Somatic Technique: A Simplified Method of Releasing Chronically Tight Muscles and Enhancing Mind/body Awareness 978-0787230159, 0787230154

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SOMATIC TECHNIQUE A Si mpli fi ed Method of Rei easing Chronically Tight Muscles and Enhancing Mind/Body Awareness

JIM DREA VER, D. C.

JIMDREAVER, D.C., a native ofNew Zealand and a 1976 honors graduate of Palmer College of Chiropractic, was a Postgraduate Faculty member ofPalmer College of Chiropractic West, where he taught over one hundred seminars on Somatic Technique for doctors and other hands-on practitioners. Jim retired from chiropractic in 2004 to pursue his life's passion, which is writing about and teaching the art of awakening to freedom, to the beautiful, powerful people we really are. He lives in California and in addition to a limited number of private sessions with people, travels widely to share his message. In addition to Somatic Technique (www.somatictechnique.com), he is also the author of a definitive book about awakening, End Your Story, Begin Your Life: The Revolutionary Practice That Sets You Free (www.endyourstory.com), and a novel with a spiritual theme, Falling Into Light (www.fallingintolight.com). He also wrote The Ultimate Cure: The Healing Energy Within You (Llewellyn Publications, 1995) and The Way ofHarmony: Walking the Inner Path to Balance, Happiness, and Success (Avon Books, 1999). For information about his events and international workshops, visit www.jimdreaver.com. You can email him at [email protected].

SOMATIC TECHNIQUE A S i m pI i f i e d Me t h o d of ReI e as i n g Chronically Tight Muscles and Enhancing Mind/Body Awareness

by

JIM DREA VER, D. C.

Wild Goose Press Sebastopol, California

The 10 lines from the Tao Te Ching by Stephen Mitchell on page 30, and the 5 lines on page 192, reprinted by permission of HarperCollins Publishers, Inc. Translation copyright© 1988 by Stephen Mitchell.

Illustrations by Greg Morrill.

Copyright © October, 2000 by Jim Dreaver, D.C.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the copyright owner. Printed in the United States of America 10 9 8 7 6 5 4 3 2 1

Contents Quick Guide to Techniques iv Author's Note vi Acknowledgments vii

CHAPTER 1: The Somatic Perspective 1 CHAPTER II: Origins and Principles of Somatics 11 CHAPTER III: Neurophysiology 27 CHAPTER IV: Evaluation and Contraindications 45 CHAPTER V: How to Learn This Work 53 CHAPTER VI: The Twenty-One Basic Techniques 63 CHAPTER VII: Extremity Techniques 145 CHAPTER VIII: Integrating Somatic Technique into Your Practice 167 CHAPTER IX: Healing the Whole Person 177 CHAPTER X: Basic Exercises 195 Appendix A Symptom Checklist 201 Appendix B Somatic Evaluation Form 202 Appendix C Resources 203 Index 205

Quick Guide to Techniques

Back Muscles 1. 2. 3. 4. 5.

Paravertebral Muscles ... unilaterally tight back extensors Trunk Extension Prone ... bilaterally tight back extensors Knee-Chest .. . lumbosacral stress & tension Ilium-Axillary ... lumbar/sacroiliac problems Psoas ... lumbosacral pain or instability

Page No. 69 73 75 79 82

Hips/Hamstrings 6. Hips Prone ... tight medial hip rotators 7. Hips Supine .. . tight lateral hip rotators 8. Hamstrings ... tight hamstrings

86

89 94

Waist/ Abdomen/Shoulder Girdle 9. Both Shoulders Prone ... bilateral shoulder/thoracic stress 10. 11. 12. 13. 14.

Shoulder Lateral ... unilateral shoulder/thoracic stress Latissimus Dorsi ... shoulder problems Obliques ... shoulder problems/constricted waist Abdominals .. . shoulder problems/ tight abdominals Pectorals ... rounded shoulders/shoulder pain

98 101 104 110 113 117

Neck/Head 15. 16. 17. 18. 19. 20. 21.

iv

Trapezius ... tight or "hunched" shoulders Cervical-Thoracic ... tight neck/upper back extensors Anterior Cervicals ... anterior cervical problems Cervical-Shoulder ... unilateral neck/shoulder tension Cervical Rotation ... tight neck rotators Occipital ... suboccipital stress and tension Temperomandibular Joint ... TMJ problems

122 125 127 130 132 135 140

Quick Guide to Techniques v

Upper Extremity 22. 23. 24. 25.

Deltoids .. . shoulder problems Biceps ... elbow problems Triceps ... elbow problems-e.g. tennis elbow Wrist .. . wrist problem-e.g. carpal tunnel syndrome

146 148 150 152

Lower Extremity 26. 27. 28. 29. 30. 31. 32. 33.

Gluteals ... hip and knee problems Gastrocnemius ... knee and ankle problems Soleus ... foot and ankle problems Quadriceps ... hip and knee problems Adductors ... hip·and knee problems Sartorius ... hip and knee problems Tibialis Anterior ... ankle and foot problems Foot . . . ankle and fo ot problems

153 155 157 158 160 162 164 166

Author's Note This manual has been written both for chiropractors and for other hands-on practitioners such as physical therapists, massage therapists, bodyworkers, and osteopaths. Any professional doing hands-on work in the musculoskeletal field will find this work of value in their practice. The method behind Somatic Technique is quite simple and I have developed a way of using it in my own practice that makes it easy to incorporate with the other procedures I use. With some study and practice of the techniques presented, you will be able to begin using this work immediately and your patients and clients will benefit. One of the criticisms I have heard of other books written about systems of neuromuscular reeducation is that the material is often dense, complicated, and difficult to learn and apply in actual practice. My goal in writing this book, therefore, is to present Somatic Technique for what it is-a simplified yet very effective method of neuromuscular reeducation that is easy to understand, learn, and use. I want practitioners to be able to pick up this book, spend an hour or two reading the introductory chapters, and then be able to study the techniques themselves and begin using them immediately in their practices. Also, while throughout this book I have used the pronoun "he" for clarity and ease of style, I would emphasize that what is often referred to as the "feminine" element or principle within each of us-the ability to be receptive to what we are feeling and experiencing in any given moment-is the most important factor in healing. As has been said, "If you can feel it, you can heal it." Indeed, this opening to what is being sensed and felt within is the basis of both Somatic Technique and of heightened sensory-motor wellbeing.

vi

Acknowledgments I would like to pay special tribute to the memory of Thomas Hanna, Ph.D., philosopher, master teacher, author, healer, and pioneer in the field of somatic education. It was through him that I was introduced to this work and given the ideas and inspiration I needed to begin using it in my own practice. I first saw Dr. Hanna at a chiropractic conference in Napa, California, in the summer of 1989, where he gave a presentation on somatics. When he walked onto the stage, I was immediately struck by his presence. He was there, in the truest sense of the word. What he talked about-somatic awareness, sensory-motor well-being-was not just academic theory for him. He embodied it. He lived and breathed his subject, and taught others how to do the same. As I listened to him that morning I realized how much of what he was saying brought together all that I had been studying around the body /mind relationship for so many years. It was as if I had found the missing link in my own· practice. For me, his somatic perspective answered the question, "What can I do for my patients that will give them a new experience of themselves in their bodies?" Then I read his book, Somatics: Reawakening the Mind's Control of Movement, Flexibility, and Health, which describes the phenomenon of sensory-motor amnesia (SMA), and its role in neuromuscular problems. Dr. Hanna's book is essential reading for any health professional dealing with the musculoskeletal system, and a prerequisite for understanding some of the principles presented in this book. Later that summer I had the opportunity to spend five days with him at a seminar he gave at Esalen Institute, on the Big Sur coast in California. There I was able to observe his clinical methods firsthand. I watched him work with the somatic problems of each of the more than thirty class members. I stood alongside him before and after class as he did more in-depth sessions with Esalen staff members. I lay on the table and experienced his work personally. I sat with him during a number of meals, and talked with him about somatic theory and related topics. What I learned inspired me to then go on and look into other approaches to neuromuscular treatment and reeducation. Over the next year, as I began to incorporate various neuromuscular techniques into my practice, keeping what worked for me, discarding what didn't-and always experimenting with new techniques along the way-so my style of practice began to change. I was no longer just a chiropractor adjusting the spine. I felt myself becoming more and more of a somatic, or whole body, practitioner, with a new and very effective methodology for addressing the soft tissues. At the same time, the somatic work gave me a new set of chiropracvii

viii Acknowledgments tic tools. I discovered that the paraspinal somatic techniques, because of the way they helped restore normal mobility to the vertebral motor unit, frequently achieved the same results as the high-velocity osseous thrust. Used with this awareness in mind, many of the somatic techniques became, in effect, a method of "neuromuscular" adjusting. A year after the Esalen seminar, in the summer of 1990, Dr. Hanna began a three-year certification program in his method of somatic education. Less than six weeks into the first session, he tragically died in an automobile accident. The training was taken over and completed by his wife, Eleanor Criswell Hanna, Ed. D., who now directs the Novato Institute for Somatic Research and Training, the institute Dr. Hanna had founded a number of years before. (For information about the Institute and its programs, see Appendix C.) Following Dr. Hanna's death, I realized I was one of the few chiropractors in the U.S. who had had any significant exposure to his ideas, especially to his clinical work. I then began to adapt what I had learned from him and gleaned from other methods of neuromuscular reeducation into the set of procedures I now call Somatic Technique. Hanna Somatic Education, as he called his own work, was developed as a complete system of sensory-motor reeducation and is based, in part, on a series of "lessons" for correcting the major reflexes that cause sensory-motor amnesia. (I will discuss these reflexes in Chapter Two.) Somatic Technique, as I have formulated it, is a method for releasing chronically tight muscles wherever and whenever they are found, while at the same time enhancing mind/body awareness. It is designed as an adjunctive procedure for practitioners already well trained in a variety of musculoskeletal techniques. Many years ago B.J. Palmer, D.C., the son of chiropractic's founder, D .O. Palmer, said, "Get the Big Idea, and all else follows." Thomas Hanna had the "Big Idea" when it came to dealing with the human body. He knew that the key to somatic well-being lay not in a doctor or practitioner" doing" something to the patient, but rather in teaching patients to become more internally aware of themselves, of what they sensed and felt in their muscles and joints as they sat, stood, reached, moved, breathed. I am grateful to Dr. Hanna for giving me the "Big Idea" around the relationship between the brain and muscles, between awareness and movement. Had it not been for our meeting, this book would never have been written. I also want to acknowledge four other individuals for their contributions: Dr. Eleanor Criswell Hanna herself, for her generosity in reading the manuscript and giving valuable feedback; Rico Provasoli, D.C., for the advice and support he has given throughout the development of this work, and for being such a fine teaching colleague; Jerry Wylie, who has assisted in many somatic seminars, and whose expertise in both the Hanna and Feldenkrais approaches has enriched my own understanding of the somatic field; and Larry Elsener, for his wisdom and guidance.

I

The Somatic Perspective

"We usually build habits in mind and body unconsciously, and although the habits are sometimes convenient, they all too often constrict us. So, as we age, the conditioning process limits movement in the body, and we become tighter. Tightness in the muscles affects glands, circulation, nerves-our energy-thus accelerating the body's breakdown. When the body becomes less flexible and open, it has a direct effect on the mind and personality. There is no way to stay the same. Life is change, and change in a person can take only two directions. You either become more rigid and crystallized, more set in your ways, or you continue to grow, transform, and open up to yourself and the world you live in." -Joel Kramer1

Getting Started Life is change, states Joel Kramer in the quotation above, and change in a person can take only two directions: people either become more rigid and crystallized, or they continue to grow and open up. Somatic Technique is a set of neuromuscular reeducation procedures designed to help release the chronically tight muscles that cause rigidity and crystallization, while at the same time giving patients a new and more dynamic awareness of themselves in their bodies and in their relationship to the world around them. The work in this manual is designed as an ancillary technique to the other hands-on musculoskeletal procedures normally used by chiropractors, massage therapists, bodyworkers, physical therapists, and osteopaths. There are twenty-one basic techniques covering the muscles of the trunk, shoulder girdle, hips, neck and temperomandibular joint, and twelve additional techniques for the extremities. Relatively easy to learn, the work takes only a couple of minutes to apply, which makes it a very useful adjunct to any form of hands-on practice. With these techniques you will be able to relieve many problems of chronic muscular pain and stiffness that do not respond to other methods. At the same time, you will be educating your patients to be 1

2 Chapter I • The Somatic Perspective

more present and aware in their bodies. Somatic Technique will help them regain control of their sensory-motor system, so that they can contract and relax their muscles at will. The enhanced awareness and control tend to result in improved posture, flexibility, strength, and health. In Chapter Eight of this manual, suggestions are given as to how to integrate Somatic Technique into your practice successfully. In the meantime, let me outline a simple four-step procedure for getting started. Follow the steps as I suggest; you-and your patients-will enjoy a smooth and easy transition into this work. Step 1 Read some of this manual daily until you get a good understanding of the work, and the neurophysiological principle-the sensory-motor feedback "loop"-behind it. Begin reading some of the other material I have referred to, such as Thomas Hanna's book, Somatics. Step 2 Start using some of the techniques with your patients, following the guidelines given in Chapters Five and Six. Step 3 While you are still becoming familiar with Somatic Technique, I suggest you use it on an "as-needed" basis. That's the way I started. Each technique addresses specific problems in the body (see Appendix A-Symptom Checklist). When you see a patient with that problem, try the technique out. Play with it. Don't be afraid to experiment-this work is generally quite safe to use (Chapter Four deals with contraindications, and these are spelled out again, where appropriate, in the technique notes themselves). Step 4 Once you begin to feel some confidence with this work, experiment with using the twelve visit protocol, described in detail in Chapter Eight.

A Guide to the Manual This manual is presented in a clear, logical, and easy-to-follow format. After reading this introductory chapter, you will come to Chapter Two-Origins And Principles Of Somatics. Read this chapter to get a basic understanding of the roots of the somatic approach, the relationship between the mind and movement, the kinds of results obtained

A Guide to the Manual 3 with Somatic Technique, principles of sensory-motor control, and the causes of sensory-motor amnesia. Chapter Three-Neurophysiology, details the negative effects of sensory-motor amnesia (SMA), and shows how SMA is corrected through reawakening cortical control; it describes subcortical neurological mechanisms, deals with weak muscles, compares the somatic approach to muscle energy, Proprioceptive Neuromuscular Facilitation (PNF), and related active muscle relaxation techniques; and it discusses using Somatic Technique as an alternative to high-velocity osseous adjusting. Chapter Four:--Evaluation and Contraindications tells you how to diagnose, or analyze, your patient. You will be given some specific criteria, things that show up consistently, to indicate whether or not there is a somatic problem. Because Somatic Technique is safe to use and can benefit almost everyone, there are only a few contraindications that need to be understood. Next, study Chapter Five-How to Learn This Work. This chapter will tell you how to learn this work without being overwhelmed by it. It will give you a step-by-step method for easing your way into it, beginning with learning the key elements of the technique itself. You will note that, regardless of which muscle or group of muscles you are working with, the technique is always the same (with the exception of the TMJ.) Learn to perform it correctly and efficiently, and your patient will receive the maximum benefit in the shortest time. After learning the basic technique, you will come to the techniques themselves, described and illustrated in Chapter Six-The Twenty-One Basic Techniques. Study them in the order suggested in Chapter Six. Practice the techniques on your assistant or another practitioner. Go through the various stages in each technique until you get a "feel" for how the technique is done. Then, once you have learned the main techniques, begin incorporating the others into your somatic repertoire. Be sure to practice the accompanying individual exercises also as they are an important adjunct to the techniques. Chapter Seven-Extremity Techniques deals with the extremities. You may find yourself u sing these techniques less often than the basic ones. On ce you release somatic tension in the middle of the body-the lower back, the abdomen, the waist, and the shoulder girdle-many extremity problems, often compensatory in origin, will clear up. Learn these additional techniques as the need arises~ The next section, Chapter Eight-Integrating Somatic Technique into Your Practice, w ill show you how to integrate this work into your current style of practice, and how to introduce it to your patients so that the y understand it and get enthusiastic about it. In Chapter Nine-Healing the Whole Person, I go into some of the emotional and psy chospiritual aspects of somatic problems, and how internal mental or emotional tension manifests as stress and imbalance

4 Chapter I • The Somatic Perspective

in the body. For those practitioners interested in relating to and serving their patients in the most complete way possible, the information in this chapter may prove invaluable. It is designed to complement and round out the more straightforward sensory-motor data and techniques presented in the main part of this book. Lastly, there is Chapter Ten-Basic Exercises. These exercises are fundamental to the long-term success and effectiveness of the hands-on work you do. They help repattern the neuromuscular system and maintain the clinical results you've achieved with the patient. You will teach them to your patients and, ideally, will be doing these exercises yourself as part of your own daily health maintenance regimen. There are three appendices. In Appendix A you will find a chart of somatic symptoms and problems, and the appropriate techniques for correcting them. Appendix B shows a sample somatic evaluation form . Appendix C tells you where to go for further information and training in the somatic field, and also mentions some other resources you may find useful.

The Somatic Perspective The theory, or principle, behind Somatic Technique is simple. The actual method of applying the technique is simple. But it is also true that what is simple is not necessarily so easy to grasp. Somatic Technique involves a different way of seeing the body. Most chiropractors, as well bodyworkers, are trained to see the body structurally-as a "thing" that is either "in" alignment or not. In traditional chiropractic, the adjustment is aimed at correcting the structural alignment so that function will improve. This perspective is based on a mechanistic, Newtonian model of health, where physical reality is viewed as being somewhat like a clockwork mechanism with, ideally, all the parts running smoothly and in harmony with each other. When things are not running optimally, then it is a matter of locating the part that is "misfiring" or is out of balance with the rest of the mechanism, and making whatever mechanical or chemical corrections are necessary. However, this model is becoming increasingly outmoded. Quantum physics is revealing to us that the universe is actually much more fluid, uncertain, and paradoxical than the Newtonian model would have us believe. In his book, Perfect Health, Deepak Chopra, M.D., points out: "We tend to see our bodies as 'frozen sculptures'-solid, fixed, material objects-when in truth they are more like rivers, constantly changing, flowing patterns of intelligence." 2 It is this "flowing pattern of intelligence" that underlies and drives our seemingly random universe, which, in spite of our desire for stability and constancy, is always in a dynamic and highly creative state of flux.

The Somatic Perspective 5 In the quantum perspective on healing, the key to returning the organism to a state of optimal health does not lie in tinkering with the parts or physiological process, as it does in the Newtonian model. In the case of allopathic medicine, where drugs or surgery are utilized to correct the offending part or process, or in certain chiropractic techniques, where the spinal vertebrae are frequently made to conform to some theoretically ideal alignment, applying the Newtonian view to healing can have negative side effects. The negative, inimical side effects . of prescription drugs are well documented. As for surgery, in just one example (back surgery), a 1988 study revealed that of 250,000 surgeries performed that year, only 10 percent were actually necessary. 3 One can only wonder as to what permanent damage may have been done to the spines of the 90 percent who did not actually need the surgery their doctors convinced them to go through. Thenegative effects of chiropractic structural adjustments are not as well documented, probably because by its very nature chiropractic is essentially a benign therapeutic procedure, especially when the chiropractic adjustment is delivered by a skilled and sensitive practitioner. Such a practitioner learns intuitively just how much force to use, how to gauge the timing involved in delivering a precise and gentle thrust, a_n d-above all-when not to manipulate. Unfortunately, not all chiropractic doctors have refined their manipulative art to the highest degree of skill and sensitivity possible. There have been some studies showing a very small incidence-ranging from 1:300,000 to 1:3,000,000-of serious complication resulting from cervical spine manipulation. 4 Ribs also occasionally get broken, and perhaps a vertebral process or two. Probably the most common negative effects are muscle spasms and inflammatory reactions caused by adjustments that are too abrupt or severe. Perhaps the main limitation of the structural model in chiropractic-and this is purely speculative, an observation based on my own twenty years of clinical experience in the field-is that repeated structural adjustments without any understanding of the subtler aspects of the patient's physical, mental, and emotional dynamics may not do very much good at all. It is also quite possible that repeatedly manipulatmg a vertebral joint over a period of many years could weaken the ligaments and create hypermobile facets. This weakening, in turn, could initiate a degenerative, osteoarthritic process in the joints as the body's intelligence seeks to stabilize the now unstable vertebral motor unit by laying down calcium deposits. The argument between structure and function is an old one in chiropractic, as old as that between "straights" and "mixers." Interestingly, both the structuralists and the functionalists-at least those who adhere to the "straight" school-acknowledge that what is fundamentally happening with the chiropractic adjustment is the release and stimulation of the body's own innate healing forces, or intelligence. In

6 Chapter I • The Somatic Perspective this regard, chiropractic always has been, and very much still is, in the vanguard of what might be called the "new wave" of healing. This "new wave" is the quantum model-and it is also the somatic perspective. Chopra addresses the quantum approach with great clarity and depth in his. book Quantum Healing .5 Essentially, the quantum/ somatic perspective is a Junctional one. It sees the organism as an interactive, highly dynamic mind/body phenomenon. The mind cannot be separated from the body, and the body cannot be separated from the mind. In the quantum model, the state of the patient's consciousness is an integral aspect of well-being. The thoughts and attitudes a patient holds in his mind intimately affect the physiological processes in the body and the degree of muscular tension or relaxation-and vice-versa. In his book, Chopra details the convincing scientific evidence for this view.

The Role of Consciousness and Innate Intelligence in Health Consciousness itself is our faculty of awareness-what Chopra, born and raised in a mystical Eastern tradition, calls the "silent witness.:' It is that in us which is aware of the continual arising and falling away of thoughts, images, sensations, feelings. When we are able to be totally present in the moment, awake and alert with all our faculties of perception-seeing, listening, feeling, tasting, smelling-then we experience our body not as a solid, mechanical, three-dimensional "structure," but rather as a dynamic and continually self-regulating process. We have physical boundaries, yes, and these are defined by the musculoskeletal system. Yet these boundaries are not at all fixed or static. They are continually changing, moving, responding to stimuli, adapting to stress, ever seeking, through the body's innate homeostatic mechanisms, a healthy state of functioning-that point of perfect balance between tension and relaxation. What guides this whole process is the body's innate intelligence coupled with the conscious awareness and cooperation of the patient himself. In his book, Chopra draws three specific conclusions about intelligence: "First, that intelligence is present everywhere in our bodies. Second, that our own inner intelligence is far superior to any we can try to substitute from the outside. Third, that intelligence is more important than the actual matter of the body, since without it, that matter would be undirected, formless, and chaotic. Intelligence makes the difference between a house designed by an architect and a pile of bricks." 6 As a chiropractor, I found these comments particularly relevant, given that the philosophical basis of chiropractic is built around the body's innate intelligence and powers of self-healing. In chiropractic philosophy, it is the "educated mind"-knowledge acquired from the

The Role of Consciousness and Innate Intelligence in Health 7 outside-that interferes with the flow of innate intelligence. The natural state of expression of the body is health, just as the natural state of expression of a quiet mind and an open heart is happiness. This is one of the fundamental teachings of the Tao Te Ching, the ancient Chinese manual on the art of harmonious living: that knowledge is a barrier to truth, and that when we put all our learning aside and just learn to be at ease in the moment, relaxed in body and mind, life unfolds in its own intelligent and perfectly appropriate way. It is when we interfere with the natural flow of events that things go awry. To illustrate to my seminar students how this can happen, I share with them the following limerick, about the plight of a centipede who made the mistake of stopping to think about how he managed to coordinate the movement of his one hundred legs: About its walk the centipede never wondered Until a frog came along and thundered, "I'd like to know, please How you move with such ease." At which the centipede tripped and blundered! In Quantum Healing, Chopra is in effect validating the philosophical basis of chiropractic-which is interesting, given that he himself is a medical doctor, and a former prominent endocrinologist. The difference, however, and the way in which Chopra's views expand the chiropractic philosophical perspective, is that intelligence is not just confined to the nervous system. Rather, as he observes in his book, it flows throughout each cell, like a "river." · The more in tune we are with the body's ceaseless flow of intelligence-which manifests, at the somatic level, as sensation, feeling, and movement-the more likely we are to become aware of the "fourth dimension" to well-being, which is the faculty of consciousness itself. In the somatic model, the development of consciousness-the ground from which all sensation and movement arise-is the key to healing and rehabilitation. In the structural model of health, the three-dimensional, linear view prevails. Consciousness is rarely acknowledged, other than perhaps recommending a change from a negative to a more "positive" attitude. Rather, the focus is on the pain or problem and things are done to the patient to bring him back into alignment and balance. The practitioner is separate from the patient. He is the active "expert." He "does" something to the patient in order to bring about a desired change. The patient is not usually required to be more aware of or sensitive to the functioning of his body /mind. He is usually a passive player in the healing process, waiting for the doctor or practitioner to "cure" him. Once the symptoms have gone, he goes about his life, probably not very

8 Chapter I • The Somatic Perspective much more conscious of his body than he was before it started acting up and making him uncomfortable. In the quantum, functional, somatic model, consciousness is everything. The practitioner is partnered with the patient. He is acting as a coach. He is teaching the patient to become more aware of his body, focusing on guiding him to a more holistic relationship with it. He helps him get acquainted with the fourth dimension through becoming more aware of himself and the way he breathes, moves, holds tension, and so on. This enhanced awareness shows up as presence. The patient is more centered within himself, more grounded. He is in his body. Being present in this way allows the patient to have more control over his muscles so that he can bend, stretch, and move with more freedom and ease. He is able to align his own will and intention with his body's innate flow of intelligence. When the mind is not obstructing or fighting the cellular wisdom of the body through negative thinking and unconscious emotional and behavioral patterns-which is what tends to happen in people who are not grounded and at ease in their bodiesthen the body's wisdom has room to operate and carry out the homeostatic and self-healing work it is meant to do.

Benefits of Learning This Work Somatic Technique, then, will add a truly educational and rehabilitative component to your work. It is important to be patient with yourself as you learn this new approach, because it involves above all a change of consciousness in the way you view the body, as much as it does the learning of any new therapeutic technique. The more present and aware you are in your own body, the easier it will be for you to help your patients or clients become present in theirs. As for the techniques themselves, study them as I suggest in Chapter Five and experiment with using some of them in your office. Use them on problem cases, especially where the difficulty seems to be primarily neuromuscular-where the patient has lost awareness, and therefore ease and flexibility, in some part of his body. Notice that you may find some of the techniques, especially at first, a little bit physically demanding. Some of the techniques may actually feel like "work." Learning Somatic Technique involves effort on your part, because it is a hands-on technique, and a new one at that. As you get better at it, however, it becomes easier. Through your own explorations you'll discover ways of doing the different techniques with minimum expenditure of your own energy. After a while you won' t even think about the "work" aspect of Somatic Technique. Your attention will be on the "play" of it, on enjoying the creative element in the work and the responsiveness you feel as the patient participates in the process.

Benefits of Learning This Work 9 Take your time. Find out how far you want to go with this. Do a little bit each day, as I did when I started learning this work, and gradually you will become good at it. In time it will become an important part of your practice and your patients will value what you do for them somatically. Of all the adjunctive therapies and educational tools available to hands-on practitioners, Somatic Technique is one of the simplest to learn and easiest to use. At the same time it is one of the most effective in terms of results because of the way it helps patients regain control of their own sensory-motor processes. Developing mastery in the technique also brings a number of very real benefits to the practitioner, and I would like to conclude this introductory chapter by outlining a few of them here: 1.

2.

3.

4.

5.

As a practitioner of Somatic Technique, you will enjoy the strength and conviction that come from having a valid, scientific, and "cutting-edge" rationale behind what you do. As you will learn, Somatic Technique is based upon sound neurophysiological principles. It makes sense, and once you grasp the principle yourself, it is easy to explain to your patients and your professional colleagues. Your knowledge of the body's sensory-motor learning system, and its relationship to healthy neuromuscular functioning, will enhance your overall understanding of the nature of health and disease. It will become clear to you that when people are not consciously relaxed and at ease in their bodies, but rather are tense and relatively inflexible, a whole host of health problems can arise. You will have a better and more intuitive understanding of Deepak Chopra's quantum healing model, which represents the "new wave" of health optimization and care. In the clinical work, you will have a powerful set of techniques for releasing the chronically tight muscles that cause pain, stiffness, postural imbalance, spinal misalignment (including both fixation and subluxation), and low energy. Your patients will appreciate this work and what it does for them. They will see that it really does give them a new sense of freedom and well-being in their bodies. They will report being able to sense and feel muscles they didn't know they had. As one of my patients once said, "It's as if I am learning to think with my muscles." You will have the satisfaction of knowing that you are making a genuine contribution to the long-term well-being of your patients by giving them tools that both educate and empower them. Patients frequently comment on the fact that they feel as though they are regaining control of their bodies-a faculty they had lost until they started the somatic work.

10 Chapter I • The Somatic Perspective 6. Your reputation as a health professional in your community will be enhanced. Whether you are a chiropractic doctor, physical therapist, massage therapist, or bodyworker, you will become known as a practitioner who brings state-of-the-art neuromuscular understanding and technique to the care of his or her patients. Professional referrals will increase as you talk about and, especially, demonstrate your work to other practitioners. 7. Doing the basic exercises and having the clinical work done on you by other practitioners will give you more energy and help you feel better physically, mentally, and emotionally. 8. Your study of Somatic Technique in particular, and the somatic field in general, will open up your mind and enlarge your perspective on the true nature of healing. You will have a better understanding of what it means to be a h ealthy, or "whole," human being. As you learn to embody your new understanding, to make it your own, it will increase the level of satisfaction and success you enjoy both in your practice and in your personal life.

References 1.

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5.

6.

Kramer, J., "The Third Perspective and Yoga: Bringing East and West Together," Yoga Journal (Nov.-Dec. 1981). Chopra, D., Perfect Health (Harmony Books, 1990), pp. 11-12. Saal, J.A. & Saat Joel S., Non-Operative Treatment of Herniated Lumbar Intervertebral Disc with Radiculopathy: An Outcome Study (San Francisco Spine Institute, 1988). Croft, A.C., "Keeping An Eye Out," (California Chiropractic Association Journal, May 1994), p. 37. Chopra, D., Quantum Healing: Exploring the Frontiers of Mind/Body Medicine (Bantam, 1989). Ibid, p. 45.

II

Origins and Principles of Somatics

The Mind/Body Connection The term somatic, as defined by Thomas Hanna, refers to an individual's internal awareness of his own sensory-motor processes. As a person becomes more kinesthetically aware of his body, he has more freedom of choice as to how he uses it. Enhanced awareness leads to improved function, which in tum results in better health. Hanna was not a licensed health professional. His Ph.D. was in philosophy; he had founded the graduate philosophy program at the University of Florida. He lectured and wrote about existentialism, a school of thought concerned with personal freedom and the meaning of individual existence. However, at some level he knew words were not enough. He became involved in the study of the mind/body relationship because he realized that to have elaborate philosophical ideas about the nature of freedom was one thing; to actually experience it in the body as a state of ease, flexibility, openness, and aliveness was another. Much of Hanna's work in somatic education was based upon the research of Moshe Feldenkrais, an Israeli physicist who was a pioneer in the field of neuromuscular learning. In 1975 Hanna directed the first training course that Feldenkrais gave in the U.S. The somatic exercises that Hanna taught, described in detail in his book, Somatics, were derived from Feldenkrais's system of awareness through movement. Many of Feldenkrais' s key insights, in turn, can be traced back to the teachings of F.M. Alexander, who developed his Alexander Technique for mindbody coordination in the early part of the twentieth century. For a more comprehensive account of this somatic "lineage," see Hanna's in-depth article in Somatics magazine. 1 Hanna was also influenced by the work of Hans Selye, the prominent Canadian endocrinologist who first introduced the concept of stress as a factor in health and disease. Selye' s General Adaptation Syndrome (GAS) describes this phenomenon and how changes in the body-such as alterations in physiology and increased neuromuscular tension-are inevitable when we are under stress. Hanna was excited by Selye's research and its "somatic" component, its discovery of just how much the mind affects the· body. As Hanna said, "Traditional medicine 11

12 Chapter II • Origins and Principles of Soma tics emphasizes the external viewpoint of what can be done to the individual's body to improve health. Selye, while fully accepting this emphasis, expanded the dimensions of medicine to include the individual's internal ability of self-control." 2 Another author, Leonard Chaitow, also noted the importance of the relationship between Selye's concept of the GAS and the neuromuscular system: "In assessing the patient the neuro-muscular-skeletal changes represent a record of the attempts on the part of the body to adapt and adjust to the stresses imposed upon it. The repeated postural and traumatic insults of a lifetime, combined with the tensions of emotional and psychological origin, will often present a confusing pattern of tense, contracted, bunched, fatigued fibrous tissue." He adds, "The chronic stress pattern that can result in the total organism will produce longterm muscular contraction." 3 Karel Lewit also makes the connection between motor patterns and states of mind such as anxiety, depression, and an inability to relax. 4 His colleague, Vladimir Janda, notes that the highest level of the nervous system regulating muscle tone is the limbic system, which is influenced by psychic reactions such as stress, fatigue, pain, and emotional states. These states, in turn, can cause demonstrable changes in muscle tone that can be accompanied by impaired muscle function and control of movement. 5 It is worth pointing out that Janda himself, a leading researcher in neuromuscular physiology, has observed that our knowledge of the function of muscles, their responses in different normal and pathological situations, and the coordination of their finer movements in relationship to each other is still extremely limited. Much of what is understood today is theoretically or empirically-based. Precise data is still lacking. The myriad cortical and spinal cord reflexes involved in even the smallest muscle movements are difficult to pin down in clinical tests. As Janda says, "Muscles do not represent an homogeneous entity ... Individual muscles behave in a different way even under supposedly similar physiological conditions." 6 It was clear to Hanna, however, that individuals adapted to stress through abnormal neuromuscular tightening, and that these patterns of adaptation tended to have certain common themes, depending on the nature of the stress. These observations resulted in his formulation of the concepts of the Red Light Reflex, the Green Light Reflex, and the Trauma Reflex, which I shall discuss later in this chapter. Once he had observed the patterns of stress, he then developed clinical techniques and exercises designed to help the client overcome them. The first goal was to get the client to becom e more aware of the unconscious adaptive mechanism s his body was making. The second was to show him how to m ove in a new way, so that h e could gradually regain normal control of his neuromuscular responses.

Tite Mind/Body Connectio11 13

Hanna's understanding of the relationship between stress and movement resulted in his creating a system of somatic education, which he then applied in his private practice. As his w ork became better known clients began coming from all over the country-sometimes even from other parts of the world-to visit him at his Novato office. These people were often regarded as medical "incurables." They had chronic musculoskeletal problems that apparently refused to respond to any form of allopathic treatment. Hanna would work with his clients for an hour, first evaluating their patterns of stress and finding out where the primary neuromuscular holding was centered. He would then work on releasing the muscular contractions through the unique "pandicular" movements he had developed. These pandiculations are the basis of the Somatic Techniques that make up this manual. The literal meaning of the term pandiculation is "to stretch." The patient or client fully contracts the involved muscle against a gentle resistive force applied by the practitioner and then gradually releases-or stretches-it while the muscle is still under tension. I will describe the exact methodology, its rationale, and its benefits, a little later in Chapter Three. Once the muscles were released through the pandicular techniques, Hanna would then teach the client a set of somatic exercises applicable to his condition or problem, to be done at home, usually first thing in the morning and last thing at night. At these times, Hanna felt, the brain was most receptive to new learning. While Hanna's work had its origins in Feldenkrais' s methods, his approach to sensory-motor learning was significantly different. The Feldenkrais clinical work is primarily passive and sensory in its application. The client sits or lies on the table and the practitioner gently moves certain muscles or limbs in ways that create a new sensory experience. Hanna's focus, as indicated above, was on eliciting the client' s active participation through having him consciously contract against resistance. This technique brought in the motor element more strongly. It created the biofeedback mechanism-the enhanced. sensation and feeling-needed to stimulate awareness and restore voluntary control of movement. Hanna seldom saw clients more than two or three times and, by all accounts, h ad a high success rate. H e describes five fascinating case studies in his book, Somatics. When researching his work, I intentionally sought out a few individuals who had gone to him and had not been helped. Whenever presented with a new and seemingly highly effective healing technique, it is always beneficial to dialogue with those with whom the technique did not work. They are the ones who h ave the most to teach us about the deeper and more mysterious aspects of human disease and d ysfunction, and I address some of these elements in Chapter Nine. The emotional and psychospiritual factors are an important element in all chronic patterns of neuromuscular stress.

