in situ, can maximalist approach is then the recommended modality determine if there are outcome variations of functional of intervention in this case. In the maximalist approach, tests, such as the time of maintaining the balance in adaptogenic global techniques (such as CV41 or total monopodalic support, or semeiological tests such as the body unwinding2) are usually used, even if sometimes, Lase`gue or Soto Hall tests. Any variation in the response of however, the operator can use an integration of the test after or during the inhibition of a dysfunctional different approaches of a global nature (such as the area, suggests the dominance of the dysfunctional struc- General Osteopathic Treatment3 or the balancing of the ture over the postural function. On the contrary, the diaphragmatic system), in order to reduce the allostatic absence of such a variation suggests the dominance of the overload (represented in this model by postural over- postural function over the dysfunctional structure. load), to normalize any aberrant neuromyofascial re- flexes, to improve postural asymmetries, to optimize the 5. Selection of the therapeutic approach synergy of musculoskeletal elements and to favor the If the evaluation reveals a decompensated myofascial integration of somatic dysfunction in an optimal neuro-  pattern, a positive crossed syndrome test, a monop- myofascial postural function. odalic load test that does not change when the somatic If the evaluation reveals a compensated (or minimally  dysfunction is inhibited, a positive core stability test, it uncompensated) myofascial pattern, a negative crossed suggests the dominating influence of the postural/ syndrome test, a monopodalic load test that does biomechanical function is undermining salutogenesis

2 An indirect dynamic fascial technique that consists in the 1 Abbreviation for compression of the fourth ventricle; a cranial unfolding of the whole body dysfunctional pattern enclosed in the technique applied to the occiput that seems to produce global body inherent fascia motion. effects such as enhancement of fluids movement, influences on the 3 Maximal treatment approach based on a specific routine of immunity response, changes in the autonomic output. articulatory techniques applied throughout the body as a whole. 796 C. Lunghi et al.

emerged, in order to provide a comprehensive and per- Box 5. Assessment of balance in monopodalic load. manent correction of postural and structural factors. So, as suggested by Lederman (2011), it proposes a ’process The monopodalic balance test evaluates the function approach’, whose purpose is to identify the processes un- of postural control, which correlated with muscle co- derlying conditions of patients and to provide stimulation, ordination, motor control (Winters and Crago, 2000) signals, management and care that will support, assist and and basic myofascial tone (Masi et al., 2010), is facilitate change. To give an example, nutritional advice expressed through a complex relationship between and physical activity exercises that fill the gap that a pas- balance and interoceptive, proprioceptive and sive manual treatment (without the subject being cogni- exteroceptive sensory mechanisms. They involve tively and proprioceptively involved) leaves in the healing somatic and visceral motor efferents, which are in process and in the recovery of the person. For the effective turn related to emotions and physiological responses implementation of dietary advice a progressive approach (Charney and Deutch, 1996). may be useful tailored to the needs of the individual pa- The test consists of the following stages (Chaitow, tient (Walker and Reamy, 2009). As regards physical activ- 2009): ity, however, until now, most sports training, be it amateur or competitive, has placed emphasis on the classical triad 1) The patient is asked, barefoot in an orthostatic of muscle strength, cardiovascular conditioning and position, to lift one foot (the raised foot should not neuromuscular coordination, perhaps leaving out certain be resting on the supporting limb). The knee should aspects related to movement. Some researchers together be raised as high as possible within the limits of with bodyworkers nowadays suggest training which works comfort; on the fascial network, considering it might be of great 2) The patient is asked to maintain their balance for importance to athletes, dancers and common people 30 s with eyes open; wanting to benefit from movement (Schleip and Mu¨ller, 3) The test is then repeated with the contralateral 2013). Schleip and his colleague Mu¨ller, argue that if the limb; fascia is well trained, that is, in such a way as to make it 4) After having carried out the test with eyes open, elastic and resilient, then it may be relied upon to perform the patient is asked to identify and visualize with effectively, with a high degree of prevention as regards eyes closed a point in front of them to then attempt injuries and their recurrence. In the osteopathic field, on to maintain their balance for 30 s. the other hand, exercises have been described and used to the management of local adaptations, such as the preven- Based upon their observation of the patient during the tion of recurrent musculoskeletal (De Stefano, 2011) as well test, the operator gives them a score corresponding to as visceral dysfunction (Brazzo, 2011). Finally, global ex- the time of maintaining balance achieved by the sub- ercises have been proposed dealing with individual energy ject, i.e. the time of the occurrence of one or more of management (Fulford and Stone, 1997). the following conditions:

