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Feelings, muscles and movement
Feelings, muscles and
movement Philip Latey can be described as a clinical philosopher. His roots are in osteopathic medicine; however, his concerns and insights are relevant to all those involved in health care provision. In this important series of articles, specially commissioned by the Journal of Bodywork and Movement Therapies, he will explore topics of interest to manual, psychosomatic, psychosocial and movement practitioners and therapists, emphasizing both primary care and community issues. His first article looks at 'feelings, muscles mad movement', while in future articles he will investigate and discuss 'common presentations' (with asthma and migraine as examples), clinical tactics (basic and complex) as well as physical, verbal, group and exercise techniques ('where to draw the line, and how to do it - the coordinated health care team') which are designed to initiate 'discussion, exploration and thought experiment'.
Editor
Philip Latey, DO 1 Toongarah Road, North Sydney, NSW 2060, Australia. (Requests for offprints to PL)
Correspondence to: 1. P. Latey, Tel: ++ 61 2992 96603, Fax: ++ 61 2992 98807
o o o e o o o o
P. Latey
Introduction This paper highlights some important diagnostic aspects of muscular function that are commonly overlooked. It is the first in a series designed to present key topics for discussion by existing practitioners as well as students training in therapeutic methods, and for those preparing to be manual and movement therapists. The paper starts with an outline of the clinical setting. This establishes the context within which these ideas about muscles and feelings may be most useful. A variety of different models of muscular behaviour are then presented for discussion and development. Please note that this paper presents topics relevant only to diagnosis. Discussions of causation examples and treatment tactics will come later in the series.
Received March 1996 Revised June 1996 Accepted July 1996
T h e clinical f r a m e w o r k
Journal of Bodywork and Movement Therapies (1996) 1(1 ), 44-52 © Philip Latey 1996
The patterns noted in this paper are not something that we think about in the ordinary living of our lives. Nor
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should we. But it is the clinician's job to be looking behind the scenes and searching out the detail of 'what is happening to what' when the patient is having problems. In the initial stages these patterns will not tell us why or how something has come about, nor what to do about it. How wide will our framework need to be? The real challenge to us lies in the complex c~onic problem involving the combined impact and tangling of many factors; especially those that have failed to respond to previous simpler attempts. To have any hope of lasting success we must be applying a rigorous 'clinical formula' to all of our clinical work. This is essential for practice with difficult problems. It sets vital boundaries around our work, providing the firm foundations and faU-back position from which we rethink and measure achievement or lack of progress. The author puts this formula, in its simplest version, in the form of a maxim and an easily recalled mnemonic: Always
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Diagnosis, Aetiology, Prognosis and Treatment Agreement - ADAPTA. With all four components firmly in place we are able to do clinical work of lasting stability.
Diagnosis In diagnostic exploration we are trying to grasp 'what is happening to what'. Single label diagnoses, as used in ordinary allopathic medicine and psychiatry, are important first stopping points, but they lack many finer distinctions. They miss the social, psychosomatic and intensely personal, unique dimensions needed for complex work. They are almost valueless until we have some good working hypotheses as to why this is all happening: the aetiological study (Latey 1983).
Aetiology and prognosis As our study of what is happening and why progresses we begin to build up a picture of the evolution of the interaction between relevant factors, past, present and anticipated that are maintaining the patient, couple or larger group's problems. Some sort of pattern is emerging. We can then start to project this into the future to consider the prognosis. Left alone what will happen to this state of affairs? Is any of it self-limiting, or self-resolving? What can we and the patient or group best do together to improve matters? Would referral elsewhere, or additional testing help to clarify this or offer any better option?
Treatment agreement With a spectrum of diagnosis, aetiology and prognosis opening up, we have further choices to make. Given the severity and complexity of the problem how much time and effort can we, the practitioners, supply from our therapeutic resources? Will this be enough? What
commitment will the patients themselves have to make - in time, fees, compliance, momentum and involvement? What are the sorts of transition, upheaval, stages and shifts in attitude or behaviour that they might have to cope with. Amongst all of this we will hope to be forging a treatment agreement and working relationship or rapport that will survive the vicissitudes of complex therapeutic work. In osteopathy the author has expanded this simple clinical formula (ADAPTA) into a large formal logical scheme known as the 'combined perspective' or 'hypothescope' (Latey 1983, 1984, 1991, 1995).
The stance of the practitioner Particular attitudes in the mind and beating of the practitioner are very helpful in complex work. Others are not. We can first acknowledge our own profound levels of ignorance and doubt; using them to fuel our interest, open-mindedness and curiosity. Our patience, forbearance and resilience will be tested. We can prepare ourselves to encounter the new, the unexpected, the different and unusual in our patients. It is most often the asymmetrical and unique aspects of their being that help us to invent ways around their problems with them. While many therapeutic schemes develop routines to assist people and groups towards 'normalcy', this is less useful as we move into an age where a considerable range of lifestyles newly open to the human community need to be developed and fine-tuned. From this point of view our emphasis needs to shift away from the restoration of homeostasis, and look carefully at the blocks and barriers preventing metamorphosis and transformation. It is typically human that we oscillate quite widely in either direction in health; gradually broadening our maturation - but never to arrive!
The vulnerable practitioner Some sorts of clinical practice carry quite a high risk to the practitioner. Alcoholism, suicide, isolation and the breakdown of relationships, depression, burnout and mental illness, and the unethical abuse of the patient are a few of the grosser hazards. The main components needed for the support of the practitioner are: regular meetings with colleagues to gossip, grumble and compare notes about the difficulties we face; further study; feedback from patients and clinical achievements; along with an active and refreshing personal and social life that has little or nothing to do with our clinical therapeutic work. We learn to close the files and stop work, enjoying the interests and engagements of ordinary living. If we don't, our clinical balance and resourcefulness are bound to suffer. The use of the clinical formula with full ethical integrity, and participation in a health care modality that examines results carefully, also save us from too optimistic, unrealistic or grandiose claims for our work.
Muscular
Often we find that we keep going back to a few very basic questions, each time in a slightly different way and with a slightly different outcome. For the author one of the most fruitful areas of questioning has to do with the sensory function of muscles. As a basic hypothesis we might suggest that we don't have five senses; we have at least nine. Aside from hearing, sight, taste, smell and tactility, we have an outward sense of onr position in space, and an inward awareness of physical fullness, depth and presence of being. Linked to these two we have a profound sense of the emergence of viscerosomatic intensities, urgencies and tone colours that we can identify at the somatic end of emotion or mood
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Latoy (Latey 1987). Without this constant undercurrent of feeling, reasoning and thought itself might be impossible (Damasio 1994). Finally the sense of self that we usually think of as cortical or cerebral, our 'ego' that observes, reflects on and coordinates all of this with socialised language and plasticity of imaginary operations, has its own range of distinct sensory functions. Purely 'mental' feelings of pain, elation, depression, emptiness, numbness, bind, effort, flow, composure and so forth are likely to be no less real in their anatomy and physiology than any of the other eight senses. Muscular behaviour, of course, is important to the function of the first five senses - to the eyes, middle ear, nose, tongue and breathing, and to the tone of the skin. Sensations generated in and by the muscles themselves are central to the outer, inner and visceral senses of bodily being. In the brain itself the muscular vascularity of each area is clearly a key factor, and subject to much contemporary research as imaging techniques improve. The 'Muscular manifesto' (Latey 1979) was the author's first attempt to draw all of these together for discussion. First drafted around 1975, it is interesting to look back over 20 years, pick out some of the ideas for presentation in this current paper and see how they have changed and evolved.
We cannot usually see the direct evidence of the trauma and pain suffered by our patients in their emotional and social lives. In the song Willie also curses his ears, because without them he would not have to recall the 'lies that you told to me'. Over time the shock, despair, numbness, rage, accusation, selfblame and grief may diminish - but the bodily and sensorial echoes from the emotional wound are likely to persevere: if only as a sensitivity or vulnerability that will tend to resonate when confronted by a similar evocative experience. More seriously the deeper emotional scars may leave a numbness, closure, withdrawal, flaccidity or brittle rigidity; a disconnectedness that might never again want to reunite those vibrant, lively and trusting aspects of the person that were so sorely wounded. There are some useful models, hypotheses and maps already developed that we can use to study mental aspects of emotional pain. Ideas of splitting, repression, defence formation, projection/introjection and others from psychodynamics and analysis are very important. But these are usually considered in isolation from their very real anatomical and physiological concomitants; nor are they studied much as group collusive behaviours and belief systems.
