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chapter_15.docxCHAPTER 15 PRINCIPLES OF BODYWORK: MANUAL AND MANIPULATIVE THERAPIES
PATRICK COUGHLIN
Modalities that involve touching, massaging, and manipulating the physical body provide a pathway to healing that are also thought to draw on the connection between body and mind, and have great antiquity. The well known abilities of touch to heal are widely recognized in modern medicine in the tradition of “laying on of hands.” These “hands-on” therapies have been well organized and widely available as contemporary systematic therapeutic practice systems. This section presents the basic physiologic principles that underlie the manual therapies, as well as explaining each specific system that makes use of manual and manipulative modalities of healing.
As with other complementary or alternative therapies, bodywork espouses a holistic philosophy that has the following outstanding tenets:
1. The body is a unit.
2. Structure and function are interrelated.
3. The body has an inherent ability to heal itself.
4. When normal adaptability is disrupted, disease may ensue.
Based on these defining principles, bodywork seeks to reverse structural imbalances to optimize the body's ability to self-correct or repair itself, which includes the defense against invasion from foreign substances or organisms.
CONCEPTS APPLICABLE TO MANIPULATION AND BODYWORK PRACTICES
A number of concepts based on physical laws and anatomical principles universally apply to manipulative and bodywork practices. These concepts are briefly described here so that they can be associated with the various forms (styles) of manipulative therapy, providing the reader with a greater understanding of the reasons for applying or seeking this type of treatment.
Concept 1: Bilateral Symmetry
The musculoskeletal system is usually described as being bilaterally symmetrical. That is, if the body is divided in half by a slice made from top to bottom and front to back along the midline (midsagittal plane), the right side should be a mirror image of the left side. This is an idealized assumption, of course, because few if any human bodies are truly symmetrical. Certain behaviors in which we engage, both consciously and unconsciously, are specifically designed to compensate for a lack of bilateral symmetry.
Concept 2: Gravity
The human organism is similar to all other organisms in that we are subject to the laws of physics. Thus, the way we interact with planet earth is governed by the pull of the earth on our bodies: the force of gravity. Because of this constant force, and because our bodies have mass, we are given the weight that we must carry as we go about our activities.
Concept 3: Tensegrity
Tensegrity was developed as a concept in the late 1940s by the renowned architect Buckminster Fuller and the sculptor Kenneth Snelson. The basic premise of tensegrity (tensional integrity) is that in many systems a balance exists between compression and tension. Tensegrity is “an architectural system in which structures stabilize themselves by balancing the counteracting forces of compression and tension which gives shape and strength to both natural and artificial forms.” Architectural systems such as suspension bridges employ this concept, but it also is seen in biological systems, including the musculoskeletal system. The muscles and other soft tissues (e.g., joint capsules, tendons, ligaments) act as tensional elements, whereas the bones resist the compression of weight bearing. By maximizing the ratio of tensional elements to compression elements, such a system enables the organism to maintain balance and move with a minimum amount of energy expenditure.
Concept 4: Postural Maintenance and Coordinated Movement
As we evolved from a quadrupedal (four-legged) to a bipedal (two-legged) stance, we became able to “manipulate” our environment because our hands were freed up, but we also became more unstable (visualize the result of removing two legs of a four-legged table; even the Eiffel Tower has four legs). From an architectural point of view, we became a buttressed arch system (the feet, legs, and pelvic girdle) supporting an elongated tower (the spine and head), with two cantilevered upper appendages (the arms) that can assist with balance. However, we are designed for movement (which is necessary for survival) and are rarely stationary, even when seated. Consider the act of walking: for about 40% of the time allotted to the normal gait cycle (the period of two strides), we are moving with only one foot on the ground. Because we engage in considerable movement, we are constantly adapting to our position relative to the earth, which exerts its gravitational pull. Accordingly, we have programmed into our neuromusculoskeletal system a device that lets us know what that position is at all times and also directs the constant physical adjustments that we make. This is commonly referred to as the “equilibrial triad,” which consists of the proprioceptive system, vestibular system, and visual system.
