What can you do for your work by looking—really looking—at your client? A lot. Ida Rolf said, “Seeing is touch at a distance,” and you can use your vision as a way of pre-feeling into any old dings in your clients’ frames, any hitches in their functional “git along,” and even subtleties of their psychological approaches to life. This information can guide your strategies, shorten your guesswork, and make your sessions twice as effective via the integration of your unwinding.
We are going to unfold this BodyReading approach as a series in this and subsequent issues, including a set of practical webinars for developing these skills. Now, you already have a lifetime’s experience of making these visual assessments—you can recognize a friend from a couple of blocks away, long before you see his or her face, just by the movement pattern, can’t you? Sure you can, so it’s just a matter of putting your native visual-kinesthetic skills to work for you.
But we need to put a strong logical foundation under those intuitive skills, so let’s get serious for a bit.
Many forms of structurally oriented manipulation, including the method of Structural Integration put forward by Dr. Ida Rolf or our version, Kinesis Myofascial Integration or KMI (www.anatomytrains.com/kmi), use an analysis of standing posture or gait as a guide in forming a treatment strategy. Chiropractors, physiotherapists, soft-tissue practitioners, and movement educators such as Alexander, yoga, and Pilates teachers have used various grids, plumb lines, and charts to help assess the symmetry and alignment of the client (Image 1, page 77).1
Our approach favors the inter-relationships within the person’s body, rather than his or her relation to anyone else or a platonic ideal like a line or a grid. For this reason, the photographs we use are devoid of such outside reference, except, of course, the line of gravity as represented in the orientation of the picture.
Global Postural Assessment
An easy upright alignment within the strong and shadowless gravitational field of the earth is inescapably a benefit to health. The advisability, however, of compelling left/right symmetry or even a straight posture on a client is far more dubious. Alignment and balance are dynamic and adaptive, not static and fixed.
The goal in making such an analysis is to understand the pattern, or story if you will, inherent in each person’s musculoskeletal arrangement—insofar as such a task is possible using any analytical method. Using what we show you here merely to identify postural faults will severely limit your thinking, the client’s empowerment, and the longevity of the results.
Once the pattern of relationships is grasped, use any treatment method available to resolve or unwind the entire pattern. The idea is to assist the client in the process of “growing out of the pattern,” not to impose symmetry or a particular ideal. As people resolve these patterns, they more closely approach a natural balance, which amounts—with allowance for different muscle fiber types and fascial densities—to an evenness of tone throughout the entire myofascial system. Accompanying this even tone comes anecdotal evidence of increased length, ease, generosity of movement, and adaptability in both somatic and psychosomatic terms.
Here, we offer a leg-up to the five-step method of structural analysis we use in the KMI Structural Integration school, in hopes that it will aid in forming your own successful strategies, whatever your modality. This system is designed to be simple, consistent, nonjudgmental, and easy to learn (though practice does help).
The five steps are 1.) a description of the skeletal geometry, 2.) an assessment of the soft tissues creating or maintaining that position, 3.) the development of an integrating story that accounts for as much of the overall pattern as possible, 4.) the development of a short- and long-term strategy to help resolve the undesirable elements of the pattern, and 5.) evaluation and revision of the strategy in the light of observed results and palpatory findings.
Only the first step—a map of skeletal positioning—will occupy us for this article.2 In subsequent articles and webinars, we will apply the second and third step, using the Anatomy Trains Myofascial Meridians as a map to soft-tissue patterning around these skeletal imbalances.3 Steps 4 and 5 are method-specific and are taught in our classes, or via our self-study videos.
A Positional Vocabulary for the Skeleton
In order to define the position of the skeleton in space, let us use a simple, intuitive, but unambiguous language, which has the advantage of making sense to (and thus empowering) clients, students, and patients, while being capable of bearing the load of sufficient detail to satisfy the most exacting practitioner. It has the disadvantage of not conforming to standard medical terminology, (e.g., protraction, varus and valgus knee, or a pronated foot), but, since these terms are often used in contradictory or imprecise ways, this disadvantage may prove an advantage.
