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Anita Boser practices Hellerwork® Structural Integration and teaches yoga in Issaquah, Washington. She wrote Relieve Stiffness and TFMeel Young Again with Undulation, which turned into a computer program, Undulation Break, that reminds people to move fluidly when at the computer. She can be reached at [email protected].

 

Abstract

Even when the primary goal is improved alignment or personal growth, typical structural integration (SI) clients have one or more physical ailments that they hope can be addressed through the series. Because physical ailments are often caused by structural imbalances—what structural integrators often term average posture—improved alignment often is the answer for both goals. The client in this case study was motivated by kyphosis. He also had low back pain and right shoulder restriction and pain. We followed a standard Hellerwork series of eleven sessions. His posture improved due to a combination of better structural alignment and knowledge of body mechanics. His low back pain resolved and he gained greater range of motion in his right shoulder; he estimated his shoulder healed 85%.

Classically, the spinal pattern of anterior lumbar and posterior dorsal has been called normal. It might be better called average. (Rolf, 1989, p. 182)

The client was referred by his wife who had previously completed the Hellerwork series. A 42-year old male presented with hyperkyphotic and head-forward posture, and occasional low back pain. He also reported an old shoulder injury that had recently been exacerbated and was being treated by his chiropractor. His medical history included a hernia repair five years earlier, and a deviated septum and fistula repaired many years prior. He didn’t have any particular goals for the series, but knew that he needed to work on his posture. Before and after undergoing the SI series, the client also received chiropractic care and massage therapy.

Method

He began the series in November 2011 and completed the eleventh session in July 2012, with average space between the sessions of three weeks. (Hellerwork Structural Integration includes a completion session after the standard tenth session of the original recipe.)

We began the series by taking photographs. I asked him to stand in his normal posture and took photos of his anterior, posterior, left, and right side views (Figure 1). To the client, the most striking part of his posture was his curved upper back and forward head. To me, the most striking parts of his alignment were the anterior shift and tilt of his pelvis, the tilts in his knees, and the rotations in his ankles. I also noted the lack of continuity from the ground through his right side, leaving a deficit of support for his right shoulder girdle.

The client was aware that his head was forward of his torso, but was surprised to note how forward his hips were of his feet. With effort, he was able to bring his hips back nearly to centerline, but was unable to hold this posture for long and even with effort was unable to bring his ribs or head over his hips.

Several years ago, I undertook an informal research project (Boser, 2008) to see if clients going through the series experienced an increase in their height.

In that process I learned that clients increase their length as much through knowledge of standing alignment as through the structural work. As a result, I wondered how much of this client’s alignment was based on bad habit and how much he could improve it with awareness. So I directed him to stand in his best posture for the record. Figure 2 shows his best posture below his typical posture. Based on this, I concluded that myofascial restrictions were a major factor in his (mis)alignment.

The Series

I performed a normal series with the usual goals of each session, with the exception of the first two integrative sessions where

I focused more on the upper body rather than limiting one of the sessions to the lower body. I tailored the goals of each session to address the client’s structure, as noted below:

Session 1

Client reported low back pain in the evening from standing that he often relieved with stretching.

Goals: Release the rib cage from the clavicles and scapulae and allow for greater breath expansion. Release the pelvis from the ribs and trochanters to allow for a more level pelvis.

Method: Freed the superficial fascia over the lateral ribs, IT band, and trochanters and  lengthened the fascia of the rectus abdominis, pectoralis fascia, and superficial layers of the neck (specifically, the platysma and sternocleidomastoid). Finished with a pelvic lift and movement education to balance his weight over his feet and bring his hips back when standing.

Figure 1. Before session one photographs

Figure 2. The client’s best pre-session posture (below) is compared to his typical posture (above).

 

Session 2

Client reported soreness in his low back bilaterally and in his right front hip. He noted feeling looser and less need for stretching. I noted reasonably good movement in his hips and knees, although he had an “O” leg pattern; his left foot was more everted and both ankles were stiff.

Goals: Facilitate horizontal hinge joints at the toes, ankles, and knees. Lengthen the back line where needed.

Method: Released the lower legs with special attention to the retinacula, lateral arches, and the fibularis (aka peroneal) compartments for fibular mobility with ankle flexion. Finished with trapezius releases and seated benchwork to bring the thoracic spine erectors toward the midline and lengthen the lumbar spine erectors and thoracolumbar fascia.