14 Chapter II • Origins and Principles of Soma tics

Observing Hanna's Work

;:~,

However, it was the results I saw with my own eyes that convinced me of the value of Hanna's somatic approach. I watched him work with several doctors at the Napa chiropractic conference. One of them had a hip problem, the result of an old injury, that had caused pain and a limp for at least ten years. Manipulation and physical therapy modalities gave only temporary relief. Hanna examined the doctor and found extremely tight lateral hip rotators on the involved side. The several hundred of us in the audience were able to see the degree of contraction clearly as we moved closer to the stage. There was pronounced lateral foot flare, and the extent of medial rotation of the leg was about half that of the other side. Hanna then performed the corrective pandicular technique. It took less than two minutes. When a post-check was done, there was no longer any foot flare and the leg on that side had full medial rotation. When the doctor rose and tested out his hip by walking the length of the stage, he grinned and pronounced the pain at least 80 percent reduced. Hanna gave him a special exercise for the hip, and then had another doctor come up onto the stage. (The technique and the exercise for this condition are described in Technique# 7-Hips Supine.) The next doctor ha d a left shoulder girdle problem resulting from an injury two years earlier. He experienced pain in the shoulder joint and under the scapula whenever he raised the arm over his head or reached forward. He was no longer able to do side-posture adjustments on his patients and had had to learn alternative, non-force techniques to deal with pelvic and low back problems. When H anna had the doctor sit and elevate b oth arms as high as he could above his head, the left hand would not go as high as the right. It had about two thirds the ran ge of motion and there was some pain. I could see the doctor wince from where I sat. At Hanna's bidding, the doctor lay on the treatment table on his left side, with his knees at right angles to his body. Hanna performed another test, gently tractioning headward on the right arm, noting the r ela tive ease of m ovement of the sh oulder, and the glide of the sca pula on the ribs. H e then h ad the d octor turn onto the other side, and tested the problema tic shoulder. H ere there was relatively little movement and no scapula glide, due to the Latissimus Dorsi being contracted. There was also considerable pain and discomfort. Carefully and gently, Hanna began to work with the doctor, having him fully contract the Latissimus o n that side, and then gradually re leasin g it, all the while keeping the muscle under tension. A gain, the process took just a couple of minutes. The doctor found the correction uncomfortable at first, and he had difficulty making the movement Hanna was asking of him. He was simply not used to exercising such a degree of conscious, intentional control with his muscles.

Observing Hanna's Work 15

As Hanna pointed out to those of us in the audience, the connection between his sensory-motor cortex and the muscle itself had been broken. Until Hanna began working with him, he was not able to even feel or sense the muscle, let alone move it intentionally. But once he sat up, and raised his arms above his head for the post-check, the difference was remarkable. The left hand went almost as high into the air as the right. And he didn't wince this time. He smiled, and said how much easier it felt to raise his arm. He then moved the whole arm about, testing it through a variety of ranges of motion, and his smile only got bigger. Then, as with the previous doctor, Hanna gave the man an exercise to do morning and evening at home. (The technique and related exercises for this problem are described in Technique 11Latissimus Dorsi.) It was Hanna's presence as a human being-the way in which he embodied his somatic understanding-combined with his articulate explanation of his work, and his skill in quickly diagnosing and correcting these two doctors' problems, that motivated me to attend an Esalen seminar with him later that same year. During the seminar I saw many more examples of the uniqueness and effectiveness of his method as he addressed the somatic problems of the participants. Just as importantly, I got to experience changes in my own body and in my awareness when it became my turn to lie on the table and be the client. As I watched him at work over the course of those five days, I saw the potential of what he was doing in terms of its application to my own profession, chiropractic. Chiropractic emphasized the importance of structural alignment; it dealt with bones, specifically the spinal vertebrae. It was all too easy to forget that bones do not move by themselves, but that muscles move bones. I had always felt that chiropractors needed to pay more attention to the soft-tissue components of structural problems, and in my own practice, use acupressure and massage as a way of doing that. Hanna's approach addressed the soft-tissue elements-specifically, the neuromuscular system-in a very sophisticated way. It was both therapeutic and educational. It worked with the patient's awareness, and this feature p articularly interested me. For many years I had been involved in the s tudy of yoga, m e ditation , and the mind/body I spirit connection as they related to healing. (In fact, after I had been working with soma tics for a year or two, I began to think of it as a "Western yoga.") I was always looking for ways of getting my patients more interested in these things, or at least in becoming more aware of themselves in their bodies. Using some of Hanna' s ideas and methods would be another tool for helping me accomplish my goal, and a very practical one at that, because it was grounded in the patient's somatic reality, in his sensory-motor experience. As it turned out, that week with Hanna, short and intensive as it was, revolutionized my thinking around the body. While it was not a

16 Chapter II • Origins and Principles of Soma tics training as such, I saw and learned enough in those five days to know that my style of practice would never again be the same. I began to see the possibility of a new way of working with people, a way that would both help my patients get free of their aches and pains, and transform their experience of themselves in their bodies. Working with the sensory-motor system not only affected the balance and alignment of the spine, but it helped bring a new and vibrant sense of well-being to the person as a whole.

The Principle Behind the Somatic Approach One of the most important things Hanna said during the seminar was in response to a question I had asked about a specific technique. "Look," he said, "once you get the principle behind this work, you can be as creative as you like in the way you apply it." The principle he was referring to is exquisitely simple and neurophysiologically sound. It has to do with the body' s sensory-motor learning system and can be stated as follows: The ability to voluntarily contract or relax a muscle is directly dependent upon the degree to which the muscle can be sensed, or felt.

In other words, sensory awareness and motor control go hand-inhand, a sensory-motor feedback loop governed by the cortex of the brain? So long as we have full sensory-or proprioceptive-awareness of our muscles, we have full control over them. We can contract and relax them at will. "Movements flood the nervous system with sensations regarding the structures and functions of the body," Deane Juhan notes. "Movement is the unifying bond between the mind and the body, and sensations are the substance of that bond.'' 8 Vernon Brooks, the Canadian researcher whose work in neurophysiology caught Hanna's interest, states: "Two-way communication between sensory and motor systems is essential for normal behavior and particularly for the learning of new tasks . ... Proprioception is the most important sense from inside our bodies. " 9 This view is confirmed by Janda, who informs us: The importance of adequate sensory input, proprioceptive control, and proper function of sensorimotor integration has probably been underestimated in the pathogenesis of low back pain. Inadequate proprioceptive stimulation from joints, muscles, skin and other structures means that no level of the sensorimotor system is facilitated to work properly. In this way, joint and muscle dysfunction can directly impair the central nervous system's motor regulation. In addition, more highly mechanized and sedentary life-

Tire Principle behind the Somatic Approach 17 styles lead to a reduction in the variety of movement. This in itself may decrease the proprioceptive stimulation essential for the performance of good motor patterns. For this reason, proprioceptive facilitation techniques should be included in the therapeutic programs for those suffering from low back pain syndromes and postural defects. 10

Janda's comments regarding the need for good proprioceptive feedback apply equally of course to all parts of the body. Problems in locomotion arise, however, when the feedback pathways are interrupted or lost. The main causes of proprioceptive disruption in the typical individual are stress and trauma. A stressful or traumatic stimulus causes a reflexive tightening of the involved musculature which, as it persists, becomes a new, learned pattern of movement, an adaptive response to a somatically challenging situation. An example of stress might be the repetitive motion of a particular work situation, such as an auto mechanic's constantly looking upward and using his arms overhead as he works on repairing transmissions. When the quality of movement is decreased due to repetitive actions (or, in another common example, a sedentary lifestyle), the amount of proprioceptive feedback to the brain is correspondingly limited, with a negative effect on overall healthy motor functioning, since optimal sensory-motor well-being depends on a continual stream of rich and varied proprioceptive impulses flowing back to the cortex. Alternatively, the stressful stimulus may be psychoemotionally induced and result in a gross postural distortion, as in Hanna's Red Light, or withdrawal reflex, when there is a tightening of the muscles on the ventral aspect of the body, causing a stooped, round-shoulder posture. (This, and the other two postural reflexes identified by Hanna, will be examined shortly.) Similarly, when there is an injury to the body, muscles reflexively tighten in order to immobilize and protect the traumatized area-or to reactively pull away from it, as in antalgia. What is common to all of these situations is that the proprioceptive feedback from these reflexively tightening muscles gradually becomes integra ted into a n ew pattern of movement. Even if there is some degree of consciousness to begin with on the part of the individual as to how he is using his body and tightening his muscles in this new or different way, the awareness is soon lost, because these movement patterns are eventually "handed down" by the cortex to the subcortex, where they become automatically mediated. The brain performs this way because reflexive movements are faster and more economical, and require less mental effort. 11 But with the gradual loss of cortical awareness there is a corresponding loss of-conscious control. The individual no longer has the ability to move freely and easily in the affected area of the body. He

18 Chapter II • Origins and Principles of Soma tics

cannot intentionally utilize muscles that he cannot feel. Thus his movements tend to be stiff, limited, and mechanical-a jerkiness or spasticity of motion resulting from the chronic tightness of the involved muscles. The two doctors at the Napa conference demonstrated such proprioceptive "failure," the first with the lateral hip rotators, the second with the Latissimus Dorsi. Involuntary, or subcortical, reflexes, as outlined above, h ad taken o ver, triggering muscle contraction and causing the affected muscles to remain in a state of chronic tension. Hanna coined his own term for this phenomenon: "sensory-motor amnesia," or SMA, which I will discuss in more detail shortly. The correction of SMA lies in the principle stated above-the reawakening of normal sensation and feeling in the muscle leading to improved motor control. As Janda says, "The patient must gain the feeling of the muscle contraction and sense the correct movement." 12 As we shall see, this is exactly what Somatic Technique is designed to accomplish.

Adapting Somatic Work to the Chiropractic Environment After the Esalen seminar, I went back to my office. Using the principle Hanna gave me, and remembering his instruction to be "creative," I began experimenting with some of .his techniques, and also started playing around with several of my own making. As new as this work was to me, I began to see some very noticeable changes in my p atients. A 76-year-old woman with chronic stiffness and immobility in her upper back and shoulders was able to fasten and unfasten her bra without pain for the first time in, as she put it, "living memory." Hers was primarily a bilateral Latissimus Dorsi, Trapezius, and Pectoralis contraction. A 35-year-old woman with a seven-year history of knife-like pains in the Rhomboid/ scapular area had all her symptoms disappear after one session. A 55-year-old man with severe low b ack p ain was afraid of m anipulation. I used only the sensory-motor work to relax the o ver-contracted extensor muscles of h is spine. After getting up from the table he n oticed there was less pain, and he was able to move more freely. Several follow-up sessions, and a commitment on his part to twice-daily somatic exercises, cleared away the remaining discomfort. Inspired by these results, I began to do more research into the whole field of ne uromuscular therapy and reeducation. In particular, I looked into two methods of working with musculoskeletal problems that, in their application, bore some resemblance to H anna's work: the muscle energy work of osteopathy, and some of the PNF techniques of physical therapy. All three approaches appear to achieve many of the

The Healthy Soma 19

same clinical results; yet, there are some differences, which I will outline in the next chapter. Somatic Technique, as I have developed it, is based on the sensory-motor learning principle-the "Big Idea" -that I learned from Thomas Hanna. There are some thirty-three techniques for dealing with all the main muscles of the body, from the TMJ to the lower extremity. Twenty-one of these constitute the "basic techniques," and are used to address the most commonly occurring somatic problems. Eight of these basic techniques are the ones originally demonstrated by Hanna; the others I have devised myself, using the principle he gave me, along with ideas gleaned from studying the muscle energy and PNF texts. Any given technique can be performed in as little as a couple of minutes, making it an ideal adjunct to chiropractic care or any other form of hands-on practice, be it physical therapy, osteopathic manipulation, massage, or one of the many forms of bodywork or movement reeducation popular today. Alternatively, Somatic Technique can be used as a method of neuromuscular reeducation on its own. I have some patients, for example, whom I schedule just for somatic work. It is an excellent technique for patients who do not respond well to osseous manipulation, and whose problems are primarily muscular and postural. Others hear that I specialize in this approach-perhaps through knowing someone who has benefited from it-and request it specifically. Often they have already tried chiropractic and other methods without success, or with only limited results.

The Healthy Soma Hanna referred to the human being as a soma. As somas, we are "self-aware, self-sensing, and self-moving"-we are self-responsible entities who can change ourselves. 13 To be a soma is to be consciously present in our bodies, attuned to our internal sensory-motor processes, to the quality of sensation, feeling, and movement in our muscles and joints. We can contract and relax our skeletal muscles at will. This heightened awareness gives us freedom of choice as to how we use our bodies. We are able to move with suppleness, grace, and ease. This enhanced awareness of ourselves as a somatic being-a unified mind/body-leads inevitably to improved function and health. But contrast this optimal state of sensory-motor well-being with the situation of the typical adult patient that we see in our practices. He has a history of injury and stress, compounded by what is probably a low level of somatic awareness. Unfortunately, all too many of our patients still do not pay much attention to their bodies-unless they are hurting. The stress has caused a reflexive, persistent tightening of the skeletal musculature, whether in the lower back, the shoulder girdle, the

20 Chapter II • Origins and Principles of Soma tics abdominal area, the buttocks, hips, hamstrings, or some other part of the body. These chronically tight muscles produce a range of negative side effects. The patient feels stiff, sore, and in pain. He may be an acute case, but more likely has lived with some degree of neuromuscular dysfunction for years. Rather than being able to move with the "suppleness, grace, and ease" of the healthy soma, he feels decidedly uncomfortable in his body. When asked to touch his toes, for instance, he may bend forward and reach down only with great difficulty due to the contraction of the lumbar paraspinal muscles, the hamstrings, and the calf muscles. But as practitioners, we may not even have to look at our patients to see how injury and stress have negatively affected the naturally relaxed and well-balanced tonus of the musculature. How many of us are consciously aware, as an ongoing reality, of our own patterns of breathing, sensing, feeling, and moving? In addition to presenting a very effective set of techniques and exercises, one of my aims in writing this book is to stimulate you, the practitioner, to be more conscious and present as a soma. The more aware you are of your own body, the easier it will be for you to establish a genuine rapport with your patients, and help them develop a more sensitive and productive awareness of their own somatic reality.

The Standard Allopathic vs. the Somatic Approach The goal of somatic education and the techniques and exercises presented in this book, is to reawaken the patient's inherent ability to be aware of and to control effectively his own sensory-motor processes. It is to become, once more, a supple, graceful and healthy soma. As such, it requires participation and commitment on the part of the patient. This is where the somatic method differs from the traditional Western medical approach to the sick patient. In the Western allopathic model, the patient is seen from a thirdperson, objective view. In this model, the patient is regarded as a person entering the office with a "condition" which must be diagnosed and treated. In a very real way, the patient and his doctor are both somewhat detached from the condition. The condition becomes the unwanted "other" -'the irritating nuisance or problem which, by its very existence, is getting in the way of the patient's capacity for enjoying a relatively normal life . As outlined in the previous chapter, the problem with this approach, even if the condition is successfully treated, is that it usually effects little real change in the consciousness of the patient. He leaves the practitioner's office after one or a number of visits, thankfully out of pain, but just as unaware of his body-the breathing, sensing, feeling,

Tlte Standard A.llopatl!ic vs. the Somatic Approach 21

moving organism he is-as he was when he first went in. Indeed, he is probably even less aware now that his symptoms have subsided. Pain can serve as a much-needed wake-up call, but one of the problems of merely palliative care is that it tends to allow the patient to slip back into complacency, thinking that everything is all right once again and he ca·n now go back to his old unconscious habits. Typical therapy tends, therefore, to disempower the patient. It makes him dependent on the doctor or therapist. With the somatic perspective, however, the emphasis is on the first-person, subjective viewpoint. When we use Somatic Technique and the supportive exercises, it is with the aim of bringing the patient fully into an awareness of his body, and especially his sensory-motor functioning. The presenting neuromuscular condition is seen not as a "thing" or "state" with which the patient has unfortunately been afflicted, but rather a result of the patient's lack of awareness and presence in how he has used his own body. Lewit also addresses the difference between the allopathic model of therapy, and care that seeks to actually rehabilitate and educate: Conscious, active cooperation by the patient is another important feature shared with rehabilitation medicine. In most fields of medicine, the attitude of the doctor is only too often that of the ancient shaman: the patient comes to be cured, whether by drugs, surgery, or miracle. The patient (as the word implies) patiently does nothing about it; he is only the object of medicine. In rehabilitation, on the contrary, the patient is the subject, and as doctors we merely advise him how to deal with his predicament. 14

Our goal, then, is to educate the patient to be more conscious of how, and in what circumstances, he tends to reflexively tighten his muscles-and how, with guidance and practice, he can learn to consciously release his own contracted musculature at will. It takes time, of course, to learn the art. The old patterns do not change overnight. Nevertheless, it can be done. I have seen it happen time and time again in my own office- middle-aged individuals as well as senior citizens, all of them with years of chronic neuromuscular stress, gradually regaining some of the flexibility and suppleness of youth. The somatic approach is one that empowers the patient, because it helps restore normal neuromuscular functioning and control. When the patient eventually leaves our care, it is with an invaluable set of tools that will allow him-so long as he continues to use the tools-to enjoy an optimal state of sensory-motor well-being throughout his life.

22 Chapter II • Origins and Principles of Somatics

The Three Reflexes That Cause SMA According to Hanna, there are three specific reflexes that cause muscles to habituate and remain chronically tight. He describes these reflexes in great detail in Part Two of Soma tics. I will present the essential components of them here, which will give you enough information to begin to recognize them. I recommend, however, tha t you read Hanna's book. In a healthy, optimally functioning body, the skeletal muscles are just tense enough to maintain a balanced posture and ease of movement. In Janda's view, muscles function as either "postural" or " phasic." The former are static and more hyperactive, involved with maintaining posture. The latter, more relaxed and pliable, perform the function of movement. Most muscles serve both functions, but one will predominate. Refer to Lewit's text for a detailed classification of the main muscle groups according to this system. 15 When there is stress or injury, however, muscles tighten, or contract, as a defense. The natural balance between the postural and phasic muscles is then frequently disturbed, resulting in a variety of locomotor problems. The postural muscles become even tighter, the phasic weaker. Very often a threat is perceived where none exists, and the muscles continue to tighten, their contractions being controlled by involuntary, or subcortical, reflexes. This is the "fight or flight" mechanism so well understood by biofeedback therapists. It is these chronically tight muscles that cause the pain, stiffness, and soreness the patient feels in his body. Unless he becomes aware of the tight muscles and learns h ow to relax them, or let them go-that is, regains n o rma l cortical control-they persist indefinitely, ending up in a state of p e rmanent contraction, or h abituation . P a in and stiffness can go on for years, sometimes for an entire lifetime. The patient literally "forgets" that he is holding tension in his musculature because he has lost awareness of his muscles-hence Hanna's term, sensory-motor amnesia. As I have indicated, what the patient cannot fee l, he cannot control-which is why he can' t relax these tight, p ainful muscles, n o matter h ow h ard h e tries. Indeed, " try ing" to relax a tight muscle tends to only make thin gs worse by creating further agitation and s tress. Hanna defines three main causes of SMA, three reflexes which all originate in the subcortical nervous system and are therefore involuntary. The first is the Red Light, or startle reflex. This is a fear, or withdrawal response, in which we instinctively contract in tow ard the center of the body to try and pro tect ourselves-a reflexive return to our original fe tal posture. The startle reflex is one of our most instinctual reflexes, and is integral to our survival. It becomes a problem, howe ver, with people who are overly sensitive and who live with a lot of anxiety or worry. Feeling continually confronted by negative energies in life-or

The Three Reflexes That Cause SMA 23 the threat of them-such people tend to live in a chronic state of contraction, or withdrawal. The telltale signs of the Red Light reflex include a wrinkled brow, a forwardprojecting head, tense jaw and face, the beginnings of a dowager's hump, hunched shoulders, flat chest, tight abdominal muscles, stooped posture, and shallow breathing. All of this is caused by the persistent contraction of the muscles in the front of the body (see Figure A). According to Hanna, the withdrawal reflex is the neuromuscular adaptation to sustained negative stress-or "distress." 16 He calls it the Red Light reflex because all forward movement tends to comes to a stop. Figure A The second cause of SMA is the Green Light, or Landau reflex. The Landau reflex is first seen at five to six months of age, when the infant, lying face down in its crib or on the floor, makes its beginning attempts to arch its back and extend its legs. It marks an important stage of development. The tightening of the posterior muscles of the body is a prelude to standing and walking. In the adult, this vestigial reflex acts as an assertive movement, the instinctive response we make when something is demanded of us. It literally readies us for action. Using Selye' s model, Hanna regarded this reflex as the neuromuscular adaptation to sustained positive stress ("eustress").1 7 It is the subjective feeling associated with effort. In the Green Light reflex, the phone rings, somebody calls us, we remember something we have to do, and immediately we arch up and back slightly as we prepare to "go" -to move into action. In our fast-paced, achievement-oriented .so_fh. ety, the harmful effects of this chronic, habitual tightening of the posterior muscles of the body include headaches, neck and back pain, disc problems, sciatica, sway-back, protruding belly and, inevitably, lack of energy and fatigue (Figure B). As people reach middle age and beyond, they may show signs of both reflexes. Most people feel under the stress of time and the need to accomplish m ore, and most people w orry to some degree. The combination of these two reflexes creates what Hanna terms the "Dark Vise," or Senile Pos- Figure B

24 Chapter II • Origins and Principles of Soma tics

ture-the back of the body pulling against the front of the body, and vice-versa. (Figure C.) The results are stiff and limited movements; chronic pain; shoulder, hip, and knee problems; fatigue; shallow breathing; a negative self-image; and, often, because of the increased pressure on the abdominal and pelvic organs, such other related medical problems as high blood pressure, constipation, menstrual difficulties, and even, according to Hanna, sexual dysfunction. Clearly, when people do not feel open and at ease in their bodies, when they live for decades with poor posture, tight muscles, and restricted ranges of motion, the function of many internal organs, Figure C as well as circulation and the general level of energy, is going to be affected to some degree. The third major cause of SMA is the Trauma reflex (Figure D), where the body tends to contract around-or away from-an area of injury, or where there has been surgery. The "abnormal" proprioceptive information from these contracted muscles becomes integrated into a new learned movement, or contracture, which tends to persist even after the pain of the initial traumatic lesion has healed. 18 Hanna noted that the Trauma reflex results in the muscles on one side of the body (primarily the Obliques) being tighter and shorter than on the other side, causing a low shoulder and high hip on the involved side, with diminished space between the twelfth rib and the iliac crest. The Trauma reflex, because of the way it can diminish neuromuscular functioning unilaterally, also offers a clue as to why people sometimes manifest their health problems and joint pains on one side of the body only, rather than both. Notice that all three reflexes tend to center in the middle of the body-Red Light fear in the abdomen, Green Light stress in the lower back, and the tightening of the Trauma reflex in the waist, causing the b ody to tilt to on e side. Thus, the techniques for freeing up the lower back and the middle of the body become very important-the "foundation" of this work, you might say. Once you free up the center of the body, Figure D

References 25

many other problems will often clear up by themselves. In the next chapter we will look at the far-reaching negative consequences of SMA, the somatic approach to correcting it, and the neurophysiological rationale behind the technique's remarkable effectiveness.

References 1. Hanna, T., "Clinical Somatic Education: A New Discipline in the Field of Health Care," Somatics: Magazine-Journal of the Bodily Arts and Sciences (Vol. 8, Autumn-Winter 1990-1991, No.1), pp. 4-10. 2. Hanna, T., Somatics: Reawakening the Mind's Control of Movement, Flexibility and Health (Addison Wesley, 1988), p. 45. 3. Chaitow, L., Neuromuswlar Technique (Thorsons, 1985), p. 15. 4. Lew it, K., Manipulative Therapy in Rehabilitation of the Locomotor System (Butterworth-Heinemann, 1991), p. 3. 5. Janda, V., "Muscles and Motor Control of Low Back Pain," Physical Therapy of the Low Back by L.T. Twomey and J.R. Taylor (New York: Churchill Livingstone, 1987), pp. 258-259. 6. Janda, V., " Muscle weakness and inhibition (pseudoparesis) in back pain syndromes," Modern Manual Therapy of the Vertebral Column, ed. G.P. Grieve (Edinburgh: Churchill Livingstone, 1986), p . 197. 7. Guyton, A., Textbook of Medical Physiology (W.A. Saunders, 1971) 689691. 8. Juhan, D., fob 's Body: A Handbook for Bodywork (Station Hill, 1987), p. XXV.

9. Brooks, V.B., The Neural Basis of Motor Control (Oxford University Press, 1986), p. 11. 10. Janda, "Muscles and Motor Control," p. 259. 11. Hubka, M.J., in a paper based on a seminar presented by V. Janda, Los Angeles College of Chiropractic, May 1988. · 12. Janda, "Muscles and Motor Control," p. 275. 13. Hanna, Somatics, p. 21. 14. Lewit, p. 279. 15. Lewit, p. 24. 16. Hanna, Somatics, p. 47. 17. Ibid. 18. Hubka.

III

Neurophysiology

The Negative Effects of Sensory-Motor Amnesia The three major somatic reflexes described in the previous chapter offer one explanation as to the cause of sensory-motor amnesia, or SMA, which Hanna defined once as, simply, "no longer remembering how to move about freely." 1 What is clear is that stress and injury cause a reflexive (involuntary) tightening of our muscles. When the stress is constant, or the injury traumatic and slow to heal, these reflexive muscular contractions, emanating from the brain stem and cord, persist and eventually become habituated. That is, the muscles become permanently tight. Because the patient has "lost" the ability to feel, or sense, the involved muscles, they remain tight and contracted. Moreover, no amount of stretching or manipulation will get them to fully let go, because the problem is not in the muscle. It is in the brain. The connecting link between the patient's awareness and his muscle has been broken. He cannot control what he cannot feel. This loss of awareness and control is the essence of SMA. Its main effects are as follows: 1.

Reduced Range of Motion and Stiffness. Chronically tight muscles themselves are a source of limitation in joint motion. For example, a contracted Latissimus Dorsi will prevent full elevation of the arm, just as contracted cervical extensors will limit forward flexion of the head and neck. Tight muscles also re·sult in stiffness due to hardening of the fascia and other connective tissues. Connective tissue exhibits a phenomenon called thixotropy. 2 It becomes softer and more supple when it is subjected to regular movement, such as shortening and lengthening, twisting and flexing. Conversely, it starts to harden, to become dry and stiff, when it is subjected to no movement at all. When a muscle is chronically contracted, its fascia "freezes" and soon loses its natural pliability. The tight muscles and hard, unyielding connective tissues-fascia, tendons, ligaments-then adversely affect the movement of the

27

28 Chapter III • Neurophysiology joints and limbs, causing a reduction in the normal ranges of motion. 2. Soreness and Pain. This effect is due. primarily to the accumulation of lactic acid. Lactic acid and the other metabolites of muscle contraction are normally drained away via the lymph system as the muscle goes through its phases of lengthening and shortening. When the muscle is chronically tight, this draining does not happen so readily. The lymphatic drainage is less effective and the lactic acid accumulates, or "pools." Another source of pain from the sustained contraction of muscles is the ischemia that results from the reduced blood flow through the capillaries in the restricted area. Decreased oxygen delivery, even if for just a short time, causes even healthy cells in the area to become painful. 3 In terms of pain in general, Hanna himself estimated that SMA is responsible for as many as 50 percent of the cases of chronic pain suffered by human beings. 4 3. Vertebral Subluxation. Chronic muscle contraction in the paraspinal muscles is a major cause of persisting patterns of spinal misalignment, or subluxation. R.C. Schafer defines the subluxation as "the alteration of the normal dynamic, anatomical, or physiologic relationships of contiguous articular structures," and extensively details the range of possible biomechanical, vascular, and neurological effects of the subluxation syndrome. He writes, "The lesion usually becomes a focus of sustained irritation from which a barrage of impulses stream into the spinal cord where internuncial neurons receive and relay them to motor pathways. The muscular contraction that provoked the subluxation is thereby reinforced, thus perpetuating both the subluxation and the pathologic process."" This is why it is important for chiropractic doctors to have procedures, such as Somatic Technique, for addressing the neuromuscular elements. The technique itself can be used as an alternative to the high-velocity thrust, as I will discuss later in this chapter. 4.

Fatigue, Energy Loss, Weakness. Muscles that are tight are constantly working, and are therefore using a significant amount of available energy. As Juhan notes, the musculature is by far the biggest energy consumer in the body. "Chronic (muscle) tension," he writes, "initiates a vicious circle which plunges the area into deeper and deeper metabolic debts, draining energy from other parts of the body, producing ischemia and toxic wastes, creating discomfort, and eventual disuse." 6

Tlte Negative Effects of Sensory-Motor Amnesia 29

In addition, Sherrington's Law of Reciprocal Inhibition states that increased activity of certain muscles leads to inhibitionand thus weakening-of their antagonistic muscles. What is often not realized is that chronically contracted muscles are themselves weaker than muscles with a more normal length to them. According to Brooks, "Excitation of the motor nerve from the spinal cord determines how frequently the muscle is excited, but how it actually contracts and relaxes is determined by the properties of the muscle tissue. One of those properties is that muscles can generate more contractile force while being stretched (lengthening) than while they are shortening . . . . Lengthening muscles store up more viscous and elastic force, which is available for release as contractile force; in other words, lengthening muscles contract more efficiently than shortening muscles." 7 As Brooks notes, this factor is important for locomotion and for the learning of all motor skills. Chronically tight muscles due to SMA (or any other cause) are an impediment to these functions because of their reduced ability to contract efficiently and strongly. 5. Increased Susceptibility to Injury. A body that is tight lacks resilience, the ability to yield when meeting resistance of any kind (as in a slip or fall, or when lifting or bending). If the opposing force is too great, something has to "give" -and it is usually the tight individual's back, neck, or one of the extremity joints. Most practitioners have seen examples of this many times, the most classic of them being the case of the construction worker who spends years bending to lift heavy beams, and noticing nothing more than an occasional feeling of fatigue or stiffness in his back. Then, one day, he bends to pick up his lunchbox, feels a sharp "snap" or tug in the lumbar region, and his low back goes into spasm. In situations like this, the metaphor of the "straw that breaks the camel's back" becomes a harsh human reality. 6. Premature Aging. One of the main physiological changes that make people feel "old" is the stiffness, poor posture, low energy, and impaired circulation that results from the chronically tight muscles associated with SMA. (I refer you again to Joel Kramer's comments on the conditioning and aging process, on page 1.) The phenomenon of premature aging was of special interest to Thomas Hanna, and is a focus in his book Somatics, the introduction to which is titled, "The Myth of Aging." "Human beings," he writes, "once they advance from crawling on all fours to walking on two, no longer need regress to a limping posture once they become older. That is to say, the bodily decrepitude presumed under the myth

30 Chapter III • Neurophysiology of aging is ~ot inevitable. It is, by and large, both avoidable and reversible." The Chinese sage, Lao Tzu, in his Tao Te Ching, considered a classic treatise on the art of harmonious living, eloquently spoke to the same issue over 2,500 years ago:

Men are born soft and supple; dead, they are stiff and hard. Plants are born tender and pliant; dead, they are brittle and dry. Thus whoever is stiff and inflexible is a disciple of death. Whoever is soft and yielding is a disciple of life. The hard and stiff will be broken. The soft and supple will prevail. 9

Correcting SMA through Reawakening Intentionality (Cortical Control) The goal of Somatic Technique is to reawaken normal sensorymotor (neuromuscular) control-to bring intentionality back into the patient's movement patterns. Cortical awareness is activated by isolating the involved muscle and having the patient fully contract it against a resistive force applied by the practitioner. Amplifying the contraction brings the muscle more into sensory awareness. The patient, able to feel the muscle more readily, has more motor control over it. This method of going with the resistance, rather than against it, was a unique aspect of the work ofMoshe Feldenkrais, Hanna's teacher. According to Hanna, it was one of Feldenkrais's most important contributions to the correction of neuromuscular problems, and came in part from his understanding of judo. Feldenkrais was a judo master, one of the first European black belts. The success of a judo throw depends upon being able to detect your opponent's direction of movement so that you can use his energy, his momentum, to defeat him. You overcome him not by opposing his force with your own, but rather by moving in the same direction. In the same way, Feldenkrais discovered that if you do the work of a tight muscle, if you approximate the origin and insertion, the muscle will relax and soften. By giving the muscle permission to do what it is trying to do anyway-that is, tighten-you create proprioceptive feedback which results in a reflexive inhibition of the contraction. I shall explain the actual neurophysiological mechanisms behind this phenomenon in the next section.

Correcting SMA through Reawakening Intentionality 31 The Swedish therapists Evejenth and Hamberg quote C.S. Sherrington, the English neurologist, in this regard: "The stronger the contraction (without pain), the greater the subsequent relaxation.'' 10 This is the intelligent way to get a muscle to relax: instead of fighting it, you go with it. The typical allopathic approach to tight muscles is to try and stretch them. The problem with this approach is that if you pull too hard on the muscle you trigger the stretch reflex: the muscle automatically responds with an equal pull in the opposite direction, and goes into spasm. The technique, then, is to have the patient contract his muscle against a resistive force of 5-15 pounds (depending on the size and strength of the patient). This process gives strong sensory feedback to the brain, increasing the patient's awareness of the muscle-both how it feels, and what it feels like to consciously tighten it. The sensory-motor cortex and the muscles are connected in the form of a feedback loop (Figure E). When you increase sensory input, sensory information floods directly into the motor cortex, and the result is enhanced motor control.

Motor cortex

Frontal lobe

Sensory cortex

Sensory neurons

Motor neurons

Muscle

Figure E

32 Cltapter III •

Neurophysiology

Enhanced awareness of sensation and feeling in the muscle, in other words, translates directly into a heightened ability to contract or relax the muscle, and to control the rate of contraction or relaxation. As Brooks says, this process of sensory-motor integration awakens "the patients' 'sense of effort' through various sensory stimulations, which seem to function as biofeedback. In this way, we can learn to 'concentrate' on performing movements for which we have had no 'feel,' and motor learning can be aided.'' 11 To further stimulate sensory awareness, the patient is instructed to close his eyes so that he can better access kinesthetic feeling. If the eyes are open, the patient tends to focus outside his body-or simply gaze mindlessly into space. Either way, it further disconnects him from his internal somatic process. At the same time, we have him inhale as he contracts. Just as we intensify the muscular contraction before we release it, so we amplify the breathing pattern. When an individual tenses his muscles, the tendency is to pull in-and hold-the breath. The more pronounced the overall pattern of muscular contraction, the shallower the breathing. Before we can get him to fully release the holding in his breath, we have him intensify it first-just as we get him to intensify the holding in his muscle. A fully conscious inhalation allows for a more complete exhalation. After the muscle is contracted, it is then gradually lengthened while still maintaining resistance, or tension (an eccentric contraction). The patient is encouraged to exhale with the release-to simultaneously let go the breath as he releases the muscle. Every 4-8 inches of lengthening (depending on the size of the muscle being worked with) the muscle is briefly contracted concentrically, shortening it 1-2 inches, before again lengthening. The purpose of the intermittent shortening of the muscle is to vary the stimulus, in accordance with the Weber-Fechner rule in neurophysiology, which states that we perceive transient changes in touch, pressure, etc. in relation to a constant background stimulus.12 If there are no changes in stimulus, then we eventually lose awareness of the original, background stimulus-in the same way that a person who moves into a house near a freeway eventually ceases to notice the constant noise of the traffic. By periodically having the patient shorten the muscle an inch or two, it keeps his brain "interested" in what is happening. It helps refocus his attention, thus ensuring a continued flow of sensory feedback to the cortex. Because the technique is done consciously-with the emphasis on a slow and controlled release-it allows the patient to become more kinesthetically and proprioceptively aware of what is actually happening with the muscle. This lengthening process is repeated twice, and then there is one final, complete contraction, followed by a quick release. After having worked slowly, this suddenness of movement further helps stimulate sensorymotor awareness. With some muscles, the antagonists will then be

How Somatic Technique Works at the Subcortical Level 33

contracted briefly-the reinforcement phase. This technique is used when we want to "remind" the cortex of where a limb or body part belongs. For example, tight upper Trapezii and Levator scapulae cause the shoulders to "hunch" up around the ears. By having patients force their shoulders downward through contracting the lower Trapezius and Latissimus Dorsi, they are "reminding" their sensory cortex that this is where the shoulders are supposed to be. A new sensory engram (learned pattern of movement) is being laid down in the cortex. 13 The motor system will then follow the new sensory pattern. As the new learning becomes ingrained, through giving the patient a horne exercise specifically for these :{Xluscles, the patient learns to consciously contract, and then release, his own shoulders whenever they start to tighten under stress. As indicated earlier, the technique has immediate therapeutic benefits, the neurophysiological reasons for which are explained in the next section. These benefits include a softening and lengthening of the muscle, elimination of or reduction in pain, improved range of motion, and increased energy. It has been established beyond doubt that active muscle relaxation techniques are very effective in treating muscular spasm, trigger points, and even referred pain. 14 The principle educative, or rehabilitative, benefit is that the patient is now more aware of the muscle. Perhaps for the first time in years he has had the experience of consciously isolating, contracting, and lengthening a muscle that, in words I have heard all too frequently in my office, "I didn't even know I had." Enhanced awareness leads to greater control. The patient can once more contract and relax the muscle at will, which is the normal and healthy state of functioning. We offer a great gift to the patient when we show him how to once again regain control of his own body. As Craig Liebenson notes, "The thrust of modern management of chronic pain is away from passive ther':Py towards active patient involvement in the rehabilitation process. "b Somatic Technique is an active muscular relaxation procedure which can effectively accomplish this rehabilitation.

