Forward Head Posture

The 42 Pound Head

Erik Dalton, Ph.D.

“For every inch of Forward Head Posture, it can increase the weight of the head on the spine by an additional 10 pounds.” -Kapandji, Physiology of Joints, Vol. 3 

It’s not uncommon to have clients walk into your office sporting a 12 pound head that’s migrated three inches forward of their shoulders. You know prior to palpation that their cervical extensors (semispinalis, splenii, longissimus and upper traps) are in a losing battle attempting to isometrically restrain 42 pounds against the unrelenting force of gravity (Figure 1).

Rene Cailliet M.D., former director of the department of physical medicine and rehabilitation at the University of Southern California wrote:

• Head in forward posture can add up to thirty pounds of abnormal leverage on the cervical spine. This can pull the entire spine out of alignment.
• Forward head posture (FHP) may result in the loss of 30% of vital lung capacity. These breath-related effects are primarily due to the loss of the cervical lordosis which blocks the action of the hyoid muscles, especially the inferior hyoid responsible for helping lift the first rib during inhalation.
• Proper rib lifting action by the hyoids and anterior scalenes is essential for complete aeration of the lungs (Fig 2: Hyoids/ant scalenes).
• The entire gastrointestinal system (particularly the large intestine) may become agitated from FHP resulting in sluggish bowel peristaltic function and evacuation.
• Cailliet also states: “Most attempts to correct posture are directed toward the spine, shoulders and pelvis. All are important, but, head position takes precedence over all others. The body follows the head. Therefore, the entire body is best aligned by first restoring proper functional alignment to the head”. 1

The effects of poor posture go far beyond just looking awkward.

In fact, the January, 2004 issue of the American Journal of Pain Management reported on the relationship of poor posture and chronic pain conditions including low back pain, neck related headaches, and stress-related illnesses. “The extra pressure imposed on the neck from poor posture flattens the normal cervical curve resulting in abnormal strain on muscles, ligaments, fascia and bones.”2

Research presented at the 31st Annual International Conference of the IEEE EMBS Minneapolis, Minnesota, USA, (2009) stated; “Over time poor posture results in pain, muscle aches, tension and headache and can lead to long term complications such as osteoarthritis. Forward head carriage may promote accelerated aging of intervertebral joints resulting in degenerative joint disease.”3 (Fig.3).

It appears posture impacts and modulates all bodily functions from breathing to hormonal production. Spinal pain, headache, mood, blood pressure, pulse and lung capacity are among the many conditions influenced by faulty posture.

“90% of the stimulation and nutrition to the brain is generated by the movement of the spine” Dr. Roger Sperry, (Nobel Prize Recipient for Brain Research)

Additionally, Dr Roger Sperry demonstrated that 90% of the brain’s energy output is used in relating the physical body to gravity. Only 10% has to do with thinking, metabolism, and healing.4

Consequently, a FHP will cause the brain to rob energy from thinking, metabolism, and immune function to deal with abnormal gravity/posture relationships and processing. The March 2000 Mayo Clinic Health Letter expounded on Sperry’s findings by reporting that prolonged FHP also leads to “myospasm, disc herniations, arthritis and pinched nerves.” Degenerative neck pain goes hand-in-hand with balance problems especially in the elderly. Sensitive cervical spine mechanoreceptors govern the body’s ability to balance and must be perfectly coordinated with the inner ear’s vestibular balance system to stabilize equilibrium in both static posture and gait. Keeping the eyes looking forward is a basic life-preserving reflex, and as such, dominates nearly all other postural considerations. Proprioceptive signals from the first 4 cervical vertebrae are a major source of stimuli for regulating the body’s pain-controlling chemicals (endorphins). FHP dramatically reduces endorphin production by limiting the cervical spine’s range of motion. Inadequate endorphin production up-regulates the central nervous system causing non painful sensations to be experienced as pain.Figure 4 shows a couple of good mobilization techniques to restore joint-play to upper cervical fixated facets.

Dr. Alf Breig, a Swedish neurosurgeon and Nobel Prize recipient coined the termed ‘adverse neural tension’ to describe the mechanism by which loss of normal cervical lordotic curve creates dysfunction and disease.5

Through cadaver studies, Dr. Breig demonstrated that neck flexion could stretch the spinal cord 5-7 cm causing tensioning of the meninges (covering of the brain and spinal cord) and elicit measurable pressure on brain-stem nuclei (nerve control centers) which control all basic life functions. The increased compression led to dysregulation of basic metabolic control functions. Recall that the spinal cord is actually only “tethered” to the bony skeleton in the upper cervical and lowest sacral areas (top and bottom ends of the spine). In between these polar attachments, the spinal cord is relatively free to move up and down. Free-floating mobility of the cord is essential in allowing bending and twisting of our bodies. Anything that reduces that freedom, i.e., exaggerated or flattened spinal curves, dural impingement, etc. increases cord and brain stem tension. Increased tensile stress on the cord and brain stem not only interferes with the control of basic body processes such as breathing and motor control but in cases of dural impingement, may encourage painful cervical radiculopathies.

Identifying Common Compensatory Patterns

Fortunately, the legendary biomedical researcher Vladimir Janda, MD has helped simplify assessment of commonly seen muscle imbalance patterns consistent with FHP. Janda’s Upper Crossed Syndrome (Fig. 5) is characterized by overactivity or tightness in the upper trapezius, levator, suboccipitals. sternocleidomastoids and pectoralis major and reciprocal weakness of the deep neck flexors and lower scapular stabilizers. Trained therapists visually recognize this aberrant pattern through postural and gait analysis and kinesthetically through tissue palpation and muscle length testing. Unfortunately, as normal movement patterns are altered by persistent pain, joint fixations or muscle imbalances, new neuronal pathways are burned into the central nervous system and gradually memorized as normal (neuroplasticity). Any deviation of normal head and neck movement alters precise firing order patterns causing the prime mover to be slow to activate. Substitution patterns develop as synergistic stabilizing muscles are recruited to do the job of the prime mover. Some believe the first step in restoring proper muscle balance is to mobilize dysfunctional joints to help reprogram these garbled neuromuscular pathways. Once normal joint play is established and muscle splinting removed, structural integrative soft tissue work creates functional length/strength balance.

Correction of Upper Crossed neck posture is key to stopping and possibly reversing decay, degenerative changes and pain from headaches, rib dysfunction, TMJ, and Dowager’s Humps …but it takes time and a concerted effort to repair the damage caused by faulty neck posture.

