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Pillow talk: the use of props to encourage repose
P i l l o w talk: the use of props to encourage repose oooooooooooo
J.C. Hannon Abstract Methods of encouraging repose are presented which may be useful with the apprehensive client as well as with those who are unable to relax. Muscular relaxation is prerequisite to the success of many manual therapy skills as well as being a desired outcome for most massage techniques. Three standards are presented to help gauge the quality of repose. These consist of: 1) determination of the degree of support of the client by the treatment surface upon which they rest; 2) observation of respiration; and 3) noting the quality of passive movements. The use of pillows or props may be useful or even necessary as a catalyst for repose. Fourteen approaches to prop placement are presented for inducing repose in the recumbent client.
Introduction
John Charles Hannon D C Certified Feldenkrais Practitioner, Private Practice, 1141 Pacific Street, Suite B, San Luis Obispo, CA USA CorrespondeJzce to: John C. Harmon, Tel.: +1 805 542 9925; Fax +1 805 541 2391 Received September 1998 Accepted October 1998 Revised November 1998
Journal of Bodywork and Movement Therapies (1999) 3(1), 55-64 © Harcourt Brace & Co. Ltd 1999
Many clients present for treatment precisely because they are unable to relax or they find themselves fatigued and overwhelmed by the demands of everyday life. In the course of treatment, aids to relaxation may be essential. One of these aids is the treatment table itself. Supplying a client with compelling surfaces upon which to relax is the subject of this paper. This presumes that many clients are unable to release muscular effort even when quietly resting. This additional effort may be both excessive and contradictory to their need for relaxation. The term 'repose' is chosen to e m b o d y the state of quiet readiness; this represents more than peace of mind or muscular relaxation, although both may be featured prominently. Repose indicates as much stillness
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and restfulness as is consistent with instant action in any direction. Recognition of the use of repose is prominent in sports, martial arts, yoga and dance. Even in the visual arts one finds the ideas o f dynamic tension and repose. In the spirit o f this journal's objective to offer material which can both increase our knowledge base while also encouraging creative, intuitive improvization' (Chaitow), this collection of prop placements is offered. Conceptual sources used in this paper are the variety of props pioneered by Feldenkrais in addition to the yoga props popularized by Iyengar. The choices of the pillows and wedges presented here are consistent with the demands for lightweight portability placed upon those serving athletes in a variety o f temporary venues.
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A wide, stable table is a prerequisite. With a narrow table, the supine client often compresses their arms to their trunk increasing tension throughout the chest, spine and upper extremities in an attempt to keep their arms from falling off the table edge. Frequently this same compressive effort is seen even on a sufficiently wide table. Almost as frequently, the person fails to notice this excessive effort even when their attention is drawn to it. The arm effort is often accompanied by unnecessary activity of the respiratory muscles which impedes easy breathing. It is speculated that clients often will stiffen their bodies as an attempt to ward off pain or protect against new or increased pain. This strategy may lead them to preemptively stiffen their muscles. Stability may be likened to the challenge of perching upon a threelegged stool. Take away one leg from the stool and the resulting instability provokes vigilance and sporadic muscle activity. Over time, the plasticity of the nervous system may allow such a perched person to attend to the activities of daily living without noticing either the vigilance or the muscle activity. If this behaviour becomes habitual, it may persist even when transferred onto a stable threelegged stool. Those who are unable to relax often have unnecessary muscle activity even when they choose to be at rest. Even a snapshot of a person may identify them as being unable to relax. Although no movement can be seen in a photograph, one can often discern a difference between rigid immobility and pliable stillness. It is assumed in this paper that such distinctions may be made based upon both visual and palpable cues. It is speculated that this failure to relax may be structurally related to both muscles and bones. In the first, a low-grade level of diffuse excessive muscle activity throughout the
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locomotor system will perpetuate tension in the limbs and trunk that may been seen and palpated. Secondly, this muscle activity, combined with postural relationships of the limbs and trunk to any supporting surfaces, will produce certain joint alignments which may be observed and palpated. Elevation of the shoulder girdle such that the humeral head rides up upon its shallow scapular socket as well as the lordoses often encountered in the supine neck and lower back are examples of the skeletal changes which accompany persistent muscle activity. It may be speculated that this excessive ambient muscle activity may have several adverse consequences besides being metabolically wasteful and a risk factor for chronic strain. Unyielding activity will tense underlying supportive fascia possibly interfering with fluid transfer within the fascial planes. In addition, even a small fluid mass may provide nociceptive input if it sufficiently compresses against mechanoreceptors embedded in neighbouring fascial and musculotendinous structures. Last of all, Janda reminds us that constant muscle activity may provoke asymmetric loading of articular surfaces leading to painful strain across the synovial lining. Long bones function as struts opposing the origin and insertion of muscles. With the muscle length thus maintained, mechanical and chemical forms of potential energy can instantly move a limb. The potential energy available mechanically by the opposed muscle attachments as well as the stored chemical energy in the muscle fibres. Decreased muscle length and increased muscle viscosity reduce the available mechanical potential energy, just as fatigue reduces available metabolic energy. Another function of the skeleton is to support the musculofascial sling just as trees and stretcher bars may
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support both dimensions of a hammock. A supine person who is unable to relax upon a table often fails to allow the underlying table to be fully supportive. The posterior deltoid and gluteal muscles as well as the cervical and lumbar lordoses often fail to rest due to unyielding isometric muscle activity. This 'activity in stillness' may have serious consequences (Hannon, p 97). Often this excessive and useless effort is completely invisible to the client. Habit makes such efforts appear to be a position not an activity. Feldenkrals spoke of 'weightlessness' and 'effortlessness'; some discussion may be necessary. The sense of weightlessness implies that the weight of the body is cancelled out. This is not only perceived in a subjective sense but also in an objective sense. The skeleton is designed to cancel out the resilient forces of the floor and the body's own elastic forces. Imagine a common piece of playground equipment, the teeter-totter. The sturdy fulcrum sits under the precise center of gravity of a plank. The plank is therefore equally arranged within the force of gravity and is tangential to the ground. In other words, the plank is horizontal and invites children to come and sit upon it. If one alights upon an end of the plank, it accomodates and drops precipitously to the ground. Often this precipitates a significant lesson in gravity for the child. What appeared to be a stable and sturdy perch proves to be fickle and liable to sudden swooping. Twins, suitably situated at the poles of the plank, often recover their composure, and continue in their apprenticeship to gravity, enjoying the gentle sway provoked by the interaction of their movements and gravity. With the appropriate arrangement of skeletal parts and the suitable interplay of muscle effort, often a person can achieve a state of balance similar to that of the teeter-totter example. A labourer with a pole
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across their shoulders, heavy burdens hanging from either end, can often walk more erect than someone unburdened. The demands of lengthy strenuous work prompt a subtle rearrangement of the skeleton. Those who often carry heavy loads upon their heads often have strikingly erect posture of their upper spines. These people appear graceful and strong, not rigid and immobilized as do some wearing neck braces. It is speculated that the human skeleton is eminently designed with the necessary fulcra to allow the limbs and spine to function in the weightless manner described by the teeter-totter example. Those who do so are described as graceful and strong. Occasionally, interviews with recordbreaking athletes elicits some statement similar to: 'I felt I was moving well, it felt easy.' Shafarman (1997) notes that the French roots of the word 'comfortable' are corn-forte (with strength). Perhaps grace and strength are qualities that coexist with effortlessness and comfort. In this weightless state, the body is buoyant like a sailboat moving light as a breeze. Effort is at a minimum and the body moves efficiently; as precise and powerful as is needed for the task. We observe Olympic athletes as moving easily through their paces yet we know the arduous training necessary to make it look easy and effortless. Further examples of this continuing apprenticeship to gravity include the progression from the tricycle to the bicycle and on to the unicycle. For some, observers are able to estimate one's success at these various activities by looking for muscle tension. A superb cyclist, unaccustomed to the unicycle, may clamber up upon one and begin pedaling, often with both legs and arms. The arms flail, bristling with clenched muscles as the athlete attempts to maintain their balance despite moving their legs. Feldenkrais (1972, p.79) suggests placing bathroom scales under one's feet while sitting. He recommends
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Fig. 1 Tupelo the cat. Note the almost palpable relaxation of the limb muscles, the sense of extension of both the front limbs and of the upper spine. Also sense the feeling of full and yet easy respiration and poise of the head. The head and neck appear so well balanced that even a slight effort of the associated muscles would instantly translate, tilt or twist the head toward almost any point of interest.
