Methodology 2.2

**The Need for Comprehensive Care**

Comprehensive Care stems from the principle known as "Holism." Holism is the idea that systems and their properties should be viewed as wholes, not just as a collection of parts. "The parts of a whole are in intimate interconnection, such that they cannot exist independently of the whole, or cannot be understood without reference to the whole, which is thus regarded as greater than the sum of its parts."

While certainly not a new topic in manual therapy, Ida Rolf, the founder of Rolf Structural Integration, used holistic principles to develop her own approach known as "system adaptation" - the idea that the entire body/fascial system must change and adapt, not just a part.

Holistic principles have been integral to the development of this work. The inclusion of holism and system adaptation into spinal manipulation has been long overdue.

In this section we will continue to detail our approach and strategy for treatment, focusing on the need for spinal interventions to be comprehensive in nature, i.e.: addressing the whole of the body; muscle, fascia, spine and ribcage, rather than just parts. In doing so, we shall also explore structural causes of pain, both chronic and acute.

Structures in Gravity

On the right is a 2-D structure of blocks equal in size and weight that is "balanced" within the field of gravity. While the blocks do not line up perfectly, the left-ward blocks are balanced by right-ward blocks and the structure remains stable within the field of gravity. It stands by itself, relatively free of strain.

To create a more stable structure, we would move blocks toward the center line. However, once we begin to move the blocks we will note that it is virtually impossible to move just one block. Should we only move one block, the structure becomes destabilized in the field of gravity. Lacking balance, it strains to stay upright. The imbalance creates a both a vulnerability and a tendency towards collapse. It becomes quite obvious that each move requires a balancing move, or the structure loses stability in the field of gravity.

2-D blocks balanced in the field of gravity. While the blocks are distorted to a vertical line running through it's center, the left-ward blocks balance the right-ward blocks and the structure remains somewhat stable.

Should we move only one block, the structure will lose stability in the field of gravity.

While the segment is now closer to a vertical axis/line, it comes at the expense of destabilizing the overall structure. It will now have a greater tendency to collapse.

If we were to instead move just one lower block, the balance of the structure is again upset.

At this point, we may add a face to the blocks to start forming our analogy. The structural imbalance imparts an element of strain to the whole.

The solution in order to bring a greater balance to the whole, relative to a center vertical axis, is for each block to be moved closer to the center line.

With this simplistic analogy, we might begin to understand some of the difficulty in changing a human structure in the field of gravity. Indeed, to change a part we must change the whole.

The Balance of Distortions

In every human body, no matter how seemingly lopsided, there remains a structural "balance" to the whole - as much as the body will permit. Distortions are balanced, generally, by other distortions. Trying to change only one distortion will generally imbalance the structure in the field of gravity and that change will either revert or cause strain to occur.

While the human body is certainly not a 2-D stack of blocks, the underlying physics work in the same fundamental way: restoring balance within the field of gravity typically requires a comprehensive effort.

I say "typically" because there are indeed many, many variables at play, including whether a structural/spinal distortion is traumatic and acute, or whether it is of the old and chronic variety and the body has had it's opportunity to compensate throughout.

In the case of an acute and recent distortion/subluxation of a vertebrae or rib, quick "spot work" at the site can reduce the necessity for more comprehensive work. But once a distortion has been in the body for some time, the entire structure will compensate around that distortion. In that scenario, one problem is followed by a cascade of compensations over time. To correct the initial distortion then requires a change to the whole.

Because of this, in general, the level of comprehensive care required goes up accordingly with the length of time a structural issue has been in the body. Which also means, for the most part, it goes up with age.

This line of reasoning and observation may seem like a vote in favor of immeidate chiropractic adjustments to all acute spinal issues, and in truth, those situations exist. But, no part of the body exists in isolation, and many if not most acutely distorted/subluxed/out of place vertebrae are chronically pre-disposed to an acute fixation and distortion beforehand. Typically, the structural tendencies are already there. And with one wrong twist the previously unknown tendency suddenly becomes acute and quite painful problem.

The vast majority of structural and spinal distortions, even acute, require some measure of comprehensive care. The only question is to what extent. And that question is greatly determined by the length of time a problem has been in the body.

With an acute/recent structural distortion, quick attention to the initial distortion will reduce the need for comprehensive work. To restore balance, we simply need to move the out of place block back.

If the block in question cannot be moved back, other blocks must be moved in order to create a semblance of "balance" in the structure. In general, mass leftwards of the vertical line is balanced by mass rightwards.

The precise balance of segments of varying size and weight in the field of gravity. Mass must be precisely distributed.

Strain and Pain

As the body attempts to balance around a vertical axis in the field of gravity, it does so by distributing and re-distributing mass around that vertical line.

Again, this means that a structural distortion is most often "balanced" by another distortion or set of distortions. Commonly, we see this type of balance where a Kyphosis (excessive curvature in the thoracic spine) and a Lordosis (excessive curvature in the lumbar spine) combine. More often than not, the two excessive curvatures will develop together. One may initially precede the other, but a compensatory distortion will generally follow.

Max Planck, a theoretical physicist who won the Nobel Prize in Physics in 1918. The father of quantum physics, he is often quoted as saying, "If you change the way you look at things, the things you look at change."

The common Kyphotic/Lordotic pattern demonstrates the body's balancing of distortions. Weight is distributed and balanced around a center axis. Weight forward of the center line (the cranium and lumbar spine) is balanced by weight backwards of the center line (the thoracics and lower sacral).

Generally, in a Kyphotic/Lordotic pattern, weight forward of a center line (in the side/sagittal view) is balanced by weight backwards of the center line. With the Kyphotic/Lordotic pattern, the lumbar vertebrae and head stray forward of a center line, balanced in back of the line by the thoracic vertebrae and lower sacrum/coccyx.

This type of structural balance relative to a center line isn't optimal in the least, but the modicum of balance to the center line more evenly distributes both strain (and fluid pressure) throughout the structure, resulting in a diminished neural response - i.e: pain.

Where greater problems and pain are often encountered are where a lower curvature is not balanced by an upper curvature. The result is often a much greater strain pattern. Strain in the field of gravity, in turn, lends itself to pain.

