TerraRosa E-mag Issue 16

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Special Feature on BioTensegrityThe shape of nature—Graham ScarrBiotensegrity, A Brief Historical Perspective—John Sharkey BioTensegrity, Powering the fabric of human anatomy— John Sharkey & Joanne AvisonThe Elastic Body, Introducing Biotensegrity as a model of Elastic Integrity in the moving body—Joanne AvisonClinical StudyA randomized clinical trial of Structural Integration as an adjunct to outpatient rehabilitation for chronic low back pain: A summary— Eric Jacobson PhD, MPHPractices & TechniquesThe Price of Smart Phones—Joe MuscolinoPutting the Maximus Back into Gluteus Maximus— John GibbonsPerspectivesCORE Structural Integration and Myofascial Therapy: A lifetime of improving structure and function— George P. Kousaleos, LMTBringing Up Baby…. Bodywork grows-up from infancy to adolescent— Art RiggsResearch Highlights6 Questions to Jo Avison6 Questions to John Sharkey Fascial Fitness Workshop

Transcript of TerraRosa E-mag Issue 16

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    Feature: BioTensegrity

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    BioTensegrity2 TheshapeofnatureGrahamScarr6 Biotensegrity,ABriefHistoricalPerspectiveJohnSharkey8 BioTensegrity,Poweringthefabricofhumananatomy JohnSharkey&JoanneAvison14 TheElasticBody,IntroducingBiotensegrityasamodelof ElasticIntegrityinthemovingbodyJoanneAvisonClinicalStudy25 ArandomizedclinicaltrialofStructuralIntegrationasan adjuncttooutpatientrehabilitationforchroniclowback pain:AsummaryEricJacobsonPhD,MPHPractices&Techniques31 ThePriceofSmartPhones:Tencommondysfunctionalpos-

    turesandinjuriescausedbysmartphoneuseJoeMusco-lino

    40 PuttingtheMaximusBackintoGluteusMaximusJohn GibbonsPerspectives45 COREStructuralIntegrationandMyofascialTherapy:A lifetimeofimprovingstructureandfunctionGeorgeP. Kousaleos,LMT48 BringingUpBaby.Bodyworkgrows-upfrominfancyto adolescentArtRiggsResearch56 ResearchHighlightsProiles60 6QuestionstoJoanneAvison61 6QuestionstoJohnSharkeyReport62 FascialFitnessKatiCooper

    ontents Coverreproducedwithkindpermissionfromcapacitor.organdthephotographerRJMuna(rjmuna.com).

    Terra Rosa E-magazine, Issue No. 16, July 2015.

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    Thenaturalworldisfullofshapes,fromthesmallestofcrys-talstothehighestofmountains,andfromsimplemolecularhelix-estothecomplexspirallingofmusclesandfascialsheetsinthehumanbody(Figure1).NaturalpatternsandshapeshavebeengeneratingwondersinceatleastthetimeoftheancientGreeksandcausedmuchspeculationinrelationtolivingorganisms,butmostexplanationshavebeen(unfairly)relegatedtotherealmoftheesotericandfanciful.Modernanatomyhastakenmanycenturiestoaccumulateabodyofknowledgethatisnowunrivalledinanyothersphere.Ithasclassi-iedstructuresaccordingtothethinkingofthedayandsoughtto

    understandtheirfunctionsusingthelatesttechnologies,butestab-lishedconventionshaveallowedmanyinconsistenciestosurvivelongpasttheirsellbydates.Or-thodoxviewsofhumanmove-ment,forexample,arebasedonthemechanicsofman-madema-chinesdescribedintheseven-teenthcenturyandhavere-mainedessentiallyunchangedeversince;butbiologyisnotcon-strainedbytherulesofclassicalmechanicsandthereisnowabet-terwayoflookingatfunctionalanatomy.Whenevernatureusesthesameprincipleinavarietyofdifferentsituationsthereisprobablyanunderlyingenergeticadvantagetoitsappearance,andbiological

    developmentandevolutionwillautomaticallyfavourthosepat-ternsandshapesthatarethemosteficientintermsofstabil-ity,materialsandmass.Eventhoughtheycanappeartobera-thercomplicated,atthemostbasiclevelallstructuresaretheresultofinteractionsbetweenatomicforces,andtheorderlyarrangementsthattheysettlein-toaregovernedbysomebasicrulesofphysics.Essentially,itisthefundamentalandinter-relatedprinciplesofgeodesicge-ometry,close-packingandmini-mal-energythatleadtothefor-mationofcrystalsandmolecules,whichthusbecomethephysicalrepresentationsoftheinvisibleforceswithinthem.

    The Shape of Nature By Graham Scarr

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    Naturealwaysdoesthingsinthesimplestandmosteficientwaypossibleandaproperunder-standingofthissimplicitynowprovidesapowerfulmeanstorelatecomplexpatternsandshapeswithfunctionalanatomy.AlbertEinsteinemphasizedthatthelawsofphysicsmustbethesameineveryplace,whichmeansthateventhemostcomplexor-ganismcanbeunderstoodintermsofthesamebasicrulesofconstruction.So,bysimplifyingtheseinter-atomicforcesintothosethatattractandthosethatrepel,andapplyingtheprinciplesdescribedabove,wenowhaveasimplemeanstounderstandbio-logicalcomplexityateverysizescale.BiotensegrityBiotensegrityisastructuralde-signprincipleinbiologythatde-scribesarelationshipbetweeneverypartofanorganismandthe

    mechanicalsystemthatinte-gratesthemintoacompletefunc-tionalunit.Itisaconceptualmodelthatiscausingaparadigmshiftinbiomechanicalthinkingandchangingthewaythatwethinkaboutfunctionalanatomy.Biotensegrityrecognizesthattheforcesofattractionandrepulsionatthemolecularscalearecompa-rablewiththoseoftensionandcompressionathighersizescales,andareeasilymodelledusingcablesandstruts,respectively(igure2).Itisasimplere-evaluationofanatomyasanet-workofstructuresundertensionandothersthatarecompressed;partsthatpullthingstogetherandothersthatkeepthemapart;basicphysics!Tensegrityconigurationsaresimilartobiologicalstructuresinthattheyarestrong,lightinweightandresilienttotheeffectsofdamagingforces,yetcanchangeshapewiththeminimum

    ofeffortandreturnautomaticallytothesamepositionofstableequilibrium.Theirstructuralme-chanicsoperatethesameinanyposition,irrespectiveofthedirec-tionofgravity,andtheyhavesim-ilarnon-linearvisco-elastictypepropertiesthatinluencemove-ment.Eachcomponentpartcanbeconstructedfromsmalleroneswithinahierarchy,witheachlev-elrelatedtoalltheotherssothattheentirestructurebecomesunitedintoasinglefunctioningunit.Therecognitionofbiotensegrityasaunifyingstructuralprincipleinlivingorganismsbeganinthemid1970swithStephenLevin(b.1932),anorthopaedicsur-geonwhoobservedthingsattheoperatingtablethatcouldnotbeexplainedthroughorthodoxbio-mechanicaltheory.Hefoundthattighteningupcertainligamentsinthekneeetccausedthebonestomoveapart,andthatnormal

    Figure1Crystalsandcomplexbiologicalstructures.a)luorite;b,c)ironpyrite;d)spinel;e)partialspiralsofmusclesandfasciainthehumanbody.Figuresb-ereproducedfromScarr2014Handspring.

    The Shape of Nature

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    bonesalwayshadaslightspacingbetweenthem,buttherewasnoknownmechanismthatcouldmakethisspacepossible;itwasliketheboneswereloatinginthesofttissues.Furtherresearchthenuncoveredarelativelylittleknownstructuralprinciplecalledtensegrityandalikelyexplana-tionfortheseindings.Thetermtensegrityisacombi-nationofthewordstensionandintegrityandthisstructuralsys-temwasirstrecognizedin1948byKennethSnelson(b.1927),ayoungsculptorwhocontinuestoproduceimpressiveworksthathedescribesas...unveil[ing]theexquisitebeautyofstructureit-self.Tensegritystructuresareparticularlyinterestingbecausethestrutsremainisolatedanddonotcompresseachotheratanypointbecausetheyaresuspendedwithinthetensionnetwork.ThearchitectBuckminsterFuller(1895-1983)recognizedthemaspartofhistheoryofsynergetics,thestudyofnaturescoordinatesystemthatconsidersthatallnat-uralstructuresareinherentdis-playsoftheforceswithinthem;andDonaldIngber,acellbiolo-gist,hasdescribedthestructurallattice(cytoskeleton)withincellsasatensegritystructurethatreg-ulatescellfunction.Mechanicalengineersalsoappreciatethedis-tinctivepropertiesoftensegritystructuresandareproducingro-botsforuseintheexplorationofspaceetc.Bothbiologistsanden-gineersnowrecognizethatthesimpleprinciplesoftensegritycanbeappliedtounderstandingthebehaviourofmorecomplex

    structures,butbecausecertainaspectsarenottransferable,Ste-phenLevinintroducedthetermbiotensegritytodistinguishbe-tweenthesetwoields.Biotensegritymodelsemulatebiologyinwaysthatwereincon-ceivableinthepastbutithastak-ensometimefortheconcepttobecomewidelyacceptedbecauseofitschallengestogenerallyac-ceptedwisdom.Biotensegrityexplainshowjointscanremaincompletelystablewithoutover-stressingthesofttissuessur-roundingthemanddemonstratesthatthespineisessentiallyaten-sionedstructurethatcanfunctionthesameinanyposition,andhowmovementiscontrolledbytheverystructureitself.Itisat-tractingtheattentionofbiolo-gistsandhands-ontherapistsbe-causeitprovidesabettermeanstovisualizethemechanicsofthebodyinthelightofnewunder-

    standingsaboutfunctionalanato-my.Abiotensegrityviewoflifesweepsawaytheman-madecon-straintsofclassicalmechanicsandre-establishesbiologyatitsverycore.Itisbasedonthelawsofphysicsirst,ratherthantheartiiciallycontrivedonesthathavedominatedbiomechanicsforcenturies,andrecognizesthatthestructureandbehaviourofeachmolecule,cell,tissueandorgan-ismmustresultfromthosesamerules.Bothsimplemoleculesandcomplexstructuresresultfromtheinteractionsofpureenergy(forces),andalthoughparticularconigurationsdominate,theyarenotespeciallychosenbynaturebutbecausetheirsimplicity,efi-ciencyandstabilityfavoursthem.Therealbeautyofnatureisthatitdoessomuchwithsolittle.

    Figure2Atensegritystructureconsistingofcompressedstrutsloatingwithinanetworkoftensionedcables.ReproducedfromScarr2014Handspring.

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    GrahamScarrisacharteredbiolo-gistandosteopath,andhasbeenresearchingthesigniicanceofnaturalpatternsandshapesovermanyyears.Hehasalsodevelopednewmodelsthatprogressourun-derstandingofthestructure-functionrelationshipinhumanbiologyandpublishedseveralpa-personthissubjectinpeer-reviewedscientiicjournals.HisfullyillustratedbookentitledBiotensegrity:thestructuralbasisoflifenowbringsalltheseind-ingstogetherfortheirsttime.gscarr3@ntlworld.comThisarticlewasoriginallypub-lishedinthethee-magazineBareessentials2014issue37http://bareessentialsmaga-zine.uberlip.com/i/437027/88)ReferencesFuller,RB.1975Synergetics:ex-

    plorationsinthegeometryofthinking.Macmillan.

    Heartney,E.2009KennethSnel-son:forcesmadevisible.HardPressEditions.

    Ingber,DE.1998Thearchitectureoflife.ScientiicAmerican(Jan),pp.30-39.

    Levin,SM.www.biotensegrity.com

    Scarr,G.2014Biotensegrity:thestructuralbasisoflife.Hand-springPublishing.

    This book brings all aspects of tensegrity/biotensegrity together for the first time, from its discovery, the basic geometry, significance and anatomy to its assimilation into current biomechanical theory.