Physical trauma
Diagnostic discussion topics Physical and emotional pain If I only had one arm to hold you, or better if I ' d no arms at all; then I wouldn't have these two arms that ache for you; there'd be one less pain to recall. If I only had one leg to stand on, a much better picture y o u ' d see of the half-a-man that you made of me of the half-a-man that you made of me. (Song lyric, abridged. Willie Nelson. 'Half a man': Accuff/Rose Chappel Music).
Actual physical trauma may easily produce some subjective emotional and psychosocial effects of similar dimensions. Oliver Sacks' account of his severe muscle/nerve/ligament tear 'A leg to stand on' (Sacks 1994) is a fine example of this. Climbing a mountain alone he ignores a sign warning people of 'the bull'. Nemesis arrives in the form of a terrifying appearance of the minotaur. He flees back down the mountain in a state of dread and fugue; falls badly and is found in shock by local people.
Sacks describes well the empty gaps in his body and sense of self that follow; his sense of incompleteness, his loss of invulnerabifity. His reactions to callous medical care are lessons for all of us. Here he is responding to the tearing apart of his bodily tissues; whereas Willie longs to sever his own extensions, already torn apart by emotional separation and loss. What is actually happening to the extra four senses of the person in emotional, physical and social trauma? If muscles are not just mechanical movers what else are they doing; and how do they do it?
Describing posture and personality From the direct description of the features of someone's physical balance we can broaden out to include elements of their character, their social interactions and their politics. And all of this by simply using ordinary descriptive words. For example, put together stature, standing, stance, status, attitude, carriage, position, poise, bearing, pose, presence, presentation, impression, impact, outlook, view, manner, footing, situation, place, nature, disposition, temperament, idiosyncracy, proclivity, bent, humour, and so on. There are important points to emerge from this. We notice how rich adult language can be in the subtleties that can be used to convey slightly different slants. We begin to appreciate how plastic and flexible our ideas of posture and personality will need to be; particularly how context-dependent are the attributes of the person we are considering. In other words they will show different aspects of themselves when considered in different circumstances - evoked by the social and physical setting that they find themselves in, and by how we want to describe them.
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important postural balancers. The hang of the jaw, sensed and balanced by the temporalis and pterygoids is also an important component of orientation, balance and position in space.
Two inner layers
Fig. 1 Image - slump.
Four layers of posture If we are looking at our patients' body and posture with them standing in the consulting room the first observations we might make are about their social being, and their reactions to being 'under the microscope'. Is what we see consistent with the person we met at the door and during the case history? Commonly this 'Image' posture is overtense; with the larger superficial fast-twitch muscles holding onto a self-consciously correct body shape. It shows us something about the social person; the persona. As we get them to relax, to move, sit, bend and so forth a second layer of posture gradually emerges (Fig. 1). This has more to do with their body's habitual response to gravity. If we call this the 'Slump' posture, we will be looking at the more longer acting muscular behaviour of the sole of the foot, the popliteus, tensor fascia lata, deep external rotators of the thigh, the adductors and the lumbosacral area. Higher up the spine the serratus posterior inferior and superior and the occipital triangle muscles with the sternomastoid are
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Once the patient is lying comfortably on our treatment table the body doesn't completely relax or become entirely s011. Some of the slow postural muscles ('slump' above) remain active. The deepest layers of the erector spinae most commonly remain very hypertonic. In any case the pattern of activity left after social interaction and gravity have been minimized can be called the 'residual' posture. The residual posture is most interesting for all of our psychophysical studies and approaches. Lying at, or just below, the usual threshold of awareness they are much closer to the involuntary processes of the body than we normally expect of skeletal muscle. The residual tone and residual activity keep up a slowish torsional undulant writhing. In health this is palpable throughout the body as a rhythm similar to breathing, but much gentler and less coordinated. In states of exhaustion and general illness it may become very feeble. Areas deeply shocked by emotional or physical trauma may freeze completely and feel lifeless, immobile, stringy and numb. A fourth layer of muscular activity, the 'inner tube' is also examinable. It is too complex to explore in full here in this survey of muscular sensation. Broadly it is composed of the respiratory, metabolic and digestive processes that take place within the innermost functioning of our subjective being. It is a compound pattern of breathing, residual postural movement and the peristaltic behaviour of all the involuntary smooth muscles lining the viscera and the vascular matrices of the body. This 'inner tube' has its own
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patterns of stasis, direction, liveliness and eccentric movement also typical for the person. It is linked closely to emotional processes, fantasising, the imagination, and the depth and breadth of psychological function for the person as a whole (Latey 1979, 1987). This is the eighth sense mentioned above. Its examination requires the practitioner to engage and entrain themselves to the subtler involuntary movements of the resting patient; rather like the shift to perceiving musical harmony instead of melody.
Muscular sensation A continuous, but relatively low level of muscular sensation is constant and normal in health. Along with vascular function this allows us to feel warm, bouncy and resilient, substantial and pleasurably full of ourselves. Stronger painless sensations generated by the muscles themselves are rarer, but obvious when we draw attention to them. The feelings of a huge yawn and stretch, just after a sneeze, a sigh or shiver can be quite strong. A really good hug, dancing closely together, and a friendly massage would mean little to us without muscular sensation. The more intense feelings generated by the movements of sensuality, sex play, orgasm and postcoital drift are clearly changes in the sensory mode of the musculature along with the skin and circulation. Being tickled and being made to laugh uncontrollably both mobilize lively muscle feelings; weeping also does this.
Violence Some of the most extreme muscle sensations accompany acts of violence and rage. These are located in the hands and arms, legs, feet, eyes and jaw. This must also include those smaller acts of cold cruelty, spite and torture.
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Latoy Much social and personal pathology springs from our propensity for aggression and its pleasurable reinforcement. We must accept that we are the most cunning, vicious and unstoppable carnivorous predator on the planet; alone or in groups; planned, opportunist or spontaneous. Triumphal muscular leaps of joy obviously enhance the flood of encephaiins and endorphins. Since they often accompany the vicarious participation in acts of violence, they may be no less socially divisive and pathological than violence itself. What do we make of group behaviours like the Nuremburg rallies?
Muscles altering bodily sensation The internal balance of sensation generated by the muscles is a highly active and dynamic aspect of living. Floods of sensation from one area can sometimes be seen to be masking stimuli arising elsewhere in the system. This is most obvious in painful experiences where our hands, feet and jaws contract fiercely. Muscles kept in a sustained hypertonic state, but still moving, generate strong sensations. Some of the behaviours associated with this may be regarded as distraction mechanisms. Muscles kept in a sustained hypertonic state, but without any movement, may start by making lively sensations, or even pain, but will quite rapidly go completely numb. If sustained over some minutes or hours the muscle group will simply feel painful and weak as the normal resting tone, movement and vascularity are restored. But if this state is kept up for weeks, months and years the muscle fibres degenerate into fibrous inelastic strings that are avascular and insensitive, more like scar tissue, and a great challenge to the manual or movement therapist. Muscular constriction can also numb the sphincters and mucocutaneous junctions of the body.
Localized tensions I rely on m y head and on my hands and on the view that every patient has his or her own illness and that the person who wants to help them has to practice the saying: nihil h u m a n u m a me alienum esse pnto (I believe nothing human is strange to me) and also on the exhortation: children, love one another! - And - I have not forgotten during m y life as a doctor that m a n ' s true profession is to become a human being (Groddeck 1930).
