ABSTRACT In our regular “Ask the Faculty” column, worldwide Rolfing® Structural Integration faculty answer a question related to the theme of the journal. In this issue, Basic and Advanced Rolfing Instructors and Rolf Movement® Instructors discuss working with scoliosis from angles related to etiology, treatment, expectations, psychobiology, and adjunct modalities that they are experienced in.
Q: As practitioners of Rolfing Structural Integration (SI), we all at some point work with clients who have scoliosis. What can you share from your experience about any aspect of that work?
Basic & Advanced Rolfing Instructor SI practitioners have an important role to play in the treatment of whole-body patterns associated with scoliosis. Not only can our manipulation and movement education skills offer clients relief and improvement, but our unique perspective of the whole-body pattern gives us the ability to associate patterns in the spine and ribs, which ordinarily define scoliosis, with effects that reach up into the cranium, out into the extremities, and deep into the viscera. This expanded view of the effects of scoliosis can then lead to approaching clients’ patterns from a broad perspective that I find to be more effective than merely zeroing in on the spine and ribs.
It is important to recognize that most bodies exhibit a mild version of spinal and whole-body patterns that become labeled as ‘scoliosis’ when the degree of the curvature is greater. In other words, most people have a spinal pattern that includes some degree of lateral curvature and vertebral rotation in each of the spinal regions. Furthermore, it is common for the orientation of the lateral curves in each of the regions of the spine (lumbar, thoracic, and cervical) to exist in an alternating arrangement. For example, a right sidebend in the lumbar region is usually accompanied by a left sidebend in the thoracic spine, and another right sidebend in the cervical spine. Naturally, the opposite pattern is also a possibility. I also find that the sacrum, L4, and L5 are a smaller lower curve that forms a base that will be either congruent or incongruent with the more superior lumbars.
Regardless of the particular pattern or the degree of curvature in the spine and ribs, there is always a corresponding myofascial twisting or spiraling in the full thickness of the tissues that surround the skeleton, from the deep ligamentous structures that are part and parcel of the way the joint surfaces meet, all the way out to the interface between the skin and the superficial fascial layers. Naturally, this nonlinear arrangement involves nerves, blood vessels, and the suspension and spacing of organs. From this perspective, because of the continuity of fascial tissues, it is easy to understand that lateral deviations of the spine, combined with rotation, exert rotational forces on the tissues of the extremities.
Conversely, tensions in the softer tissues exert vectors of force on the skeletal structure. These effects can be observed visually in static standing and in motion, felt through palpation, and worked with using SI techniques. In my experience, with most people, regardless of whether or not their curvature warrants being called scoliosis, the greatest integrative effects come from interventions that work back and forth between the spinal complex and the related patterns of the legs, arms, viscera, and cranium.
When the degree of lateral curvature is greater than 10?, with vertebral rotation, it meets the criteria to be diagnosed as scoliosis (see https://www.aafp.org/ afp/2014/0201/p193.html). As with all circumstances that involve the tissues and joint surfaces, SI is most beneficial if our client is younger and all body tissues are more adaptable, and there is less spinal and whole-body adaptation to the asymmetrical forces placed on the joint surfaces and supporting ligamentous tissues. This is when we have the greatest chance of significantly improving the curvature.
When the degree of curvature has progressed and the client is older, we must temper our expectations of ‘correction’ according to the age and adaptability of the client’s tissues. In the most progressed cases, the vertebrae, facet joints, ribs, and bones of the pelvis have changed shape as have the thoracic, abdominal, and pelvic cavities. Not only does the pattern spiral, but it compresses due to the loss of columnar support and the shortening effect of twisting. It follows that organs have to conform to the twisted, diminished space, and breathing can become difficult.
When working with scoliotic patterns I find it most useful to focus on the regions in the spine where the curve changes direction. This usually happens at the sacroiliac joints, at L3 (since S1-L4 often function as a single segment), at the thoracolumbar transition around L2-T10, and at the cervicothoracic transition around T2-C6. Secondarily, I find working on the convex side of the apex of the laterally flexed curves in the lumbar and thoracic region to be helpful. In the thoracic region the ribs also have a significant effect, both close to the spine and at the sternum where, due to the cartilaginous connections, adaptations to the spinal pattern occur.