    Available at

    www.terrarosa.com.au

    The Shape of Nature

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    Stephen Levin is the father of Biotensegrity. Dr Levin trained as an Orthopaedic and Spine Surgeon having formerly been a Clinical Asso-ciate Professor at Michigan State University and Howard University, Washington, D.C. He studied General Systems Theory with the dis-tinguished biologist, Timothy Allen but is now retired from clinical practice. Following years of tirelessly working to seek appropriate focus of the biotensegrity model, it is currently en-joying growing acceptance and widespread academic approval.

    Work on biotensegrity started in the mid 1970s, when Levin, a young orthopaedic surgeon, was try-ing to understand what he was doing as a body mechanic. Medical education and surgical training, was to Levin the most anti-intellectual training ex-perience outside of military combat training. Levin was of the opinion that like combat situations, life and limb are at stake and there is no room for learn-ing from your mistakes, but only from the mistakes of others. Being overloaded with facts, given little time to think, too much to do, and little time to do it in original thought and experimentation was discouraged and usually punished rather than rewarded. It was only afterward, after all exams were completed, could one begin to think for oneself.

    ABriefHistoricalPerspective

    JohnSharkey

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    Having reached retirement from a distinguished career in clinical practice, Dr Levin finally had the time to do some thinking of his own. He hoped it was not too late. He was interested in spine mechanics and, after all, he should know something about spine mechanics since he spent so many years operating on the spine. What he had been taught during his residency training, by some of the top biomechanics people at the time, was the appli-cation of first year college phys-ics to biologic structures and par-ticularly how it applied to the human frame. This has been, and continues to be, the accepted me-chanics since first described by Borelli, a mathematician and renaissance man, in 1680. Since that time little or nothing has changed. Levin was to find that the promotion of new ideas and new models that run contrary to the accepted way of thinking was to be no bed of roses.

    The accepted biomechanics for living tissue was based on New-tonian mechanics such as would be applied to a column or build-ing built with rigid materials and standing in one place on solid ground. But Levin argued that humans, and all biologic structures, are mobile, omnidirectional, gravity independent structures built of soft matter, foams, colloids and emulsions, (Levin contended that bone and wood are stiff foams, structured more like Styrofoam), and mechanical laws as applied to these structures would be different. Over time Levin came to the conclusion that it is impossible to explain the mechanics of a dinosaurs neck using standard Newtonian mechanics and so he walked a road less travelled. The road to the model of bioten-segrity beckoned and became more compelling. Dr Levin lives outside of Washington, DC, and, in the mid 1970s in his efforts to better understand living mechanics he went to study the dinosaurs at the Smithsonians Natural History Museum. He could not accept the Borellian model, but could find no other suitable model to explain how the dinosaurs could hold up their long neck and tail. There are no tail prints in the sands of time, asserts Levin. Sitting on the mall in front of the museum, Levin looked across and could see the Needle Tower, a Kenneth Snelson sculpture, right across the mall at the Hirshhorn Museum. The forces that allowed the Snelson sculpture to exist, tension and compression, provided the missing link for Levin and the model of biotensegrity began, slowly, to emerge.

    Article (copyright Stephen Levin) and Images supplied with kind permission from Dr Stephen Levin.

    BiotensegrityA historical Perspective

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    IntroductionMassagetherapyisrecognisedasthemanualmanip-ulationofthesofttissuesnamelymuscles,connec-tivetissue(fascia),tendons,ligamentsandjoints.Withaclinicallyorientedbiasmassagehelpsallevi-atethediscomfortassociatedwithdailylivingstrainsandoveruseissuesleadingtopaincondi-tions.Toensurehighstandardsofeducationmas-sageschoolshavelongincludedacomplementarymedicalapproach.Thishasledtomassageschoolssyllabicontentincludingmodulesonhumananato-myandNewtonianbasedbiomechanics.Allthiswasinanefforttounderstandthemechanicalstructure-functionrelationship.Thisleverbasedbiomechanicsandonemuscleone-movementphilosophyhaslongbeenatoddswithwhatmassagetherapistsintuitive-lyfeelandclinicallyobserve.Theleverbasedbiome-chanicsmodelpromotestheexistenceofindividualpartsworkingindependentlyundercontinuousgravitationalcompression.Insuchamodelthefoothaslittlerelationtothewrist,thesuboccipitalstructuresworkautonomous-lywithnoconcernforthesacrumandpainexperi-encedintheshoulderwouldrequiremassagingtheshoulderandlocalsofttissuesonly.Manymovementpractitionersarealsoeducatedundertheselawsofbiomechanics.Assuchtheexperienceforteachersin

    manydifferentmovementmodalitiescanbeatoddswiththebasisoftheanatomy,physiologyandbio-mechanicsintheirtrainingstudio.Newtonian-basedmechanics,usingapostandbeamconstruct,hasallowedmankindtobuildamazingstructuressuchasskyscrapers,bridges,airplanesandautomobiles.Toprovidestabilityandcontrolledmotioninanymanmadestructureapinjointmustbeemployedtoprovidearigidhinge(Fig.1).Thisisaleversystem.InorderforpartAorBtomoveinacontrolledmanneraneedexistsfortheadditionofanengineasasourceofkineticenergyprovidingaforcetomoveoneoftheleverarms.Thisishowau-tomobiles,trainsandplanesareconstructedanditallworksverywell.Transferringthispostandbeam,leversystemtobiologicalstructuresandcellularnet-works(suchashumans)seemstowork,initially.Howeverthoroughinvestigationandappropriatescrutinyrevealsbasiclawsthatcallfornewexpla-nationsandnewmodels.BioTensegrityisthenewmodeloflivingmotion,orbiomotionalexperience.Itprovidesclearandconciseexplanationsbasedoncontinuity,tension,compressionandMechnotrans-duction(Sharkey,2008).Thesearecongruentwiththehumanexperienceofnaturalmotion.

    PoweringtheFabricofHumanAnatomy

    JohnSharkeyJoanneAvison

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    MassagetherapyandmovementnourishingourinnerspaceMassagetherapistsworkdirectlywiththecellularnetwork.Sodoesthebodyinmotion.Anymovementpractice,beitexerciseprotocolsorMartialArtsin-vitesustoworkatthegrossandcellularlevel.Thecellularnetworkisubiquitousthroughoutnatureandcanberepresentedbyfoamsandfroth.Foamsandfrothcanbeseeneverywhere.Takesomewater,soap,mixbyshakingandyouwillgetlotsofbubblesmakingawonderfulfroth.Thefrothonthetopofyourmorningcappuccino(Fig.2)isanothergreateverydayexampleofacellularnetwork.Itmayevenexplaintheirstbasiccell3000millionyearsago.Lookcloselyatthebubblesandyouwillnoticetheyhaveadistinctnumberofsides,aninnateandmobilegeometry.Somewillhavethreesideswhileothersmayhaveuptoeightsides(polygonal).Thisarrangementcanbeseeneverywhereinnatureandisanessentialaspectofthehierarchicalorganizationofallbiologicalorganisms(Scarr,2014,Avison.2015)).Itexistsatthemicroscopiclevelsuchaslookingatthearrangementofconnectivetissue(Fig.3)tothemacrolevelofskinmarkingsonanimalssuchastheGiraffe(Fig,4).Molecules,cells,tis-sues,organs,andorganismsareallconstructedonthesetensegrityprinciplesofenclosedgeometricstructureswithinenclosedgeometries.Allareinfacttensegritieswithintensegritieswork-ingcollaborativelyonabiologicallyhierarchicalba-

    sis.Withinthesehierarchicalbiologicaltensegritysystems(BioTensegrity),theindividualcells,whichareselfstressed(AKAPre-stress),arepoisedandreadytoreceivemechanicalsignalsthatarethenconvertedintobiochemicalexpression,termedmechanotransduction(Ingber,2008).Thegeometricpatternsororganisationsofthecellularnetworkisevenusedtoexplaintheanatomyofspace.Astro-physicistscallthedistributionofgalaxiesthecosmic

    Fig1.Thisistheupperlimbrepresentedasaleversystemwherejointspace(attheelbow)wouldrequireapinforpointA(shoulder)andpointB(ist)tomovetowardseachother.Therearenopinjoints,orlevers,inbiologicforms.Theycanappeartomakelever-likemotions,howeverthisisnotthebasisorthelimitoftheirstructure.Copyright:JoanneAvison

    Fig.2.Thefrothonthetopofyourmorningcoffeeisanevery-dayexampleofacellularnetwork.(Image:Authorsown)

    BiotensegrityPowering the Fabric of Human Anatomy

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    Fig.3.Hierarchicalorganisationexistsatthemicroscopiclevelsuchaslookingatthearrangementofconnectivetissue(WithkindpermissionofDrJ.C.GUIMBERTEAUandEndovivoProductions)

    Fig.4.HierarchicalorganisationalsoexistsatthemacrolevelofskinmarkingsonanimalssuchastheGiraffe.ImagebyShaneMcDermottPhotographyreproducedwithhiskindpermission(www.wildearthilluminations.com)

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    foamdemonstratingacommonfabricfromNanotoMacro(smallesttobiggest).Thefabricofourinnerspaceismadeupofacontin-uumofsoftmattercomprisingspecialisttissuevari-ations,alldesignedaroundthesenaturalprinciplesofbiologicalstructure.Variationsrangefrombloodcellstobones,digestivecellstoautoimmunestruc-tures,mesentery,muscle,nervesandeverythinginbetween.Inmassagetherapywemakecontactwiththatinnercellularnetworkbytouchingtheouter-mostreachesofthesamecellularnetwork,theskin.Inmovement,weorganisetheoutsideviatheinsideandviceversa.Whilethetopicoffasciainmovementhasbeenthefocusofanatomicalstudyinthelastnumberofyearsthetopicofcontinuityhastakensecondplace.Fasciaistheprimaryfabricprovidingcontinuoustensionthroughoutthewholeorganism.Fasciaisoneofthespecialtiesofourconnectivetissuesin-cludingthebones(providingcompressionalforces)classicallyreferredtoastheskeletalsystem.Acriti-calpointtodrivehomeatthisjunctureisthatfasciaandbonesarenotseparatetissues.Theyarespe-cialtiesexistinginacontinuum.Theyhavedifferentdensitiesandspeciicorganisations,howevertheyformandevolvetogetherembryologicallyandthroughoutlifeasacontinuum.Theymaybedis-tinct,offeringdifferentfrequencieswithinthesameforcetransmissionsystem.However,allbodies,whethertheyaremovingthemselvesorbeingmovedbythemassageormovementtherapist,arechangingandorganisingviatheseresponsiveandintimatelyrelatedtissuesthatdonotariseseparate-lyfromeachother.Tensegritystructurescanincludebridgesandgeo-desicdomes,whicharenon-livingstructures.(Fig.5)BioTensegrity(Levin1982)referstolivingthings.Atensegrityhasnobreath,noconsciousdrivenelectromagneticactivity,nooriginalthought,noimagination,noloveformusicorprose.Tensegritydoesnotsufferpain.BioTensegritycan.Livingcellsandtissuesshareacommonstructuralrelationshipwithnon-biologicaltensegritystruc-tures.Eachhastwomembersnamelytensionandcompressionexistingtoprovidestructuralintegritytothewhole.Otherdifferencesincludethefactthatinnon-livingtensegritystructuresthesetensionalandcompressionalmembersareconnected.InBio-Tensegritythesemembersarenotsomuchconnect-edbutarecontinuous.Theychangeshape(andcanchangeroles)dependingontheforcesactinguponthem.Theyareshapeshifting.Inatensegritysys-tem,suchasabridgeorabuilding,bolts,screwsand

    pinsarerequiredtojointhemembersandensureintegrity.Inbiologicaltensegritiesthereisnoneedforscrews,bolts,beamsorgravity.Thereisnofric-tion,nosliding.Tissuesgliderelativetooneanother,astherearenolayers.Theyallexistasspecialtiesalongthelivingcontinuum.Tissuescanresonateandrespondtotheforcesaroundthemandsharepropertiessuchastheincorporationofpolarityinnatetothetension-compressiondesign.Thewholenessandintegrityofthatstructuralcoherencereliesupontherelation-shipandbalanceoftheseco-existingforces,unitedtoformthewholestructure.Inotherwords,with-outsuchspecialtiestheirintegritywouldbecom-promised.Thusthereisabuilt-inmutualco-dependencyfromwhichcomfort,easeandbalancedmotionorstabilityarise.Whenaclientattendsamassageclinicthefocusforthetherapististorestorewhathasbeenlost,throughpainorinjuryforexample,whenthebal-anceoftheseforceshasbeencompromised.In