Georg Groddeck, a manual and natural therapist who worked closely with the Freudians in the 1920s wrote this to a colleague at the age of 64. He discussed in many papers and books the covert influences on health that emerged during his massage treatments. Around 1910 he was first to describe a pattem he called 'the frozen pelvis'. He associated this with sexual shock, withdrawal, retraction, denial and retention. His discussions of many symptom patterns (e.g. constipation, oedema, arthritis, quoted in 1929, 1977) show his acute awareness of the significance of stasis. Wilhelm Reich greatly expanded the study of sexuality (1927, 1980) and what he began to call the muscular armouring of the body (1933, 1949). Many of his clinical observations were enormously insightful and valuable. He was an acute observer of rigidity and restraint, and pointed out the common fear of voluptuous sensation. He noted people's mistrust of the body, and their fear of surrender to the quasi-peristaltic movements of the whole body in orgasm. In spite of these glimpses of genius Reich's work must be approached with caution. His therapeutic technique at that time seems appalling. A very domineering and tyrannical man, he became invasive and accusatory towards his patients; aiming to arouse their hostility and rage; forcefully confronting resistance and repression. Sadly the rise of the Nazis, the war years and two emigrations precipitated the decompensation of his incipient paranoid/schizoid psychosis, largely eroding and erasing
what had been good in his earlier work. His deeply disturbed childhood, and his seduction/impregnation of his earliest female patients clearly predisposed him to much of this (Reich 1922, 1988).
The three fists Whatever we think of the history of these ideas, this author finds it most valuable to use the analogy of a clenched fist to describe three main areas of focal tensions in the body. Simplifying analogies of this sort are a real help with an overview of diagnosis, and often form a useful part of our dialogue with some patients. But they are illustrations only: never complete or precise. A clenched fist represents the closing down of open interaction and engagement; it may be rage, fear, defiance and defensiveness; it might be a recoil in shock and denial when something awful has happened. The clenching may be enclosing something very precious; could be simply expressing tenacity and determination, or enforcing stillness. Unclenching of any area of the body, after an initial stage of weakness, vulnerability, ache and unsteadiness, should bring physiological relaxation (Latey 1979). Warmth, breathing and involuntary movements are restored. Where skin sensation was poor or numb it may itch or feel unusually hot to the patient as it recovers. When there is unclenching parasympathetic tone is recovered in autonomic function; so their interpersonal boundaries become softened and less brittle. The three broad areas noted by the author are the pelvic girdle; the lower ribs and upper abdomen; and the head, neck, and shoulder girdle. These are discussed in greater detail in Palpatory skills (Chaitow 1996), and will be summarized very briefly here. The lower fist When exploring 'the lower fist' we are
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Fig. 2 Lower fist: anterior.
Fig. 3 Lower fist: posterior.
looking at pelvic behaviour. This has the perineum at its centre, with two contrasting layers of muscle surrounding it. If the genitals, urethra or anus need to be compressed for any reason the deep muscles of the pelvic floor and pelvic diaphragm can be contracted and held tight. This alone is not enough when there is a very pressing or more long-term need for closure. The next layer of muscles that can be brought into action reinforces the compression. If the pelvis is retracting away from the front, the adductors, internal rotators, lumbar erector spinae and hip flexors close in around genitals and urethra: tipping the pelvis forward (Fig. 2). If the pelvis is retracting away from the rear, the coccyx is tucked under and pulled forwards, combined with contraction of the glutei and deep external hip rotators with slight abduction of the hips, and contraction of the quadratus femoris and the lower abdominal muscles (Fig. 3). On their own these patterns of contraction would not be compatible with the need to move around and coordinate, so they are not seen in this simple form. Nevertheless, infants and young children show these two
primary postures very clearly when trying to hold back and restrain a sudden urge to defaecate or urinate. If we need to keep the primary contraction at a sustained level, all of the opposing group must be brought into action so that we can move around normally. There are, of course many psychodynamic, sociosomatic and physiological reasons why the body might be doing this; and our work with the individual patient may unearth some of them. The point here is to note that these three pelvic behaviours overlap and conflict with each other on a grand scale, creating major problems for the function of hips, low back, pelvic tilt and stabilization. Commonly one leg overlaps the other in very tense states and also produces a lateral tilt of the sacral base. This is likely to be important in musculo-skeletal pain, dysfunctional imbalances and general attrition. The generation, obliteration or control of muscular and perineal sensation, with stasis, inflammation or congestion of the bowel, bladder and genitalia may also make more sense to us; with far-reaching consequences for health.
The middle fist The next set of muscles with significant sensory function are all respiratory in action. Breathing is a complex balance between opposing sets of muscles. We do not just breathe out by the simple relaxation of inspiratory muscles. Lively, energetic or forced expiration is produced by an active contraction of the muscles drawing the lower ribs together. Abdominally this is done by the external obliques and the upper part of transversus abdominis. This continues as transversus thoracis at the lower part of the sternum, and some detailed anatomy texts show a sternocostalis muscle within the thoracic cavity. Posteriorally the ribs are moved downwards and inwards by the quadratus lumborum, and particularly the serratus posterior inferior muscles. These arise from the upper lumbar spine and spread out to grasp the lower ribs; pulling them together. These muscles push air out of the body, producing the bellows-like action of the chest. So they are all expressive muscles. They are the powerhouse of many intensely emotional movements and feelings. They all tend to be very touch and pressure sensitive. The lower intercostals and abdominal obliques can be extremely ticklish. With the patient prone the serratus posterior inferior, a very variable muscle, will often be seen twitching and fasiculating when the patient talks emphatically or emotively. Interestingly this is a migratory muscle. Unlike most other back muscles it is innervated by the anterior primary rami of the spinal nerves. It is also often very sensitive to pressure and stretch reflex; sometimes producing bruised, vulnerable or sickening feelings when worked on quite gently. The 'kidney punch' that winds boxers lands here. The anterior muscles are much more closely linked to the sensation of large scale emotional abreaction.
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Latoy
Fig. 4 Middle fist.
Fig. 5 Upper fist.
Laughing, giggling, weeping, wailing and screaming, and sometimes vomiting can all be seen as 'safety valve' functions; discharging high pressures of some sort. Feelings in the stomach, gut feelings, butterflies in the tummy, the sobbing and ache of emotional loss, and some sorts of physiological dread and terror are felt here quite deep below the sternum. The body's own way of freeing this area up is quite revealing. A yawn and stretch nearly always starts with a very large inbreath and expansion of the lower ribs. A particular sensation of muscular delight accompanies the release of these middle fist muscles. During treatment there is often a noticeable transition in the breathing range, rhythm and depth that is marked by an involuntary sigh that releases both inspiratory and expiratory muscles. The sigh may also indicate a softening of attitudes in psychotherapy; although it may also be a gesture of defeat. Occasionally the patient is stuck having to repeat these movements too often, without completing them fully or resolving something. In these cases the experienced practitioner learns to sense the right questions, pause,
change of movement or change of contact that will enable them to let go more fully. A slight fluttering of panic might be a sign that this is ready to happen. The overtense, stuck or lifeless 'middle fist' (Fig. 4) compresses the lower thoracic and thoracohimbar spine; helping to cause spinal osteochondrosis in adolescence, and putting a huge conflicting burden onto the fine control of spinal movements. The overtight or overactive crus of the diaphragm may contribute to this. Physiologically many aspects of breathing and digestion might be affected; so we could look at its relevance in cases of asthma, ulcers, reflux, hiatus hernia and so forth.
The upper fist The analogy of the clenched fist helps explain the internal dynamics of pelvic sensation, and the thoraco/abdominal powerhouse of emotional expression. The metaphor applied to the head, neck and shoulder girdle, the 'upper fist' (Fig. 5), attempts to illustrate the perception, response and restraint of response to the outer world, and some of the complexity of thought. A huge variety and blend of feelings of unease of all sorts may be noticeable here.