Since the cervicals have more freedom, it is less predictable what will occur there in response to the patterns. The cranium, due to the fact that all facial layers anchor somewhere on it, will reflect and play a role in maintaining the whole-body pattern associated with scoliosis. It is essential to remember that the pattern spirals, and to search circumferentially for aspects of it. One cautionary note: in older clients it is safe to assume that bone density is diminished, so a thorough history and sensitive use of force is warranted.
Apropos of the principle of support, it follows that when the spinal pattern has lateral flexion and rotation, then the connection/ integration between pelvis and legs will be affected. I usually find asymmetrical concentrations of adapted tissue density around both hip joints (illiopsoas, abductors, adductors, hamstrings), across the knee joints (hamstrings, quadriceps, posterior knee compartment), and at the ankles and feet where all of the imbalances from above funnel down to dense adaptations. The importance of addressing the scoliotic pattern from the feet and legs cannot be overestimated. In my opinion, this essential feature, namely working with the whole-body pattern through the legs and feet to provide support for structures and segments that lie above, gives Rolfing SI an advantage over methods that focus more narrowly.
As for the shoulders and arms, the spinal pattern will reflect there too. The simple fact of twisted vertebrae in the thoracic spine, and the concomitant reflection into the rib cage, creates a ripple effect through the myofascial web of tissues that connect the scapula, humerus, radius, ulna, wrist, and hands. The pattern in the arms also directly involves the lower portion of the cervical plexus and relates to the transitional area associated with the thoracic and cervical regions. Since the arms are not weight-bearing, they have the freedom to adapt in space and reflect in the whole-body pattern in their own ways. For these reasons, and to get the best possible results, it is important to also include the arms in the whole-body treatment of scoliosis.
Larry Koliha Rolfing Instructor
I have worked with numerous scoliosis clients over the years. Each client has his or her own set of conditions and opportunities. I’ll share a few thoughts that I’ve found helpful with most clients.
Think titration – work slowly and do not release more than the client can integrate. With scoliosis, it’s particularly important not to free patterns too quickly. Remember that this person has found support and adaptability with the scoliosis. Disturbing compensatory patterns too quickly can throw the client into a painful tailspin that can last a long time. Titration helps the client with integration and prepares the body for the deeper work. By the end of the session, check to see that you have freed both ends of the spine (C1 and sacrum), as well as openings into the appendicular. This reduces the chances of aches and pains after the session.
Scoliosis holds at the deepest muscular skeletal levels of the body. Once you get into deeper spinal work it will take a while for the client’s body to understand what it needs to untwist. If you work too quickly, removing contact after a minute or so, the communication may never be received in the body. At times it is necessary to maintain contact for several minutes to allow the ripples of your work to progress into the holding patterns.
I have tried to simplify a subject usually explored in entire books. My list gives very simple guidelines to a complex situation. Scoliosis is a lifetime condition for most people and the goal is to help clients improve their quality of life. Scheduled exercise combined with post-ten Rolfing sessions usually helps the situation. You may not give clients a ‘textbook’-looking spine, but improved movement and quality of life are well within our scope of work.
Basic & Advanced Rolfing Instructor Whenever SOSORT, an international society for the conservative management of scoliosis, plans its annual conference, I receive an invitation to contribute by giving a lecture or teaching a seminar. So far, I have never had the courage to accept the invitation, because there are so many different ways to look at scoliosis, and there is the danger that we will limit the perspective to our own somewhat limited view. However, to find productive clear results that we can discuss and that are felt and lived in a positive way by our clients, we have to see scoliosis from several different perspectives.
Traditional orthopedic medicine tried to keep it simple and just documented the development of scoliosis by taking X-rays of the vertebral spine. All therapeutic issues were related to the angle of deviation of the spine from the central midline of the trunk. To limit your view to the bony part of the back helps to keep things clear and easy. However, this limited view only allows simplistic approaches that follow clear guidelines, and unfortunately produces very limited results.