The following traits are often seen in those presenting with Upper Crossed Syndrome:

• Suboccipital pain syndromes
• Mouth breathing (sleep apnea)
• Difficulty swallowing
• Teeth clenching
• Face & neck pain
• Migraine headaches
• Uncoordinated gait and loss of body balance

Summary

Often seen as a structurally subtle body segment, the neck is burdened with the challenging task of supporting and moving the human head. Because of tension, trauma and poor postural habits inherent in today’s workplace, it comes as no surprise that head-on-neck and neck-on-thorax disorders rank high among the most common pain generators driving people into bodywork practices. When spinal tissues are exposed to continued compression, they deform and go through a transformation that can become permanent. Correction of Upper Crossed neck posture is key to stopping and reversing degenerative joint disease and pain from headaches, rib dysfunction, TMJ, and Dowager’s Humps. English philosopher Bertrand Russell once stated, “A physical system expresses its energy through function”. Any loss of function sets off reactions within the body’s open, dynamic system which manifests as structural abnormalities…and vice-versa. When treating functional problems such as loss of joint play, therapists must look beyond the symptoms and the artificial dividing of the body into systems and treat the whole.

References

1. Cailliet R, Gross L, Rejuvenation Strategy. New York, Doubleday and Co. 1987
2. American Journal of Pain Management, January 2008, 4:36-39
3. 31st Annual International Conference of the IEEE EMBS Minneapolis, Minnesota, USA, September 2-6, 2009.
4. Sperry, R. W. (1988) Roger Sperry’s brain research. Bulletin of The Theosophy Science Study Group 26(3-4), 27-28. Nerve Connections. Quart. Rev. Biol. 46, 198.
5. Breig, Alf. Adverse Mechanical Tension in the Central Nervous System: An Analysis of Cause and Effect. 1978. Almqvuist & Wiksell International, Stockholm, Sweden. Pg. 177.

Scoliosis and Massage Therapy

by Erik Dalton, Ph.D.

During adolescence, most of us recall our mother’s marching orders to “Stand up straight!” Fortunately, standing up straight wasn’t a problem for many: simply retract the shoulders, contract the abdominals, allow the head to come back, and lift the torso out of the pelvis. Yet for others, the act of standing upright wasn’t, and still isn’t, quite that easy — one hip may be higher than the other, one side of the rib cage lower — whatever the case, all the pelvic tucking, shoulder retracting and chin-raising are usually in vain. For these individuals, “straightening up” is a frustrating experience, like they are fighting their bodies just to get through the day.

The reality is some people really are fighting their bodies and those bodies have acquired an unusual amount of lateral “curvature” where they should be “straight.” Eventually, most of these individuals end up in the office of their family doctor, chiropractor or massage therapist hoping to find ways to alleviate the postural strain and pain they are feeling. Following an assessment of their condition, they may be introduced to the meaning of the word “scoliosis.”

Figure 1—Scoliosis. If discovered in time, this commonly seen functional scoliosis responds well to manuel therapy as leg length discrepancy, pelvic balance and related compensations are assessed and corrected. Adapted from Bill Allen with permission.

When the general population hears the word scoliosis, the visualization of a hump-backed, crooked and painful body usually comes to mind see (Fig. 1). It is, indeed, a frightening experience when parents receive a call from the school nurse informing them that a scoliotic “deformity” has been discovered during their child’s routine screening exam. Ten in every two hundred children develop scoliosis between the ages of 10 and 15. Although boys and girls seem equally affected, the curvatures in females are three to five times more likely to progress into more pronounced aberrant postural patterns. 1 As scoliosis is frequently asymptomatic, it is often overlooked, and the parent may only notice that the child’s clothing no longer fits properly.

Fortunately, scoliosis takes many forms and need not always fall into a frightful medical category. Although it can be a very complex musculoskeletal condition, successful treatment options are available if the disorder is discovered in time. This article offers an overview of scoliotic classifications, types of curvatures, accompanying symptoms, and hands-on examples for correcting the dysfunction.

Is it Fixable or Is it Fixed?

Scoliosis may be classified in a myriad of ways: by its reversibility, severity, etiology, or type and location. A primary consideration for manual therapists is the type of scoliosis … Is it “structural” or “functional?” Spinal curves that improve during forward-bending, sidebending and specific rotational movements are generally referred to as “functional” or “secondary” scoliotic curves. If the curve does not straighten during any of these maneuvers, it is considered a “structural,” “fixed” or “primary” scoliosis. Many functional curves remain in the body too long and may become fixed as the brain valiantly attempts to compensate for asymmetry by altering length-tension balance in associated soft tissues, i.e., muscle guarding. Prolonged postural compensations eventually decompensate in adjacent structures. Then the client begins experiencing increased symptoms, signs and disease.

Spinal Curves — Types and Motion

Abnormal spinal curves can occur in more than one of the body’s planes see (Fig. 2). Names familiar to manual therapists like hyperkyphosis and hyperlordosis describe excessive sagittal plane curvatures, whereas horizontal (transverse plane) compensations are commonly referred to as rotations or torsions. Although scoliotic (side-to-side) curves are primarily considered coronal plane deviations, sagittal and coronal influences often occur in tandem. An excellent example is the frequently seen humped-back (lateral and posterior) scoliokyphotic deformity see (Fig. 3).

Around the turn of the century, osteopathic physician Harrison Fryette introduced the “Laws of Spinal Motion” in his classic book entitled Principles of Osteopathic Technique. 2 By studying movements of cadaver spines, Fryette not only helped manual therapists understand how vertebral segments respond to normal movements but also aberrant spinal fixations such as scoliosis. Although his second law appears slightly flawed, these classic spinal biomechanical principles wonderfully detail underlying vertebral motion characteristics during the acts of forward bending, backward bending, rotation and sidebending.

Comprehension of basic joint biomechanics is fundamentally essential when assessing and treating structural and functional scoliotic clients. For example, when confronted with a right thoracic scoliosis, therapists must recognize that vertebrae at the apex of the curve are sidebending left and rotating right causing associated ribs to form a convex hump. Conversely, a lumbar scoliotic curve that sidebends right and rotates left produces bulging in the lower left torso see (Fig. 4). Formation of these distorted postures is explained in Fryette’s first law which states that lumbar and thoracic joint coupling typically occur to opposite sides.

Therapists must learn to immediately identify aberrant joint coupling responsible for these crooked patterns so hands-on activating forces can restore balance and symmetry to all affected spinal and soft tissues Hands-on approaches.

As a rule, scoliotic curves are named according to the side of the convexity. Thus, in the most commonly seen right thoracic scoliosis, the ribcage will be convex right with an accompanying posterior bulge on the right between the spinal column and scapula. When therapists encounter this knotty protruding ribcage, they usually begin digging on the thin layer of overstretched paravertebral fascia covering the bony ribs mistakenly believing they are releasing fibrotic muscles. In most instances, this well-intentioned maneuver may actually worsen the condition.

During the formation of a right thoracic scoliosis, the spinal transverse processes sidebend left and rotate right pushing the longissimus and iliocostalis erectors laterally. The weakened serratus posterior superior muscles responsible for binding the erectors close to midline, allow the erectors to spread much like the linea alba often permits rectus abdominis spreading during a mother’s third trimester of birth. When distended, compensations develop as bulging babies and protruding ribs are left with a terribly inadequate support system.