There are really two parts to this that only function together in quite tense states of the person. The lower part is centred at the thoracic inlet and superior mediastinum anteriorally with the scaleni, pectoral and subclavius muscles reinforcing. Posteriorally the centre is found at the serratus posterior superior muscles, with the levator scapulae and rhomboid minor muscles reinforcing. So some of the dynamics here are similar to the pelvis, some are like a mirror to the lower ribs and upper abdomen. The serratus posterior superior expands outwards and downwards from the lower cervical vertebrae to grip the upper three or four ribs. An inspiratory muscle, it can brace and compress the cervicodorsal junction and the whole upper part of the rib cage from behind. Like the inferior serratus it is an anteriorally innervated migratory muscle, and is strongly sensory. When it has been overtense this is where people want you to really dig your thumbs in; often with the release of considerable satisfaction. This muscle contracts and holds very strongly in states of shock, impact, the startle reflex, and in preparedness for conflict. Physiologically and anatomically it seems to function together with the upper thoracic chain ganglia of the sympathetic nervous system. This will therefore be linked to cardiovascular function, blood pressure and stroke volume control, and also to the overall state of alermess and vigilance of the organism as a whole (reflecting limbic, pituitary and adrenal functions). Skin tone, and therefore blushing, pallor and sweating control of the upper body may also come from this centre. So we are not only looking at responses to terror, rage and aggressive impulse, but possibly shame, guilt and embarrassment as well. This part is also released by the big yawn and stretch, with the release of muscular pleasurable feelings and resettling of the breathing pattern.
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humiliation or disgust. Overall there is nearly always a gross impoverishment of the imagination and of the sense of good humour in chronic problems.
Exhaustion, flaccidity and withdrawal
Fig. 6 Fight? Flight? Play dead and stink!
Sometimes we can know that the person has been choked up with emotion, has a big sob like a ball stuck in the throat, or is terrified that they may be unable to draw another breath. We may sense that they are enraged by the impositions and ill fortune that life has dumped on them. Most commonly we will encounter the permanently set grim determination that the person has found necessary in order to survive, thrive or achieve in life. In a sense this area is also keeping the stopper in the neck of the 'safety valve' emotional pressure bottle! The uppermost part of all of this, the sternomastoid, occipital triangle and temporalis muscles especially, have the same range of emotional dynamics. They are touch and pressure sensitive, with quite strong sensations generated by stretch and activity. These are more difficult for the manual therapist to work with, but treatment here is often most rewarding and effective. They are also most closely associated with mental processes and the special senses. So all of the problems that we meet around the cranio-orofacial girdle may have a profound muscular component. The temporalis and pterygoids
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seem to reflect the tenacity of the serratus posterior superior, and can completely jam the jaw in extremis (trismus). They also carry out an agitated mastication movement in some restless states of mind (bruxism), and a much slower gentle ruminative wandering when the mind is in more of a state of reverie. Different patterns of upper fist seizure usually accompany migraines and most headaches; temperomandibular, dental bite and some ear problems; some sinusitis and some chronic recurring infections of the throat and nasopharynx. In early life the orofacial muscles are associated with real and imagined breastfeeding movements, and will commonly come into conflict with the urge to bite (Latey 1987). The thought patterns associated with this uppermost range of muscular seizures share some common features. Thoughts and fantasies of extreme dread and violence, often sexualized, may have become stuck in a repeating pattern that changes very little. If these are too unacceptable they are heavily repressed, worsening the somatic and physiological state, but may leave a component of shameful disgrace and
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The author's description of these three regions of muscular behaviour may have given the impression that the body is going to be found in a lively state of high tension, and obvious 'bind'. This is actually rare except in some more extreme and acute cases. What we find is a much more confusing picture of mixed fatigue, flaccidity and lifeless tone to the flesh that is much less interesting to the hand and eye of the therapist. What remains of the conflicting dynamics lies at a much lower level. Breathing movements and voice tone will give us some clues to this underlying pattern. They are discussed in the next paper. Setting these subtleties aside, how did they become so unappetisingly drained and leaden? Certainly the internal muscular conflicts must have absorbed huge amounts of energy; but that is only a part of the picture. In the author's opinion there is no flight or fight reflex. It is actually a fight, flight or play dead and stink reflex; and the preferred option is the third (Fig. 6)! So the body's most usual response when assaulted by the shocks, knocks and severe setbacks of life, is to switch off or tone down to an absolute minimum whole areas of function, with a slight odour of decay. This is usually compounded and maintained by a profound deadening of the appetites. There is no great desire or passion for eating, sleeping and waking up, moving, good company, achievement, reproduction or sensual interplay (libido). So our first therapeutic interventions with the chronic sufferer usually aim at better function somewhere across this spectrum of lifestyle appetites, if they are not improving spontaneously.
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Latey Until we have at least a little more vitality available to work with the opening phases of a long job can be very dire. Physiological withdrawal is closely related to the cognitive dynamics of 'splitting', 'fragmentation' and 'attacks on linking'. These mechanisms were brilliantly explored by W.R. Bion, whose work is extremely useful for us, but too complex to enlarge on here (Bion 1977, etc.).
Conclusion The author hopes that we will never again think of mind as restricted to the brain and central nervous system. The sensory functions of muscle sketched out in this paper give us much more to observe, study and think about. Andrew Still, the founder of osteopathy, claimed that it was all about mind, matter and motion. He insisted that we have to study psychology alongside the anatomy and physiology that are essential to general health care (Still 1887, Latey 1991). Unfortunately there was little psychology worth a light in his days but we are beginning to draw and explore a wider range of distinctions that will help us in our therapeutic work of all sorts, and starting to link things together better. This requires us to shake down many of the basic assumptions and premises that health care has been based on. The basics of sanitation,
shelter, water supply, nutrition, sterile procedures and so forth can remain the same. Our understanding of the human being's individual life and social ecology, internal and external, have to go through the upheavals of a complete paradigm shift (KtLhn 1970, Chalmers 1976) to be mapped into our medical model. If holism is the study of 'that tendency in nature for wholes to be formed from the ordered grouping of units' (Smuts 1926, in the Shorter Oxford Dictionary 1973), the sensory function of muscle must be seen as an absolutely crucial element of this formative tendency. Our awareness and sensing of ourselves as substantial and whole people is clearly in large part muscular. And also isn't our need to be a moving part of a community essential for us to feel complete in ourselves?
ACKNOWLEDGEMENTS Artwork by Maxwell John Phipps. Half A Man, words & music by Willie Nelson © Copyright 1962 Pamper Music, USA. Acuff-Rose Music Limited, 25 James Street, London W1, UK. Used by permission of Music Sales Limited. All Rights Reserved. International Copyright Secured.
REFERENCES Bion WR 1977 Seven servants. Jason Aronson, New York Chaitow L 1996 Palpatation skills. Churchill Livingstone, Edinburh, in press Chalmers AF 1976 What is this thing called science. University of Queensland Press, Queensland Australia,. p. 86
Damasio R 1994 Descartes' Error. Emotion, Reason and the Human Brain. Grosset/Putnam, New York Groddeck G 1930 Letter to Professor Hans Vaihinger. In: Der Mensh und sein Es. Quoted in: The meaning of illness. Hogarth Press, London, 1977; The unknown self. C.W. Daniel, London, 1929 Kuhn TS 1970 The structure of scientific revolutions. University of Chicago Press, Chicago Latey PJ 1979 The muscular manifesto. Osteopathic Publishing, London Latey PJ 1982 The attentive osteopath and migraines. British Osteopathic Journal 14 Latey PJ 1983 An expansion of modem osteopathic diagnostic theory. British Osteopathic Journal 15 Latey PJ 1984 An expansion of modern osteopathic theory of technique. British Osteopathic Journal 16 Latey PJ 1987 Psychosomatic holism. Holistic medicine 2 Latey PJ 1991 Osteopathy ancient and modem. Australian Journal of Osteopathy 3:2 Latey PJ 1992 Some notes on basic clinical tactics. Australian Journal of Osteopathy (December) Latey PJ 1994 Basic clinical tactics. Australian Journal of Osteopathy 6:1 Latey PJ 1995 Osteopathy: the future. Australian Journal of Osteopathy (August) Reich W Passion of youth 1922. Farrar, Strans and Giroux,. New York, 1988 Reich W 1927 The function of the orgasm. Republished as: Genitality. Farrar, Straus and Giroux, New York, 1980 Reich W 1933 Character analysis. Farrar, Strans and Giroux, New York, 1949 Sacks O 1994 A leg to stand on. Picador, London. Shorter Oxford Dictionary 1973 Clarendon press, Oxford, p. 974 Still AT 1897 Autobiography. Kirksville, USA
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movement Philip Latey can be described as a clinical philosopher. His roots are in osteopathic medicine; however, his concerns and insights are relevant to all those involved in health care provision. In this important series of articles, specially commissioned by the Journal of Bodywork and Movement Therapies, he will explore topics of interest to manual, psychosomatic, psychosocial and movement practitioners and therapists, emphasizing both primary care and community issues. His first article looks at 'feelings, muscles mad movement', while in future articles he will investigate and discuss 'common presentations' (with asthma and migraine as examples), clinical tactics (basic and complex) as well as physical, verbal, group and exercise techniques ('where to draw the line, and how to do it - the coordinated health care team') which are designed to initiate 'discussion, exploration and thought experiment'.