noticing if the needle swings far beyond one's weight upon standing. As a person uses less effort in arising, the needle swings less and less beyond their actual weight. The concept of tensegrity has been promoted to explain how muscle tension may be balanced by the compression carried by shafts and struts of the long bones, their tubercles and the processes of the vertebrae. Levine (1997) states that ... shortening one soft tissue element has a tippling effect throughout the structure', and that 'the body is a symphony of movement orchestrated by the natural oscillations of its component parts .... when it all functions together, it is a harmonic work of great complexity. When one of the players misses a beat it can produce a discordant mess ... these are disorders of systems that can be described as a breakdown of the control or coordinating mechanisms. When in spasm, a muscle failing to oscillate in the normal cycle of contraction-relaxation may be likened to a uselessly fibrillation heart unable to pump in a fruitful way.
Many animals often lie resting in repose yet they are able to flee predators instantly or to pursue prey. The house cat provides a convenient
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example. Note the full expanse of abdominal and limb flesh resting upon the floor in Figure 1. Despite this state of muscular relaxation, the cat's thoracic spine is maintained in a raised and expanded state ready for action. The configuration of the spine, ribs and scapulae erect the thorax skyward; this lift is accomplished primarily through the skeleton not the muscles. Isometric chest and forelimb muscle activity would compress rather than open the lungs. Maintaining the thorax in a raised position enables effective breathing with least muscular effort. This position also allows the cat to quickly respond if purposeful motion is necessary. In other words, the cat's locomotor system is in a state of quiet readiness poised for movement. It may be useful to explore why a client fails to take advantage of repose. Just as procrastinating before making a decision is, in itself, a decision, resting without really resting may reveal much of client's approach to life. This information may be vital to planning treatment based upon actively restoring the client to fulfilling activities of daily living.
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Passive therapy also is aided by discernment of a p e r s o n ' s ability to relax. R e c o g n i z i n g the m o m e n t o f relaxation is a prerequisite to manipulation and mobilization, as in L e w i t ' s post-isometric m u s c l e relaxation and the m y o f a s c i a l release techniques o f Travell and Simons. L e w i t notes that a crucial step in manipulation, stretching, postisometric relaxation, fascial shifting, is taking up the slack. H e states that: ...this must be carried out very gently, with the patient relaxed. The most important source of error is to mistake active resistance by the patient for the sign that we have taken up the slack.
Fig. 2 Notice how a sturdy, well anchored pillow supports the shin and feet at 90 ° to each other. This may be effective in releasing tension in the intrinsic muscles of the foot as well as passively stretching the calf muscles.
system. This m a y explain w h y so m a n y p e o p l e are unable to relax.
Travell and S i m o n s state that the: ...involved muscle cannot be effectively stretched if it is not fully relaxed, and full relaxation requires a comfortable, warm, well-supported patient. All the limbs must be supported comfortably when the patient is in the recumbent position....As demonstrated by Basmajian (1997), relaxation is not a passive process, but an active one that requires learning how to turn off motor unit activity. For most patients, the trick is to divert attention from themselves and have them concentrate on the support. They must feel the armrests of the chair supporting their forearms, or think about the wrinkles in the sheet on which they are lying. (Comfortable blankets are a necessary adjunct to props in many offices with forced air cooling.) It is the purpose o f props to supply support in such a persuasive m a n n e r that this active resistance is dissolved. For this reason the supports m u s t be introduced in a gentle and nonconfrontational fashion. Prop p l a c e m e n t must be decisive so that the support is clearly sensed as still and solid. M i n s k y (1986) b e l i e v e s that w e understand anything, including ourselves, ' b y using one or another kind o f analogy- that is, by representing each n e w thing as though it r e s e m b l e s s o m e t h i n g we already k n o w ' . If a person, early in life, b e c o m e s c o n v i n c e d that excess effort is the best strategy, then this s a m e strategy m a y be applied to any n e w skills learned by the l o c o m o t o r
Observing and palpating the e x t e n t of repose 1. C o n t o u r
of table contact
A c o m p u t e r salesperson m a y tout the c o n v e n i e n c e o f their m o d e l ' s ' f o o t p r i n t ' upon y o u r desktop. O n e can also speak o f the 'tableprint' of a r e c u m b e n t client the contour o f the c l i e n t ' s f o r m resting on the table, their breathing and their response to perturbation o f their limbs. This contour o f contact changes as the person relaxes upon the table. K e y
Fig. 3 Two knee pillows are demonstrated here with the larger one made form firm foam; the knees need to be supported enough that the heels do not touch the table. Approximately 90 ° of knee flexion works well. More important is the pillow width, which must be wide enough to support the thighs in slight of abduction without the client feeling of the possibility of the knees falling laterally off the pillow. The part supporting the knee's popliteal fossa must be soft. Often by establishing relaxation of the thigh muscles the lower back extensors, diaphragm and the iliopsoas will relax. By sheathing the pillow in textured soft fabric such as corduroy, the resulting friction gives a greater sense of anchoring of the leg and thigh upon the pillow. The leg falls toward the foot and the thigh falls toward the pelvis creating a comfortable sense of separation at the knee.
areas to m o n i t o r are the shoulder and pelvic girdles, the lumbar and cervical spinal erector muscles and the distal extremities. As a p e r s o n ' s erector spinae muscles relax, the spinal lordoses decrease their depth. In a
Tableprint The contour of a client's contact upon the table will widen as their muscles relax. Look to eight areas: the two girdles of the shoulder and pelvis; the lordotic curves in the lumbar and cervical spine and all four limbs. Breathing As a person's muscular tension relaxes. Their breathing will deepen in three different directions. The chest will rise more fully towards the ceiling, there will be wider expansion of the breath laterally, ;and a pulsation of the abdomen will extend down towards the pubic arch during each inhalation. Perturbation Passive genre movement of a body part should not produce 'shuddering'. Look for this shuddering to occur at the same point repeatedly during a limb trajectory. Gentle jostling can also be used to provoke a 'startle~ response. Deeper levels of repose require a stronger jostle to evoke a startle response. Summary Presume increased repose when observing a larger 'tableprint'; deeper breathing despite less effort; smoother, lighter passi-;'e movements with a greater tolerance of gentle jostles.
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Fig. 5 A large flat firm pillow may be placed between the table and the head and neck of a client. Often this pillow is best placed also under the superior aspect of the scapulae near the supraspinatus. The pillow is placed such that the forehead is parallel with the table. Often in this position there is an initiation of release of tension across the clavipectoral fascia as well as the scalenes and posterior cervical muscles. Many headaches may be relieved with ergonomic advice regarding pillow type and placement. As relaxation deepens the underlying sternocleidomastoid bellies soften and often the sternum will lift during inspiration. The mimetic muscles of the face generally are reliable indicators of the presence of absence of relaxation. Many signs may be observedjust in the region of the eyes. Eye blink rate; speed and force of lid closure may indicate the degree of inner composure.