How Somatic Technique Works at the Subcortical Level Significant neuromuscular changes occur at the local level when the muscle is contracted against resistance, and then gradually lengthened. Irvin M. Korr' s studies in this area provide an understanding of the feedback mechanisms and spinal cord reflexes involved (Figure F). 16 First, the technique of contracting the muscle against resistance, or under tension, triggers a response in the Golgi tendon organs, located near the musculotendinous junction. The contraction under tension, as the muscle is being stretched or lengthened (eccentric contraction),

34 Chapter III • Neurophysiology

Spinal cord

Figure F

causes an increased afferent discharge of the organ, which excites inhibitory intemeurons controlling the same muscle. The effect of the discharge, then, is inhibitory; that is, it causes the muscle to relax, especially if the stretch, or lengthening, is done slowly. The more tension on a tendon, the more the Golgi organ will seek to counterbalance it through relaxation. (As a side note, understanding this mechanism can enhance the value of stretching as an exercise. By stretching slowly to the maximum comfortable length of the muscle and then pausing to hold the stretch, the Golgi reflex is allowed to "kick in." Fifteen to twenty seconds later, it will be easier to stretch the muscle even further. Stretch too quickly, however, and the Golgi reflex may not activate. Instead there will be pain and a severe restriction of further movement-and possibly even a reactive spasm, due to the stretch reflex, described next.)

A.ddressing Weak Muscles 35 Second, the length of a muscle is controlled by the spindle, another vital feedback mechanism in the control of skeletal muscles. There are a number of spindles in each muscle, embedded in the main fibers. They are like "mini-muscles." When a muscle is stretched or lengthened, the spindle is also stretched, causing an increased discharge of the gamma motoneurons going back to the spinal cord. The result of this gamma discharge is a reflexive contraction of the muscle. This is the stretch reflex in action. It can be easily observed with a sitting patient. Simply push down on both shoulders to maximally stretch the Levator scapulae and upper Trapezius muscles. The shoulders will fully depress, but as soon as you take your hands off them, will "bounce" back up to their original position, due to the reflexive contraction initiated by the spindle. When the muscle is consciously shortened, however, as in the somatic method, the gamma discharge is turned down. This procedure reduces excitation of the motoneurons, and brings about a relaxation and subsequent lengthening of the muscle. "In tension and anxiety states," Korr writes, "or in situations that are (or are perceived to be) threatening, gamma activity may be set too high for efficient, smoothly coordinated motion. In these states, the muscles are tense, stiff, resistant to changes in length." Summarizing the involuntary, or subcortical action, then, we can see that: 1) actively contracting the muscle against resistance deals with the tension factor by stimulating relaxation through the Golgi tendon discharge, and 2) the technique addresses the length factor by "resetting" the gamma loop, so that the chronically contracted muscle can release itself and return to a more normal state of tonus.

Addressing Weak Muscles Given that Somatic Technique is aimed at releasing chronically tight muscles, the question inevitably arises as to its role in addressing weak muscles. Firstly, and with Sherrington's law in mind, it is important to remember that one of the most common causes of muscle weakness is overly tight agonists inhibiting their antagonists. The resulting imbalance then tends to produce uneven or poorly coordinated movement. Stretching or in other ways normalizing the length of tight muscles-as in the Somatic Techniques-frequently results in a spontaneous disinhibition of the weaker antagonists and improves their activity, their contractile strength and the overall motor pattern. 17 In terms of specific exercises for strengthening weak muscles, Janda notes: Strengthening and particularly endurance training of muscles that have true weakness is quite a delicate procedure. Therefore, the

36 Chapter III • Neuroplzysiologtj therapist must carefully design the exercise so that the correct muscle is activated. Furthermore, the patient should have a perfect understanding and awareness of both the feeling of muscle activity and the exercise. The emphasis must be on quality of performance and not on speed, number of repetitions, or maximum resistance at this stage. It is not only important to regain muscle length, endurance and strength, but to ensure that the patient has good coordination and control of muscle activity. 18

These comments also help explain why it is of benefit to isolate and work with, say, a single muscle, even though standard neurophysiological wisdom may lead us to think otherwise. While it is true, as Korr informs us, that "the brain thinks in terms of whole motions, not individual muscles" 19 and, in the words of another author, "Normal muscle action is a patterned response of groups of muscles. Muscles have anatomic individuality, but they do not have functional individuality,"20 there is a way to access the entire system through a single part of it. As Janda notes, a single tight muscle can affect overall movement performance in a number of ways, for example, through overactivation of the muscle itself causing more contraction in a parti~ular direction than is needed for balanced movement. Alternatively, coordination may be disrupted, as noted above, because of the inhibitory effect on the antagonist. Either way, Janda recommends placing the therapeutic emphasis on regaining normal length of the contracted muscle before seeking to facilitate and strengthen weak muscles. He also notes that muscle reactions to given situations do not necessarily remain confined to the local region: "They may cause a chain reaction, which can eventually involve the whole motor system, thus ca using symptoms in other areas. Conversely, the low back pain may be the symptom of muscle imbalance elsewhere and thus be a local expression of general muscle and motor dysfunction." 21 I have observed a phenomenon in my clinical experience, which I have termed the "ripple" effect, and which is the reverse of the chain reaction phenomenon Janda is describing. As patients bring their felt awareness to a particular muscle and learn to regain full sensory-motor control over it, they start to understand kinesthetically what they are supposed to do with a particular muscle-that is, how to contract and release it at will. This new understanding and control then tends to extend more effortlessly out to adjacent muscles. Weaker or otherwise less responsive muscles are gradually "recruited," or facilitated, into an overall more optimally balanced pattern of movement. Because chronic tension and contraction tend to be a greater problem than weakness itself in the neuromuscular system, I will not discuss s treng thening exercises per se in this book. However, the Basic Exercises in Chapter Ten, as well as the other exercises given throughout the

Muscle Energy, PNF, attd Related Techniques 37 technique pages in Chapter Six, all serve to stimulate cortical awareness, which helps balance and strengthen the entire musculature and give the patient better control of his movements. Strength, remember, is primarily a function of intention, not muscle mass. One thinks of the example of the young mother who, in spite of her relative frailty, is able to lift up the car that has just rolled over her small child. Such an unlikely act of strength can only come about as a result of an extremely focused will and determination. The primary rehabilitative goal of Somatic Technique, while obviously less dramatic, is to restore this kind of intentionality to the neuromuscular system-and, with it, improved coordination and strength.

Muscle Energy, PNF, and Related Techniques As mentioned earlier, the Somatic Techniques bear some resemblance, in their application, to osteopathy's muscle energy, the holdrelax techniques of PNF, and related methods such as post-isometric relaxation, reciprocal inhibition and strain/ counterstrain. 22- 27 These can all be classified as" active muscle relaxation therapies," and at times the distinction between them appears to blur. Certainly, they purport to accomplish similar ends, and very often achieve the same clinical results: relaxation of contracted muscles and strengthening of weak ones; stretching of tight fascia; stimulation of circulation and lymphatic drainage; reduction of trigger points; improved joint motion, posture, coordination and muscle balance; and other results. There is a difference between the somatic approach and the other techniques, however. Except for the more comprehensive PNF procedures designed to correct dysfunctional movement patterns and even treat certain neurological disorders, such as stroke and paralysis, the other methods are still essentially therapies aimed at treating peripheral problems. The focus is not necessarily on developing heightened awareness of and sensitivity to overall neuromuscular activity. The practitioner is still " doing" something to the patient to bring about a clinical result: the reduction of a muscle spasm, the lengthening of a too-short muscle, an increase in range of motion of a joint or limb. While therapeutic goals are important, improving the qualitative awareness of proprioception and movement is, in some ways, even more so. Ultimately, healing is not just about feeling better-it is about feeling more. We start to become more whole as our capacity grows to sense and feel internally what is going on in our body. A metaphor might h elp to clarify this idea. When I consult with m y patients, r often ask them what kind of relationship they have with their bodies. Usually they give me an enquiring look, as if to say, "Huh?" The fact is, that most patients-unless they are athletes, mind / body enthu-

38 Clzapter III • Neurophysiology

siasts, or in some other way persons highly committed to physical fitness and well-being-do not have much of a relationship with their bodies at all. They live mostly in their heads, in their thoughts, dreams, goals, aspirations, hopes, wishes, memories and fantasies. Their bodies tend to be something that they carry-sometimes even "drag" -along with them. They usually only pay attention to it when they are hungry, tired, sexually aroused or-and this is of course what brings them into our offices-in pain. I sometimes then say to them, "Do you realize that if you had a relationship with your spouse like you have with your body, you'd probably be heading for a divorce by now?" At this point they laugh. No matter how deficient they may be in sensory-motor awareness, they are aware enough to know exactly what I am talking about. I then elaborate. "You know, the key to happy and fulfilling relationships is communication. It's no different when it comes to having a happy and heathy relationship with your body. You've got to be really present in it. You've got to listen to it. You've got to be conscious in the way you move inside it. You've got to nurture it and love it. You've got to welcome your body fully into your life, just as you welcome the man or woman you love." If the active muscular relaxation techniques mentioned above are used in a way that fosters this kind of heightened mind/body relationship, then they clearly have the potential for making a significant contribution to overall sensory-motor well-being. All too often, however, I have observed other practitioners utilizing them only as mechanical techniques to correct a peripheral problem in the muscles and joints. Usually no attention is paid to whether the patient's eyes are open or closed, or whether the breathing is coordinated with the technique. Also, I have noticed that many of the PNF techniques start with the muscle lengthened, and then move toward the shortened position. In the somatic approach, we always begin by intensifying the problem-by having the patient contract the tight muscle even further as a way of overcoming resistance and heightening sensory-motor awareness. Closing the eyes, coordinating the breath, and beginning with the muscle fully contracted are important aids to reawakening cortical control-bringing the fundamental problem of holding and tensing into the patient's awareness. There may indeed be symptomatic relief and functional improvement when muscle techniques are done differently from this, primarily because of the effect on the Golgi tendon organ and muscle spindle. However, as Liebenson observes, "Treatments aimed at the periphery (joints, muscles, skin, and fascia) are often not sufficient to reprogram proper sensory-motor control. This limitation holds for active muscular relaxation techniques, adjustments, imd strengthening exercises. " 28 With Somatic Technique, the goal is to get the patient to the point where he is not just free of pain, but has a more conscious and easeful

A Note to Chiropractors 39 relationship with his entire body. It elicits the active participation of the patient, making the technique an educative as well as a therapeutic process-a true rehabilitation. As the patient brings his "felt" awareness to the muscle he is contracting and gradually lengthening, so he is regaining conscious control over that "forgotten" area of his body. The emphasis is not so much on the quantity of the movement, as it is on the quality of it. As each tight or contracted group of muscles is worked with over a series of visits, the patient begins to regain a new awareness of himself as a somatically alive-and healthy-human being. A series of sensory-motor exercises, such as those developed by Hanna and Feldenkrais, 29- 31 help the patient maintain his new level of awareness. Having taught this work to over 1,200 practitioners in the last four years, many of whom have had introductory courses-and sometimes quiet extensive training-in the other active muscle therapies, I can also say, based on student feedback, that Somatic Technique is remarkably easy to learn. Unlike PNF, say, which consists of a rather involved and complex set of methodologies and procedures for working with the proprioceptive and neuromuscular systems, Somatic Technique is clear and straightforward both in its concept and its application. Its neurophysiological basis, outlined in the sections on cortical and subcortical mechanisms above, is well grounded in current scientific understanding, and the actual method of applying the technique, once learned, is essentially the same for every muscle. This feature makes Somatic Techniquean extremely attractive and useful adjunctive procedure for the busy practitioner seeking a simple, practical, and effective form of neuromuscular work to enhance his or her practice.

A Note to Chiropractors-Somatic Technique as an Alternative to High Velocity Adjusting As noted in the first section of this chapter, chronically contracted paraspinal muscles can cause recurring patterns of vertebral subluxation, or fixation, in the spine. The effects of such fixation may not be immediately noticeable to the patient but, if left unattended, will often result in somatic symptoms. Janda notes, for example, that lumbar distortions and pain can, over time, initiate strain and cause problems and symptoms in the remainder of the spine, including the cervical vertebrae. One study showed that over 50 percent of subjects with low back pain developed cervical problems an average of six years after the onset of low back dysfunction. 32 Chiropractors, when expla ining chiropractic to their patients, speak of the "holistic" nature of the spine and how the alignment or balance at one end of the spinal column affects the structural integrity at the other. Full spine practitioners, especially (as opposed to those who

40 Chapter III • Neurophysiology focus their attention on the upper cervical spine only), frequently refer to the pelvis as the "foundation" of the spine, and explain how if the foundation is uneven, it will create stress on the cervical vertebrae, just as an uneven foundation in a building will cause the plaster in the ceiling to crack. The study quoted by Janda confirms the validity of this model. The symptoms of vertebral subluxation may include stiffness and localized muscle or nerve pain; loss of normal ranges of motion in the affected part of the vertebral column; radicular pain, numbness, or tingling; headaches if the fixation is in the cervical spine; abnormal gait if it is in the lumbosacral or pelvic area; and possibly even visceral complications. Every experienced chiropractic clinician has encountered and often successfully dealt with the following three common situations: mid- to upper-thoracic fixation resulting in diaphragmatic contraction accompanied by pain and/ or difficulty on taking a deep breath; mid- to lower-thoracic fixation associated with digestive problems, such as heartburn or upset stomach; and lumbosacral fixations coupled with menstrual cramps or irregularities. Lewit, a medical doctor and professor at Charles University in Prague, has addressed the vertebrovisceral correlations in his book, and presents some fascinating findings in this area. For example, he quotes one study in which segmental restriction at the craniocervical junction is related to tonsillitis, and that "blockage at this level increases the susceptibility to recurrent tonsillitis." 33 In another section, he states that "mobilization of the ribs and of blocked segments of the thoracic spine, and training of correct breathing patterns, will thus be the logical treatment for patients with respiratory disorders." 34 Further on, he notes, "Menstruation pain with otherwise normal gynecological findings, especially when localized in the low back, is usually of vertebrogenic origin." Given the medically initiated controversy that has always surrounded the application of manipulation when there are visceral symptoms present, it is especially interesting to hear him relate how female sterility may be attributable to pelvic dysfunction, in particular the coccyx, and that adequate treatment (i.e., manipulation) gives favorable results. 35 Lewit is very clear that the most appropriate treatment of joint or spinal segm ent movement restriction is manipulation, and that the procedure of choice for disturbed motor patterns is rehabilitative exercise. 36 In terms of manipulative techniques, the traditional chiropractic adjustment involves a manually delivered, low-amplitude, high-velocity thrust. When indicated and when expertly given, it is an extremely effective technique, one that usually produces immediate results in terms of improved segmental motion and, frequently, reduction in presenting symptoms. However, when the paraspinal muscles are very tight, when there is disc involvement or nerve root irritation, or when the patient is nervous and resistant to manual manipulation, a high-velocity thrust

Summarizing the Benefits ofTitis Work 41 may be contraindicated. The risk of causing a reflexive muscle spasm, exacerbating symptoms, and possibly even injury to the tissues around the vertebral joint may be too great. In this case, Somatic Technique can be used as an alternative to osseous manipulation. Through contracting and lengthening the muscles against resistance, the muscles themselves are used as levers to gently restore mobility to the vertebral motor unit. At least twelve of the techniques described in this book deal directly with the paraspinal muscles, from the lumbosacral area all the way up to the suboccipital muscles.

Summarizing the Benefits of This Work With Somatic Technique, the patient is regaining control of one of the most fundamental systems in his body, his sensory-motor learning system. He is getting involved in his own healing. As a result of this new feeling of control he has more flexibility, is freer of pain, and feels more relaxed and energized. From a chiropractic perspective, because of the new and more dynamic muscular balance he experiences, he holds his adjustments better. It is an especially fine technique for the musculoskeletal practitioner who prefers to work with his or her hands (rather than using therapeutic modalities and devices that are electrically or mechanically based), and who enjoys seeing measurable, and often immediate, results: improved ranges of motion, postural changes, relief of pain, increased energy and well-being; and a heightened awareness, sensitivity, and presence in the patient. The somatic approach represents the leading edge of bodywork technology, precisely because of the way it educates patients to sense, feel, and move in a new way. There will always be a need for the kinds of passive therapies (such as manipulation, massage, and myofascial work) on which most musculoskeletal practices are based. However, the true healer is above all a teacher.,...-and the mark of a good teacher is that he or she empowers the student (or patient) to heal and transform his or her own life from the inside out. By bringing the patient's consciousness back into the muscles, this is exactly what Somatic Technique does. For the practitioner, this work offers a new and very satisfying way of relating to one's patients or clientele, and appreciating the overall context of their musculoskeletal problems. One begins to see them not just as structural entities that are contracted, stiff or out of alignment, but as somatically unaware human beings who, in order to be healthy, need to learn again how to sense, stretch, bend, twist, brea the, and move in the way nature meant them to perform these functions. Patients and clients who are strongly motivated to self-healing and self-regulation experience the deepest understanding and appreciation for this work, and the exercises that accompany it. They realize that, with

42 Chapter III • Neurophysiology the somatic approach, they are being given something that complements their care in a unique way. They feel empowered by it. Their heightened sensory-motor awareness gives them back control over their own bodies. They begin to discover a whole new range of possibilities in terms of movement, flexibility, energy, and health.

References 1. Hanna, T., Somatics: Reawakening the Mind's Control of Movement, Flexibility and Health (Addison Wesley, 1988), p. xiii. 2. Juhan, D., Job's Body: A Handbook for Bodywork (Station Hill, 1987), pp. 68-69. 3. Ibid., p. 330. 4. Hanna, T., "Clinical Somatic Education: A New Discipline in the Field of Health Care," Somatics: Magazine-Journal of the Bodily Arts and Sciences (Vol. 8, Autumn-Winter 1990-1991, No.1), p. 7. 5. Schafer, R.C., Clinical Biomechanics: Musculoskeletal Actions and Reactions (Williams & Wilkins, 1987), p. 233. 6. Juhan, p. 133. 7. Brooks, V.B., The Neural Basis of Motor Control (New York: Oxford University Press, 1986), 48-50. 8. Hanna, Somatics, p . xii. 9. Mitchell, S., Tao Te Ching: A New English Version (New York: Harper & Row, 1988), p. 76. 10. Evejenth, 0., and Hamberg, J., Muscle Stretching in Manual Therapy (Sweden: Alita Rehab Forlag, 1985). 11. Brooks,p.55. 12. Guyton, A.C., Textbook of Medical Physiology, 6th ed., (Philadelphia: W.B. Saunders, 1981), p. 594. 13. Guyton, p. 668. 14. Lewit, K., Manipulative Therapy in Rehabilitation of the Locomotor System (Butterworth-Heinemann, 1991), p. 278. 15. Liebenson, C., "Active Muscular Relaxation Techniques," Journal Of Manipulative and Physiological Therapeutics (Vol. 12, No. 6, Dec. 1989), p . 453. 16. Korr, I.M., "Proprioceptors and Somatic Dysfunction," Journal of the American Osteopathic Association, (Vol. 74, March 1975). 17. Janda, V., "Muscles and Motor Control of Low Back Pain," Physical Therapy of the Low Back by L.T. Twomey and J.R. Taylor (New York: Churchill Livingstone, 1987), p . 200. 18. Ibid., p . 274. 19. Korr, I.M., "The Spinal Cord as Organizer of Disease Processes: Some Preliminary Perspectives," Journal of the American Osteopathic Association, (Vol. 76, 1976), 34-45. 20. Little, K., "Toward More Effective Manipulative Management of Chronic Myofascial Strain and Stress Syndromes," Journal of the American Osteopathic Association (Vol. 68, 1969), 675-685.

References 43 21. Janda, p. 260. 22. Greenman, P., Principles Of Manual Medicine (Williams & Wilkins 1989), Ch. 8. 23. Mitchell, F., Moran, P., and Pruzzo, N., An Evaluation and Treatment Manual of Osteopathic Muscle Energy Procedures, (Mitchell, Moran & Pruzzo Associates, 1979). 24. Voss, D., Ionta, M., and Myers, B., Proprioceptive Neuromuscular Facilitation: Pattems and Techniques, (New York: Harper & Row , 1985). 25. Grieve, G., Modern Manual Therapy of the Vertebral Column, (Edinburgh: Churchill Livingstone, 1986), Ch. 58, 59, 77. 26. Liebenson, C., "Active Muscular Relaxation Techniques," Journal of Manipulative and Physiological Therapeutics, (Vol. 13, No.1, Jan. 1990). 27. Jones, L.M., Strain and Cormterstrain (Colorado Springs: American Academy of Osteopathy, 1981). 28. Liebenson, p. 5. 29. Hanna, Somatics, Part 3. 30. Feldenkrais, M., Awareness through Movement, (New York: Harper & Row, 1977). 31. Zemach-Bersin, D. and K., Reese, M., Relaxercise: The Easy New Way to Health and Fitness, (New York: Harper & Row, 1989}. 32. Janda, p. 258. 33. Lewit, p . 259. 34. Ibid. 35. Ibid., p. 263. 36. Ibid. p. 3.

IV

Evaluation and Contraindications

The Initial Somatic Evaluation The initial somatic evaluation of the patient will usually be done concurrently with your normal first visit examination. I will outline the main signs to look for here. At the end of the book, in Appendix A, you will find a sample Somatic Evaluation Form, which can be incorporated into your regular examination form. Do not be too concerned if you cannot at first clearly differentiate the reflexes that categorize the patient as Red Light, Green Light, or Trauma. Just concentrate on looking for the more obvious anatomical signs, the main patterns of muscular contraction and holding. Few patients will be "textbook" cases. Most will exhibit a combination of signs and symptoms and may have indications of all three reflexes. In each of the techniques you will find a set of "indications" that summarize the clinical signs and appropriate tests for each individual muscle. In time, as you develop an intuitive feel for this work, it will become easier to evaluate neuromuscular problems during the course of a regular office visit or therapy session.

Step 1-Patlent Standing First, stand in front of the patient and look for differences in shoulder height. If there is a low shoulder, the patient will also frequently be inclining slightly to that side. This is an indication of the Trauma Reflex. (See FigureD, p. 24.) If you have a full-length mirror in your office, let the patient see the asymmetry in his posture. Second, stand behind the patient and place your hands on the iliac crest. The ilium will usually be higher on the side of the low shoulder. This is because of the contraction of the Oblique muscles, the main muscles of the waist. Palpate them. If they are contracted, they will be tighter and more tender than the other side. Look for a narrowing of the gap between the ilium and the last rib. Note the tension in these muscles (the Obliques). If the patient is ticklish, it is a sign that the muscles are tense. For correction of the Obliques, see Technique 12. 45

46 Chapter IV • Evaluation and Contraindications Third, view the patient from the side. Look for signs of the Red Light or Green Light reflexes, and their combined effect, the Senile Posture. The Red Light reflex will show as a forward projecting head, elevated and rounded shoulders, elbows flexed, fists tending to be clenched, taut and tender abdominal muscles, shallow breathing. There may be obvious facial tension, a wrinkled brow, and TMJ problems. The patient may also be somewhat pigeon-toed due to flexing and inward rotation of the legs. (See Figure A, p. 23.) Upon palpation, the Pectoralis muscles will usually be taught and tender, as will the Abdominals and the Trapezii and cervical musculature. In the Green Light syndrome, the patient will be erect, even arched back slightly due to contraction of the extensor muscles of the spine. The head will be pulled back, shoulders down, arms extended, hands slightly open. The abdominal muscles will be stretched; there may even be a "pot-belly" if the arched-back posture is exaggerated. The legs will be extended, knees locked, feet tending to point out. (See Figure B, p . 23.) Palpation will reveal taut and tender paraspinal muscles in the lumbar area, and possibly the cervical spine. Speaking of the Senile Posture, or Dark Vise, Hanna says this is "a very familiar posture, seen in millions of aged bodies." 1 Here you have the back of the body pulling against the front, and vice-versa. The static signs of the senile posture are swayed back combined with slumping shoulders and a forward-protruding head. Both the anterior and posterior trunk muscles will be taut and tender to palpation. Perhaps the most telltale evide nce, however, is observed d ynamically. When th e patient moves there will be pronounced stiffness and limitation of movement, stemming from the muscle contraction around the center of the body. The individual will not be able to turn his head easily without moving his whole body; his arms will not swing freely when he walks; shoulder ranges of motion will be restricted; the trunk will be rigid; balance may be a problem. (See Figure C, p . 24.)

Step 2-Patient Prone First, palpate the thoracolumbar paravertebral musculature. Look for patterns of hypertonicity, and for palpatory tenderness and painsigns of the Green Light Reflex. Second, have the patient put his fists in the small of his back. Doing one arm at a time, lift the elbow s up and then let them drop. If the arms do n ot fall e asily and loosely from the elevated to the dropped position , it indicates a possible Rhomboid contraction. (See Figure El.) For correction, see Techniques 9 or 10. Third, have the patient separate his extended legs. Take one leg at a time, bring the foot up so that the knee is bent to 90 degrees, then rotate

The Initial Somatic Evaluation 47 the leg medially, toward the mid-calf of the opposite leg. Note how far the foot moves toward the opposite leg. If it does not come down all the way, this indicates a restriction of the medial hip rotators. (See Figure E2.) For correction, use Technique 6.

Step 3-Patlent Supine First, notice if one or both of the shoulders are rounded and lifted up off the table. This is an indication of a Pectoralis contraction. For correction, use Technique 14. Figure E1 Second, look for foot flare. Stand at the foot of the table, lift both feet up, rotate them medially, toward each other. The flared foot will not rotate medially as far as its opposite. Have the patient raise his head so that he can see the problem for himself (and can then observe the difference once the correction has been made) . This is an indication of the lateral hip rotators being contracted. It is a very common problem. Expect to see it frequently in chronic low back and hip cases. (See Figure E3.) To confirm the problem and demonstrate it a different Figure E2 way to the patient, have him bring his knee on the normal side (the one without the foot flare) up, so that the foot is flat on the table, level with the knee of the flared leg, and about 18 to 24 inches away from it. Then gently but quickly push the normal knee toward the flared leg. (Instruct the patient not to help. He should be passive throughout this.) The knee should fall easily toward the opposite leg. (See Figure E4.)

48 Chapter IV • Evaluation and Contraindications Then extend the normal leg and bring the knee of the flared leg up. When you do the same quick, pushing action, it will not move as far, or as easily, due to the contraction of the lateral hip rotators. For correction, see Technique 7.

Step 4-Patlent Lying On Side First, with the patient on his right side, have him bring his knees up so his thighs are flexed at 90 degrees to his trunk. Stand at the head of the Figure E3 patient, take the left arm above the elbow and begin to pull the arm and shoulder headward. You are checking for freedom of movement of the Latissimus dorsi. The scapula and shoulder should move somewhat independently of the rib cage. As you do this, you may hold the fingertips of your other hand level with the axillary seam of the patient' s shirt or blouse. Notice how far the seam moves beyond your stationary fingertips. If the shoulder is truly free, you should see and feel several inches of movement, or glide. In many cases, however, there will be Figure E4 little or no movement at all and the scapula, shoulder, and rib cage will be fixed, or frozen. (See Figure ES.) For correction, see Technique 11. Second, while the patient is in the same position, pull the right shoulder out from under him (i.e., toward the right side) and let the left one fall back towards the table, so that the patient's trunk is twisted. His upper body and head will be supine, while his waist and pelvis remain in the lateral position.

Contraindications 49 Note whether the left shoulder drops all the way to the table or not. If it doesn't (sometimes it will be as much as 6 to 8 inches off the table), this indicates Abdominal contraction on that side, pulling the shoulder down and forward. (See Figure E6.) For correction, see Technique 13. Third, perform the above two examination procedures with the patient lying on his left side. This completes the basic Somatic Evaluation.

Figure E5

Contraindications Fortunately, the contraindications to Somatic Technique are few , and none of them neces sarily applies in every case. You must use your own judgment and common sense here. If in doubt, gently and carefully perform the technique, and notice how the patient responds as you are doing it. It is n ot uncommon for a Figure ES patient to experience pain during the first one or two contractions if there is some inflammation present, if the muscle is extremely contracted, or if the contraction has been going on a long time and there is a buildup of lactic acid. Usually as the muscle begins to release the pain will lessen. If the pain continues and / or gets worse, however, tha t is a signal to stop. Somatic Technique is contraindicated in this case, at least on this visit. You may try it again next time.

50 Chapter IV • Evaluation and Contraindications Here are the five main contraindications: Pathology. In the case of any known or suspected bone or softtissue pathology, Somatic Technique may be contraindicated. In order to know exactly what you are dealing with, it is important to do your normal examination procedures and diagnostic workups. If in doubt, refer the patient to a specialist, or at least get a second opinion. 2. Radicular Pain. Sometimes, when there is radicular pain, as in a brachial neuritis or sciatica, especially when due to a disc problem, using Somatic Technique will exacerbate the pain because of the way the contraction of muscles exerts more pressure on the discs. As explained above, if in doubt, proceed slowly and cautiously. 3. Joint Inflammation or Injury. When there is a specific joint problem, the joint needs to be addressed. Even though there may be muscle contraction around the joint, working with the muscles using Somatic Technique may aggravate the injured joint, especially if immobilization, for example, is what is needed. Again, proceed carefully. Remember that Somatic Technique, while a fine technique for neuromuscular problems, is not a cure-all for every condition that may present in your office. 4. The Aged or Infirm Patient. It is an irony, but aged or infirm people-the ones who potentially have the most to gain from having their chronically tight muscles released through Somatic Technique-sometimes have difficulty with this work. Some older patients are so tight that contracting any muscle causes too much of a painful stretch on both the muscle being worked with and the adjacent muscles, which are also usually tight. In these cases, it is best to work gently and conservatively with the patient, perhaps doing only a partial contraction and release. After a few sessions, the muscles will begin to let go their holding. With other elderly patients, the physical act of contracting their muscles against a resistive force is just too much work for them, and causes fatigue or strain. Most can handle it, however, and will derive great benefit from it-but you must go gently and slowly, and don't do too much on one visit. In time, this work will actually help strengthen their weak muscles. 5. Hyperextension Sensitivity. Occasionally you will find patients who, whenever they hyperextend through contracting the paraspinal muscles, experience a worsening of their symptoms. Whatever the reason for this (a swollen or herniated disk is one likely explanation), most of the Somatic Techniques for the

1.

A Note Regarding Children 51 paraspinal muscles will be contraindicated. They involve extension and will generally only aggravate the problem. Technique 3, Knee-Chest, can often be used safely, however. Try it out gently two or three times and find out. If it doesn' t work, then use other procedures-such as manipulation, if appropriate, myofascial techniques, electrocurrent therapy, or ice at hometo deal with the inflammation.

A Note Regarding Children Somatic Technique can be done safely with children. However, because they are young and have not had the kinds of stresses that result in sensory-motor amnesia, they rarely need it. In fact children, with their alertness, flexibility, and boundless energy, are ideal models of what it means to be a somatically healthy human being.

Reference 1.

Hanna, T., Somatics: Reawakening the Mind's ContrOl of Movement, Flexibiiity and Health (Addison Wesley, 1988), p. 69.

v

How To Learn This Work

Developing the Rigllt Attitude Somatic Technique is not hard to learn. I have designed this manual so that even if you cannot get to a hands-on seminar in person, you can learn from the information presented here. The technique we will use for initial study and practice is the upper Trapezius. It is an easy muscle to work with, and it is one of the techniques you will use frequently. Start out with this one, become accomplished in it, and then you can add the others to your repertoire, one technique at a time. Learn them by simply looking at the illustrations, and then following the instructionsand remember, always, to go slowly. It is better to do one technique slowly and correctly, the way it is meant to be done, than to do three in a hurried-and thus less than fully effective-manner. There are twenty-one basic techniques, which cover the neck, trunk, shoulders, and hips, as well as the TMJ and hamstrings, and twelve additional techniques for the extremities: Many of the techniques you will use every day, and some of them not very often at all. What makes this work relatively easy to learn is that every technique has the same method of application. (The only exception is the TMJ.) This means that you only have to learn one technique well, and then it is just a matter of applying what you have learned to the other muscles. The method is always the same. The new learning in each technique has to do with how you position the patient and yourself, the contacts, and the subtle points related to that particular technique. To get a hands-on feel for the technique, practice it on a colleague or assistant. Then have him or her perform the technique on you, so that you can experience what it is like to have your own muscles somatically released. Remember too that with Somatic Technique you are learning a new way of working with the body. While you will be able to begin The thirty-three techniques obviously do not cover every muscle in the body, but they cover th e main ones involved in somatic problems. As I explain at the end of this chapter, once you learn the method, you can then apply it to virtually any skeletal muscle in the body. You are limited only by your own knowledge, imagination, and dexterity.

53

54 Chapter V • How to Learn This Work using these techniques immediately in your office and get good results with them, as with learning any hands-on technique, whether it be spinal adjustment or some form of soft-tissue manipulation, it w ill take time to develop any degree of mastery. Maintain the right attitude toward this work, however, and mastery will one day come. The attitudinal keys to keep in mind are presence, sensitivity,feeling, and intuition. Be really present with the patient, be sensitive to what you are feeling with your hands (let your touch be soft, and learn to "listen" with your hands), and trust your intuition. Somatic Technique is based on a rational an:d neurophysiologically correct premise, and the techniques have been developed accordingly. If you merely use them mechanically, as a "cookbook" methodology, you will get results with them. But in any authentic learning or creative process, the real value is to be found in remaining open to the potential and the possibility of the moment. Just as it is the spinning clay beneath his or her hands that tells the master potter what to do next, so you will find that the patient's muscles themselves-the degree and quality of tension, contraction, congestion-will guide you in your somatic work, if you will but attune to what is happening with them. Lastly, it will help you to remember that this work, in regard to the patient or client, is principally an exercise in communication. Neuromuscular reeducation is a process of learning new patterns of movement, more efficient ways of moving muscles and joints. As a practitioner, your job is to know what healthy or optimal neuromuscular function is, and then to teach your patient or client how to achieve it. It is not always going to be easy. Many patients will be locked into chronically inefficient and even dys functional movement patterns. We human beings do not break our old patterns-whether of movement, behavior, belief, or attitude-easily or willingly! We get very attached to the safe and familiar, even when it is not working very well. So, keep this in mind and be patient. You may understand perfectly within your own mind and body how optimal function looks and feels, but if you cannot communicate what you know through clear, duplicable instructions, your expertise won't be of much help to the patient. Your attempts to get the patient to do what you want him to do will not succeed, resulting in frustration for you and confusion for the patient. Communication between two people is successful when the words and nonverbal expression passing between them result in a genuine, shared understanding. The eyes meet in openness and clarity, there is a nod of agreement, nothing more needs to be said. You both "get it." You 3:re seeing reality from the same perspective. In Somatic Technique we are looking for a similar process to occur. We want our communication to be successful. We want the patient to "get" what we are communicating to them. To this end, I have found the following three communication tools to be effective:

The Technique 55 Demonstrate the Movement. I will often demonstrate the movement I want the patient to make. In the practice technique given below, the upper Trapezius, I might hunch my own shoulders up and then slowly lower them, so the patient gets a visual picture of what I want him to do. 2. Guide the Patient in the Experience of the Movement. Help him to experience the proper movement by guiding him with your hands. Have the patient be passive while you put your hands on him and actually move the limb or muscle for him. You are in effect doing an origin-insertion technique. This gives him an internal, subjective, kinesthetic experience of how to move the muscle. 3. Give Clear Instructions in Somatic Language. Learn the language that most effectively communicates what you want the patient to do. Don' t tell him to tighten his upper Trapezius muscle. Using anatomical language only gets him into his head, as in, "Now, let me see .. . which is the upper Trapezius?" We want him to be in his body. Better, therefore, to use your hands to touch the muscle you want him to move, and then say something like, "Now, contract this muscle by bringing your shoulders all the way up." This is what it means to communicate somatically. Once the patient is able to do the movement, and can successfully feel the muscle shortening and lengthening, then, if he is interested, you can tell him the names of the different muscles. 1.

The Technique Let us begin, then, with the basic five-step method for performing the hands-on art of Somatic Technique, using Technique 15, the Trapezius, for illustration and practice.

