Introduction

Twenty years ago I became a Rolfer. Rolfing Structural Integration (SI) training changed my way of looking at a person, a client, a patient – seeing the whole person not just the parts, and also understanding the relationship of the parts. This also led me to a new sense of myself and has been extremely important in my life. Consequently, a transformation also happened in my work. Looking back I see clearly now that many of the things that I have accomplished would have not been possible without it.

In 1998 I was invited to run part of the physiotherapy program for a Swedish organization in Spain. The program, located in a non-hospital environment, was to provide rehabilitation for Swedish patients with rheumatic conditions. For adults, a four-week residential program, and for children, a three-week program were offered in my hometown of Benicassim, Spain, located along the Mediterranean Sea. For me it was a dream come true. We would have one group of patients for one month! I could do anything that I wanted incorporating movement and manual therapy.

One of my first tasks was to research programs done in other places. I had worked as a physiotherapist in the Centre Termalismo in Benicassim, and I checked out other cities in Spain – Ternerife and Malaga – where similar programs were being offered. In the first year we did movement exercises, such as streching, general active movement for joints, massage, and hydrotherapy, and I did small myofascial interventions. At this point I did not use Rolfing SI per se; I was cautious as I did not wish to damage their tissues.

When I started the program, I created a conventional physiotherapy program; but through the years, I came to realize that working only with symptoms was not enough. The residential program gave us the opportunity to provide clients with more education and self-care. However, there was still something in me that was not satisfied. I was not working as in my training as a Rolfer, and it took me a few years to discover this. I began to explore the evolution of the program with a Rolfing vision. The result became the 3H Rehab program: Hands, Head, Heart.

R o l f igd u c a t i oc h agd m y understanding of how to work with individual clients. This was how I really wanted to work. Rather than focusing on the patient’s symptoms, part of our goal was to engage the patient in understanding his/ her physical condition and learning all that was possible about that condition. This goal became the core of my approach to organize a multidisciplinary team.

Who We Are and What We Do

The healthcare team now consists of three to five additional physical therapists (trained in myofascial release and postural alignment, aquatic exercises, and relaxation), one massage therapist, a Pilates and tai chi instructor, a nurse, an ergonomic therapist, a physician, other support movement practitioners like 5Rhythms™, and myself.

The physician assesses the health condition of each patient at the beginning (I am with him) and end of the program. We use a pain analogic scale; joint measurements are taken; and spinal measurements are recorded for those presenting with ankylosing spondylitis. The patients complete a questionnaire regarding their pain scale, joint mobility, and morning stiffness at the start of each day and at the end of the program. This helps the doctors evaluate their progress and guides the treatments they are given.

Patients receive daily treatments at four stations including: 1) hydrotherapy; 2) movement exercises, body awareness exercises, kinesiotherapy (therapeutic active and passive movements); 3) massage and myofascial release (MFR); 4) ergotherapy (beause the hands of rheumatic patients are adversely affected, this work helps to restore and improve hand function). Some treatments are provided in groups and others are given individually. The activities depend on the needs of each person; there is not a single standard program provided for all participants.

With a maximum number of thirty people in the program at one time, we divide them into groups, depending on their limitations, pain level, age, surgeries, heart problems, and other associated illnesses. We usually divide them into four groups so we can do individual and group work. The treatments are held in the morning, from 8:30 am to 2:00 pm; the afternoon consists of more education and fun activities, such as flamenco or cooking clases! (We have the priviledge of living in a region of great gastronomy and cultural activities.)

How the Program Evolved

To evolve and design the program, I asked myself many questions: How to discover, even with limitations, that health is possible? How can we teach prevention and maintenance? (I begin to understand that many of the things that we do as Rolfing practitioners could really be applied to the patient’s needs.) How does one change the system while still in the system? How do we get results and be economically feasible? How could I do something that I would be satisfied with using a holistic approach? – that one put a great deal of pressure on me, and I could not change everything as it was necessary to do beforeand-after assessments and evaluations.

When I studied Rolfing SI, we were told we should not work on rheumatic patients: that we should not work deeply on them. Initially I kept that in mind when they told me to run the program. I was afraid to work with them in the way I worked with my clients as a Rolfer – I probably did not know what ‘deep’ really meant and confused ‘deep’ and ‘hard’ as I see many MFR practitioners still do. Over the years, I have come to realize that you can go really deep without damaging tissues.

Education and Prevention

When working with rheumatism, we went back and forth between the symptoms and working with and understanding prevention – gaining an understanding of what is the potential of each person. When patients are not in an acute phase of the illness, it is possible to work on prevention and education. This is different from a hospital program, where the work is with acute symptoms.