Fig. 4 In this position (padded blocks such as these are used in chiropractic for SacroOccipital Technique) may be placed under the pelvis and/or the lower back (A) Suitable sites include the posterior superior iliac spines; the gluteus medius posterior belly; the gluteus maximus and the greater trochanter. For example, the lumbar lordosis may be reduced by tilting the pubic arch superiorly with blocks placed as in the picture. Another example would be an asymmetric block placement to level the heights of the anterior superior iliac spines from the table surface. There are any number of vectors which may be used.
similar way, the pronated forearms in the supine client may relax to allow the distance from the wrists to the table surface to decrease. The same process of relaxation may be observed of the posterior deltoids, the gluteal muscles as well as the lateral thigh, and calf muscles as the hip rotators release their tension.
Fig. 6 A cervical round pillow may be placed with or without the large flat pillow. Often shearing of the middle cervicals is prevented by this prop and a comfortable mild long axis extension passive traction may be evoked along the cervical spine.
2. Breathing The necessity of breath makes it the most valuable method of assessing repose. One may judge a client' s relaxation by observing or palpating which portions of the body are passively moved by the act of breathing. This process of assessment may be compared to a series of snapshots that make up an animation. Each still picture provides information but the animation's value is far greater than its parts. You might
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Fig. 7 Shoulder wedges may be used to lift the shoulder, either at the glenohumeral junction (A) or under the scapula itself (B) (lifting both the glenohumeral junction and the scapula). Often this propping will allow chronic contraction of muscles to be released.
observe a trend by watching the behaviour over time; this could be confirmed with reference to the stills. Faced with a film of a metronome, we could determine the amplitude of the pendulum by reviewing certain key still frames. If we were practised, we might even be able to gain that information without stopping the film. The skill in observing and palpating the cyclic movements of the breath are similar to that of observing a metronome, except that the pendulum of the breath potentially moves in a multiplicity of directions and is instantly mutable. The ribs may rise and fall in one trajectory only to change in the next breath. If a client raises an arm while otherwise being still and supine, an observable change in the trajectory of the ribs will be seen. If an observer mentions this change to the client, often yet another breathing change will be seen. This last change brought about by nothing more than the observer's comment.
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Folded blank
Shoulders droop
Fig. 8 Support may be placed interscapularly using a coarse wool blanket. The blanket is folded accordion-like to a compressed height of one or two hand widths. The blanket just fills the space between the two scapula from the crown of the head to the sacral base. Additional pillows are arranged to support the neck and the head with the forehead parallel to the floor. The blanket opens up the anterior chest and allows the scapulae freedom, as they dangle in space, to explore new directions of movement. This prop may be used to good effect with those who are chronically unable to depress their scapular girdle as well as for those who have both anterior head carriage and anterior shoulder carriage.
It is recommended to first observe the breath before palpating, since the act itself of palpation may change the pattern. It is also recommended that this observation be carried out long enough that the observer gains such a strong sense of the breathing pattern that it becomes predictable. In other words, the observer would be able to describe, in advance, the time of inhalation and exhalation as well as the pattern and amplitude of breathing. This may take only a few breath cycles or even minutes depending upon the client. With experience, an obs6rver is able to maintain awareness of the changing breath in their sensory background while other therapeutic duties are attended to. This contemplates that the breath is observed for its period and amplitude
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as well as subtle distinctions such as the individual trajectories of the ribs. It is even possible to entertain hypotheses such as the apparent site of the initiation of inhalation (where the breathing appears to start from), and update these hypotheses during each breath cycle. If the client's attention is directed to their breathing, they often are unable to verify that they are 'holding their breath'. They may deny the assertion pointing out that they are indeed breathing. Often, their only distinction is binary; either the thorax is sealed off at both its bottom and top ends (such as with the bearing down effort associated with defecation), or the person is breathing. At this point it may be useful to explain the concept of the quality of breath. The ideal breath uses the least effort without compromising
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effectiveness. The lungs complete their gas transfer such that the blood is well rejuvenated with a minimum of muscular activity. A sufficiently strong and mobile respiratory system has the capacity to be effective and efficient in this way in a multitude of postural positions. For example, quite different demands are placed upon the system when side-lying compared to standing while side-bending. Another example is the difficulty many people have breathing, in an easy fashion, kneeling with their head lower than their sacrum. Those of the Islamic faith, praying in this position many thousands of times, might find breathing quite easy in this posture. But, even these faithful might be challenged in obtaining an ideal breath if they were asked to simultaneously kneel and side-bend. Despite these typical stiffnesses of most adults, we need look no further than any healthy infant for instruction in how an ideal breath appears in all of these positions. The diaphragm is an unusual muscle; when unencumbered by adverse muscular tension, it powers chest movement in all three spatial dimensions. An infant sleeping in repose provides an example; close observation of the child reveals the chest wall rising and falling. Further observation allows distinctions to be made of the various movements occurring simultaneously. In the absence of physical constraints such as binding clothes, the chest will be seen to spread forward, backward as well as to both sides. In addition, the upper chest rises and the abdominal contents are displaced downwards. During inhalation the chest is stretched in all three dimensions as if having a balloon inflated inside the basket of ribs. Restrictions applied to the chest hamper this expansion; an example for the recumbent child is the surface they are lying on. The weight of their chest settling upon the surface restricts movement downward into the surface. Other restrictions come to mind, the binding of tight clothes sizes too
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Fig. 9 Here the knees are supported without a prop but as if the pillows used in Fig. 3 were in place. To support the bent knees in repose requires the bones of the lower extremity to be aligned. The knees are wider than the hips with the knee, ankle, medial foot and hip in a straight line. In this alignment, the skeleton supports the knee without muscle involvement from the thigh or calf. The limb hangs from the skeletal elements of the lower elements. The use of props mentioned in this paper is similar to using training wheels on a child's bicycle; the extra wheels are removed once stability in motion is achieved.
Fig. 10 On the side, pillows may be placed between the knees and lower legs such that the muscles of the thigh are relaxed and the lower extremities are approximately parallel although flexed at the knee. This prop placement is well tolerated for long periods of time; many people (pregnant women, those with hip arthritis, wasting of the thigh muscles), will prefer to use pillows such as this while sleeping on their sides.
small, belts and sashes tightly cinched. As adults, one has only to notice the sound and feel of one's own breathing while stooping from the standing position (as if to tie shoelaces), to feel the restrictions potentially brought about by the binding of clothes and positional constraints. Many teachers promote an ideal way to breathe, but it is more likely that there is no one universal ideal of breathing. Instead, for each person and for every activity there are many ways to breathe satisfactorily (Feldenkrais 1972). What may be more valuable clinically is skill in determining if the breath expands with equal effort in all directions. Let us visualize a set of lungs as balloons inside a basket, let us further specify that the basket is woven of ribs that are both resilient and compliant (think of freshly cut reeds). Sufficient inflation of the batloons will bring about an expansion of the woven reeds as the balloon surfaces expand. If all the reeds are similar in their resistance to bending, the expansion will be equal in all directions just as a balloon of equal thickness would expand spherically. If we substitute a clay pot for the basket, we see that expansion will be stopped once the balloon expands to fill the pot's interior. The value of this oversimplification of the respiratory structures may be in realizing that unremitting activity of the many muscle layers attached to the ribs may impair the resilience and compliance of the thorax. When we palpate the chest wall we may encounter rigid clay-like resistance rather than the flexibility of reeds.