    Fig.5.ThiscomplexarchitectureformsadomeintheancientUlmMunsterinGermany.Unlikelivingorganisms,thishastheattributesofalinear,non-biologicarchitecturewhichreliesonspeciicixedarrangementsofcompressionstructures.Geo-desicDomesfollowtherulesoftension-compressionarchitec-ture;incorporatingmutuallyinterdependentforces.(Image:Authorsown)

    BiotensegrityPowering the Fabric of Human Anatomy

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    manycaseswhathasbeenlostisstructuralintegrityduetoexcessivetensionand/orcompression.Atypi-calpresentationseenintheclinicisroundedshoul-ders.Insuchacaseitisobviousthatexcessivecom-pressionisbeingexertedanteriorlywhileexcessivetensionisexperiencedposteriorly.(Thiswillappearasshorteningatthefrontandoverlylongtissuesattheback).Jointspacebecomescompromised,fas-ciathickenstosupportthenewpostureandbonesandothersofttissuescandriftoutofalignmentifsuchasituationperpetuateswithoutattention.Wemightgenerallyrefertosuchpostureasacompensatorypattern.Forcesmaynotbedealtwithappropriatelycreatingadditionalstrainthuscreatingadownwardspiralthroughouttheentireorganism.Thesolutionwouldbetorestorebalancebetweentheforcesoftensionandcompression.TreatingtheanteriorchestandupperbackmayseemtobetheorderofthedayhowevertreatingthepersonontheprinciplesofBioTensegrityrequiresawholebody,wholepersonapproach.Whilethetreat-mentoflocalbodypartsisrequiredthisapproachalonewillseldomresultinsustainablesuccess.Acombinationoflocalchangesandglobalre-inforcement,withmovementeducationcanbringaboutanewsofttissuepatternthatpermitsthewholestructuretograduallychangeandsustainamoreusefulone;especiallyifitmeanslesspainandthepossibilityofreversingthedownwardspiraltoanupwardone;beneitingthewholeorganism.IntheBioTensegritymodelstrainsareevenlydis-tributedthroughoutthestructure.Whengoodtis-suesgobadtheclientwillexperiencepainandchangesinsensationsattheweakestpointsinthestructure.Thesepointsmaybesomedistancefromthesourceoftheissueortheoriginalinsult.IntheBioTensegritymodelthehardersoftmatter(theskeletaltissues)actasspacersprovidingvirtualspacebutrealdistancebetweenthebones.Bonesshouldnevertouch.Inanatomytheendsofbonecanbedescribedasarticulatingsurfacesbutthetruthistheyarenearfrictionless.Theuprighthumanisnotastackofbonesrestingontopofanother,despitethefactthespine,forexample,iscommonlydescribedastheSpinalColumn.Ifitreallybehavedasacolumn,thenasmalltiltwoulddisruptitsstructureandmas-sagewoulddestroyitsstructuralintegrity.Bonesaresuspendedinternally,loatingintheseaofconnec-tivetissuesthatprovidesthenutrienttensionallaroundthem;emphasisedbythesurroundingskin.Bonesprovidethecompressiveenergyandtogetherwiththefasciaprovideuswithtensionalintegrityorlift.Thisisthereasonhumansdontfalldownorfallapartwhentheyliedownandgetupagain.Thesearemutuallyco-dependentorinter-dependentforc-

    es,givingrisetotheabilitytomovearoundashu-mansandanimalsdo;thewaytheydo.BioTensegrityisanessentialmodelformassagetherapistsandmovementpractitionersofeverystripe.Understandingthismodelwillprovideyouwiththevocabularyandunderlyinglogicofbodyarchitecturethatformsthecontextoftherapeuticbeneits.BioTensegritywilladdtoyourconidenceandabilitytoachievethosetherapeuticgoals.Aneweraisdawninginourunderstandingofanatomyandlivingmovement.Thatnewanatomyandunder-standingofwholebodystructureisBioTensegrity.References1.Levin,S.M.,1982.Continuoustension,discontinu-ouscompression,amodelforbiomechanicalsupportofthebody.BulletinofStructuralIntegration,RolfInstitute,Bolder:31-33.2.IngberDE.2008.Tensegrity-basedmechanosens-ingfrommacrotomicro.ProgBiophysMolBiol.97(6-3):163-179.3.Scarr,G.M.,2014.Biotensegrity,TheStructuralBasisofLife.HandspringPublishingLtd.ISBN:9781909141216.4.Sharkey,J.2008ConciseBookofNeuromuscularTherapy.ATriggerPointManual.LotusPublishingandNorthAtlanticPress.5.Avison,J.2015.YOGAFascia,AnatomyandMove-ment.HandspringPublishingLtd.JohnSharkey,ClinicalAnatomistandFounderEuropeanNeuromuscularTherapy.MSc.,Depart-mentofClinicalSciences,UniversityofChester/NTC,Dublin,Ireland.E-mailaddress:john.sharkey@ntc.iewww.johnsharkeyevents.comJoanneAvisonProfessionalStructuralIntegratorandAdvancedYogaTeacher(E-RYT500)KMI,CTK,IASI.KinesisMyofascialIntegration.E-mailaddress:[email protected]&Joonpage60-61.

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    Maximise Oxygenation A NAT O M Y F O R T H E 2 1 S T C E N T U RY

    BIOTENSEGRITY with John Sharkey

    Sydney, June 2016

    For more information & Registration, visit www.terrarosa.com.au

    Myofascial Trigger Points (MtPs) Versus Neuropathies

    A unique integrated neuromuscular approach for the treatment of unresolved pain due to MtPs or nerve

    insults.

    This is that one stop workshop that covers everything you need to know about identifying and treating Myofas-cial Trigger Points and nerve injury. David G Simons (Travel and Simons), the farther of Myofascial Trigger Points was mentor to John Sharkey and wrote the for-ward to Johns first book (a trigger point manual). Differ-entiating between neural generated pain and Myofascial Trigger Point pain is essential in providing the correct soft tissue interventions for successful therapeutic out-comes.

    The Theory of EverythingBioTensegrity, anatomy for the 21st century

    This workshop is ideally suited to the advanced manual and movement therapist with appropriate clinical experience and a desire to take on fresh new ideas, new models and a new way of thinking. Therapists are warmly encouraged

    to demonstrate their current screening, assessments and therapeutic applications with John while he will provide feedback and suggestions offering a new vision supported by connective tissue techniques for successful manual

    and movement interventions for all participants. This workshop provides you, the chronic pain soldier the effective full body kinetic chain ammunition you need in the war on pain.

    John Sharkey MSc is a world renowned presenter and authority in the areas of bodywork and movement therapies. He is a Clinical Anatomist (BACA), Accredited Exercise Physiologist (BASES) and Founder of European Neuromuscular Therapy with more than 30 years of experience gained throughout his career working alongside his mentors and colleagues Leon Chaitow, David G. Simons, Stephen Lev-in MD, Prof. Kevin Sykes. John is recognised as a leading protagonist of BioTensegrity (providing new models and paradigm shifts concerning living movement and anatomy promoting therapeutic interven-tions for the reduction of chronic pain.

    The Final Frontier

    Working within Endangerment sites, providing Manual and Movement Techniques to stay mobile

    and pain free.

    This informative workshop provides therapists with the necessary anatomical and palpatory excellence to ex-pertly navigate the holy grails of the human body (endangerment sites). Providing safe neuromuscular techniques using digital applications guarantees effec-tive therapeutic interventions for soft tissue based chronic pain conditions. Through your newfound ana-tomical knowledge and unique hands-on clinical pearls each learner will develop a greater appreciation of local and global anatomical connections.

  • 14 Terra Rosa E-mag

    Everyonehasamotionpatternthatwecouldcallamovementsignature.Workinginyoga,oranymovementmodality,ateachernaturallydevel-opsamorereinedsenseofpeoplesindividualstylesandmovementexpressions.Consideringthefascialmatrixasadynamic,self-organising,BioTensegrityarchitecturecantransformourabilitytoseehowindividualsdeveloptheiruniquemovementsignatureswithintheprotocolofagivenclass.Partofthisincludesrecognisingdifferentfascialtypesandthevalueofelasticin-tegrity.Inthisarticleitisviewedasanassetto

    optimisinganyindividualsqualityofmovement.Aswellasshiftingmorepopularideasonstretchingforitsownsake,theBioTensegritymodelprovidesavaluabletoolforrecognisingoptimummovementpatternsatthespeedofmo-tion.Thisdiscussionemphasisesthegeneralshiftfromseeingmusclesasfunctionalunits,tounderstandingthefascialmatrix(includingmus-clesandbones)asawholebodyarchitectureofsofttissues,morphologicallyuniquetotheself-motivatedindividualmovingit.

    TheElasticBodyIntroducingBioTensegrityasamodelofElasticIntegrityinthemovingbody

    JoanneAvison

    Fig. 1. Image used for the First BioTensegrity Summit in Washington DC; September 18th 2015. [biotensegritysummit.events.] and reproduced with kind permission from capacitor.org and the photographer RJ Muna (rjmuna.com).

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    Body-writinginOurOwnHandFlexibilityandstretchingtendtobeheldasthear-chetypalmovementcelebrities,particularlyinyoga.Thosewithnaturallybendybodiescangettopmarkswhilethestiffpeople,whofeeltheycannotstretchtotwistandcontortwithease,areoftenconsiderednotasgoodastheirnaturallylexiblecompanions.Thereis,however,amuchmorevaluableandpower-fuldistinctionavailable,onceweappreciatethemyofascialbodyanditsstructure,asawholedynam-icanatomyofcontinuity.Thisdistinctionliesinrec-ognisingelasticityasparamountandunderstandingthatforsomeindividualsitisenhancedbystretchingandforothersitistheopposite.Therearethosethatwillincreasetheirnaturalelasticintegritybystiffen-ingthetissues.ThismakessenseifthefoundationsofBioTensegrityandthecontextitprovidestodescribehumanmovementaredeined.Thisisasthebasisofthecollagennetworkofeveryhumanform:amatrixintimatetoeverytinypartofus,formedunderten-sionsincewebegantoself-assembleasembryos.EnergyStorageCapacityElasticityisthesource(andcontainmentandreplen-ishment)ofourenergystoragecapacity.Onceweunderstanditandtherearealotofmisconceptionsarounditwehaveanimmeasurablyvaluablere-sourceforvitality.Reallyitcomesdowntoanappro-priatebalancebetweenoveralltensionalstiffness

    andoveralltensionalsogginess.Thisdependsonthefascialbodytypeofanindividualandthewaytheyloadtheirtissuesovertime.1,2Drawingfromseveraldifferentaspectsofrecentre-search,wemightconsiderthetwoendsofascalefromstrengthtostretchiness,innaturaltendenciesoffascialbodytypes.Forexample,astrong,Vikingtype3bodymaytendtowardsstrengthandstiffnessnaturally.Abendyorsinewy,jungletypebodymayerronthesideoflexibility.Referringtothemem-bersofamovementclassroom,thekeyisindingbal-ancebetweenthetwoextremesofthegraphdepend-ingontheirparticularmovementsignature.Thebene-itsofstretchingorstrengtheningwillbefoundinrelativelyoppositewaysforeachofthesetypes,ifthevalueofelasticintegrityistobringvitalitytotheirverydifferentsignatures.ElasticityasanAssetIdentifyingauthenticelasticityisextremelyvaluableasateachingtoolandanimportantkinaestheticdic-tionarytoexpandandreferto.Thisispartlybe-causeofitsglobalapplicationinreadingbodiesaccu-ratelyandpartlybecauseitmakessenseofstructur-alintegrityofthewholeanimatedform.Elasticityreallymeansresistancetodeformationandimplieseficiencyofreformation.Inotherwords;howdowechangeshape,respondappropriatelyandthenre-storeoptimumshapeafterdoingso?Thebestwayofobtainingstructuralintegritymightincludestretch-

    Fig.2.TheElasticBodyreliesondifferentelementstoindElasticIntegrityforeachindividualmovementsignature;relatingcloselytothefascialbodytype.

