THE BACK BONE OF STRUCTURAL INTEGRATI0N
By Jeffrey Maitland
Robert Schleip’s article “Lecture Notes on P’soa, and Adductors”` is very interesting; and helpful. It specially appreciate how he has allowed us to sharpen our evaluative skills through explicating the very important work of Vladimir Janda and I want to acknowledge him for bringing this work to our attention. I have some critical remarks that are aimed not at Schleip”s central ideas, but al his parenthetical comments about Freyette’s laws of spinal motion. It may appear overly fussy to criticize remarks that are tangential to an article’s central ideas. But I don’t think so since the parenthetical remark, are inaccurate in a way that could support unwarranted conclusions about the usefulness of Freyette’s laws and our understanding of scoliosis.
In the body of his tort Schleip discusses the relation of the psoas to scoliosis and sacs, “In terms of side bending one would then suspect the lumbar spine to side bend toward the side of the shorter psoas. In terms of rotation one would suspect the psoas fibers attaching; at the lateral side, of the vertebral to rotate this side more anteriorly which would result in a general rotation of those vertebrae away from the side of the short psoas.
Yet, according to the generally accepted Freyette’s First Iaw the lumbar vertebrae tend to rotate as a group in the opposite direction … this rotation is also how just about all scoliosis spines appear in X-rays.2 In a fool note to this assertion he says, Freyrtte’s Second Law Is not generally accepted”‘ and cites Basmajian and Nyberg’s anthology, Rational Manual Therapy4 as his source. Schleip seems confused about these laws. Just so we know clearly what these so called laws are, let me begin by stating the two under discussion: the first law says that in neutral side bending; and rotation are coupled to the opposite side and the second law says that in non neutral (hyper fIexion or hyper extension) side bending and rotation are coupled to the same side. I read Rational Manual Therapy a number of years ago, and apart from Schleip’s misunderstanding of Freyette’s laws, something else about his interpretation of the article didn’t ring true. So I checked the reference and discovered the cause of my misgivings.
Leg’s look at Schleip’s misunderstanding of these laws first. When Schleip says that the fibers of the short psoas rotate the “vertebrae more anteriorly” and that the vertebrae rotate “away Irons the side of the short psoas” he is using a different convention for describing rotation than the one laid down by Frevette. However, contrary to what Schleip believes, lie is describing the very same situation described by Freyette’s first law. Let’s imagine that the lumbar spine is being side bent left by a left short psoas. According to Schleip’s description the vertebrae are being rotated anteriorly on the side of the left short psoas and away from the side of the left short psoas. This description is just another way of say tog that the vertebrae are rotating right. If the vertebrae are rotating right and the lumbar spines side bending left, then side bending and rotation are being coupled oppositely In this case. But this is exactly what Freyette’s first law states. By not fullowing the convention laid down by the osteopaths about how to describe rotation, Schleip think, that he has described the opposite of what Freyette’s first law says when in fact he is describing the very same situation.
Let’s look next at how Schleip understands the article lie cites. The article was written by the well known osteopath, Dr. Fred Mitchell, Jr. Here is what he actually said: “Unfortunately, it is quite difficult to demonstrate the validity of the first two ‘laws.’ Obscure radiographic evidence has cropped up from time to time, but the concepts have not been generally accepted.” So according to Mitchell, it is not true that the first is generally accepted and the second is not as Schleip maintains – both concepts are not generally accepted. So according to Mitchell, it is not true that the first is generally accepted and the second is not as Schleip maintains both concepts are not generally accepted!