3. Perturbation Fig. 11 In this side-lying position the forearm is placed such that the middle of the forearm is placed so that it is balanced on the fulcrum created by the midaxillary line of the ribcage. This allows the muscles of the shoulder girdle, specifically the brachialis and biceps muscles, along with the triceps and rotator cuff to be relaxed along with the latissimus dorsi and the serratus anterior. Often this allows deeper lateral excursion of the breath which further relaxes the shoulder muscles. Use this position only for a few minutes at a time since many people have slight shoulder is stability combined with muscle imbalance. This often leads to asymmetric loading of the involved joints, which may tug at the pressure-sensitive layers of the affected joint capsules.
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Movement during treatment can be divided into that performed by the client and that imposed upon the client. This has been codifed as active and passive movement. Quality of motion, although difficult to describe in an unequivocal manner, is an excellent way of determining the
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Figure 12 A large pillow may be suggested to people with lower back pain. The arms are arranged allowing their arm and legs to be supported and with their limbs parallel to each other. Often a lower back release and a deeper abdominal breath will be obtained. This effect is maximised if the client is instructed to notice the moment their belly pushes into the girth of the pillow while simply breathing normally. The mental effort of selfobservation often will distract them long enough for this novel, for most people, position to act on the excess muscle activity.
Figure 13 A fetal curve may be useful in obtaining deeper breathing and relaxed deep spinal intrinsic muscles along the length of the spine. The procedure is completed in three stages. In the first stage the client is instructed to flex into a fetal curve; often you notice that they have minimal flexion at both the junctions of the neck to the trunk and the spine to the pelvis. Second stage involves passively pulling on their belt so their spine is placed into a greater kyphosis with the apex at the lower thoracic spine. The last stage is to bring the entire upper body into more flexion. As a unit, the head and shoulders are pulled into a fully tucked and comfortable position. This position is usually tolerable for long periods of time. If the person resists being placed into this position, either by active muscle activity or through the passive lack of elongation of their fascia and ligaments, respect their reluctance and only apply this fetal curve to a minor extent. The great value of observing accurately breath changes allows a clinician to adapt the posture or prop for greatest effect. Too much stretch will provoke stiffness and/or pain, sometimes delayed. Too little stretch fails to encourage repose. In either case, an experienced observer will adjust the extent of the posture or prop's effect to quickly bring about a relaxed breath knowing that muscular repose will follow.
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normal response, a person unable to relax is often unable to avoid excessive muscular reactions to passive jostling of their body. Even slow, gentle lifting can evoke not only active lifting of the limb but also a generalized increase in muscle tone, a change in breathing, speech and eye movements consistent with increased levels of alertness. It may be speculated that this excessive arousal may lead to sleep disorders. This state of muscular vigilance fades often when a person's muscle tone relaxes; then, provoking a startle response becomes more and more difficult using gentle shaking or other perturbations. Figure 14 Here pillows are arranged in the armpit and under the arm and forearm. The arm is passively abducted and slightly flexed. The aim is to induce a relaxed dependency of the arm and forearm upon the pillows and tabletop. This position is generally tolerated for 15 minutes or more; care must be made to comfortably stretch the arm from the shoulder socket and then arrange the limb upon the pillows without sacrificing.
extent of repose. A person in repose safely tolerates gentle, slow passive movements without adding his or her own muscle activity. They allow their limbs to be towed through space. A client bedeviled by adverse muscle tension will be unable to release their muscles and therefore they will resist even the most gentle of passive movements. Often it shocks them to discover that they are able to sense their previously unconscious muscular shadowing of every passive movement. Just as shocking may be the difficulty in changing this pattern of unnecessary muscle activity. Frequently 'startle responses' are provoked in the course of perturbations. As a person's level of neurological alertness drops, their muscular reaction to stimuli may become muted. When a person is sleeping, one says they are in a deep sleep when one is unable to rouse them with shaking. In distinction to this
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Conclusion Inducing relaxation in the recumbent client may provide a hotbed of tranquility from which greater potency of movement may arise. To this end, props may be useful in treatment. Encouraging repose reduces muscular resistance and, with little commotion, it may also increase sensitivity to previously indiscernible processes of thoughts, sensations and emotions. A prop imposes a still fulcrum around which chronically tense tissues may relax, encouraged by the ebb and flow of breathing and circulatory rhythms. The stillness of the prop acts as an invariant pressure and position stimulus, which may be used by the client's nervous system to orient itself spatially and with respect to gravity. In addition, it is speculated that the perception of relaxation may 'reset' a kinesthetic threshold. If so, the client may learn to relax areas such as the spinal curves or the shoulder or hip regions. It is further speculated that the repetitive experience of such releases of muscular tension may aid the learning of generalized selfrelaxation throughout the locomotor system. Normal alignment of the skeleton allows a feeling of weightlessness; the arrangement of bones securely
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supporting the w e i g h t o f the body in such a way that almost all m u s c u l a r effort is u n n e e d e d in maintaining a posture. A b a l a n c e d l i m b or trunk so loaded requires m u c h less m u s c l e action than one w e i g h t e d d o w n with persistent and unnecessary m u s c l e tension. T h e kinesthetic sense m e a s u r e s differences in strain rather than variations in w o r k output, but it m a y b e c o m e habituated as any other sensory input. M a n y p e o p l e h a v e lost the ability to m a t c h their m u s c u l a r p o w e r to the task at hand. W e e x p e c t to take time to learn the n o v i c e unicyclist the necessary coordination. M a n y o f our clients w h o are unable to relax lie stiffly u p o n out tables, s w a d d l e d in bands o f superfluous m u s c l e tension. T h o s e are the p e o p l e w h o lie on our treatment beds like
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lumps o f clay. R e g a i n i n g delicacy in m a t c h i n g effort to task is an important m i l e s t o n e in the e m a n c i p a t i o n o f a client f r o m treatment; it demonstrates self-reliance arising out o f selfawareness. Feldenkrais described this as: ' I f you k n o w what you are doing, you can do what y o u want.'
REFERENCES Chaitow L 1996 Are skilled manual practitioners and therapists artists or technicians or both? Journal of Bodywork and Movement Therapies 1(1): Feldenkrais M 1971 Unpublished audiotape transcript of a September week-long seminar at Esalen, California Feldenkrais M 1972 Awareness through movement. Harper and Row, New York, p 162-71 Hannon J 1998 The Man who mistook his patient for a chair. Journal of Bodywork and Movement Therapies 2(2): 88-100
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Iyengar BKS 1991 Unpublished notes of a seminar on the medical uses of yoga presented at University of California, San Diego School of Medicine Janda V 1985 Pain in the locomotor system - A broad approach. In: Glascow EF, Twomey LT, eds. Aspects of manipulative therapy. Churchill Livingston, Melbourne, p 149 Levine S 1997 The importance of soft tissues for structural support of the body. In: D'Ambrogio KJ, Roth GB, Positional release therapy. Mosby, St Louis, (vii):243-244 Lewit K 1991 Manipulative therapy in rehabititation of the locomotor system. Butterworth Heinemann, Oxford, p 143-144 Minsky M 1986 The society of mind. Simon and Shuster, New York, p 57 Shafarman S 1997 Awareness heals: the Feldenkrais method for dynamic health. Addison-Wesley, Reading, p 48 Travell J, Simons D 1983 Myofascial pain and dysfunction vol. 1. Williams and Wilkins, Baltimore, p 65-66
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J.C. Hannon Abstract Methods of encouraging repose are presented which may be useful with the apprehensive client as well as with those who are unable to relax. Muscular relaxation is prerequisite to the success of many manual therapy skills as well as being a desired outcome for most massage techniques. Three standards are presented to help gauge the quality of repose. These consist of: 1) determination of the degree of support of the client by the treatment surface upon which they rest; 2) observation of respiration; and 3) noting the quality of passive movements. The use of pillows or props may be useful or even necessary as a catalyst for repose. Fourteen approaches to prop placement are presented for inducing repose in the recumbent client.