- The raised foot touches the ground or rests on the Conclusions other foot; - The limb supporting the load jumps, moves or fingers The approach to posture through the revised BMM focuses are raised; on the person, understood in their full range of psychoso- - The hands touch something other than the body. cial and physical expressiveness. This is expressed in the promotion of the inherent capabilities of self-regulation, N.B. The test may also be recommended as a daily mostly through the use of the musculoskeletal system as a exercise, sometimes using tables or swinging sandals, key tool for adaptation and intervention (Rogers et al., in order to increase the time maintaining balance with 2002). The centrality of this apparatus is definitely one of eyes closed. the components that has produced an expansion in the use of BMM on the part of the community of many manual therapists. Experts who have examined the issue of BMM and its increased use, concur with the need to move away change when the somatic dysfunction is inhibited, a from the dogmas that have characterized the idea of health negative core stability test, it suggests the dominating dependent on ideal posture, to promote dynamic ap- influence of the somatic dysfunction (structure) in proaches through which the person “participates more undermining salutogenesis with respect to the postural/ fully” in the healing process (Chaitow, 2011). In the field of biomechanical function. In this case, a minimalist osteopathy, specifically, use is made of the five ‘models’ approach or any technique specifically addressing the (biomechanical, neurological, respiratory-circulatory, dysfunctional somatic area may be the best choice of metabolic, biopsychosocial), five forces of activation/ intervention. adaptive capabilities (Tozzi et al., 2015), both in the 6. Ongoing management of the case evaluation phase and in that of the intervention, drawing on the correlation between the corresponding body ele- In the debate concerning the BMM (Chaitow, 2011) the ments. Nevertheless, it is possible to organize manual necessity of “opening” the biomechanical model to include therapy with a specific emphasis on one or more models, social activities, occupational and recreational activities directing the therapeutic stimulus to a chosen structural The biomechanical model in manual therapy 797 and functional component, according to the type of allo- Chaitow, L., 2006. Local adaptation syndromes wholistic solutions static load of the person in care. Therefore, through the depend on contextual thinking. Massage Today 6 (2). integration of traditional principles and contemporary sci- Chaitow, L., 2009. Terapia manuale dei tessuti molli. Principi e entific evidence a rational biomechanical intervention tecniche di positional release, third ed. 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American Association of Colleges of Osteopathic Medicine (A.A.C.O.M.), Chevy Chase, dysfunctional structures and in adaptogenic approaches MD, p. 26. addressing a function (in this case biomechanics) Educational Council on Osteopathic Principles (E.C.O.P), 2011b. (Lunghi, 2015b). Glossary of Osteopathic Terminology. American Association of Colleges of Osteopathic Medicine (A.A.C.O.M.), Chevy Chase, Interventions on posture and the application of BMM should MD, p. 53. therefore be based on a multimodal approach that makes Erhard, R., Bowling, R., 1977. The recognition and management of the person a participant in the process also through active the pelvic component of low back and sciatic pain. Bull. Orthop. everyday gestures connected with their lifestyle, in a sal- Sect. Am. Phys. Ther. Assoc. 2 (3), 4e15. utogenic approach that, from a traditional perspective, Frank, C., Lardner, R., Page, P., 2009. 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