Step t Stand behind the seated patient. Have him close his eyes, tap both upper Trapezii with your finger tips, and instruct him to bring his awareness into these muscles. This begins the process of reawakening sensory-motor awareness. With his eyes closed he is able to focus his awareness on what he is internally sensing, feeling, and experiencing in his muscles as he contracts them and gradually releases them. (With the eyes open, people tend to be visually distracted and less in contact with kinesthetic sensation.) Then p assively guide the patient through the movement h e will be making. Because people are not used to isolating and consciously controlling the movement of individual muscles, it makes it easier for them

56 Cltapter V • How to Learn This Work if you first of all show them what you want done. Grasp the patient's elbows and passively lift the shoulders up into a fully contracted position, and then slowly bring them down again. Explain: "This is the movement you are going to be makingfully contracting like this, and then slowly releasing all the way down."

Figure 15A

Then, one more time, passively bring the shoulders up. With a hand on each shoulder, apply a resistive force of 5-15 lbs. with both hands, for 3-5 seconds. (See Figure 15A.)

Say: "Now, I want you to contract against my resistance. "

In terms of the exact degree of resistance to apply, you must use your own common sense and good judgement here. You can safely apply a 15-lb. resistive force to a well-developed patient who does not have an injury. With an older, frailer person, or someone who is injured, however, you must lighten the resistance to as few as 5 lbs. To get a feel for exactly how much 5 lbs. or 15 lbs. of pressure is, simply press down on a scale with one hand. If you don't have a scale, go to the produce section of your local supermarket. The important point to remember is that it is better to apply too little resistance than too much. Even a little resistance will create some sensory feedback-which is the goal-whereas too much could fatigue or stress the patient. This is why it is important to be tuned in to the quality of the feeling as you work with the patient.

Step 2-A Have the patient slowly lower his shoulders a third of the way down, while continuing to maintain pressure against your hands. He is still contracting against your resistance, but now he is gradually lengthening the muscles by bringing the shoulders down-in effect, an eccentric contraction. Remember, it is a slow and controlled release. Some patients will find this difficult to do at first, because two things are happening at once: they are both maintaining the contraction, the feeling of resistance, while at the same time they are letting the muscle lengthen.

The Technique 57

Part of the value of this process is that doing two things at once forces the patient to be more aware, which of course stimulates the sensory-motor system. The whole idea of this work, remember, is to enhance the patient's sensory-motor awareness and control. Note. Even if the patient is not very attuned to his body, this process facilitates the muscle's relaxing anyway, because of the activation of the Golgi tendon and gamma motoneuron pathways. That is why this work is effective. Bringing in the intentional, voluntary element by having the patient consciously participate in what is happening just makes it doubly so.

You can help the patient do this movement correctly by instructing him as follows: "Slowly release the shoulders without letting go the tension against my hands." If you feel the tension lessening until there is no longer any resistance, it is usually because he is releasing the muscle too quickly. Instruct him: "Go more slowly," or "Slow down and keep the tension on my hands." Remember to reinforce his awareness of what is happening by saying something like, "Feel the muscle lengthening as you do this." It is also good to remind the patient periodically of his ability to regulate and control his own movements with a statement such as, "Notice how you have total control of your muscles. Because you' re now feeling them, you can consciously contract them and relax them at will. " Note. Once a patient is familiar with Somatic Technique, you won't need to say as much. You'll tend to just observe the main instructions around contracting and releasing, while just occasionally reminding the patient to "tune in" to what he is feeling.

Step 2-B After the shoulders have come down a third of the way, have the patient contract them again, coming back up an inch or two, with you applying the same resistance. Instruct the patient: "Now come up an inch or two, and really feel the muscles tighten again." (Or, you can say "contract back up, " or "tighten back up.") Hold the contraction for a couple of seconds, and then gradually release it again, as before.

58 Chapter V • How to Learn This Work This step is repeated two more times until the shoulders are fully down (See Figure 158.)

The value of having the patient bring his shoulders back up 1-2 inches several times during the lengthening process is that it varies the signal to the brain. These periodic strong contractions provide a fresh stimulus to the sensorymotor cortex, thus enhancing awareness and change. Note that very tight muscles will tend to be extremely Figure 158 resistant to lengthening all the way. If there is a lot of resistance during the last phase of lengthening, use much smaller increments in the "contract/release" cycle, perhaps releasing an inch or two and then tightening back up a half-inch or so. As you become more experienced in Somatic Technique, your intuition will guide you in this process. With patients who are very tight, to the point of being almost "frozen," their shoulders may not release very far at all during the first few sessions of this work. With these patients the muscles will tend to lengthen a little more with each application of the technique. On the other hand, many patients will experience a significant, sometimes even dramatic, release. Even though you may never have worked with a particular patient before, you will feel the shoulders dropping down into a place where they clearly haven't been in a long, long time. When this happens, I will often say: "Notice how your shoulders are entering totally new territory. Pay attention to how this feels. You're letting go of a burden you've been carrying for a long time."

Step 3 Once the shoulders have released as far as they will go, have the patient bring them all the way up again and repeat the entire, slow, lengthening/ contracting process one more time. Then do one final contraction against resistance. Instruct him: "Bring your shoulders all the way up and really feel the contraction. Hold it until I count to three, then quickly let your shoulders drop all the way down."

The Technique 59 As the patient firmly contracts, slowly count out aloud to three, and let him quickly release. This final contraction and release sends yet another strong signal to the sensory-motor cortex. Strong sensory input, remember, results in newer and better motor function.

Step 4-The Reinforcement Phase With the shoulders fully down and the upper Trapezius muscles now lengthened and soft, hold the patient's elbows and, as you endeavor to push the shoulders up, instruct him to hold his shoulders down, by pushing them toward the floor. Say: "Hold your shoulders down while I try and push them up."

Using the antagonists in this way allows the sensory cortex to record a new engram (learned pattern of movement) of the shoulders in a lower, more relaxed position.

Step 5 Instruct the patient to let his shoulders completely relax as you take his arms or elbows and vigorously pump the shoulders up and down a half-dozen times. I usually give an instruction such as: "Let your shoulders flop loose now." This allows the patient to experience how loose and supple his shoulders are now that the technique has been completed. As a final step to stimulating the patient's proprioceptive awareness of his newly relaxed upper Trapezii, you may also gently knead or massage the muscles for a few seconds. Conclude by saying: "Now, just notice what you're feeling in those muscles."

Then invite the patient's feedback. Ask him what new sensations he is aware of. This encourages him to begin paying attention to his body through speaking the language of feeling, sensation, and heightened sensory-motor awareness. The beauty of doing this work is that even in those few cases where not much improvement in terms of pain reduction or range of motion is noted, there will always be, at the very least, increased sensation and feeling. Every patient you do these somatic techniques with will become more aware of his or her muscles. As my young son said, when I first demonstrated the Trapezius technique on him, " You put energy in my muscles, Dad!" (Of course, what he didn't realize is that he actually did it himself. I just helped him.) If we keep in mind that one of the most important steps in healing is for patients to begin to feel themselves again, then somatics is an excellent tool. It is a fact of life that often we have to begin to feel more before we can actually begin to feel better. It is just like a married couple

60 Chapter V • How to Learn TTtis Work

who are having serious problems in their relationship. They have to really get in touch with the underlying problems, they have to feel their suffering at a core level, before they can expect to move toward any realistic resolution. To fail to feel one's somatic or existential reality is to live in denial. There is little chance of any genuine healing occurring-in the body, in the psyche, in one's relationships-when denial prevails. This step-by-step method of doing the Somatic Technique helps patients move out of denial around their bodies, and especially their neuromuscular system. (Interestingly, some patients will be resistant to doing this work, principally because it involves effort and change on their part. Some people prefer to continue to live with their heads buried in the sand, no rna tter what the cost in terms of aliveness and health!)

How You Know When the Patient Is Doing It Right When first working with a chronically tight patient, the movement of his muscles as he releases them under resistance will often be stiff and jerky. Certain muscles (as in the Hamstrings) may even want to cramp. This stiffness and jerkiness is normal. It is the classic sign of sensorymotor amnesia: an inability to consciously and easily control the contraction and relaxation of the muscular system. As the patient learns to regain control of his muscles through the somatic work, his movements will become smoother, more fluid, more graceful. His breath will flow. There will be a deep sense of letting go, of genuine ease. He will be able to reverse his movements more effortlessly, going from contraction to relaxation, and back again. When you start to see these changes happening, you know that the patient is regaining true somatic integrity.

Learning the Twenty-One Basic Techniques You will find most of the techniques easy to understand and apply. There are a few that may be moderately difficult, usually because they involve a sequence of movements unfamiliar to the patient, and perhaps even new for you. Yet these more challenging techniques are at the same time very important. The good news is that once you understand them, and have effectively communicated what is needed to the patient, they become easier to perform. Somatic Technique is a process of sensorymotor relearning; learning to let go of old, dysfunctional patterns of movement and opening up to new, healthier ones is inevitably going to take time.

Learning tlte Twenty-One Basic Techniques 61 Once you have grasped the upper Trapezius technique, there are nine more you should study as soon as possible, for a total of ten. With these ten you can deal with 80 percent of the somatic problems you will encounter in your office. The techniques are: Two-Trunk Extension Prone (fairly easy) Three-Knee-Chest (more difficult) Four-Ilium-Axillary (fairly easy) Five-Psoas (easy) Seven-Hips Supine (easy) Nine-Both Shoulders Prone (easy) Eleven-Latissimus Dorsi (more difficult) Fifteen-Trapezius (easy) Sixteen-Cervical-Thoracic (easy) Twenty-Occipital (fairly easy) Learn these ten techniques first. Learn them at the rate of one or several techniques a day. Within a week or two, you'll have them all. Then, as you start to feel some confidence with the work and begin to see results with your patients, you can study the remaining techniques that constitute the basic twenty-one. Once you've gained some experience with those, start playing around with the twelve additional techniques, which deal with the extremities. Don' t be afraid to experiment, to try out a new or untested technique, if you think it might be appropriate for a patient's problem. Trust your own creative process. Once you master the basic somatic method-fully contracting the muscle and then slowly releasing it against gentle resistance-you may well find yourself coming up with new techniques, as I did. A word of caution, however: when being taught a proven procedure, the wisest course of action is to pay attention and learn it properly-literally, by the book. Then, once you have fully grasped the technique and are able to duplicate it, so that it brings the intended results, you can s tart to be creative. You can begin to change it, modify it, or sh ortcut it if you feel so inclined. The advantage of having learned the procedure by the book to begin with, however, is that if any of yo ur own methods fail or cause a problem , you always have the time-tested procedure to fall back on. Remember this. It is a good rule for life, not just for Somatic Technique!

VI

The Twenty-One Basic Techniques

In the pages that follow, you will find detailed, illustrated instructions on each of the twenty-one basic techniques. As you study them according to the guidelines recommended in the previous section, keep in mind the following points: Read the Instructions. Don't just rely on the illustrations. The substance of how to correctly perform each technique is contained in the instructions. Here you will find the fine points, the subtleties. Read them carefully and follow them step by step, using the illustrations as a guide. 2. Look at the Illustrations. The muscle illustrations are offered as a quick "reminder" of where the muscle is and what it looks like. For accurate and specific information regarding origin and insertion attachments, innervation, action, and so on, refer to a good muscle anatomy text. It is important to remember that the arrows on the technique illustrations indicate the direction in w hich the patient is contracting against the doctor' s resistance. 3. Acute Problems. While Somatic Technique is a procedure for releasing chronically tight muscles, it can sometimes be useful in acute situations, where the muscle is tight, or in spasm. At other times, because of localized inflammation or nerve irritation, these techniques may not be of much help with acute problems. Remember too that a large percentage of acute musculoskeletal problems arise because of an underlying pattern of chronic muscle tension. 4. Women. Female patients will be more comfortable wearing slacks or sweat pants when doing any of the Somatic Techniques involving the lower back, hips, and legs. 5. What to Say to the Patient. As outlined in the first section of the previous chapter when I discussed the art of communication, I will often give the p a tient a p articular verbal ins truction to make the technique more easily understood and performed. In many of the techniques that follow, I have included these instructions 1.

63

64 Chapter VI • Tile Twenty-One Basic Techniques in italics, to give you an idea of what to say. I use these instructions because they tend to produce the desired result consistently. As you become more familiar with these techniques, you may come up with different instructions, ones that work better for you. Part of the fun of doing this work is that there is a lot of room for creativity. When introducing somatics for the first time, try something like this: "I'd like to do something new today. It's called Somatics. It's a method of releasing chronically tight muscles, and giving you a new feeling of freedom in your body. You'll feel more flexible, and you'll have more awareness of your muscles. There are some great exercises that go with it too. They 're easy to learn, and I'll teach them to you."

6.

Guide Them in the Experience of the Movement. Because patients are not used to isolating and consciously controlling the movement of individual muscles, it makes it easier for them if you (1) visually demonstrate with your own body what you want them to do, and / or (2) guide them, passively, through the movement first. 7. Breathing. Some patients may be concerned about how to breathe during the procedure. Instruct the patient to breathe in with contraction, and to breathe out with the release. This is the opposite of the breathing rhythm used during exercising with weights, for example. We do it this way because tight muscular holding is generally associated with a holding of the breath. Just as we begin the procedure by exaggerating the somatic tendency-to tense the muscle-so we want to exaggerate the respiratory tendency, which is to hold, or grasp, the breath. Similarly, when the patient begins consciously to release, or lengthen the muscle, we also want the breath to be released, so that there is a true letting go of both neuromuscular and respiratory tension-which, in turn, will help in letting go of emotional stress and tension. 8. Number of Repetitions and Frequency of Application. In terms of frequency of visits, Somatic Technique need not be a longterm process. With many patients, it will take only a few applications of a technique to reawaken cortical control and release the involved muscles to the degree where the patient feels a new freedom of movement and well-being. With very chronic problems, however-as, for example, in persistent low back stress, TMJ conditions, or upper back and neck tension-repeated applications have a definite value, a repatterning effect. They help patients who have a difficult time being

65 in their bodies become more familiar with neuromuscular sensation and feeling. As for the number of repetitions in a session, I usually do each technique twice (and sometimes three or four times if there is a lot of resistance and holding), as follows: do the initial full contraction, then the gradual releasing of the muscle under tension, intermittently shortening it an inch or two, until the muscle is fully lengthened. Repeat this a second time. Then do one final contraction with resistance, followed by a quick and total release. 9. Exercises. With many of the techniques you will find, at the end of the notes, suggestions for exercises that the patient can do at home. These exercises are specifically designed to support the patient in repatterning his neuromuscular system and returning him to optimal health and function. The correction gained through applying the clinical techniques is more lasting when the patient is doing something at home, on a daily basis, to help his own healing. In almost twenty years of practice, I have seen over and over that the patients who take responsibility for their own health and diligently do the exercises given them make the best progress. Without the exercises, the body all too easily reverts to its old, contracted patterns. My advice, then, is to utilize the exercises I recommend, or use ones that you hav e already found to be effective. For the average patient I have found it best to give no more than one to three exercises. If you give them more than that, the chances are they won't do them. (As it is, I have observed that whenever I give patients an illustrated exercise handout, half the time they " forget " to take it with them. I go out to the reception area and find it still sitting on the counter, where the patient left it while making his next appointment. The unconscious message is clear: " I really don't want to do these exercises." I enjoy kidding them about this the next time I see them!) 10. Prescription Drugs. Muscle relaxers and anti-inflammatories do not generally interfere with the effectiveness of Somatic Technique. 11. Reinforcement. With some muscles, the antagonists are contracted briefly, after the final contraction and release. As explained in Chap ters Three and Five, this is done when we want to "remind" the cortex of where a limb or body part belongs. Instructions for the reinforcement are given with the appropriate techniques.

66 Chapter V1 • The Twenty-One Basic Techniques 12. Standing vs. Sitting. With most of the techniques, I have described the practitioner's position as "standing," which is how I prefer to do them. Many of the standing techniques can also be done from the sitting position, however. You may want to experiment with this, to see which method works best for you. 13. Cramping. When sensory-motor amnesia is long-standing and the patient's muscles are very tight, there may be a tendency for the muscle to cramp or spasm. The hamstrings, especially, are prone to this. If this problem arises, back-off. You may need to massage the tightness out first. Then try the technique again, working slowly.

67

Guide to the Techniques (Note: Includes the abbreviations I use in my Chart Notes, and the main indications/symptoms.)

Back Muscles

Page No.

1. Paravertebral Muscles* (PVM) .. . unilaterally tight back extensors 2. Trunk Extension Prone (TEP) ... bilaterally tight back extensors 3. Knee-Chest (KC) ... lumbosacral stress and tension 4. Ilium-Axillary (Il-Ax) .. . lumbar/sacroiliac problems 5. Psoas (Ps) ... lumbosacral pain or instability

69 73 75 79

82

Hips/Hamstrings 6. Hips Prone* (Hip P) ... tight medial hip rotators 7. Hips Supine* (Hip S) ... tight lateral hip rotators 8. Hamstrings (Ham) .. . tight hamstrings

86

89 94

Waist/ Abdomen/Shoulder Girdle 9. Both Shoulders Prone (BSP) ... shoulder/thoracic stress 10. Shoulder Lateral (Sh Lat) ... unilateral shoulder/thoracic stress 11. Latissimus Dorsi* (LD) . . . shoulder problems 12. Obliques* (Ob) . . . shoulder problems/constricted waist 13. Abdominals* (Ab) ... shoulder problems/tight abdominals 14. Pectorals* (Pee) ... rounded shoulders/shoulder pain

98 101 104 110 113 117

Neck/Head 15. 16. 17. 18. 19. 20. 21.

Trapezius (Trap) . .. tight or "hunched" shoulders Cervical-Thoracic (CT) . .. tight neck/upper back extensors Anterior Cervicals (AC) ... anterior cervical problems Cervical-Shoulder (CS) . . . unilateral neck/shoulder tension Cervical Rotation (CR) ... tight neck rotators Occipital (Occ) . .. suboccipital stress and tension Temperomandibular Joint* (TMJ) . . . TMJ problems

122 125 127 130 132 135 140

68 Chapter VI • Tize Twenty-One Basic Techniques

Upper Extremity 22. Deltoids (Delt) ... shoulder problems 23. Biceps (Bi) .. . elbow problems 24. Triceps Tri) ... elbow problems-e.g., tennis elbow

146 148 150

25. Wrist (Wr) .. . wrist problem-e.g., carpal tunnel syndrome

152

Lower Extremity 26. 27. 28. 29. 30. 31. 32. 33.

Gluteals (Glut) ... hip and knee problems Gastrocnemius (Gast) ... knee and ankle problems Soleus (Sol) ... foot and ankle problems Quadriceps (Quads) . .. hip and knee problems Adductors (Adds) .. . hip and knee problems Sartorius (Sart) ... hip and knee problems Tibialis Anterior (Tib) ... ankle and foot problems Foot (Ft) .. . ankle and foot problems

* These techniques were originally developed by Thomas Hanna .

153 155 157 158 160 162 164 166

TECHNIQUE 1 Paravertebral Muscles 69

TECHNIQUE 1

Paravertebral Muscles (Chart Notes Abbreviation-PVM) Indications. This technique is excellent for addressing unilaterally tight low back extensors, as in a scoliosis. When done on both sides, it helps correct the Green Light reflex. When done correctly, you should notice a softening of the tight muscles. Contraindications. Using this technique may sometimes worsen radicular leg pain-e.g., sciatica-when there is a disc problem. Sometimes the pain will increase initially, but then lessen as the tension in the muscles is relieved. Be careful in the presence of a known or suspected disc lesion. Muscles Involved. This technique brings into play all the back extensors, from the sacral area up to the neck-Erector spinae and its divisions (Iliocostalis lumborum, thoracis and cervicis, Longissimus thoracis, cervicis and capitis, Spinalis thoracis, cervicis and capitis), Semispinalis thoracis, cervicis and capitis, Splenius cervicis and capitis. (See Figure 1.) Patient Position. (In this example, the left paravertebral muscles are the ones being addressed.) Patient should be prone, head turned toward the involved side, left elbow out, left hand (dorsal surface) under right cheek, trunk flexed slightly to the left. Note: In all the Somatic Techniques, the patient is placed in the position that best facilitates the further shortening of the contracted muscles. Remember, with this method, we starr by taking the tight muscle and having the patient contract it even further, so that the origin and insertion are approximated as closely as possible. In this example, the left paravertebral muscles are now shorter, and the muscles on the right side of the spine are lengthened.

Practitioner Position. Stand on the left side of the patient. Contact. Begin by placing your left hand on the neck, your right hand on the lumbosacral junction.

70 Chapter VI • The Twenty-One Basic Techniques

Transversosplnalis {Deep paraspinal muscles)

Figure 1

Procedure. There are three parts to this technique when you are first teaching it to the patient (later, you will eliminate Part 2). The first part involves simple thumb or hand pressure to stimulate the muscles proprioceptively; the second part is where the patient contracts the muscles without resistance; the third part is where the contraction is against resistance. Part 1. Begin by pressing your thumbs or the heels of your hands into the shortened extensor muscles on the left side of the spine, using a few pounds of pressure. Start at the neck with one hand, and the sacrum with the other, and then work toward the middle of the spine. Encourage the patient to f eel what is happening. This process is to stimulate proprioception, so that the patient becomes aware of the muscles before contracting them .

TECHNIQUE 1 Paravertebral Muscles 71 Part 2. First, instruct the patient to contract the back muscles and slowly raise the upper body, including the head and left arm, up from the table. (You may use your hands under the left elbow and right shoulder to give some initial help with this. Don' t actually lift the patient-he must do the work. Simply guide him in the correct movement.) The patient should come up as high as possible with both shoulders, although because of the left arm being up and the head being turned to the left, the left paravertebral muscles will be slightly more involved. The bent arm comes up with the head, with the cheek remaining against the hand. Have him hold the contraction for a few seconds, and then slowly and consciously release it by coming back down to the table. Second, instruct him to stretch out the opposite (right) leg, and then slowly raise it into the air, keeping the leg straight. This will tighten the low back extensors, particularly the contralateral muscles (the ones on the left). Tap these low back extensors so that the patient feels the muscles working. Again, have him hold the contraction a few seconds before slowly releasing it by bringing the leg down. Third, instruct him to lift up both the upper body/head/left arm and the right leg simultaneously, so that the contraction of the back extensors can be felt from the neck down to the low back. Hold the contraction a few seconds, and then slowly, consciously, come back down to the table. Part 3. Instruct the patient to again lift up the upper body/head/left arm, and the right leg-keeping the leg as straight as possible. This time apply res istance, with your left hand pressing down in the area of the left shoulder blade, and your right hand near the popliteal f os sa of the rig ht leg . (S ee Fig ure 1A.) After a few seconds, have him slowly lower the upper body and leg about a third of the way, and then con tract back up 1-2 inches against resistance, as you increase the resistance slightly.

Figure 1A

72

Chapter VI • The Twettty-One Basic Techniques Repeat this procedure two more times until his body is fully on the table again. It helps to instruct him, during the f inal phase of releasing: "Feel the wave of relaxation in your back muscles as you allow your body to sink into the table."

Go through this entire Part 3 process one more time, then have him come up again for one final contraction in maximum extension. Hold for a count of three, and then release all the way down on the count of three. Reinforcement. It is not necessary to work the antagonists in this technique. Just tap and knead the back extensors to stimulate proprioceptive awareness. If n ecessary, you can then do the other side of the body in the same way, beginning with Part 1.

Conclude this technique by having the patient lie supine (or on his side) and bring the knees to the chest for a few seconds. Anteriorly flexing like this helps eliminate any stress that may have resulted from strong paravertebral extension. Variation. As the upper body / head / arm is being raised, experiment with having the patient rotate the bent-arm side more posterior. This brings the muscles on that side of the spine even more into play, which can be useful when dealing with a thoracolumbar scoliosis. Exercise. See the chapter titled "Basic Exercises." The third exerciseLift-Ups-is the main exercise for the paravertebral muscles, and for the other low back techniques which follow.

TECHNIQUE 2 Trunk Extension Prone 73

TECHNIQUE 2

Trunk Extension Prone (Chart Notes Abbreviation-TEP) Indications. This technique is used when the paravertebral muscles are bilaterally tight. It is an easier technique for the patient to perform than the previous one because of the assistance provided by the arms. Those familiar with hatha yoga will note that the positioning in this technique is the same as for the Cobra posture. Contraindications. As with the first technique, be careful of any increase in radicular leg pain. Muscles Involved. This technique also works with the back extensors, especially from the lumbosacral area up to the mid-thoracic spine. (Figure 1, p. 70.) Patient Position. Prone, chin resting on the table, elbows at the side, hands flat on the table with the fingertips level with the shoulders. Practitioner Position. Stand on the left side (in this example) of the patient. Contact. Left hand on the spine, between the scapulae. Right hand monitoring the tension in the lumbar muscles. Procedure. Tap the paravertebral muscles in the lumbar and lower thoracic spine, and instruct the patient as follows: "I want you to tighten these muscles, bend at the waist, and lift your head and upper body up off the table as far as you can. The idea is to bend your upper body back, as if you're trying to look directly behind you, over the top of your head." Encourage him to pay attention to the increased contraction in his back muscles. Have him hold the position for a few seconds before slowly coming back down to the table. Then repeat the process, adding, "I want you to do the same thing again, but this time use a little help from your hands and arms, bending your upper body back as far as you can." Note: It is important that the main work be done with the back muscles, with only secondary assistance from the arms. The mis-

74 Chapter VI • The Twenty-One Basic Techniques take most patients make is to attempt a push-up, where they are using the pectoral muscles, rather than the back extensors. Be watchful for this. Also, older or less strong patients may prefer to keep their forearms flat on the table, and push up from this position, rather than up from their hands.

Figure 2

When the spine is in maximum extension, apply a few pounds of resistance with your left hand, while your right hand continues to monitor the muscle tension. (Figure 2.)

Then have the patient slowly lower about a third of the way while still maintaining the resistance. Then contract back again, instructing him, "Come back up 1-2 inches," while you increase the resistance slightly. Then lower another third, and repeat this procedure. In all, there should be about three phases of lengthening in the eccentric mode, each punctuated by a brief concentric contraction. When the upper body is completely at rest on the table again, go through the entire process one more time. Then have the patient come up for one final contraction in maximum extension against your resistance. Instruct as follows: "On the count of three, I want you to let everything go and just sink down into the table. " Reinforcement. There is no antagonistic procedure for this technique. Just tap and knead the extensors on either side of the spine to reinforce proprioceptive awareness.

TECHNIQUE 3 Knee-Chest 75

TECHNIQUE 3

Knee-Chest (Chart Notes-KC) Indications. For low back pain and stress. This technique addresses the Erector spinae fibers that extend down into the lumbosacral area, and is usually very effective for releasing tension here. It is also a good technique to use with pregnant women, even those in advanced stages of pregnancy. (See Procedure, Part 2, below.) Contraindications. This technique is generally safe to use even in the presence of radicular pain. Always test it out first. Muscles Involved. Lower aspects of the Erector spinae muscles. (Figure 1, p. 70.) Patient Position. Supine, arms overhead, knees up, feet together and positioned against your forearm (see illustrations). The feet should be slightly below the level of the knees. Practitioner Position. Standing on one side of the patient (in this example, the left). Contact. Left arm braced against the table, with the patient's feet resting in the crook of your right arm . You may also want to bring your right knee up onto the table. It is important throughout this technique to keep your contact arm locked near your side so that when you apply resistance, you do so with your whole body. If you resist with your arm and shoulder alone, you are likely to give yourself a rotator cuff injury. Note: Unlike all the other techniques, this one uses indirect leverage-from the pushing action of the iegs-to contract the involved muscles.

Procedure. There are three parts to this technique.

Part 1. Before you take up the contact position, have the patient first become aware of the lumbosacral muscles by slipping your hands under his back, palpating them, and drawing the patient's attention to them. Then take up your position and give the instruction to gently but firmly push with the legs and feet into your right arm. This will cause the lumbosacral muscles to shorten and tighten. As the patient does

76 Chapter VI •

The Twenty-One Basic Techniques this, you apply resistance (remembering to use your body, not just your arm and shoulder). While the patient is pushing, have him feel the tightening of his low back muscles. You can use the fingertips of your left hand to help him make the connection between his brain and the muscles. To further help him, instruct him to push and relax a few times. The contrast will make it easier for him to sense what is happening in his low back.

Note: It is important, throughout this technique, that the patient keep his hips and buttocks on the table. Only the legs are involved in the pushing. This helps isolate the lumbosacral paravertebral muscles and avoids recruiting the hip and leg muscles.

Figure 3A

Part 2. After the patient has had an opportunity to feel his low back muscles contracting, stabilize yourself by placing your left hand on the table, bracing your arm, and, if you wish, bringing your right knee up onto the table. (Figure 3A.) Then have him again push against your right arm and hold the contraction for a few seconds, then slowly release it by having him bring his knees a third of the way toward his chest. This will cause the lumbosacral muscles to gradually lengthen. Make sure he continues to maintain tension against your arm so that the contraction isn't completely released. Then have him contract firmly again by pushing back against your arm two inches for a few seconds, and then slowly release another third.

Figure 38

Repeat this procedure several more times until the patient's

TECHNIQUE 3 Knee-Chest 77

knees are close to his chest, with his low back in a neutral, or slightly anteriorly flexed position, and the muscles lengthened. (Figure 3B.) Note: You will be moving with the patient as he releases the knees toward the chest. Again, you will be moving with your body, not just your arm and shoulder. (In cases of pregnancy the knees will be held apart, allowing the thighs to flex toward the chest on either side of the swollen abdomen.)

Then go through the whole process again 3-5 times. I have found, with this particular technique, that the more repetitions I do, the more the patient notices the tension in his low back beginning to release. Part 3. Once his knees are against or near his chest, have him steadily and slowly push your arm away until his knees are back in the starting position (with the lumbosacral muscles shortened again). Then have him contract one final time by pushing into your arm and then, on the count of three, quickly release the knees to the chest. Reinforcement. With the patient's knees positioned close to his chest, wrap your left arm around his knees and instruct him to pull them into his chest while you apply resistance. This will cause his abdominal muscles to contract. Hold for a count of three, then have him quickly release. Place his feet on the table, knees up, and slip both hands under his low back so that you can knead the lumbosacral muscles, thereby stimulating proprioceptive awareness. Notes. 1. Until you get used to it, this is one of the more difficult somatic techniques, because of the mechanics involved. Stay with it, however, because it is an extremely effective method for releasing tension in the low back. As a variation to this technique, some practitioners like to kneel on the table, with the patient's feet planted against the chest, or anterior shoulders, one on either side . Alternatively, the practitioner may sit astride the table. (Figure 3C.) 2. It is also important to in-

struct the patient, especially if he is big, not to

Figure 3C

78 Chapter VI • The Twenty-One Basic Techniques use too much force when he pushes. There should be just enough to cause the muscles to tighten. (I generally do not use this technique with patients weighing over 200 lbs.) 3. Another way I conserve my own energy is by switching sides. With one patient I will do the technique from the left side, using my right arm, and with the next patient I will do it from the right, using my left arm.

TECHNIQUE 4 Ilium-Axillary 79

TECHNIQUE 4

Ilium-Axillary (Chart Notes-Il-Ax) Indications. This is a good technique for unilateral lumbosacral and sacroiliac problems. This technique can also be useful for bilateral tension when it is chronic. Simply do both sides. Contraindications. Radicular leg pain is the main potential contraindication. Gently test the technique out first.

Obliquus externus abdominis

Figure 4

Obliquus internus abdominis

80 Chapter VI • The Twenty-One Basic Techniques Muscles Involved. The lateral trunk, flexors-Quadratus lumborum, external and internal Obliques. (Figure 4.) Patient Position. Prone, holding head of table with both hands. Practitioner Position. Standing at the foot of the table. Contact. Take the patient's leg on the involved side, grasping it with both hands just above the ankle (in this example, the patient's right side). Procedure. Instruct the patient to contract the musculature on his right side by drawing his right hip (ilium) up toward his right armpit (axillary fossa). The goal is to shorten his right side, between axillary fossa and ilium, as much as possible. Instruct him to try not to lift his hip up off the table as he does this, but to keep his whole body flat on the table. To help him make the correct movement you can (1) stand in front of him and demonstrate the movement by holding your arms up at right angles, as if holding the table, and pulling your right hip up toward your armpit, and/ or (2) place your hands on his hips and passively guide him through the movement. Once he has fully contracted the ilium toward his axillary fossa, use his leg as a lever to pull in the opposite direction (toward you), so that you are providing a resistive force to his contraction. (Figure 4A.) Have him hold the contraction for a couple of seconds, and then slowly and consciously release it a third of the way, before contracting again 1-2 inches. Repeat this process several times until the patient's right side is fully lengthened (Figure 4B.) Go through the entire process one more time, then have him contract his hip all the way up for

Figure 4A

TECHNIQUE 4 Ilium-Axillary 81 a final contraction. Apply resistance by tractioning on the leg as before, then have him release quickly on the count of three. Note: As the patient does the quick release, do not pull down on his leg. There is an adjustive procedure that involves this movement, but if it is done with this somatic muscle release, it can cause injury to the hip or low back.

Reinforcement. H a v e h i m fully extend his right side Figure 48 and hold it extended (by contracting the muscles on the other side), while you attempt to push his leg and ilium toward his axillary fossa. After a few seconds, gently pump the leg and hip up toward the armpit and down again a few times, and then tap the involved muscles to further stimulate proprioceptive awareness.

82 Chapter VI • The Twenty-011e Basic Techniques

TECHNIQUE 5

Psoas (Chart Notes-Ps) Indications. The Psoas should be checked bilaterally whenever there is a chronic low back problem, as it is an important muscle in stabilizing the pelvis and low back. With the patient supine, stand at the head of the table, take both arms by the wrists and extend the arms fully superior, above the patient's head. Instruct the patient: "Bring your hands together and point your fingers toward me. " Traction gently but firmly on the patient's arms to make sure they are fully extended.

If there is a contracted Psoas on one side, there will usually be three findings present: (1) There will be a feeling of "drag" or constriction in the shoulder girdle on the involved side (because the contracted Psoas is flexing the trunk laterally to that side); (2) The fingertips will not meet equally, with the fingers on the contracted side being shorter than on the normal side. If this is the case, keep the hands together as you instruct the patient to bend his elbows. Then bring his hands over his face so that he can see the difference in length); and (3) The Psoas will be tender to palpation (though you must always be gentle when pressing into the abdominal/pelvic cavity). Sometimes, especially in chronic low back cases when the pain is generalized and not unilateral, the Psoas will be bilaterally tight, and the hand measurement test will not reveal any discrepancy. Tests 1 and 3 will still be useful, however, and if you are still in doubt, simply go through the Psoas release procedure on one side, then check the hand measurement. If the hand is now longer on that side, this confirms a bilateral Psoas involvement. Contraindications. This is generally a safe technique to use at any time. Muscles Involved. The Iliopsoas, consisting of the Iliacus, and the Psoas major and minor. (Figure 5.) Together these three muscles are the major hip flexor (with the lumbar origin fixed) . When acting bilaterally and with the insertion fixed, they flex the trunk on the femur, as when sitting up from the supine position. Patient Position. Lying supine, feet 18-24 inches apart.

TECHNIQUE 5 Psoas 83

Psoas minor

Iliacus

Figure 5

Practitioner Position. Standing just below the knee on the involved side. Contact. (For the left Psoas.) With your right hand, grasp the left knee. Take the left foot in your left hand, let the knee fall outward so that the femur is slightly flexed, laterally rotated and abducted 10-15 degrees. In this position the left foot will cross toward the opposite leg. Procedure. Move the patient's left knee toward the right shoulder, following the line of the Psoas muscle. Instruct him, as you tap the shoulder, " Bring your knee toward this shoulder." Then say, " Close your eyes, breathe in as you contract the muscle, and focus on what's happening here." (Tap the abdominal area to draw the patient's attention to it.)

84 Chapter VI • The Twenty-One Basic Techniques At this point you will resist the contraction by placing your right hand over the superior medial aspect of the knee. (Figure SA.) Have the patient hold the contraction a few seconds, then slowly release it a third of the way, while still maintaining the resistance. The patient should then shorten the muscle again by about 2 inches, as you increase your resistance slightly. Then do the lengthening phase again, repeating this pattern until the knee is close to the table. (Figure SB.)

Figure SA

Go through the entire process one more time, then do one final contraction before quickly releasing the muscle. Note : During this technique, it is important to visualize and follow the line of the Psoas. Avoid the mistake of moving the leg too far laterally (which brings the Adductors more into play).

Figure 58

Reinforcement. With the Psoas fully lengthened and the knee near the table, place your right hand under the lateral aspect of the knee and instruct the patient: "Press down into the table." Conclude by taking the knee and leg and moving the Psoas back and forth several times, through its complete range of motion. Exercises.