Stretch-weakened muscles, ligaments and fascia are reciprocally overpowered as hypertonic erectors on the opposite side shorten forcing the spine to “bow.” Typically, these myofascial tissues become neurologically inhibited due to joint dysfunction, trauma, overuse syndromes, faulty posture, or paralysis. In (Figure 5) the therapist’s fingers tonify stretch-weakened erectors and serratus posterior muscles with fast-paced spindle stimulating maneuvers via the dynamic gamma motoneuron system. Extended fingers then hook and reposition the laterally migrated paravertebrals back on top of the bulging ribs. To lengthen the erector spinae muscles on the concave side, the therapist reaches across with extended fingers, digs into the left lamina groove, scoops out the wiry spinalis muscles, and stretches all the erectors laterally.

Once some spinal bowing has been removed, additional ribcage flattening can be accomplished by depressing the scapula see (Fig. 6), lengthening latissimus dorsi see (Fig. 7), releasing the diaphragm and obliques see (Fig. 8), and stretching the inferior end of the transab-dominal fascial column see (Fig. 9).

Classifying Spinal Curves

Scoliotic curvatures are generally classified by four degrees of severity:

1. Optimal spine — no scoliotic dysfunction.
2. Mild scoliosis — demonstrates a thoracic curve of 5 degrees to 15 degrees.
3. Moderate scoliosis — denoted by 20 to 45 degrees of curvature.
4. Severe scoliosis — represents curvature of 50 degrees or more.3

(Note: Radiologists usually allow a gray zone that represents a 5 degree range between each classification.)

Etiology and Bone Density

Approximately 70 percent to 90 percent of scoliosis is termed “idiopathic,” implying no known cause for the dysfunction. However, structurally trained manual therapists often find that many idiopathic scoliotic deformities labeled as fixed (irreversible) are actually compensations due to sacral or cranial base unleveling see (Fig. 10). If sacral and cranial base unleveling indeed prove to be causal factors in a portion of presumed idiopathic cases, the “no-known-cause” definition should no longer apply. Information sharing among complementary medical professionals concerning possible biomechanical and biochemical origins of scoliosis provides hope that someday many more cases will lose their idiopathic classification.

It is also possible that the term idiopathic scoliosis may become outdated, as recent studies demonstrate a clear link between scoliosis and lowered bone densities. For years, various research groups have focused on finding a “scoliosis gene” or singular cause for the disorder. Yet searching for a single solution for a complex problem may only serve to slow down the process.

Scoliosis is closely linked to low bone densities that may be influenced by a wide variety of overlapping factors that includes genes, estrogen levels, nutrition, exercise, and drugs. In animal studies, lowered bone density is known to be caused by a wide variety of conditions including lack of physical activity, pesticide exposure and nutritional deficiencies. Some of these same conditions, especially the lack of exercise and nutritional deficiencies, are known to also lower bone density in humans.4

Based on these facts; it seems, as with most human conditions, illogical to assume that human scoliosis would be caused by a single gene, or even by genetic factors alone. And while idiopathic scoliosis is considered to have no discernible cause, hereditary links have been established. Thus, if one child in a family presents with scoliosis, it’s well worth the time to check the others. Since this disorder can pass to offspring, parents with scoliosis should watch their children for any related signs, particularly during early teenage years.

Closer look at Structural Scoliosis

Ever since Hippocrates coined the term “scoliosis” to describe deformity of the spinal column, “structural scoliosis” (the fixed type) has occupied the attention of researchers and physicians. Early treatment modalities were often crude and sometimes violent, as well-meaning practitioners would walk on the scoliotic hump or apply excessive force using homemade, full-body traction devices. Nevertheless, these pioneering therapists did develop a number of sound therapeutic principles that still constitute essential features of many modern treatments, including:

• Reducing gravitational exposure;
• Using traction as a basic corrective force;
• Applying pressure over the convexity of the curve;
  and
• Creating myofascial extensibility to the concavity.

Structural scoliosis as a physical deformity is often accompanied by functional changes in the thoracic and abdominal organs as well as psychological and emotional disturbances. The extent of functional change in the heart, lungs, and other viscera is in direct proportion to the degree of the physical deformity. From puberty through middle age, scoliotic symptoms such as backaches, head/neck pain, arthritic symptoms, chest pain, and organ dysfunction cause people to seek help.

Fundamentals of functional scoliosis

“Nonstructural” or “functional” scoliosis refers to a structurally normal spine that appears curved. This condition can be a temporary abnormality — caused by various conditions — leg length inequality, spasmodic muscles, or inflammatory conditions such as appendicitis. Although the disorder is considered temporary, proper muscle and spinal biomechanical approaches are often needed to address the underlying imbalance pattern.

Functional scoliosis is characterized by an asymmetric position of the trunk and back that usually diminishes during forward bending, sidebending, rotational, or tractioning maneuvers. Functional scoliotic cases are frequently accompanied by other signs of faulty and relaxed posture, such as rounded shoulders, prominent abdomen and flat feet see (Fig. 11). Occurring with equal frequency in boys and girls, functional cases appear in a large percentage of all school-age children as well as adults. People presenting with crooked spines commonly suffer from a condition termed rotoscoliosis where the base of the spine “corkscrews” headward as the vertebral column turns on its axis see (Fig. 12). These coronal deviations often result from leg length discrepancy or pelvic imbalances.

An interesting note: Functional scoliosis is a physiologic posture that can be assumed by any “normal” child or adult simply by bearing more weight on one leg while standing. It is pathologic only if it becomes habitual. One may justifiably assume the existence of a constitutional defect in muscles, ligaments, body alignment, nutrition, or structure of the bones. Such a deficiency explains why, for instance, some people naturally sit and stand erectly, while others may tend to slouch and slump — whether sitting, walking, or standing.

Common functional patterns

Pain management therapists are often presented with a predictable functional scoliotic
postural pattern that closely follows the description in Figure 13. If seen from
the back, the following asymmetries are exhibited:

• Pronated left foot/supinated right;
• Up-slipped left innominate (posterior/superior);
• Cephalad left pubic symphysis;
• symptomatic scoliosis
• Left on left sacral torsion;
• Lumbar spine sidebent left/rotated right;
• Compensatory thoracic scoliosis convex left;
• Low left shoulder;
• Torsioned shoulder girdle (right forward and left back);
• Compensatory left rotation of atlas on axis, and
• Left sidebending of occiput on atlas.

In a forward-bent position, the left side of the upper back may be more posterior than the right, while at the thoracolumbar junction, the right side is more prominent than the left. The ability to recognize the various rotational components and compensations is highly important during the functional scoliotic screening exam. Typically, the vertebrae in the curve tend to sidebend in one direction and rotate oppositely. If three or more consecutive vertebrae sidebend together to one side and rotate in the opposite direction, osteopaths refer to this as a “type 1 group curve” or a functional scoliotic pattern see (Fig. 14).