Currently, a new generation in orthopedics is ready to see scoliosis as more than merely an arrangement of unusual curvatures of the spine. There are new concepts being developed even in the field of non-conservative methods like surgery. For example, some surgeons are paying more attention to the role that the dura mater may play in scoliotic development. As manual practitioners we have the chance to start a dialogue with these new orthopedic doctors and surgeons, and also with researchers who have found new insights into the various manifestations of scoliosis. For example, we may benefit from the recent discovery of a certain chromosome that seems to play a dominant role in certain phases of scoliotic development.
In my own practice I had the chance to treat three generations of a family: the grandmother, the mother, and the daughter. The three showed the same scoliotic pattern, a very unusual three- dimensional spatial arrangement of all the different parts of their organisms. In the center of these arrangements they show what I call a ‘stomach scoliosis’ – where the stomach is strongly connected with the liver and does not extend into the left side of the body. For these individuals, the stomach is, probably since the third month of embryonic life, fixed to the center of the body. (When I started Rolfing practice forty years ago, I thought that people with this particular pattern did not have a well-developed quadratus lumborum muscle on their left side. I was not aware then of the role that the stomach played deep in front of this muscle.) Those of us who have made similar observations and see a strong visceral impact on spinal structure will find support looking into the conclusions that scientists have recently made about the relationship. A study group at the University of Utrecht (Schlösser et al. 2017) has published relevant findings about visceral anatomy and scoliosis.
But including the viscera in our view is certainly not enough. Scoliosis is everywhere inside the organism, even beyond anatomical units. It is also present in orientation and perception. For that reason, it makes sense that Hubert Godard works with the visual perception of scoliotic people. When he suggests unilateral ‘blindfolding’ [Editor’s note: through placing a sticker or patch on eyeglasses, to block central vision with that eye], he may successfully bridge between the person’s inner world and his/ her visual orientation.
There are many – quite different – modalities for working with scoliosis. We may benefit from elements of all these modalities. So far we are at the beginning of potentially new treatment strategies. And it is a very interesting and challenging beginning, indeed.
Burwell, R.G., et al. 2006. “Etiologic Theories of Idiopathic Scoliosis: The Breaking of Bilateral Symmetry in Relation to Left-Right Asymmetry of internal Organs, Right Thoracic Adolescent Idiopathic Scoliosis (AIS) and Vertebrate Evolution.” Research into Spinal Deformities 5, D. Uyttendaele and P.H. Dangerfield (Eds.). Amsterdam: IOS Press. (Also available to request at https:// bit.ly/2Tj4LWl.)
Chan, V. et al. 2002 Aug. “A Genetic Locus for Adolescent Idiopathic Scoliosis Linked to Chromosome 19p13.3,” AJHG 71(2):401-
Schlösser, T.P.C. et al. 2017 Jun. “Scoliosis Convexity and Organ Anatomy Are Related.” European Spine Journal 26(6):1595-1599. Available at https://bit.ly/2A0iwQP.
Neal Anderson Rolfing Instructor
I’ll share my experience with one client who started out as a classroom client for one of my students (now Certified Rolfer™ Melissa Dailey), and then became a client of mine after the class ended. “Kathy,” an active woman in her sixties, had her first exposure to Rolfing SI in a Phase III student clinic in the fall of 2017. Prior to the class, she had been addressing her scoliosis by working with Schroth Method practitioners. You can read one study about the effectiveness of this method here: https://www.ncbi.nlm.nih. gov/pubmed/28976171.
Kathy found the experience of the Ten Series quite helpful. Among the preconceived impressions she came in with was that “they” (meaning the Schroth practitioners) told her to “never” engage in activities that required spinal movements in multiple planes. This eliminated activities she enjoyed, like yoga. “They” also said to keep her torso very still as much as possible. Without denigrating the Schroth Method, we gently chipped away at this mandate’s hold by explaining that even walking was an activity that required spinal movements in multiple planes. We also introduced Kathy to the phrase “motion is lotion,” which helped her to be less afraid to move.
