Members of the Advisory Board to the National Center for Medical Rehabilitation Research, I thank you for this opportunity today to testify. I am a physical therapist and researcher representing Christie Clinic Association in Campaign, Illinois.

The area of research that we have been involved in pertains to the effects that soft tissue manipulation (STM) has on anatomical structure and autonomic nervous system activity. By the term “soft tissue manipulation”, I am referring to a hands-on manipulative therapy that is designed to correct myofascial and associated structural imbalances in order to integrate the body’s weight masses in the gravitational field. The techniques are based on the Rolf Method of soft tissue manipulation, developed by Dr. Ida P. Rolf. 1,2

Advocates for the use of soft tissue mobilization have stressed an integrative, body-systems approach towards treatment of disabilities. For example, they propose that physical trauma, degenerative pathophysiology, chronic emotional stress can contribute to various forms of low-back syndrome, that in turn are characterized by patterns of anatomical misalignment and autonomic misalignment and autonomic dysfunction.1,2,3 Such a configuration may be found in certain types of degenerative joint disease (DJD) of the lumbar spine.

In its early stages, one type of lumbar degenerative joint disease is characterized by moderate narrowing of the intervertebral disc space, spurring along the lips of the vertebrae and arthritic changes in the paired facet joints that join adjacent vertebrae posteriorly. In terms of anatomical alignment, this type of DJD typically shows a relative exaggerated lumbar lordosis and an excessive forward or anterior tilt of the pelvis in the sagittal plane (See Figure 1). It is interesting to note that proponents of manual mobilization techniques have claimed that this form of low-back pathology is also associated with decreased parasympathetic (PNS) outflow (e.g. vagal outflow) and concurrent increased sympathetic output.’1, 2,4, 5 In more descriptive terms, such patients are said to exhibit an autonomic imbalance characterized by heightened sympathetic arousal responses and dampened vagal/parasympathetic responses that are associated with a relaxed, attentive physiological state.

<img src=’https://novo.pedroprado.com.br/imgs/1992/374-1.gif’>
Figure 1. A radiograph of pilot study subject #2 before soft tissue mobilization treatment with diagnosis of lumbar degenerative joint disease. Note the excessive lumbar lordosis (extension) and exaggerated anterior pelvic tilt. There is also evidence of spurring along the lips of the vertebrae and arthritic changes in the right facet joints. In addition, significant subluxations are evident with L3 positioned posteriorly on L4 and L4 posteriorly with L5 (retrolithesis). The patient, a 49-year old male, reports radiating symptoms down the right anterior thigh to knee, suggesting nerve impingement at the L3 level.

According to the advocates of manual therapy, this pattern of anatomical misalignment and autonomic dysfunction can be remedied by a sequence of soft tissue manipulations. However, to my knowledge, this theory has not been substantiated through controlled, experimental investigations until the studies that were conducted with healthy adult subjects by myself and my research colleague, Professor Stephen Porges 4,5,6 Dr. Porges is presently the Director of the Developmental Assessment Lab at the University of Maryland. These studies are summarized in my abstract and are referenced in the written statement I have presented to the Board today. Because of time limitations, I will only briefly summarize here. In three separate investigations, we chose young, healthy adult subjects who were pre selected as having excessive anterior tilt of the pelvis (See Figure 2). The subjects then underwent a sequence of soft tissue mobilizations (Rolf Method). Following the manipulative treatment, subjects exhibited a statistically significant reduction in standing pelvic tilt, lumbarlordosis, and a concurrent significant increase in PNS activity when compared to controls5,6,7,8,9. In addition, through follow-up assessments, we discovered that these shifts in spinal/pelvic alignment and autonomic activity were sustained for at least two weeks following the completion of treatment.6

<img src=’https://novo.pedroprado.com.br/imgs/1992/374-2.gif’>
Figure 2. These two illustrations represent the patterns of postural misalignment that were preselected in our studies of young healthy adults. Note that both (a) and (b) have the common attributes of excessive anterior pelvic tilt and lumbar lordosis (extension). According to a somato-typology developed by Sultan, both of these structural patterns are also associated with internal rotation of the femur .12 That is, figure (a) is classified as a “non-conflicted internal type exhibiting protracted scapula, thorax fixed in expiration, increased lumbar lordosis, anteriorly titled pelvis, hyperextended knees, and flat, longitudinal arches. In contrast, figure (b) is classified as a “conflicted internal type” because the thorax is fixed in inspiration and the shoulders are retracted.
Both types of postural dysfunction also served as prototypes for patient selection in the current lumbar degenerative joint disease investigation with the common characteristics centering around the anterior pelvic tilt, increased lordotic curvature, and internally rotated femurs.
It should be emphasized that many back problems (e.g. bulging or protruding lumbar intervertebral discs) involve patterns of posterior lumbar curvature and posterior pelvic tilt that are typically associated with external rotation of the femur. The “external” femoral type of low back dysfunction will be the subject of a future investigation.

Using the experimental results from our healthy-subject data as a prototype of low-back dysfunction, we are currently conducting a pilot study of six patients who have been diagnosed as having early stages of DJD. All patients were pre selected for exhibiting excessive pelvic tilt and increased lumbar lordosis as well as signs of degenerative facet and disc disease (e.g. sub luxations). Our early results, with four subjects having completed a three-week treatment protocol involving soft tissue mobilization to the pelvis and spine, indicate the following for three of the four patients:

1) As determined from pre- and post treatment radiographs, a reduction in anterior pelvic tilt, in lumbarlordosis, and in the sub luxation of lumbar vertebrae (retrolithesis) were observed (See Figure 3);

2) An enhancement of patient’s post treatment PNS activity was found when compared to pre-treatment baselines; and

3) Patient’s subjective reports taken upon completion of treatment described decreases in low-back pain and radiating dermatomal symptoms and improved, pain-free distances of ambulation.