During the initial screening exam, the client is seated and asked to forward bend. Typically, the thoracic vertebrae will rotate to the side of the hump and side bend to the opposite side. Occasionally, when assessing asymmetrical type 1 group curves, the therapist will find non-neutral vertebral coupling of rotation and side bending to the same side. This usually depends on whether the therapist is examining above or below the apex of the thoracic curve and whether side bending or rotation is introduced first.

Short leg syndromes

In cases of functional scoliosis, some may exhibit asymmetry without leg-length differences, but rarely will one find a leg-length discrepancy without structural asymmetry. Many younger clients develop a long C-shaped lateral curvature with the convexity toward the short-leg side similar to that shown in Figure 15(Fig. 15). Most of this population present with only minimal symptoms, if any. Correction of the short leg is usually accomplished by balancing the iliosacral joints which allows the youthful spine to grow straight. Early pelvic-balancing work prevents the development of more severe curves with accompanying secondary musculoskeletal changes later in life.

If the convexity of the curve is opposite the short-leg side, the therapist should look for non-neutral dysfunctions (facets stuck open or closed) in the lower lumbar vertebrae and lumbosacral junction.

These individuals fill our practices daily complaining of low back and hip pain where no pathology is present. Attempting to relieve functional scoliotic pain without a good understanding of spinal and muscle biomechanics is usually futile. Functional scoliosis is extremely common and treatment options must be developed to help this ailing population. Of course, early detection and deep-tissue corrections are vital in preventing painful compensatory spinal problems that could manifest throughout adulthood.

Perfecting Scoliosis Massage Therapy

The etiology of scoliosis has received great attention during the last century and, while considerable progress has been made, much greater knowledge is needed to clarify and completely explain the predominate dysfunctional mechanics of the scoliotic deformity.

The search for more effective therapy continues, and the present systems or methods of treatment are a great deal more effective than older procedures. In particular, postural distortions are being recognized at an earlier age (sometimes at inception), allowing the immediate use of manual therapy modalities to treat the scoliotic pattern while still in a mild to moderate stage. This alone frequently prevents progression to a severe stage that brings with it attendant functional disturbances.

So there’s good news and bad news when approaching the question of scoliosis. On the one hand, it’s all too prevalent a disorder — linked to factors that need more careful monitoring, such as environmental toxins, nutrition, and general activity levels. On the other hand, with more attention being given to the condition through objective and subjective research, comes an increase in medical and manual therapy treatment options, and perhaps, soon, a cure for idiopathic and structural scoliotic cases.

Erik Dalton, Ph.D., originator of the Myoskeletal Alignment Techniques and founder of the Freedom From Pain Institute, shares a broad therapeutic background in Rolfing and manipulative osteopathy in his innovative pain management workshops and top selling home study Massage Therapy CEUs courses.

References

1. Peterson, B. Ed. Postural balance and imbalance. American Academy of Osteopathy Yearbook. 2003:
2. 148–152.
3. Fryette, H.H. Principles of Osteopathic Technique. Indianapolis, Ind.; 1918: 231–255.
4. Kuchera, M.L. Biomechanical considerations in postural realignment. Journal of the American
5. Academy of Osteopathy. 1987 Nov: 781–782.
6. Walker, J.M. Musculoskeletal Development. Physical Therapy. 2002 71: 879–899.

Puzzle of Perfect Posture

Erik Dalton, Ph.D.

No therapeutic approach to pain management is satisfactory until body posture is generally improved. Whatever the cause of the client’s problem, special focus should always be given to posture. Overall body alignment may seem time consuming and is therefore frequently neglected because both therapist and client are often content with immediate symptom alleviation.

In recent years, however, the manual therapy community has been blessed with scientific advances spearheaded by researchers such as J. Gordon Zink (Common Compensatory Pattern)1 and Vladimir Janda (Upper and Lower Crossed Syndromes)2 which has sparked renewed interest in the neuromyofascial formation of commonly seen postural patterns. As a result, practical new structural balancing approaches have surfaced that not only save time but also offer more satisfying long-lasting results. By integrating these new strategies, the demands for structurally-trained pain therapists increases as chronic sufferers find relief from long-standing musculoskeletal ailments. This ultimately sets these bodyworkers apart in the eyes of clients and referral sources.

For today’s touch therapist to gain a basic understanding of how distorted postural patterns lead to chronic head, neck and back pain, the concept of perfect posture must first be defined. Simply put, perfect posture is a condition where body mass is evenly distributed and balance is evenly maintained during standing and locomotion, i.e., “body mass is evenly dispersed in relation to gravity over a given base of support.” Since our bodies are eloquently designed to react to any shift in center of gravity through sophisticated somatic mechanisms, if the normal function of any part of the mind/body system becomes overstressed, a vicious cycle of pain and dysfunction begins. Structural alignment pain therapists seek to restore normal mobility to all components of the somatic system by correcting postural imbalances to minimize compressional loading from gravitational exposure (Fig. 1).

Perfect posture is a condition where body mass is evenly distributed and balance is evenly maintained during standing and locomotion

Each of us is affected by the mysterious and potentially stressful force of gravity. If, for a moment, we assume that posture is the result of the dynamic interaction of two groups of forces acting on the human body—the environmental force of gravity on one hand and the strength of the individual on the other—then posture could be considered as the ideal expression of balance between these two groups of forces. Therefore, any deterioration of posture indicates that the individual is losing ground in the contest with gravity’s unrelenting power.

Proprioceptive Influence on Posture

Postural homeostatic lessons are learned early in life by the central nervous system (CNS). Visual and proprioceptive input continually supplies the toddler with the necessary information for growth and development. Normally, as a child progresses into adolescence, compressive forces on spinal intervertebral discs and facet joints are beautifully balanced through ligamentous tension allowing minimal energy expenditure from postural muscles.

However, structural or functional body stressors (tension, trauma, genetics, etc.), may prevent achievement of optimum posture. Faulty posture from physical occurrences such as leg length discrepancies, cranial imbalances, and scoliosis alters the body’s center of gravity which requires mechanical adjustments (compensations) leading to muscle, fascial and osseous adaptations (Fig. 2).

If a joint’s mechanical behavior is altered, flexibility and range of motion suffers. The increase in mechanoreceptor stimulation from chronically locked joints results in neuroreflexive muscular changes, i.e., protective muscle guarding. Long-standing over-activation of abnormal joint reflexes causes changes in spinal cord memory that eventually “burns a groove” in the CNS as the brain and cord are unknowingly saturated with a constant stream of inappropriate proprioceptive information. Regrettably, the brain comes to rely on this faulty information about where it is in space to determine how to establish perfect posture. The brain simply forgets what its alignment should be. Many of us have experienced the distress of standing in a three-way mirror trying on a suit or dress when suddenly a shocking profile appears. We ask ourselves where, when and how did this protruding belly, slumped shouldered and accompanying forward head posture develop? The silent progression of aberrant postures is all part of the reflexogenic relationship between muscles and joints.