Editor
Philip Latey, DO 1 Toongarah Road, North Sydney, NSW 2060, Australia. (Requests for offprints to PL)
Correspondence to: 1. P. Latey, Tel: ++ 61 2992 96603, Fax: ++ 61 2992 98807
o o o e o o o o
P. Latey
Introduction This paper highlights some important diagnostic aspects of muscular function that are commonly overlooked. It is the first in a series designed to present key topics for discussion by existing practitioners as well as students training in therapeutic methods, and for those preparing to be manual and movement therapists. The paper starts with an outline of the clinical setting. This establishes the context within which these ideas about muscles and feelings may be most useful. A variety of different models of muscular behaviour are then presented for discussion and development. Please note that this paper presents topics relevant only to diagnosis. Discussions of causation examples and treatment tactics will come later in the series.
Received March 1996 Revised June 1996 Accepted July 1996
T h e clinical f r a m e w o r k
Journal of Bodywork and Movement Therapies (1996) 1(1 ), 44-52 © Philip Latey 1996
The patterns noted in this paper are not something that we think about in the ordinary living of our lives. Nor
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should we. But it is the clinician's job to be looking behind the scenes and searching out the detail of 'what is happening to what' when the patient is having problems. In the initial stages these patterns will not tell us why or how something has come about, nor what to do about it. How wide will our framework need to be? The real challenge to us lies in the complex c~onic problem involving the combined impact and tangling of many factors; especially those that have failed to respond to previous simpler attempts. To have any hope of lasting success we must be applying a rigorous 'clinical formula' to all of our clinical work. This is essential for practice with difficult problems. It sets vital boundaries around our work, providing the firm foundations and faU-back position from which we rethink and measure achievement or lack of progress. The author puts this formula, in its simplest version, in the form of a maxim and an easily recalled mnemonic: Always
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Diagnosis, Aetiology, Prognosis and Treatment Agreement - ADAPTA. With all four components firmly in place we are able to do clinical work of lasting stability.
Diagnosis In diagnostic exploration we are trying to grasp 'what is happening to what'. Single label diagnoses, as used in ordinary allopathic medicine and psychiatry, are important first stopping points, but they lack many finer distinctions. They miss the social, psychosomatic and intensely personal, unique dimensions needed for complex work. They are almost valueless until we have some good working hypotheses as to why this is all happening: the aetiological study (Latey 1983).
Aetiology and prognosis As our study of what is happening and why progresses we begin to build up a picture of the evolution of the interaction between relevant factors, past, present and anticipated that are maintaining the patient, couple or larger group's problems. Some sort of pattern is emerging. We can then start to project this into the future to consider the prognosis. Left alone what will happen to this state of affairs? Is any of it self-limiting, or self-resolving? What can we and the patient or group best do together to improve matters? Would referral elsewhere, or additional testing help to clarify this or offer any better option?
Treatment agreement With a spectrum of diagnosis, aetiology and prognosis opening up, we have further choices to make. Given the severity and complexity of the problem how much time and effort can we, the practitioners, supply from our therapeutic resources? Will this be enough? What
commitment will the patients themselves have to make - in time, fees, compliance, momentum and involvement? What are the sorts of transition, upheaval, stages and shifts in attitude or behaviour that they might have to cope with. Amongst all of this we will hope to be forging a treatment agreement and working relationship or rapport that will survive the vicissitudes of complex therapeutic work. In osteopathy the author has expanded this simple clinical formula (ADAPTA) into a large formal logical scheme known as the 'combined perspective' or 'hypothescope' (Latey 1983, 1984, 1991, 1995).
The stance of the practitioner Particular attitudes in the mind and beating of the practitioner are very helpful in complex work. Others are not. We can first acknowledge our own profound levels of ignorance and doubt; using them to fuel our interest, open-mindedness and curiosity. Our patience, forbearance and resilience will be tested. We can prepare ourselves to encounter the new, the unexpected, the different and unusual in our patients. It is most often the asymmetrical and unique aspects of their being that help us to invent ways around their problems with them. While many therapeutic schemes develop routines to assist people and groups towards 'normalcy', this is less useful as we move into an age where a considerable range of lifestyles newly open to the human community need to be developed and fine-tuned. From this point of view our emphasis needs to shift away from the restoration of homeostasis, and look carefully at the blocks and barriers preventing metamorphosis and transformation. It is typically human that we oscillate quite widely in either direction in health; gradually broadening our maturation - but never to arrive!
The vulnerable practitioner Some sorts of clinical practice carry quite a high risk to the practitioner. Alcoholism, suicide, isolation and the breakdown of relationships, depression, burnout and mental illness, and the unethical abuse of the patient are a few of the grosser hazards. The main components needed for the support of the practitioner are: regular meetings with colleagues to gossip, grumble and compare notes about the difficulties we face; further study; feedback from patients and clinical achievements; along with an active and refreshing personal and social life that has little or nothing to do with our clinical therapeutic work. We learn to close the files and stop work, enjoying the interests and engagements of ordinary living. If we don't, our clinical balance and resourcefulness are bound to suffer. The use of the clinical formula with full ethical integrity, and participation in a health care modality that examines results carefully, also save us from too optimistic, unrealistic or grandiose claims for our work.
Muscular
Often we find that we keep going back to a few very basic questions, each time in a slightly different way and with a slightly different outcome. For the author one of the most fruitful areas of questioning has to do with the sensory function of muscles. As a basic hypothesis we might suggest that we don't have five senses; we have at least nine. Aside from hearing, sight, taste, smell and tactility, we have an outward sense of onr position in space, and an inward awareness of physical fullness, depth and presence of being. Linked to these two we have a profound sense of the emergence of viscerosomatic intensities, urgencies and tone colours that we can identify at the somatic end of emotion or mood
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Latoy (Latey 1987). Without this constant undercurrent of feeling, reasoning and thought itself might be impossible (Damasio 1994). Finally the sense of self that we usually think of as cortical or cerebral, our 'ego' that observes, reflects on and coordinates all of this with socialised language and plasticity of imaginary operations, has its own range of distinct sensory functions. Purely 'mental' feelings of pain, elation, depression, emptiness, numbness, bind, effort, flow, composure and so forth are likely to be no less real in their anatomy and physiology than any of the other eight senses. Muscular behaviour, of course, is important to the function of the first five senses - to the eyes, middle ear, nose, tongue and breathing, and to the tone of the skin. Sensations generated in and by the muscles themselves are central to the outer, inner and visceral senses of bodily being. In the brain itself the muscular vascularity of each area is clearly a key factor, and subject to much contemporary research as imaging techniques improve. The 'Muscular manifesto' (Latey 1979) was the author's first attempt to draw all of these together for discussion. First drafted around 1975, it is interesting to look back over 20 years, pick out some of the ideas for presentation in this current paper and see how they have changed and evolved.
We cannot usually see the direct evidence of the trauma and pain suffered by our patients in their emotional and social lives. In the song Willie also curses his ears, because without them he would not have to recall the 'lies that you told to me'. Over time the shock, despair, numbness, rage, accusation, selfblame and grief may diminish - but the bodily and sensorial echoes from the emotional wound are likely to persevere: if only as a sensitivity or vulnerability that will tend to resonate when confronted by a similar evocative experience. More seriously the deeper emotional scars may leave a numbness, closure, withdrawal, flaccidity or brittle rigidity; a disconnectedness that might never again want to reunite those vibrant, lively and trusting aspects of the person that were so sorely wounded. There are some useful models, hypotheses and maps already developed that we can use to study mental aspects of emotional pain. Ideas of splitting, repression, defence formation, projection/introjection and others from psychodynamics and analysis are very important. But these are usually considered in isolation from their very real anatomical and physiological concomitants; nor are they studied much as group collusive behaviours and belief systems.