Introduction
John Charles Hannon D C Certified Feldenkrais Practitioner, Private Practice, 1141 Pacific Street, Suite B, San Luis Obispo, CA USA CorrespondeJzce to: John C. Harmon, Tel.: +1 805 542 9925; Fax +1 805 541 2391 Received September 1998 Accepted October 1998 Revised November 1998
Journal of Bodywork and Movement Therapies (1999) 3(1), 55-64 © Harcourt Brace & Co. Ltd 1999
Many clients present for treatment precisely because they are unable to relax or they find themselves fatigued and overwhelmed by the demands of everyday life. In the course of treatment, aids to relaxation may be essential. One of these aids is the treatment table itself. Supplying a client with compelling surfaces upon which to relax is the subject of this paper. This presumes that many clients are unable to release muscular effort even when quietly resting. This additional effort may be both excessive and contradictory to their need for relaxation. The term 'repose' is chosen to e m b o d y the state of quiet readiness; this represents more than peace of mind or muscular relaxation, although both may be featured prominently. Repose indicates as much stillness
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and restfulness as is consistent with instant action in any direction. Recognition of the use of repose is prominent in sports, martial arts, yoga and dance. Even in the visual arts one finds the ideas o f dynamic tension and repose. In the spirit o f this journal's objective to offer material which can both increase our knowledge base while also encouraging creative, intuitive improvization' (Chaitow), this collection of prop placements is offered. Conceptual sources used in this paper are the variety of props pioneered by Feldenkrais in addition to the yoga props popularized by Iyengar. The choices of the pillows and wedges presented here are consistent with the demands for lightweight portability placed upon those serving athletes in a variety o f temporary venues.
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A wide, stable table is a prerequisite. With a narrow table, the supine client often compresses their arms to their trunk increasing tension throughout the chest, spine and upper extremities in an attempt to keep their arms from falling off the table edge. Frequently this same compressive effort is seen even on a sufficiently wide table. Almost as frequently, the person fails to notice this excessive effort even when their attention is drawn to it. The arm effort is often accompanied by unnecessary activity of the respiratory muscles which impedes easy breathing. It is speculated that clients often will stiffen their bodies as an attempt to ward off pain or protect against new or increased pain. This strategy may lead them to preemptively stiffen their muscles. Stability may be likened to the challenge of perching upon a threelegged stool. Take away one leg from the stool and the resulting instability provokes vigilance and sporadic muscle activity. Over time, the plasticity of the nervous system may allow such a perched person to attend to the activities of daily living without noticing either the vigilance or the muscle activity. If this behaviour becomes habitual, it may persist even when transferred onto a stable threelegged stool. Those who are unable to relax often have unnecessary muscle activity even when they choose to be at rest. Even a snapshot of a person may identify them as being unable to relax. Although no movement can be seen in a photograph, one can often discern a difference between rigid immobility and pliable stillness. It is assumed in this paper that such distinctions may be made based upon both visual and palpable cues. It is speculated that this failure to relax may be structurally related to both muscles and bones. In the first, a low-grade level of diffuse excessive muscle activity throughout the
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locomotor system will perpetuate tension in the limbs and trunk that may been seen and palpated. Secondly, this muscle activity, combined with postural relationships of the limbs and trunk to any supporting surfaces, will produce certain joint alignments which may be observed and palpated. Elevation of the shoulder girdle such that the humeral head rides up upon its shallow scapular socket as well as the lordoses often encountered in the supine neck and lower back are examples of the skeletal changes which accompany persistent muscle activity. It may be speculated that this excessive ambient muscle activity may have several adverse consequences besides being metabolically wasteful and a risk factor for chronic strain. Unyielding activity will tense underlying supportive fascia possibly interfering with fluid transfer within the fascial planes. In addition, even a small fluid mass may provide nociceptive input if it sufficiently compresses against mechanoreceptors embedded in neighbouring fascial and musculotendinous structures. Last of all, Janda reminds us that constant muscle activity may provoke asymmetric loading of articular surfaces leading to painful strain across the synovial lining. Long bones function as struts opposing the origin and insertion of muscles. With the muscle length thus maintained, mechanical and chemical forms of potential energy can instantly move a limb. The potential energy available mechanically by the opposed muscle attachments as well as the stored chemical energy in the muscle fibres. Decreased muscle length and increased muscle viscosity reduce the available mechanical potential energy, just as fatigue reduces available metabolic energy. Another function of the skeleton is to support the musculofascial sling just as trees and stretcher bars may
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support both dimensions of a hammock. A supine person who is unable to relax upon a table often fails to allow the underlying table to be fully supportive. The posterior deltoid and gluteal muscles as well as the cervical and lumbar lordoses often fail to rest due to unyielding isometric muscle activity. This 'activity in stillness' may have serious consequences (Hannon, p 97). Often this excessive and useless effort is completely invisible to the client. Habit makes such efforts appear to be a position not an activity. Feldenkrals spoke of 'weightlessness' and 'effortlessness'; some discussion may be necessary. The sense of weightlessness implies that the weight of the body is cancelled out. This is not only perceived in a subjective sense but also in an objective sense. The skeleton is designed to cancel out the resilient forces of the floor and the body's own elastic forces. Imagine a common piece of playground equipment, the teeter-totter. The sturdy fulcrum sits under the precise center of gravity of a plank. The plank is therefore equally arranged within the force of gravity and is tangential to the ground. In other words, the plank is horizontal and invites children to come and sit upon it. If one alights upon an end of the plank, it accomodates and drops precipitously to the ground. Often this precipitates a significant lesson in gravity for the child. What appeared to be a stable and sturdy perch proves to be fickle and liable to sudden swooping. Twins, suitably situated at the poles of the plank, often recover their composure, and continue in their apprenticeship to gravity, enjoying the gentle sway provoked by the interaction of their movements and gravity. With the appropriate arrangement of skeletal parts and the suitable interplay of muscle effort, often a person can achieve a state of balance similar to that of the teeter-totter example. A labourer with a pole
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across their shoulders, heavy burdens hanging from either end, can often walk more erect than someone unburdened. The demands of lengthy strenuous work prompt a subtle rearrangement of the skeleton. Those who often carry heavy loads upon their heads often have strikingly erect posture of their upper spines. These people appear graceful and strong, not rigid and immobilized as do some wearing neck braces. It is speculated that the human skeleton is eminently designed with the necessary fulcra to allow the limbs and spine to function in the weightless manner described by the teeter-totter example. Those who do so are described as graceful and strong. Occasionally, interviews with recordbreaking athletes elicits some statement similar to: 'I felt I was moving well, it felt easy.' Shafarman (1997) notes that the French roots of the word 'comfortable' are corn-forte (with strength). Perhaps grace and strength are qualities that coexist with effortlessness and comfort. In this weightless state, the body is buoyant like a sailboat moving light as a breeze. Effort is at a minimum and the body moves efficiently; as precise and powerful as is needed for the task. We observe Olympic athletes as moving easily through their paces yet we know the arduous training necessary to make it look easy and effortless. Further examples of this continuing apprenticeship to gravity include the progression from the tricycle to the bicycle and on to the unicycle. For some, observers are able to estimate one's success at these various activities by looking for muscle tension. A superb cyclist, unaccustomed to the unicycle, may clamber up upon one and begin pedaling, often with both legs and arms. The arms flail, bristling with clenched muscles as the athlete attempts to maintain their balance despite moving their legs. Feldenkrais (1972, p.79) suggests placing bathroom scales under one's feet while sitting. He recommends
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Fig. 1 Tupelo the cat. Note the almost palpable relaxation of the limb muscles, the sense of extension of both the front limbs and of the upper spine. Also sense the feeling of full and yet easy respiration and poise of the head. The head and neck appear so well balanced that even a slight effort of the associated muscles would instantly translate, tilt or twist the head toward almost any point of interest.