Our terms describe the relationship of one bony portion of the body to another, or occasionally to the gravity line, horizontal, or some other specified outside reference. The four terms employed are: tilt, bend, rotate, and shift. These terms are modified with the standard positional adjectives: anterior, posterior, left, right, superior, inferior, medial, and lateral. These modifiers refer to the top or the front of the named structure. In other words, in a left tilt of the head, the top of the head would point to the left. In a left rotation of the rib cage relative to the pelvis, the sternum would point more left than the pubic symphysis (while the thoracic spinous processes might have moved to the right in the back). This use of modifiers is, of course, an arbitrary convention, but one that makes intuitive sense. Right and left always refer to the client’s right and left.
One strong advantage of this terminology is that these terms can be applied in a quick, overall sketch description of the posture’s major features, or used very precisely to tease out complex spinal, intra-pelvic, shoulder girdle, or intertarsal relationships. For this article, we are going to stick to the more obvious and visible problems; the more complex relationships are best taught in a class. We have included a few diagrams, but we strongly recommend that you learn the terms and test the patterns by putting your own body into the suggested positions.
Compared to What?
Because the terms are mostly employed without reference to an outside grid or ideal, it is very important to clarify exactly which two structures are being compared. To look at one common example that leads to much misunderstanding, what do we mean by “anterior tilt of the pelvis”? Imagining that we share a common understanding of what constitutes an anterior tilted pelvis (and there is really not a shared definition for pelvic neutral), we are still open to confusion unless the question, “Compared to what?” is answered. If we consistently compare the tilt of the pelvis to the horizontal line of the floor, for instance, this reading will not lead us to useful treatment protocols of femur-to-pelvis myofasciae since these tissues relate the pelvis to the femur, not the ground. Since the femur can also be commonly anteriorly tilted, the pelvis can easily be anteriorly tilted compared to the ground, while at the same time being posteriorly tilted compared to the femur. Or, a pelvis can be posteriorly tilted when compared to the femur, but anteriorly tilted when compared to the rib cage (see Image 1C). Both descriptions are accurate as long as the point of reference is agreed.
To create this common pattern, let your pelvis shift forward over your toes, but scrunch your butt muscles to posteriorly tilt the pelvis and lean your chest back a bit over your heels. Look at yourself sideways in the mirror. Your pelvis may look anterior tilted, but it is really those posterior tilters—the deep lateral rotators—that need a break.
Let’s define the terms and then put them to use:
Tilt. This describes simple deviations from vertical or horizontal, in other words, a body part or skeletal element that is higher on one side than another.
Tilt is modified by the direction to which the top of the structure aims. Thus, in a left tilt of the pelvic girdle, the client’s right hip bone would be higher than the left, and the top of the pelvis would lean to the client’s left (Image 2). An anterior tilt of the pelvic girdle would involve the pubic bone going down relative to the posterior spines. In a posterior tilt of the head, the eyes look up, the back of the head approaches the spinous processes of the neck, and the top of the head points posteriorly.
Tilt is commonly applied to the head, shoulder girdle, rib cage, pelvis, and tarsum of the feet. Tilt can be used for a broad sketch of the client’s pattern, such as “a right tilt of the ribs relative to gravity” or “a medially tilted foot” (instead of a pronated foot). But this language will also support very specific intersegmental analysis: “an anterior tilt of the left scapula relative to the right,” “a posterior tilt of the left inominate bone relative to the sacrum,” “a right rotation of T11 on T12,” or “a medial tilt of the navicular on the talus.”
Once again, for clarity in communication and accuracy in translating this language into soft-tissue strategy, it is very important to understand to what the term being used is related. An “anterior pelvic tilt relative to the femur” is a useful observation: a simple “anterior pelvic tilt” opens the door to confusion.
It has taken a number of words to formally describe a tilt—but it is a simple concept, and easily understood on a common level.
Bend. This refers to a series of tilts resulting in a curve, usually applied to the spine, but occasionally also applicable to the legs. If the lumbar spine is side-bent, this could be described as a series of tilts between each of the lumbar vertebrae, which we usually summarize as a bend, which can, like a tilt, be to either left or right side, forward, or back. Image 2A has a right bend of the lumbar spine; Image 2B has a posterior bend of both lumbar and cervical areas.
The normal lumbar curve thus has a posterior bend, and the normal thoracic spine an anterior bend. A lordotic spine could be generally described as a “strong posterior bend in the lumbars,” or could be specified in more detail: “the lumbars are strongly posteriorly bent from L5–S1 to about L3, but show an anterior bend from L3 to T12.”