Taught the client to walk with toes and knees aligned forward and to roll through the joints in his feet.

Session 3

Client reported that his left leg didn’t reach as easily to the ground when walking. I noted that his left ankle eversion prevented the foot from contacting the ground appropriately. Shortness in the right lateral line caused the hip and shoulder to drop.

Goals: Lengthen and balance the lateral lines. Create more equal anterior-to-posterior depth in the body.

Method: Myofascial release from the fibularis compartment through the IT band, obliques, intercostals, and axillae. Introductory release of the quadratus lumborum. Paid special attention to the lateral ankles, brought tissue posteriorly at the lumbar spine, lengthened the right torso, and balanced the anterior and posterior folds of the shoulder. Finished with a seated trapezius and thoracolumbar fascia release. Taught the client to press into his feet to create lift through his spine.

Session 4

Client reported low back pain when sitting at the computer or putting on his pants. It used to be at his spine, now was across the back. “It’s the worst it’s been.” I noted that his legs were abducted and observed the shortness in the medial line of the legs that contributed to his “O” leg pattern.

Goals: Open the bottom of the core for greater grounding. Lengthen the medial lines with attention to how they balance with the lateral lines for alignment of the ankles and knees, and for ankle flexibility. Prepare for the front of the core session.

Method: Worked tissue anteriorly and posteriorly to create a midline of the inner lower leg and thigh. Released tissue that restricted motion of the thigh along the pubic and ischial rami. Completed a deeper release of the quadrati lumborum.

Lengthened fascia along the rectus abdominis and related movement of the rectus to the transversus abdominis. Finished with seated thoracolumbar fascia release. Taught the client, in a supine position, to stabilize his pelvis while engaging his hip flexors.

Session 5

Client reported that he had reactivated an injury over his left lower rib that first occurred in 2010. He was experiencing occasional cramps there. I noted that his right side was still shortened with the right ribs and shoulder rotated to the right. His transversus abdominis was weaker than his obliques.

Goals: Release the front of the core/deep front line from knees to shoulders. Create balance between the core (iliopsoas) and superficial (rectus abdominis) abdominal muscles. More than usual attention to creating a level pelvis.

Method: Released the deep quadriceps compartment and fascia of the rectus abdominis, transversus abdominis, and iliopsoas. Found and released visceral restrictions in descending colon. Included extra active movement participation with the right arm when working on the psoas. Started release of the deep external hip rotators. Finished with seated work on the psoas and thoracolumbar fascia as the client raised his arms. Taught active engagement of the transversus abdominis on exhale.

Session 6

Client reported that his left low back “sticks” when side-bending and also when straightening from a side bend. I noted that his left ribs did not fold in a side-bending motion. Also, I noted that in a forward bend his lumbar spine straightened, but did not reverse the curve, and he had excess curve in his thoracic spine.

Goals: Create even tone through the back of the body. Create a floating sacrum. Balance the front and back of the core.

Method: Released the trochanters from the ischia and sacrum. Released the compartments of the spinal erectors and paraspinals. Added attention to the transversus abdominis and left intercostals.

Finished with seated psoas, back, and trapezius work. We revisited standing alignment and I measured the client’s height. He was 174.0 centimeters tall after the session, but “grew” to 174.5 centimeters when he stood with hips back and lifted from his feet to this head.

Session 7

Client reported no more low back pain. I noted that his head was forward, although not as much as when he started the series. His right shoulder was still low and head tilted to the left.

Goals: Create better alignment of the cranium over the body in the sagittal, coronal, and transverse planes. Relate the top of the core to the front, back, and bottom of the core.

Method: Released fascial planes that connect the lateral cervical spine to the ribs and shoulders.

Released the mid-layers of the anterior cervical spine and mandible (infra- and supra-hyoids). I do not have complete chart notes from this session, so I did not document whether I did intraoral work or not.

I finished with a release with the client seated on the table with his knees to his chest. After flexing forward, he then tilted his pelvis to neutral and rolled up through his spine to put his head on top  as I nudged the connective tissue layers along his spine to assist. For a movement lesson, I taught him to let go of his head (let his cervical spine flex) when bending over to pick up items, and we also reviewed reaching the crown of his head to the ceiling when standing.