noticing if the needle swings far beyond one's weight upon standing. As a person uses less effort in arising, the needle swings less and less beyond their actual weight. The concept of tensegrity has been promoted to explain how muscle tension may be balanced by the compression carried by shafts and struts of the long bones, their tubercles and the processes of the vertebrae. Levine (1997) states that ... shortening one soft tissue element has a tippling effect throughout the structure', and that 'the body is a symphony of movement orchestrated by the natural oscillations of its component parts .... when it all functions together, it is a harmonic work of great complexity. When one of the players misses a beat it can produce a discordant mess ... these are disorders of systems that can be described as a breakdown of the control or coordinating mechanisms. When in spasm, a muscle failing to oscillate in the normal cycle of contraction-relaxation may be likened to a uselessly fibrillation heart unable to pump in a fruitful way.
Many animals often lie resting in repose yet they are able to flee predators instantly or to pursue prey. The house cat provides a convenient
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example. Note the full expanse of abdominal and limb flesh resting upon the floor in Figure 1. Despite this state of muscular relaxation, the cat's thoracic spine is maintained in a raised and expanded state ready for action. The configuration of the spine, ribs and scapulae erect the thorax skyward; this lift is accomplished primarily through the skeleton not the muscles. Isometric chest and forelimb muscle activity would compress rather than open the lungs. Maintaining the thorax in a raised position enables effective breathing with least muscular effort. This position also allows the cat to quickly respond if purposeful motion is necessary. In other words, the cat's locomotor system is in a state of quiet readiness poised for movement. It may be useful to explore why a client fails to take advantage of repose. Just as procrastinating before making a decision is, in itself, a decision, resting without really resting may reveal much of client's approach to life. This information may be vital to planning treatment based upon actively restoring the client to fulfilling activities of daily living.
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Passive therapy also is aided by discernment of a p e r s o n ' s ability to relax. R e c o g n i z i n g the m o m e n t o f relaxation is a prerequisite to manipulation and mobilization, as in L e w i t ' s post-isometric m u s c l e relaxation and the m y o f a s c i a l release techniques o f Travell and Simons. L e w i t notes that a crucial step in manipulation, stretching, postisometric relaxation, fascial shifting, is taking up the slack. H e states that: ...this must be carried out very gently, with the patient relaxed. The most important source of error is to mistake active resistance by the patient for the sign that we have taken up the slack.
Fig. 2 Notice how a sturdy, well anchored pillow supports the shin and feet at 90 ° to each other. This may be effective in releasing tension in the intrinsic muscles of the foot as well as passively stretching the calf muscles.
system. This m a y explain w h y so m a n y p e o p l e are unable to relax.
Travell and S i m o n s state that the: ...involved muscle cannot be effectively stretched if it is not fully relaxed, and full relaxation requires a comfortable, warm, well-supported patient. All the limbs must be supported comfortably when the patient is in the recumbent position....As demonstrated by Basmajian (1997), relaxation is not a passive process, but an active one that requires learning how to turn off motor unit activity. For most patients, the trick is to divert attention from themselves and have them concentrate on the support. They must feel the armrests of the chair supporting their forearms, or think about the wrinkles in the sheet on which they are lying. (Comfortable blankets are a necessary adjunct to props in many offices with forced air cooling.) It is the purpose o f props to supply support in such a persuasive m a n n e r that this active resistance is dissolved. For this reason the supports m u s t be introduced in a gentle and nonconfrontational fashion. Prop p l a c e m e n t must be decisive so that the support is clearly sensed as still and solid. M i n s k y (1986) b e l i e v e s that w e understand anything, including ourselves, ' b y using one or another kind o f analogy- that is, by representing each n e w thing as though it r e s e m b l e s s o m e t h i n g we already k n o w ' . If a person, early in life, b e c o m e s c o n v i n c e d that excess effort is the best strategy, then this s a m e strategy m a y be applied to any n e w skills learned by the l o c o m o t o r
Observing and palpating the e x t e n t of repose 1. C o n t o u r
of table contact
A c o m p u t e r salesperson m a y tout the c o n v e n i e n c e o f their m o d e l ' s ' f o o t p r i n t ' upon y o u r desktop. O n e can also speak o f the 'tableprint' of a r e c u m b e n t client the contour o f the c l i e n t ' s f o r m resting on the table, their breathing and their response to perturbation o f their limbs. This contour o f contact changes as the person relaxes upon the table. K e y
Fig. 3 Two knee pillows are demonstrated here with the larger one made form firm foam; the knees need to be supported enough that the heels do not touch the table. Approximately 90 ° of knee flexion works well. More important is the pillow width, which must be wide enough to support the thighs in slight of abduction without the client feeling of the possibility of the knees falling laterally off the pillow. The part supporting the knee's popliteal fossa must be soft. Often by establishing relaxation of the thigh muscles the lower back extensors, diaphragm and the iliopsoas will relax. By sheathing the pillow in textured soft fabric such as corduroy, the resulting friction gives a greater sense of anchoring of the leg and thigh upon the pillow. The leg falls toward the foot and the thigh falls toward the pelvis creating a comfortable sense of separation at the knee.
areas to m o n i t o r are the shoulder and pelvic girdles, the lumbar and cervical spinal erector muscles and the distal extremities. As a p e r s o n ' s erector spinae muscles relax, the spinal lordoses decrease their depth. In a
Tableprint The contour of a client's contact upon the table will widen as their muscles relax. Look to eight areas: the two girdles of the shoulder and pelvis; the lordotic curves in the lumbar and cervical spine and all four limbs. Breathing As a person's muscular tension relaxes. Their breathing will deepen in three different directions. The chest will rise more fully towards the ceiling, there will be wider expansion of the breath laterally, ;and a pulsation of the abdomen will extend down towards the pubic arch during each inhalation. Perturbation Passive genre movement of a body part should not produce 'shuddering'. Look for this shuddering to occur at the same point repeatedly during a limb trajectory. Gentle jostling can also be used to provoke a 'startle~ response. Deeper levels of repose require a stronger jostle to evoke a startle response. Summary Presume increased repose when observing a larger 'tableprint'; deeper breathing despite less effort; smoother, lighter passi-;'e movements with a greater tolerance of gentle jostles.
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A
Fig. 5 A large flat firm pillow may be placed between the table and the head and neck of a client. Often this pillow is best placed also under the superior aspect of the scapulae near the supraspinatus. The pillow is placed such that the forehead is parallel with the table. Often in this position there is an initiation of release of tension across the clavipectoral fascia as well as the scalenes and posterior cervical muscles. Many headaches may be relieved with ergonomic advice regarding pillow type and placement. As relaxation deepens the underlying sternocleidomastoid bellies soften and often the sternum will lift during inspiration. The mimetic muscles of the face generally are reliable indicators of the presence of absence of relaxation. Many signs may be observedjust in the region of the eyes. Eye blink rate; speed and force of lid closure may indicate the degree of inner composure.