In our advanced classes we teach these “laws” as well as the tests developed by the osteopaths for determining which facets are dysfunctional. We also teach Rolfing soft tissue techniques designed to release facet dysfunctions in the service of our holistic goal of structural integration. With no further discussion, if Mitchell’s idea is left in the incomplete form in which Schleip rendered it, you might question the usefulness of Freyette’s laws and the wisdom of what we are doing. You might suppose that we are simply wasting our time teaching something that has no real value. But it you were to read Mitchell’s complete idea, you would not he misled in this way by Schleip’s article. What Mitchell says next, in fact, is rather interesting: “Nevertheless, as a model for joint dysfunction there is no other theory with the predictive power of Frevette’s formulation.5″‘ I am not suggesting that there are no problems in learning how to use Freyette’s laws in a clinical setting or that they are true in all cases. But that admission should not lead anyone to suppose that they are not useful. Because these laws have the predictive power Mitchell indicates, with proper instruction, practice, and clinical experience they can guide us toward becoming very effective in handling vertebral joint dysfunction. It is important that the wrong conclusion not be drawn from an improperly quoted source.
So how does it work’ If your client is in neutral position (for example, sitting comfortably straight) and you find a vertebra that is rotated and side bent to the same side, then you know that something is amiss. In neutral position vertebrae don’t normally exhibit side bending and rotation to the same side; if they do, there is a facet restriction involved. Even though it is very difficult in the beginning for many students to learn how to palpate rotation, palpating for side bending is next to impossible, even for many experienced clinicians. The osteopaths developed a forward and backward bending test that helps you determine not only that the vertebra is side bent and rotated to the same side, but also which facets are fixed and whether they are fixed intension (closed) or flexion (open). For these tests to work you must first determine rotation and then watch how the rotated vertebra behaves in forward and backward bending whether it appears to derogate or get worse. From how the vertebra behaves you can deduce whether the facets are fixed closed or open. Once you know how the facets are fixed, it is a simple matter to release them. The Rolling soft tissue techniques I developed to deal with these problems take advantage of this understanding of how facets become fixed.
Now hen is where things get sticky. Even though these tests give you a way to find a loss of function through a kind of motion test (forward and backward bending), their use requires you to palpate rotation first. Anyone who has taught or tried to learn spinal biomechanics knows that palpating rotation is notoriously difficult for many beginning students. Positional palpation is a highly developed perceptual skill that some people never master. A chiropractor friend of mine tells me that most of his colleagues can’t even do it well – if at all! And if that were not disconcerting enough, just consider this: a vertebra can be rotated without showing joint dysfunction and joint fixation can exist without rotation. Some time ago I discovered that facets actually can be fixed in more planes than the osteopath’s forward/ backward bending and translation tests reveal. Also vertebrae can he bilateral1v fixed in extension or flexion, and, of course, when they are fixed in this way, they do not show rotation. But the most troublesome feature about palpating for rotation is the fact that facets can maintain their fixation even after your manipulation has derogated the vertebra. ‘I his sort of occurrence is espccia11′ common in the neck. So it you rely on palpating rotation to determine whether your manipulation is successful, you could be misled. You could palpate a vertebra, successfully determine that you derotated it, and then conclude that you released the fixed facets when Ill fact you may not have. When you add all of this together you can certainly understand why some of the concepts of biomechanics mow not be generally accepted.
There are some important lessons to be learned front these tacts. -Rue reason I am writing this rather lengthy response to Schleip’s tangential and parenthetical remarks is because I do not want anyone to think the lesson to be learned is that understanding Frevette’s law is a hopeless waste of time. One of the important lessons is that we should study and practice until we gain a high degree of confidence in our ability to evaluate joint dysfunction and a high degree of palpatory accuracy. If we do, we will help a lot more people and our ability to achieve our goal of structural integration will increase significantly.
The other important lesson is that if you only know how to test for joint restriction by palpating rotation, then you will not only miss a lot of the other ways facets can be restricted, you will also pass over those cases where you managed to derotate the vertebra but didn’t release its fixation. So we need know how to use another more reliable and accurate form of palpation known as motion palpation. Due to the very real limitations in position palpation (for example, palpating for rotation to evaluate fixation or its release). Motion palpation (motion testing for joint fixation or its release) is almost always superior. If you have spent any time palpating necks, you know how difficult it can be. Since it is difficult for many to feel rotation and since cervical vertebrae are especially prone to both showing some rotation without fixation and showing no rotation with fixation, motion testing the cervical spine by using the translation test (developed by the osteopaths) is clearly superior to palpating for rotation. Also, sure the, pane urn exhibit more facet restrictions than the forward /backward bending test is capable of revealing, if you can motion test facets, You will he snore successful in finding and, l releasing joint fixations. Therefore, I now use and leach a variety of motion palpation tests for locating facet fixations throughout the entire spine. I still use the forward and backward bonding tests because they work. But I have added a variety of motion palpation tests that make my manipulations more, accurate and hence more effective.