1. A good isometric exercise for strengthening the Psoas and stabilizing the low back is to sit on the edge of the table with one foot (in this

TECHNIQUE 5 Psoas 85 illustration, the right) crossed over the opposite leg above the knee. The right knee will fall outward. Then place one hand on top of the right knee, and the other over it. Contract the Psoas by gently forcing the knee upwards, while resisting the contraction with downward pressure of the hands. Hold for 6 seconds. (Figure SC.)

2. The Psoas can also be worked somatically by Figure SC pulling the knee all the way toward the chest and then gradually lengthening the muscle under resistance, periodically contracting it back up a little, as in the Somatic Technique.

86 Chapter VI • Tile Twenty-One Basic Techniques

TECHNIQUE 6

Hips Prone (Chart Notes-Hip P) Indications. With the patient prone, test each leg by first separating the extended legs 18-24 inches. Then bring one foot to the vertical and, stabilizing the ilium on that side w ith your superior hand, arc the foot toward the mid-calf of the opposite leg. If the m edial hip rotators are free, the foot should move all the way down to the other leg. If the muscles are contracted, the foot will go only part of the way, and then the tight muscles will prevent any further movement, indicating the need for this technique. Check both sides. (Figure E2, p. 47.)

Doing this technique will usually completely free up the medial hip rotators. Contraindications. If there is a lesion in the hip joint, using this technique may aggravate the symptoms, and may have little effect on any neuromuscular involvement. Test it out gently. Muscles Involved. The medial rotators of the hip, consisting of the Tensor fascia latae, Gluteus minim us and Gluteus medius (anterior fibers). (Figure 6.) Patient Position. Prone, arms at head of table. Left leg bent at the knee (for left-sided contraction), with left foot in the vertical position. Practitioner Position. Standing at the left side of the patient, midway between the iliac crest and the knee. Contact. Stabilize the ilium with your left hand, while grasping the patient's foot w ith your right hand, so that his lateral malleolus is positioned in the palm of your hand. Alternatively, you may simply grasp his foot with both hands, as it is not essential to stabilize the ilium. (Experiment with what works best for you.) Procedure. Instruct the patient to push his left foot directly late ralward against your hand. Make sure that he does not push at an oblique angle, o r in a direction that would tend to straighten his

TECHNIQUE 6 Hips Prone 87

medius Gluteus mimimus

Figure 6

leg. The lower leg must remain, initially, at 90 degrees to the thigh. (Figure 6A.) This lateral pressure against your hand contracts his medial hip rotators. Have him hold the contraction for a few seconds against your resistance, and then slowly start to bring his left foot towards the mid-calf of the opposite leg, while still maintaining the pressure against your h and. After going a third of the way toward the opposite leg, have him contract directly outward again, 2 inches, against your resistance. Hold for a few seconds, and then slowly release another third.

88 Chapter VI • The Twenty-One Basic Techniques Repeat this process until the left foot is all the way down on (or as close as possible to), to the midcalf of the right leg. (Figure 6B.) Go through the process one more time. Then have the patient bring his left foot out all the way again, to the beginning position, for one final contraction, before quickly releasing it down. Reinforcement. Stabilize the left ilium with your left hand, and place your right hand under the left foot while it is down on the right leg. Instruct the patient as follows: "Hold your foot down while I try to pull it up."

Figure SA

Conclude the technique by briefly kneading and massaging the medial hip rotators. Then, if necessary, go to the opposite side of thetable and do the other leg. Exercise. See the next technique for hip exercises.

Figure 68

TECHNIQUE 7 Hips Supine 89

TECHNIQUE 7

Hips Supine (Chart Notes-HipS) Indications. With the patient supine and legs extended and separated 18-24 inches, look for external foot flare, which is the first and most obvious indication of contracted lateral hip rotators. Should you get a positive reading on one foot, you can turn both feet in to confirm-and demonstrate to the patient-that one leg is indeed rotated outward (the foot will not r otate in as far). (Figure E3, p . 48.) This technique will often correct sciatic pain. A second, confirming test is to bring one knee up, so that the foot is flat on the table, approximately level with the other knee. (The legs are still separated.) Then, standing on the raised knee side of the patient, gently but quickly push the knee toward the opposite leg. Instruct the patient not to help. He should be passive during this test. If the lateral hip rotators are free, the knee should fall easily toward the opposite leg. If it doesn't go all the way, it should go most of the way. If the lateral hip rotators are contracted, it will prevent the free movement of the knee and leg medially. The leg will only go part way and then will "catch." (Figure E4, p. 48.) Contraindications. As for Technique 6, Hips Prone, a h ip joint lesion may contraindicate this technique. Muscles Involved. Lateral rotators of the hip, consisting of the Piriformis, Obturators, Gemelli, Quadratus femoris, Gluteus maximus (Figure 7), and the Gluteus medius (posterior fibers ). (Figure 6, p. 87.) Patient Position. Patient supine, legs extended and separated 18-24 inches. Bring the right knee up (in this example) so that the right foot is flat on the table, approximately level with the left knee. Practitioner Position. Standing at the right side of the patient, midway between the patient's ilium and knee. Contact. Stabilize the ilium with your left hand, while grasping the knee with your right. (As with the previous technique, it is not essential to stabilize the ilium, and you may prefer to contact the knee with both hands.)

90 Chapter VI • The Twenty-One Basic Techniques

Piriformis

Quadratus femoris

Gluteus maximus

Figure 7

Procedure. Instruct the patient to contract his lateral hip rotators by firmly pushing his right knee directly outward, while you resist his pressure with your hand. He will feel the contraction in his hip muscles. (Figure 7A.) Have the patient hold the contraction for a few seconds, and then gradually move his right knee towards the opposite leg, while still maintaining the pressure against your hand. After releasing a third of the way toward the opposite leg, have him contract directly outward again 2 inches, against your resistance. Hold for a few seconds, and then slowly release. Repeat this process several times until his right knee is all the way down on (or as close as possible to) the left leg. (Figure 7B.)

TECHNIQUE 7 Hips Supine 91 Go through the entire process one more time, then have the patient bring his knee back to the initial position for one final contraction, and a quick release. Note: If patients have a lot of contraction in the hip/pelvic area, this technique can be uncomfortable for them. I have found this to be especially so with women who are ultrasensitive. A lot of emotional energy gets locked in the pelvis and hips. You can monitor the patient's level of comfort by simply watching the expression on his or her face .

Figure 7 A

Reinforcement. Stabilize the right ilium with your left hand, and place your right hand under the patient's right knee while it is down across the opposite leg. Instruct the patient as follows: "Hold your knee down while I try to pull it up." Conclude the technique by briefly kneading and massaging the lateral hip rotators.

Figure 78

Then, if necessary, move to the other side of the table and perform the same procedure on the other leg. Exercises. There are three good exercises for addressing hip contracture. The first two address both the medial and lateral hip rotators, the third just the lateral:

92 Chapter VI • The Twenty-One Basic Techniques 1. Knees To Side. Lie supine with your feet about 36 inches apart, knees up, feet flat on the floor. Slowly move both knees to the left and bring them as close to the floor as possible. Then slowly move them to the other side. Repeat a total of ten times each side. (Figure

7C.) 2. Knees Turned In-Part One. In the same supine position, start with the knees up and feet together, about 12 inches away from the buttocks. Then , slowly slide the feet away from the body, straightening the legs while turning the knees inward, so that the feet are pronating (soles turning outward). When the legs are fully lengthened, they will be in an e xagge rated " knockkneed" position. Breathe out as you do this. (Figure 70.)

Figure 7C

Knees Turned OutPart Two. Then the feet are slowly drawn toward Figure 70 th e pelvis aga in , thi s time being supinated as the knees are allowed to drop outward. (Figure 7E.) Finish with the soles of the feet touching and drawn as close to the groin as possible, with the knees spread wide. Breathe in as you do this. Then slide the feet away again and repeat the first part of this exercise. Do each part ten times. 3. With Resistance. The third exercise is a way of doing the actual somatic technique, with the resistance, on oneself. Lie supine with the feet about 12 inches apart and flat on the floor, knees up. Cross the left

TECHNIQUE 7 Hips Supine 93 leg over the right, jllst above the knee. Press the right knee outward so as to contract the latera/hip rotators on that side. Provide resistance with the left foot. (Figure 7F.) Maintaining the tension, slowly move the right knee medially (to the left), elongating the right hip rotators. Lengthen a third of the way, then shorten 2 inches, still maintaining the resistance. Continue this pattern till the right leg has moved all the way medially , as close to the floor as Jar as possible. Repeat the whole process one more time, finishing with a final contraction followed by a quick release.

Figure 7E

Do the same technique with the left hip rotators if necessary.

Figure 7F

94 Chapter VI • The Twenty-One Basic Techniques

TECHNIQUE 8

Hamstrings (Chart Notes-Ham) Indications. Tight or short hamstrings are one of the main signs of the Green Light reflex, and are commonly involved in chronic low back pain. Lengthening and softening the hamstrings help free up the low back, and also take stress off the hips and knees. To test hamstring length, have the patient lie supine with his low back flat on the table. Do a straight leg raising test. The longer and freer the hamstring, the closer the raised leg will come to 90 degrees or beyond. (If the low back is arched off the table, the test will not be accurate. To prevent this, place a small pillow under the opposite leg.) Contraindications. If the hamstrings are very tight, doing this technique may causing cramping. Move slowly and carefully with it. Muscles Involved. The medial hamstrings (the Semitendinosus and Semimembranosus) flex and medially rotate the knee, and assist in extension and medial rotation of the hip . The lateral hamstrings (the Biceps femoris) flex and laterally rotate the knee, and assist in extension and lateral rotation of the hip. (Figure 8.) Patient Position. Prone, right leg extended, left leg bent to 90 degrees. Practitioner Position. Standing on the left side of the patient (in this example), midway between his ilium and knee. Contact. Your left hand acts as a stabilizer over the belly of the muscle. Pressing firmly h elps minimize cramping. With your right hand, grasp the lower leg just above the ankle. (You may find it more comfortable to reverse the hand positions). Procedure. Instruct the patient to contract his hamstrings by pulling his left heel toward his buttock, while you apply a resistive force with your right hand. (Figure 8A.) Have him hold the contraction for a few seconds and then slowly begin to straighten his leg about one third of the way, while still

TECHNIQUE 8 Hamstrings 95

Semimembranosus

Medial Hamstrings

Lateral Hamstrings - Biceps Femoris

Figure 8

maintaining the pressure against your hand. (If the muscle begins to cramp, ease off the resistance and massage the cramp out.) Then have him contract back again, 1-2 inches toward the buttock, while you resist. Then again gradually release. Repeat this process several more times until the leg is almost fully extended. (Figure 8B.) Repeat the entire process one more time, then have the patient brL.'l.g his leg back to the initial position for a final contraction, and a quick release. Reinforcement. Stabilize the left ilium with your left hand and put your right hand under the patient's extended leg, just above the ankle. Instruct the patient: "Hold your leg straight while I attempt to bend it. "

96 Chapter VI • The Twenty-One Basic Techniques Conclude the technique by briefly kneading and massaging the hamstring muscles. Then do the same technique on the other side. Variation. You can also do this procedure with the patient supine. Have him bring his knee up at 90 degrees to his trunk. Stabilize the leg by putting your hand under the popliteal fossa. With your other hand, grasp the leg just above the ankle. Instruct him to contract by pulling his heel toward his buttock. As he begins to straighten the leg, bring the knee down gradually.

Figure SA

Notes. You can work your own hamstrings in this same manner if you wish, and you can teach your patients how to do it. There are two methods to choose from (remember to coordinate the breath with the technique): 1. Lying prone, bend your Figure 88 left leg (jar left hamstring) and approximate the heel to your buttock. Then bend your right leg and bring the leg across, tucking your right foot in behind the left Achilles tendon. Pull the lef t foot back toward the left buttock to tighten the hamstring. Apply resistance with your right foot and leg. (Figure BC.) Lengthen the muscle one third of the way, then shorten 1-2 inches, maintaining resistance with the right foot throughout the movement. Repeat this pattern until the muscle is fully lengthened. Do the tech-

TECHNIQUE 8 Hamstrings 97

nique twice,finish with a final contraction and quick release, then knead and massage the muscle when you are done.

2. Sit on the floor, with your knee flexed toward your abdomen. Place the extended fingers of both hands against the upper part of the Achilles twdon. (Figure 80.) Pull your heel towa rd your buttock to contract the hamstring, and then gradually straighten your leg, while continuing to maintain pressure against your extended fingers. As you straighten the leg, you will need to lean forward. Do the standard contract/release technique as in (1) above.

Figure SC

Patients who are athletes or runners and who have tight hamstrings can be taught this exercise as part of their warm-ttp and warm-down regimen. Figure 80

98 Chapter VI • The Twenty-One Basic Techniques

TECHNIQUE 9

Both Shoulders Prone (Chart Notes-BSP) Indications. This is a simple, effective technique for patients with general stress and tension across the shoulders, and in the mid/upper thoracic spine. If you wish, you can test the Rhomboids individually by having the patient put his fist in the small of his back. (Figure El, p. 47.) Do one arm at a time. Notice if, when you lift the elbow up, it then drops easily and quickly to the table. If it catches, it is an indication of Rhomboid contraction.

Contraindications. This is a generally safe technique.

Trapezius

Rhomboid major

Figure 9

TECHNIQUE 9 Both Shoulders Prone 99 Muscles Involved. Shoulder adductors, consisting of the Rhomboids, Trapezius (especiaily the middle fibers), Levator scapulae. (Figure 9.) Patient Position. Prone, arms by the side, palms up. Practitioner Position. Standing at the head of the table. Contact. Place both your hands on the patient's upper back/ shoulders on either side, so that your hands are covering the superior borders of the scapulae. Procedure. Instruct the patient as follows: "Keep your head down and your hands on the table. Now raise your shoulders toward the ceiling as high as you can. Squeeze your shoulder blades together. Feel the contraction of these muscles." As you say this, tap the Rhomboids so that the patient can sense what muscles he is using. Apply resistance for several seconds. (Figure 9A.) Then have the patient gradually bring his shoulders down toward the table one third of the way, and then instruct him to raise them 1-2 inches again, while you increase the resistance slightly. Repeat this several more times until the shoulders are all the way back down on the table. Go through the above sequence one more time, then have the patient bring the shoulders all the way up for a final contraction, followed by a quick release. Reinforcement. S 1 i p y o u r hands under the anterior surface of the patient's shoulders, and instruct him to push his shoulders down into the table while you resist. Figure 9A

100 Chapter VI • The Twenty-One Basic Techniques Conclude the technique by briefly tapping and kneading the involved muscles, and "flopping" the shoulders up and down off the table. Variations. 1. If one shoulder is significantly tighter or more stressed in the patient's awareness than the other, you may do this technique on one side only.

2. If there is neck involvement, as in a torticollis, you can bring the Levator scapulae more into play by having the patient, as he raises his shoulders toward the ceiling, also move them slightly superior and medially, toward the External Occipital Protuberance. Again, this technique can be done bilaterally or unilaterally. 3. The shoulder adductors may also be released with the patient lying on his side, as in the next technique, 10, Shoulder Lateral. .

4. Another technique for working with the Rhomboids (if you have a positive finding, as in "Indications," above) is to have the patient put his fist in the small of his back, bring the elbow all the way up, then apply your resistance. Then have him gradually release, down toward the table.

Exercise. See Technique 11, Latissimus Dorsi, for shoulder girdle exercises.

TECHNIQUE 10 Shoulder Lateral 101

TECHNIQUE f 0

Shoulder Lateral (Chart Notes-Sh Lat) Indications. This is an alternative technique to the previous one. The benefit of this technique is that it allows for greater range of motion of the shoulder girdle, and therefore increased lengthening of the involved muscles, than when the patient is prone. It is especially appropriate for unilateral Rhomboid spasm, the "knife-like" stabbing pain, sometimes accompanied by difficulty in taking a deep breath, that we frequently see in our offices. Contraindications. Generally safe. Muscles Involved. The shoulder adductors, especially the Rhomboids and Trapezius (middle fibers). (Figure 9, p. 98.) Patient Position. Lying on right side (in this example), legs slightly flexed, left arm resting against side, right arm under the head/ out of the way. Practitioner Position. Standing behind the patient, level with his shoulders. Contact. Stabilize the left ilium with your left hand, with your right hand applying resistance to the posterior aspect of the shoulder. Procedure. Before you begin the technique, let the patient get a feel for the kind of movement to be made with the shoulder. Have the patient m ove the shoulder all the way to the posterior first (guiding the movement with your hands) so that the R...~omboids are contracted, and the gap between the medial border of the scapula and the spine is fully closed. The shoulder will now be positioned over the table behind the patient. Then bring the shoulder all the way forward, so that the Rhomboids are fully lengthened, and the gap between the medial border of the scapula and the spine is wide open. Then return to the starting position, with the shoulder brought fully posterior. Instruct the patient to contract the shoulder against your resistance. (Figure lOA.)

102 Chapter VI • The Twenty-One Basic Techniques (You may find it easier if you lean down and allow the elbow of your resisting arm to stabilize against your own body, so that you actually use your body weight to provide the resistance.) Then have the patient gradually bring the shoulder forward, lengthening it one third of the way, and then give the instruction to contract back again 1-2 inches against your res istance.

Figure 1OA

Repeat this several times until the shoulder is all the way forward. (Figure lOB.) Go through this sequence one more time. Note: Remind the patient to keep the head down on the table throughout this maneuver.

Then have the patient bring the shoulder all the way back to the starting position for one final contraction, and a quick release.

Figure 108

Reinforcement. With the shoulder pulled all the way forward and the involved muscles fully lengthened, have the patient push with the shoulder into your left hand. (He is using the Pectoral muscles here.) Conclude the technique by briefly tapping and kneading the involved muscles. Then go to the other side.

TECHNIQUE 10 Shoulder Lateral 103

Variation. While the patient is in this position, you can also work with the upper Trapezius and Levator scapulae by having the patient contract the shoulder toward the ear. Go through the standard Somatic Technique procedure until the upper Trapezius is fully lengthened and the shoulder is released as far down toward the ilium as possible.

104 Chapter VI • The Twenty-One Basic Techniques

TECHNIQUE l 1

latissimus Dorsi (Chart Notes-LD) Indications. In terms of immediate results, this technique often produces a dramatic improvement in range of motion of the arm and shoulder. The main indication for this technique is pain and I or restriction in movement or function of the upper extremity. If the Latissimus is contracted, it will usually be tender to palpation. Test the range of motion of the muscle as described in Chapter Four. (Figure ES, p. 49.) Here is the method again: Have the patient lie on his side, with the knees drawn up at 90 degrees to the trunk. Stand at the head of the table, take the arm above the elbow, and begin to pull the arm and shoulder head ward. If the Latissimus is free, there will be a feeling of "glide," of free movement, between the shoulder and the rib cage. The scapula should move independently, to some degree, of the rib cage. Use the axillary seam of the patient's shirt or blouse as a guide. There should be several inches of free movement of the arm and shoulder. Many patients have less than a half-inch of movement here, and some have none at all. The Latissimus is literally quite frozen. Contraindications. A lesion in the shoulder joint itself is the main potential contraindication to this technique. Test the technique gently if you are in doubt. Be careful with a shoulder that dislocates easily. (See Note 2 below.) Muscles Involved. The Latissimus dorsi is an important muscle in shoulder joint movement (medial rotation, adduction, and extension). It also plays a role in lateral flexion of the trunk, anterior and lateral movement of the pelvis, and hyperextension and flexion of the spine. (Figure 11.) Patient Position. Lying on left side (in this example), with both knees drawn up at 90 degrees to the trunk. Practitioner Position. At the head of the table.

TECHNIQUE 11 Latissimus Dorsi 105 Contact. Have the patient bend his arm, then grasp it by "hooking" your hands around the forearm, at the point where it meets the elbow. With this contact, you don't need to grip tightly (which can cause discomfort-or, in older, frailer patients, bruising of the skin). As an alternative contact, you can have the arm extended and hold the wrist with one hand, and the forearm near the elbow with the other. Once the procedure begins, another option is to "hook" the elbow with one hand, and stabilize the patient's iliac crest with the other. (This was the method Thomas Hanna used. It can enhance the effectiveness of the technique, although I have not found stabilization to be essential for a good release. Many practitioners find it difficult to both stabilize the ilium and apply traction to the arm, especially with a larger patient.)

Figure 11

106 Chapter VI • The Twenty-One Basic Techniques Procedure. Have the patient get into a sway-backed, or hyperlordotic position. Instruct him as follows: "Make a sway-back by sticking your belly as far forward as you can." Doing this causes the Latissimus to partially shorten. Explain this to the patient so he understands the rationale behind the movement. Then put your right hand on the right scapula and, as you gently move the Figure 11A scapula downward, toward the hip, instruct the patient: "Contract your shoulder down toward your hip, like this." This is to fully contract the Latissimus. You will be able to palpate the contraction when it is being done correctly. You can tap the lower aspects of the Latissimus and tell the patient, "The idea is to shorten this muscle as much as you can. " The muscle should be short and hard. Encourage the patient to feel what is happening internally with the muscle. (Figure llA.) Note: The patient must pull down with his whole shoulder girdle, not just his arm. The movement is in effect one of posterolaterally flexing the entire trunk, so that the scapula and ilium are approximated. It also helps the patient perform this initially difficult movement correctly if you manually move him into the contracted position while instructing him as follows: "Each time I say 'contract, ' this is what I want you to do: sway your back, contract the muscle by pulling your shoulder blade down toward your hip, and breathe in-all at the same time."

Then instruct the patient to fully contract, or tighten, the Latissimus. As he does so, apply resistance by pulling in the opposite d irection with both hands on the elbow. Use 3-10 p ounds of force. (Figure llB.)

TECHNIQUE 11 Latissimus Dorsi 107 After a few seconds, have the patient slowly release the contraction one third of the way, and then contract back again 2 inches, against your resistance. Repeat this procedure several more times until the Latissimus is fully lengthened. At this point the patient will no longer be sway-backed. Instead, the trunk will be elongated, and the right arm will be fully extended over the head (Figure

Figure 11 B

llC.)

Note: Patients who are very tight in the shoulder girdle area may feel a lot of discomfort and pulling in their muscles as the Latissimus lengthens. If this happens, go gently. You don't need to release the muscle all the way on the first visit. You can do it gradually over several sessions. Remember, reeducation or repatterning of the sensory-motor system often takes time.

Go through the above se- Figure 11 C quence one more time, then have the patient contract all the way down again, while you again apply resistance by exerting pressure on the arm. Instruct: "Now, when I count to three, I want you to quickly and fully release the contraction by letting your muscle go, and thrusting your arm directly over your head-as in a fen cer's lunge." Count to three and, as the patient thrusts, gently but quickly pull headward on the arm, helping with the thrusting and elongation.

108 Chapter VI • The Twentt;-One Basic Teclzttiques Make sure to step out of the way if necessary so that you don't get hit by the patient's thrusting movement. Note. You may demonstrate to the patient what you want done before the final contraction, by taking the right arm and putting gently but quickly all the way past his head, straightening it as you do so.

Reinforcement. It is not necessary to reinforce the antagonists with this technique. Simply move the scapula back and forth down toward the hip several times, to shorten and lengthen the Latissimus. Then tap and knead the muscle. Then go to the other side if necessary. Notes. 1. If you are of a curious bent and interested in experimenting with the many ways Somatic Technique can be applied, you can work more generally with the shoulder joint by doing an inventory of movements with the arm and shoulder. Notice where it seems restricted, and then go ahead and release the restriction using the somatic procedure. 2. With a shoulder that has a tendency to dislocate, it is usually because one or several of the rotator cuff muscles are too tight, and therefore already partially pulling the shoulder out of alignment. Releasing th~se muscles helps balance and align the shoulder, but you must work carefully. 3. On this technique, and the next two-12 and 13-it is a good idea to

use a small pillow under the patient's head. It makes the patient more comfortable, allowing more attention to be given to what is actually being done with the muscles. Exercises. There are two very effective exercises for releasing the shoulder, upper back, and lower neck stress and tension. The first one is described and illustrated in Chapter Ten. It is Exercise 2-Spinal Twist. The second exercise is as follows, and has three parts to it: Part 1. Kneel on the floor, with the thighs at right angles to the floor, knees 12- 18 inches apart. Reach forward as far as you can with your hands, so that your arms are fully stretched out in front of you, with your palms flat on the floor, 12-18 inches apart. Allow your head and sternum to relax down toward the floor. Rotate the pelvis anteriorly so that the lumbar spine is hyperlordotic and the buttocks are pointed toward the ceiling. Then, anchoring the heels of your hands to the floor, pull backward and toward the ceiling, so that you are literally opening up the should joints. You should feel the entire upper body stretch during this

TECHNIQUE 11 Latissimus Dorsi 109

movement. Hold this position for about five slow breaths. (Figure 11 D.) Part 2. Then slide your but-

tocks onto your heels, bring your hands behind your back and join your palms together, interlacing your fingers. Keeping your buttocks on your heels and your head on the floor, fully extend (as much as you can) your arms behind you. Squeeze your elbows together, if you can, and bring your extended arms toward your head. Hold for five slow breaths. (Figure 11£.)

Figure 110

Part 3. Release the hands,

sit up on your heels, with your back erect but relaxed, and look straight ahead . Close your eyes and quickly bounce your shoulders up and down several times to release any remaining tension. Then get very still, and notice what you feel in your shoulders and upper back. You will probably ex perience a profound sense of relaxation, and a lot of new energy moving in your upper body.

Figure 11 E

110 Chapter VI • The Twenty-One Basic Techniques

TECHNIQUE t 2

Obliques (Chart Notes-Ob) Indications. One of the main indications of contraction of the Obliques is seen in the Trauma reflex, where one shoulder is lower than the other and the hip on the same side is high. Check the space between the last rib and the iliac crest. If the Obliques on that side are contracted, the space will be noticeably less than that of the other side. The muscles will also be tender to palpation. Contraction of the Obliques may also pull the shoulder itself down and forward. (See the next technique, the Abdominals, for further explanation of this phenomenon.) Contraindications. This is generally a safe technique to use. Muscles Involved. The Oblique muscles, consisting of the Obliquus externus abdominis and the Obliquus intemus abdominis, are responsible for flexion, lateral bending, and rotation of the vertebral column. (Figure 4, p. 79.) Patient Position. Lying on left side (in this example), with both knees drawn up at 90 degrees to the trunk. Practitioner Position. At the h ead of the table, slightly posterior to the patient. Contact. As for the Latissimus technique. Have the patient bend his right arm and "hook" his forearm with both hands, just at the point where it meets the elbow. If you wish, you can hold this point with one hand, and u se your other hand to stabilize the ilium. Procedure. Have the patient lift his right foot up into the air, as high as he can, while keeping the knees together. This approximates the ilium and rib cage, causing a partial contraction of the Obliques. Then put your right hand on the lateral aspect of the patient's ribs and, as you gently push them down toward the ilium, instruct him as follows : "Move your rib cage toward your hip so that you make your waist as tight as possible." If he is doing the technique properly, his right side will be concave, with the muscles tightly contracted and the ribs pressing against the iliac crest.

TECHNIQUE 12 Obliques 111 As he contracts, apply resistance by pulling on his elbow with both hands, as you did with the Latissimus technique. (Figure 12A.)

After a few seconds, have him slowly release the contraction one third of the way, both by bringing the foot down, and letting the muscle lengthen. Instruct him as follows : "Now, very slowly begin to release the muscle a few inches, while also bringing your foot down part way." Continue to maintain your resistance as he does this.

Figure 12A

Then have him tighten the muscle again, while raising the foot a couple inches. Hold the contraction, then go through the same release procedure. Repeat this process several more times until the foot is all the way down, and the side is fully lengthened, with his right arm extended o ver his head. (Figure 128.)

Figure 128

Go through the sequence one more time, then return to the beginning position for one final contraction against resistance. As with the Latissimus technique, instruct him to thrust his arm directly overhead to release the Obliques, while at the same time thrusting his right leg in the opposite direction, fully extending it.

112 Chapter VI • 11ze Twe11ty-One Basic Techniques

Reinforcement. It is not necessary to reinforce the antagonists. Simply move the rib cage back and forth several times, closing and opening the space between the iliac crest and the ribs, and then massage the muscles. Exercise. To release contracted Obliques , where the shoulder is depressed and the ilium elevated, the following exercise should be done in the morning and again at night:

Figure 12C

Lie on the floor on your side, with the side of contraction uppermost (in this example, the right side is the contracted side). With the knees together, bring them at right angles to the body. Bring your right hand over your head, grasping the left side of your head with the fingers of your right hand. As you breath in, elevate the right foot as high as you can, keeping the knees together. At the same time, use your right hand to help lift your head and upper body, so that you are bringing your right foot and your upper body toward each other. This will result in contraction of the right Obliques being fully contracted. (Figure 12C.) Then, breathing out, slowly release the foot and upper body and come back down to the floor. Then breathe in again and repeat the process. Do this five times total. (This exercise is based on Lesson 3 in Chapter Fourteen of Thomas Hanna's book, Somatics.)

TECHNIQUE 13 Abdominals 113

TECHNIQUE t 3

Abdominals (Chart Notes-Ab) Indications. Contraction of the Abdominal muscles is the main cause of the Red Light syndrome. It pulls the trunk forward and down, making the shoulders rounded, the head protrude forward, the chest flat, and the posture stooped. To test for Abdominal contraction, have the patient on his side, with the knees drawn up to 90 degrees. (Figure E6, p . 49.) Pull the inferior shoulder out from under him, so that his opposite shoulder can fall back toward the table. (His trunk will now be twisted, with his upper body and head facing the ceiling, and his waist and pelvis still in the lateral position.) If the Abdominals are free, the opposite shoulder will drop loosely all the way down to the table. Very often, especially in a pronounced Red Light reflex, the shoulder will be as much as 6-8 inches off the table. If so, this indicates Abdominal contraction on that side, pulling the shoulder anterior and inferior. (There is usually some Oblique contraction involved in this as well.) Like the previous two techniques, the Abdominal technique is a powerful release, and will usually completely correct the shoulder fixation. It may need to be repeated over several visits, however. Contraindications. This is generally a safe technique to use. Muscles Involved. The Rectus abdominis is the main flexor of the trunk. (Figure 13.) Patient Pos ition. Lying on right side (to release left abdominal muscle) with both knees drawn up at 90 degrees to the trunk. Pull right arm out so that left shoulder can fall back toward table. Practitioner Position. At the head of table, somewhat p osterior to the patient. Contact. The contact is the same as that for the Latissimus and Oblique techniques.

114 Chapter VI • The Twenty-One Basic Techniques

Rectus Abdominis

Figure 13

Procedure. Instruct the patient to contract his Abdominal muscles by assuming a slightly fetal position. Help him with this by placing your left hand on the rib cage (lateral and inferior to the left nipple), and gently pushing the ribs down toward his pubic bone. Instruct him as follows: "Tighten your abdominals by flexing forward slightly and squeezing your stomach muscles together." As he contracts, apply resistance by pulling in the opposite direction as you did with the previous two techniques. The direction of pull, however, is superior, posterior, and slightly oblique-the goal is to open up the thorax and shoulder, so that the left shoulder ends up lying flat on the table. (Figure 13A.)

TECHNIQUE 13 Abdominals 115

After a few seconds, have him slowly release the contraction one third of the way, before again shortening the muscles a couple of inches. Repeat this process several more times until the Abdominal muscle is fully lengthened, the left shoulder is flat on the table, and the left arm is extended all the way past the patient's head, superior, posterior, and slightly oblique to the shoulder itself (Figure

Figure 13A

13B.)

Go through the sequence a second time, then have him return to the beginning position for one final contraction against resistance. As with the previous two techniques, instruct him, on the count of three, to release his Abdominal muscle by thrusting his arm directly out behind his head. It helps with maximum lengthening of the Abdominals if, at the same time he thrusts his arm, you have him thrust and fully extend both legs.

Figure 138

Reinforcement. It is not necessary. to reinforce the antagonists. Just manually move the rib cage back and forth several times, closing and opening the space between the rib cage and the pubis, and then massage the muscle. Then go to the other side if necessary.

116 Chapter VI • The Twenty-One Basic Techniques Notes. When the shoulder has been r eleased, there is a very effective demonstration you can do for the patient which will show him just how insidious sensory-motor amnesia can be. Simply lift his shoulder back up off the table to its original, fixated p osition. Instruct the patient to hold it there, and then say: "I want you to feel how much energy you were using to hold your shoulder in the contracted position . . . . N ow that w e've freed it up, you've got all that extra energy available to you." Exercise. See the chapter titled "Basic Exercises." The first exercise-the Pelvic Arch-w orks the Abdominals.

TECHNIQUE 14 Pectorals 117

TECHNIQUE 14

Pectorals (Chart Notes-Pee) Indications. The Pectorals tighten in the Red Light reflex and bring the shoulders forward, making them rounded. When tight, these mus. cles will be tender to palpation and they may contribute to a variety of shoulder problems. Standing observation and palpation in this way is one test of Pectoralis contraction. Another test is to have the patient lie supine, then sit at the head of the table and note whether the shoulders are flat against the table, or rise up off it. Try slipping your hands under the shoulders. If one slides in a lot more easily, it is indicative of Pectoralis contraction. Contraindications. Generally a safe technique to use. Muscles Involved. The anterior flexors of the shoulder girdle-the Pectoralis major, which adducts and medially rotates the humerus, and the Pectoralis minor, which tilts the scapula anteriorly. (Figure 14.) Both muscles play a role in respiratory inspiration; if contracted, they can cause shallow breathing by limiting expansion of the rib cage. Patient Position. Supine, arms at side, head turned to the left (when, as in this example, working with the left Pectoralis). The knees should be up, feet flat on the table, as this helps release tension on the Abdominals and, to a lesser degree, the Pectoral muscles.

PART 1-PECTORALIS MINOR Practitioner Position. Standing to the left side of the patient, slightly inferior to the shoulder. Contact. Right hand covering the anterior aspect of the shoulder, left hand grasping the left humerus, just above the elbow. Procedure. Instruct the patient to contract the left Pectoralis by rotating his arm medially (you can guide the rotation with your hand), and lifting the left shoulder up off the table as high as he can, so that the shoulder draws close to his face.

118 Chapter VI • The Twenty-One Basic Techniques

Figure 14

As he contracts, apply resistance by pressing down on the shoulder. (Figure 14A.) After a few seconds, have him slowly release the contraction a third of the way by bringing the shoulder down and rotating the arm slightly lateral. Then have him again contract against resistance by bringing the shoulder up an inch or so, and rotating the arm slightly medially, before again releasing. Repeat this process several more times until the shoulder is all the way down on the table, with the left arm rotated laterally as far as possible, and the left scapula moved as close to the spine as possible (Figure 148.) (You can assist with the movement of the scapula at the end of this procedure by manually helping tuck it all the way medially, toward the spine.)

TECHNIQUE 14 Pectorals 119 Repeat the sequence a second time, then return to the beginning position for one final contraction against resistance, before releasing all the way down. Reinforcement. S I i p y o u r right hand under the patient's left shoulder and instruct him to push down against your resistance. Hold for a few seconds, then move the shoulder up and down a few times, so that the patient can experience it moving loosely and easily. Conclude by tapping and kneading the muscle.

Figure 14A

PART 2-PECTORALIS MAJOR Practitioner Position. Standing at the head of the patient.Contact. (For the left Pectoralis) Have the patient fully extend the left arm, with the shoulder in 90 degree flexion and slight Figure 148 medial rotation, and the humerus horizontally adducted toward the sternoclavicular joint. Apply pressure against the forearm, near the elbow, so that you resist the adductive movement. With the right hand, stabilize the opposite shoulder. (Figure 14C.)

Procedure. Instruct the patient to contract the left Pectoralis by simply saying, "Tighten the muscle by pushing in against my hand. " Then, as you tap the Pectoralis major with your right hand, say, "Feel the contraction here."

120 Chapter VI • The Twenty-One Basic Techniques After a few seconds, have him slowly release the contraction a third of the way by letting the arm move laterally away from the body and in a slightly headward direction. Then have him again contract back several inches against resistance, before releasing again. Repeat this process several more times, gradually laterally rotating the arm (to fully lengthen the Pectoralis major) until it is all the way down on the table. (Figure 140.)

Figure 14C

Note. You may have the patient lie near the edge of the table so that you can bring the arm down over the table, toward the floor, to achieve even greater lengthening.

Do the technique a second time, then return to the beginning position for one final contraction against resistance, before releasing all the way down.