The Sagittal Balance Model

The following study from the International Journal of Spine looks squarely at this issue. "Positive Sagittal Balance and Management Strategies in Adult Spinal Deformities." This study looks at spinal curvature and structural distribution around a plumb line (vertical axis).

http://ijsonline.co.in/positive-sagittal-balance-and-management-strategies-in-adult-spinal-deformities/

The author, Dr. Dhillon states, "(The) Human Spine has adapted a curved morphology to compensate for the upright posture. Normally these curves are sagittally balanced and a vertical line drawn from the center of the C7 vertebral body (the C7 plumb line) passes within a few millimeters of the posterior-superior corner of S1."

The study goes on to find that surgery is most often only considered for a lack of sagittal balance in spinal curvature, typically occurring with a lack of lumbar curvature to balance upper thoracic curvature, resulting in too much body mass forward of a center line. The imbalance creates strain and not surprisingly, a level of pain sufficient for surgical intervention.

It is here we can begin to make distinctions between structural distortions that cause pain and distortions that do not. Many in the field of Medicine are mystified that many obvious structural distortions in people cause no or little pain. They are equally mystified when clients who have little to no apparent structural distortion are constantly in pain. On that basis alone, various "experts" have taken to dismissing structural distortions as a cause of pain. See, for instance:
https://medicalxpress.com/news/2018-06-myth-persistent-musculoskeletal-pain-obvious.html

Their dismissal appears quite shortsighted. As we have seen, not all structural distortions are the same and strain/pain often has a lot to do with how well we can balance around a vertical axis rather than the number or even severity of distortions present.

Thus with human structure, causality of pain is not necessarily in the distortion itself, but may rather be a body's inability to compensate to that distortion. Where the body cannot compensate to a distortion and maintain a semblance of balance in the field of gravity, the result will be a structural strain -- muscles and connective tissue working hard to maintain erectness. What follows is constant tension, fatigue and, ultimately, pain -- the type and severity of pain for which a surgical remedy is quite commonly sought. The type of pain for which people are willing to risk being cut open, hardware & screws, infection, a long recovery and a risk of surgical "failure" that compounds with age.

Pressure and Pain

Pain from constant strain to stay upright is not the only type of pain involved. Other types of spinal pain, or the absence of such, deserves explanation as well. That explanation however is partly about mechanics, but also quite a bit about fluid and fluid pressure. It is at the fluid level that we might begin to shed some light on acute spinal pain and whether it disappears or becomes chronic in nature.

Pain and fluid pressure distortion share a fairly direct relationship. As we have explored in Theoretics 1, the nervous system of the human body is acutely sensitive to variations and distortions in fluid pressure: from a zit to a boil, from compartment syndrome to a headache, a sucking chest wound to a hematoma; the relationship between fluid pressure distortion and registered pain is close, constant, and consistent and direct.

How can fluid pressure become a pain signal? Well, we need not look further than the ubiquitous mechano-receptors of the nervous system that appear in almost limitless quantities throughout every corner of the human body. Included within the group of 'mechano-receptors' are the "stretch receptors": mechano-receptors that line both muscle and fascia. And sure, the "stretch" receptors register a pull on the tissue -- like when we stretch our muscles in yoga. But activating the stretch receptors also includes stretching a fascial membrane by increasing its internal fluid volume. By analogy we may stretch and increase the surface area of a balloon by manually stretching it between two points, or we may simply add air or water to it. Either way, it stretches.

Our bodies are more than 60% fluid content. That fluid is contained within a vast network of fascial (connective tissue) membranes. Omnipresent, ubiquitous, everywhere; the human body is, essentially, a system of fluid-filled fascial membranes -- membranes within membranes within membranes. All the way from the wall of a microscopic cell to our outer layer of skin and superficial fascia.

The fascia, the body's connective tissue that encapsulates all parts, is itself a system of fluid-filled membranes. The fluid-filled fascia has recently been declared an "organ" unto itself:
"The Interstitium"
https://en.wikipedia.org/wiki/Interstitium
https://www.livescience.com/62128-interstitium-organ.html

Lining the endless web of fascia/Interstitium are neural stretch receptors. Dependent on location in the body, stretch receptors range in sensitivity, quantity, and the message ultimately interpreted by the brain. For example, stretch receptors in the stomach relay a feeling of satiety when stretched and activated. Meanwhile a stretch receptor at the site of a sprained ankle relay the throbbing pain of an accompanying swelling.

Fluid Pressure in the Spine

In the spine, once a mechanical distortion to a spinal segment is applied (a vertebrae goes out-of-place), an interruption in both fluid flow and pressure occurs within the nervous system as a direct result. That pressure distortion produces pain -- just like swelling/inflammation in other parts of the body. And while the nervous system in general is very sensitive to fluid pressure distortions anywhere, the fluid pressure distortion that follows a spinal misalignment occurs within the superhighways of neurology, ultimately crowned by the brain. The sensitivity of the mechano-receptors surrounding the spine and neural system appear in general to be remarkably high.

Is this just theory? No. Check out this study from the Massachusetts General Hospital:

https://medicalxpress.com/news/2018-05-neuroinflammation-spinal-cord-nerve-roots.html

Anatomical Planes of Motion

From the International Journal of Spine. A "normal" thoracic kyphosis is balanced by a lumbar lordosis.

An excerpt from the International Journal of Spine study on "sagittal" (from the side view) balance. Here, where no lumbar curve exists to balance an upper distortion, mass relative to a center line is shifted back via the hips and knees to maintain verticality.

Stretch Receptors in Muscle Tissue.

The "Interstitium" - the network of fluid-filled, fascial membranes that encapsulates everything in the body. The interstitium is both congruous and connected to the lymphatic system.

An X-Ray showing the forward shift of L4 on L5, compressing the Central Nervous System and creating a fluid pressure and flow distortion of Cerebrospinal Fluid (CSF) at the site of structural distortion.

"In their paper published in the May issue of the journal Pain, the (Massachusetts General Hospital) research team reports finding that average levels of a marker of neuroinflammation were elevated in both the spinal cord and the nerve roots of patients with chronic sciatica. Additionally, the study showed an association between neuroinflammation and response to anti-inflammatory steroid injections, with levels of neuroinflammation differing between those whose pain was and those whose pain was not relieved by steroid injection treatment."
(emphasis added).