Gravity and Tensegrity

Some humans appear genetically blessed with optimal posture—where muscles are not actively working as restraining tissues, ligamentous tension is perfectly balanced against compressive and tensegrity forces—and normal everyday activities such as standing and walking require minimal energy expenditure. Buttressed by a dynamic anti-gravity tensegrity system, tensional and compressive forces are evenly dispersed through the entire organism. The ligamentous pelvic bowl is a key structure and part of an eloquent myofascial web designed to transmit forces from above and below during locomotion. When working properly, trunk stabilizers such as transversus abdominis, thoracolumbar fascia, multifidus, and pelvic/respiratory diaphragms form a perfect antigravity pump that lifts the thorax with each step (Fig. 3). In the presence of normal spinal curves, the body’s bony framework is effectively supported and moved by this remarkably elastic myofascial network. As the person walks or runs, the antigravity springing mechanism decompresses intravertebral discs and facet joints allowing lubricating synovial fluids (metabolic substrates) to be sucked in (Fig. 4).

Gluteus medius and minimus are excellent examples of the power generated by tensegrity muscles. Regrettably, they are possibly the least appreciated and most important of all of the body’s antigravity structures. When firing in proper order (during the stance phase), these primary hip abductors must elevate the contralateral ilium to allow the leg to swing through preventing the foot from dragging the ground (Fig. 5).

Wasted Energy

Ideally, during the static act of standing, postural muscles are in a state of normal tonus and not actively contracting. In reality, however, most people have less-than-perfect postural balance and as a result, active muscular contraction is required to redistribute body mass and effectively hold it in place. Muscles are now working against gravity and performing the job of ligaments as they are forced to stabilize the spine. If a person’s homeostatic threshold has been violated, tonic postural muscles tighten and shorten while their phasic antagonists become overstretched and weak. Asymmetric patterns develop and soon the antigravity function of the body’s myofascial system collapses sending warning alarms to deep intrinsic structures such as spinal ligaments, joint capsules, and intervertebral discs to brace against the onslaught of overbearing compressional loads. Because locomotion requires the controlled loss and regaining of balance, movement of any body part with respect to the rest of the body shifts its centerline of gravity, causing an inevitable change in overall balance. Muscle and ligamentous tension is maintained by negative feedback from sensory receptors located in joint capsules, ligaments, fascia, and intervertebral discs. Structural asymmetries increase sensory information to the CNS which is then interpreted and reflected in predictable asymmetrical postural patterns such as Vladimir Janda’s upper crossed syndrome (Fig. 6). An enormous amount of information can be gleaned by manually and visually assessing for these postural irregularities (Fig. 7). Observation of posture provides the clinician with the first and most important clues to the client’s overall physical, emotional and psychological condition.

Compensation

For the body to sail smoothly through life, it must have the ability to repair, regulate and protect itself. Humans possess a complex self-regulatory mechanism that allows for adjustments to environmental stresses while maintaining homeostasis in all systems—myofascial, skeletal, nervous, circulatory, endocrine, etc. These compensatory mechanisms work to keep the body in balance regardless of what works upon it or what happens around it. Although innate compensation is obviously a much needed protective device for repairing worn out parts and maintaining bodily homeostasis, its role in maintaining posture is often confusing as overlapping strain patterns accumulate. In simple terms, compensation is the counter-balancing of any defect of bodily structure or function (Fig. 8). Compensated postures are the result of an individual’s homeostatic mechanism working smoothly even though they exist within a body exhibiting less that ideal posture. Fortunately, this neurologically hard-wired compensatory mechanism allows the person to operate as efficiently as possible in less than perfect circumstances. Most clients entering our workplace are compensated in one way or another. In the early stages, the individual with structural compensation appears to function normally despite some occasional aches and pains. When physical injury occurs, local myofascial structures tighten (splinting reflex) allowing the body to compensate and continue on its journey—safely, healthfully and productively. Regrettably, as time passes, these compensations accumulate and integrate into myofascial, osseous and visceral systems. Repeated traumatic physical episodes also leave emotional scarring that buries deep within our self-regulating energy system. Micro or macro traumas never leave the body but infiltrate and integrate into every cell and system of the organism. In time, these compensations surface and are visually reflected in every step taken.

Decompensation

When an individual’s homeostatic thresholds are overwhelmed, decompensation occurs. The most destructive postural adaptations occur at the four transitional zones (cervicocranial, cervicothoracic, thoracolumbar, and lumbosacral). These critical cross-over junctions are areas where anatomical structural changes create the greatest potential for neuromyoskeletal dysfunction (Fig. 9). By developing acute visual and palpatory skills, therapists can quickly become proficient in monitoring and correcting regional zone asymmetry in clients. Many find that assessing and correcting transitional zone decompensations alone produces surprisingly dramatic postural improvement and helps attune therapists to the visual art of unraveling complex strain patterns. Because of an accumulated history of genetic, traumatic, and habitual processes requiring compensations—in the real world—few clients actually present with ideal posture.

The Battle between Intrinsics and Extrinsics

Deep intrinsic postural muscles such as the iliopsoas, quadratus, transversus abdominis, and multifidus contain more slow-twitch fibers and prefer burning oxygen for fuel (oxidative metabolism). These tonic muscles have a higher capillary density than extrinsics (rectus abdominis, rhomboids, lower trapezius, gluteals, etc.) and are better designed to withstand sustained compressional loads during normal activities such as standing and walking. Since tonic (postural) muscles have more high-density slow-twitch fibers, they react to functional disturbances by shortening and tightening. Problems appear when the muscle shortening process compresses and twists spinal joints. In the presence of joint dysfunction, the muscle spindles’ gamma system can neurologically weaken the transversospinalis and erector spinae muscles creating scoliotic patterns. As deep intrinsic muscles become spasmodic, their fascial bags react by forming contractures. This leads to a loss of oxygen fuel causing muscle fatigue and eventual collapse of the body’s antigravity system. The compressive load must then shift to the extrinsic (phasic) muscles. Phasic shoulder girdle muscles such as the rhomboids, lower trapezius, posterior rotator cuff, serratus anterior, and triceps brachii are usually the first to respond. Since these tissues contain a greater number of fast-twitch fibers, they are dynamic and emit bursts of energy. However, their reliance on glucose for fuel (glycolytic metabolism) causes them to fatigue easily. As the supply of glucose diminishes, the extrinsics “give-out” and reluctantly shift the load back to the already overworked and exhausted intrinsics. Many aberrant postural patterns entering our practices belong to bodies screaming out for help—either because they are in an intrinsic or extrinsic stage of collapse (Fig. 10).