Physical trauma
Diagnostic discussion topics Physical and emotional pain If I only had one arm to hold you, or better if I ' d no arms at all; then I wouldn't have these two arms that ache for you; there'd be one less pain to recall. If I only had one leg to stand on, a much better picture y o u ' d see of the half-a-man that you made of me of the half-a-man that you made of me. (Song lyric, abridged. Willie Nelson. 'Half a man': Accuff/Rose Chappel Music).
Actual physical trauma may easily produce some subjective emotional and psychosocial effects of similar dimensions. Oliver Sacks' account of his severe muscle/nerve/ligament tear 'A leg to stand on' (Sacks 1994) is a fine example of this. Climbing a mountain alone he ignores a sign warning people of 'the bull'. Nemesis arrives in the form of a terrifying appearance of the minotaur. He flees back down the mountain in a state of dread and fugue; falls badly and is found in shock by local people.
Sacks describes well the empty gaps in his body and sense of self that follow; his sense of incompleteness, his loss of invulnerabifity. His reactions to callous medical care are lessons for all of us. Here he is responding to the tearing apart of his bodily tissues; whereas Willie longs to sever his own extensions, already torn apart by emotional separation and loss. What is actually happening to the extra four senses of the person in emotional, physical and social trauma? If muscles are not just mechanical movers what else are they doing; and how do they do it?
Describing posture and personality From the direct description of the features of someone's physical balance we can broaden out to include elements of their character, their social interactions and their politics. And all of this by simply using ordinary descriptive words. For example, put together stature, standing, stance, status, attitude, carriage, position, poise, bearing, pose, presence, presentation, impression, impact, outlook, view, manner, footing, situation, place, nature, disposition, temperament, idiosyncracy, proclivity, bent, humour, and so on. There are important points to emerge from this. We notice how rich adult language can be in the subtleties that can be used to convey slightly different slants. We begin to appreciate how plastic and flexible our ideas of posture and personality will need to be; particularly how context-dependent are the attributes of the person we are considering. In other words they will show different aspects of themselves when considered in different circumstances - evoked by the social and physical setting that they find themselves in, and by how we want to describe them.
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important postural balancers. The hang of the jaw, sensed and balanced by the temporalis and pterygoids is also an important component of orientation, balance and position in space.
Two inner layers
Fig. 1 Image - slump.
Four layers of posture If we are looking at our patients' body and posture with them standing in the consulting room the first observations we might make are about their social being, and their reactions to being 'under the microscope'. Is what we see consistent with the person we met at the door and during the case history? Commonly this 'Image' posture is overtense; with the larger superficial fast-twitch muscles holding onto a self-consciously correct body shape. It shows us something about the social person; the persona. As we get them to relax, to move, sit, bend and so forth a second layer of posture gradually emerges (Fig. 1). This has more to do with their body's habitual response to gravity. If we call this the 'Slump' posture, we will be looking at the more longer acting muscular behaviour of the sole of the foot, the popliteus, tensor fascia lata, deep external rotators of the thigh, the adductors and the lumbosacral area. Higher up the spine the serratus posterior inferior and superior and the occipital triangle muscles with the sternomastoid are
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Once the patient is lying comfortably on our treatment table the body doesn't completely relax or become entirely s011. Some of the slow postural muscles ('slump' above) remain active. The deepest layers of the erector spinae most commonly remain very hypertonic. In any case the pattern of activity left after social interaction and gravity have been minimized can be called the 'residual' posture. The residual posture is most interesting for all of our psychophysical studies and approaches. Lying at, or just below, the usual threshold of awareness they are much closer to the involuntary processes of the body than we normally expect of skeletal muscle. The residual tone and residual activity keep up a slowish torsional undulant writhing. In health this is palpable throughout the body as a rhythm similar to breathing, but much gentler and less coordinated. In states of exhaustion and general illness it may become very feeble. Areas deeply shocked by emotional or physical trauma may freeze completely and feel lifeless, immobile, stringy and numb. A fourth layer of muscular activity, the 'inner tube' is also examinable. It is too complex to explore in full here in this survey of muscular sensation. Broadly it is composed of the respiratory, metabolic and digestive processes that take place within the innermost functioning of our subjective being. It is a compound pattern of breathing, residual postural movement and the peristaltic behaviour of all the involuntary smooth muscles lining the viscera and the vascular matrices of the body. This 'inner tube' has its own
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patterns of stasis, direction, liveliness and eccentric movement also typical for the person. It is linked closely to emotional processes, fantasising, the imagination, and the depth and breadth of psychological function for the person as a whole (Latey 1979, 1987). This is the eighth sense mentioned above. Its examination requires the practitioner to engage and entrain themselves to the subtler involuntary movements of the resting patient; rather like the shift to perceiving musical harmony instead of melody.
Muscular sensation A continuous, but relatively low level of muscular sensation is constant and normal in health. Along with vascular function this allows us to feel warm, bouncy and resilient, substantial and pleasurably full of ourselves. Stronger painless sensations generated by the muscles themselves are rarer, but obvious when we draw attention to them. The feelings of a huge yawn and stretch, just after a sneeze, a sigh or shiver can be quite strong. A really good hug, dancing closely together, and a friendly massage would mean little to us without muscular sensation. The more intense feelings generated by the movements of sensuality, sex play, orgasm and postcoital drift are clearly changes in the sensory mode of the musculature along with the skin and circulation. Being tickled and being made to laugh uncontrollably both mobilize lively muscle feelings; weeping also does this.
Violence Some of the most extreme muscle sensations accompany acts of violence and rage. These are located in the hands and arms, legs, feet, eyes and jaw. This must also include those smaller acts of cold cruelty, spite and torture.
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Latoy Much social and personal pathology springs from our propensity for aggression and its pleasurable reinforcement. We must accept that we are the most cunning, vicious and unstoppable carnivorous predator on the planet; alone or in groups; planned, opportunist or spontaneous. Triumphal muscular leaps of joy obviously enhance the flood of encephaiins and endorphins. Since they often accompany the vicarious participation in acts of violence, they may be no less socially divisive and pathological than violence itself. What do we make of group behaviours like the Nuremburg rallies?
Muscles altering bodily sensation The internal balance of sensation generated by the muscles is a highly active and dynamic aspect of living. Floods of sensation from one area can sometimes be seen to be masking stimuli arising elsewhere in the system. This is most obvious in painful experiences where our hands, feet and jaws contract fiercely. Muscles kept in a sustained hypertonic state, but still moving, generate strong sensations. Some of the behaviours associated with this may be regarded as distraction mechanisms. Muscles kept in a sustained hypertonic state, but without any movement, may start by making lively sensations, or even pain, but will quite rapidly go completely numb. If sustained over some minutes or hours the muscle group will simply feel painful and weak as the normal resting tone, movement and vascularity are restored. But if this state is kept up for weeks, months and years the muscle fibres degenerate into fibrous inelastic strings that are avascular and insensitive, more like scar tissue, and a great challenge to the manual or movement therapist. Muscular constriction can also numb the sphincters and mucocutaneous junctions of the body.
Localized tensions I rely on m y head and on my hands and on the view that every patient has his or her own illness and that the person who wants to help them has to practice the saying: nihil h u m a n u m a me alienum esse pnto (I believe nothing human is strange to me) and also on the exhortation: children, love one another! - And - I have not forgotten during m y life as a doctor that m a n ' s true profession is to become a human being (Groddeck 1930).