An anti-inflammatory, of course, reduces the fluid pressure distortion, i.e.: swelling. Hence the benefit. And following the line of logic presented here, the chronic aspect of spinal inflammation present would suggest that the structural compensatory abilities of the patients in the study had been compromised to some extent.

Sciatica itself is most often a structural issue, with neural compression as a chief cause. But the compression is only part of the problem. The result of a neural compression is a disruption in both fluid flow and pressure. Within the spine, the fluid in question is Cerebrospinal Fluid (CSF).

While we have throroughly explored the importance of CSF in Theoretics 1, suffice to say, we are only beginning to understand the impact of flow restriction and stasis of CSF throughout the entire neurological system, including the brain.

Below is a study on CSF flow/velocity, pressure, and hydrocephalus -- an extremely painful condition whereby CSF fails to drain properly from the cranium.

http://www.adina.com/newsgH64.shtml

This study found CSF pressure levels to be five times greater than normal in the cases of hydrocephalus. Headaches, migraines, loss of vision, incontinence, mental impairment...are some of the symptoms. And of course, pain.

CSF fluid pressure and flow (velocity) calculated using MRI's, Navier-Stokes and Darcy flow equations.

The common cause of hydrocephalus is stenosis -- a narrowing of the spinal canal. A stenosis hence causes a neural compression that interrupts fluid flow. The interruption in fluid flow creates pressure distortions within the system. The stenosis itself may be caused by an unnatural growth into the spine, or the structural distortion of vertebral elements which then in turn distort the neural pathway. The pain however is not necessarily the compression itself, but rather the fluid pressure distortion within the neural system that is created by the compression.

Cervical MRI showing spinal cord and CSF compression. Vertebral distortion and stenosis are clearly seen.

Scoliotic Spine, thoracic/dorsal MRI

The Price of Compensation

At this point we have articulated the case for a direct relationship between fluid pressure distortion and pain. We now turn our attention to how the body deals with it.

Whether the acute fluid pressure distortion and pain response is abated or not is a product how well the body and nervous system can compensate to the initial mechanical/spinal distortion. If it the body cannot, a pressure distortion may devolve into a chronic issue.

A local structural distortion results in a local pressure distortion. This creates an imbalance in overall system fluid pressure.

By structurally distorting above as a compensation, a balance of distortions occurs in the field of gravity, giving some stability to the structure and easing acute strain. The distortions above also serve to equalize fluid pressure throughout the system. Acute pain is dulled, but the overall system function slows.

With an "open" and spacious structure, the structural compensatory process will distribute pain, strain, and fluid pressure fairly evenly throughout the structure. The body will "absorb" the initial distortion and the acute pain levels will diminish significantly. The initial structural distortion, however, will still be there to some extent -- a movement and spacial distortion fixated into the structure. But pain levels are mitigated; the acute sharpness is dulled by an overall distribution and the body may resume a fairly normal course of function.

But even with a compensatory process and response a price must still be paid. The result of the compensatory response is that the load and strain of a singular spinal distortion will be carried by the rest of the body and the system overall. The trade-off in the compensatory process is that the overall system will slow down just a bit for every trauma it absorbs. That slow-down in the short-term and especially at a young age is imperceivable to the average person. But as trauma's and compensations stack over time, the slow-downs stacks too, eventually becoming quite real and quite felt.

A compensatory process is not a perfect one. It is simply a way for the body to "deal". "Balance" as a result of a compensatory process is not optimal in any way either. But it is a measure of system balance, and that lends itself to system function.

But should a system be incapable of the compensatory process and absorbing a problem, whatever fluid pressure distortion within the neural system that was created while acutely twisting one's back out will likely remain at the site of injury in some shape, form or fashion for some time to come. And when that happens, what was an acute problem becomes a chronic one. The acute pain becomes a chronic pain.

But why would a structure be "closed" and incapable of compensations? The obvious answer is of course "space" within the structure/skeleton to move. i.e.: "joint space" - the space between the bones (the "interosseous" space). And this includes the space between the ribs. Joint space, as we have seen, often closes first in the shoulders. Over-time, joint space decreases with age and compression in the field of gravity, making the compensatory process a greater challenge as we get older.

Thus, for instance, if someone's shoulders and neck are already jammed-up at the time they twist their lower back out, the acute issue at the lower back stands a much greater likelihood of becoming a chronic one. And that likelihood increases with age.

With that we may begin to understand how a older human structure, rife with movement restrictions, may have a much much more difficult time adapting and compensating to a fresh trauma, and how a young, spacious body will more easily absorb one. It is simply a question of available joint space.

We may also draw parallels to the declining success rates of spinal fusions and other spinal surgeries with age. Generally, the older a person is, the greater the likelihood a spinal surgery will "fail". The reasons are the same.

If structural space is generally compromised with age, then so is the ability of the body to compensate to a change. With, for instance, a lumbar spinal fusion that suddenly jacks open a neural space with hardware and screws, localized neurological pressure in the lumbars will change as well, prompting a compensatory change throughout the rest of the structure. Indeed, one problem is being fixed, but the demand for the rest of the body to change creates other problems. With a fixated thoracic above, no such compensatory change may occur. A pressure distortion, relative to the rest of the system, will likely be created at the site of surgery (or just above), and the lumbar surgery may likely "fail" due to high levels of pain and immobility.

Hence, as structural spacial limitations compound (with age and trauma), compensatory ability drops, and the likelihood of chronic pain goes up.

Again, this all supports the idea that not only is comprehensive manual therapy a smart idea at any age, but that the necessity for comprehensive treatment also increases with the age of the client and the length of time a problem has been in the body.

Chronic Strain and Chronic Inflammation

When a human structure is out of balance in the field of gravity, it is the muscles and connective tissue that must continually strain in order to remain upright in the field of gravity.

This type of chronic strain creates a chronic inflammatory response in the effected soft tissue and muscle that is under strain.

In turn, the chronic inflammation creates higher levels of fluid pressure within the effected muscles and fascia. Chronic inflammation is essentially, swelling, and such distortion in fluid pressures creates, in all likelihood, a pain response in the nervous system.

Again, the process by which the pain response is produced is a continual, distorted load on the neural stretch receptors within muscle and fasica: Golgi tendon organs, muscle spindles, etc. These stretch receptors are activated in the inflammation/swelling process by a direct increase in fluid pressure within the fasical membranes that they line. And just like direct over-stretching, continually loading the stretch receptors results in pain response.