Fig. 4 In this position (padded blocks such as these are used in chiropractic for SacroOccipital Technique) may be placed under the pelvis and/or the lower back (A) Suitable sites include the posterior superior iliac spines; the gluteus medius posterior belly; the gluteus maximus and the greater trochanter. For example, the lumbar lordosis may be reduced by tilting the pubic arch superiorly with blocks placed as in the picture. Another example would be an asymmetric block placement to level the heights of the anterior superior iliac spines from the table surface. There are any number of vectors which may be used.
similar way, the pronated forearms in the supine client may relax to allow the distance from the wrists to the table surface to decrease. The same process of relaxation may be observed of the posterior deltoids, the gluteal muscles as well as the lateral thigh, and calf muscles as the hip rotators release their tension.
Fig. 6 A cervical round pillow may be placed with or without the large flat pillow. Often shearing of the middle cervicals is prevented by this prop and a comfortable mild long axis extension passive traction may be evoked along the cervical spine.
2. Breathing The necessity of breath makes it the most valuable method of assessing repose. One may judge a client' s relaxation by observing or palpating which portions of the body are passively moved by the act of breathing. This process of assessment may be compared to a series of snapshots that make up an animation. Each still picture provides information but the animation's value is far greater than its parts. You might
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B
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Fig. 7 Shoulder wedges may be used to lift the shoulder, either at the glenohumeral junction (A) or under the scapula itself (B) (lifting both the glenohumeral junction and the scapula). Often this propping will allow chronic contraction of muscles to be released.
observe a trend by watching the behaviour over time; this could be confirmed with reference to the stills. Faced with a film of a metronome, we could determine the amplitude of the pendulum by reviewing certain key still frames. If we were practised, we might even be able to gain that information without stopping the film. The skill in observing and palpating the cyclic movements of the breath are similar to that of observing a metronome, except that the pendulum of the breath potentially moves in a multiplicity of directions and is instantly mutable. The ribs may rise and fall in one trajectory only to change in the next breath. If a client raises an arm while otherwise being still and supine, an observable change in the trajectory of the ribs will be seen. If an observer mentions this change to the client, often yet another breathing change will be seen. This last change brought about by nothing more than the observer's comment.
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Folded blank
Shoulders droop
Fig. 8 Support may be placed interscapularly using a coarse wool blanket. The blanket is folded accordion-like to a compressed height of one or two hand widths. The blanket just fills the space between the two scapula from the crown of the head to the sacral base. Additional pillows are arranged to support the neck and the head with the forehead parallel to the floor. The blanket opens up the anterior chest and allows the scapulae freedom, as they dangle in space, to explore new directions of movement. This prop may be used to good effect with those who are chronically unable to depress their scapular girdle as well as for those who have both anterior head carriage and anterior shoulder carriage.
It is recommended to first observe the breath before palpating, since the act itself of palpation may change the pattern. It is also recommended that this observation be carried out long enough that the observer gains such a strong sense of the breathing pattern that it becomes predictable. In other words, the observer would be able to describe, in advance, the time of inhalation and exhalation as well as the pattern and amplitude of breathing. This may take only a few breath cycles or even minutes depending upon the client. With experience, an obs6rver is able to maintain awareness of the changing breath in their sensory background while other therapeutic duties are attended to. This contemplates that the breath is observed for its period and amplitude
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as well as subtle distinctions such as the individual trajectories of the ribs. It is even possible to entertain hypotheses such as the apparent site of the initiation of inhalation (where the breathing appears to start from), and update these hypotheses during each breath cycle. If the client's attention is directed to their breathing, they often are unable to verify that they are 'holding their breath'. They may deny the assertion pointing out that they are indeed breathing. Often, their only distinction is binary; either the thorax is sealed off at both its bottom and top ends (such as with the bearing down effort associated with defecation), or the person is breathing. At this point it may be useful to explain the concept of the quality of breath. The ideal breath uses the least effort without compromising
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effectiveness. The lungs complete their gas transfer such that the blood is well rejuvenated with a minimum of muscular activity. A sufficiently strong and mobile respiratory system has the capacity to be effective and efficient in this way in a multitude of postural positions. For example, quite different demands are placed upon the system when side-lying compared to standing while side-bending. Another example is the difficulty many people have breathing, in an easy fashion, kneeling with their head lower than their sacrum. Those of the Islamic faith, praying in this position many thousands of times, might find breathing quite easy in this posture. But, even these faithful might be challenged in obtaining an ideal breath if they were asked to simultaneously kneel and side-bend. Despite these typical stiffnesses of most adults, we need look no further than any healthy infant for instruction in how an ideal breath appears in all of these positions. The diaphragm is an unusual muscle; when unencumbered by adverse muscular tension, it powers chest movement in all three spatial dimensions. An infant sleeping in repose provides an example; close observation of the child reveals the chest wall rising and falling. Further observation allows distinctions to be made of the various movements occurring simultaneously. In the absence of physical constraints such as binding clothes, the chest will be seen to spread forward, backward as well as to both sides. In addition, the upper chest rises and the abdominal contents are displaced downwards. During inhalation the chest is stretched in all three dimensions as if having a balloon inflated inside the basket of ribs. Restrictions applied to the chest hamper this expansion; an example for the recumbent child is the surface they are lying on. The weight of their chest settling upon the surface restricts movement downward into the surface. Other restrictions come to mind, the binding of tight clothes sizes too
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Fig. 9 Here the knees are supported without a prop but as if the pillows used in Fig. 3 were in place. To support the bent knees in repose requires the bones of the lower extremity to be aligned. The knees are wider than the hips with the knee, ankle, medial foot and hip in a straight line. In this alignment, the skeleton supports the knee without muscle involvement from the thigh or calf. The limb hangs from the skeletal elements of the lower elements. The use of props mentioned in this paper is similar to using training wheels on a child's bicycle; the extra wheels are removed once stability in motion is achieved.
Fig. 10 On the side, pillows may be placed between the knees and lower legs such that the muscles of the thigh are relaxed and the lower extremities are approximately parallel although flexed at the knee. This prop placement is well tolerated for long periods of time; many people (pregnant women, those with hip arthritis, wasting of the thigh muscles), will prefer to use pillows such as this while sleeping on their sides.
small, belts and sashes tightly cinched. As adults, one has only to notice the sound and feel of one's own breathing while stooping from the standing position (as if to tie shoelaces), to feel the restrictions potentially brought about by the binding of clothes and positional constraints. Many teachers promote an ideal way to breathe, but it is more likely that there is no one universal ideal of breathing. Instead, for each person and for every activity there are many ways to breathe satisfactorily (Feldenkrais 1972). What may be more valuable clinically is skill in determining if the breath expands with equal effort in all directions. Let us visualize a set of lungs as balloons inside a basket, let us further specify that the basket is woven of ribs that are both resilient and compliant (think of freshly cut reeds). Sufficient inflation of the batloons will bring about an expansion of the woven reeds as the balloon surfaces expand. If all the reeds are similar in their resistance to bending, the expansion will be equal in all directions just as a balloon of equal thickness would expand spherically. If we substitute a clay pot for the basket, we see that expansion will be stopped once the balloon expands to fill the pot's interior. The value of this oversimplification of the respiratory structures may be in realizing that unremitting activity of the many muscle layers attached to the ribs may impair the resilience and compliance of the thorax. When we palpate the chest wall we may encounter rigid clay-like resistance rather than the flexibility of reeds.