Georg Groddeck, a manual and natural therapist who worked closely with the Freudians in the 1920s wrote this to a colleague at the age of 64. He discussed in many papers and books the covert influences on health that emerged during his massage treatments. Around 1910 he was first to describe a pattem he called 'the frozen pelvis'. He associated this with sexual shock, withdrawal, retraction, denial and retention. His discussions of many symptom patterns (e.g. constipation, oedema, arthritis, quoted in 1929, 1977) show his acute awareness of the significance of stasis. Wilhelm Reich greatly expanded the study of sexuality (1927, 1980) and what he began to call the muscular armouring of the body (1933, 1949). Many of his clinical observations were enormously insightful and valuable. He was an acute observer of rigidity and restraint, and pointed out the common fear of voluptuous sensation. He noted people's mistrust of the body, and their fear of surrender to the quasi-peristaltic movements of the whole body in orgasm. In spite of these glimpses of genius Reich's work must be approached with caution. His therapeutic technique at that time seems appalling. A very domineering and tyrannical man, he became invasive and accusatory towards his patients; aiming to arouse their hostility and rage; forcefully confronting resistance and repression. Sadly the rise of the Nazis, the war years and two emigrations precipitated the decompensation of his incipient paranoid/schizoid psychosis, largely eroding and erasing
what had been good in his earlier work. His deeply disturbed childhood, and his seduction/impregnation of his earliest female patients clearly predisposed him to much of this (Reich 1922, 1988).
The three fists Whatever we think of the history of these ideas, this author finds it most valuable to use the analogy of a clenched fist to describe three main areas of focal tensions in the body. Simplifying analogies of this sort are a real help with an overview of diagnosis, and often form a useful part of our dialogue with some patients. But they are illustrations only: never complete or precise. A clenched fist represents the closing down of open interaction and engagement; it may be rage, fear, defiance and defensiveness; it might be a recoil in shock and denial when something awful has happened. The clenching may be enclosing something very precious; could be simply expressing tenacity and determination, or enforcing stillness. Unclenching of any area of the body, after an initial stage of weakness, vulnerability, ache and unsteadiness, should bring physiological relaxation (Latey 1979). Warmth, breathing and involuntary movements are restored. Where skin sensation was poor or numb it may itch or feel unusually hot to the patient as it recovers. When there is unclenching parasympathetic tone is recovered in autonomic function; so their interpersonal boundaries become softened and less brittle. The three broad areas noted by the author are the pelvic girdle; the lower ribs and upper abdomen; and the head, neck, and shoulder girdle. These are discussed in greater detail in Palpatory skills (Chaitow 1996), and will be summarized very briefly here. The lower fist When exploring 'the lower fist' we are
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Fig. 2 Lower fist: anterior.
Fig. 3 Lower fist: posterior.
looking at pelvic behaviour. This has the perineum at its centre, with two contrasting layers of muscle surrounding it. If the genitals, urethra or anus need to be compressed for any reason the deep muscles of the pelvic floor and pelvic diaphragm can be contracted and held tight. This alone is not enough when there is a very pressing or more long-term need for closure. The next layer of muscles that can be brought into action reinforces the compression. If the pelvis is retracting away from the front, the adductors, internal rotators, lumbar erector spinae and hip flexors close in around genitals and urethra: tipping the pelvis forward (Fig. 2). If the pelvis is retracting away from the rear, the coccyx is tucked under and pulled forwards, combined with contraction of the glutei and deep external hip rotators with slight abduction of the hips, and contraction of the quadratus femoris and the lower abdominal muscles (Fig. 3). On their own these patterns of contraction would not be compatible with the need to move around and coordinate, so they are not seen in this simple form. Nevertheless, infants and young children show these two
primary postures very clearly when trying to hold back and restrain a sudden urge to defaecate or urinate. If we need to keep the primary contraction at a sustained level, all of the opposing group must be brought into action so that we can move around normally. There are, of course many psychodynamic, sociosomatic and physiological reasons why the body might be doing this; and our work with the individual patient may unearth some of them. The point here is to note that these three pelvic behaviours overlap and conflict with each other on a grand scale, creating major problems for the function of hips, low back, pelvic tilt and stabilization. Commonly one leg overlaps the other in very tense states and also produces a lateral tilt of the sacral base. This is likely to be important in musculo-skeletal pain, dysfunctional imbalances and general attrition. The generation, obliteration or control of muscular and perineal sensation, with stasis, inflammation or congestion of the bowel, bladder and genitalia may also make more sense to us; with far-reaching consequences for health.
The middle fist The next set of muscles with significant sensory function are all respiratory in action. Breathing is a complex balance between opposing sets of muscles. We do not just breathe out by the simple relaxation of inspiratory muscles. Lively, energetic or forced expiration is produced by an active contraction of the muscles drawing the lower ribs together. Abdominally this is done by the external obliques and the upper part of transversus abdominis. This continues as transversus thoracis at the lower part of the sternum, and some detailed anatomy texts show a sternocostalis muscle within the thoracic cavity. Posteriorally the ribs are moved downwards and inwards by the quadratus lumborum, and particularly the serratus posterior inferior muscles. These arise from the upper lumbar spine and spread out to grasp the lower ribs; pulling them together. These muscles push air out of the body, producing the bellows-like action of the chest. So they are all expressive muscles. They are the powerhouse of many intensely emotional movements and feelings. They all tend to be very touch and pressure sensitive. The lower intercostals and abdominal obliques can be extremely ticklish. With the patient prone the serratus posterior inferior, a very variable muscle, will often be seen twitching and fasiculating when the patient talks emphatically or emotively. Interestingly this is a migratory muscle. Unlike most other back muscles it is innervated by the anterior primary rami of the spinal nerves. It is also often very sensitive to pressure and stretch reflex; sometimes producing bruised, vulnerable or sickening feelings when worked on quite gently. The 'kidney punch' that winds boxers lands here. The anterior muscles are much more closely linked to the sensation of large scale emotional abreaction.
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Latoy
Fig. 4 Middle fist.
Fig. 5 Upper fist.
Laughing, giggling, weeping, wailing and screaming, and sometimes vomiting can all be seen as 'safety valve' functions; discharging high pressures of some sort. Feelings in the stomach, gut feelings, butterflies in the tummy, the sobbing and ache of emotional loss, and some sorts of physiological dread and terror are felt here quite deep below the sternum. The body's own way of freeing this area up is quite revealing. A yawn and stretch nearly always starts with a very large inbreath and expansion of the lower ribs. A particular sensation of muscular delight accompanies the release of these middle fist muscles. During treatment there is often a noticeable transition in the breathing range, rhythm and depth that is marked by an involuntary sigh that releases both inspiratory and expiratory muscles. The sigh may also indicate a softening of attitudes in psychotherapy; although it may also be a gesture of defeat. Occasionally the patient is stuck having to repeat these movements too often, without completing them fully or resolving something. In these cases the experienced practitioner learns to sense the right questions, pause,
change of movement or change of contact that will enable them to let go more fully. A slight fluttering of panic might be a sign that this is ready to happen. The overtense, stuck or lifeless 'middle fist' (Fig. 4) compresses the lower thoracic and thoracohimbar spine; helping to cause spinal osteochondrosis in adolescence, and putting a huge conflicting burden onto the fine control of spinal movements. The overtight or overactive crus of the diaphragm may contribute to this. Physiologically many aspects of breathing and digestion might be affected; so we could look at its relevance in cases of asthma, ulcers, reflux, hiatus hernia and so forth.
The upper fist The analogy of the clenched fist helps explain the internal dynamics of pelvic sensation, and the thoraco/abdominal powerhouse of emotional expression. The metaphor applied to the head, neck and shoulder girdle, the 'upper fist' (Fig. 5), attempts to illustrate the perception, response and restraint of response to the outer world, and some of the complexity of thought. A huge variety and blend of feelings of unease of all sorts may be noticeable here.