The incredible river rock balancing and photography in this section is by artist Manu Topic.

Side to Side Balance and Expanding Upon the Sagittal Balance Model

The Sagittal Balance Model; both extremely insightful while also somewhat limited in scope, looking only at balance from the side/sagittal plane. The human body, of course, is not a 2-dimensional structure, and balance must occur on far more than simply the sagittal plane. It must occur in three dimensions. But before we get there, we'll look for 'side to side' balance in the human structure.

In the "frontal plane" (as seen from the front or rear), side-to-side ("lateral") balance to a vertical line is also as important as front to back balance ("sagittal"). And where a lateral structural distortion is involved, such as a scoliotic curve, we may expect a similarly compensatory behavior occurring on the 'frontal plane' to that which occurs on the sagittal -- a curve or distortion occurring laterally balanced by another lateral curve elsewhere in the chain.

This type of lateral "balance" would most easily be seen in the common scoliotic "S" pattern where a lower lateral curvature is balanced by an upper curvature to the opposite side. As is the case with a balanced Kyphosis/Lordosis occurring in the sagittal plane, the lateral deviations of scoliosis balance and distribute weight around a vertical axis in a similar manner.

Scoliosis is not comfortable, to anyone, ever. But, again, a more balanced lateral curvature in a scoliosis helps to balance structural strain and fluid pressure while keeping pain levels to a tolerable level.

Where lateral balance is lacking, the structure is more likely to be both in strain and in pain. Where lateral balance in curvature is present, it will lend itself to better function, less strain, and less pain.

We may just as easily draw our human facing forward with our simplistic analogy. A side-to-side "balance" of sorts is present in the structure.

A scoliosis showing a balanced "S" curve.

A scoliosis showing poor lateral (side to side) balance of curvature. A surgical correction follows.

The product of a Google image search on male scoliosis.

Three Dimensional Balance

At this point, we are starting to redefine what "balance" in the field of gravity means. Without a doubt we are attempting to change the picture some. As manual therapists, this may prompt us to see the body differently. Importantly, it may also shift our perspective and change the objectives of our manual interventions away from merely trying to create a "perfect" spine to instead look for where structural balance is lacking, and also where, specifically, the structural compensatory processes of the body have been halted or compromised.

But in changing the picture we are not done complicating it. "Sagittal" and "frontal" balance are still limited concepts when considering the human body. Actual balance in the human body occurs in three dimensions around a vertical axis, with spirals and rotations within the structure being the norm rather than the exception. All planes of movement are involved.

Stacked play blocks showing 3 Dimensional distortion from a vertical axis in all planes of motion including rotational.

The Scoliotic Twist

Scoliosis itself is quite often misconceptualized as only being "lateral" structural distortion -- i.e.: a side-to-side problem. However, in all cases, there are less-obvious rotational distortions and rotational patterns in scoliosis that are always present.

The same may be said of the above Kyphotic/Lordotic pattern that is so common. While our attention is drawn to the obvious lumbar and thoracic curvature, what inevitably accompanies that curvature are rotational patterns -- usually, quite similar to what is seen in scoliosis: a large group left rotation in the pelvis and lumbars being balanced by a large right rotation in the bottom of the thoracic (around T11-T12). The group rotational pattern then again switches back to a left rotation around T3-T5 - making the area between the shoulder blades a junction for a major rotational change, placing a high degree of structural demand upon the body at that point. As it turns out, the area around T4 is a "problem" area for most everyone.

The 'Normal' Spine

What follows is the general observation that the very same rotational patterns we seen in scoliosis, kyphosis, and lordosis, are quite commonly seen on much less extreme cases: i.e.: "normal" spines. Sure, different rotational patterns may occur and do, but the 'pelvis/lumbars to the left, lower/mid thoracic to the right, and upper thoracic back to the left' group rotational patterns is, without a doubt, the most commonly seen throughout the human form.

(These three large group rotations are not, however, the only rotations likely present in a given spine. Another large counter-rotation may be present in the cervical, and even between individual vertebrae, rotational patterns are quite normal. At present, however, we will concentrate on the three large group rotations identified above, as they are easily seen in photographs.)

Rotational Balance

With that we may add a third category of distortional "balance": rotational balance. We may observe that strong degrees of a rotational distortion at one point in the body are generally balanced by an equally strong rotation to the other direction.

In scoliosis, we normally see a pronounced right rotation. ANd it is that right rotation that is typically used as an indicator of scoliosis (above right). But that strong right is always sandwiched between 2 lefts. It is arguable that the strong and obvious large right thoracic rotation is "balancing" the cumulative sum of the two adjoining, but less obvious, left rotations -- above at the shoulders, and below at the pelvis.

In the non-scolitic, "normal" spine the same rotational patterns will often apply, but at far less severity. Typically as well, the right rotation of the lower thoracic will not dominate in relation to the leftward rotations. Normally, the two lefts will balance the the whole of the picture, or even dominate it. There are however, strong, built-in tendencies for the one large right twist in between to slip into an extreme.

Why? One reason is that the movement potential (the range, space and ability of the spine to move) of the vertebrae changes significantly from the lumbar spine to the thoracic, making it likely that a strong rotation will occur at the lower thoracic/upper lumbar.

Attached ribs in the thoracic restrict movement and add to whatever spacial limitations are present. Generally, of the three vertebral groups, it is the cervical that moves the easiest, followed by the lumbar, and in a not-so-close third, the densely-crowded thoracic.

A severe scoliosis in a forward bend. On the far right, the forward bend illustrates a strong right rotation in the lower and mid thoracic.

Physicians measure for a strong right rotation in the thoracic when diagnosing Scoliosis. However, the strong right rotation is generally embedded between two very strong group rotations that go left -- at the pelvis and lower lumbar, and again at the shoulders.

Common group rotational patterns in both scoliosis and the average body. The pelvis and lumbars rotate left followed by a right counter-rotation around T12, followed by another left rotation around T4.

The same pattern seen here.