3. Perturbation Fig. 11 In this side-lying position the forearm is placed such that the middle of the forearm is placed so that it is balanced on the fulcrum created by the midaxillary line of the ribcage. This allows the muscles of the shoulder girdle, specifically the brachialis and biceps muscles, along with the triceps and rotator cuff to be relaxed along with the latissimus dorsi and the serratus anterior. Often this allows deeper lateral excursion of the breath which further relaxes the shoulder muscles. Use this position only for a few minutes at a time since many people have slight shoulder is stability combined with muscle imbalance. This often leads to asymmetric loading of the involved joints, which may tug at the pressure-sensitive layers of the affected joint capsules.
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Movement during treatment can be divided into that performed by the client and that imposed upon the client. This has been codifed as active and passive movement. Quality of motion, although difficult to describe in an unequivocal manner, is an excellent way of determining the
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Figure 12 A large pillow may be suggested to people with lower back pain. The arms are arranged allowing their arm and legs to be supported and with their limbs parallel to each other. Often a lower back release and a deeper abdominal breath will be obtained. This effect is maximised if the client is instructed to notice the moment their belly pushes into the girth of the pillow while simply breathing normally. The mental effort of selfobservation often will distract them long enough for this novel, for most people, position to act on the excess muscle activity.
Figure 13 A fetal curve may be useful in obtaining deeper breathing and relaxed deep spinal intrinsic muscles along the length of the spine. The procedure is completed in three stages. In the first stage the client is instructed to flex into a fetal curve; often you notice that they have minimal flexion at both the junctions of the neck to the trunk and the spine to the pelvis. Second stage involves passively pulling on their belt so their spine is placed into a greater kyphosis with the apex at the lower thoracic spine. The last stage is to bring the entire upper body into more flexion. As a unit, the head and shoulders are pulled into a fully tucked and comfortable position. This position is usually tolerable for long periods of time. If the person resists being placed into this position, either by active muscle activity or through the passive lack of elongation of their fascia and ligaments, respect their reluctance and only apply this fetal curve to a minor extent. The great value of observing accurately breath changes allows a clinician to adapt the posture or prop for greatest effect. Too much stretch will provoke stiffness and/or pain, sometimes delayed. Too little stretch fails to encourage repose. In either case, an experienced observer will adjust the extent of the posture or prop's effect to quickly bring about a relaxed breath knowing that muscular repose will follow.
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Use of props to encourage repose
normal response, a person unable to relax is often unable to avoid excessive muscular reactions to passive jostling of their body. Even slow, gentle lifting can evoke not only active lifting of the limb but also a generalized increase in muscle tone, a change in breathing, speech and eye movements consistent with increased levels of alertness. It may be speculated that this excessive arousal may lead to sleep disorders. This state of muscular vigilance fades often when a person's muscle tone relaxes; then, provoking a startle response becomes more and more difficult using gentle shaking or other perturbations. Figure 14 Here pillows are arranged in the armpit and under the arm and forearm. The arm is passively abducted and slightly flexed. The aim is to induce a relaxed dependency of the arm and forearm upon the pillows and tabletop. This position is generally tolerated for 15 minutes or more; care must be made to comfortably stretch the arm from the shoulder socket and then arrange the limb upon the pillows without sacrificing.
extent of repose. A person in repose safely tolerates gentle, slow passive movements without adding his or her own muscle activity. They allow their limbs to be towed through space. A client bedeviled by adverse muscle tension will be unable to release their muscles and therefore they will resist even the most gentle of passive movements. Often it shocks them to discover that they are able to sense their previously unconscious muscular shadowing of every passive movement. Just as shocking may be the difficulty in changing this pattern of unnecessary muscle activity. Frequently 'startle responses' are provoked in the course of perturbations. As a person's level of neurological alertness drops, their muscular reaction to stimuli may become muted. When a person is sleeping, one says they are in a deep sleep when one is unable to rouse them with shaking. In distinction to this
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Conclusion Inducing relaxation in the recumbent client may provide a hotbed of tranquility from which greater potency of movement may arise. To this end, props may be useful in treatment. Encouraging repose reduces muscular resistance and, with little commotion, it may also increase sensitivity to previously indiscernible processes of thoughts, sensations and emotions. A prop imposes a still fulcrum around which chronically tense tissues may relax, encouraged by the ebb and flow of breathing and circulatory rhythms. The stillness of the prop acts as an invariant pressure and position stimulus, which may be used by the client's nervous system to orient itself spatially and with respect to gravity. In addition, it is speculated that the perception of relaxation may 'reset' a kinesthetic threshold. If so, the client may learn to relax areas such as the spinal curves or the shoulder or hip regions. It is further speculated that the repetitive experience of such releases of muscular tension may aid the learning of generalized selfrelaxation throughout the locomotor system. Normal alignment of the skeleton allows a feeling of weightlessness; the arrangement of bones securely
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supporting the w e i g h t o f the body in such a way that almost all m u s c u l a r effort is u n n e e d e d in maintaining a posture. A b a l a n c e d l i m b or trunk so loaded requires m u c h less m u s c l e action than one w e i g h t e d d o w n with persistent and unnecessary m u s c l e tension. T h e kinesthetic sense m e a s u r e s differences in strain rather than variations in w o r k output, but it m a y b e c o m e habituated as any other sensory input. M a n y p e o p l e h a v e lost the ability to m a t c h their m u s c u l a r p o w e r to the task at hand. W e e x p e c t to take time to learn the n o v i c e unicyclist the necessary coordination. M a n y o f our clients w h o are unable to relax lie stiffly u p o n out tables, s w a d d l e d in bands o f superfluous m u s c l e tension. T h o s e are the p e o p l e w h o lie on our treatment beds like
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lumps o f clay. R e g a i n i n g delicacy in m a t c h i n g effort to task is an important m i l e s t o n e in the e m a n c i p a t i o n o f a client f r o m treatment; it demonstrates self-reliance arising out o f selfawareness. Feldenkrais described this as: ' I f you k n o w what you are doing, you can do what y o u want.'
REFERENCES Chaitow L 1996 Are skilled manual practitioners and therapists artists or technicians or both? Journal of Bodywork and Movement Therapies 1(1): Feldenkrais M 1971 Unpublished audiotape transcript of a September week-long seminar at Esalen, California Feldenkrais M 1972 Awareness through movement. Harper and Row, New York, p 162-71 Hannon J 1998 The Man who mistook his patient for a chair. Journal of Bodywork and Movement Therapies 2(2): 88-100
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Iyengar BKS 1991 Unpublished notes of a seminar on the medical uses of yoga presented at University of California, San Diego School of Medicine Janda V 1985 Pain in the locomotor system - A broad approach. In: Glascow EF, Twomey LT, eds. Aspects of manipulative therapy. Churchill Livingston, Melbourne, p 149 Levine S 1997 The importance of soft tissues for structural support of the body. In: D'Ambrogio KJ, Roth GB, Positional release therapy. Mosby, St Louis, (vii):243-244 Lewit K 1991 Manipulative therapy in rehabititation of the locomotor system. Butterworth Heinemann, Oxford, p 143-144 Minsky M 1986 The society of mind. Simon and Shuster, New York, p 57 Shafarman S 1997 Awareness heals: the Feldenkrais method for dynamic health. Addison-Wesley, Reading, p 48 Travell J, Simons D 1983 Myofascial pain and dysfunction vol. 1. Williams and Wilkins, Baltimore, p 65-66
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