Even though Freyette’s “laws” may not be generally accepted, are not always true, and often Muss other planes of facet restriction, their predictive power makes them a great pedagogical device for teaching how to understand and analyze vertebral joint dysfunction. They provide you with a good place to begin your learning, and from them you can expand your understanding of and ability to release vertebral joint dysfunctions. If you build on this understanding by adding motion palpation to how you test joints your palpatory accuracy will increase, and you will be even more effective in helping your clients to find integration in gravity.
Since this article began as a commentary on parenthetical remarks, allow me to close with a parenthetical remark not all together unrelated to my main points. Michael Salveson and Jan Sultan began our investigations into understanding the spine and how to release its restrictions. From their inspiration and on the basis of reading osteopathic texts I discovered and experimented with using the osteopath’s forward and backward bending test to explore facet restrictions. With a little more experimentation, I was able to create a number of soft issue techniques that were capable of releasing facet restrictions ill the spine and sacrum without resorting to high velocity love amplitude techniques, muscle energy techniques or techniques developed in other systems. Since we are Rolfers and not osteopaths or chiropractors, the teachers agree that it is important that we do not use or teach techniques from these other disciplines to release facet restrictions. I mention this point because it is important to understand that even though we are teaching how to understand joint dysfunction and use evaluation tests from other disciplines, we are not ago teaching the techniques developed by these other disciplines. Also we are not teaching “fix-it” work, as it is improperly called, in the place of the holistic goals of Rolfing.
1 Rolf Lines, November, 1999. Vol. XXVI, n.5 pp. 19-24.
2 Ibid , pp 21-22.
3 Ibid., footnote #3. p. 24
4 John V. Basmajian and Rich Nyberg, Rational Manual Therapy, (Baltimore 1993). p. 295
5 Ibid., p. 295, Mitchell’s italics.
WALKING ON SOLID AND LESS SOLID GROUNDS: REPLY TO JEFF MAITLAND
By Robert Schleip
Amazing how much a little tangential footnote can trigger. Dear Jeff, here is an illustration of the spine in a typical shaped scoliosis, as seen from posterior. It fits the description of side bending and rotation of scoliosis in my article and shows how the explanatory theory of an unilateral psoas shortness (e.g. on file left here) world be partly in conflict with the direction of rotation shown. Yes, there are also other options for example in the less frequent thoracolumbar C-curve scoliosis which would fit more your description. My text had the below picture in mind, which is based on an x-ray photo of the most common scoliosis type in a standard orthopedic text book1. Don’t think I got Freyette’s First Law wrong here.
I have a fairly good overview of the literature on scoliosis’, which describes the behavior of a group of vertebrae which are side bent and rotated. At least for the very common type of idiopathic scoliosis all the books seem to support Freyette’s First Law, i.e. that the vertebral bodies tend to rotate towards the convexity of their side bending curvature. And very clear and impressive: most of these books include x-ray pictures which also show this very convincingly. These two things-and not Mitchell’s article lead me to the statement that this feature of Frevette’s laws seems to be “generally accepted.”