This kind of observation allows a grounded logic to apply to our assessments. If we see the rib cage tilted off to the left, we can presume that either 1. the pelvis is likewise left-tilted, or 2. the lumbar spine has a left side bend. Further, spinal mechanics dictates that the left bend in the lumbars very likely involves a right rotation of some of those vertebrae involved. Et voilà, we have a strategy for undoing the pattern: the left psoas and quadratus lumborum are going to figure high on our list of keys to the solution.
But that’s jumping into step 2; let’s continue with our definitions.
Rotation. In standing posture, rotations occur around a vertical axis in the horizontal plane, and thus often apply to the femur, tibia, pelvis, spine, head, humerus, or rib cage. In singular structures, such as the rib cage or spine, the rotation is named for the direction in which the front of the named structure is pointing. For instance, in a left rotation of the head (relative to the rib cage), the nose or chin would face to the left of the sternum (Image 3A).
Notice that, if the rib cage were left rotated relative to the pelvis, the head could be right rotated relative to the rib cage and still be neutral relative to the pelvis or feet (Image 3B). This situation is quite common, as most people have rotations in their spine, but most people still prefer their eyes going in the same direction as their feet—so rotations often come in twos.
In paired structures like the arms and legs, we use medial or lateral rotation. While this is in common use in regard to femoral or humeral rotation (in other words, a medially rotated femur is, in our language, exactly what you think it is), we extend this vocabulary to all structures.
What physiotherapists commonly call a “protracted” scapula would, in our vocabulary, involve various amounts of lateral shift, anterior tilt, and medial rotation—thus “protracted” is simply not an exact enough term on which you can build an effective soft-tissue strategy. The amount of medial rotation—in other words, how much are the points of the shoulders pulled toward each other in the front—will dictate where we might look for a soft-tissue solution.
Shift. This broader, but still useful term for displacements of one center-of-gravity relative to another: right-left, anterior-posterior, or superior-inferior (Image 4). Shifts may or may not involve a tilt. Balinese dance involves a lot of pure head shifting—side-to-side movement while the eyes stay horizontal. “A right shift of the head over the rib cage” means that the center of gravity of the head is to the right of the center of gravity of the ribs. “A posterior shift of the rib cage relative to the pelvis” means that the rib cage has dropped back over the pelvis (and thus more weight is directed down through the sacroiliac joints)—a pattern commonly seen in the models that grace the fashion pages.
Shifts of the rib cage or pelvis, of course, can commonly involve tilts, bends, and most often rotations of individual vertebrae as well. We can use our terminology to specify these particular relationships when called for, but we have found that “left shifted rib cage” or “the head is shifted to the right relative to the pelvis” to be a useful shorthand.
The mobile scapula is commonly shifted in any of the six modifying directions. The pelvis is commonly described as being anteriorly or posteriorly shifted relative to the ankles, with the understanding that some tilts must occur along the way for that to happen.
Putting It To Use
This intuitive terminology requires only two or so hours of practice to manage, and only a couple of weeks of regular use of the notation for reasonable facility with the process. In practice, it becomes a matter of one or two minutes to perform and note down what you see. Of course, more usual language such as “fallen arches” or “pronated feet” can be used when they meet the needs of the moment, but reversion to this BodyReading terminology can be used for argument or simple accuracy to resolve ambiguity.
Once the skeletal geometry of the client’s standing, resting posture has been described to the satisfaction of the practitioner—and we are going to practice this for the rest of this article—we would proceed to step 2.
Step 2 is to see how those skeletal relationships might have been created or are being maintained by shortness in the soft tissue. Individual muscle shortness might be responsible, or feel free to use some other way of analyzing the soft-tissue patterning. The Anatomy Trains Myofascial Meridians represent one such model (one we are prejudiced toward and will be using in subsequent articles and the webinars) but other available models could be employed as well.4 If you can see the skeleton clearly in the body, you also can make up your own soft-tissue strategies and apply them.
It is very important to note here that there is no virtue involved in having a symmetrical, balanced structure. Everyone has a story, and without doubt the most interesting and accomplished people with whom I have had the pleasure and challenge to work have had strongly asymmetrical, unbalanced structures. In contrast, some people with naturally balanced structures face few internal contradictions, and as a result can be a bit bland and less involved.