Kathy expressed a Ten-Series goal of wanting to walk with a sway like the film star Mae West. For Kathy, West was the epitome of feminine grace, power, and ease. Using this as a psychobiological handhold, Melissa did the standard Ten Series with a focus on increasing contralateral movement in Kathy’s walk. They were successful. Kathy exhibited much more ease and movement in her walk. There was also a slight decrease in the severity of the scoliosis. One key piece was Melissa’s suggestion to “walk with your inner Mae West.” This idea delighted Kathy and gave her a touchstone to remind her to engage in and be okay with contralateral movement when walking. While Melissa was disappointed to not eliminate the scoliosis (structural outcome), I was able to shift her focus to what success was for Kathy. Simply increasing the motion, and therefore the ease in her structure, was a hugely successful result (functional outcome).
I have seen Kathy as a post-Ten client several times. She is still engaged with the Schroth Method practitioners while continuing to see me for Rolfing SI. She credits the former with increased core strength and the latter with increased range and ease of motion. We work mainly to ease compensatory patterns in Kathy’s shoulder girdle resulting from the primary scoliotic spinal and rib pattern. I blend non- formulistic structural work with movement repatterning at about a 60:40 ratio.
Kathy accepts that she has scoliosis and through Rolfing SI has come to appreciate the functional success over a structural fix. From an expectation-management perspective, this significantly helps me as a practitioner. She knows and accepts the structural pattern without letting it preclude activities she once thought of as “dangerous.” This, to me, is an ideal outcome.
Rita Geirola Rolfing Instructor
Rolf Movement® Instructor
The first issue I had to deal with when I started my career as a bodyworker was in fact related to scoliosis. It was 1980, and I had the privilege and the honor to learn from, and then work with for seven years, Anita Gandini, the person who brought the Mézières Method to Italy. Françoise Mézières, a French physiotherapist, developed the methodology, which works on the muscle chains. She noticed that in the continuity of the spinal curvatures, the back muscles are tense and retracted and work as a single, continuous unit. In order to regain elasticity and better organization in the system, it is crucial to take away all compensations and stretch the entire chain in the same moment. Méziéres practitioners position the client’s body, mainly supine on the floor, as symmetrically as possible and elongated. Keeping that posture, they then ask for deep breathing.
This postural approach is very effective in addressing scoliotic patterns (see Figures 1 and 2). Méziéres was concerned with biomechanics and stretching, but based on this knowledge and my experience of thirty-one years in Rolfing practice, I think that much of the excellent results from the Mézières approach is related to the great amount of work on the diaphragms and in the reorganization of the head position in relation to the rest of the body. Neck, hands, forearms, lower legs, and feet are precisely addressed in every session. Mézières was also aware of a compensatory pattern that she called “antalgic reflex a posteriori” that developed due to trauma or disease, and the importance of addressing it as soon as possible (see Figure 1). I still use some of the competence I acquired during that time, and include elements of the work in my Rolfing sessions.
Focusing solely on muscles and bones, however, is not the best way to address a complex issue like scoliosis. This condition is strongly related to all levels of the person’s experience: body image, felt sense, orientation and the ‘right’ to occupy space, maturity, perception, coordination, as well as the neurological and visceral components.
Scoliosis manifests in the body’s adaptation to gravity, but can also happen in space. Our kinesphere is full of ‘ghosts’ such as desire, attraction, or avoiding that act as a magnet, drawing us or repelling us. A key question concerns the client’s clarity and definition of up/down, side/ side, back/front, in/out. The body system needs to acquire meaningful information to reorient in gravity and address tonic function. All parts of the body that have been neglected need to be experienced and owned again. In the scoliotic pattern, I find there is a lack of up orientation, and front-back definition is poor.
The back and the spine, the source of pain and a sense of inadequacy, the ‘enemy’ to be controlled and corrected, cannot be the resource for change. What I try to do is to empower my clients with a sense of inner space, and the line of gravity that is behind the sternum within that space. I also want them to develop a different, more refined way to use their senses and eyes to perceive and build the space they move in. Discovering that s/he can rely on this inner and outer space, and using the pressure of the visceral area as gentle three-dimensional support, is extremely beneficial in creating a different level of organization where muscle control is less in the foreground and tonic function can be addressed.
From Souchard (1982) Ginnastica Posturale E Tecnica Mézières (Fig. 98, pg. 126), used with permission.