A lack of movement potential in a vertebrae also serves to stifle compensatory ability while forcing that demand elsewhere. In our typical case, a heavy left twist below at the pelvis/lumbar will force a right counter-rotaton to occur in the thoracic. But because the thoracic has less movement potential over-all and especially as we go up towards the upper thoracic, the "lion's share" of the right compensation may tend to occur much earlier -- in the lower thoracic and upper lumbar - L3 up to T10, where the ribs are still very mobile relative to the rest of the thoracic. The center point of this critical area is T12, the lowest lumbar vertebrae

A second vulnerability exists at the T12 area. In regards to weight and mass distribution, the thoracic upon the T12/upper lumbar is a bit like a spinning toy-top: mass is concentrated in the middle section and decreases as it goes down. With body mass, gravity and rotational tendencies combined, there is a strong tendency for rotational distortion and instability at the T12 area.

The mass of the thorax narrows at the T12 area creating a tendency for instability and rotation relative to the rest of the thorax. Like a toy spinning top, the ability to easily spin (rotate) is created by a taper - a narrowing of mass. This tendency for instability often results in the right rotation of a group of vertebrae at the T12 area.

A Balance of Distortions

In 3 dimensions the human body strives to balance curvature and structural distortions with other curvatures and distortions. Hence we can see how changing one part of a pattern will generally require attention to the rest. While there are exceptions to the rules, changing the right means changing the lefts, and visa versa. No part of the body exists in isolation, nor any spinal pattern. To change a part means to change the whole.

Thus the importance of comprehensive work in manual therapy, especially as it applies to more-focused structural interventions, cannot be overstated. But that importance, and the critical underlying understanding, applies equally as well to other modalities in massage and in manual therapy - even where structural changes are not necessarily intended.

Treatment
A Cautious Approach

The ancient Hippocratic Oath in Medicine essentially boils down to "first, do no harm."

In manual therapy we quickly run up against a wide-spread belief that manual therapy is fairly innocuous/incapable of harm. That belief is, of course, just plain silly. Harm via manual therapy is fairly easy to do and as well, a common occurrence. However, pinning causation to a manual therapy is often difficult if not impossible, provided no action is overtly outside of the basic standards of practice. In other words, harm via manual therapy is really hard to prove, and as well, quite difficult to understand the process by which a harm could occur in the first place. Manual therapy flies significantly under the radar in terms of the power to change the human body - both for better or worse.

Hippocrates, the "Father of Medicine" and author of the Hippocratic Oath.

In Law, a proximate cause is an event sufficiently related to an injury that the courts deem the event to be the cause of that injury. With manual therapy, it is difficult if not impossible to prove that a soft-tissue intervention caused any sort of relatable pain or structural change. Pain, on the whole is subjective and difficult to measure. Some sort of physical evidence of harm along with negligence on the part of the practitioner is generally required. Negligence is an action outside of the normal standards of practice, broad as though they be. In manual therapy, that almost means negligence to the point of breaking a bone or doing something else that is monumentally stupid and objectively provable -- a deep bruising, a torn labrum, a dislocation, etc. These things are pretty rare. And that is a primary reason why a 3 million dollar massage therapy insurance policy can be purchased for $125 a year.

But just because harm via manual therapy is difficult to legally prove doesn't mean it doesn't occur. It does. And the deeper you poke around in the human body, the more risk you take.
Of course, there is the tremendous upside, and we are barely scratching the potential of all of this, but I would be a poor educator to not impress upon you, dear reader, the specter of danger, and the need for caution. Yes you can effect structure, even when you don't intend to.

If we find manual therapy to be powerful in a good way, we must also allow that it may also be powerful in a bad way.

How many things are wrong with this picture?

In these pages I am advocating the use of manual therapy for deep changes into the body and structure that ultimately impacts the neural system. This type of intervention is risky per se and that risk goes up with age and accumulated trauma's. Each move made on the interosseous level must be done mindfully. Fragile clients are just that. The margin for error is very small. Callous or thoughtless work will fuck-people-up in no short order. Be forewarned. However, don't panic; an unwinding approach into the body is gentle and gradual, and non-effective strategies may easily be reversed. Still, this is not a job for someone looking for a second income, or a divorcee in need of a new path. This is, in all aspects, a serious endeavor which requires a good bit of practice and study. It's not for everyone.

That being said, practitioners need not dive so deeply into the spine and interosseous in order to utilize and benefit from the information presented here. Soft tissue modalities, including massage, can well utilize these ideas and principles to improve outcomes and successfully ease strain patterns in clients and loved ones while avoiding unintended structural consequences. For my part, I will offer guides that range from dedicated structural spinal work to standard massage and where to focus effleurage with confidence.

The idea of course is to work smarter, not harder, and get to causes, not just effects. That requires refinement of an understanding of where to work - and as well, what to avoid.

In regards to technique, the more-refined a practitioners technique is, the less energy they will expend while providing a better session (and result) to their clients. While unwinding is my preferred technique, softening tissue can be done in a variety of ways. Mostly, it just requires an element of slow. I employ other techniques as well. But mostly, I just go very, very slow, with a good engagement into the tissue or joint. The caveat is thus: don't try to fix a problem with a hammer. If you are traumatizing tissue, all benefit will be lost. Go slow, and be patient.
....

Body & Pattern Reading
A Posterior Assessment

Body & Pattern reading remains one of the more difficult and important aspects of assessment. Here we will start with nothing but a posterior photo.

At right (fig. 1) we have a stock photo of what to many looks like a fairly normal spine. If we look a bit closer however, we can note some lateral curvature. This is a scoliosis in a young man.

Tracing the spinal route (fig 2), we can note a balance of curvatures: at the pelvis, lower thoracic and upper thoracic.

Drawing a vertical line down the back and through the sacrum, (fig. 3), we can note how body mass, especially in the upper thoracic, favors the right side.

At the shoulders (fig. 4), we can see how the left shoulder appears pinched and compressed relative to the right.

Along with the lateral curves we can also see some visible group rotations (fig. 5), left at the pelvis and lumbar followed by a right at lower thoracic and another left at the shoulders. Note the bulge in the lumbars on the left side, the more prominent right scapula, and the prominence of the left trapezius area. Other rotations and counter-rotations may exist, but these main three are easily visible.