Through the years I have realized that although we must deal with the presenting symptoms, what is most important is to emphasize education when the person is not in an acute crisis. Our patients improve vastly when we integrate a more mindful approach. We achieve our best results working with prevention, noting where the compensations occur and where we anticipate the next problem area. Taking care of oneself is not just taking medicine or doing exercises. Self-care with rheumatoid arthritis is about understanding yourself as a person.

I believe it is extremely important that all therapy is delivered to the individual needs of each patient. Often these patients have other health complications that need to be addressed or taken into consideration with a complementary health professional. I started to incorporate the Rolfing vision into the program since many problems I saw were related to the person’s structure – the uneven distribution of stress in the body – and not only to the rheumatism itself. Thus, I adapted the Rolfing principles to work with rheumatoid arthritis clients.

The sessions use SI strategies to accomplish the goals of balance and alignment. The work is not based on a ten-session model; rather it is based on SI’s unique understanding of the human body and structure. The clients receive twenty-fiveminute hands-on treatment sessions, two to three times per week. For example, in manual therapy I position the tissue in a way to challenge the joint and tissue restrictions while applying gentle and firm pressure. I listen to the body and wait for the person´s nervous system to respond so that motion restrictions are diffused as the client’s awareness grows. I listen to the tissues, listen to the nervous system.

Understanding Rolfing principles of connective-tissue work and working the body from the sleeve to the core made us focus on the feet and hands due to their sensory potency, functional importance in daily activities, and continuity with the core of the body. This is so important for rheumatic patients. We use MFR as a complement to Rolfing SI, particularly as preparatory work: softening the tissue and creating body awareness. When possible, I work using Rolfing strategies for the patient to have a better relationship in gravity. We also use Swedish massage, lymphatic drainage, and other massage techniques. All the team of physiotherapists have being trained by me in MFR. The principles and vision of Rolfing SI complement the other therapies offered in the 3H Rehab program.

Other Therapies

Offered Hydrotherapy and land exercises are included, starting with mobility exercises and progressing slowly into cardiovascular and resistance exercises. Integral Aquatic Therapy works with the fascial and joint restrictions of the client within the lowergravity environment of a heated swimming pool. In this method, the client is supported by the water and held by the therapist’s arms and some floats while being moved in ways that are not easily accessible on a table. This work achieves fascial release and activation of the parasympathetic nervous system. Since the patients have so many limitations, water is a key point within the program.

We also do kinesiotherapy (movement in general outside of water) and ergotherapy. Not much time is spent on bicycles or gym exercises as these are activities that can be done at home. Howver, a great deal of attention is paid to the hands since this affects almost everyone. We ask questions like: What are the hands? What do they mean in context? Hands are our way of expressing. Deformity in the hands affects the way one moves, and sooner or later a problem will develop in the shoulder, or a limp, or a stiff back will come from not having controlled balance. While the medical system attributes many of the symptoms of rheumatoid patients to their rheumatism, my experience and observation is that many of them relate to compensations developed over the years. Discovering those compensations helps to work with symptom prevention.

Most of the patients are emotionally or psychologically affected by their illness. With the loss of the ability to express with the hands and the capacity to move with ease, life becomes very limiting – especially since they live in a country where the winters are cold with snow and ice. Because rheumatic clients tend to have emotional up and downs, they are inclined to isolate socially as well.

Many patients receive cortisone shots and many are under heavy medication, so the tissues are very much affected. The most significant side effect of cortisone use is atrophy (thinning) of the skin, making it extremely fragile. When used over large areas, cortisone is absorbed into the body and causes bone demineralization (osteoporosis). Further, with their immune system suppressed, patients see a worsening  of skin infections (fungal, psoriasis, viral). So we have to be very careful with our touch and manipulations.

The Art of 3H

It is an art to work with the patients – discovering what kind of touch one can apply. Movement education and body awareness are important aspects of the exercise therapy so patients can adequately adapt and maintain new movement and alignment patterns. Patients can change the way they perceive and understand their bodies through movement awareness, allowing them the potential of further progress when they go home.

Many patients have afflictions or deformities of their feet and easily lose proprioception, so work to recover the body schema is very important. We teach patients foot exercises that will lead to a greater sense of connection to the way they walk. We give them tools that they can use at home, such as tennis balls or balls of different sizes to help them regain proprioception and mobilization. Tai chi is also offered to provide structural support as well as spatial, emotional, and mental adaptability. Education also includes daily care routines for different body parts according to the patient’s needs.

We want to support and educate each person to live in his or her own body. Rheumatioid patients become oriented around pain. When they are fine, they are not really enjoying their bodies. We want to give the message, “Come back to the body. Come back to your own perception. Come back and feel you are alive. “

The structure of the 3H Rehab program offers rheumatoid arthritis patients time to recognize – and learn to respect – their capabilities based on their condition on any given day, neither forcing an unrealistic expectation of performance nor being hindered by physical limitations of the previous day. In my opinion, this acknowledgment and acceptance of being in the present is very important for fascial release and their well-being.