One patient demonstrated no preto post-test change in any of the above dependent variables.

Conclusions from this pilot study would at best be speculative. However, if, indeed, manual therapy procedures do produce favorable results with lumbar DJD, such treatment strategies may be a conservative alternative to the present surgical interventions involving decompression and spinal fusion. Furthermore, the difference in cost effectiveness between soft tissue mobilization and surgical procedures could be quite dramatic.

Finally, it is important to emphasize the integrative aspect of the manual therapy protocol in the pilot study and our other investigations. Maitland has recently described three hierarchical levels or paradigms of therapeutic myofascial intervention: relaxation, corrective, and wholistic.10,11. The first paradigm, the relaxation approach, focuses on the alleviation of symptoms, like pain and stiffness and includes the modalities of massage and moist heat. The second paradigm, the corrective approach, attempts to restore local physiological dysfunction and anatomical misalignment; it involves such techniques as spinal and soft tissue mobilization, as well as corrective exercise and movement. The third paradigm, the wholistic approach, relies on eliminating pathophysiology, structural misalignment, and symptoms through a global orientation, based on constitutive principles of structural integration of the myofascial system. For the above case of spinal degenerative joint disease, the wholistic approach focuses on reducing excessive secondary spinal curves and reducing anterior pelvic tilt, in order to balance the body’s major segments in the field of gravity. Maitland stresses that the wholistic paradigm is not mutually exclusive or in opposition to the other two approaches; but, instead, it may utilize the relaxation techniques and corrective strategies of the first two paradigms as components of a wholistic intervention. Furthermore, our research indicates that not only does the wholistic soft tissue approach improve overall musculo-skeletal balance and alignment, but other body systems are altered also. Specifically, autonomic shifts toward increased parasympathetic (vagal) tone were demonstrated that have been correlated with enhanced neural functions, including improved attention-span and cognitive discrimination, as well as decrease levels of autonomic stress7.

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Figure 3. A radiograph of pilot study subject #2 after soft tissue mobilization treatment protocol consisting of six sessions administered twice weekly for three weeks. Note the reduction of lumbar lordosis and decrease in anterior pelvic tilt from pre-treatment radiograph. Furthermore, the retrolithesis subluxations seen at L3 on L4 and L4 on L5 are significantly reduced. The right lumbar facet joints also appear to be less compressed. The patient’s post-treatment parasympathetic activity exhibited an increase from pre-treatment levels as well. A post-treatment patient self-report indicated diminished radiating symptoms down right anterior thigh, decrease low back pain, improved ambulatory endurance. A one month follow-up assessment has revealed that these anatomical, autonomic, and self-report shifts were sustained.

I urge the Advisory Board to consider in their research plan the study of manual therapy, including wholistic, soft tissue mobilization techniques, as possible methods of reducing the anatomical and functional impairments associated with degenerative spinal disabilities.

Acknowledgements

I would like to thank the Rolf Institute for their grant support of our preliminary research with healthy adults and Christie Clinic Association for their financial assistance in conducting our ongoing investigation of low-back dysfunctional patients.

References

1. Rolf, Ida P.: “Structural Integration: A Contribution to the Understanding of Stress”. Confmia Psychiatrica 16(2)69-79, 1973.

2. Solit, M.: “Study in structural dynamics”. J. Am Osteopathic Assoc. 62:3040,1962.

3. Juhan, Dean: Job’s Body: A Handbook for Bodywork. Barrytown, N.Y., Station Hill Press, 1987.

4. Cottingham, John T., Porges, Stephen W., Lyon, T.: “Soft tissue mobilization (Rolfing pelvic Lift) and associated changes in parasympathetic tone in two age groups”. Phys Ther 68: 352-356, 1988.

5. Cottingham, John T., Porges, Stephen W., Richmond, K.: “Shifts in pelvic inclination angle and parasympathetic tone produced by Rolfing soft tissue manipulation”. Phys Ther 68: 1364-1370, 1988.

6. Cottingham, John T., Soderberg, G.J., Porges, Stephen W.: “Effects of sequential Rolling soft tissue manipulation on lumbar mobility, pelvic alignment, and autonomic function: longitudinal study”. (Manuscript in preparation).

7. Porges, Stephen W. :Autonomic regulation and attention. In B.A. Campbell, H. Hayne, and R. Richardson (eds). Attention and information processing in infants and adults. Hillsdale, NJ, Lawrence Erlbaum Associates, 1992, pp. 201-223.

8. Billman, G., Dujardin, J.: “Dynamic changes in cardiac vagal tone as measured by time series analysis”. Amer J of Physiology 258:896-902,1990.

9. Walker, M.L., Rothstein, J.M., Finurane, S.D., et al: “Relationships between lumbar lordosis, pelvic tilt, and abdominal muscle performance”. Phys Ther 67:512-516,1987.

10. Maitland, Jeffrey: “What is the recipe?” Rolf Lines 19 (3): 1-5, 1991.

11. Maitland, Jeffrey: “Rolling is the philosophy, science and art of integrating the human body-structure in space/time and gravity through myofascial manipulation and movement education”. Unpublished manuscript, 1992.

12. Sultan, Jan H.: “Toward a structural logic”. Notes on Structural lntegration 1: 12-16,1986.Effects of Soft Tissue Mobilization on Pelvic Inclination Angle, Lumbar Lordosis, and Parasympathetic Tone