    The Elastic Body

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    ingandstrengtheningbutsucheficiencyandresili-ence(seeFig.1)isbynomeanslimitedtoeither.Elasticityemergesastheparamountassettoefi-cientmovementandpoiseinstillness.Itreferstomoment-by-momentchangeslocallyandglobally,whilenourishingstructuralintegrityovertime.ExploringNewTermsIthasbeenshownthatfascialstiffnessandelasticityplayasigniicantroleinmanyballisticmovementsofthehumanbody.Firstdiscoveredbystudiesofthecalftissuesofkangaroos,antelopesandlaterofhors-es,modernultrasoundstudieshaverevealedthatfas-cialrecoilplaysinfactasimilarlyimpressiveroleinmanyofourhumanmovements.Howfaryoucanthrowastone,howhighyoucanjump,howlongyoucanrun,dependsnotonlythecontractionofyourmuscleibres;italsodependstoalargedegreeonhowwelltheelasticrecoilpropertiesofyourfascialnetworkaresupportingthesemovements.RobertSchleip4RobertSchleiprefersinthisquotetotheelasticre-coilpropertiesoffasciainballisticmovements.However,ifbiotensegrityisthebasisofthearchi-tectureofourcollagenmatrix,thenitalsohaselas-ticintegritywhenwearestill.Wedonotdelate.Thebodybeneitsfromthevalueofelasticityjustasmuchwhensittingonameditationcushionorrun-ningamarathon:peakperformanceandpeakpre-formancearebothanimatedbythesamesystem.Understandingandrecognisinginnateelasticityismademoredificultbythemanydifferentmeaningswehaveforthewordelasticityitself.Thereisageneralperceptionthatitisassociatedwithstretch-inessandlexibility(thearchetypalheroesinmostyoga-basedmovementclasses).Theenemiesinthatenvironmentmightbeseenastension,stiffness,strainorstress.Inthedefinitionofelasticityhowev-er,itisthelackofsuitablestiffnessthatcanbeadeicittostructuralintegrity.Despitetheleveltowhichitisfavouredinyogateaching,stretchingisjustoneaspectofamuchbroaderpicture:onethatbecomesclearifBioTensegrityprinciplesareappre-ciated.Inordertoseethisasageneralandglobaldistinc-tionformovementintegrityandoverallvitality(includingatrest)wecanincludefourmainattrib-utesofelasticintegrity(Fig.2).

    TheusefulschematicinFig.2isdeceptivelysimple.Balanceandaccesscomefromthecentre:itisaquestionofensuringbalanceofsuitablestiffness,whichmeanssuitableresistancetodeformationandeficientreformation.Thisisuniqueforeachindi-vidual.Infact,BendyWendy(seeFig.3)mayneedmorestiffness,notmorestretching.Theterminologyneedssomereframingandtheideathatyogaissynonymouswithstretchingmightbeadisservicetothepotentialpowerofitscontributiontoelasticintegrity.Elasticenergyisverylow-costmetabolically:itistheessenceofhealthy,vitalmovement.Onoroffthemat,weseekasignatureourbodysignswithvitalitywhatevermovementswearedoing.Mixingmodalitiestobringthisbal-ancemaybethemostusefulwaytoworkandfosterthisvaluableassetofarchitecturalintegrity.Inoth-erwords,abalancebetweenstretching-typemove-mentsandthosebaseduponresistancemayholdakeytoelasticintegrity.

    Fig.3.TheBendyWendybodytype,sketchreproducedwithper-missionfromtheauthor.

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    TheMiddleWaySuitableStiffnessasanAttributeofBiotensegrityConfusionaboutelasticityisalsocreatedbytheuseofelasticbandsinbuildingbiotensegritymodels.Thedistinctionisbetweenelasticityasapropertyofanymaterialandelasticatedbands.Biotensegritymodelsareactuallyoptimisedusingnon-elasticatedmaterials,todemonstratestrengthandaccurateexamplesofhowcollagenbehavesinourbodyar-chitecture.Itisthesumoftheircombinedtensioncompressionorganisationcombinedinspecificge-ometries,thebalancebetweenthelengthoftheinter-

    nalstrutsandthedensityoftheexternaltensionalelementsthatprovideselasticitytothedifferentaspectsofouroverallform.Thiscanbedemonstrat-edwiththemodelsin(Figs.4and5).Youmaybeabletoseethatthetoyontheleftissoggy:ithasverylowtension,orstiffness.Theoneontherightcanbouncemore.TheseareTensegritoys7(Fig.4)withelasticatedtensionmembersandcompressionshaftsmadeofwood,organisedasonecontinuousstructure.Theyareidenticalinsizebuttheleft-handtoyhaslostitsten-sileintegrityandismorecollapsed.Ithascompara-tivelylowstiffness.Thisdoesnotrepresentlexibil-ity,ratheritshowslackofsuficienttensileintegrity

    Elasticity can be considered asone side of a coin. The other sideof that coin is stiffness. Stiffness is the resistance to deformation of a material. Elastici-ty is the efficiency of reformation. The literal defini-tion is stored energy capacity which is a function of elasticity and stiffness in mutual balance. The amount of stored energy capacity is relative to the stiffness and elasticity of a material. On this basis, steel has higher energy storage capacity (elasticity) than rubber. A steel car spring has high stiffness, while a Slinky toy has low stiffness. Both have elas-ticity. The car spring (higher stiffness and elasticity) is better able to resist deformation and therefore to be supportive.

    Viscoelasticity. In liquids, this same principle is measured in viscosity (thickness). Honey is more viscous than water because it resists deformation when you stir it. Water has relatively lower viscosity and is less resistant to deformation. Viscoelasticity acts as a damper (i.e. such as would be placed on a stiff car spring to modify the rate of elastic return). It

    is a time-dependent way of regulating elastic spring-back. The internal tissues of the human body rely on this to change from one movement to another.

    Poroelasticity is a feature of geology that is also rele-vant to the extracellular matrix.5 The combination of our tissues and contained fluids includes these characteristics as essential ingredients of our archi-tectural form, from embryo to elder. They change constantly and yet remain in integrity, re-arranging as we do, movement-by-movement and moment-by-moment; inwardly and outwardly. This is what de-fines us as living forms and is re-defined by under-standing the geometries of biologic forms, such as the full model of BioTensegrity represents on every scale. We are made up of various chambers in and around the Extra Cellular Matrix; holding together a variety of colloids, foams and emulsions of our in-ternal chemistries and fluids. Thus a poroelastic as-pect of our internal close packing systems may be a valuable aspect of the BioTensegrity model.

    Fig.4.TensegritoysthesetensegritymodeltoyswerecreatedbytheManhattanToyCompanyinconsultationwithTomFlemonsofIntensionDesigns.6

    Fig.5.SuitableStiffness:Thistensegritymasthasnoelasticatedcomponents.Nevertheless,itdemonstrateshighelasticity,be-causeithassuitablestiffness.ModeldesignedbyBruceHamil-tonandconstructedbytheauthor.9

    The Elastic Body

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    toholditselfup.8Inthesemodels,thesoggiestone(Fig.4)isthemoststretched,whichinthismodelmakesittheweakestofthethree.Stretchingisaningredientintherecipeforstructuralintegritybutonlyinbal-ancewithsuitablestiffnessanddepending,tosomeextent,onthemovementsignatureoftheindividual.Themast,withnoelasticatedfabric,retainsitselas-ticitywhenitisbounced,heldoutoruporhungup-sidedown.Itisindependentofgravityinthatsense.Itisthemostbalancedandresilientofthethreemodelsbecauseithasthehighesttensionalintegrityandstiffness:itisbyfarthestiffestofthethree.Inthiscontext,itistheguardianofthehighestenergystoragecapacity.ThemastinFig5ismadeofguitarstringsandhol-lowsteelarrowshafts.11Itisexceptionallylightandenclosesamaximumofspacewiththefewestmate-rials.Anyforceappliedtoitcanbeseenandfelttobetransmittedtovaryingamplitudesthroughoutthewholestructure.Thisisacompellingmodelofbiologicaldynamicarchitecture,seenthroughoutthedynamicanatomyoflivingformsandtheirhigh-lyeficientabilitytomovearound.12Itisatriangu-latedstructure(whichprovidessomerelativesta-bility)andrevealsahostofpropertiesthatwehavethroughoutourtissues.Itstandsup,inalldirec-tions,byitselfand,asawhole,itcanbounce.Itisalsoamodelofaclosedkinematicchainwithmulti-barlinkageandnolevers.13(SeealsoFig.1onpage9).Whateverdirectionyoupullorpushthismodelin,thestructuregives,butnaturallyresistsdefor-mationwhichmeansithashighelasticity.Whetheryoupull,push,bendortwist,thearchitecturalge-ometriesnaturallycounteranymovementbystiff-eningthewholestructureinresistancetodefor-mation.Itthenreformsimmediatelyfromdefor-mation(withinitsresiliencerange)maintainingtherightinternalspatialrelationships.Thisrelatestoourabilitytoperformposturesorathleticfeats,withouttopplingbodyparts.Ifthehumanspinalcolumnreallywasastackedverticalcolumn,thenevenaslighttilt,woulddestroyourstructuralinteg-rity.Columnsarecompressionstructures,likestackedbricksinahousewall.Theyconformtothelawsofhardmatterandnon-biologicallinearor-ganisation.Ifwechangetheangleofthegroundorattempttomovethestructureitposesasigniicant

    threattoitsstructuralintegrity.Inacartwheelorayogaposewiththespineparalleltotheground,theboneswouldbreakapartifthespinefollowedtherulesofastackedlinearstructure.Itcannotbeuse-fullyanalysedonthebasisofNewtonianphysicsandlawsofcompression-based,hardmatterorgani-sation.Humanbodiesdonotconformtothatlogic.Ourvarioussofttissues(harderbonesandsoftertissuesaroundthemofvaryingdensitiesareallsofttissues)conformtotheverydifferentlawsofsoftmatter.Theyarenon-linearbiologicstructures.Onceweplaceourselvesinahandstand,orpoundaroundarunningtrack,bitsofusdontfalloff!!Asageneralrule,inhealthybodies,werestoreourformsoonaftermakingshapechanges.ThismakesuslivingexamplesofhowBioTensegrityprinciplesworkasdynamicwholephysiologies.Whatthissuggestsis,effectively,themusclescanactmorelikebrakes,whilethetendinoustissueslengthenandshortenlikesprings.Intermsofap-

    Whilethetissueitselfhasrecoilproperties,acom-monmisunderstandingisthatthebalanceofelas-tinandcollagenwithinthefascialibresgivesrisetoourelasticity.Elastinibrescanelongateupto150%oftheirlengthandrestoreorreform.Itis,infact,oneofthesuiteoftissuesthebodycallsuponinwoundhealing.10Suitabletensilepropertiesinourtissuesandtheiroverallelasticintegrityrelyuponthestiffnessofthecollagenmatrix,whichisessentiallylowindeformationandrelativelyhighinresistancetoit(i.e.stiffness).(Itstretchesuptoabout5%only.)This,inbalancewithourarchitec-ture,createsoverallenergystoragecapacity.Ifweweretooelasticatedwecouldnotfunction:theenergyliterallyleaks.Itcanlooklikeasoggystruc-turethatneedsstrengthening,stiffening,ormak-ingtaut.Amarqueeisnotatensegritystructureassuch,becauseitreliesonbeingpinnedbyguywirestotheground(wedonot,eventhoughweareboundtoreturntoit.Wecanmoveinde-pendentlyofgravity).However,atentisatension-compressionmodelofsorts.Imagineusingelasticguywiresandbendytentpoles.Theywouldnottensionorstiffenthefabricofthemarqueesuf-icientlytotakeappropriatecareoftheinternalspaceortheexternalforcesactinguponit.Theywouldhavelowresistancetodeformation.Thisisthebasicandsimplewaytobeginunderstand-ingourinnatedependencyonthelogicofBioTen-segrityasapowerfulmodelofthearchitectureofourlivingform.