Athletics and Posture

The issues of faulty posture are often magnified in athletic clients. Imbalances such as short-leg syndromes resulting from a tilted innominate or pronated foot can dramatically reduce speed, strength, coordination and endurance. Moreover, an athlete’s joints are often subjected to abnormal mechanical stresses. Alterations in joint function caused by capsular restriction or loss of joint play either inhibit or facilitate muscles that cross the misaligned joint.3 Muscle imbalances occur as the length-tension relationship surrounding a given joint is disrupted.

Therefore, when treating muscle imbalances in athletes, the primary goal is restoration of length, strength, and control of muscle function. Many of today’s exercise programs address length and strength, but few deal with the issues of motor control. Any successful exercise program must focus on restoring proper central nervous system control. Muscle firing order sequencing is of particular concern to today’s sports therapist. The following myoskeletal approach has proved successful in restoring muscle balance, reducing nociception and improving proprioception in competing athletes and the general population as well:

• Lengthen short, hypertonic muscles, and their enveloping fascia;
• Strengthen weak, inhibited muscles through specific hands-on spindle techniques and Thera Band retraining exercises;
• Correct aberrant hip
• hyperextension, hip abduction, shoulder abduction, and neck flexion firing order patterns;
• Restore proprioceptive
• motor balance (mini trampolines, yoga, etc.); and
• Maintain a good aerobic exercise program.

Electromyographic studies have repeatedly demonstrated how alterations in the proper sequence of muscle activation (firing order) adversely affect speed and coordination in competing athletes. Clinically, it has been found that in some athletes, inhibition of dynamic extrinsic muscles—commonly due to joint dysfunction— may be so great, that attempting to strengthen the inhibited muscles through resistance training may only serve to further intensify the inhibition.4 This is a vital piece of information for the sports therapist. The bottom line is to first create myofascial balance and restore proper joint function before recommending strengthening exercises. Once muscle balance, posture, and pain-free movement have improved, the client can resume resistance retraining and aerobic exercises.

Moving Forward

Because muscle contraction requires energy, postural imbalances drain energy in proportion to the magnitude of the imbalance. This is wasted energy, energy unavailable for its original purposes. Energydrains dramatically affect the limbic system—the highest cortical level regulating muscle tone. As whole-body tension builds, therapists begin to see energy-draining symptoms reflected in conditions such as fibromyalgia, chronic fatigue syndrome and digestive or hormonal disorders.

It has long been known that psychological factors play a large part in creating distorted postures through selective tightening of specific muscle groups. The word “uptight” is an expression commonly used to denote that feeling of tightness, stiffness and fatigue. The power mantra: Poor posture is always perpetuated as tight muscles become tighter—weak muscles become weaker—and CNS motor control becomes disrupted. If not properly assessed and corrected, this commonly seen postural progression leads to agonizing, self-perpetuating pain/spasm/pain cycles.

Erik Dalton, PhD, originator of the Myoskeletal Alignment Techniques and founder of the Freedom From Pain Institute, shares a broad therapeutic background in Rolfing and manipulative osteopathy in his innovative pain-management workshops. Visit www.erikdalton.com to view additional Myoskeletal Alignment Technique articles and new products and to register for a free monthly technique newsletter.

Notes

1. G.J. Zink,“Respiratory and Circulatory Care:The Conceptual Model,” Osteopathic Annals (1997): 108-112.
2. V. Janda,“Evaluations of Muscular Imbalance.” Rehabilitation of the Spine 2nd edition ed Craig Liebenson (Lippincott,Williams & Wilkins, 2006), 203.
3. V. Janda,“Muscle Weakness and Inhibition in Back Pain Syndromes,” In Modern Manual Therapy of the Vertebral Column ed. Gregory P. Grieve (Churchill Livingstone, 1986), 197.
4. F.P. Kendall and E.K. McCreary, Muscle Testing and Function (Williams & Wilkins, 1983).

Fibromyalgia Pain: Fact or Fiction

by Erik Dalton Ph.D.

as published in Massage & Bodywork Magazine

Fibromyalgia syndrome (FMS) is a widespread musculoskeletal pain and fatigue disorder for which the cause is still unknown. Ongoing investigations continue as medical and manual therapy offices are flooded with increasing numbers of reported fibromyalgia cases but, like the oft-quoted analogy of the blind man and the elephant, we currently know more about the components of FMS than we know about the “beast” as a whole. Now that rheumatologists have granted legitimacy by labeling and classifying this vague and controversial syndrome current beliefs regarding possible origins must be discussed.

Fibromyalgia primarily manifests as pain in muscles, ligaments and tendons — the fibrous tissues in the body. FMS was originally termed fibrositis, implying the presence of muscle inflammation, but contemporary research proved that inflammation did not exist. Some in the complementary medical community believe that fibromyalgia should be a primary consideration in any client/patient presenting with musculoskeletal pain that is unrelated to a clearly defined anatomic lesion. Conversely, many researchers question the very existence of the syndrome since fibromyalgia sufferers typically test normal on laboratory and radiologic exams.

For more than a century, medical science has continued to move forward in its ability to recognize, categorize, and name painful patient disorders. Technological advances have made it much easier for medical doctors to rule out specific maladies from a variety of symptoms presented in the clinical setting. Additionally, modern testing methods have allowed researchers to become more confident in their ability to determine what is and what is not a disorder or disease. However, this newfound confidence has created controversy and debate over some disorders, which cannot be universally proven, even though the symptoms are undeniable. In recent years, many common diseases have been named and treatments discovered. This applies to mental health as well as physiological disorders. Today’s society seems to be more open now than ever before to the possibility that there exists mental and physical dysfunctions not yet recognizable through medical testing, but real just the same.

Part of this acceptance comes from mankind’s history of disease discoveries. It was not so long ago that people with epilepsy were believed to be possessed by the devil. Today, it is an accepted disorder with known biological causes and medical treatment options. The historical fact that symptoms, dysfunctions, and diseases often appear long before researchers are able to devise reliable diagnostic testing procedures to identify and treat the malady makes it appear unreasonable that the existence of the condition would be doubted or debated … but this is the case with fibromyalgia.

Psychosomatic or Physiologic

Fibromyalgia has come under fire in many circles including medical, psychological, and manual therapy. There are two camps firmly divided on their beliefs as to the cause and treatment of the disorder while a third group of researchers and medical practitioners reject the existence of fibromyalgia altogether.1 Simply put, one camp believes that FMS is a mental health issue without a biological origin. Whereas, the other camp is firmly convinced that it is a physiological disorder even though researchers have yet to identify definitive diagnostic criteria. While each side squabbles over the fibromyalgia conundrum, thousands of Americans each year suffer diverse and sometimes disabling symptoms with little help coming from the medical and insurance industry.

Meantime, the debate as to the true reality of the disorder carries on as scientific evidence continues to accumulate in favor of the physiological aspect of fibromyalgia. Currently, traditional and complementary medicine success rates in treating the disorder points to the fact that it is primarily a physiological condition with biological origins.