Figure 1: The result of work on a girl who developed a sudden scoliotic pattern after a fall (antalgic reflex a posteriori pattern). Treatment started in 1974, and the second X-ray was done after six days of treatment.
Most often adolescents are brought to my office by worried parents, and it’s quite common that the boys/girls are disoriented and detached. They have a sense of being ‘wrong’ or unhealthy. Also, with adults who have been ‘cured’ in their youth according to medical protocol, there is often a sense of denial of that part of their body, or the feeling of being inadequate and fragile. The use of a brace bars feeling and becoming competent in the adaptive use of the spine, so the girdles then need to take over.
Of the people I have met in my years of practice, very few had a real, pathological condition. In the majority of the cases, there was no real health problem, only a fear for the future of their ‘poor’ back. So my first goal with scoliotic clients is to reassure them that having a scoliosis is quite normal. It is a special, subjective way our bodies adapt to gravity and context, and for some people the rotational pattern and the compression are more evident than for others. Of primary importance for a healthy body is flexibility and adaptability – not a straight shape to the spine, and symmetry even less so. There is nothing wrong with being asymmetrical; we all are; it is normal and physiological. And it’s what makes us interesting. Beauty is based upon imperfection sometimes.
I integrate the hands-on work with contralateral activation, both during the manipulation and/or as exercises. I want the client experiencing connections through the inner space of the body, from up to down and vice versa. It is so important that the client become familiar with the part of the body that has been labeled as imperfect (and that often creates the pain and maladaptation). Through active movement and awareness of what is doing what, and how the elements of our system can be associated, a new and more complete map of the territory can be designed. From there, a new journey can begin.
Resources on the Mézières Method:
Françoise Mézières, F. 1984. Originalité del la Méthode Mézières. Paris: Editions Maloine.
Souchard, P.-E. 1982. Ginnastica Posturale E Tecnica Mézières. Rome: Marrapese Editore.
Figure 2: A client with severe scoliosis, before and after a Mézières Method session. At the time of this session, she had been doing Mézières Method treatments for about a year. Over the course of the sessions, her lumbar pain almost disappeared, her endurance improved, she gained better stability and motor control, and she gained a few centimeters of height.
Basic & Advanced Rolfing Instructor Rolf Movement Instructor
I have been using Structural Stretches combined with manipulation and functional and psychobiological approaches to our work to help clients with scoliosis. I developed Structural Stretches some years ago, and as I note in my manual (Prado 2000), “when these stretches are performed with awareness, they will access and activate our somas’ inherent orthotropic nature, that is, the innate tendency of our bodies to correct themselves and seek uprightness. As a result, the integration we all desire is not imposed on us from the outside, but discovered within.”
The strategy is to design a posture (different for each individual, according to his/her scoliotic pattern) in which we align the biomechanical segments of the body in gravity (standing, sitting, or lying down, depending on the case and existing support) in a way that respects the available congruence of segments (shoulder girdle, pelvic girdle, axial, core, sleeve) in relationship with the ‘Line’. The basic process is as follows. I have the client stretch from core to extremities, finding the first resistance point. Helping him to keep this position, I encourage micromovements through the body, coordinated with breathing, and orient the client’s perception towards either space or ground, depending on the nature of the holding he presents. As he stretches, I wait for myofascial mobilization (release) and shifts in autonomic tone (sympathetic/ parasympathetic resilience). With the corresponding discharge, there is a change in nervous-system holding patterns. I monitor the client’s experience during the discharge, the shift in myofascial tonus, and as the structure organizes in gravity through shifts in position that I guide, laying to sitting to standing. Finally, I assist the client in orienting, moving, and relating.
Psychobiological experiences may come into play, and as physical and emotional patterns are triggered and addressed, new meanings to these perceptions may also emerge. As the client ‘hosts’ them, I support the change in the physical body in gravity. I find that the shifts are sustainable as they address many layers of being simultaneously.
This work has been a twenty-five-year- long experiment that keeps unfolding.
Prado, P. 2000. Structural Stretches: Self Exploration and Cultivating the Vertical. Manual available at https://bit.ly/2Duvv0t