  • Terra Rosa E-mag 19

    pliedBioTensegrity,thebody-wideimplicationsofthishaveglobaleffectsonorganisationofthestruc-tureasawhole.Inotherwords,themuscle(whichofcourseisamyofascialcomponentofaglobalnet-workormatrixofsofttissues)actsmorelike(inDr.StephenLevinswords)aturnbuckle15inthebody-widetensionedweb.Theinternalcompressionmembers(bones)globallytensiontheexternalsofttissuessurroundingthem,whichinturncompressthebones,whichinturntensionthetissuesandsoonandon.Thustheyareinamutualbalancethatallowsforcestobeappropriatelytransmittedthroughoutthestructureasawhole.Thisbalancealsopreservesinternalspaces;suchasatthejoints16orthroughtheneuro-vascularvessels.Themorewelook,themoreexamplesofelasticintegrityweindineveryaspectoftheformandonevery

    scale.Whatthisresearchallsuggestsisthatwerelyonelasticityperhapsmorethanwerealise.Therevela-tionsaboutthefascialmatrixareshiftingtheexpla-nationswehaveforbiomechanicalfunction.Theyalsoraisemanynewquestionsandbegintomakesenseofwhydescribingtheexperienceofanimatingyogaposturesintermsoflevers,forexample,issoawkward.AccordingtoDrLevintherearenoleversinbiologicsystems.Anywhere.17

    Fig.6ImagesofresearchbyKawakamiandcolleagues(seenote13),afterSchleip,showingthecooperationofmusclesandfascialtissues.Aistheclassicalviewofthemusclemovingwitharelativelystatictendon;Bistheresearchresult,showingthemuscleactingmorelikeabrake,whilethetendonlengthensandcontracts,actingmorelikeaspring.NewStrategies:ElasticIntegrityasaNewValueAusefulexampleoftheparadigmshiftbetweenmoreclassicalnotionsandthatofBioTensegrityasabio-mechanicalmodel,isinresearchontheAchillestendon.Classicalkinesiologicalmodelssuggestthatinjumping,forinstance,theAchillestendonisthestrong,supportive,relativelylessmobilebinding,con-nectingthecalf(gastrocnemius)muscletotheheel(calcaneus)atthebackoftheanklejoint.Themovementoccursat,orhasbeenclassicallyassignedto,thecalfmuscle(gastrocnemius),asitactivelycontractsandreleases(i.e.basedontheactionclassicallyassignedtothatparticularmuscle).Usingmodernultrasoundequipmentcapableofmeasuringthemusclesandthefascialtissuesinvivo,however,researchersweresurprisedtodiscoverthatinoscillatorymovement,themuscleibrescontract,orstiffen,almostisometrically(withoutchanginglength)andtheAchillestendoninfactactslikeastrongelasticspring(Fig.6).14Thiswouldmeanthemusclecanactmorelikeabrakeonthespring-loadedrecoilofthepre-tensionedAchilles,undersuchcircumstances.Thismightsuggestthemuscleshavearoleinmodifyingorregulatingstiffnessandelasticityinappropriatelengthtotensionalbalance.

    The Elastic Body

  • 20 Terra Rosa E-mag

    JointSpaceLeversLeversaretwo-bar,open-chainlinkagesystemsthatdonotexplainourmulti-jointandmulti-directionalabilitiestomoveandbalance.Therearenopinsatthejoints,suchaswouldbenecessaryinatwo-bar(lever)open-chainsystem.Wemaintainthejointspaceanditsintegritythroughtheomni-directionalityofourlivingtissues,continuousfromingertotoe,fromsidetoside,fronttobackandtoptobottom.Thismovesusfromlinearmechanics,hingelikejointsandonemuscleworksatatimementalitytoamoreglobal,continuousten-sionedcontractilefabricthatfacilitatesclosedchainkinematiclinkages.Athreebarlinkagesystemwouldbetoorigidandwouldnotallowmovement.[suggestingthatclosedchain4-barandmulti-barlinkagesaretheminimum]JohnSharkey18Howcanthisbeapplied?Weareinvitedbyvariousresearchintothefascialmatrix19toviewthemuscles(andanyothercompo-nentsofourform)aspartofthecontinuityofmyo-fascialbalancethroughoutthetensionalwebofourarchitecture,inmultipledimensions.Thetissuesclearlyparticipateinthesubtletranslationandme-diationofalltypesofmovement.Whilethisre-searchfocusesondifferentspeciictypesoftendi-nousorganisations,wemustrememberthatthebodyitselfdoesnotgoaboutgettingagreementfromeachseparatepart.Itorganisesandactsasaninstinctivewholeandthefascialmatrixmaybetheunitingmediuminwhichthesespecialisationsoc-cur.AnatomyTrains20encouragesustoseethemuscles-in-fasciainlongitudinalbandsofcontinuity.Thissuggestsbothfascia(inclusiveoftendons,ligamentsandtendinoussheets)andmuscle(inwhichitisprofoundlyinvested)formintegratingbandsfromheadtotoe.21Whetheryouagreewiththeanatomi-calcontentofindividuallines,slingsorlayers,My-erstakesustowardsananatomicalviewofthebodythatendorseswholeness.Hereferstothemyofas-cialmeridiansaslinesofpull,whichisanim-portantdistinctionintermsofelasticity.Theyarepulledevenwhenweareresting.ThebonesofourBioTensegrityarchitecturemaintainthemundertension.Theyhavetohavesomethingtopullon!

    Fig.7showstheSupericialBackLineofAnatomyTrains(whichincludesthetissuesofthefoot,theAchilles,thecalfandallthewayupthehamstrings,erectorspinaeandoverthebackoftheheadtothebridgeofthenose)canbeshowntoformacontinu-ouslayerandband,undertension.Wehavetoexpandourviewtoincludethewholebodytogetasenseofwhythebonesplaysuchanimportantroleincreatingsuitabletensioning,orstiffness,inourtensioncompressionform.Thisisthequantumleap,frommusclesasleverstomus-clesasmoderatorsofstiffnessandstretch.Wemightcallthemtightenersormodiiersintheweaveofourthree-dimensionalarchitecture.Whenyoutensionanelasticbandandstretchit,Fig.8youaresensingitsresistancetodeformation,thatis,itsstiffness.Whenyoureleaseityouaredemon-stratingitselasticity,thatis,itsabilitytoreturn,orreformation.Twoimportantfactsarisefromdoingthisexercise,whichare:(1)Youneedsuficientre-

    Fig.7.Theso-calledSupericialBackLine22isametaphorforcon-tinuity.Itisnotseparateinthelivingbodyfromthelayerbeneathorthoseeithersideofit.Inamovementclasswedonothavetimetoassessmusclebymusclenordoesthebodymovethatway.23

    The Elastic Body

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    sistancetodeformation(stiffness),orthebandisloppyandpulledoutofshapetooreadily.(2)ByfullyreleasingthebandyoudoNOTdemonstraterestingtensioninthehumanbody.Itisthehalfwaypointoftheelasticband,thesemi-tensionedstageBthatdemonstratesrestingtensioninthehumanbody.Wearepre-stiffenedorpre-tensionedbe-causewedonotdelate.Weneverexperiencethestaterepresentedbytheelasticbandatrest.Westartatthesecondstage,themiddleway,whichisourdefaultelasticityatrestandinstillness.Elasticityisanenergyassetthroughoutmanyformsofourinternalandlocomotivestructure,andmanyaspectsofourarchitectureactuallyrelyonitinhealth.thevisco-resilientnervesareunderaconstantinter-naltension.Thestrengthoftheseforcesisseeninrupturednerves.Simplybecauseoftheirtremendouselasticity,thetwoseverednervestumpsshortenbyseveralmillimeters.Inrepairprocedures,thesurgeonhastouseaconsiderableamountofstrengthtobringthetwonerveendstogetheragain...Itiselasticitythatallowsnervestoadjusttothemovementofajointwithoutlossoffunction.24

    Theresearchthatisaccumulatingonthestudyofbiotensegrityisperhapssocompellingbecauseinsomeaspectsitsuggestsascale-freeexplanationofourmovements:fromorganelleswithinacell,cellswithinanorgan,vesselsthroughoutthebodyandsoontoincludethewholeorganism.Werecapitulateatthecellularlevelthesamemicro-patternsaswholebodiesperformingmacro-movements,onalargerscale.Thisisalsorelectedinourpersonalevolutionanddevelopmentfromembryotoelder.Itisinvariablyonanindividualbasisaseachpersonmovesuniquelyatanygivenmomentintime:accu-mulatingtheirownphysicalandemotionaltenden-ciesandgestures.Arecognisedcharacteristicofconnectivetissueisitsimpressiveadaptability.Whenregularlyputunderincreasingphysiologicalstrain,itchangesitsarchi-tecturalpropertiestomeettheincreasingdemand.25Whicheverwaywedomovements,exercises,yogaorotherphysicalpursuits,wearelookingforaplaceofelasticintegrity,whereverweare(atthetime)intermsofrestingtension.Whilewearealive,wedonotgettoabstainfromthischoice.Thevoteforinertiasetsupitsownstrain(orlackofstrain)patterns.ThelackofstrainallowsforthesogginessweobserveintheweakerofthetwomodelsinFig.4.Whatisalsocrucialisthetimingofhowourstrainpatternsareaccumulated.Themyopartof

    Fig.8.Anelasticbandatnon-tension(A),semi-tensionedormid-point(B)andfullystretched(max-point)(C)(Reproducedwithpermissionfromtheauthor)

    Fig.9.Thispuppyisusingitswholebody,fromtailtiptonosetiptobalancetheoverallstructure.TheBioTensegritymodelexplainsthisasawholebodyarchitecture;expressingemergentpropertiestobalancefrommomenttomoment,asdistinctfromthemoreclassicallevermechanics.(Reproducedwithkindper-missionfromShaneMcDermott,www.wildearthilluminations.com)

    The Elastic Body

  • 22 Terra Rosa E-mag

    themyofascia(tensionedasitisbythebones)worksinco-dependentrelationshiptomodifystiff-nessandelasticityinbalance.Eachaspectcanre-spondindifferenttimeframes.SummaryandnewconsiderationsSohowdoweputallthistogether?Besidestheknowledgewehavefortrainingandexercise,weuncoverabody-wideexplanationthatincludesus-ingmusclesforstrengthandtensioning,whilebene-itingfromusingtissuesforstretchandlexibility.Itbeginstoexplainmotionin360degreeswithawholerangeofvariabilities.Italsoinvitesustore-considerstretchingorstiffening(e.g.throughresistance)asbetterorworseformsoftrainingthebody.Therelativevalueofeitherofthesetypesofmovements,residesinwhetherornottheyworkfortheindividualaccumulatingthemintheirtissuesandtowhatdegree.Thatis,whatvaluedotheyhaveinthegoalofoptimisingresilienceandbalanceorpoisefortheiruniqueelasticbody?BioTensegrityraisesmanynewquestionsasamod-elofhumanformandmovement.Itdoesntiteasilyintothebiomechanicalmodelsofdisconnectedpartsthatmightbedescribedasactinginde-pendentlyofoneanother.Italsoinvitesnewseman-ticdistinctionsandconnotationsforwordslikestiffness,tension,resistanceandstrainandstress.Wearecalledtoredeinestretching,forex-ample26,27,28,andreviewthecontextinwhichitisupheldandusedinmovementtraining.OneofmanydificultiesencounteredinexplainingtheessentialorganisationofBioTensegrity,istheneedtoresideinparadox:thatwhichconnects(thefascialconnectivetissues)alsodisconnects(themembranesthereof).Thatwhichtensionsalsocom-presses.Thatwhichisundercompressionissimul-taneouslytensioning.Inessence,theabilitytofullyappreciatetheartoftheElasticBodyisenhancedbyunderstandingthesciencebehinddynamicmodelssuchasBioTensegrity.ItisanewscienceofBodyArchitectureandonethatmaytransformtheabilitytolearn,teachandexpressourmovementsigna-turessafelyandwithvitality.