In the face of the debate as to the origin of disorder, the American College of Rheumatology comprised a list of criteria for the purpose of classifying fibromyalgia. The list includes classic symptoms such as having a history of widespread pain for more than three previous months. The college went on to define a series of 18 checkpoints (tender points) for the pain sites.

(See Figure 1). A client is required to have pain in 11 or more of the 18 sites to be considered a true case of fibromyalgia.2 Since the symptoms are relatively simple to recognize, why the continued debate? Part of the trouble lies in the fact that the symptoms are sometimes vague and reminiscent of other musculoskeletal complaints.

Confusing Symptoms

From the massage therapist’s office to the traditional medical facility, clients/patients are presenting in increasing numbers with a variety of unexplained symptoms. However, there are definitely some shared symptom commonalities such as predictable tender points, extreme fatigue, poor sleeping patterns, and whole-body pain upon awakening.Regrettably, musculoskeletal pain research generally lags behind wellfunded scientific projects with possibilities for more lucrative outcomes. It often takes years to definitively confirm and classify conditions with vague, widespread symptoms like fibromyalgia. This confusing disorder continues to be poorly understood, and clients often suffer for several years before a medical diagnosis is made. Figure 2 illustrates an interesting biological explanation detailing the downward degenerative spiral seen in many fibromyalgia clients.

Fibromyalgic symptoms have been described as steady, radiating, burning, and spreading over large areas of the body. The pain often involves the neck, shoulders,back, and pelvic girdle. Clients report that pain seems to emanate specifically from muscles, tendons, ligaments, bursa, and joints. Most identify pain as their cardinal symptom. Fibromyalgia pain appears to worsen with cold temperatures, increased humidity, weather changes, overexertion, and stress. Many clients report symptomatic pain reduction with hot baths, heating pads, and warm weather.

Fatigue and lethargy are also on the following list of symptoms (see below) for the disorder. Clients commonly complain of feeling extremely fatigued and unable to muster the energy to do the things that they need to get done. This can entail a lack of energy for cleaning house, getting to work, performing at work, participating in social outings, etc. Poor sleeping patterns are another classic symptom of the disorder. Many report that they wake several times each night and often have a difficult time returning to sleep.3

Irritable bowel syndrome (IBS) is another commonality that fibromyalgia clients tend to share. It is interesting that IBS is an accepted medical disease even though there is no concrete medical proof of its origin or existence. Yet IBS is widely accepted by the field of medicine while fibromyalgia is still under scrutiny. The reduced ability to concentrate as well as frequent bouts of depression also tops the fibromyalgia symptom list.

Physical Examination

Careful examination reveals areas of pain on palpation but without the classic inflammatory signs of redness, swelling, and heat in the joints and soft tissues. Skill in palpating tender points is critical to establishing a correct assessment for fibromyalgia. Physical findings encountered during soft-tissue palpation include tender points, increased resting muscle tension, and tissue texture changes in the skin and subcutaneous fascia.

When assessing the possibilities of fibromyalgia, it is important that other potential conditions be ruled out as well. The symptoms may mimic dysfunctions such as myofascial pain syndrome, peripheral neurogenic pain, medicinal toxicity, and some types of arthritis. Therefore, when presented with the possibility of a true fibromyalgia case, detailed assessment and history intake are of utmost importance. Since the most significant area of pain tends to shift over time, the first step in assessing true fibromyalgia is to determine if similar functional/structural disorders are at play.

Commonly Associated Symptoms of Fibromyalgia

• Chronic headaches
• Cognitive or memory impairment
• Dizziness or light headedness
• Fatigue
• Irritable bowel syndrome
• Jaw pain
• Muscle pain or morning stiffness
• Painful menstruation
• Skin and chemical sensitivities
• Sleep disorders

Myofascial Pain or Fibromyalgia

Myofascial pain syndrome (MPS) emanating from hyperirritable trigger points is often confused with fibromyalgia. To complicate the situation, MPS may occur in clients suffering with fibromyalgia. However, a carefully conducted history intake and physical examination usually helps the therapist determine if the client is presenting with fibromyalgic symptoms, MPS, or both. While fibromyalgia pain is widespread with changing areas of emphasis, myofascial tender points are typically restricted to one spot, though the point may refer pain to other areas.

Contrary to popular belief, many in the medical field do not believe MPS symptoms arise from taught myofascial trigger point bands, but instead from peripheral nerve pain at motor end plates.4 Much of the neurological literature today does not include the trigger point taut band theory as a recognized anatomical cause of entrapment neuropathy. Since the connective tissues of human peripheral nerves are well-innervated, some researchers believe peripheral nerve pain (aching, tingling, and numbing) best describes the symptoms occurring in many myofascial pain syndrome cases. MPS is said to result from hyperexcited chemoreceptors activated by inflamed, disorganized nerve ending bundles.

Regardless of the outcome of the myofascial pain syndrome debate, the disorder still should be easy to identify during the evaluation process since the client’s pain will be limited to a particular region (over time), often eliciting a referral pattern when digital pressure is applied. Although location does little to distinguish between MPS and fibromyalgic tender points (since they often occur in similar body areas), specific hands-on assessments help to clearly differentiate between myofascial pain and fibromyalgia (See Figure 3).

The Psychologic Debate Goes On

As is the case with many disorders, fibromyalgia is attracted to one gender more than another. This agonizing condition is more pervasive in women with the most common onset between 25 and 50 years of age. Estimates of prevalence are 3.4 percent for women and 0.5 percent for men.5 It is estimated that 20 percent of the female population will end up in a rheumatologists’ office. Women suffering fibromyalgia often report high levels of stress in their daily lives, which also contributes to the idea that it may have roots as a mental health disorder and not completely physiological in nature. Because the brain’s emotional center (limbic system) is the highest cortical level regulating muscle tone, any alteration in limbic function may precipitate myofascial pain patterns.

Psychologic disorders have been, and continue to be, researched to determine if a relationship exists with fibromyalgia. The disorders of depression, somatization, panic, and obsessive-compulsive behavior have been seen in some fibromyalgia clients. Depression occurs in about 20 percent of clients and may be the result of having to live with chronic pain. The debate is based on the belief that some think fibromyalgia is actually a mental health issue. There are those who believe it to be a subconscious attempt to avoid the stresses of daily life and work. Currently there is not a known physiological explanation for the widespread array of symptoms common to all sufferers of the disorder.

It is because of the lack of a generally accepted physiologically-based explanation that it is often suggested to be a mental rather than a physical disorder. Fibromyalgic symptoms could also be caused by mental malfunctioning according to those who do not believe it has a physiological basis. Over half of those diagnosed with the condition have a past history of other ailments, which also have no medical proof of existence including chronic fatigue syndrome, irritable bowel syndrome, and chronic headaches.6 It is this dilemma that causes some experts to reject a medical origin and point to mental health networks for answers to the problem.