Figure 140

Reinforcement. With the arm all the way down on the table, have the patient push down while you apply a resistance in the opposite direction. Hold for a few seconds, then move the arm back and forward a few times, so that the patient can experience the new freedom of movement in the shoulder and Pectoralis muscle. Conclude by tapping and kneading the muscle. Notes. The following is a good exercise to help confirm the new learning, especially if you do the Abdominal release as well:

TECHNIQUE 14 Pectorals 121 Have the patient stand with his head turned to the right, so that he is looking over his shoulder, at his right scapula. Tell him to notice the lengthening of his Abdominals, and the way his left chest has widened, so that there is more space now between the sternum and the shoulder. Then h ave him bring his head back to the cen ter, while keeping the Abdominals long and the chest expanded. (If the Abdominals and Pectorals have been released bilaterally, he can do this exercise on both sides.)

122 Chapter VI • The Twenty-011e Basic Techniques

TECHNIQUE 1 5

Trapezius (Chart Notes-Trap) Indications. This is an excellent technique for neck and shoulder stress and tension, especially the classic "hunched" shoulders syndrome, where the patient's shoulders are brought forward and contracted up around the neck (as in Hanna's Red Light Reflex) . Contraindications. Generally a safe technique to use. Muscles Involved. The muscles that elevate the shoulders toward the head-the upper Trapezius, Levator scapulae, Rhomboids (to some degree). (See Figure 9, p. 98.) Patient Position. Seated, preferably with feet flat on the floor. Practitioner Position. Standing directly behind the patient. Contact. Place your hands on the patient's shoulders. Procedure. Instruct the patient to fully contract the upper Trapezius muscles by "hunching" both shoulders up around the ears. Apply resistance with your hands. (Figure lSA.) After a few seconds, have the patient slowly release the contraction by letting the shoulders come down a third of the way. Then have him contract a couple of inches ba ck up again, while you increase the resistance for a second or two, before again slowly releasing. Repeat this process several more times until the shoulders are all the way down. (Figure lSB.) Then

Figure 15A

TECHNIQUE 15 Trapezius 123 go through the sequence again. Then have the patient elevate the shoulders to the beginning position for one final contraction against your resistance, followed by a quick release. Reinforcement. W i t h t h e shoulders fully down and the upper Trapezius muscles now lengthened and soft, hold the arms and, as you attempt to push Figure 158 them up, instruct the patient to hold the shoulders down, by pushing them toward the floor. Then say, "Now let your shoulders go completely loose," as you take the arms and vigorously pump the shoulders up and down, so that the patient can experience the new freedom of movement. Conclude by tapping and kneading the shoulder muscles. Variation. This technique can also be done with the patient lying prone or supine, although it tends to be most effective in the sitting position (where the effects of gravity help stimulate proprioceptive awareness). You can also do one shoulder by itself when the patient is lying on his side-a useful technique when there is extreme unilateral tension. Exercise. Patients who have a tendency to be chronically tight or sore in the upper Trapezius area can learn to release their own tension. Teach them to make a practice of consciously contracting their shoulders all the way up around their ears, and then slowly releasing them all the way down. They should inhale on the contraction, exhale on the release. After repeating this for a total of three times, there should be one final, maximum contraction followed by a quick release, then a rapid bouncing of the shoulders up and down half a dozen times, to "shake" them out. The exercise can be done as often as needed throughout the day-for example, sitting i.n the car waiting at a

124 Chapter VI • Tite Twenty-One Basic Techniques

stoplight, between phone calls or clients at the office, or during a pause in any other kind of activity. Doing this exercise will increase patients' awareness both of their tension and their ability to release it. In time they will begin to catch themselves tightening up in the very act of doing it-and it will be easy for them to then let go.

TECHNIQUE 16 Cervical-Thoracic 125

TECHNIQUE t 6

Cervical-Thoracic (Chart Notes-CT) Indications. For tight cervical/upper thoracic extensors causing neck and shoulder pain, and/ or restricted anterior flex ion of the neck. Contraindications. 1. Hypermobility and weakness of the neck muscles due to whiplash or other trauma. 2. Radicular pain into the arm or shoulder, when due to a disc lesion, may also be a contraindication. Muscles Involved. The main extensors of the neck and upper backsemispinalis capitis, cervicis and thoracis. Longissimus capitis, cervicis and thoracis. Iliocostalis cervicis. Spinalis thoracis. Trapezius. Splenius capitis and cervicis. (Figure 1, p . 70.) Patient Position. Seated, preferably with feet flat on the floor. Practitioner Position. Standing behind and slightly to the left of the patient (if right-handed). Contact. Place your left forearm across the shoulders of the patient, left hand lightly grasping the right shoulder for stabilization. Your right hand is placed against the back o f th e p atient's head, covering the External Occipital Protuberance (EOP). Procedure. Instruct the patient to bring the head back into maximum ex tension, a gainst r esistance fr om your right hand. (Figure 16A.) Afte r a fe w seconds, have the patient

Figure 16A

126 Chapter VI • The Twenty-One Basic Techniques slowly release the contraction by bringing the head forward one third of its maximum flexion. Then have the patient contract back again 1-2 inches. Apply the same resistance for a few seconds, before again slowly releasing. Repeat this process several more times until the neck extensors are fully lengthened. (Figure 16B.) Figure 168 Do the sequence one more time, then have the patient come back to the beginning position for a final contraction. As the patient contracts, shift your left hand around to the forehead while continuing to hold the EOP with your right hand (you can stabilize the upper back with your right forearm).

Gently pat the forehead several times and say, "When I count to three, I want you to quickly release your head into my hand." (Having the patient release the head into your hand prevents the possibility of whiplash from occurring.) Reinforcement. With the head forward, instruct the patient to press the forehead into your left hand, while you resist. Conclude by kneading and tapping the neck extensors. Variation. If the cervical/upper thoracic tightness is more on the posterolateral aspect of one side, have the patient turn his head 45 degrees toward the involved side. This brings into play the posterolateral neck extensors on that side. Do the entire procedure with the head at this 45-degree angle. Exercise. See Technique 20.

TECHNIQUE 17 A11terior Ceruicals 127

TECHNIQUE 17

Anterior Cervlcals (Chart Notes-AC) lndications. For tight anterior cervical muscles causing neck pain and/ or restricted posterior extension of the neck. Contraindications. 1. Hypermobility and weakness of the neck muscles due to whiplash or other trauma. 2. Radicular pain into the arm or shoulder, when due to a disc lesion, may also be a contraindication.

Longus

co IIi

Figure 17

128 Cltapter VI • The Twenty-One Basic Techniques Muscles Involved. The main cervical flexors are the Sternocleidomastoideus, Scalenus anterior, Longus capitis and colli, Rectus Capitis anterior. (Figure 17.) Patient Position. Seated, preferably with feet flat on the floor. Practitioner Position. Standing to the right side of the patient (if you are right-handed). Contact. Place your left forearm across the shoulders of the patient, left hand lightly grasping the left shoulder for stabilization. Your right hand is placed a gainst the patient's forehead. Procedure. Instruct the patient to bring the head forward into maximum flexion, against resistance from your right hand. (Figure 17A.) After a few seconds, have the patient slowly release the contraction by bringing the head back one third of its maximum extension. Figure 17A

Then have the patient contract forward again 12 inches. Apply the same resistance for a few seconds, before again slowly releas ing. Repeat this pr ocess se v e ra l m o r e times until the neck flexo r s a r e length e ned as much as is comfortable for the patient. (Figure 17B.) Go through the sequence one more time, then have the patient come b ack to the beginning position for a final contraction. As the

Figure 178

TECHNIQUE 17 Attterior Cervicals 129 patient contracts, take your left arm off the shoulders and cover the EOP with your left hand. Gently pat the EOP several times and say, "When I count to three, I want you to quickly release your head into my hand." Reinforcement. With the head extended, instruct the patient to press the back of his head into your left hand, while you resist. Conclude by very gently massaging the neck flexors. Variation. If the muscle tension is primarily in the anterolateral flexors (such as the SCM), have the patient turn the head 45 degrees away from the involved side. This brings into play the anterolateral neck extensors on that side. Do the entire procedure with the head at this 45-degree angle. Exercise. See Technique 20.

130 Chapter VI • The Twenty-One Basic Techniques

TECHNIQUE 18

Cervlc.ai-Shoulder (Chart Notes-CS) Indications. Unilateral neck and shoulder tension or spasm, especially when unilateral, as in a torticollis. Contraindications. As for Technique 16. Muscles Involved. The muscles responsible for laterally flexing the neck: the Sternocleidomastoideus, Scalenus anterior, medius and posterior (Figure 17, p. 127); Iliocostalis cervicis, Longissimus cervicis and capitis, and Intertransversarii (Figure 1, p. 70.); and those muscles that elevate the shoulder on the same side-the upper Trapezius, Levator Scapulae, and, to some degree, the Rhomboids (Figure 9, p. 98). Patient Position. Seated, feet flat on the floor, head laterally flexed to the left (in this example), left shoulder elevated so that it is approximated to the left ear. Practitioner Position. Standing behind the patient. Contact. Place your left hand on the patient's left shoulder, your right hand on his head, covering the left ear. (Some practitioners find it easier if they reverse the hand position.) Procedure. (Figure 18A.) Instruct the patient to "sque eze" his ear and shoulder together, against your resistance. After a few seconds, have him slowly separate his ear and shoulder a third of the way, by lowering the shoulder, and moving his head to the right. Then have him contract back

Figure 18A

TECHNIQUE 18 Cervical-Shoulder 131 again, 1-2 inches, with the same "squeezing" together motion. Apply the same resistance, before again releasing. Note: It is important to remind the patient to contract with equal force from both the shoulder and the neck. Otherwise the patient will tend to get focused on either his shoulder or neck, and the forces will be unequal.

Repeat this process several more times, until the Figure 188 shoulder is fully depressed and the head is flexed somewhat to the right. (Figure 188.) Go through the sequence one more time, then have him come back to the beginning position for a final contraction of the shoulder and neck, followed by a quick release. Note: With the quick release, just instruct the patient to drop the shoulder, which will allow the neck to release on its own, thus avoiding any whiplash effect to the neck.

Reinforcement. There is no need to do the antagonists with this technique. However, you may find that releasing both sides works to relieve general neck/ shoulder stress and tension. Conclude by tapping and kneading the involved muscles. Variations.

1. This technique can also be done with the patient lying supine. 2. If you want to work with the lateral neck flexors only, simply instruct the patient to bend his head to the side without elevating the shoulder.

Exercise. See Technique 20.

132 Chapter VI • The Twenty-One Basic Techniques

TECHNIQUE 19

Cervical Rotation (Chart Notes-CR) Indications. Check cervical ranges of motion for rotation. If the rotators are contracted on one side, it will limit the range of motion toward the other side. General neck stress and tension is also helped by performing this technique. Contraindications. The two main contraindications are: 1. Hypermobility and instability of the neck due to whiplash or other trauma, and 2. Radicular pain into the arm or shoulder, when due to a disc lesion. Muscles Involved. The neck rotators: Sternocleidomastoideus, Longus colli, Scalenus anterior, medius and posterior (Figure 17, p . 127); Splenius cervicis and capitis, Longissimus capitis, Semispinalis thoracis, cervicis and capitis, Multifidus, Rotatores (Figure 1, p. 70); upper Trapezius (Figure 9, p. 98). Note: Muscles that rotate head to same side are the Longus col/i, Longus capitis, and Rectus capitus anterior. Muscles that rotate hea d to opposite side are the Sternocleidomastoideus, Scalenes (anterior, medius, and posterior), Semispinalis cervicis, upper Trapezius, cervical Multifidi, and cervical Rotatores.

Patient Position. Supine, head rotated fully to the left (when working with the cervical rotators on that side). Practitioner Position. Seated on a s tool at the head of the table. Contact. Hands placed on either side of the patient's head, p alms covering the ears, fingers on the side of the face and jaw. Procedure. Instruct the patient to fully tighten his neck rotators b y turning his head all the way to the left, into your left hand, while yo u apply resistance against his con traction. (Figure 19A.) Note: It is important that the patient turn his head into your hand, so that the rotators come into play. If he just presses his head into

TECHNIQUE 19 Cervical Rotation 133 your hand, he is using the posterolateral extensors, rather than the rotators.

After a few seconds resistance, have him slowly turn his head to the right a third of the way, before again turning back to the left 1-2 inches, against your resistance. Have him hold the contraction a second or two, and then again turn to the right another third, before contracting to the left once more.

Figure 19A

Repeat this process until the head is turned a few inches past the centerline, toward the right. (Figure 198.) Do the sequence again, then come back to the beginning position for a final contraction and a quick release. Reinforcement. Have the patient turn his head all the way to the right, and contract briefly against resistance from your right Figure 198 hand. Tap and knead the left cervical rotators. Then go to the other side and release the right rotators. Notes. 1. Unless there is pronounced contraction on one side, I usually release both sides of the neck as a matter of course because of the way it helps free up neck tension and improve the overall range of motion. if you are doing both sides, the reinforcement procedure is not necessary, as doing the technique on one side automatically reinforces the other.

134 Chapter VI • The Twenty-One Basic Techniques 2. A technique for working

with chronic neck contraction and stiffness that can help bypass resistance from the neck is as follows: stand over the patient and pull his arms toward the ceiling, then move the shoulders back and forth several times (posterior to anterior) in a rocking motion. (Figure 19C.) Exercise. See Technique 20. Figure 19C

TECHNIQUE 20 Occipitals 135

TECHNIQUE 20

Occlpltals (Chart Notes-Occ) Indications. This is an excellent technique for suboccipital stress and tension, and persisting upper cervical fixation or vertebral subluxation. Contraindications. Generally a safe technique to use. Muscles Involved. The suboccipital group of muscles responsible for extending, laterally bending, and rotating the head on the upper neck, consisting of the Rectus capitis posterior major, Rectus capitis posterior minor, Obliquus capitis inferior, Obliquus capitis superior. (Figure 20.)

Rectus capitis posterior minor

Obliquus capitis superior Transverse process orC1

Obliquus capitis inferior

Figure 20

136 Chapter VI • The Twenty-One Basic Techniques Patient Position. Supine, with the head extended all the way posterior on the upper cervical spine. (The neck itself is not extended. The head is simply tipped backwards, with the chin toward the ceiling, so that the occiput-atlas gap is fully closed.) Practitioner Position. Seated on a stool at the head of the table (slightly to the left of the patient, in this example). Contact. Left hand cradles the occiput and provides resis- Figure 20A tance, the right hand covers the superior aspect of the frontal bone to guide the movement of the head. (If you prefer to work with your opposite hands, simply switch the contacts.) Procedure. Instruct the patient to tighten his suboccipital muscles by tipping his chin all the way back toward the ceiling. This ensures that the head extends posteriorward on the atlas/ axis vertebrae only-rather than having the whole neck go into extension. (Figure 20A.) Figure 208 Apply resistance with your left hand against the occiput, in the direction of the forehead. After a few seconds, have him slowly move his chin down toward his sternum a third of the way, before again tipping it back 1-2 inches. Have him hold the contraction a few seconds as you increase your resistance slightly, and then slowly release it another third, before again tipping back. Repeat this process several times until the chin is tucked toward the sternal notch and the suboccipital muscles are fully lengthened. (Figure 20B.)

TECHNIQUE 20 Occipitals 137

Go through the sequence one more time, then return to the beginning position for a final contraction and a quick release. Reinforcement. With the chin tucked into the sternal notch, your left hand still cradling the occiput, and your right hand on the frontal bone, instruct the patient: "Hold your chin down while I press on your forehead." Conclude the technique by kneading and massaging the suboccipital muscles.

Figure 20C

Variation. 1. An alternative way of doing this technique is to cradle the occiput in both hands. Resist the patient's con traction by pressing your fingertips back against the occipital ridge. (Two cautions for this method: your fingers may slip on the occipital ridge, and sometimes the pressure of your fingertips can be uncomfortable for the patient.)

2.

Figure 200

If the muscular tension is

more on one side of the suboccipital area, you can isolate it by having the patient turn his head 45 degrees toward that side. Exercises. There are two exercise series that I have found effective for the neck:

1. Move the neck slowly and consciously through its main ranges of motion: First, slowly bend your head all the way fo rward into flexion, hold for a few seconds, then bend all the way back into extension, for a total of six to ten times each direction (Figures 20C & 200); second,

138 Chapter VI • The Twenty-One Basic Techniques

Figure 20E

Figure 20F

Figure 20G

Figure 20H

follow the same procedure for lateral flexion (Figure 20E); third, then do rotation to either side (Figure 20F); fourth, finish the series with a complete 360-degree "neck roll" (Figure 20G). If any movement causes pain, it should not be done.

2. Patients may also be shown how to apply the somatic method to themselves, by flexing, extending, or laterally bending the neck and applying resistance with the fingertips to their own contraction. This is an isotonic contraction. (Figures 20H, 201 & 20J.)

TECHNIQUE 20 Occipitals 139

Figure 201

Figure 20J

140 Chapter VI • Tlte Twenty-One Basic Techniques

TECHNIQUE 21

Temperomandlbular Joint (Chart Notes-TMJ) Indications. This is an excellent technique for TMJ problems where the cause is tension and holding in the jaw muscles. The jaw is one of the most common areas for holding stress, and is a direct manifestation of the Red Light reflex, where the muscles in the front of the body tighten. Many patients have a tendency to "grind" or "clench" their teeth at night (bruxism), or to tighten their jaw when under stress. It is almost instinctual, for example, to tighten the jaw when feeling tense, angry, or afraid. The extreme sensitivity of the jaw muscles is explained by the fact that fully one third of the sensory-motor cortex is given over to the innervation of the jaw, face, and the oral pharynx. (The remaining two thirds are divided between the upper extremities, and the trunk/lower extremities equally.)' TMJ problems can be difficult to diagnose and treat, and not all practitioners appreciate the relationship between emotional stress and muscle tension. Combining the somatic procedure with the exercises given at the end of this section may eliminate the need for expensive and complicated dental and/ or surgical procedures. Contraindications. Generally a safe technique to use, provided there is no pathological condition in the TMJ. If there is severe clicking or mis-tracking in the jaw, proceed with caution. Muscles Involved. The muscles involved in mastication, and in opening and closing the jaw-the Temporalis, Masseter, Pterygoideus medialis and lateralis. (Figure 21.) Patient Position. Lying supine on the table. Practitioner Position. Seated at the head of the table. Contact. With your thumbs and forefingers, grasp each side of the lower jaw (mandible) on either side of the chin, just below the corners of IIi'

See Thomas Hanna's The Body of Life (Healing Arts Press, Vermont, 1993), 141-142.

TECHNIQUE 21 Temperomandibular Joint 141

the mouth. The thumbs should be just inferior to the mental foramina, with your forefingers hooked directly underneath the body of the mandible. Procedure. Have the patient go through the entire movement first, so that he knows what is expected of him. Using your thumb and forefingers to guide him, have him move in the following p a ttern: First, open all the way; second, move the tip of the jaw as far to the left as possible; third, close it up to the left of the midline; fourth , open it all the way down, still keeping to the left of the midline; fifth, move the jaw across to the right as far as possible; sixth, close it up all the way, to the right of the midline.

Figure 21

142 Chapter VI • The Twenty-One Basic Techniques This completes one cycle. Now have him do the same movements in the exact reverse-all the way down, keeping to the right of the midline; across to the left; close up to the left; open all the way down, keeping to the left; and so on. Now, begin the movement cycle again, but this time with resistance from your thumbs I forefingers. Use very light pressure-from a few ounces up to a pound. (Figure 21A.)

Figure 21 A

Note: Unlike the other somatic techniques, the patient will not be holding the contraction at any stage. This is a dynamic technique. He will be slowly but continually moving his jaw in a "U," or pendulum-like pattern, while you offer a moderate resistance.

After he has opened the jaw against resistance, have him slowly move it across to the left, against resistance from your left thumb/forefinger. Instruct him, as you tap the left side of his jaw: "Now move your chin to this side." (Figure 21B.)

Figure 218

Note: It is more effective to touch the side you want him to move to. When you start saying "Move to the left or right, • it gets the patient trying to conceptualize the correct movement and often results in confusion.

TECHNIQUE 21 Temperomandibular Joint 143

Then have the patient slowly close it up to the left, against resistance. Instruct him: "Now, close your mouth by bringing your chin all the way up to this side." (Figure 21C.) Once it is fully closed to the left, have him now open it all the way, again with most of the resistance coming from your left thumb I forefinger. Then have him slowly move it all the way to the right, against resistance. Then have him slowly close it up to the right, against resistance.

Figure 21 C

This completes one cycle-going down (opening the jaw), moving the chin to the left, closing up to the left, going down, moving to the right, closing up to the right. Repeat this process for six to eight cycles. Caution: If the patient has a "clicking" or mis-tracking jaw, this technique can still be used, but it is important to instruct the patient to move very slowly and gently when he comes up against the "clicking."

Reinforcement. The technique itself works both the agonists and antagonists. Once the six to eight cycles have been completed, you can move slightly to the left side of the patient and grasp the jaw with your left hand, while stabilizing the patient's right cranium (temporal/parietal area) with your right hand. Gently stretch the right TMJ open by using your left hand to traction anterior and inferior on the mandible. Do this a few times with a soft, slow, gentle pumping motion. This opens the joint and helps eliminate any remaining tension in the muscles. Then go to the other side, and do the same procedure on the left TMJ. Conclude by tapping and kneading the TMJ muscles.

144 Chapter VI • Tlte Twenty-One Basic Techniques Exercises. A patient with a chronically clicking or mis-tracking TMJ can do an exercise at home that will often help minimize or eliminate the problem. Instruct him to lie down on his back, firmly hold the lower jaw with the thumb and forefinger (as for this technique), and then slowly open his mouth wide by moving his head and upper jaw back as far as he can. Once the head is back and Figure 21 D the jaw fully open, he should then bring his head all the way forward again, so as to close the mouth. Opening the jaw this way is usually a totally new experience for people and may take some learning. (Figure 21D.) He should do this for ten repetitions, once in the morning, and once at night. He can also do the pendulum technique, as described in the "Procedure" above, as a home exercise, providing light resistance to his own movements.

VII

Extremity Techniques

The techniques that follow are for the upper and lower extremities. Extremity problems are often a compensation for middle body distortions. For example, the tight Abdominals of the Red Light reflex pull the body forward, which puts more weight on the soles of the feet. At the same time, contraction of the medial hip rotators (Gluteus minimus, etc.) will cause the toes to point in. The combined effect of these two patterns can adversely stress the knee joints, resulting in medial meniscus pain and other problems. When you free up the center of the body-along with the hips, the Hamstrings, the shoulder girdle, and the neck-many extremity problems will clear up by themselves. As the pelvis, trunk, and shoulders regain their normal alignment and flexibility, the upper and lower extremities will be able to move freely and easily once again. However, there are times when the muscles of the extremities need to be addressed directly. The presenting symptom may be pain or stiffness in the muscle itself, or there may be a joint problem that you suspect may be caused by muscle imbalance. Keep in mind that when dealing with a specific joint-the elbow, say, or knee-it is a good idea to release all the main muscles of the involved extremity. Doing this over several sessions can bring an entirely new state of ease and balance to the affected limb. I will not describe these additional techniques in detail, nor will I cover every single extremity muscle. By now, you will be familiar enough with the method of Somatic Technique to know-or to be able to figure out-what to do with any skeletal muscle in the body. As I pointed out in Chapter Five, you are limited only by your understanding of muscle anatomy and your own creativity. Note: The main contraindication in .extremity work is pathology in the muscle or associated joint.

145

146 Chapter VII • Extremity Techniques

UPPER EXTREMITY TECHNIQUE 22

Deltoids (Chart Notes-Delt) Indications. Shoulder problems. Muscles Involved. The Deltoid and the Supraspinatus are the principal abductors of the shoulder joint. (Figure 22.) Patient Position. Seated, arm flexed, elbow raised 30 degrees above the horizontal plane, and pointed directly out from the body.

Supraspinatus

Figure 22

TECHNIQUE 22 Deltoids 147 Practitioner Position. Standing behind the patient. Contact & Procedure. Stabilize the patient's shoulder with one hand, while pressing down on the patient's elbow with the other. At the same time, the patient contracts his shoulder muscles by bringing his elbow up, toward the ceiling. (Figure 22A.) The direction of release will be down toward the patient's rib cage.

Figure 22A

Variation. When the restriction or contraction is located more in the anterior or posterior aspect of the Deltoid, move the elbow forward or back accordingly.

148 Chapter VII • Extremity Techniques

T~CHNIQUE

23

Bleeps (Chart Notes-Bi) Indications. Elbow problems. Muscles Involved. The main flexors of the elbow joint-the Biceps Brachii and the Brachialis. (Figure 23.) Patient Position. Seated, with the arm raised and the elbow almost fully flexed.

Biceps Short head

Figure 23

TECHNIQUE 23 Biceps 149 Practitioner Position. Standing in front of and to one side of the patient. Contact & Procedure. Stabilize the elbow with one hand, grasp the patient's forearm with the other. Apply resistance to the forearm as the patient contracts his Biceps. (Figure 23A.) The direction of release will be toward you, as the patient gradually straightens his arm.

Figure 23A

150 Chapter VII • Extremity Techniques

TECHNIQUE 24

Triceps (Chart Notes-Tri) Indications. Elbow problems-e.g., tennis elbow. Muscles b.wolved. The main extensors of the elbow joint-the Triceps brachii and the Anconeus. (Figure 24.) Patient Position. Seated, with the arm raised and the elbow almost fully extended.

Triceps

Long head

Figure 24

Media/ head

TECHNIQUE 24 Triceps 151

Practitioner Position. Standing in front of and to one side of the patient. Contact & Procedure. Stabilize the elbow with one hand, grasp the dorsal surface of the wrist with the other. Apply resistance to the wrist as the patient contracts his Triceps. The direction of release will be away from you, as the patient gradually flexes his arm. (Figure 24A.) Figure 24A

152 Chapter VII • Extremity Techuiques

TECHNIQUE 25

Wrist

(Chart Notes-Wr) Indications. Wrist problems-e.g., carpal tunnel syndrome. Muscles Involved . There are many small muscles involved in wrist ranges of motion. Refer to an anatomy text for more detail. Patient Position. Seated, with the wrist held out. Practitioner Position. Standing in front of the patient. Contact & Procedure. Stabilize the distal end of the forearm with one hand, while grasping the patient's hand with your other. Depending upon where the muscle tension is (you can palpate for this), have the patient contract the involved muscles by flexing, extending, abducting or adducting his wrist. Then apply resistance to his contraction. (Figure 25.) A good, general somatic appro ac h to loc a lized wrist problems is to work with all four main directions of movement. This frees up and mobilizes the entire wrist.

Figure 25

TECHNIQUE 26 Gluteals 153

LOWER EXTREMITY TECHNIQUE 26

Gluteals (Chart Notes-Glut) Indications. Hip and knee problems. Muscles Involved. The Gluteus maximus is involved mainly in extension and lateral rotation of the hip joint. It also helps stabilize the knee in extension. (Figure 26.)

Figure 26

154 Chapter VII • Extremity Techniques Patient Position. Prone, with the knee flexed to at least 90 degrees and the thigh lifted as high off the table as possible. Practitioner Position. Standing beside the patient, midway between the hip and the knee. Contact & Procedure. Stabilize the raised leg by holding just below the ankle, while you apply resistance downward on the belly of the hamstrings. The patient contracts his thigh up against your resistance. (Figure 26A.)

Figure 26A

The direction of release will be down toward the table.

TECHNIQUE 27 Gastrocnemius 155

TECHNIQUE 27

Gastrocnemius (Chart Notes-Gast) Indications. Knee and ankle problems. Muscles Involved. The Gastrocnemius and Plantaris plantar flex the ankle joint, and assist in flexion of the knee joint. (Figure 27.) Patient Position. Prone, legs extended, foot on the involved side plantar flexed-i.e., bent toward ceiling.

Plantaris

Gastrocnemius

Figure 27

156 Chapter VII • Extremity Techniques Practitioner Position. Standing at the foot of the table. Contact & Proced,u re. Stabilize the lower leg with one hand, while grasping the sole and toes with the other. The patient contracts his Gastrocnemius and Plantaris by firmly flexing his foot into your contact hand, while you apply resistance. Instruct him to: "Bend your foot toward the ceiling." (Figure 27A.) Figure 27A

The direction of release will be downward, toward the floor.

TECHNIQUE 28 Soleus 157

TECHNIQUE 28

Soleus (Chart Notes-Sol) Indications. Foot/ ankle problems. Muscles Involved. The Soleus is a main plantar flexor of the foot. (Figure 28.) Patient Position. Prone, with the knee flexed to 90 degrees, the foot itself plantar flexed (i.e., toward the ceiling). Practitioner Position. Standing level with the patient's flexed knee. Contact & Procedure. Stabilize the lower leg with one hand, while you grasp the sole and toes of the foot with your other. The patient contracts the Soleus by firmly flexing his foot into your contact hand, while you apply resistance. Instruct him to: "Bend your foot toward your head." (Figure 28A.)

Figure 28

The direction of release will be downward, toward the floor. Note. To save time, you can combine the Gastrocnemius and Soleus into one technique. Have the patient flex his leg at a 45-degree angle, and do the movement involving the foot from that position.

Figure 28A

158 Chapter VII • Extremity Techniques

TECHNIQUE 29

Quadriceps (Chart Notes-Quads) Indications. Hip and knee problems. Muscles Involved. The Quadriceps femoris flexes the hip, and extends the knee. (Figure 29.) Patient Position. Supine, with the leg raised so that the thigh is flexed toward the abdomen, and the lower leg is parallel to the table.

Figure 29

TECHNIQUE 29 Quadriceps 159 Practitioner Position. Standing at the side of the patient, approximately level with the hip. Contact & Procedure. (Figure 29A.) Stabilize the leg, just above the ankle, with one hand, while your contact hand applies resistance to the distal end of the femur, just above the knee . The patient contracts his Quadriceps by drawing his knee back into your contact hand. Figure 29A The direction of release is away from your contact hand, with the patient gradually straightening and lowering his leg.

160 Chapter VII • Extremity Techniques

TECHNIQUE 30

Adductors (Chart Notes-Adds) Indications. Hip and knee problems. Muscles Involved. The Adductors adduct the hip, with some of the fibers being involved in flexion and extension. The Gracilis, in addition to being an adductor, also flexes and medially rotates the knee joint. (Figure 30.)

0

0

longus (overlays Adductor

mag nus)

Figure 30

TECHNIQUE 30 Adductors 161 Patient Position. Supine, with the leg flexed so that the knee is pointing toward the ceiling, and the foot placed alongside the knee of the opposite leg. Practitioner Position. Standing to one side of the patient, level with the flexed knee. Contact & Procedure. This technique is the reverse of 7, Hips Supine. Contact the medial side of the flexed knee with both Figure 30A hands (or one hand on the knee, one hand stabilizing the ilium). Instruct the patient to contract his Adductors by pressing his knee medially, into your hands. Apply resistance. (Figure 30A.) The direction of release is outward, so that the knee will eventually fall all the way out to the side of the table. The foot remains in the same position.

162 Chapter VII • Extremity Techniques

TECHNIQUE 3 1

Sartorius (Chart Notes-Sart) Indications. Hip and knee problems. Muscles Involved. The Sartorius is the longest muscle in the body. It flexes, laterally rotates, and abducts the hip joint, and also flexes and assists in medial rotation of the knee joint. (Figure 31.) Patient Position. Supine, with the leg raised so that the thigh is flexed toward the abdomen, then abducted and laterally rotated, so that

0

Figure 31

TECHNIQUE 31 Sartorius 163 the knee is away from the body. The raised foot should be over the thigh of the extended leg, just superior to the knee. Practitioner Position. Standing to the side of the patient, level with the raised knee. Contact & Procedure. Stabilize the raised knee with one hand, while you grasp the ankle I heel with the other. The patient contracts his Sartorius by drawing his heel back toward his groin, into your hand. Apply resistance. He releases the contraction by straightening his leg. (Figure 31A.)

Figure 31A

164 Chapter VII • Extremity Techniques

TECHNIQUE 32

Tibialis Anterior (Chart Notes-Tib) Indications. Ankle and foot problems. Muscles Involved. Tibialis anterior, which dorsiflexes the ankle joint and assists in inversion of the foot. (Figure 32.) · Patient Position. Supine, with the leg extended and the foot flexed toward the knee.

Figure 32

TECHNIQUE 32 Tibialis Anterior 165 Practitioner Position. Standing at the foot of the table. Contact & Procedure. Grasp the dorsal surface of the foot with both hands, and apply resistance as the patient contracts. (Figure 32A.)

The direction of release is down, toward the table.

Figure 32A

166 Chapter VII • Extremity Techniques

TECHNIQUE 33

Foot (Chart Notes-Ft) Indications. Ankle and foot problems. Muscles Involved. As for the wrist, there are a number of muscles involved in foot/ ankle ranges of motion, several of which are involved in the previous techniques. Refer to an anatomy text for more detail. Patient Position. Seated, with the legs extended on the table. Practitioner Position. Standing at the foot of the table. Contact & Procedure. Stabilize the distal end of the tibia, just above the ankle, with one hand, while grasping the foot with the other. As for the wrist, have the patient contract the muscles being worked with by flexing , extending, inverting, or everting the foot. Then apply resistance to his contraction. Again, working with all the main directions of movement frees up and mobilizes the entire foot and ankle. (Figure 33.)

Figure 33

VIII

Integrating Somatic Technique into Your Practice

Using Somatic Technique as an Adjunctive Procedure Most practitioners will use this work as an adjunctive procedure, to complement whatever hands-on skills they currently use. Some may be interested in using it in a more in-depth way, and I offer a method of doing that at the end of this section. What follows now is a reiterationwith additional suggestions-of the four-step procedure outlined in Chapter One. Following these steps will help you successfully integrate this work into your practice.

Step 1 Read some of this manual daily until you get a good understanding of the work, and the neurophysiological principles-the sensory-motor feedback "loop," the Golgi tendon and gamma motoneuron reflexesbehind it. Begin reading related material, such as Hanna's book, Somatics, and some of the other material I have referred to in this manual. Take your time with the reading. Don' t try and learn it all at once. As you practice this work and begin to develop a "feel" for it, the neurophysiology behind it will make more sense.

Step 2 Start using some of the techniques with your patients, following the recommendations for learning them made in Chapters Five and Six.

Step 3 While you are in the process of becoming familiar with this work, I suggest you use it on a piecemeal basis. Here' s one way of implementing your new learning: A. Practice doing some Somatic Evaluations, especially when you have a little extra time to spend with a new patient-or a regular p atient whom you want to evaluate somatically. It won't take too long to become fairly accomplished at this.

167

168 Chapter VIII • Integrating Somatic Technique into Your Practice B. Each time you see a patient, ask yourself if he might be a candidate for Somatic Technique. Does he have a persisting problem that might be neuromuscular in origin? Look for the following telltale signs, and also use the Symptom Checklist in Appendix A: • A scoliosis, indicating over-contracted muscles on one side of the spine. • Persistent soreness in the neck or lower back. • Tight, hunched, or sore shoulders. • Pain or limited movement in a shoulder joint. • Hip problems. • Tight hamstrings. • Poor posture-either slumped, sway-backed, or leaning to one side (as in the Trauma reflex). • Sore abdominal muscles. • Chronically shallow breathing (due to tight Abdominals). • TMJ syndrome. • Chiropractic adjustments won' t hold. • General stiffness and tension. • Lack of energy. • Extremity problems that are not responding to your other methods of treatment.

C. When you have executed a technique, look to see if there is a change. Usually there will be, if the problem was neuromuscular. The muscle will be softer, less tense, there will be less pain and soreness, and there will be an improvement in the range of motion. Ask the patient what he notices. Have him move the muscle or joint. He will usually remark that it feels "lighter, freer," or that there is more "energy," increased sensation, a feeling of expansiveness. D. Check the same area on the next visit. Muscles that have been contracted for years, once released, will tend to go back into their old patterns. Sometimes a muscle will need to be worked with over a number of visits. When you use Somatic Technique you are teaching the patient to become more aware of his muscles and how he moves his body. The work has a repatterning effect. Above all, remember that the clinical work is most effective when it is supported by one or two exercises, specific for the problem area, that the patient can do at home. Step 4 Once you are familiar with the twenty-one basic techniques, experiment with using the twelve-visit protocol. With this approach you will

Using Somatic Technique as an Adjunctive Procedure 169 do an average of two Somatic Techniques on every visit, gradually working through the whole body (except for the extremity techniques, which will only be necessary if there is an extremity problem), over a series of twelve visits. The amount of pain the patient is experiencing will dictate whether he needs to be seen, initially, once, twice, or three times per week. An average schedule in my office, for someone who has chronic muscle contraction but is not in significant pain, is to see that person twice a week for the first three to four weeks and then once per week for the remaining visits. On the twelfth visit I will reevaluate him. If more care is needed it can then be recommended. (Patients with a lot of pain may need to be seen more frequently than twice a week, and for a longer period.) Explain the program to the patient this way: "Somatic Technique is an advanced method of neuromuscular reeducation. Once we work through your whole body, you'll feel more relaxed, you'll be more flexible, and you'll have more energy. We'll do a little bit each visit, so as to give your body time to get used to the changes."