    Endnotes:1SchleipR.Schleip,D.G.Muller,TrainingPrinciplesforFascialConnectiveTissues:ScientiicFoundationandSuggestedPracticalApplications,JournalofBodyworkandMovementTherapies17:103115;2013andTerraRosae-magazineNo.7,March2011.2JoanneSAvison,YOGAFascia,AnatomyandMovement,HandspringPublishing2015,Chapter8,TheElasticBody3JoanneAvison,YOGAFascia,AnatomyandMovement,HandspringPublishing2015,Chapter13,PostureProil-ing4RobertSchleip,Foreword,inLuigiSteccoandCarlaStecco,FascialManipulation:PracticalPart,Englishedi-tionbyJulieAnnDay,forewordbyRobertSchleip,Piccin,Padua,2009.5LeonidBlyum(http://blyum.com/).Privatepresenta-tionattheBiotensegrityInterestGroup(B.I.G.)Europe,Ghent,20136TomFlemonsmadeandsoldtoysdesignedontensegri-typrinciplesformanyyears.HisSkwishtoyswereli-censedtoalocalcompanytomanufacturein1987.Man-hattanToyssubsequentlyboughtthatcompanyandthelicensingrightsin1995.7Ibid.Seealso,forfurtherreading:http://www.intensiondesigns.com/bones_of_tensegrity.html8Note:Foranexampleofinsuficientstiffness,thisrefer-encelinkstoailmaboutaconditioncalledSwimmerpuppysyndrome:seeYouTubereferencestoSwimmerPuppySyndrome:http://www.wimp.com/puppytherapy/forvideo9BruceHamiltonsdesignscanbeseenatwww.tensiondesigns.com.10AdjoZornandKaiHodeck;In:ErikDaltonsTheDy-namicBody,FreedomfromPainInstitute,Oklahoma,2011.11BruceHamiltonsdesignscanbeseenatwww.tensiondesigns.com.13GrahamScarr,www.tensegrityinbiology.co.uk,article:Geodesic.Seealso:Biotensegrity:TheStructuralBasisofLife,HandspringPublishingLtd.,Pencaitland,2014.13JoanneAvison,YOGAFascia,AnatomyandMovement,Hand-springPublishing2015,Chapter7.14Y.Kawakami,T.Muraoka,S.Ito,H.KanehisaandT.Fukunaga,InvivoMuscleFibreBehaviourDuringCounter-MovementExerciseinHumansRevealsaSigniicantRoleforTendonElas-ticity,JournalofPhysiology540:635646;2002.14StephenLevin,personalcommunicationattheBioten-segrityInterestGroup,Belgium,2013;http://www.biotensegrity.com/muscles_at_rest.php;A.T.MasiandJ.C.Hannon,HumanRestingMuscleTone(HRMT):NarrativeIntroductionandModernConcepts,JournalofBodyworkandMovementTherapies12(4):320332;2008.

  • Terra Rosa E-mag 23

    16JohnSharkey,BioTensegrity.Thefallacyofbiomechan-ics.JournalofAustralianAssociationofMassageThera-pists.Volume14,issue2Winter201517StephenLevin:www.biotensegrity.com:HomePageandseveralarticlesunderPapers:Tensegrity:TheNewBiomechanics.18JohnSharkey,seearticleinthiseditionofTerraRosamagazineBioTensegritypage6-10.19RobertSchleip,ThomasW.Findley,LeonChaitowandPeterA.Huijing,Fascia:TheTensionalNetworkoftheHumanBody,ChurchillLivingstone/Elsevier,Edinburgh,2012.20ThomasW.Myers,AnatomyTrains:MyofascialMeridi-ansforManualandMovementTherapists,2ndedition,ChurchillLivingstone,Edinburgh,2009.21JoanneAvison,YOGAFascia,AnatomyandMovement,HandspringPublishing2015,Chapter12,YogaandAnat-omyTrains22ThomasW.Myers,AnatomyTrains:MyofascialMeridi-ansforManualandMovementTherapists,2ndedition,ChurchillLivingstone,Edinburgh,2009.TheSupericialBackLine23Foramoredetailedexplanationexpandingonthis

    themeseeYOGAFascia,AnatomyandMovement,Hand-springPublishing2015,Chapter12,YogaandAnatomyTrains24Jean-PierreBarralandAlainCroibier,ManualTherapyforthePeripheralNerves,ChurchillLivingstone,Edin-burgh,2007.25RobertSchleip,ThomasW.Findley,LeonChaitowandPeterA.Huijing,Fascia:TheTensionalNetworkoftheHumanBody,ChurchillLivingstone/Elsevier,Edinburgh,2012.26LuizFernandoBertolucci,Pandiculation:NaturesWayofMaintainingtheFunctionalIntegrityoftheMyo-fascialSystem?,JournalofBodyworkandMovementTherapies15(3):268280;2011.27DougRichards,UniversityofToronto,AssistantProfes-sor,MedicalDirector,DavidL.MacIntoshSportMedicineClinic.Alsoseewww.youtube.com/watch?v=7qYYhkfu_vcfora45minutepresentationbyDougRichardscalledStretching:TheTruth.28ForamoredetailedexplanationexpandingonthisthemeandfurtherreadingreferencesseeYOGAFascia,AnatomyandMovement,HandspringPublishing2015,Chapter4,BiotensegrityStructuresandChapter8,TheElasticBody

    YOGA: Fascia, Anatomy and Movement seeks to bridge the divide between the application of classical anatomy and real-life experiences of practicing and teaching yoga.

    Whatever your style of yoga, YOGA: Fascia, Anatomy and Movement makes sense of the experience of the moving body in and beyond the yoga classroom. It is a groundbreaking and invaluable resource in the con-temporary art and science of yoga.

    The book is written in straightforward and accessible language, and is divided into three parts:

    Part 1 examines recent research and the paradigm shift from the classical anatomy of the musculoskeletal system to the new perspective the fascia provides.

    Part 2 applies this perspective to the practice of yoga with highly illustrated, clear descriptions of techniques and exercises.

    Part 3 considers the metaphysical aspect of yoga and the hidden geometry of our biotensegrity architecture as a metaphor for consciousness.

    YOGA: Fascia, Anatomy and Movement is intended pri-marily for Yoga Teachers, but can be adapted for use with Pilates and all other movement training programs. It is also a resource for therapists working in the fields of sport, dance, and movement therapy as well as man-ual practitioners.

    Available at www.terrarosa.com.au

    The Elastic Body

  • 24 Terra Rosa E-mag

  • Terra Rosa E-mag 25

    Introduction

    Chronic low back pain is among the most burdensome of health problems in prevalence and cost of care.[1] It is the leading cause of years lived with disability worldwide and the most frequent cause of disability related loss in high-income countries.[2,3] Much of this economic burden is expended on costly surgical and rehabilitative services. Up to one third of acute low back pain cases may become chronic and lead to disability.[4] In a majority of chronic cases (estimated at 8595%) a definitive diagnosis, that is, infection, neoplasm, osteoporosis, arthritis, fracture, radiculopathy, or inflammatory rheumatic processes, is ruled out, and these are designated as chronic uncomplicated, mechanical, or nonspecific low back pain (CNSLBP).[5] There is no consensus on the optimal approach to the treatment of CNSLBP. Management typically includes some combination of analgesic or anti-inflammatory medication, directed therapeutic exercise, manipulation, cognitive-behavioural therapy, and patient education.[6] However, systematic reviews have generally concluded that the benefits of these approaches are limited and mostly short-lived. [7-11] A large survey in the United States found that 54% of patients with low back or neck pain used complementary therapies and that approximately one third of all visits to alternative care practices were for back or neck pain.[12] Low back pain has been reported to be the primary complaint in 40% of all visits to chiropractors, 20% to massage therapists, and 15% to

    acupuncturists.[13]

    Structural Integration (SI) is increasingly turned to for the treatment of chronic musculoskeletal pain and disability. A few preliminary studies with small samples suggest possible effectiveness for musculoskeletal pain, but aside from a single case report, no clinical studies of SI for CNSLBP have appeared to date.[14] Studies of SI for musculoskeletal pain, and preliminary evidence regarding a number of hypothesized therapeutic mechanisms have been reviewed elsewhere.[15-17] SI treatment sometimes involves notable discomfort which has led to a reputation of being excessively painful and even to concerns as to its safety.[18] This has been a barrier to a more widespread adoption by conventional medical clinics, although SI was successfully incorporated into at least one.[15,19] Despite these concerns, published data on adverse events associated with SI are limited to a single case and a small prospective case series.[20,21]

    This study was designed to collect preliminary data on the feasibility, effectiveness, and adverse events associated with SI as an adjunct to outpatient rehabilitation (OR) versus OR alone for CNSLBP. The outcomes will inform our design of a more adequately powered clinical trial. We hypothesized that we could recruit and retain qualified participants who would comply with treatment and data collection, that a course of SI + OR would improve low back related pain and disability

    A randomized clinical trial of Structural Integration as an adjunct to outpatient rehabilitation for chronic low back pain: A summary

    By Eric Jacobson PhD, MPH

  • 26 Terra Rosa E-mag

    significantly more than OR alone, and that SI could be delivered with acceptable levels of adverse events.

    Methods

    Institutional context: This study was conducted at the Motion Analysis Laboratory, Spaulding Rehabilitation Hospital, Partners HealthCare, LLC, Boston, and was approved by the Spaulding institutional review board. The study was registered with ClinicalTrials.gov (NCT01322399) prior to beginning the recruitment of participants.

    Design: Following screening, enrolment, and baseline data collection, participants were randomized in a 1:1 ratio to parallel treatment groups: OR alone versus SI + OR. Follow-up data were collected at 20 weeks after baseline.

    Subjects: We included men and women aged 1865 living in the greater Boston area, with CNSLBP of 6 months duration which was not attributed to infection, neoplasm, severe radiculopathy (assessed by frequent severe pain radiating down a leg), fracture, or inflammatory rheumatic process, with a patient rated bothersomeness of pain on average over the preceding 6 months 3 on an 11-point ordinal verbal response scale (0=none, 10=worst imaginable), i.e. moderate to severe range. Prior arrangement to enter or having recently entered treatment at any Boston area outpatient rehabilitation clinic was also required.

    We excluded candidates for i) impaired hearing, speech, vision, or mobility; ii) current or anticipated receipt of payments from Workers Compensation or other disability insurance; iii) prior treatment with any type of SI; iv) plans to initiate additional treatment for back pain other than outpatient rehabilitation care during the period of the study; v) exclusions for safety; vi) exclusions for anticipated lack of therapeutic response; vii) conditions that might confound measures of balance and movement; viii) conditions that would confound data on inflammatory biomarkers; ix) any other condition that would impair the patients ability to complete the study.

    Sample Size: Using data from a clinical trial of massage and a meta-analysis of trials of balneotherapy, both for low back pain, a sample size of 40 was estimated as adequate to detect Minimal Clinically Important Differences (MCID) in pain and disability.[22,23] The sample was later increased to 46 to compensate for dropouts.