The proprioceptive system gives us positional information based on the state of contraction of each muscle in the body, as well as the position of each joint. The vestibular system is our “gyroscope,” which gives us information on the position of the head and how it and the rest of the body are rotating or accelerating in space. The visual system allows us to be well aware of our surroundings and position because we can “see” where we are. In fact, because the visual system is so important in our normal range of activity, the other two parts of the triad act to support it. The proprioceptive and vestibular systems sense the position of the head relative to the body and adjust the posture so that the head is situated with the eyes aligned parallel to the horizon. Together, these three systems act with the motor system to produce coordinated movement, balanced posture, and a properly aligned head.
Concept 5: Connective Tissue (Fascia)
Connective tissue can be highly organized, as in the case of joint capsules, ligaments, tendons, the meninges of the central nervous system (CNS), intervertebral discs, and articular cartilage, or it can be more diffuse and seemingly less organized. Fascia is another name for the connective tissue that surrounds and gives architectural form to the tissues and organs of the body.
Fascia can be divided into two major components: superficial fascia and deep fascia. The superficial fascia resides just under the skin (the hypodermis) and serves as a staging center for the immune system (large quantities of antigens from the skin are presented to immune cells in this layer) and as a fat storage depot (the cause of significant attention). The deep fascia is much more extensive than the superficial fascia and exists throughout the body, serving to “connect” virtually all the tissues and organs. Skeletal muscles are surrounded by capsules of deep fascia, as are nerves and blood vessels (e.g., neurovascular bundles are wrapped in deep fascia). In this sense the deep fascia forms compartments that separate these tissues, but it also forms a structural continuum, and if physical stress is applied to one area of fascia, this continuity will result in effects’ being “felt” in other areas or fascial layers as well (Figure 15-1). The compartmentalization of tissues by the deep fascia also results in the formation of specific pathways for, and limits to, the spread of infection (i.e., along fascial planes), as well as for the accumulation of fluid. Both superficial fascia and deep fascia are richly
Figure 15-1 A force applied to one part of the fascial continuum affects the entire system.
supplied by blood and lymphatic vessels and by nerves (especially pain fibers).
On the molecular level, fascia is composed of a fibrous component (primarily the macromolecular proteins collagen and elastin) and a soluble, gel-like component, mostly water. The combination of fibrous and soluble components of the fascia creates, in effect, a molecular sieve through which chemical compounds diffuse to and from the cells of the body. Therefore the fascia has a great impact on the function of the organs it surrounds and infiltrates. Cells also reside in the fascia, including fat and immune cells in the superficial fascia. Fibroblasts, a major population of connective tissue cells, are responsible for the secretion of fibrous proteins that make up the scaffold of the fascia. Immune cells constantly patrol the fascia, seeking out foreign antigens as well as ingesting and destroying extracellular debris, including used constituents of the fibrous matrix. This creates a significant turnover in the components of the fascia and contributes to its innate adaptability to changing body conditions. The cellular component of the fascia can be significantly altered by a state of inflammation, in which large numbers of immune cells migrate into the area in response to tissue damage or antigenic challenge. Inflammation also stimulates fibroblasts to secrete larger amounts of collagen to reseal any breaches in the continuum, which results in scar formation or fibrosis.
Not only is the fascia very adaptable to the ever-changing internal environment, but it is also significantly affected by the aging process. As the human body ages, the chemical bonds that bind collagen molecules together, known as cross-links, become more prevalent. As this occurs, less space is available in the fascia for water and the other soluble components. The end result is a loss of tissue water and an increase in the fibrous component, which in turn decreases the relative elasticity and physical adaptability of the tissue. In other words, the tissues dry up and become more brittle. This leaves the musculoskeletal system, in particular, significantly more susceptible to microtrauma and macrotrauma.
The physical properties of fascia have stimulated manual therapy practitioners to devise specific techniques to address these properties and the relations among the fascia and the tissue it surrounds. Just as the fascial matrix can become distorted from the forces brought to bear on it, it also can be restored to its original structural relationships by manual means. In addition, because of the continuity of the fascia throughout the body, local fascial distortions can produce distant effects. This is especially true in the case of muscle-associated deep fascia, which, if distorted, can alter the vector and function of that muscle.
The gel-like consistency of the soluble component of the fascia enables it to behave as a colloid, which resists force in direct proportion to its velocity. On the other hand, because of this property, fascia, like a colloid, will respond much more readily if force is applied slowly and gently. In addition, gentle application of force results in gradual yet sustained realignment of the fibrous component of the fascia, which can be palpated in the form of a “release.” This is the rationale behind the development of myofascial, craniosacral, and other low-velocity techniques.