Where the rotations transition are marked in (fig. 6). These are the centers of the twists and where the twist goes from left to right and then back to left. These are likely areas for problems, strain, and pain. Neurological compression here will also extend into all systems of the body.

fig. 1

fig. 3

fig. 5

fig. 2

fig. 4

fig. 6

We can also see how the right rotation at the lower thoracic helps to cause the right shoulder to dip. Below the shoulder there is a loss of support. The space below is pinched. Because of this, a structural collapse is present, relative to the left side. (fig. 7)

With a loss of support here, strain will be transferred to some of the "usual suspects" in manual therapy - the effected muscle groups: trapezius, rhomboids, and the levator scapulae. (red highlight) (fig. 8)

This area is a popular place for strain, pain, and all sorts of manual therapy and stretching exercises. Not surprisingly, most current therapeutic methods are simply focused directly on the area of strain -- the result of a loss of structural support. In other words, most therapies are typically treating the effect, not the cause.

fig. 7

fig. 8

Many therapies employ a version of "Caveman Assessment" : Hurts here, rub, stretch (etc.). Results are mostly temporary.

The Short Lived Effect

Not surprisingly, for upper back muscular issues, pain relief via direct manual therapy and stretching exercises is generally short-lived, if it occurs at all. The reasoning being that muscle tonus (or tension) is primarily set by the neurological system, and despite our best efforts to lengthen and soften tissue, muscle and fascial tissue tonus will reset over time. How much time varies greatly and it appears that the timeline correlates with the amount of strain that is at work on the area; i.e.: the more strain, the quicker the tension/tonus reasserts itself, and the sooner the pain returns.

The temporary nature of the pain relief requires that sufferers come back for more. And more. Another temporary fix. Massage-junkies are a real thing. It is understandable of course, and a staple of many a therapists practice, but it comes with a very real danger.

The Wrecking Ball: Removing Support

Here we will expand upon a subject covered previously in Methodology 1; working in the holes, not the "humps."

While a neurologically set tonus (tension) can and will come back into muscle and fascia after it has been softened or lengthened, there remains a window of time in which our interventions into the soft tissue may effect the structural aspects of the body, both negatively and positively. Softening tissue in a structurally vulnerable area can have very real consequences to structural support. And a therapist doesn't need to be trying to do "structural" work. Effecting the structure of the human body can be done quite unintentionally.

In our example, we have a combination of distortions that should clue us in as to where we might want to exercise caution. The lower and mid-thoracic shows a strong right rotation combined with a right shift of the spine (and body mass) in the upper thoracic. Thus there is a concentration of body mass in the thoracic that is rightward and posterior of a vertical center line.

If we were to take a cross-section at the thoracic level, and look from the top-down, we would see something like this:

Body mass is pushed rightwards and posteriorly of a vertical axis.

fig. 9. A right shift of the upper thoracic combined with a right rotation of the mid and lower thoracic.

With the constant force of gravity at work, pushing down upon a sloping right rotational distortion, the tendency is for the body structure to continue to distort in that direction. To prevent this, the present tension in the muscles of upper back -- rhomboids, trapezius, levator scapula, is partially an attempt from the body to prevent just that from happening. Hence when we remove all the tonus from the effected musculature and fascia, we are potentially removing some of the structural support holding it all together.

At some point we must acknowledge that holding patterns in the body may exist for a good reason.

So, is taking a hammer to the back upper right shoulder a good idea? Not in the slightest. Is overworking the tissue there going to accomplish anything good? No. Can we do worse?
Yes.

Work in the Hole, Not on the Hump

Where the body is most pushing back at us (the "hump") is here at the lower right scaplula area. It is advisable to use caution here. Manually de-constructing the soft tissue will allow the skeletal system and upper thoracic to slide into the softened tissue, and further into the right rotation and shift. As the spine slides further into distortion, the neurology running through it's bony confines is ultimately compressed to a greater degree. How critical is that? Let me count the ways...

The goal is to create a more balanced structure, not a pile of mush.

This "hump" in the structure will likely be where pain in different severities is often felt. A client may even ask for or expect direct attention to that area. Digging in here however, won't help the cause. In satisfying the client who insists on directing both location and pressure (go deeper!), the area may be numb in the immediate aftermath; the symptoms relieved to some degree. Later however, with gravity given a chance to do its thing and push the distortion further into pattern, the symptoms will return -- and often in greater severity.

This can set up a vicious cycle whereby a client returns again and again for spot work that helps in the immediate aftermath, but over time causes a structural tendency to worsen, which then in turn worsens the symptoms for which the spot work is continually sought.

fig. 10. Caution should be exercised in the lower right scapula area

A picture repeated from Methodology 1. Here again, the structure bulges rightwards and posteriorly on the right side. Caution should be exercised on the right lateral side; at the posterior lower right scapula and below.

The Concave Side of Things

Looking at lateral scoliotic curvature, we may begin to draw in the lateral curves present. Where such curves are visible, focused soft tissue work is better suited to the concave side of the curvatures. Avoid focused, deep, or sustained work on the convex side.

Even with a full-body routine, it is still quite useful to have an idea of what to focus on and what to give less attention to. And when a client requests fix-it work on a problem, or to go "deeper"; there are very good places to fulfill that request, and very poor places as well. Don't trust your clients to necessarily know the difference.

The sides of a curve.

Drawing in lateral curvature.

Green highlights the areas more receptive to soft tissue work. Red for where caution is emphasized.

Reconciling Tensegrity

The theory of Tensegrity has been discussed at length. The word is a combination of "tension" + "integrity" coined by Buckminster Fuller, famed theorist, and architect. Originally applied to architecture, Tensegrity theory was soon applied to the human body as well. Within that realm, Tensegrity is a balance of tensions within the soft and connective tissue (muscle and fascia) to give the structure (the skeleton) support and space.

At a joint, applied Tensegrity can be described as the balance between agonist and antagonist muscles (muscles that act in opposite directions, such as biceps and triceps on the arm).

Tensegrity in the body is based on the mechanical understanding of tissue lengths that span a joint from insertion to attachment, and when those tissues shorten, the joint shortens (or flexes) with it. Chronically shortened tissue at a joint will tend to chronically restrict Range of Movement ("ROM") at that joint. And because chronically shortened tissue always accompanies structural distortions (such as scoliosis), it is also often and commonly regarded as the primary causative factor in the structural distortion of the human body.