    Treatment: All participants were required to attend a recently arranged course of outpatient rehabilitation at any rehabilitation clinic in the Boston area. Typical courses of outpatient rehabilitation (OR) for CNSLBP employ varying combinations of analgesic and anti-inflammatory medication, joint manipulation, therapeutic exercise, cognitive behavioural treatment, and education. Participants were allowed 20 weeks to complete their course of OR. The number and frequency of treatments were determined by each participant and their therapist.

    Ten sessions conforming to the Rolf Ten Series protocol were provided free of charge to each participant assigned to the SI+OR group. SI treatments were provided by five therapists who met the criteria of graduation from the training

    programs of the Rolf Institute of Structural Integration,[24] the Guild for Structural Integration,[25] or Kinesis Myofascial Integration (KMI)[26]; a minimum of 10 years clinical practice of SI; and membership in the International Association of Structural Integrators.[27] The KMI graduates agreed to provide the Rolf Ten Series instead of the twelve sessions taught by KMI, which include the Ten Series.

    Outcomes: The primary outcome of the study was pre-defined as a comparison across treatment groups of change between baseline and 20-week follow-up on a patient-rated visual analog scale (0100 mm) of bothersomeness of pain on average over the preceding week (VAS Pain), anchored as 0=none, 100 mm=worst imaginable.[28] The secondary outcome was a comparison of changes in the total of the Roland-Morris Disability Questionnaire (RMDQ) over the same period.[29,30] Pre-defined exploratory outcomes included the Short Form 36 Health Survey (SF36),[31] the sum of days and half days disabled over the past week, and Global Satisfaction with Care. These questionnaires are all patient-completed and have been recommended for use together in low back pain trials.[32,33] All data were analysed on an intent-to-treat basis, i.e. the last available data for each dropout was substituted for their missing 20 week data. Because of our small sample size, the Wilcoxon rank sum test was specified to test the significance of between group differences in change scores.

    Adverse events were monitored through reports submitted by study staff and a biweekly Patient Questionnaire. We also recorded all elevations VAS Pain scores 30mm above baseline as adverse events. In addition we collected feasibility data on the demographic characteristics of unenrolled compared to enrolled candidates, compliance with assigned treatment, and dropouts.

    Results

    Recruitment, Enrollment, Treatment Compliance, and Dropouts: The study was conducted between April, 2011 and August, 2013. Enrolled compared to unenrolled candidates were approximately equivalent in gender, age and race. The demographic and prognostically relevant characteristics of the treatment groups were also acceptably similar at baseline. Attendance at OR treatments was unexpectedly low, but was not significantly different between treatment groups. In the SI+OR group, attendance at SI was almost perfect. The overall rate of dropout was 11%, which is within the range that has been recommended as a standard for assessing back pain trials, and was not significantly different between groups.[34]

    Outcomes: The median reductions in VAS Pain, the primary outcome, of 26 mm [Interquartile range 31.5, 3.0] in SI+OR compared to 0 mm [24.5, 6.5] in OR alone were not significantly different (Wilcoxon rank sum 2-sided test p=0.075#) (Figure 1). However, the median reductions in RMDQ, the secondary outcome, of 2 points [4.5, 1] in SI +OR compared to 0 [2, 0] in OR alone, were significantly different (p= 0.007) (Figure 2). The between group difference in median change of two points is the smallest suggested absolute MCID for the RMDQ [37].

  • Terra Rosa E-mag 27

    Other pre-specified outcomes which were different between treatment groups at a significance level of p

  • 28 Terra Rosa E-mag

    Improvements in the primary outcome, VAS Pain, were not significantly different between treatment groups, but improvements in the secondary outcome, RMDQ, were significantly greater in SI+OR than in OR alone, with the difference between median change scores satisfying the lowest recommended absolute MCID.[37] Among pre-defined exploratory outcomes the SF36 subscale for Bodily Pain, and Global Satisfaction with Care both improved more in SI+OR than in OR alone.

    With respect to feasibility, we successfully recruited and enrolled a sample whose demographic characteristics did not differ significantly from those unenrolled. Randomization produced treatment groups that were acceptably equivalent on prognostically significant variables. Compliance with SI treatment was high, suggesting that any discomfort associated with it did not dissuade the majority of participants assigned to SI+OR from attending. Neither the incidence nor the seriousness of adverse events was significantly increased by the addition of SI to OR. Dropouts were within acceptable limits, and we found no evidence of crossover between treatment regimes. However, the length of time to recruit the cohort was unexpectedly long, and compliance with the requirement to receive OR treatment was unexpectedly low. Both would need to be remediated in a follow-up study.

    Limitations: Because this study assessed the effect of SI as an adjunct to OR compared to OR alone, its outcomes should not be taken to indicate the effect that SI alone might have on CNSLBP. The large number of exclusion criteria might have resulted in the enrolment of a sample that was not representative of the typical clinical population, and this might limit the generalizability of these results. It was not possible to blind participants or therapists to treatment assignment because of obvious differences between the experiences of SI and OR treatment. Effective maintenance of the initial blinding of investigators proved to be impossible due to limited administrative staffing, but the potentially biasing effect of this was mitigated by the fact that all outcomes were patient-rated. Compliance with the requirement to receive OR was unexpectedly low and might

    have contributed to the median change scores of zero for both VAS Pain and RMDQ in the OR alone group. We did not directly monitor SI treatment sessions for fidelity to protocol, nor require the therapists to report their treatment interventions in detail.

    The additional 10 hours of hands-on treatment received in SI+OR might have contributed to the more favourable outcomes in that group compared to OR alone (Hawthorne effect). A placebo effect might also have contributed, because members of the SI+OR group were aware that they were receiving the treatment that was the object of our investigation (SI). The absence of follow-up at a longer duration is an additional limitation.

    Recommendations: A follow-up study should provide SI according to a specific treatment protocol such as the Rolf Ten Series, should use therapists who are adequately trained and experienced in whatever protocol is used, and should allow for the individualization of treatment strategies to reflect actual practice. The collection of information on the specific SI techniques employed in each treatment session would enable closer monitoring of the treatment protocol. At

    Table 1: VAS Pain responder analysis: responder/non-responder ratios compared across treatment groups .

    Pain Reduction SI+UC (n=23) UC alone (n=23) RR (CI) p

    10-20% 17 (74%) 9 (39%) 1.89 (1.07-3.32) 0.036*

    >30% 15 (65%) 7 (30%) 2.14 (1.08-4.26) 0.038*

    >50% 12 (52%) 6 (26%) 2.00 (0.91-4.41) 0.130

    >20 mm 12 (52%) 7 (30%) 1.71 (0.83-3.56) 0.231

    >40 mm 5 (22%) 2 (9%) 2.50 (0.54-11.60) 0.414

    n: sample size; RR: relative risk, the percentage for SI+UC divided by the percentage for UC alone; CI: 95% confidence intervals# for RR; 1. Fisher's exact 2-sided p value; * significant difference at p

  • Terra Rosa E-mag 29

    least a three-month follow-up should be included. We speculate that SI alone might be superior to outpatient rehabilitation alone and note that a direct comparison of the two could control for time, attention, and skin stimulation across treatment groups. Our positive outcome for greater reduction in disability in the SI+OR group suggests that hypothesized mechanisms for mediating a therapeutic effect of SI are also worthy of future investigation.

    Conclusions

    The outcomes of this study suggest that adding SI to outpatient rehabilitation for CNSLBP should not be expected to enhance reductions in patient-rated pain, but might enhance reductions in low back pain related disability at least for the short term and modestly increase patient satisfaction without significantly increasing the rates of adverse events. If these indications were confirmed by a more definitive study, that might support the recommendation of SI as an effective adjunct to outpatient rehabilitation for this condition. Data on enrolment, retention, data collection, and compliance with SI treatment suggest that a follow-up study is feasible. However, the study design should increase the efficiency of recruitment and improve compliance with OR.

    A more detailed report of this study is given in Jacobson et al. 2015 J Evid Based Complment Altern Med. 813418, which is publically available at www.hindawi.com/journals/ecam/ 2015/813418

    Acknowledgements

    This study would not have been possible without the generous collaboration of Alec Meleger, Paolo Bonato, Peter Wayne, Helene Langevin, Ted Kaptchuk, and Roger Davis. Major study expenses and Dr. Jacobsons effort were funded by a career development award from the National Center for Complementary and Integrative Health, National Institutes of Health (NCCIH/NIH, K01AT004916). Dr. Kaptchuks effort was supported by a mentorship award from NCCIH/NIH (K24AT004095). Supplemental funding was provided by the Ida P. Rolf Research Foundation, Harvard Medical School, the Rolf Institute of Structural Integration, Dean Rollings, and Hal and Sonya Milton. Administrative and technical support was generously provided by the Motion Analysis Laboratory, Spaulding Rehabilitation Hospital, Partners Healthcare, LLC, and by Harvard Medical School. We also thank the volunteers who served as independent monitor and on the data safety monitoring committee, and the SI practitioners: Lou Benson, Lisa Grey, Ellen Halpern, Tim Roode, and Garret Whitney.

    The Author

    Eric Jacobson, PhD, MPH, investigates alternative medicine at Harvard Medical School. He was trained by Ida Rolf in 1974, completed advanced training with the Rolf Institute in 2005, and has a private practice of Structural Integration in Boston.

    References

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    2. Vos, T., Flaxman, A. D., Naghavi, M., Lozano, R., Michaud, C., et al. (2013). Years lived with disability (YLDs) for 1160 sequelae of 289 disease and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet, 380, 2163-96.

    3. Luo, X., Pietrobon, R., Sun, S. X., Liu, G. G., Hey, L. (2004). Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine, 29, 79-86.

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    5. Deyo R., Weinstein J. N. (2001). Low back pain. New England Journal of Medicine, 344(5), 363-70.

    6. Dagenais S., Tricco A. A., Haldeman S. (2010). Synthesis of recommendations for the assessment and mangement of low back pain from recent clinical practice guidelines. Spine, 10(6), 514-29.

    7. Lee, T. (2010). Pharmacologic treatment for low back pain: one component of pain care. Physical Medicine & Rehabilitation Clinics of North America, 21, 793-800.

    8. Kuijpers, T., van MIddlekoop, M., Rubinstein, S. M., Ostelo, A., et al. (2011). A systematic review on the effectiveness of pharmacological interventions for chronic non-specific low back pain. European Spine Journal, 20, 40-50.

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    10. van Tulder. M., Koes, B., Malmivaara, A. (2006). Outcome of non-invasive treament modalities on back pain: an evidence-based review. European Spine Journal, 15(Suppl 1), S64-81.

    11. von Middlekoop, M., Rubinstein, S. M., Kuijpers, T., Verhagen, A. P., et al. (2011). A systematic review on the effectiveness of physical and rehabilitation interventions for chronic non-specific low back pain. European Spine Journal, 20(19-309.

    12. Wolsko, P. M., Eisenberg, D. M., Davis, R. B., Kessler, R., Phillips, R. S. (2003). Patterns and perceptions of care for treatment of back and neck pain: results of a national survey. Spine, 28(3), 292-97.

    13. Cherkin, D., Deyo, R. A., Sherman, K. J., Hart, G. L., et al. (2002). Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians. Journal of the American Board of Family Practice, 15(6), 463-72.

    14. Cottingham, J. T., Maitland, J. (1997). A three-paradigm treatment model using soft tissue mobilization and

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    guided movement-awareness techniques for a patient with chronic low back pain: a case study. Journal of Orthopaedic & Sports Physical Therapy, 26(3), 155-67.

    15. Deutsch, J. E., Derr, L. L., Judd, P., Reuven, B. (2000). Treatment of chronic pain through the use of structural integration (rolfing). Orthopaedic Physical Therapy Clinics of North America, 9(3), 411-25.

    16. James, H., Castaneda, L., Miller, M. E., Findley, T. (2009). Rolfing structural integration treatment of cervical spine dysfunction. Journal of Bodywork and Movement Therapies, 13(3), 229-38.

    17. Jacobson, E. (2011). Structural Integration: an alternative method of manual therapy and sensorimotor education. Journal of Complementary and Alternative Medicine, 17(10), 891-99.