Assisting someone with a strongly challenged structure out of his or her pattern toward a more balanced pattern does not make them less interesting, though perhaps it will allow them to be more peaceful or a better performer or less neurotic or to carry less pain. Just, at this juncture, let us be clear that we are not assigning any ultimate moral advantage to being straight and balanced. Each person’s story, with so many factors involved, has to unfold and resolve, unfold and resolve, again and again over the arc of a life. It is our privilege as manual therapists to be present for, and midwives to, the birth of additional meaning within the individual’s story.
In practice, a couple of steps precede the skeletal analysis. First, take note of your initial impression when you first cast your eyes on your client. You have a lifetime of first impressions in your experience box, and this is an important moment.5 Notice what you notice—it will come in handy later.
Secondly, don’t just look for the faults, but take note of the strengths your clients bring to the process as well. I assure you, many more things are going right than are going wrong. Are they well-toned, basically right-left symmetrical, or have a twinkly attitude? Great. Take note of the advantages they bring, as well as the problems. These are resources clients bring, and aspects you can employ to help. At the very least, it tells you the good parts that don’t need work.
And finally, a note on method: when you first start this, it is easiest for you to see when standing in front of semi-clothed clients and having them turn to show you their front, sides, and back. But understand that this can be very confrontational, especially in this culture where we are judged and found wanting if we don’t measure up to the cover of Allure or Men’s Health (and none of us do).
You can take the sting out of this process—and turn it into an involving piece of client education—by standing them in front of a full-length mirror. Stand behind and to the side of clients, so you can see their image in the mirror, as well as seeing them. Right away, you are on their side, and you are both looking in the same direction, at that person in the mirror. This makes it much easier for you both right away.
Gently lead clients through their strengths first, “See how open your chest is,” or “You feel very grounded.” Then you can guide them into some of the aspects you hope to correct: “Can you see one shoulder is higher than the other?” and let that guide you into the other details. Most clients start by being reluctant to look at themselves, and they have a long list of things they don’t like, but many get fascinated when they start seeing these structural asymmetries, especially if they are introduced to them with the nonjudgmental language we have just set out.
Let’s practice the basic assessment vocabulary on some real people: (You can cover the analysis below each picture with your hand to see what you see before you read what we have written. These analyses only point out a few of the more obvious patterns in each photo.)
The best way to build these skills is to practice on your clients or friends, via looking at them or through photos if you take client photos for your records. In developing this talent, go for the obvious anomalies; if you have to get out your micrometer to measure the differences between one hip and the other, it probably is not a significant functional problem, so let it be.
Next time, we will include some refinements to these basic skills, and start taking our analysis into the soft-tissues.
Thomas Myers is the founder of Anatomy Trains. He studied with Drs. Ida Rolf, Moshe Feldenkrais, and Buckminster Fuller, and has practiced integrative bodywork for more than 30 years in Europe, the United Kingdom, and the United States. He incorporates many movement and manual disciplines in his work. For more information, visit www.anatomytrains.com.
Notes
1. Judith Aston, Aston Postural Assessment Workbook (San Antonio: Therapy Skill Builders, 1998). W.H. Sheldon, The Varieties of Human Physique (New York, New York: Harper & Brothers Publishers, 1940). Stanley Keleman, Emotional Anatomy (Berkeley, California: Center Press, 1985). R.M. Alexander, The Human Machine (New York: Columbia University Press, 1992).
2. M. Morrison, “Structural Vocabulary,” Rolf Lines (Winter 2001).
3. Thomas Myers, Anatomy Trains (Edinburgh, United Kingdom: Elsevier, 2009). This book also contains an expanded version of this method with a number of examples.
4. J. Sultan, “Toward a Structural Logic—The Internal-External Model” Notes on Structural Integration 86:12–18, 1986. (Available from Dr. Hans Flury, Badenerstr 21, 8004 Zurich CH). Stanley Keleman, Emotional Anatomy (Berkeley: Center Press, 1985). Judith Aston, Aston Postural Assessment Workbook (San Antonio: Therapy Skill Builders, 1998). Leopold Busquet, Les Chaines Musculaire, Tome 1–1V; Freres, Mairlot, Maitres et Cles de la posture. 1992.
5. Malcolm Gladwell, Blink: The Power of Thinking Without Thinking (New York: Back Bay Books, 2007).