Session 8

Client reported that the range of  motion  in  his right shoulder was restricted. It caused a “pinch.” He couldn’t raise his right arm higher than his head, and couldn’t place his right hand behind his head or behind his back. He did not want to get an MRI because of the cost. I noted that his right shoulder girdle was not as integrated to his torso as the left and that he was unable to pronate his right forearm. In addition, his left shoulder extensors had full range of motion (180°), but his right was limited to 100°.

I did not make a note of the range of his internal shoulder rotators.

Goals: Integrate the sleeve and core of the upper body. (I decided to do an upper body session before a lower body session.)

Method: Much of the session was done with the client supine on the table using the table as a frame of reference to align his spine, shoulders, elbows, and wrists so that he could stabilize his shoulder girdle without compensating from his spine. We also worked so he could better internally and externally rotate his humerus bilaterally and pronate and supinate his forearms without tilting or retracting  his scapulae. I then stabilized the fascial planes in his arms and shoulder girdle as I directed him to initiate movement from his spine through elbows in the coronal plane. We finished with seated work on the thoracolumbar fascia, scapulae, and elbows. For movement education, I urged him to move and stretch without activating the pinch in his shoulder.

Session 9

Client reported that his right arm had improvement, but he still couldn’t put his right hand on his hip comfortably. I noted that his right humerus could abduct and internally rotate much better than in the previous session. However, the elbow couldn’t bend with the arm in that position. I also noted that his legs still had a significant “O” pattern.

Goals: Integrate sleeve and core of the lower body. I also decided to spend some of the session on the arms again.

Method: I began at the pelvis, worked the fascial planes around the trochanters and ilia to relate the alignment in the sagittal, coronal, and transverse planes. I did the same in the lateral ribs and related planes of the pelvis to the ribs and then to the scapulae and then to the elbows. It is worth noting that I did not release fascial planes in the thigh and lower legs.

Session 10

Client reported that his posture has improved to the point where other people notice. His right  arm was better, but still had an area, he believed, with structural damage. He did not want to see an orthopedist or physiatrist because he suspected an MRI would be recommended and his insurance had a high deductible. He felt like he had achieved 85% improvement in his shoulder and that was good enough for that point in time. I noted that his head and hips still tended to shift forward and that his weight was uneven on his feet. Also, his right shoulder girdle was still not as integrated into his body as the left.

Goals: Normalize the joints throughout the structure in the sagittal, coronal, and transverse planes. Relate segments to each other across multiple joints.

Specifically for this client, my goals were to address the balance of weight between his two feet, bring his hips and head back and in line, and to bring more connection between the right shoulder and the body. I think it is worth noting, after the fact, that although I did include them in the session my primary goals did not include addressing the ankle and knee joints.

Method: Release with client movements at the occiput, neck, shoulders, spine, posterior hips, knees, and ankles. In addition to releases intended to improve motion at each joint, my intention was to improve connection and movement through multiple joints at once. I did not include a new movement lesson in this session, but reviewed alignment in standing.

Session 11

I did not take notes on the client’s observations.

Goals: The standard goal for the eleventh session in the Hellerwork series is to review movement lessons and finish any needed integration. My goal is to get what I missed in sessions 8-10. In this case, it was clear that integration through the legs was still needed. The client had greater anterior tilt in his right pelvis and continued to exhibit a dropped right shoulder with external rotation of the humerus.

Method: Simultaneously contacted the medial and lateral lines of both legs (one leg at a time) as I directed the client in movements that originated in the core. I integrated the deep, anterior myofascial planes as I directed the client in movements of his arms. We finished with seated bench work. We also compared before and after photos and briefly reviewed the movement lessons given during the series. I give my clients a written summary of all movement lessons that they can take home.

I usually also review the client’s goals in this session, but this client did not have specific goals other than his posture, so it was a short discussion.

Results

We mean that bodies—average physical bodies of flesh and blood—are amazing plastic media, which can change quickly toward a structure that is more orderly and thus more economical in terms of energy.

(Rolf, 1989, p. 14)

The client was pleased with his improved posture and how much easier it was to maintain it. His before and after photographs are shown in Figure 3. The first thing I notice is improved length and lift throughout the body. The anterior tilt and shift in his pelvis were reduced (more so on the left than the right), which brought his lumbars posterior, thoracics anterior, and his neck and head better balanced over his body. His feet were still everted, although less so, and his pattern of standing with his left foot anterior was still present.