Concept 6: Segmentation (Functional Spinal Unit)
Anatomically, the human body is arranged lengthwise as a series of building blocks or segments. This can be observed most directly by the looking at the individual vertebrae that make up the spinal column, which extends from the base of the skull to the coccyx (“tailbone”). Just above the coccyx is the sacrum, a single bone resulting from the fusion of five vertebrae. This fusion is significant, because the sacrum articulates with the pelvic bones, which in turn articulate with the femurs. This relationship produces an arch that has the sacrum as its keystone.
Passing between the vertebrae and going from the spinal cord to the periphery are 31 pairs of spinal nerves (one for each side, with the exception of the coccygeal nerve, which is fused at the midline of the body). Each of these spinal nerves contains sensory and motor nerve fibers that are distributed around the body (Figure 15-2).
Most nerves are accompanied by arteries that supply blood to the same region supplied by the spinal nerve. In addition, the neurovascular bundle contains veins and lymphatic vessels, which serve to drain away waste products from the same territory. Thus, each segment of the body receives information (and is sending information back to the CNS) as well as nourishment, and each is being drained of waste products. It might appear that each segment functions as a separate entity, but this is not the case. Because of significant overlap both inside and outside the
Figure 15-2 Spinal nerves and dermatomes.
(Modified from Thibodeau GA, Patton KT: Anatomy and physiology, ed 7, St. Louis, 2010, Mosby.)
CNS, each segment is “aware” of what is transpiring in the segments adjacent to it.
The individual spinal nerve and all the tissues that it innervates, called the segment or the spinal segment, is also referred to as the functional spinal unit (FSU). The FSU thus includes two adjacent vertebrae and the spinal nerves, skeletal muscles, and fascia between them; other bones, muscles, and fascia associated with the segment (e.g., ribs, intercostal muscles); the blood and lymphatic vessels that supply these tissues; and visceral structures within the body cavities that receive innervation from the autonomic portion of the spinal nerves.
Concept 7: Reflexes and Autonomic Nervous System
The CNS, consisting of the brain and spinal cord, can be compared to a computer in that it is designed to integrate and process information. This information basically takes two forms: sensory (input) and motor (output). The most fundamental unit of information processing is the reflex. Information enters the CNS through a sensory neuron and is processed in the spinal cord or brain stem through an interaction between the sensory neuron and the motor neuron at a location known as a synapse. Motor information then leaves the CNS directly through a motor neuron to effect a response in a skeletal muscle. The most common example of this type of reflex (called somatic for the type of tissue involved) is the withdrawal response when a painful stimulus is encountered (e.g., when the hand touches a hot burner). The pain information is relayed through the spinal cord and out to the muscles, which causes the hand's removal before the sensation reaches the cerebral cortex and is perceived.
Although much of the sensory information coming into the CNS reaches consciousness (is perceived), much does not, and we go about our business neither knowing nor feeling what is happening. The same is true of motor activity, which can be voluntary or involuntary (see the discussion of the autonomic nervous system later and Chapter 8). An example of this involuntary phenomenon is the digestive system, which, under normal circumstances, functions without our knowledge (with the important daily exception of elimination). With respect to postural maintenance, if we are asked to attend to our position, we are usually able to do so (a test of this system [conscious proprioception] is to ask an individual to close the eyes and state the location and position of different parts, such as the hands and feet). However, we usually are not particularly attentive to our position (unless we lose our balance), and there is an entire division of the proprioceptive system (unconscious proprioception) that is never perceived. In short, we are constantly adjusting ourselves to adapt to the gravitational pull of the earth and our position relative to it, and most of this activity takes place at the level of the reflex.