For example, "over-tightness" in the hamstrings (below) would restrict the ability to bend forward and may be causally linked to a loss of lordotic curvature in the spine. But are tight hamstrings the only thing restricting the ROM? Are they necessarily the driving force for structural distortion present in the lumbars, hips and sacrum?

Or could it be the other way around? Are spinal distortions to blame for shortened muscles and fascia?

Buckminster Fuller, theorist and architect who coined the term "Tensegrity": tension + integrity.

Architectural Tensegrity was then applied to the human body and has become a dominant theory in biomechanics.

Tensegrity theory as applied to the human body may be described as a balance of agonist and antagonist tissue (muscle and fascia) that span a joint.

Soft tissue restrictions such as hyper-tonused (tight) hamstrings may restrict range of movement (ROM). That ROM may however increase as a result of direct manual softening of the tight muscles and fascia. Results however are often short-lived. This type of soft-tissue approach to ROM issues is the most common in manual therapy today and provides a measure of relief. However, this type of approach and analysis often overlooks spinal (bony) distortions as primary contributors in dictating a person's structural balance as well as ROM.

Span

Easing soft tissue restrictions in muscle and fascia is required as part of a comprehensive approach in manual therapy. The question has never been it's necessity but rather "what else can we do?"

But why is a purely soft-tissue, insertion to attachment, applied Tensegrity approach often lacking or inconsistent in result, especially as applied to the spine?

With a tensegrity approach, we may note that often the muscles and fascia we are working with in order to increase balance, ease, and ROM in the spine span a numerous joints, leading to questions and problems of particularity in treating a specific spinal issue. In the picture to the right, the muscles and fascia that are normally therapeutically treated (in a Tensegrity based approach) to ease structural curvature and increase ROM also span up to 139 synovial joints in the spine. Five muscle groups, 139 joints.

Sure, we could argue that we can simply be much more specific with say, the spinal erectors. But all groups of spinal erectors span multiple(more than 2) vertebrae (Iliocostalis, Longissimus, Spinalis). We could increase our specificity with the smaller yetw transversospinales group of muscles - semispinalis (spanning 4-6 vertebrae), multifidus (spanning 2-4 vertebrae), and rotatores (spanning 2 vertebrae). But at this point things are getting very small indeed.

[...I would note that the body in function certainly does not subdivide and categorize each sliver of muscle like we do academically. That is for us who can't see the forest but for the trees. When the body requires muscular action, it does so on the basis of "what tissue is available for which action". It doesn't select individual muscle groups. It doesn't discriminate. For a particular movement, only parts of each muscle group may be called into action.

Ask yourself this, "when you stand on a chair, and as you step up, are the hamstrings extending or flexing?"
....
The answer is...both - the tissue of the upper hamstrings is flexing while the tissue of the lower hamstrings is extending. Now go figure that one out...]

So, which muscles will we work to fix a twist/rotation in a particular vertebrae? Which erectors will control a specific vertebral shift (picture at right)? There appear to be no agonist/antagonist muscles for such a thing. And which tiny muscles are which in the practical working space of less than an inch?

The muscular approach tends to become implausible, impractical, and pretty much impossible in dealing with a distorted vertebrae. Hence the current solution for most bodyworkers is just to send the client to a chiropractor to deal with the "subluxation". But this makes "comprehensive" treatment a parceled, segmented thing, and left to the care of other manual practitioners.

Model Overlap

"Lengthening" soft tissue/musculature according to Tensegrity does work to a degree. A measure of success can be achieved with pain and strain patterns and even structure. Why? Because the soft tissue holding patterns are a part of the overall structural issues at play.

As well, the Tensegrity approach often has us working on the concave side of spinal curves. Softening/lengthening tissue there not only addresses the soft tissue holding patterns, but may also create the desirable fluid pressure changes within the fascia/interstitium that allows new movement tendencies in the spine to occur.

Thus the model presented here and the Tensegrity approach overlap to some degree. Neither is exclusive or invalidates the other. On the contrary, in the wake of Tensegrity, the inclusion of fluid and pressure dynamics fills a rather prominent theoretical hole.

A Tensegrity based approach would look for shortened muscle and fascia on the concave sides of spinal curves. The targeted muscle groups however span multiple vertebrae. The approach lacks specificity.

In the spine, agonist/antagonist muscles are not so clear. Which spinal muscles are controlling on a vertebral shift? There is no clear answer. The Tensegrity approach for this type of problem becomes very difficult. However, by unwinding the tissue to the rear of the vertebrae (L4) and changing hydrostatic pressure within that particular fascia/interstitial layer, L4 may be induced to move back (posteriorly) towards a position of greater balance and ease while reducing compression on the neural pathways running through it's bony confines.

The founder of Rolf Structural Integration, Ida Rolf instructed early practitioners to work in the holes and shallows of the body where there was no movement or breath. While effective, the focus and technique lacked an explanation supported by Tensegrity. Note where she is working here: left lateral thorax/armpit.

If you change the way you look at things, the things you look at change...
What are we looking at?
Range of Motion (ROM), Joint Space & Shortening the Neural System

With an industry-wide focus on Tensegrity and the relative lengths of fascia and muscle as primary factors in both structural distortion and Range of Motion, we shall end this chapter with a focus on bony distortion in the spine and how it effects, among other things, Range of Motion.

The common mindset in manual therapy today is that Range of Motion (ROM) of a joint is primarily controlled by the length of the muscle and fascia spanning that joint.

With ROM there is no question that muscle contracture and tight fascia can and will restrict the movement of joints (and that loosening said muscle and fascia helps). There does remain the question of whether we are again pre-occupied with an effect rather than a cause. We must of ask, "What causes muscle and fascia to tighten in the first place?"

Without beating a dead horse, part of the answer lies in neurological compression created by bony distortions. And while it is well-supported to find that Tensegrity and relative lengths of muscle and fascia are certainly a prominent player in joint and structural issues, there is more than ample evidence to suggest that they are not the controlling entity in the structural game. Control instead lies with the same 'control' for the rest of the body -- the nervous system. And it is the neural system that is ultimately responsible for the set tonus (tension) in the soft tissues.

Apart from tight muscles and fascia, how else is ROM lost?