Let them know that, even though they may have come in with only a low back or a neck problem, the entire body functions as a single, integrated unit. For optimal well-being, the whole body needs to be addressed. Then, follow the protocol outlined below. Using techniques from the basic twenty-one, you will cover in twelve visits the Somatic Evaluation and the key areas of (1) low back and hips; (2) the waist, abdomen, and shoulder girdle; and (3) the upper shoulders and neck. You will also be teaching them, on the third visit, the Basic Exercises. Use the protocol as a guideline, and don't be limited by it. Again, experiment with this work. Be creative. Once you have gone through the entire body, you may need to focus on problematic areas-such as the lower back, the hips, the shoulders, the abdominals, or the TMJ-in subsequent visits. Remember, there is virtually no limit to how relaxed and supple any of us can be, or how much energy we can enjoy. The more you do this work with a patient, the more that patient will benefit. With each session of Somatic Technique, no matter how brief, he will gain in awareness, balance, flexibility, and health. (Note: Unless a muscle or area of the body is already relaxed and free, most techniques will need to be done bilaterally.)

170 Chapter VIII • Integrating Somatic Technique into Your Practice

Twelve Visit Protocol 1. Techniques for the Low Back and Hips 1st visit: Somatic Evaluation and Technique #1, Paravertebral Muscles 2nd visit: #2 Trunk Extension Prone, #3 Knee-Chest 3rd visit: #8 Hamstrings, Basic Exercises 4th visit: #4 Ilium-Axillary, #5 Psoas 5th visit: #6 Hips Prone, #7 Hips Supine, 2. Techniques for the Waist, Abdomen and Shoulder Girdle 6th visit: #9 Both Shoulders Prone, #10 Shoulder Lateral 7th visit: #11 Latissimus Dorsi, #12 Obliques 8th visit: #13 Abdominals, #14 Pectorals 3. Techniques for the Upper Shoulders and Neck 9th visit: #15 Trapezius, #16 Cervical-Thoracic lOth visit: #18 Cervical-Shoulder, #19 Cervical Rotation 11th visit #20 Occipital, #21 Temperomandibular Joint 12th Visit Reevaluate, Review Basic Exercises

A Note To Chiropractors The most common question I get from chiropractic doctors who learn this work is whether they should do Somatic Technique before or after delivering an osseous adjustment. When using it as an adjunctive procedure, I u sually do the somatic work prior to the adjustment. Releasing the muscle beforehand makes the patient more relaxed and receptive to the adjustment, and the thrust is much easier to deliver. However, in order to avoid having the patient constantly change position on the adjusting table, I may alternate osseous adjusting with somatics, depending on which area of the spine I am working with. As discu ssed in Chapter Two, Somatic Technique can also be used as an alternative to high-velocity adjus ting, because of the w ay it utilizes the muscles as levers to restore m obility to the vertebral motor unit.

Guidelines for Physical Therapists, Massage Therapists, and Bodyworkers Physical therapists are generally already well trained in a variety of neuromuscular techniques and procedures, especially those of PNF. Several of the physical therapists I have introduced to Somatic Technique have told me that the main benefit of the somatic work is that it

Guidelines for Physical Therapists 171 can be done quickly, in just a few minutes. With the changes in the health care industry and the onset of managed care, many physical therapists (like medical doctors and chiropractors with insurance-dependent practices) are likely to find that they cannot spend as much time with the patient as they once did. It will simply become economically unfeasible. In the past, most P.T.s spent an hour with a patient. In the new managed care system, the time available is usually no more than a half-hour. Somatic Technique can allow the P.T. to achieve maximum results, in terms of neuromuscular release and rehabilitation, in the minimum amount of time. As for massage therapists, learning Somatic Technique can take the practice of massage to a new level. Massage therapists who do a fullbody, oil-based massage sometimes find it difficult knowing when to utilize the somatic work, mainly because they don't want to interrupt the flow of the massage. Massage, remember, is a passive therapy, and one of the things clients enjoy about it is that they are able to lie on the table and not have to do anything. Perhaps for the only hour in their entire week they can completely relax, let go, and enjoy the caring touch and healing ministrations of another human being. I have a massage therapist working with me in my office and I have noticed for years that whenever her clients come out of her office, they always look five to ten years younger. The stress has literally been drained away from their faces. No wonder my patients love being referred for massage! In the time that I have been teaching Somatic Technique, massage therapists have always been very receptive to it. They understand that massage, in part because it is so relaxing, can also be extremely healing. Yet massage has its limitations. There are many chronic musculoskeletal conditions it has no effect on, other than providing temporary relief from pain and tension. Adding Somatic Technique gives the therapist a unique and effective set of tools for actually correcting a variety of musculoskeletal problems, while heightening the patient's mind/body awareness. Undoubtedly there will be doctors who disagree with the idea of a massage therapist expanding the scope of his or her practice in this way, but I personally feel that the body of knowledge around soma tics is too important to be confined to any one professional group. As I have indicated throughout this book, it is my view that this work should be available to all qualified hands-on practitioners. This is the only way it will get to those who need it: the people in pain who come through our doors every day, looking for relief and healing. A trained, skilled, and caring massage practitioner is in an excellent position to help these people. To this end, I have trained my own massage therapist in this work. She utilizes it when she sees a need with her own clients, and works according to my recommendations when it comes to dealing with patients I have referred to her.

172 Chapter VIII • Integrating Somatic Technique into Your Practice As for the actual method of integrating Somatic Technique into the practice of massage, it will again be different for every practitioner. Many like to deal with the somatic problems first, while the patient is still clothed. The advantage of doing this is that by checking for and releasing the main areas of contraction, the client frequently becomes more receptive to the massage that is to follow. It also means that the massage itself will not be interrupted by the need for any active, participatory work on the part of the patient. However, some practitioners who use a lot of somatic work prefer to blend it in with the massage itself. They like to evaluate somatic problems during the course of the massage and deal with them as they arise. The more skilled the practitioner, the less such "interruptions" feel like a disturbance. Rather, they make for a more interesting and multidimensional massage. If you are a massage therapist reading this book, probably the best way to get started with Somatic Technique is to, again, utilize it with those clients who are complaining of a specific musculoskeletal problem. Do it before you begin the massage. Say to the client something like: "I'm learning something new. It's called Somatic Technique, and it's designed to release the chronically tight muscles that may be the cause of your pain. I'd like to do this with you first, and that way you'll get even more value out of the massage. Shall we give it a try?"

Then go ahead and do one or several techniques as you have been taught in this manual. At the end of the massage, you may give an exercise or two. The next time you see your client, ask them what they noticed in their body and how they feel, and reevaluate the musculature and range of motion in the problem area. Depending on your interests and orientation, you may find yourself doing Somatic Technique on a regular basis with many of your clients, or just once in a while. As for those practitioners involved more in the field of bodywork in general, rather than massage specifically, I suggest following the same guidelines as for massage therapists. Whether you do deeptissue w ork, trigger-point technique, acupressure, Trager, Rolfing, movement reeduca tion, or any one of the dozens of other neuromuscular therapies being taught these days, there is a place for Somatic Technique in your inventory of skills. Once you learn the work, your trained eye and your intuition-guided by the client's feedback-will tell you when to use it.

Somatic Technique and Insurance Billing 173

Somatic Technique and Insurance Billing Somatic Technique falls under the categories of "neuromuscular reeducation" or "soft-tissue mobilization." There are insurance codes which cover both these procedures. As all practitioners know, insurance is very much a "game." The better you comprehend the rules of the insurance game (which the insurance companies, in order to maintain the upper hand, annoyingly keep changing!), the higher your chances of being paid for the services you render. At the time of writing, for instance, workers' compensation insurers in California arbitrarily decided that "neuromuscular reeducation" was a one-time event-similar to an exercise or rehab class-and that they would therefore not pay for subsequent sessions. As practitioners, we have to be just as creative in the way we bill as the insurers are in the way they handle our bills, in order to ensure that our patients' and clients ' needs are met. The actual amount billed depends, of course, on the length of time given to the somatic procedures, along with what is usual, customary, and reasonable in terms of charges in the practitioner's geographical area. In my office I will occasionally take an entire fifteen- or thirty-minute session for soma tics. More often, however, it is utilized as an adjunctive procedure to the adjustment, and requires not more than three to five minutes of time. It is then billed accordingly, as I would bill for any other additional procedure, be it trigger-point therapy, traction/mobilization, myofascial release, and so on.

A Word about Feldenkrais and Other Methods Over the years, I've met a number of chiropractors and other practitioners who have been interested in the sensory-motor methods of F.M. Alexander and Moshe Feldenkrais, and the deep-tissue work of people like Ida Rolf, Joseph Heller, and others. Some doctors have gone so far as to take training, and even get certified, in these systems of neuromuscular reeducation and bodywork. Integrating these new methods into their practices u sually involves a m ajor change in the way they run their practice. The techniques in these systems are not designed to be performed in just a few minutes as an adjunct to other procedures. A Fe!denkrais practitioner may spend an hour or more with a client. A Rolfing session can go for as long as an hour-and-a-half. For many practitioners-and probably most chiropractors-it does not make sense to spend this kind of time with their patients. The office overhead and other practice commitments simply wouldn't allow it. Besides, for chiropractors, such a lengthy session isn ' t necessary to achieve therapeutic goals.

174 Chapter VIII • Integrating Somatic Technique into Your Practice The advantage of Somatic Technique is that it is an effective tool for neuromuscular therapy and reeducation, yet it does not take more than a few minutes on any given visit. It is not a replacement for Feldenkrais, or any other system of bodywork, however. Every method serves different kinds of problems, and each has its own unique benefits to offer. Some people need more in-depth, more subtle, or more timeconsuming work. This is especially so when there are complex neurological problems relating to function, movement, balance. For these, the Feldenkrais method can be especially appropriate. Feldenkrais, however, is primarily passive in its application. The client sits or lies on the table, and the practitioner gently moves certain muscles or limbs so as to create a new sensory experience. Somatic Technique, on the other hand, elicits the client's active participation through having him consciously contract his muscles, which brings in the motor element more strongly. Having him contract against resistance creates the enhanced sensation and feeling needed to stimulate awareness and bring about new motor choices. It is a form of kinesthetically based biofeedback. As a technique for quickly and effectively releasing tight muscles and enhancing mind/body awareness, it is unparalleled.

Using Somatic Technique over a Longer Session Some of you reading this manual may wish to experiment with doing more extensive somatic work with a patient. At times, for the purposes of research, I have scheduled patients for a half-hour of Somatic Technique. I've had certain patients, for instance, who have presented with chronic neuromuscular problems that have not responded to chiropractic care or other forms of therapy. They have heard that this work is different, and want to see if it will help them. As part of my own investigation into this work I've found it valuable to take more time with them. It has been beneficial for them and instructive to me. When it comes to doing a longer session, I have found, for my style of practice, that a half-hour is enough. I will usually schedule a patient for six half-hour sessions, initially, although some end up needing around ten or twelve visits. In the first session, I will take a case history, evaluate them somatically, and talk to them about somatic awareness and the need for regaining conscious control of their muscles and their movement. I will then begin freeing up the back and the middle of the body, as per the twelve-visit protocol. I will usually do six to eight Somatic Techniques during this first session and, depending on time, may also teach the three Basic Exercises. Be aw are that there is a difference in doing Somatic Technique on its own like this, and using it as an adjunctive procedure. I do not believe in mixing too many therapies, as it only confuses the body. When using

Using Somatic Technique over a Longer Session 175 Somatic Technique on its own, it is fine, in a given session, to do a series of techniques that cover all the main areas of the body. But when used as an adjunct to the chiropractic adjustment, and perhaps a number of physical therapies as well, I have found it works best to do no m;:,re than one to three somatic procedures. During the subsequent sessions, I will continue working through the protocol, covering all the basic techniques and focusing on those areas that need special attention. I will also review the exercises at some point, to make sure the patient is doing them correctly. The advantage of these longer sessions is that you have more time to really be with the patient. You have more of an opportunity to educate them somatically-to help them become more aware of, and sensitive to, their bodies. It is an excellent approach for the practitioner who has a very low overhead, and who wants to spend extra time with his or her patients Remember, to get the most out of it, the work requires the conscious participation of the patient. Each time you perform a somatic procedure, engage and involve your patient by doing the following: 1.

Make sure he understands what is happening. Explain it to him this way, letting him know about the sensory-motor feedback loop: "Muscles are controlled by a sensory-motor feedback loop which connects your brain with your muscles. What that means is that the more you can sense or feel your muscles, the more motor control you have over them. "Stress or injury has caused you to 'forget' what it feels like to consciously control your muscles. You've literally lost awareness of them. This work will help you get back in touch with them, so that you can contract them and relax them at will."

2.

Have him close his eyes and put his awareness in his muscle. Instruct him to really feel the contraction of his muscle, as you apply resistance. Have him breathe in as he contracts. 3. Tell him to notice, as he slowly lengthens the muscle, how in control of his own movement he is. 4. Encourage him to let the release be as smooth and as conscious as possible, breathing out as he does so. 5. When the procedure is complete, ask him to report on what he is now feeling and sensing in the muscle, and invite him to experience the new range of movement. The effects of this work are sometimes quite dramatic, and sometimes more subtle. Some patients, particularly those who are very tight and are not really "in" their bodies, may not notice much at all initially .

176 Cltapter VIII • Integrating Somatic Technique into Your Practice They're simply not very attuned to their somatic experience. Give them time. Remember, they are learning a new way of moving their muscles, joints, and limbs. After you've worked with them over a number of visits, their natural capacity for sensory-motor awareness will reawaken and they will start to sense and feel themselves in a new way.

IX

Healing the Whole Person

"To see what you've done, look at your body. To see what you'll be, look at your actions." -The Great Path of Awakening1

The Body We Have and the Person We Are In this chapter I want to explore in more depth some of the concepts I touched upon in Chapter One, especially the relationship between consciousness and health, between the "person" we are and the body we have.2 The patients I have worked with over the years who have been (or have become) psychologically and emotionally the healthiest-that is, the most at ease and at peace with themselves, regardless of their physical condition-are those who have been able in some way to find a harmonious balance between the person they are and the body they have. They have undergone an inner transformation, and this transformation is expressed in an openness and balance of body, mind, and spirit. Stephen Levine, an American meditation teacher and skilled counselor of the dying, emphasizes over and over again in his work that the real healing-the "healing we took birth for"-is not so much what happens with the physical body, but what takes place in the human heart and soul. 3 As practitioners, we have all seen how patients, when they finally relax and iet go their inner tension, often experience a healing of their somatic symptoms, whether they be musculoskeletal, visceral, o r metabolic. We can observe this phenomenon simply through paying attention to our own bodies, and taking note of the relationship between mental attitudes and physical states. All our fears, defenses, and insecurities display themselves as unconsciou s patterns of tension and holding in our muscles and our posture. These p atterns affect o ur breathing, our movement, our gestures, our actions. The more black-or-white we are in our thinking, the more tense we appear and the stiffer our movements. Energy, the life force, cannot flow easily through our cells. Over time we feel this tension as fatigue, weariness, a lack of creativity, premature aging.

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178 Chapter IX • Healing tlte Whole Person In the case of fear, for example, the body tends to stiffen, even to the point of paralysis, so that we are literally unable to move to save ourselves. An aggressive stance in the world so tenses our musculature that, if it persists, it is as if we are wearing a suit of armor. Such armoring, while it may protect us from outside assault, also renders us invulnerable and insensitive. We are incapable of feeling any subtle sensory input. Depression also numbs us to feeling, depletes our energy, makes us lethargic, and reinforces the psychological sense of futility, meaninglessness, hopelessness. Restlessness, ambivalence, and chronic anxiety tend to cause us to be disassociated from our body and make us feel insecure. We cannot find our center, our ground. Karlfried Graf Durckheim, a German philosopher, psychologist, and body therapist, once defined a neurotic as "a person who cannot find himself in his own body.'' 4 Another European, Jean Klein, a yoga master, former medical doctor, and one of my teachers, has this to say about the body /mind connection: One should thoroughly understand that fundamentally, the body is nothing but an idea . It is nothing but a bundle of ideas. These are crystallized, set and solidified by repetition and stagnation. The regeneration of the body may be obtained by a therapy which should employ the contrary process, establishing a discriminating attention which will dissolve and destroy all our set patterns. After all, the body is nothing but. a collection of mental habits: the mind alone has produced them and the mind alone can destroy them by the reverse process. Such a process will allow us to acquire a regenerated, purified body.5

Klein's view may seem radical to those who do not yet appreciate the degree to which the body and mind are interrelated, yet Durckheim says essentially the same thing: "When the body is seen not as something that people have but as something that they are-as the sum total of the gestures in which they live themselves out, that is, express and realize themselves in a visible, external form-then this form must also point to what they really are." 6 In other words, the body is an expression of the person-his attitudes, his beliefs, his conditioning-and the person, in turn, is reflected in the body. Durckheim, whose life work was devoted to the need for bringing consciousness into the body, addresses the process of regeneration from the same perspective as Klein. He acknowledges the importance of being grounded and centered in one's physical, or somatic, experience-and emphasizes that it is the person inside the body who must ultimately be encountered. "Every true teacher, doctor, therapist, and indeed, pastor," he says, "knows that his relationship with pupil, patient, or seekerafter-help changes dramatically when he is suddenly driven to open

The Body We Have and the Person We Are 179 himself entirely, step through his official function, and confront the other as the person he really, totally is. The dangers are many, but he knows deep down that he is now getting through as person to person for the first time." 7 It is the personal element in the healing equation that is too often overlooked by practitioners whose focus is on the body alone. This is what Klein and Durckheim are getting at. They are reminding us that many health problems are a direct manifestation, a "somatizing," of an individual's state of mind. If emotional pain or tension, arising from the person's self-image or ego identity, is causing muscular holding, then any attempts to alleviate the person's pain through releasing the muscles will usually be futile. After all, the muscle contraction is secondary, not primary. It is the effect, not the cause. Too often we view the body as something separate from the mind, and then the mind as something separate from the person, the subjective "I" that lives inside the body. In the end, it is this "I" that must be addressed. Learning to sense and feel our somatic reality is a vital step in healing, but sooner or later we must ask the question, "Who is it that is sensing and feeling?" All genuine healing leads us to this question, or to variations of it. As such it is very much an emotional and spiritual process-a process of self-enquiry and self-knowing. We can start with the body, because that is where we see the first and most obvious signs of malfunction and imbalance. By working with the body, whether through chiropractic, physical therapy, acupuncture, massage, or some other means, many problems will be eliminated. But unless the person living inside the body is healed at an emotional and spiritual level-becomes truly "whole," or self-actualized, as the psychologist Abraham Maslow expressed it8then the mental, emotional, and psychic tensions will merely manifest elsewhere, in a different set of symptoms. Anybody who understands the psychosomatic nature of disease is familiar with this phenomenon. You can cure the back pain, but then the person starts to have prostate or bowel problems. You can control the blood pressure with medication, but then they develop arthritis or diabetes. You can cut out the cancer from the breast or the stomach, but unless the person learns to release the tension, fear, or resentment they carry within them, it is likely to crop up somewhere else. As our self-enquiry and self-understanding deepen, we begin to manifest, to embody, three distinct attributes, or qualities of wholeness. These are the hallmarks of actualization, the fruits of the transformational journey. They are wisdom, love, and creative power. Taken just as words, they can remain in the realm of mere concepts or ideals, yet each of them in fact has a somatic "home." Wisdom is clarity in seeing, thinking and communicating, and is expressed through the upper part of the body-the head and throat. In my practice I have observed repeatedly that problems around self-understanding and self-expres-

180 Chapter IX • Healing the Whole Person sion tend to manifest in cervical pain, headaches, throat and voice problems, and eye disorders. Love is experienced in the heart, which is the center of feeling, of compassion, of our shared humanity. Patients who are struggling with issues of self-acceptance, being more open to their feelings, and loving themselves and others frequently experience problems in the midthoracic spine, as well as the heart itself. They often feel a tightness in their chest, difficulty with breathing fully and easily, and a stiffness-a rigid protectiveness-in their upper back. Power is the creative force, life energy, and is expressed through the body. It rises from the earth-our somatic ground-and flows up through our legs, into our pelvis and belly. Issues relating to personal will, survival, financial security, relationships, and sexuality often manifest in this area. Low back pain, psoas contracture, nervous or "knotted" stomach, irritable bowel syndrome, and hip problems are common physical findings I have observed in patients who are struggling with questions or problems relating to personal power. From a holistic perspective, then, wisdom comes from above, power comes from below, and love is the connecting force that links them together, keeps them in balance, and makes us whole.

Opening to Wisdom Wisdom teaches us to differentiate between the true and the false. It is through wisdom, the power of discernment, that we resolve our own

inner contradictions-the self-doubt that is so much a part of the human condition-and attain a measure of inner peace. Wisdom is having insight into the nature of reality. As we clear away all beliefs and ideas about what things mean, we begin to see life as it actually is. When we strip away all the words and concepts and learn to live in pure looking, listening, sensing, feeling, we begin to perceive the fundamental unity, beauty, and sacredness of life. We become freer of both the bondage of the past-our personal psychological and emotional history-and any undue worry about the future. We become freer of our ego, its fears and insecurities, and this freedom is experienced in a healthier, more relaxed, more vital body. We live more consciously and passionately in the present, take care of business as it arises, and "shape" the future based on a sane, healthy appreciation of what is in our individual and collective best interests. For we practitioners, it may be that our first duty is to do all we can to alleviate the patient's pain so that he is more comfortable and less fearful. But our second duty-and the more important one, in my viewis to educate him, to teach him how to have a conscious relationship with his body and mind so that he can begin to face his suffering, and

Opening to Wisdom 181 ultimately transform it. This is how illness can serve as a powerful teacher. For Jean Klein, the notion of healer as educator is primary. In response to a question about the healing of illness, he said: "The first thing a doctor must do is instill in the patient the correct attitude so that he can live with himself." 9 What is the correct attitude? "See the illness objectively, as if in front of you so that you are not lost in it," Klein says: Look at your body as if it belonged to another. Then you will have a glimpse of freedom from the burden of it, a moment of psychological space. Become interested in this feeling of freedom and it will be effortlessly sustained. It is only from this free perspective that you can act most correctly. You are not the body, neither the healthy nor the unhealthy body. So your illness is a gift to come more quickly to realize what you are not. 10

Klein goes on to state, as other astute observers of the body have done, that illness, or malfunction, is an energy pattern, a quality of sensation that is fueled by emotionally-charged concepts or beliefs. For example, the word "cancer" and all the fear behind it can actually reinforce the idea that one really does have cancer-even when the disease may not yet be accurately diagnosed. This is how illness all too often becomes a self-fulfilling prophecy. I have seen it in my own practice many times-the patient who has bought fully into the belief that he has a "bad back" and that it is something he must live with for the rest of his life. 11 Medicine, with its addiction to specialization and labels, the ascribing of names to every condition that arises, does not help in this regard. Indeed, it feeds the notion of disease as an "entity" that is somehow separate from us and that is out to "get" us, to destroy us if we don' t "get" it first. While modern medicine may at times be brilliant in its technical application of scientific knowledge, especially in the way it deals With life-or-death situations, it all too often fails the patient when it comes to addressing chronic disease, or conditions that d on' t fit neatly into recognizable "boxes." Its approach is basically dualistic, non-holistic, separative. It still views disease as "it," the other. It does n ot yet appreciate the concept of dis-ease, and that when something goes wrong in the body, it is because there is something out of balance with the patient. Real h ealing, on the other hand, is integrative, embracing. Lis ten to what Jean Klein has to say about this: The best way to bring a malfunction to an end on either the physical or psychological plane is not to refuse the sensation, the perception. You must accept it but this does not mean accepting it morally

182 Chapter IX • Healing tire W1tole Person or psychologically, both of which are a kind of fatalism . ... Acceptance is lucid, watchful awareness in which all the facts are seen. It is this acceptance of the facts of a situation that brings about the cure. When you live in acceptance, illness no longer has any substance, and you have then the greatest possible chance of getting better. Non-acceptance prevents all possibility of a cure being brought about. 12

Learning to live in awareness and acceptance of our body, mind, and senses creates a feeling of neutrality within us. Because we're less identified with arising thoughts and sensations, we see the whole more clearly. Our real nature, we begin to discern, is more than the body and mind. Like the body itself, the mind is a function, a tool, an instrument for survival and creativity. The thoughts, images, and memories that make up the content of our mind, like the feelings and sensations in our body, can be observed-and by definition, we cannot be what we are looking at. Rather, we are whatever it is that is doing the looking. And what is that? In the end, it cannot be named. Just as the eye cannot see itself, our real nature cannot be known "objectively." Anything we can verbalize about it is at most only a pointer, a fragment of the multidimensional reality . But if our real nature cannot be known in the objective sense, it can be intuited. As space opens up within us, as we stop resisting our somatic experience, conflict and tension dissolve and a feeling of ease and well-being begin to pervade both body and mind. The body returns to its natural state, which is health. The mind comes back to its natural condition, which is clarity, openness. The quieter and clearer we get, the more this feeling of well-being expands, until we realize that it is beyond even the apparent borders of our own body and mind. Because of this expansion, our personal boundaries are no longer set in cement, and our beliefs and concepts about reality are more fluid, which means we can change and grow with the times. We have less fear. Mystery and change, instead of being a threat and causing us to contract, become an invitation to dive more deeply into life. We see suffering for what it is-a call to heal, to learn, to grow. We' re more appreciative of the gifts, the beauty, to be found in each moment. Our body becomes softer, more supple. Our movements are more graceful. We are more present, more spontaneous and playful. We begin to radiate more life force, chi, vital energy.

The Healing Energy of Love Karl Menninger, M.D., cofounder of the Menninger clinic, once said that "Love is the medicine for the sickness of the world." 13 Love begins to bloom, to give off its healing fragrance only as we open our hearts.

The Healing Energy of Love 183

Love requires vulnerability, the willingness to be open to suffering. To be vulnerable is to come down out of our heads-out of our ego's fortress of rationalization and self-defense-and into our bodies, into our feelings and emotions. To be vulnerable is to become an authentic human being. It is to own our dark side, our human self. Men especially, with their attachment to their egos and their ceaseless jockeying for power and control, fear vulnerability more than women. Yet the only power that is real, the only power that truly heals and nurtures us, is love. In regard to men and the issue of vulnerability, Rachel Naomi Remen, M.D., a leading proponent of mind/body medicine, has this to say: There is a general lack of meaning and purpose and significance that seems to underlie illness. What we call stress might really be spiritual isolation . ... What is spiritual isolation? Basically to me it seems that it is living with a closed heart. ... A cardiologist once said to me that the most popular surgery in this country, coronary bypass surgery, is probably a metaphor. The problem with our culture is that we have bypassed the heart, especially in men. And we keep acting that out, over and over again in the operating room. It is very interesting how often the process of physical healing runs concurrently with the healing of the heart. 14

What is significant about the healing of the heart, I have observed, is that it is essentially "uncontrollable." Such a deep level of healing only comes about when all attempts at control-which come from the mind, the ego, from self-will-are let go of and there is an openness, a receptivity, to something new, to something unknown. It requires humility, patience, and trust to be able to open ourselves in this way. These are very much qualities of the heart. So often, it is the absence of them that makes us sick in the first place, and results in premature aging and untimely death. Love manifests as action, but it begins with a feeling-and it is the feeling of love, of connectedness to another, that leads to compassion. We begin by getting quiet and still and feeling our connection to the larger whole, to the energy of life itself. As we bring this feeling into our body and, by extension, into our relationships, we become more aware both of our own suffering and the suffering of others. Compassion means to "be with suffering." Like all virtues, it begins at home. We cannot be with another's suffering until we first know how to be with our own. Suffering manifests internally as conflicting thoughts in the mind-the specter of self-doubt-and distressing feelings and emotions in the body. Thinking about our suffering does no good. We must be somatically aware in order to fee l it. Vulnerability, the willingness to feel our pain, our loneliness, our fear, is the first step in healing. Remem-

184 Chapter IX • Healing the Whole Person ber, if we can feel it, we can heal it-and somatics is above all about learning to sense and feel again. Human relationship is where we learn love. Spiritual practices such as prayer, meditation, and contemplation help get us in touch with divine love, the source of Being. But it is relationship that brings it into our bodies, that allows love to flower in daily life. "Love is the desire to understand another," as a friend once told me. That's a beautiful, practical definition of love. It is the willingness to understand each other, to open our hearts and really meet-to share our tears, our pain, our joy-that ignites the flame of love in our lives. To do this, we must be in our bodies.

Authentic Power Love is the key to authentic power, to the right use of will. Power comes from the earth, through our contact with physical reality. Power is vitality, the energy of creation, growth, and destruction. It is our soma, our physical body, our aliveness. It is our passion. It is our emotion, anger, darkness. It is the shadow, our primal, animal nature, the disowned aspects of ourselves. It is our sexuality. It is the "juice," the force that enables us to do, to act, to produce, to accomplish. It is what makes things happen, gets things done in the world. "Power" may be one of the most dangerous words in our language. It is something we all seek and something most of us fear. Misused, power creates enormous suffering-and, tragically, the misuse and abuse of power is pandemic. Yet there is fundamentally only one power, one energy, and that is the creative force of life itself. But there are two ways we can access this energy-through the ego, or through the heart. Ego power relies on will, force, domination-the compulsive urge to manipulate and control others. It is the power we see exercised too much in society, the power that tends inevitably to be concentrated in the hands of the few who are most accomplished in wielding it, whether it be the state, the church, the corporation-or, at the level of the family, a tyrannical parent. Ego power is destructive. It divides the world into "you" and " me, " into "us" and "them." In order to build and maintain itself, this kind of power depends upon the control and disempowerment of others. But in the end, it always destroys itself. Power, which is the life force within all of us, is an awesome and inexhaustible river of energy. It will eventually annihilate anyone who tries to dam the flow of it, or hoard it for themselves. When this energy gets stopped up in the body through somatic tension and holding, it constricts our very metabolism. As Joel Kramer points out in the quotation at the beginning of this book, it forces an acceleration in the body' s breakdown.

Bringing Wisdom, Love, and Power into the Body 185 Healthy power is a function of somatic integrity-of being relaxed yet alert in body, mind, and spirit. For power to express itself constructively, it needs a vehicle. As we get clearer about who we are and what we are here to do, the vehicle begins to take shape. It forms itself in the kind of work we will do, the cause we will get behind, the project we are committed to completing. What characterizes authentic power is that it is always shared; it serves a larger purpose than just taking care of our own needs. Indeed, as we get freer of self-interest and the kind of overweening personal ambition that is the chief trait of ego-centered living, more creative energy becomes available to us than we could ever have imagined. When this is harnessed in the service of others, our own needs are more than amply provided for. The best examples of the right use of power, of will, are shown in the lives of the great humanitarians, people like Albert Schweitzer, Mahatma Gandhi, Martin Luther King, Jr., and Mother Teresa. While Mother Teresa may not have the strongest body, she has enormous energy and will, both of which are directed in the service of God. The power that comes through her is authentic power. It is the power of love, flowing out to help and heal others, and it continually renews itself. She is a shining example of what happens when the personal self bows to a higher order of energy, when "my" will becomes Thy will. She is living proof that when this transformation happens, we human beings are very powerful indeed.

Bringing Wisdom, Love, and Power into the Body Intellectual understanding points the mind in the direction of truth, helps prepare it for a deeper level of insight, but there are limits to cognitive knowledge. The way to bring our understanding out of the conceptual realm into our lived experience is to bring our awareness into the body. This is where I see the field of somatic education playing such a vital role in healing and transformation. Thomas Hanna' s work was concerned with teaching people how to be more aware of their movements, feelings, sensations, and intentions. People are not just bodies, he taught, but "Self-responsible somas (who) can change themselves." 15 In the Esalen seminar I attended, he made a statement about the deeper ramifications of the somatic approach. As you get more voluntary control over your body, you 'll have more control over the reactions in your body. You won't be subject to fear so much. There'll be a freedom from emotional content and reaction. You'll get freer of that feeling of fear and anxiety. Voluntary control over the startle reflex, for instance, frees you from its fearful effects. It gives you more control over your emotional life. You can then put a lot of demons to rest.

186 Chapter IX • Healing the Whole Person The field of soma tics deals with self-empowerment, whereas traditional medicine and therapy tend too often to see the patient or client as a victim, a helpless third-person "object" to be examined, diagnosed, treated-and then left to fate. To be somatically alive is to be in our bodies, to have a conscious and highly attuned awareness of ourselves as living, moving, breathing, feeling, sensing organisms. It is to know, at any moment, the quality of contraction or relaxation in our muscles, what the joints are doing, the degree of ease or tension that we feel in each part of the body. It is to be grounded, to be centered in what the Japanese call the hara, 16 the "seat" of our soul, that point just below the navel which also marks the physical center of gravity. When we breathe and move from our hara it means we are no longer caught up in our heads, in analytical thinking. When we think too obsessively, our breathing becomes shallow. We don't get enough oxygen. We limit the amount of energy available to us. Energy tends to concentrate at the top part of our body-the head, chest, and upper lobes of the lungs. We're usually not even aware of our body below the neck. Consequently, we become unbalanced more easily. A crisis, a negative emotional encounter, an unexpected tum in events can quickly throw us off center. But when we are centered in the hara, fully present in our body, we are physically and psychologically secure. We have our feet planted firmly on the ground, both actually and metaphorically. We knowwhere we stand. Like the bamboo, that favorite image of Oriental philosophy, we can bend and sway with the wind, with opposing forces, without being broken apart or knocked over. It is the goal of somatic education, in my view, to help us come to this place of a relaxed, confident relationship with our body. And the very first step, more important than any new set of physical exercises we may learn, is the bringing of awareness into the body. This was the practical aspect of Jean Klein's work that appealed to me. The yoga he taught emphasized not so much the finished postures as it did the awareness of movement, sensation, and feeling. In this regard, his approach to the body /mind relationship was similar to Thomas Hanna's. Both men were masters at showing people how to find a new sense of ease in their bodies. In fact, it was because I had already been studying Klein's work for five years that I then became interested in Hanna's somatic philosophy. While Klein's focus was the transformation of consciousness, I saw that Hanna-who was very much a pragmatist-had a unique contribution to make to somatic practitioners. In learning to breathe and move with more emphasis on the awareness of what is happening, and less on trying to "do" or "achieve" something, we begin to get some freedom from our body and mind. We find ourselves becoming naturally quiet, clear, centered, and this brings us closer to our authentic self. As Klein says,

Working at a Transfonnational Le-vel in Your Practice 187 Become more attuned to these moments, beyond energy and function. Do not emphasize the energy, the object, body, senses and mind. These are perceived. So the question arises: Who is the perceiver? And since r,ou can never perceive the perceiver the mind comes to a stop. 7

It is in the stop that our real nature-pure consciousness, manifesting as energy and form-is awakened. "A person 'is there' in the right way, is personally present in the true sense," Durckheim informs us, "when he mediates effectively between the Absolute and the relative, between Being and (bodily) existence. Existence rooted in Being is what counts." 18 Anything less than that, he is saying, and our spirituality remains ungrounded and impotent, unable to bring about a transformation in our everyday lives. The key to transformation, to healing the whole person, lies in bringing awareness back into the body. When we're able to put our ego aside and stop interfering with our somatic experience, both body and mind are allowed to come back to their own organic wholeness, or harmony. Then we find ourselves alert and present in the now moment, which is the ground of all possibilities. We are firmly in touch with our inner Being and with the world around us. From this place, right action can follow.

Working at a Transformational Level in Your Practice When dealing with patients whose symptoms are not responding to your clinical methods, it is an indication that there may be personal and emotional issues involved that need to be addressed. If you are a holistically oriented practitioner, you may want to explore this area with your patients or clients. This does not mean that you need to act as a psychotherapist, or in any other way go outside your scope of practice. But you can certainly engage in a meaningful dialogue with your patients. You can let them know that you care, and you can perhaps help point them in the direction of deeper healing and transformation through asking the kinds of questions that almost always elicit a heartfelt response. Examples of these include: "So, what's really going on?." "If there was an emotional aspect to your pain (or problem), what do you think it might be?" "What's the major stress in your life?" "How's your marriage?" "Do you enjoy your work?" "What do you want to do with your life?" " Are you happy?" "What feeds your soul?"