The autonomic nervous system has as one of its responsibilities the unconscious control of visceral structures. These structures include smooth muscle (e.g., surrounding blood vessels and the bronchial tubes), cardiac (heart) muscle, glands, and lymphoid (immune) tissue. There are two divisions of the autonomic nervous system that have opposite actions: the sympathetic (thoracolumbar) division, responsible for arousal, or the “fight or flight” reaction; and the parasympathetic (craniosacral) division, responsible (among other functions) for stimulating the activity of the digestive system, or the “rest and digest” function. Although each division predominates in certain situations, the two divisions normally coexist in balance with one another to maintain a state of homeostasis, which is a form of internal equilibrium. The names “thoracolumbar” and “craniosacral” indicate the origin of the motor nerves of each division. Therefore the spinal nerves of the thoracolumbar region contain both somatic and sympathetic nerve fibers, whereas some of the cranial nerves and sacral nerves contain both somatic and parasympathetic nerve fibers.
Within the CNS, interactions between sensory and motor nerves are constantly taking place through reflexes. Although it has been long known that somatic and visceral reflexes occur, it has only recently been discovered that the two types of reflex loops overlap with one another. That is, stimulation of a visceral structure can produce a somatic response, and stimulation of a somatic structure can elicit a visceral response. This discovery is of extreme importance to the practitioners of manipulation, because it essentially validates the claim that manipulation has global effects on the body, especially with the maintenance or reestablishment of proper blood and lymphatic flow. In fact, it is quite arguable that manipulation of somatic structures (the musculoskeletal system) is entirely capable of restoring proper blood flow to visceral structures through reflexes mediated through the CNS.
Concept 8: Pain and Guarding, Muscle Spasm, and Facilitation
Patient: “Doc, it hurts when I do this.” Doctor: “Then don't do that!”
Pain is the result of a noxious stimulus that produces tissue damage. This stimulus can come from outside the body, such as a thermal or chemical burn, which is perceived at the skin and produces a classic withdrawal response. The stimulus can also come from inside the body, such as a sprained ankle, in which the damage is perceived at a muscle, joint or ligament.
If pain results from damage to a bone, joint, or ligament, a natural response is for the surrounding muscles to contract reflexively, producing a natural splinting of the area. This is also known as guarding. Another result of this type of damage is an altered gait pattern (a limp), which is merely an attempt by the body to “get off” the affected joint, if weight bearing causes additional pain. This can also happen when a paravertebral muscle is overstretched from a bending or lifting maneuver. Proprioceptors in that muscle report the stretch, causing a reflex contraction of that muscle. If the amount of damage is sufficient, the reflex contraction becomes stronger, and other muscles in the area are recruited to “guard” against further stretching and damage. The involved muscles are now considered to be in spasm. This reaction can spread (through reflex spread within the CNS) until much of the back musculature is involved. This is what happens when the back “goes out” and the person suffers back spasms. Because of the altered position of the body away from the norm and the prolonged spastic contraction, the involved muscles are required to do much more work than normal, which results in fatigue. When this occurs, muscle contraction results in the compression of local blood vessels, which in turn affects the nutrition of local tissue; this then exacerbates the problem by causing more pain. A downward spiral of pain → spasm → more pain → spasm can result.
Over time, as more and more sensory input is being fed to the CNS, the nerves that are reporting this information, as well as the nerves that are reacting (the motor neurons), become more sensitive. That is, their threshold for activity becomes significantly reduced. This situation is known as facilitation and is responsible to a large extent for the downward spiral just mentioned.
Presumably, muscle spasm lasts until the injury is healed and the surrounding muscles are allowed to release their grip on the area. This is why most allopathic physicians prescribe bed rest for back pain (and tell patients, “Don't do that”). Sooner or later the spasm will resolve on its own. However, this is not always the case, and the spasm can persist on a reduced level. This can cause the vertebrae normally moved by that muscle to become fixed in a certain position. The vertebrae may remain in that fixed position even when the muscle spasm is completely resolved. This also creates a need for a compensatory reaction or altered behavior to avoid the generation of more pain, as with a limp (see following discussion). In many patients it is possible to break the cycle of pain → spasm → more pain by the application of manipulative therapy.