The confusion with the mental health suggestion is that it does not explain certain physical changes that take place in patients with fibromyalgia. Certain organic aberrations have been found in people with fibromyalgia, although it is not yet known whether these came before or after the syndrome developed. Among them are changes in nervous system chemicals that may explain the common problem of disturbed sleep. Fibromyalgia patients typically lack restorative or slow-wave (theta and delta sleep, which can result in chronic fatigue and heightened sensitivity.

Researchers have found levels of substance P, a chemical related to pain, and some abnormal painrelated peptides to be excessively high in the cerebrospinal fluid of fibromyalgia patients.7 Heightened levels usually mean the person perceives more pain. In a study reported in the Journal of Rheumatology, Muhammad Yunus, M.D., and associates, discovered that people with fibromyalgia actually had diminished blood flow — meaning less functional activity in two areas of the brain that help regulate the amount of pain signals the brain receives.8 This study supports the author’s belief that poor upper cervical alignment from forward head postures may be a contributing structural factor to fibromyalgia. Poor occipitoatlantal (O-A) and atlantoaxial (A-A) alignment can compromise (occlude) vertebral and basilar artery output to posterior and mid-cranial regions, robbing the brain of vital nutrients, especially oxygen (See Figure 4).

Careful What You Say

Massage and other bodywork therapists should be cautious when assessing, speculating and particularly labeling perceived causes contributing to a client’s neck and back pain — i.e., work-related accidents, specific diseases or overuse syndromes (fibromyalgia, degenerative disc disease, sciatica, etc.). A good history with helpful notes can be recorded without verbally labeling our individual thoughts about the client’s condition.

Very few states grant massage therapists the legal authority to label (i.e., diagnosis). And for good reason — most lack the diagnostic ability or testing equipment to properly label a client’s acute or chronic condition beyond dispute. In addition, verbally attributing musculoskeletal pain conditions to specific causes can create inappropriate fears, anxieties, or avoidant behavior in clients.

Noted pain specialist Dennis Turk, Ph.D., believes that “since fear is a natural consequence of pain, pain-related anxiety and fear may actually accentuate the pain experience in many chronic pain cases.”1 If clients with pain are exposed to fearful situations, they typically respond with either unnecessary worry or escapist behavior to avoid any anticipated harm.

Avoidant behavior can sometimes be useful in the context of acute pain but loses beneficial quality in clients suffering chronic pain disorders such as fibromyalgia. Reliance on the acute model of pain in cases of chronic pain is often inappropriate. For example, leading the client to believe that activity might aggravate the disorder and cause more harm can result in fear of engaging in rehabilitative efforts.This can lead to obsessive mental preoccupation with bodily symptoms and physical deconditioning that only exacerbate the pain, thus causing the client to maintain the disability.

Treatment Options

Because the symptoms of fibromyalgia wax and wane, treatment (as with that of other chronic diseases) should be considered an ongoing process rather than management of a single episode. Flare-ups often exacerbate the client’s underlying stress. Furthermore, stress can also precipitate flare-ups of fibromyalgia. The first line of defense for relieving basic fibromyalgic symptoms should be body therapy and exercise. Although pain from this condition primarily manifests in specifically designated areas, the trained manual therapist refrains from “chasing the pain” and instead, seeks to restore whole body function by testing for ART: asymmetry; restriction of motion; and tissue texture abnormality. Postural evaluations using Vladimir Janda, M.D.’s Upper and Lower Crossed Syndromes (see Figure 5)have proven extremely beneficial in identifying asymmetrical muscle imbalance patterns that exasperate fibromyalgic symptoms. Specific hands-on techniques that lengthen tight, neurologically facilitated muscles and tonify weak, inhibited muscles helps restore balance and symmetry while fighting off the compressive forces of gravity. Tissue texture abnormalities must be closely evaluated in clients presenting with fibromyalgic symptoms. Boggy, leathery, fibrotic, contractured, and spasmodic tissues are potential pain generators, with each requiring a uniquely different hands-on approach. Post isometric relaxation routines such as those demonstrated in Figures 6 and 7 prove very beneficial in recovering lost range of motion to fibrotic spine related tissues such as joint capsules, ligaments, and paravertebral myofascia. Any deep tissue technique that calms central nervous system hyperactivity and lowers sympathetic tone will greatly benefit those with fibromyalgia

While it is tempting for the client to relax and not move joints and muscles that are hurting, moving them is one of the best preventive and curative measures found so far to alleviate the painful symptoms. Traditional massage techniques are helpful in desensitizing hyperexcited cutaneous (skin and fascial) neuroreceptors. However, deep-tissue techniques that incorporate active client movements (enhancers) during the hands-on work add additional therapeutic power by calming pain generating articular (joint) receptors. Intrinsic muscles and joints are inseparable; what affects one always affects the other. Therefore, a more holistic approach to treating fibromyalgia and myofascial pain syndromes should include soft-tissue techniques that create extensibility in contractured tissues; tonify weak muscles; and decompress impacted, motion-restricted joints and their supporting ligaments.

Exercise … gooood!

Incrementally, the more exercise clients are able to do, the better they will feel. It doesn’t matter what kind of aerobic exercise — swimming, biking, jogging, walking, dancing — as long as they hit their target heart rate for at least 30 minutes a day. Some clients report feeling better as they gradually increase their exercise programs to 30 minutes twice a day.

Why do clients suffering fibromyalgia improve with vigorous exercise? One notion suggested is that aerobic exercise beefs up the body’s supply of endorphins, a natural pain-dampening and sleep-deepening substance. Exercise increases levels of serotonin and growth hormones, the exact pain-reducing, muscle-repair hormones that people with fibromyalgia may lack. Exercise also increases blood flow to the muscles. It is well-documented that people with fibromyalgia do have slightly less blood flow to their muscles, which might also contribute to pain. Exercise and bodywork together are often just the answer for helping reverse this often debilitating condition.

*** Fibromyalgia is a disorder with no widely accepted medical proof. It is a chronic condition characterized by symptoms of widespread pain and tender points as well as fatigue, depression, and sleep disorders. While scientists at the present time have found no generally accepted way to medically document the existence of fibromyalgia, it has been proven that there are physiological changes present in many who have the disorder. The debate will continue to rage as to its origin and existence. Some insist that it is a medical condition while others are convinced that it is a mental health issue. Meantime, as the research rolls in and the truth is eventually decided, it is in the client’s best interest to immediately begin routinely scheduled bodywork sessions in conjunction with a specialized exercise regime regardless of origin. Well structured manual therapy sessions and individualized rehabilitation programs appear to be the treatment of choice for this chronic and sometimes disabling condition that affects an estimated 2 million Americans each year.

Erik Dalton, Ph.D., Certified Advanced Rolfer founded the Freedom From Pain Institute and created Myoskeletal Alignment Techniques to share his passion for massage, Rolfing, and manipulative osteopathy. Visitwww.erikdalton.com for workshop, book, and video information.