Yet regarding the specific assumptions of Freyette’s Second Law, I have only beets aware of its acceptance within the osteopathic literature, not in the much larger field of manual medicine in general2. I don’t know why there seems to be general acceptance of the basic features of Freyettes First Law, whereas such agreement is still lacking for his second law3. Maybe this is due ht the fact that no real life images have been published in its support vet, despite the popularity and relative precision of modern imaging procedures like biplantar x-rays, cat scan, etc.4
Its is true that Freyette’s Second Iaw allows its believers to make some simple and easy predictions about the most likely behavior of a vertebrae. Or as Mitchell says, “There is no other theory with the predictive power of Freyettes formulation.” Hopefully that is not the same situation as in meteorology where traditional weather forecasters often used some handy theories with an appealingly high predictive power and precision5: whereas the forecasts of modern meteorologists tend to be less simple and precise, yet on average a bit more accurate. So my statement was not is not referring to how handy and useful Freyette’s Second Law’s prediction is for the mind of the believing practitioner, but on making its aware that the scientific justification of its accuracy6″ is still missing.
Yes, I have seen some peer reviewed scientific studies on the short term therapeutic success of osteopathic treatments – with pretty identical success rates as those from chiropractor, (which often work with different assumptions about the vertebra position) from McKenzie practitioners from various exercise modalities, and front acupunture. Therapeutic success of a modality is not identical with accuracy of its theoretical assumptions.-Any little footnote only related to this second aspect. I can not criticizing the inclusion of these osteopathic concepts in our Rolfing classes. As an instructor I do ask my students to become knowledgeable and familiar with lots of contemporary concepts for which we still do not have sound scientific approval and acceptance. We wouldn’t be Very effective if we limited ourselves In teach and practice only those few features of our work which have already gained general worldwide acceptance.
Yet while walking forward it is useful for ns to he aware of when we are moving on rock solid ground and when we it practicing the fine art of walking on shifting sand as Ida Rolf called it. A wise practitioner I suggest still steps down laid continues moving oil less solid terrain, yet less loudly and more with the modesty of what Ida Rolf called “the wisdom of insecurity. The purpose of my little footnote was to incite its to be aware of these two different adequate walking styles, by indicating that Freyette’s First Law seems pretty “rock solid,” whereas his second law appears as yet a bit more sandy. I think little footnotes like mine should be tolerated as tiny but helpful reminder posts’ on the noire sandy portions of our path while we continue walking.
1.Alfred M.Debrunner, Orthopädie, Bern/Switzerland. 1995, p.416.
2.Wich includes the different kind of chiropractic schools, the academic fields of orthopedics and physiotherapy, as well as several established schools (each usually much larger than ours) like McKenzie, Cyriax/Dos Winkel, Geoffry Maitland, Kaltenborn, Ackermann, Dorn, Mulligan and several other approaches.
3.The French osteopath Bienfait attempted to prove Freyette?s prediction with theoretical biomechanical reasoning. Unfortunately his whole argumentation depended on the assuption that the nucleus pulposus of a disc does not slide away from its exact center position during side bending. Yet according to other authors that is a very questionable assumption (e.g.I.Akapandji, The Physiology of the Joints, Vol.3, p.41)
4.Unfortunately your insistenceJeff, to have this discussion published in ROLF LINES and the very short time left for me to respond does not allow me to ground this statement with additional literature sources besides the sentences by Mitchell. Yet I have followed as na avid reader several scientifically oriented manual medicine journals during the last years, wich shaped and supported my above impression. If any of the readers knows indeed about a clear scientific imaging study in support of Freyette?s Second Law, please let us all know.
5.For example the old Bavarian rule that if you count how many hours of sun you get on a certain day in spring, that is exactly how many sunny weeks you will get at the rest of the season.
6.What would we needed here is a descriptive study showing that the redictions of Freyette are accurate in more than random frequency within in a group of clients when compared with x-ray or other imaging analysis.
7.See for example the impressive literature on Anton Messmer, whose work unintentionally became a major root for the development of the clinical field of psychology several decades later. Or see the recent acupuncture research of F.M.Kovacs wich showed na analgesic effect even when the therapeutic skin irritations were done on non-acupuncture points within the same dermatomes.
8.See mey detailed didactic teaching script on ?/spinal Mechanics? at http://www.somatics.de My original article (published in ROLF LINES, Nov 98, title ?Lecture Notes on Psoas & Adductors?) wich contained that tangential footnote wich unintentionally triggered this public debate, is also available at that site.