    18. Considine, A. (2010). Rolfing, excruciatingly helpful. New York Times. New York, NY: New York Times, E1. Oct 7. http://www.nytimes.com/2010/10/07/fashion/07rolfing.html?_r=0

    19. Krotenberg, R. (2004). Alternative therapies join the mainstream. Focus on Rehabilitation. West Orange, NJ: Kessler Institute for Rehabilitation. Summer. July, 2004.

    20. Kerr, H. D. (1997). Urethral stent displacement associated with deep massage. Western Medical Journal, 96(12), 57-58.

    21. Perry, J., Jones, M. H., Thomas, L. (1981). Functional evaluation of Rolfing in cerebral palsy. Developmental Medicine and Child Neurolology, 23(6), 717-729.

    22. Cherkin D. C., Eisenberg, E., Sherman, K. J., Barlow, W., et al. (2001). Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. Archives of Internal Medicine, 161(1081-88.

    23. Pittler M. D., Karagulle M. Z., Karagulle, M., Ernst, E. (2006). Spa therapy and balneotherapy for treating low back pain: meta-analysis of randomized trials. Rheumatology (Oxford), 45(7), 880-84.

    24. Rolf Institute of Structural Integration. (2014). Rolf Institute of Structural Integration. http://www.rolf.org, accessed March 1, 2015.

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    March 1, 2015.

    26. Kinesis Myofascial Integration. http://www.anatomytrains.com/kmi, accessed March 1, 2015

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    28. Dunn, K. M., Croft, P. R. (2005). Classification of low back pain in primary care: using "bothersomeness" to identify the most severe cases. Spine, 30(16), 1887-92.

    29. Roland, M., Morris, R. (1983). A study of the natural history of back pain. Pt I: development of a reliable and sensitive measure of disability in low-back pain. Pain, 8(2), 141-44.

    30. Roland, M., Fairbank, J. (2000). The Roland-Morris Disability Questionnaire and the Oswestery Disability Questionnaire. Spine, 25(3115-24),

    31. Ware, J. E., Sherbourne, C. D. (1992). The MOS 36-item short-form health survey (SF-36): I. Conceptual framework and item selection. Medical Care, 30(6), 473-83.

    32. Deyo, R. A., Battie, M., Beurskens A. J., Bombarider C., P. et al. (1998). Outcome measures for low back pain research. a proposal for standardized use. Spine, 23(18), 2003-13.

    33. Bombardier C. (2000). Outcome assessments in the evaluation of treatment of spinal disorders: summary and general recommendations. Spine, 25(24), 3100-03.

    34. Koes B. W., Bouter, L. M., van der Heijden, G. J. (1995). Methodological quality of randomized clinical trials on treatment efficacy in low back pain. Spine, 20(2), 228-35.

    35. Hansen, A., Price, K. S. , Feldman, H. M. Myofascial structural integration: a promising complementary therapy for young children with spastic cerebral palsy. Journal of Evidence Based Complmentary and Alternative Medicine, 17(4), 131-35.

    36. Stall, P., Teixeria, M. J. (2014). Fibromyalgia syndrome treated with the structural integration Rolfing method. Rev Dor Sao Paulo, 15(4), 248-52.

    37. Bombardier, C., Hayden J., Beaton, D. E. (2001). Minimal clinically important difference. low back pain. outcome measures. The Journal of Rheumatology, 28,431-38.

  • Terra Rosa E-mag 31

    Theintroductionofanynewtech-nologyoftencomeswithunex-pectedconsequences.Thisiscer-tainlytruewithwidespreaduseofthesmartphone.Althoughitisawonderfulmarvelofcommuni-cationthatallowsustobecon-nectedwithourlovedones,friends,andbusinesscolleagues,aswellasconnectustotheinter-netandthereforetheworldaroundus,unfortunatelyitcomesataprice.Thatpriceisthephysi-calstressthatitcanplaceonourbody.Oneonlyneedstogotoapublicplaceandobserveotherswhileusingtheirsmartphones.Theoddsarethatwewillseemanydysfunctionalposturalpat-ternsandfutureinjuriesinthemaking.However,mostoftheseconditionscanbeavoidedifwepayattentiontoourbiomechan-icsasweholdandusethesmartphone.

    Astherapists,itisimportanttobeawareofthesecommoncondi-tionssothatwecanbepreparedtoassessforthem,andiffound,providetheappropriateclinicalorthopedicworktoamelioratethecondition.Beingawareofthesepotentialproblemsalsoarmsuswiththeknowledgeneededtobeabletoofferthecli-entvaluableposturaladviceabouthowtoproperlyholdandusethesmartphonesothatthedevelopmentoftheseproblemscanbeavoided.Followingaretenofthemostcommondysfunctionalposturalpatternsandinjuriesthatmayoccurwithsmartphoneuse.Someoftheseconditionsarepurelyposturalandcanbeavoid-edbyimprovingtheposturethatisemployedwhenusingasmartphone.Otherconditionsmaybet-

    terbedescribedasrepetitiveoveruseconditions.Thesecondi-tionsarethereforelessposturerelatedandmoreduetothechronicrepetitiveuseofsmartphones.However,evenwithre-petitiveoveruseconditions,im-provingsmartphoneposturecanhelptominimizeoravoidtheironset.Forthesereasons,somesuggestedposturesforsmartphoneuseareofferedattheendofthisarticle.1.GolfersElbowGolferselbow,alsoknownasme-dialepicondylitisormedialepi-condylosis,isaconditioninwhichinlammationand/orde-generationofthecommonlexortendonoccurs,usuallyaccompa-niedbyhypertonicityofthebel-liesoftheassociatedmuscles.Thisconditioniscausedbyover-

    The Price of Smart Phones Ten Common Dysfunctional Postures and

    Injuries caused by Smart Phone Use

    By Joe Muscolino

  • 32 Terra Rosa E-mag

    useofthemusclesofthecommonlexortendonthatattachestothemedialepicondyleofthehumer-us.Thesemusclesarethethreemusclesofthewristlexorgroup(lexorcarpiradialis,palmarislongus,andlexorcarpiulnaris),thepronatorteres,andthelexordigitorumsupericialis.Asawhole,thesemusclesdolexionofthewristjointandtheingers;inotherwords,thejointactionsnecessarytogripandholdanyobjectincludingasmartphone(Figure1).Holdingthesmartphoneoccasionallyforafewminutesatatimeisnotaprob-lem.Theproblemoccurswithoverusethatrequiresprolongedisometriccontractionoftheasso-ciatedmusculature,leadingtofatigueandeventualinjury/dysfunctionofthecommonlexortendon.Thedevelopmentofthisconditionisacceleratedifthecli-entgripsthesmartphoneharderthannecessary,therebyincreas-ingthecontractionstrengthandthereforestressuponthemuscu-latureanditscommontendon.2.TennisElbowTenniselbow,alsoknownaslat-eralepicondylitisorlateralepi-condylosis,isaconditioninwhichinlammationand/orde-generationofthecommonexten-sortendonoccurs,usuallyaccom-paniedbyhypertonicityofthebelliesoftheassociatedmuscles.Thisconditioniscausedbyover-useofthemusclesofthecommonextensortendonthatattachestothelateralepicondyleofthehu-merus.Thesemusclesaretheex-tensorcarpiradialisbrevis,ex-tensordigitorum,extensordigitiminimi,andtheextensorcarpiulnaris.Asagroup,thesemusclesdoextensionofthewristjointandtheingers.Itwouldseemthatthesemusclesdonotneedtocontractwhengrippingandhold-ingasmartphonebecausethis

    Figure 1. Prolonged holding of a smart phone can lead to overuse, fatigue, and dysfunction of the common flexor tendon. This condition is known as golfers elbow.

    Figure 2. Prolonged holding of a smart phone (or shown here as pen) can lead to overuse, fatigue, and dysfunction of the common extensor tendon. This condition is known as tennis elbow.

    Figure 3. Crimping a smart phone between the shoulder and ear physically stresses muscles of scapular elevation.

  • Terra Rosa E-mag 33

    activityrequirescontractionbylexionmusculature,notextensormusculature.However,extensormus-culatureisneededtocontractisometricallytostabi-lizethewristjointandpreventitfromlexingwhenthelexorsdigitorumsupericialisandprofundusmusclescontracttolextheingers.Mostoften,itistheextensorcarpiradialisbrevisthatengagesinthisscenario(Figure2).Therefore,holdingasmartphonedoesphysicallystressmusculatureofthecommonextensortendonandcancontributetoten-niselbow.Occasionaluseisnotaproblem;likegolferselbow,tenniselbowisanoverusecondition.Grippingthephonemoreforcefullythannecessarywillalsoincreasethestresstotheextensormuscu-latureandthereforethelikelihoodthatthiscondi-tionwilldevelop.3.UptightShouldersDevelopinguptightelevatedshoulderswithasmartphoneoccurswhenthephoneiscrimped(compressed)betweentheearandshoulder,be-causethisposturerequirescontractionofscapularelevationmusculaturetobringtheshoulderuptoholdthephoneagainsttheear(Figure3).Musclesofscapularelevationthatareused/overusedandlikelytobecomefatigued,tight,andinjuredaretheuppertrapeziusandlevatorscapulae.Crimpingaphonealsorequirescontractionofsame-sidelaterallexionmusculatureofthenecktohelppresstheeardownwardagainstthephoneandshoulder.Thisfurtherrequirescontractionof,andthereforephysi-callystresses,theuppertrapeziusandlevatorscap-ulae,aswellasothermusclesoflaterallexion.Thisproblemisnotnewwithsmartphones.Itwasandstilliscommonforpeopletocrimplandlinephonestoo.However,becausesmartphonesaremuchsmaller,theamountofmusculareffortnecessarytocrimpasmartphoneisgreaterthantocrimpaland-linephone.4.AnteriorShoulderStrainItiscommonforpeopleusingasmartphonetoholdthephoneintheairoutinfrontoftheirbody.Thedificultywiththispostureisthatitrequiresisomet-riccontractionofthemusculatureofhumerallex-ionattheglenohumeraljointtoholdthearmoutintheair.Foremostamongthesemusclesistheanteri-ordeltoid(Figure4).Holdingthearmoutinlexionalsorequiresstabilizationofthescapula,whichre-quirescontractionofandthereforestresstotheup-pertrapezius.Andifthepersonalsoaddsineleva-tionoftheshouldergirdletoholdthephoneuphigher,itplacesevengreaterstressontheuppertrapezius,aswellasthelevatorscapulae.Therefore,excessiveengagementofthisposturecanleadto

    anteriordeltoidstrainaswellasstrainoftheuppertrapeziusandlevatorscapulae.5.RotatorCuffStrain/TendinitisHoldingaphoneoutinfrontofthebodywithhu-merallexioncanalsostressandinjuretherotatorcuffmusculature.Wheneverthearmisliftedup-wardintheair,whetheritisupintolexion,exten-sion,abduction,oradduction,itisnecessaryfortherotatorcuffmusculaturetocontracttostabilizeandholdthe(proximal)headofthehumerusdownintotheglenoidfossaasthedistalendofthehumerusraises(Figure5).Overuseofthisposturecan,overtime,contributetofatigue,tightening,andstrainoftherotatorcuffmusculature,aswellastendinitisoftherotatorcuffmuscles.

    Figure 4. Holding the phone out in front of the body can overly stress, fatigue, and injure musculature of the anterior shoulder.

    The Price of Smart Phones

  • 34 Terra Rosa E-mag

    6.RoundedShouldersRoundedshouldersisaposturaldis-tortionpatterninwhichthescapu-laeareprotractedandthehumeriaremediallyrotated.Thereforetheshouldergirdlesandarmsareroundedin,hencethename.Theclientwithroundedshouldershasscapularprotractors(pectoralismi-norandmajor)andhumeralmedialrotators(subscapularis,pectoralismajorandteresmajor)thatarelockedshortandtight,accompaniedbyscapularretractors(middleandlowertrapeziusandrhomboids)andhumerallateralrotators(teresmi-n


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