Inspiration

How do we get the patients involved in their own process? How can they become engaged? As practitioners we know that this is an art. We know that we can start the process of changing them. We have to be an inspiration. That became my goal: to be an inspiration.

Because rheumatoid arthritis is a chronic disease, without inspiration they will tend to not do anything, to view their time with us as a holiday with good food, good climate, and good company. But if we give them too much information, they may feel overwhelmed, that they have to change their whole life. My team must be an inspiration for our patients to get them involved with the process of recuperation. We co-create a team, patients and therapists. I tell the patients that we are not working on them, I do not work on them or do only a physical intervention, it has to be a collaboration. This is sometimes difficult because many of them are not ready for that. So this is something we have to encourage as a team. It’s very important that the whole team understands this concept.

All the treatment programs I have seen in hospitals or in centers look the same: exercise, pools, and massages. Yet there is a key ingredient for success: awareness. It has been so important that we as practitioners understand what awareness means. We want the patients to live in their bodies. This is something that is missing many times in rheumatism treatment.

The question to our patients is, “Aside from the fact that you are an ‘ill’ person, can you be healthier while being ill?” When a person is ill and in an atmosphere of illness, he becomes more ill. So working in a non-hospital environment is also a key point, in my opinion, to bring out the best in the patients. Our location helps. The clients stay in hotels with the sea and mountains surrounding them. Then in this environment we work to nurture awareness. We want to give the rheumatic patient the possibility to choose what kind of movement they need, what kind of manual therapy they need, and what kind of enjoyment they want. They can only get this understanding through awareness.

Special Work with Children

Once a year, we have a group of children. Working with them is a very different experience because we are working with the children and their parents. We do the same four stations, and we bring the parents to each of the stations. We need the parents to understand why we emphasize a particular treatment/exercise so they help or encourage their child to do it. Parents have to learn about the disease, about nutrition and rest; they need to recognize when a joint is inflammed, and massage the child daily and do mobilization exercises. How they work with their child and teach their child daily to care for him/herself will improve the child’s future. If they simply drop off their child every day for a physiotherapy treatment, there is no followthrough care and it becomes expensive and not as effective. When we involve and work with parents, we really see progress in their children.

Summary

Many of the characteristic symptoms of rheumatoid patients are very difficult to treat. Because it is a chronic systemic disease, it is not something you have but then it goes away. It is always there. Yet working with symptoms is not enough. What I have learned through these eighteen years is that I am really interested in the whole person. By creating a better order through our work, our clients have a different awareness of their bodies and thus functional movement and daily movement options can improve. It really makes a difference.

Through my experience, I have learned that the principles of SI can be developed, modified, and continually evolved for different structural dysfunctions including rheumatic disorders. SI can be used effectively within a team of other health professionals to provide life-giving opportunities for patients of different ages with rheumatism. SI is a powerful method to implement in more holistic programs, and a structural integrator is well-prepared to coordinate such programs: he has the ability not only to see, work holistically, and create better structure and a more functional body; he also has an orientation of engaging and educating patients in self-care, which can help patients prevent future problems so they can enjoy a higher quality of life.

While my particular program is with rheumatic patients, I believe this kind of understanding can be applied to any program for well-being: for backpain disorders, personal growth, and preventative programs for children at school. As practitioners, we have the goal of discovering the potential in our clients and patients, finding a way to create vitality, equilibrium, and well-being. I have no doubt that prevention is the best medicine if we carry it out in a way that we enjoy.

Our thoughts, our emotions, our postures, and our movements are the history of our lives, and they take a toll over the years. The model of 3H Rehab is not just a holiday program: it is the beginning of a new outlook towards health, well-being, and mindfulness.

Bibiana Badenes is a physical therapist (graduated from the University of Valencia in 1988) and a Certified Advanced Rolfer and Rolf Movement Practitioner. She directs Kinesis Center for Physical Therapy and Harmony through Movement (www.kinesis.es) and works with a wide variety of patients and different conditions, from athletes to children to the elderly. She developed one of the most comprehensive residential treatment programs available in the world today for rheumatoid arthritis, where she has worked with more than 2,000 patients. Her website is http://www. bibianabadenes.com

At the leading edge of body-mind treatments and education in southern Europe, Bibiana is co-creator of the innovative Terapia Integral Acuatic as well as Myofascial Release Trainings, and teaches both internationally. For more than a decade she has collaborated with Spanish and Swedish businesses to offer a range of powerful rehabilitative seminars in the area of stress management, burnout, and personal empowerment. A pioneer in building bridges of contact among distinct therapeutic disciplines, she created the Bodywisdom Spain conference to promote inter-disciplinary dialogue through health that is accessible to everyone.Rolfing® SI as Part of Healthcare[:]