188 Chapter IX • Healing the Whole Person "What do you do for spiritual renewal?" "What are you passionate about?" "If you could change something in your life, what would it be?" "If there was a lesson in this for you, what do you think it would be?" Naturally, the extent to which you, the practitioner, will feel comfortable asking these questions will depend on the degree to which you have examined them for yourself. Have you looked into your own heart and soul recently? Do you feel free of your own past emotional wounds, the legacy that virtually every adult carries forth from childhood? Is there genuine harmony in your personal relationships? Are you connected to your feelings? Can you express upset or anger without blaming others? Are you able to be vulnerable and human with your patients, or do you still need to hide behind the mask of authority known as "doctor" or "therapist"? It is important to understand that the most vital element in the doctor I patient or therapist/ client relationship is the relationship itself. More than any technique or therapeutic method, it is the establishing of a meaningful and personal dialogue with our patients that will lead them to a deeper connection with their own inner truth. We cannot do that if we hide behind our credentials or techniques-our "official function," as Durckheim termed it. As you confront the above questions for yourself and begin to come to terms with the unhealed aspects of your own life, so you will better be able to help your patients. This doesn' t mean that you will necessarily deal with their emotional issues yourself. Most likely you will have limitations in terms of time, if not training. You may need to refer certain patients out to other health professionals, such as a p sychologist or psychotherapist. Some of your patients will already be in therapy. Through their interaction with you, whether verbal or somatic, they may experience a new insight, or have some form of emotional or spiritual opening, which they can then work with in their therapy or on their own. If they are seeing a therapist who really understands the body, the somatic nature of emotional problems, so much the better. Using Somatic Technique in the way I have described it in this manual, it is unlikely that you will very often provoke strong emotional reactions in your patients. You will be presenting it as a tool for neuromuscular release and heightened sensory-motor awareness, and most patients will accept it as such. The most common reaction to the work will be a sigh of relief or a smile of delight at the new feeling of freedom and openness they experience in their muscles and joints. In the event that your somatic work does elicit an emotional response, however, you will need to deal with it as best you can. Encouraging the person to breathe and stay in their body, with whatever it is they are feeling, is the most helpful thing you can usually do. Sometimes, holding and massaging the person's feet also helps stabilize and ground

Practical Steps 189 their energy. The more comfortable you are with your own feelings and emotions, the easier it will be. Most of the time, if patients start to cry, or get agitated or upset in some way, it is enough to just give them a little time to be with whatever they're feeling. The calmer and more accepting you are of whatever is happening, the more space they have to process whatever they need to go through, and the sooner they will quiet down. Whatever they were feeling will be absorbed into their entire somatic, or body / mind, experience. They may wish to talk about it, or they may not. The important thing is that if they can sense that you are okay with whatever has happened, that gives them permission to be okay with it. And, as a wise psychotherapist friend once said to me, "You know, what we're really doing with our clients is just letting them know that they're okay." By "okay," he was referring to self-acceptance. Selfacceptance is the prerequisite for inner peace, and inner peace is what the healing journey is all about. When we are at peace within, when there is trust and love in our hearts, then we can deal with any problem that may be affecting the body (or any other aspect of our life), from a clear, intelligent, and unafraid place. Before we, as healers and therapists, can show others the way to .self-acceptance and inner peace, however, we must first have come to it ourselves-or at least be well on the path toward it. And so, in the end, whether our practice is chiropractic, allopathic medicine, physical therapy, massage, bodywork, or psychotherapy, the dictum we must keep foremost in our minds, ahead of all our techniques and scientific knowledge, is this: "Physician, heal thyself. "

If we can remember this, if we realize that the work we do and the service we provide is equally for our own healing, then any technique or therapy we employ will be of benefit to our patients.

Practical Steps I want to conclude this chapte r by offering a few practical steps for those of you interested in learning how to more fully integra te the person you are with the body you have. In particular, I have found the following to be important: 1.

A Somatic Discipline. Chronic physical knots and em otional blocks prevent the free-flo w of energy in our body . Through learning to sense, feel, and release the unconscious patterns behind the tension and stress in our body, we start to get free of them. Yoga, somatic exercises, martial arts, and other practices that foster conscious breathing, movement, and body·centering

190 Chapter IX • Healittg the Whole Person teach us how to move our own energy and stay grounded in our bodies. They help us become fine-tuned instruments for the universal energy. The more grounded we are in our bodies, the less likely we are to be taken over by fear, anger, depression, and other negative emotional states. A trained somatic practitioner, skilled in mind/body work, can be extremely helpful here. When learning Somatic Technique, for example, it is a good idea to have a "buddy," a fellow practitioner with whom you can trade ideas and hands-on work. Also, related to the somatic component of transformation, the question of diet must be considered. I will not go into the subject of nutrition here, but suffice it to say that a healthy, light, and predominantly vegetarian diet contributes enormously to keeping our energy at an optimal level. 2. Meditation. The practice of sitting still for a period of time each day and being fully, bodily present is very healing. The physiological benefits of such periods of meditative stillness and quiet (which may also include prayer and contemplation) have been well documented.19 Ideally, we should sit for anywhere from fifteen to forty minutes, preferably every morning-and again, for a short time at least, in the evening. Sitting meditation helps us become more sensitive to whatever is happening in the now moment. By not resisting our restlessness, pain, boredom, and mental chatter, but just allowing them the space to be there, these states gradually have less of a hold on us. We grow quieter and clearer, more detached from the endless flow of thoughts, images, and sensations. Awareness becomes global, multidimensional. In the stillness that unfolds, we touch upon the peace and joy that are our real nature. 3. Self-Knowledge. We can meditate for twenty years and get no closer to the truth of our being, however, unless we also develop clear insight into the many aspects of our personality, our ego. We need to heal the hurts of our childhood , our mother and father wounds. This involves recognizing, accepting and expressing our feelings. Th en we must live with the question, "Who am I?" and its variants-"Who is it that' s afraid?" "Who is it that desires?" "Who is it that seeks?" and so on. In time we see how the "I" we have taken ourselves to be is but a story we have made up about ourselves, a contraction of energy tha t limits our ability to be open to deeper levels of reality beyond the mind. As we let go of trying to "know" ourselves a t a conceptual level, we become quieter inside. We stop objectifying reality so much. We perceive the true, energetic nature of things more readily. We're more in the "flow," and the

Practical Steps 191 flow nourishes us in a way that objects never can. We start to feel our oneness with something much larger than ourselves, and living takes on new meaning. 4. Conscious Relationship. Relationships, with all their emotional charge, are where we directly confront our egos. For this reason they can be a difficult path, yet they are the true test of our wholeness. Time and again we find that all too many of our chronically suffering patients are in unhappy marriages or relationships. These situations need to be addressed and the problems resolved if people are to heal in body, mind, and heart. Relationships succeed to the degree we're able to integrate the masculine and feminine energies within ourselves. Men need to learn that they can be both strong and soft and nurturing. Women need to learn that they can take charge and be strong without losing their softness. In general, people struggle in their relationships because they are afraid-or don't know how-to be honest with each other. They are so busy trying to relate to an image, an object, they are not seeing the real person. It means pulling all our projections back in. Vulnerability, the willingness to share one's pain and fears, is essential. Relationships are an exercise in courage, honesty, mutual respect, and love. 5. Work and Creating. Work is an important way of expressing our creative energy and giving form to our inner nature. Like relationships, it is an opportunity to be present to the moment at hand. We may not yet be doing what we love (again, how many of our unhappy patients are in unfulfilling jobs?) but learning to be grateful for the work we have is a step in the right direction. It helps if we can see our work as a spiritual exercise-appreciating it as an opportunity to serve, as well as to earn money. As we get more in touch with our real values and needs, the work we are meant to be doing becomes clearer to us. The goals we set then become an outgrowth of our inner joy, rather than a compensation for feeling empty. We live more from a desire to give than to get. We no longer seek success for its own sake, but it comes as the by-product of the commitment and passion we bring to our chosen work. 6. Guidance. Personal guidance from a healer, therapist, or teacher who radiates clarity and presence, who understands the body /mind relationship, and who is secure in his / her role in the world can be invaluable on the path. We usually learn best by example. Transformation, like any other human capacity, needs to be modelled for us. A wise and trusted guide, or mentor, holds up a mirror so that we can see ourselves more clearly . He or she reflects back to us the truth a nd beauty of our inner self, while simultaneously inviting us to look more closely at what is getting in the way of that truth from expressing itself.

192 Chapter IX • Healing the Whole Person

To Summarize Somatic work gets us into our bodies; transformational work awakens our inner potential. We open to the source of energy within us through being as consciously aware and as somatically present in each moment as we can, one moment at a time. It is important not to worry about whether we can be aware tomorrow, or even later today. As we learn to stay in the present, the global nature of consciousness becomes more real for us. Then the creative fullness that is at the heart of life is always available to us, a constant presence to which we can turn at any moment for nourishment, renewal, inspiration, and guidance. It is through the mind that we form the vision for our lives, and it is our somatic energy, our power to act and to do, that manifests the vision in reality. So long as the vision springs forth from our heart, from love, then whatever we create will serve both our own and others' well-being. It will add richness and joy to our lives. This is the meaning of the quotation with which I began this chapter, from The Great Path of Awakening, a five-hundred-year-old Tibetan text. The way we have lived up till now is reflected in our bodies-in our posture, our countenance, in the physical stress and tension we experience. The choices we make and the acts we perform now will, in turn, dictate the kind of person we are going to become. This is the law of cause and effect. What we sow now, we'll reap later. Wise is the person who realizes that every action has its consequence and lives accordingly. Powerful is the person who has his feet on the ground, and is wholly present in his body. Happy is the person who is awake to his true nature, and who understands that love is the main lesson we are here to learn. Such a person is on the path to mastery-and mastery is the real goal of transformational work. It is what we as practitioners need to be aiming for in our own development, and it is what we need to be communicating, as best we can-and to the degree they can receive it-to our patients and clients. The Somatic Techniques and exercises described in this book, and the insights I have shared in this chapter, are available as tools for realizing a higher level of mastery and satisfaction in both your practice and your personal life. For a concluding picture illustrating just what that might look like-its implicit somatic nature-listen, once more, to the words of Lao Tzu's Tao Te Ching:

His body is supple as a newborn child's. His heart and mind open as the sky. Realizing that nothing is lacking, The whole world belongs to him. This is the Master's secret. 20

References 193

References 1. Kongtrul, Jamgon, Tile Great Path of Awakening, trans!. by Ken McCleod, (Boston: Shambala, 1987), p. 64.

2. Parts of this chapter originally appeared as an article in Somatics Magazine, Spring/Summer 1993, Vol. 9, No.2. 3. Levine, Stephen, Healing into Life and Death (New York: Anchor Books, 1987). 4. Durckheim, Karlfried Graf, Zen and Us (New York: E.P. Dutton, 1982), p. 97. 5. Klein, Jean, Be Who You Are (London: Watkins, 1978) p. 74. 6. Durckheim, Karlfried Graf, The Call for the Master: The Meaning of Spiritual Guidance on the Way to the Self (New York: Dutton, 1989), p. 99. 7. Ibid ., p. 143. 8. Maslow, Abraham H., The Farther Reaches of Human Nature (New York: Arkana, 1993). 9. Klein, Jean, I Am (Santa Barbara: Third Millenium Publications, 1989), p. 130. 10. Ibid., p. 129. 11. For more discussion of the relationship between the mind and disease, see Michael Talbot's The Holographic Universe (New York: HarperPerennial, 1992), Ch. 4. 12. Klein, I Am, 129-130. 13. Parker, William R., Prayer Can Change Your Life (New York: PrenticeHall, 1957), p. 83. 14. Exeter, Michael, "When The Light Comes Through," Healing Currents: The Journal of the Whole Health Instit ute (Spring, 1991), p . 8. 15. Hanna, Thomas, Somatics: Reawakening the Mind's Control of Movement, Flexibility, and Health (New York: Addison-Wesley, 1988), p . 21. 16. For a full discussion of the nature of hara, see Durckheim's Hara: The Vital Centre of Man (London: Unwin Paperbacks, 1977). 17. Klein, The Ease of Being, p. 91. 18 . Durckheim, Zen and Us, p. 97. 19. For an account of the health benefits of meditation, see Dr. Dean Ornish's, Stress, Diet and Your Heart (New York: Signet, 1984). 20. I have paraphrased this quotation from a number of verses in Stephen Mitchell's ve rsion of the Tao Te Ching (New York: Harper & Row, 1988).

X

Basic Exercises

The three basic exercises given here are a modified version of the "cat stretch" described by Thomas Hanna in his book, Somatics. For a more comprehensive series of somatic/ neuromuscular exercises, refer to his book, or to the book Relaxercise (see Appendix C-Resources). Having worked with and taught these three basic exercises for more than six years now, I feel that, for the average patient, they represent a complete somatic workout. If the patient were to do nothing else at home other than these three exercises, on a daily basis, he would be doing enough to keep his musculoskeletal system supple and balanced. The advantage of them is that, once learned, they are simple to perform, taking less than ten minutes. Alternatively, they can be used to supplement the patient's own exercise program, or any other exercises you may prescribe. Of course, these exercises, based on the Feldenkrais principles, are designed to accomplish more than just improve flexibility. They are, above all, meant to enhance sensory-motor learning, so that the patient can move with more ease, awareness, and aliveness in his body. They should, therefore, be done slowly. Instruct the patient to really feel the contraction and relaxation of his muscles. He should pause for a minute between each exercise to allow time for this internal sensing and feeling. Impress upon him that these exercises actually reprogram the sensory-motor part of his brain, so that he will have more control over his body. Greater control will, in turn, lead to deeper relaxation, improved flexibility, more energy, and an increase in strength. In order to teach these exercises confidently and correctly, you must know them well yourself. So be your own first student. The exercises should be done once every morning, soon after waking, and again, ideally, at night. (It is at these times that the brain is most receptive to new learning.)

195

196 Chapter X

• Basic Exercises

1 . Pelvic Arch Lie on your back. Part tA

Hands under your head, knees up and together, feet flat on the floor. As you breathe in, arch your belly and chest up towards the ceiling, tipping your pelvis away from you (Figure Exl). Part 18

As you breathe out, flatten your spine to the floor, lift your head and shoulders up , tip your pelvis (your pubic bone) toward you (Figure Ex2).

Figure Ex1

D o the b r e at hi n g in movement again, arching your chest and belly up as before. Repeat this series 6 to 10 times, doing the movements slowly.

Figure Ex2

1. Pelvic Arch 197 Part 2A As you breathe out and bring your head up, this time twist your body and bring your left knee to your right elbow (Figure Ex3).

Breathe in and arch your chest and belly up as in Part lA. When you breathe out and bring your head up again, this time twist and bring your right knee to your left elbow. Breathe in and arch your chest and belly up.

Figure Ex3

Part 28 When you breathe out again and bring your head up, this time bring both knees toward your chest and wrap your arms around your knees (Figure Ex4).

Then breathe in and arch your chest and belly up as before. R e p e a t t h i s l a s t s equence~the twist to the left and the right, and wrapping your arms around both knees-6 to 10 times.

Figure Ex4

Now pause for one minute, and allow yourself to really feel the internal sensations in your muscles and joints. Breathe into the movement of energy you are experiencing throughout your entire body.

198 Chapter X

• Basic Exercises

2. Spinal Twist Part t

Lying on your back, arms directly out at right angles to your body, left palm down, right palm up. Knees up and together, feet together on the floor. Visualize your knees and feet bound together so they do not separate during the following movements. Take a deep breath in. As you breathe out, bring your knees over to the palm down side (the left) until they touch-or get close to-the ground. Turn your head to the palm up side-i.e., to the right (Figure ExS).

Figure Ex5

(Notice how good it feels to stretch and twist like thisjust like wringing out a towel).

Part 2

Take in a deep breath again and then, as you breathe out, turn your left Figure Ex6 p alm up, your right palm down a nd, s imultan eously, bring your knees over to the palm down (the right) side, with your head going to the palm up (left) side (Figure Ex6). Repeat this whole process a total of 5 to 10 times to each side. (Note: The feet remain on the floor during the entire series, so

that only the knees move from one side to the other.)

3. Lift-ups 199 Again, pause for one minute, and allow yourself to feel the internal sensations in your muscles and joints. Breathe into the movement of energy you are experiencing throughout your entire body.

3. Lift-ups Lie on your stomach, feet slightly apart, head to the left, cheek resting on your left hand, right arm beside you. Figure Ex7 Lift up your left elbow, hand, head, shoulder and trunk, while simultaneously stretching and lifting up your right leg. Breathe in as you do this (Figure Ex7).

Hold for a moment, feel the contraction of your back muscles, then slowly lower your body and leg as you breathe out. As you come back to the floor, internally sense the letting go-the relaxation and softening-in your muscles. Repeat 4 more times. Then turn your head to the right, cheek resting on your right hand and lift up the right arm/ shoulder I trunk, while you raise the left leg. Hold for a moment, then slowly and consciously come back down. Do this 5 times total. Conclude this last exercise by either (1) coming up into the crouched/ fetal position, with your buttocks on your heels and your head covering your knees; or (2), turning onto your back, and bringing your knees to your chest for a few seconds. This helps clear away any stress that may have been caused by strongly contracting your low back muscles. Again, pause for one minute, and allow yourself to feel the internal sensations in your muscles and joints. Breathe into the movement of energy you are experiencing throughout your entire body.

200 Chapter X • Basic Exercises When you stand up to go about your day or your evening, notice how you feel in your body as you move and walk. Be very aware of your internal sensations and feelings, of your sense of balance and of the environment around you. A keen, alert awareness, remember, and an openness to whatever is being felt and experienced within, are the keys to optimal physical, mental, and emotional well-being.

Appendix A-Symptom Checklist

Symptom/Problem

Techniques

Abdominal pain, soreness Adjustments not holding

12, 13

Cervical

15 through 20

Thoracic

9 through 11, plus 15, 16, 18

1 through 8

Lumbar Brachial Neuritis

9, 10, 11, plus 15 through 19, 22

Carpal tunnel syndrome Cervical pain

9, 10, 11, plus 22 through 25 15, 16, 17, 18,19,20

Chest pain (muscular)

13, 14

Foot/ankle problems

27, 28, 32, 33

Headaches-s uboccipital

20

Hip joint problems Jaw-pain, clicking, tension

5, 6, 7, 8 20,21 5, 6, 7, 26 through 31 1 through 8

Knee pain Lumbar pain Sacroiliac problems

13, 14 4, 5

Sc1atica Scoliosis

3, 4, 5, 6, 7, 26, 27, 28 1, 5

Shallow breathing Shoulder joint problems

9 through 14

Rounded shoulders

9 through 15, 22

Sway-back

1 through 5, 8

Tennis elbow

11, 22, 23, 24, 25

Tho racic pain

1, 2, 8, 9, 10, 11,12

201

Appendix 8 Somatic Evaluation Form

Standing

Red Light

(use check mark if positive)

Green Light

(use check mark if positive)

Senile Trauma: Low shoulder

(note which side, & #of inches)

High ilium

(note which side, & #of inches)

Narrow waist

(note which side, & #of inches)

Prone

Palpation

(note tightness / bunching of paravertebral muscles)

Rhomboids

(note side of contraction)

Hips

(note side of contraction)

Supine

Psoas

(note side I degree of contraction)

Pectoralis

(note side of contraction)

Hips

(note side of contraction)

Cervical extensors

(note areas of contraction)

Lateral

Lat. dorsi

(note side/ degree of contraction)

Abdominals

(note side / degree of contraction)

202

Appendix C-Resources 1.

For a catalog of books and tapes by Thomas Hanna, and for a subscription to Somatics: Magazine Journal of the Bodily Arts and Sciences (published twice yearly) write to: Somatics Educational Resources 1516 Grant Avenue, Suite 212 Novato, CA 94945

There is an excellent video interview with Hanna: Unlocking Your Body, done by Jeffrey Mishlove, creator of the "Thinking Allowed" series. There are also complete audio tapes of all the somatic exercises developed by Hanna. 2. For information about the three-year training course in the clinical techniques of Hanna Somatic Education, conducted by Eleanor Criswell Hanna, Ed.D., write to Hanna Somatic Education at the above address. 3.

4.

Hanna's books can also be ordered through your local bookstore. In addition to Soma tics and several w orks on existential philosophy, he has written Bodies In Revolt: A Primer in Somatic Thinking (Freeperson Press), considered the basic philosophical text for studying the field of somatics, and The Body of Life (Knopf), which explores the theory and practice of somatic education and bodywork, and makes reference to F.M. Alexander, Moshe Feldenkrais, and other well-known teachers of body / mind awareness. Check your bookstore also for books on F.M. Alexander and the Alexander Technique; Moshe Feldenkrais and his work in Functional Integration; and the book of Feldenkrais exercises, Relaxercise: The Easy New Way to Health and Fitness (Harper & Row), by David and Kaethe Zemach-Bersin, and Mark Reese .

5.

The physiology, manual therapy, muscle energy, and PNF b ooks referred to in Chapter Two, and the muscle anatomy books referred to in Chapter Six, can be obtained through any chiropractic, osteopathic, or medical college bookstore.

6.

For those interested in exploring some of the ideas expressed in Chapter Nine, I recommend the following: a)

Yoga Journal, published b y the California Yoga Teachers' Association and available at newsstands or on subscription from Yoga Journal, P .O. Box 469018, Escondido, CA 92046-9952. Phone 1-800-359-YOGA.

203

204 Appendix C • Resources 204

b)

c)

d)

e)

f)

g)

h)

Joan Borysenko's Minding The Body, Mending The Mind (Bantam New Age) offers a holistic approach to reducing stress and enhancing physical, mental, emotional, and spiritual well-being. Healers On Healing (Jeremy P. Tarcher), edited by Richard Carlson and Benjamin Shield, is a moving collection of interviews with such p eople as Stephen Levine, Ram Dass, Norman Cousins, George Goodheart, D.C., Elizabeth KublerRoss, M.D., and Bernie Siegel, M.D. Richard Moss, M.D., went through a personal healing crisis and left the practice of medicine to do transformational work. His books, The I That Is We, The Black Butterfly: An Invitation To Radical Aliveness, and The Second Miracle: Intimacy, Spirituality, and Conscious Relationships (all published by Celestial Arts), are excellent reading for anyone facing a critical health problem, a major life change, or simply looking for something deeper in life. The Ease of Being (Acorn Press) by Jean Klein, is written in beautifully clear language, and points us back to the peace and joy that are our real nature. Three other books of his that I recommend are Who Am I? (Element Books), Transmission of the Flame (Third Millenium Publications) and Beyond Knowledge (Third Millenium Publications). There are three books by Karlfried Graf Durckheim worth investigating: The Way of Transformation: Daily Life as Spiritual Exercise, Hara: The Vital Center of Man, and Zen and Us (Dutton) . Like Klein, Graf Durckheim is very clear, grounded, and pragmatic. He understands the importance of the b ody, yet has looked deeply into the personal and spiritual dimensions of healing, and what it means to be a whole human being. For an enlightened view of intimate and love relationships, I recommend John Amodeo' s Being Intimate: A Guide to Successful Relationships (Arkana) and Love and Betrayal (Ballantine), and Gay and Kathlyn Hendricks' Conscious Loving: The Journey to Co-Commitment (Bantam). Lastly, my own book, The Ultimate Cure: Awaken ing the Healing Energy W ithin You (Llewe llyn ), offers an in-depth guide to the healing and transformational journey, and is filled with tools, techniques, insights, and stories.

Index Acceptance as key to healing illness, 181-182 as pre-requisite for inner peace, 189 Active muscle relaxation therapies (AMRTs), 37-39 Acupuncture, 179 Acute conditions, 63 Adjustments extremely effective, 40 hold better, 41 integrating Somatic Technique with, 170 not holding, 168 small incidence of negative effects, 5 Aging, premature, 29-30, 177 Alexander, F.M., 11, 173, 203 Antalgia, 17 Armoring, 178 Attitudinal keys to learning Somatic Technique, 54 Awareness global, 190 importance of bringing into bodv, 182, 185-187, 192 loss o( 17, 27, 175 low level of somatic, 19-21, 32-33 and presence, 8 regaining, 30, 38-39, 41, 55, 57-59, 174, 176 See also Consciousness and Cortical Control

Benefits of Somatic Technique for patient, 33, 41-42 for practitioner, 8-10, 41-42 Big Idea, viii, 19 Biofeedback sensory-motor integration as form o f, 32 Somatic Technique as form of, 174 Bodyworkers, guidelines for, 172 Boundaries, personal, 182 Breathing

and dealing with emotional reactions, 188 importance of in Somatic Technique, 32 instructing patient in, 64 shallow, 168 Brooks, V., 16, 29, 32 Bruxism, 140

Calcium deposits, 5 Cancer, 181 Chain reaction, 36 Cat-stretch, 195 Chaitow, L., 12 Children, 51 Chiropractic, 179 emphasizes structural alignment, 15 and innate intelligence, 5-7 integrating Somatic Technique, 170 limitations of structural model, 4-8 manipulation a skilled art, 5 small incidence of negative effects, 5 and Somatic Technique as method of adjusting, 39-41, 170 Chopra, D., 9 on bodies as flowing patterns of intelligence, 4 on quantum healing, 6-7 Cobra posture, 73 Communication Somatic Technique an exercise in, 54-59 what to say to patient, 63-64, 169, 172, 175 with one's body, 38 Compassion, 180, 183 Consciousness global nature o f, 192 need for bringing into body, 19, 41, 178, 180 real nature as, 187 role of in health, 6-8, 177 transformation of, 186

205

206 Index Contraindications to Somatic Technique, 49-51 in extremity work, 145 See also individual techniques Cortical control of muscles, 30-33, 38 Cramping, 66, 94

Dark Vise. See Senile Posture Deep-tissue work, 173 Denial, as barrier to somatic well-being, 60 Depression, 178 Dialogue, importance of with patients, 187-188 Diet, 190 Dis-ease, 181 Disk problems, 50, 69 Drugs, prescription, 65 Durkheim K.G. books by, 204 definition of neurotic, 178 on key to transformation, 187 on personal element in healing equation, 178-179, 188 Eccentric contraction, 32-33, 56 Educated mind, 6-7 Ego clear insight into, 190 and fear of vulnerability, 183 freedom from, 180 and power, 184-185 See also Self Image Elderly taking care not to bruise, 105 using Somatic Technique with, 50,56 Emotional pain, 179, 188 Emotional reactions, 188-189 Energy fundamentally only one, 184-185 illness as pattern, 181 increased,33,42, 116,168-169 lack of, 168, 186, 189 and life force, 177, 182, 192 musculature biggest consumer of, 28 universal, 190 Engram, 33, 59 Esalen, vii-viii, 15, 18

Evaluation of patient, 45-49 Evejenth, 0., and Hamberg, J., 31 Exercises, 13, 39, 65, 169-170, 189 audio tapes of, 203; three basic, 195-200 See also individual techniques Existentialism, 11 Extremity problems as compensation for mid-body, 145 not responding to other methods, 168

Fear, 177-178, 183 freedom from, 185 and Red Light reflex, 22, 24 Feelings being open to, 180 recognizing and accepting, 188, 190 and suffering, 183 Feldenkrais, M ., 11, 203 contribution to neuromuscular field, 30 Feldenkrais principles, exercises based on, 195 Feldenkrais technique appropriateness of, 174 different than Hanna's work, 13 Female patients, 63 Financial security, 180 Flow, 190-191 Fourth dimension in well-being, 7-8 Frequency of application of Somatic Technique, 64-65 Functional vs. structural model, 4-8

Gamma motoneurons, 34-35, 57, 167 Gandhi, Mahatma, 185 General Adaptation Syndrome,

11-12 Golgi tendon organ and reflex, 32-35,38,57,167 Great Path of Awakening, 177, 192 Green Light Reflex, 12, 23-24, 45-46 to correct, 69 Guidance, importance of on transformational journey, 191

Index 207 Habituation, 22, 27 Hanna, E.C., viii, 203 Hanna Somatic Education, viii, 203 Hanna, T., vii-viii background and training, 11-13 catalog of books and tapes, 203 on deeper ramifications of somatic approach, 185-186 method of working, 12-16 on myth of aging, 29-30 principle behind his work, 16-18 on Senile Posture, 46 on sensory-motor amnesia, 18 techniques originally developed by, 67-68, 105 on three main somatic reflexes, 22-24, Hara, 186 Heart, emotional healing of, 183 Heller, J., 173 Homeostatic mechanisms, 6 Healer as educator, 181 Hyperextension sensitivity, 50-51

Illness acceptance of, 182 as teacher, 181 Indications, 168, 201 See also individual techniques Inflammation and injury as contraindications, 50 Innate intelligence, 6-8 Insurance billing, 173 Intention, 30, 37 Intuition, 54

Janda, V., 12, 16-18 on connection between lumbar and cervical problems, 39-40 on postural and phasic muscles, 22 on strengthening w eak muscles, 35-36 Juhan, D., 16, 28

King, M.L., Jr., 185 Klein, J. on awakening to real nature, 186-187 books by, 204

on correct attitude with patients, 181 on relationship between body, mind, and personal self, 178-179 Korr, I.M., on subcortical mechanisms, 33-36 Kramer, J., 29, 184 life as change, 1 Lao Tzu, 30, 192 Lactic acid, 28 Landau Reflex. See Green Light Reflex Levine, S., on real healing, 177 Lewit, K., 12, 21-22 on need for manipulation and rehabilitative exercise, 40 on vertebrovisceral correlations, 40 Liebenson, C., on active muscle relaxation techniques, 33, 38 Love as attribute of wholeness, 179-180 healing energy of, 182-184 somatic problems relating to lack of, 180

Manipulation, 5, 14, 40 Martial arts, 189 Maslow, A., 179 Massage therapists, guidelines, for, 171-172 Mastery, 54, 192 Medicine, allopathic, 5, 20-21 dualistic approach, 181 sees patient as victim, 186 Meditation, 15 physiological benefits of, 190 Menninger, K., 182 Mind/body connectioD-, 11- 13 See also Chapter Nine Muscle energy, 18-19, 37 Muscle function cramping, 66, 94-95 cortical control, 30-33, 38 precise data lacking, 12 subcortical control, 17, 33-35 Muscles Abdominals, 46, 49, 113, 120-121, 168

208 Index Adductors, 84, 160 gracilis and pectineus, 160 Anconeus, 150 Biceps brachii, 148 Brachialis, 148 Deltoid, 146 Erector spinae, 69, 75 Gemelli, 89 Gluteus maximus, 89, 153 medius, 86, 89 minimus, 86 Gastrocnemius, 155 Hamstrings, 60, 94 Iliacus, 82 Ilicostalis cervicis, 69, 125, 130 lumborum, 69 thoracis, 69 Intertransversarii, 130 Latissimus dorsi, 14-15, 18, 33, 48, 104 Lateral hip rotators, 14, 18, 47-48,89 Lateral trunk flexors, 80 Levator scapulae, 33, 35, 99, 122, 130 Longissimus capitis, 69, 125, 130, 132 cervicis, 69, 125, 130 thoracis, 69, 125 Longus capitis and calli, 128, 132 Medial hip rotators, 47, 86 Multifidus, 132 Obliques, 24, 45, 80, 110 Obturators, 89 Pectoralis, major and minor, 18, 46-47, 117 Piriformis, 89 Plantaris, 155 Psoas, 82, 180 Quadratus fe moris, 89 Quadratus lumborum, 80 Quadriceps femoris, 158 Rectus abdominis, 113 Rectus capitis anterior, 128, 132 Rhomboids; 18, 46, 98-99, 101, 122, 130 Rotator cuff, 108 Rotatores, 132 Sartorius, 162 Scalenus anterior, 128, 130, 132 medius and posterior, 130, 132 Semispinalis

capitis, cervicis, thoracis, 69, 125, 132 Soleus, 157 Spinalis capitis, cervicis, 69 thoracis, 69, 125 Splenius capitis, cervicis, 69, 125, 132 Sternocleidomastoideus, 128, 130, 132 Suboccipitals obliquus capitis inferior and superior, rectus capitis posterior major and minor, 135 Supraspinatus, 146 Temperomandibular joint (TMJ), 46,53 masseter, temporalis, pterygoids, 140 Tensor fascia latae, 86 Tibialis anterior, 164 Trapezius, 18, 33, 35, 46, 55-59, 99, 101, 122, 125, 130, 132 Triceps brachii, 150 Muscles, negative effects of chronic tension in, 20, 27-29 Muscle spindle, 34-35, 38 Muscles, weak, 35-37 Myofascial release, 173

Neurotic, definition of, 178 New wave of healing, 6 Newtonian model of health, 4-5 Novato Institute, viii Number of repetitions of Somatic Technique, 64-65

Palmer, B.J. and D.D ., viii Pandiculation, 13 Pathology as contraindication, SO, 145 Peace, inner, 189-190 Perfect Health, 4 Personal element in healing, 178-179 Physical therapists, guidelines for, 170- 171 Physical therapy, 18, 179 Post-isometric relaxation, 37 Power authentic, 183-185

Index 209 creative, 179-180 somatic problems and strugo-les with, 180 "' Pregnancy, 75 Presence, 8, 15,54,192 Proprioception, importance of, 16-17 Proprioceptive feedback, 17, 30 Proprioceptive Neuromuscular Facilitation (PNF), 18, 37, 39 Pyschosomatic nature of disease, 179-180 Psychotherapy, 187-189

Quantum perspective, 4-8 Quantum Healing, 6-7

Radicular pain as contraindication, 50, 69, 73, 79, 125, 127, 132 safe technique for, 75 Real nature awakening to, 186-187 can be intuited, 182 Reciprocal inhibition, 37 Sherrington's Law of, 29, 35 Red Light reflex, 12, 17, 22-24, 45-46, 145 correction of, 113, 117, 122, 140 Regeneration of body, 178 Reinforcement phase, 32-33, 59, 65 Relationships, 60, 191 Relaxercise, 195, 203 Remen, R.N., on healing of the heart, 183 Resistance, correct degree of when using Somatic Technique, 56 Ripple effect, 36 Rolf, I., 173 Rolfing, 172

Sacroiliac problems, 79 Schafer, R.C., 28 Schweitzer, A., 185 Sciatica, 69 techniques for, 89, 201 Scoliosis, 168 techniques for, 69, 201 Self-actualization, 179 Self-expression, issues around, 180

Self-image, as cause of emotional pain, 179 Self-knowledge, 190-191 Selye, H., 11-12 Senile posture, 23-24, 46 Sensory-motor amnesia (SMA), vii-viii, 18, 22-25 classic signs of, 60 correcting, 30-33 exercise to demonstrate insidiousness of, 116 negative effects of, 27-30 Sensory-motor feedback loop, 2, 31, 167 Sensory-motor neurons, distribution of, 140 Sexuality, 180, 184 Sherrington, C.S., 31 Shoulder dislocation, 104, 108 Shoulder girdle, 14, 117 Soma, healthy, 19-20, 185 Somatic education, goal of, 186 Somatic integrity, 60, 185 Somatic principle, 16 Somatics Magazine, 11, 203 Soma tics: Reawakening the Mind's Control of Movement, Flexibility, and Health vii, 2, 11, 13, 22, 29, 167, 195 Somatic Technique and emotional reactions, 188 how to learn, 1-2, 53-61 integrating into practice, 167-176 as method of neuromuscular adjusting, 39-41, 170 as method of neuromuscular reeducation, 19 primary rehabilitative goal, 37 trading with "buddy," 190 using over longer session, 174-176 and vertebral subluxation, 28, 39-41 Spiritual isolation, 183 Spirituality, 179, 187-188 Spiritual practices, 184 Startle reflex. See Red Light reflex Strain/ counterstrain, 37 Strength, as function of intention, 37 Stress affects physiology and neuromuscular system, 11-13 causes reflexive muscle tightening, 17, 19, 22,27

210 Index and Red Light reflex, 23 reversing patterns of, 21, 189 Stretch reflex, 34-35 Structure vs. function, 4-8 Subcortical control, 17, 33-35 Suffering, 60, 180, 183 Surgeries, spinal. only 10% necessary, 5 Symptoms. See Indications

Tao Te Ching knowledge as barrier to truth, 7 Master's secret, 192 soft and supple vs. stiff and hard,30 Temperomandibular joint (TMJ), 46,53 See also Muscles Teresa, Mother, 185 Thixotropy, 27 Torticollis, 130 Trager, 172 Transformation, 177, 185, 190, 192 as aspect of practice, 187-189 fruits of, 179 key to, 187 and mastery, 192 needs to be modelled, 191 Trauma reflex, 12, 24, 45-46, 168 correction of, 110 Trigger point therapy, 173

Twelve-visit protocol, 168-170 Vertebral subluxation, 28 correcting with Somatic Technique, 39-41 symptoms of, 40 Vulnerability in personal relationships, 191 of practitioner with patients, 188 and suffering, 183 Weber-Fechner rule, 32 Whiplash as contraindication, 125, 127, 132 preventing when using technique, 126 Wholeness relationships as test of, 191 three qualities of, 179-180 Will, 180, 185 Wisdom, 179-182 of body, 8 Withdrawal reflex See Red Light reflex Work, as spiritual exercise, 191 Yoga, 15, 73 as somatic discipline, 189 as taught by Jean Klein, 186