There are really two parts to this that only function together in quite tense states of the person. The lower part is centred at the thoracic inlet and superior mediastinum anteriorally with the scaleni, pectoral and subclavius muscles reinforcing. Posteriorally the centre is found at the serratus posterior superior muscles, with the levator scapulae and rhomboid minor muscles reinforcing. So some of the dynamics here are similar to the pelvis, some are like a mirror to the lower ribs and upper abdomen. The serratus posterior superior expands outwards and downwards from the lower cervical vertebrae to grip the upper three or four ribs. An inspiratory muscle, it can brace and compress the cervicodorsal junction and the whole upper part of the rib cage from behind. Like the inferior serratus it is an anteriorally innervated migratory muscle, and is strongly sensory. When it has been overtense this is where people want you to really dig your thumbs in; often with the release of considerable satisfaction. This muscle contracts and holds very strongly in states of shock, impact, the startle reflex, and in preparedness for conflict. Physiologically and anatomically it seems to function together with the upper thoracic chain ganglia of the sympathetic nervous system. This will therefore be linked to cardiovascular function, blood pressure and stroke volume control, and also to the overall state of alermess and vigilance of the organism as a whole (reflecting limbic, pituitary and adrenal functions). Skin tone, and therefore blushing, pallor and sweating control of the upper body may also come from this centre. So we are not only looking at responses to terror, rage and aggressive impulse, but possibly shame, guilt and embarrassment as well. This part is also released by the big yawn and stretch, with the release of muscular pleasurable feelings and resettling of the breathing pattern.
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humiliation or disgust. Overall there is nearly always a gross impoverishment of the imagination and of the sense of good humour in chronic problems.
Exhaustion, flaccidity and withdrawal
Fig. 6 Fight? Flight? Play dead and stink!
Sometimes we can know that the person has been choked up with emotion, has a big sob like a ball stuck in the throat, or is terrified that they may be unable to draw another breath. We may sense that they are enraged by the impositions and ill fortune that life has dumped on them. Most commonly we will encounter the permanently set grim determination that the person has found necessary in order to survive, thrive or achieve in life. In a sense this area is also keeping the stopper in the neck of the 'safety valve' emotional pressure bottle! The uppermost part of all of this, the sternomastoid, occipital triangle and temporalis muscles especially, have the same range of emotional dynamics. They are touch and pressure sensitive, with quite strong sensations generated by stretch and activity. These are more difficult for the manual therapist to work with, but treatment here is often most rewarding and effective. They are also most closely associated with mental processes and the special senses. So all of the problems that we meet around the cranio-orofacial girdle may have a profound muscular component. The temporalis and pterygoids
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seem to reflect the tenacity of the serratus posterior superior, and can completely jam the jaw in extremis (trismus). They also carry out an agitated mastication movement in some restless states of mind (bruxism), and a much slower gentle ruminative wandering when the mind is in more of a state of reverie. Different patterns of upper fist seizure usually accompany migraines and most headaches; temperomandibular, dental bite and some ear problems; some sinusitis and some chronic recurring infections of the throat and nasopharynx. In early life the orofacial muscles are associated with real and imagined breastfeeding movements, and will commonly come into conflict with the urge to bite (Latey 1987). The thought patterns associated with this uppermost range of muscular seizures share some common features. Thoughts and fantasies of extreme dread and violence, often sexualized, may have become stuck in a repeating pattern that changes very little. If these are too unacceptable they are heavily repressed, worsening the somatic and physiological state, but may leave a component of shameful disgrace and
OF BODYWORK AND MOVEMENT THERAPIES
The author's description of these three regions of muscular behaviour may have given the impression that the body is going to be found in a lively state of high tension, and obvious 'bind'. This is actually rare except in some more extreme and acute cases. What we find is a much more confusing picture of mixed fatigue, flaccidity and lifeless tone to the flesh that is much less interesting to the hand and eye of the therapist. What remains of the conflicting dynamics lies at a much lower level. Breathing movements and voice tone will give us some clues to this underlying pattern. They are discussed in the next paper. Setting these subtleties aside, how did they become so unappetisingly drained and leaden? Certainly the internal muscular conflicts must have absorbed huge amounts of energy; but that is only a part of the picture. In the author's opinion there is no flight or fight reflex. It is actually a fight, flight or play dead and stink reflex; and the preferred option is the third (Fig. 6)! So the body's most usual response when assaulted by the shocks, knocks and severe setbacks of life, is to switch off or tone down to an absolute minimum whole areas of function, with a slight odour of decay. This is usually compounded and maintained by a profound deadening of the appetites. There is no great desire or passion for eating, sleeping and waking up, moving, good company, achievement, reproduction or sensual interplay (libido). So our first therapeutic interventions with the chronic sufferer usually aim at better function somewhere across this spectrum of lifestyle appetites, if they are not improving spontaneously.
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Latey Until we have at least a little more vitality available to work with the opening phases of a long job can be very dire. Physiological withdrawal is closely related to the cognitive dynamics of 'splitting', 'fragmentation' and 'attacks on linking'. These mechanisms were brilliantly explored by W.R. Bion, whose work is extremely useful for us, but too complex to enlarge on here (Bion 1977, etc.).
Conclusion The author hopes that we will never again think of mind as restricted to the brain and central nervous system. The sensory functions of muscle sketched out in this paper give us much more to observe, study and think about. Andrew Still, the founder of osteopathy, claimed that it was all about mind, matter and motion. He insisted that we have to study psychology alongside the anatomy and physiology that are essential to general health care (Still 1887, Latey 1991). Unfortunately there was little psychology worth a light in his days but we are beginning to draw and explore a wider range of distinctions that will help us in our therapeutic work of all sorts, and starting to link things together better. This requires us to shake down many of the basic assumptions and premises that health care has been based on. The basics of sanitation,
shelter, water supply, nutrition, sterile procedures and so forth can remain the same. Our understanding of the human being's individual life and social ecology, internal and external, have to go through the upheavals of a complete paradigm shift (KtLhn 1970, Chalmers 1976) to be mapped into our medical model. If holism is the study of 'that tendency in nature for wholes to be formed from the ordered grouping of units' (Smuts 1926, in the Shorter Oxford Dictionary 1973), the sensory function of muscle must be seen as an absolutely crucial element of this formative tendency. Our awareness and sensing of ourselves as substantial and whole people is clearly in large part muscular. And also isn't our need to be a moving part of a community essential for us to feel complete in ourselves?
ACKNOWLEDGEMENTS Artwork by Maxwell John Phipps. Half A Man, words & music by Willie Nelson © Copyright 1962 Pamper Music, USA. Acuff-Rose Music Limited, 25 James Street, London W1, UK. Used by permission of Music Sales Limited. All Rights Reserved. International Copyright Secured.
REFERENCES Bion WR 1977 Seven servants. Jason Aronson, New York Chaitow L 1996 Palpatation skills. Churchill Livingstone, Edinburh, in press Chalmers AF 1976 What is this thing called science. University of Queensland Press, Queensland Australia,. p. 86
Damasio R 1994 Descartes' Error. Emotion, Reason and the Human Brain. Grosset/Putnam, New York Groddeck G 1930 Letter to Professor Hans Vaihinger. In: Der Mensh und sein Es. Quoted in: The meaning of illness. Hogarth Press, London, 1977; The unknown self. C.W. Daniel, London, 1929 Kuhn TS 1970 The structure of scientific revolutions. University of Chicago Press, Chicago Latey PJ 1979 The muscular manifesto. Osteopathic Publishing, London Latey PJ 1982 The attentive osteopath and migraines. British Osteopathic Journal 14 Latey PJ 1983 An expansion of modem osteopathic diagnostic theory. British Osteopathic Journal 15 Latey PJ 1984 An expansion of modern osteopathic theory of technique. British Osteopathic Journal 16 Latey PJ 1987 Psychosomatic holism. Holistic medicine 2 Latey PJ 1991 Osteopathy ancient and modem. Australian Journal of Osteopathy 3:2 Latey PJ 1992 Some notes on basic clinical tactics. Australian Journal of Osteopathy (December) Latey PJ 1994 Basic clinical tactics. Australian Journal of Osteopathy 6:1 Latey PJ 1995 Osteopathy: the future. Australian Journal of Osteopathy (August) Reich W Passion of youth 1922. Farrar, Strans and Giroux,. New York, 1988 Reich W 1927 The function of the orgasm. Republished as: Genitality. Farrar, Straus and Giroux, New York, 1980 Reich W 1933 Character analysis. Farrar, Strans and Giroux, New York, 1949 Sacks O 1994 A leg to stand on. Picador, London. Shorter Oxford Dictionary 1973 Clarendon press, Oxford, p. 974 Still AT 1897 Autobiography. Kirksville, USA
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