Although not as “droopy” as at the beginning of the series, his right shoulder was still not very well connected to his core.

Figure 3 Before session one (above) and after session eleven (below) photographs

 

Discussion

First, it is worth noting how much I learned from writing this case study. As I review the chart notes and photographs and know that I am sharing them with colleagues, I can see more clearly the lines and angles that were nebulous to my sight before. In retrospect, I see the twist in the client’s right leg/ pelvis and wish I had devoted more time in the series to it.

The dropped shoulder and head tilt to the opposite side is classic spiral line shortening (Myers, 2009).

I notice is improved length and lift throughout the body. The anterior tilt and shift in his pelvis were reduced (more so on the left than the right), which brought his lumbars posterior, thoracics anterior, and his neck and head better balanced over his body. His feet were still everted, although less so, and his pattern of standing with his left foot anterior was still present.

Although my teacher, Donna Bajelis, included the Anatomy Trains fascial lines in my training—we even dissected the lines in cadaver labs—I have been addressing this line within the context of the classic Hellerwork series rather than in a separate session, as is part of the KMI series. In retrospect, I wish I had devoted a single session to the spiral line for this client.

From Tom Myer’s article in the 2004 Yearbook, “Developments in Ida Rolf ’s Recipe,” I know that both KMI and the Soma series include a session devoted to the arms. I have concluded that in the future I will offer an extra arm integration session to clients if the client’s arms are not well integrated after the upper body integration session.

At the 2010 IASI Symposium in Denver, in his presentation Clinical Diagnosis of Low Back Pain—Is there Value?, Serge Gracovetsky referenced research that demonstrated that clinicians of all types misdiagnose and mistreat low back pain. “The problem is rooted in the clinician’s strong dependency on reported pain, which may not always be a reliable source of objective information” (Gracovetsky, Marriott, Richards, Newman, & Asselin, 1997, p. 21). SI principles caution me to stay on task with the objectives of alignment and integration, even when considering my client’s symptoms. However, I must admit that I am affected by my client’s subjective findings, especially when he is pleased by the improvements, and I want to create more. While I did not “chase symptoms,” I certainly was motivated to do what I could to improve this client’s shoulder range of motion, and that took me off track in the final integration sessions. It is unfortunate, because the client’s shoulder injury, in all likelihood, required an additional intervention for full recovery, but without diagnostic tests from a physician, we don’t know the answer. The other unfortunate aspect is that I could have given the client a more integrated foundation.

 

Conclusion

Nonetheless, this client’s structure did change to one that is more orderly and more efficiently uses energy. He has much greater ability to find his alignment and to organize his structure, and he was pleased with the results. As a practitioner, I see the detail of tilted and rotated lower legs. As a client, he is aware of his improved posture and mobility.

SI practitioners see the average pattern of “anterior lumbar and posterior dorsal” around us every day and know the wear and tear it creates on the body that will sooner or later manifest as physical ailments.

By addressing the underlying structure, ailments can often, but not always, resolve. This case study is typical of the results structural integration can achieve in moving average posture toward more functional alignment.

References

Boser, A. (2008). Lessons from an attempt to research the effect of structural integration on client height. In M. Beech, P. Kemper, & K. Schumaker (Eds.), IASI 2008 yearbook of structural integration (pp. 78-80). Missoula, MT: International Association of Structural  Integrators.

Gracovetsky, S. A., Marriott, A., Richards, M. P., Newman M., & Asselin, S. (1997). The impact of inefficient clinical diagnosis on the cost of managing low back pain. Journal of Healthcare Risk Management, 17(3), 21-31.

Myers, T. (2009). Anatomy trains myofascial meridians for manual and movement therapies. Churchill Livingstone Elsevier.

Myers, T. (2004). Developments in Ida Rolf ’s recipe. In M. Beech (Ed.), IASI 2004 yearbook of structural integration (pp. 9-13). Missoula, MT: International Association of Structural Integrators.

Rolf, I. P. (1989). Rolfing, reestablishing the natural alignment and structural integration of the human body for vitality and well-being. Rochester, VT: Healing Arts Press.

 

 

 

[:]Average Client with Low Back Pain and Shoulder Injury