ROM is also lost with structural distortion - vertebral, rib, or otherwise. We all know this. Throw your back out and ROM goes to hell. Three main issues generally apply here:

1. A fixated rib or vertebrae effects the movement of everything attached to it. A spinal or rib distortion will result in both a distorted movement pattern at that segment and everything that attaches to it, including the adjoining ribs and vertebrae.

For example, if T2 is jammed, it won't move correctly or with a full ROM. Neither will T3 or T1 since they are adjoining. Or Rib 2, since it is attached to T2. And then Ribs 1 and 3...and so on. In fact, one distorted movement pattern in a rib or vertebrae will have a cascade of effects, up and down the spine.

2. Generally, a spinal or rib distortion will result in a loss of accompanying joint space. This also limits ROM. For example, if T2 is jammed up into T1, there will be a loss of joint space between T1 and T2. While this changes the movement pattern, the loss of joint space also mechanically limits ROM at that joint.

A loss of joint space in the spine will also increase compression upon the nervous system at the site, tightening local muscle and fascia in a protective response.

In scoliosis, the link between structural distortion, a loss of joint space, and mechanical limitations on ROM are very clear. The study below finds a clear loss of ROM with scoliosis finding that "the presence of a scoliosis deformity alters normal spine biomechanics leading to poor global balance and possible detriment to quality of life."
(emphasis added)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5282845/

Along with a loss in ROM are come some other serious implications in joint space. In the Discussion section of the study, the authors address the effect upon the intervertebral disc space, stating:

"The disc architecture changes depending on the convex or concave side of the curve, but nevertheless, high intervertebral disc hydrostatic pressures occur due to asymmetrical weight loading. Both disc and endplate physiology hence becomes abnormal. The definitive effect of intervertebral pressure change rate on the curve progression and degeneration is unknown but nevertheless these alterations hasten the degenerative processes in the IVDs. Losing its pliability, a negative feed-back loop occurs in the spine as disc degeneration further reduces the flexibility of the spine, and the increased spinal stiffness leads to further degeneration. The implications of disc degeneration in scoliosis include earlier development of back pain, poorer quality-of-life, self-image, self-care, physical disabilities and mood problems."
(emphasis added)

In other words, the structural distortions have the effect of accelerating the breakdown of the body...something that has a strong correlation with this thing we call "aging".

Of course and as well, the "scoliotic" pattern and disc deterioration is just a common "extreme" of what is seen all the time. As well, Kyphotic and Lordotic patterns of structural distortion will also see asymmetrical weight loading of a disc. Imbalanced and asymmetrical joint loading is more the norm rather than the exception. The degree of which will tend to directly accelerate the degeneration of the joint and the joint space available. Hence the more structural distortion present, the greater the likelihood that ROM, among other things, in the spine will suffer as a result of a loss of joint/disc space.

See also:
"High pressures and Asymmetrical Stresses in the Scoliotic Disc in the Absence of Muscle Loading."
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1820774/

Side-bending Range of Motion (ROM). Any loss of space between vertebrae or vertebral distortion will negatively effect ROM.

ROM in flexion and extension. Note how joint-space limitations effect ROM and movement patterns. Here, look closely at C6/C5.

3. Spinal distortions effect on the appendicular skeleton -- the arms and legs. In short, when the spine twists or is otherwise distorted, the nervous system itself shortens throughout the body. Bony distortions pull the nervous system with it, and as things rotate/twist and bend within the spine, the pull on the appendicular nervous system increases. This central torsion by the controlling system in the body will then distort the appendicular skeleton - arms, shoulders, hips, pelvis, femurs, tib/fib's, feet and hands. They will rotate along with the spine, and the same rotation/counter-rotation patterns we see in adjoining spinal segments will also tend to occur with the femur and tib/fib, as well as the humerus and ulnar/radius.

Contrary to common misperceptions, what ultimately stops a stretch, like a forward, touch-your-toes-type of stretch, isn't the muscles or fascia and their associated lengths. What ultimately stops a stretch is the pull on the nervous system. The less neural restriction, the greater the ROM. But the more twisted things are in the spine, the less ROM will be available throughout the appendicular.

How does this happen? If we look at the very common pattern of scoliosis and it's fairly typical big left group rotation at the pelvis and lumbars followed by the counter right at the T12 area, followed by another big left in the shoulders, we can easily understand how the entire nervous system is twisting with it, and as it does so, just like twisting a towel, the whole system shortens throughout the body including down through the arms and legs.

A subject with a scoliosis. The shortening of the neural system extends down the arms and legs. The skeletal system follows.

A scoliotic forward bend. What stops the stretch? The common myth is the hamstrings.

Injuries and Yoga

With this understanding, we may shed some light on how people get injured in yoga and why people with spinal distortions tend to be more prone to it.

On occasion, yoga practitioners are pushing past the extension limitations of their neural system, and when the sensitive neural system is over-stretched and traumatized, the result can be a very painful neural inflammation along with acute muscle spasm. A failure to listen to the body and the common mindset of "no pain, no gain" can have very serious repercussions. And with twists and spinal distortions present in a structure, the danger is significantly heightened.

With a deep stretch, the increase in tension through the nervous system also goes both ways -- a long stretch on the sciatics (in the legs) also tensions the neural system upwards into the spine, up into the thoracic, all the way to the cranium. And if there are spinal distortions/twists and shifts present that are already compressing the neural system, over-tensioning a spinal nerve that is already compressed and impinged will only serve to seriously aggravate the problem.

Those with spinal distortions and fixations will be mechanically limited to doing less. Peer and social expectation however will demand more than the system can tolerate. Be gentle. Listen.

A common issue.

Forcing a stretch to keep up with classmates or a very flexible instructor is generally a bad idea.

Section Conclusion
No Part Exists in Isolation

To fully realize the potential of manual therapy, the importance of a comprehensive approach cannot be over-emphasized. The human body is more than just a collection of parts. It is a synergistic expression of a whole, and a change to a part necessarily involves change to the whole.

In the coming sections, we'll dive deeper into Methodology, all the way from basic massage routines to specific interventions and sequencing on fixated/distorted vertebrae.

Artist Jorge Mendez Blake created the work "One Book Under Bricks" mostly as a metaphor for the power of education. Here we will instead seek to analogize the influence of a single distortion upon the whole.