Concept 9: Compensation and Decompensation
As mentioned, the proprioceptive system is constantly reporting sensory information to the CNS regarding body position so that postural adjustments can be made, primarily to maintain the eyes parallel to the horizon (horizontal gaze). However, such compensatory behavior becomes more prolonged in certain situations. For example, in a person with one leg longer than the other (asymmetry), the pelvis on the “longer” side would be elevated relative to the other side. Because the sacrum is strongly connected to the pelvic bones, the base on which the fifth lumbar vertebra (L5) rests would be tilted toward the short side. This information would be reported by the proprioceptive system, and the FSU above the L4-L5 level would begin a compensatory reaction (through muscular contraction) to move the spine back into vertical alignment, creating a scoliotic curve. These compensatory reactions can occur all the way up the spine, as long as the result is a level head. This creates an overall increased load on the system as a whole and significantly increases the amount of work needed to maintain proper alignment.
In most cases, these responses work well, and no pain or damage is produced. This is especially true in younger people. As persons age, however, changes in body tissues, most notably loss of water and reduced elasticity, alter the mechanical properties of the body as a whole. Eventually the system fails and begins to decompensate. This results in an increase in the amount and number of compensatory reactions as the system becomes further decompensated; this eventually leads to tissue damage (usually on the microscopic level), which ultimately leads to pain, which may be chronic. This scenario explains in part the preponderance of complaints of low back and neck pain in the general population. In fact, musculoskeletal complaints cause about one third of all the office visits to physicians in the United States. On a holistic or preventive level, intervention to correct a musculoskeletal problem or dysfunction before it becomes chronic or debilitating would be sensible and cost effective in the long run. This is where manipulative therapy is indicated and most effective.
Concept 10: Range of Motion and Barrier Concept
Each joint of the body has a normal direction and amount of motion associated with it. This is referred to as range of motion (ROM). When motion is outside of this normal range (a statistical norm that can very considerably), that joint is said to be “hypermobile” or “hypomobile.” In addition, joints with a greater ROM are generally less stable than those with less ROM (e.g., hip and shoulder joints). In the spine the lumbar and cervical areas have the greatest ROM, which establishes an increased probability of instability and injury, especially in the lumbar spine, where significantly greater weight is being borne. This is the principal reason for the relative frequency of lumbar and cervical problems in the general population.
Concept 11: Active Versus Passive and Direct Versus Indirect
In treating musculoskeletal disorders with manipulation, two approaches can be used in a variety of techniques. Active versus passive refers to the activity level of the patient: is the patient actively participating in the treatment, or is the practitioner doing the mechanical work?
Direct versus indirect refers to the motion barrier and the practitioner's approach to it. As discussed, a motion barrier is a decrease in normal ROM caused by an increase in the normal physiological motion barrier. The practitioner seeks to remove or release this barrier and restore normal motion. The technique employed can move the affected joint either toward the motion barrier (direct) or away from the barrier (indirect). As a simple example, consider a case in which the flexors of the elbow joint are in spasm, holding the elbow in flexion (bent) and creating a barrier to extension (straightening). A direct technique would be an attempt to move the joint into extension, that is, into or toward the motion barrier. An indirect technique would be to move the elbow joint further into flexion, producing a change in the position of the joint, which would be reported by the muscle and joint proprioceptors. Over a short time, this causes a reflex release of the spastic contraction of the flexor muscles, thereby eliminating the motion barrier.
The various techniques and healing traditions relating to manual and physical manipulations described in this section have their effects based on these eleven principles that describe the movement of the human body as an object in space and living on earth. In addition, many of these “hands-on” techniques consider the human body to have an energetic component whereby physical manipulations also affect the energy of the body, as well as the “mind-body.” It is useful to keep in mind this duality of human beings both as physical bodies and as energetic bodies when reading the chapters of this section.
In summary, the practitioner of manual therapy seeks to restore proper anatomical and physiological balance in the patient. At least three types and subtypes of balance are potential targets of the various styles and techniques employed, as follows:
1. The restoration of proper joint range of motion and body symmetry
2. The restoration of balance of nervous activity
a. Between sensory and motor systems
b. Between somatic and autonomic nerves
c. Between the sympathetic and parasympathetic divisions of the autonomic nervous system
3. The restoration of proper arterial flow and venous and lymphatic drainage for proper nutrition of all tissues of the body
Chapter References can be found on the Evolve website at http://evolve.elsevier.com/Micozzi/complementary/ (Micozzi 205)
Micozzi, Marc. Fundamentals of Complementary and Alternative Medicine, 4th Edition. W.B. Saunders Company, 2011. VitalBook file.
The citation provided is a guideline. Please check each citation for accuracy before use.
