Which way is up? It is such a simple question, but with such large implications. When you are upright, your body orients itself to gravity and to your surroundings, trying to keep your eyes and head level. This sense of “up” provides a point of reference for all balance, movement, posture, and position.

An even more important question might be, “Which way is down?” Having a stable, trustworthy base of support is one of the body’s prerequisites for a state of ease. Imagine trying to stand upright on top of a teetering stepladder—what happens in your body? Do you tighten, stiffen, or clench? This involuntary gripping reaction is triggered, to a greater or lesser extent, whenever your body senses instability or disrupted equilibrium. A neck affected by whiplash, an unstable ankle, or a painful sacrum are just a few examples of the many conditions that can throw off our body’s fundamental sense of stability and orientation.

Equilibrium is, of course, a whole-body phenomenon; for the purposes of simplicity, I’ll focus in this column on the vestibular system, which is the single greatest contributor to your body’s sense of balance.

Together with the cochlea, which is the sense organ of hearing, the vestibular system constitutes the labyrinth of the inner ear. Arising from the ectoderm—the same embryonic layer that gives rise to the nervous system, eyes, and skin—the inner ear is the first sense organ to form in the embryo. By six to eight weeks after fertilization, an embryo has developed the inner ear’s semicircular canals, making the sensation of movement our earliest sensory experience.

The vestibular system detects head movement; the central nervous system then uses this information to coordinate body and eye motions. Through its remarkably geometrical arrangement of three interconnected, fluid-filled semicircular canals in each ear, the vestibular system can detect movement in any of the three ordinal planes.

The vestibular system detects two types of motion: rotational and linear. Rotational motions of the head (such as turning from side to side, tilting, looking up, or nodding) cause fluid in the semicircular canals to rush by specialized mechanoreceptors called the ampullary cupulae, which are embedded with sensitive, hair-like cells. Depending on which way they’re bent by the fluid, these hair cells either open or close ion channels in their corresponding nerves, transducing the fluid’s motion to a nerve impulse, which is processed in the brain. Linear motions, such as an elevator dropping or an airplane taking off, are detected by other hair cells elsewhere in the inner ear, which sense the inertia of embedded calcium carbonate crystals called otoliths.

One common form of persistent dizziness or vertigo (benign paroxysmal positional vertigo, or BPPV) is thought to be caused by these otoliths (sometimes known as “ear stones”) working free and tumbling to parts of the semicircular canals where they are not usually found. This overstimulates the hair cells in those areas, and floods the brain’s processing centers with unexpected, random signals. There are other possible causes of vertigo—some of which require medical care—so persistent, unexplained vertigo is sufficient reason to refer your client to a physician for evaluation. (For more information about BPPV and exercises for its self-management, search the web for “Epley’s exercises” or see Ruth Werner’s column “Benign Paroxysmal Positional Vertigo,” Massage & Bodywork, July/August 2010, page 99, available at www.massageandbodyworkdigital.com/i/68175/99).

Vertigo is not the only reason we should include the vestibular system in our thinking. Even small amounts of vestibular input can have significant effects in the body. Many studies have linked vestibular stimulation to sympathetic (fight-or-flight) autonomic nervous system activation and physical reactions such as higher blood pressure, respiratory changes, and increased muscular tension throughout the body.1

Vestibular disquiet can also trigger body-mind reactions. Moshe Feldenkrais, a body therapy pioneer, postulated that humans begin their process of growth and learning with just one built-in purpose: the fear of falling.2 His contemporary and colleague, Ida Rolf, the originator of Rolfing structural integration, is purported to have said, “Ninety-five percent of all neurosis is the fear of falling down.” Though both of their statements were probably more hyperbole than substantiated fact, the underlying point is valid: our physical functioning—in this case, the functioning of our vestibular system—strongly influences our psychology, emotions, and inner state.

In hands-on work, we can use this body-mind relationship to our advantage. When disturbed, the vestibular system causes sympathetic fight-or-flight activation, anxiety, tension, and unrest. Change in the opposite direction is possible, too: when soothed, supported, and steadied, the vestibular system can trigger a palliative, quieting, relaxing, and calming response instead.

Vestibular Orienting Technique
Because of its power to relax and calm, the Vestibular Orienting Technique is useful in the initial, preparatory phases of most manual therapy sessions; when working with stress; in most cases of “hot” whiplash (see “Working with Whiplash, Part 1,” Massage & Bodywork, March/April 2010, page 108, available at www.massageandbodyworkdigital.com/i/68173/109); and when working with vertigo itself, as it is a simple and effective way to assess and reduce vestibular hypersensitivity and disturbance when done with care (see the special considerations below).

Begin the technique by slowly lifting your client’s head while gently flexing the neck. If your client suffers from vertigo, neck pain, or hot whiplash signs (spasm, guarding, or pain), ask him or her to keep her eyes open, and lift the head slowly enough to avoid triggering any dizziness or pain. If your client’s dizziness or pain is acute, you may be able to lift only half an inch, but in most clients, you’ll be able to slowly take the chin to the chest without causing discomfort or guarding. A large amount of cervical flexion is not the goal; focus instead on sensing your client’s comfortable limit.

Be sure you are very comfortable in your own body, as well. Your ability to stay relaxed and extremely stable will be key to the effectiveness of the technique, as you’ll be holding your client’s head up for several minutes. If your client is much larger than you, or has a particularly heavy head, you’ll need to experiment with hand and body positions to find variations that work for you. Although I typically use the hand position pictured in Image 6 (seated with one hand under the head, forearm on the table, and my elbows close to my sides), some practitioners find it easier to stand, cross their arms behind the client’s head with hands palm-down, right palm on the client’s left shoulder and left palm on the client’s right shoulder, and lift using their legs and body, rather than just the arms.

Whatever your position, make sure your supporting point of contact is physically beneath your client’s head. The supporting sensation of touch on the back of the head feels reassuring and safe, and this will help encourage release and relaxation.

Once both you and your client are comfortable in this lifted-head position, begin to gradually lower the head, ever so slowly, bit by infinitesimal bit. At this point, we come to the most important part of the technique: as you lower the head in super-slow motion, feel for your client’s ability to let the head go, every millimeter of the way. If you’re sensitive and slow enough, you’ll feel small variations in the perceived weight of your client’s head along the way. If your client’s head seems to get lighter, it means you’re lowering faster than his or her ability to release; stop, back up a millimeter, and wait for your client to surrender the head again.

Avoid casual chatter or other talking that might distract your client; however, verbal cues that help him or her focus can be invaluable. If you wait for a while with no release, try a gentle verbal prompt: “Just allow your head to be heavy,” or “On your next exhale, let your head release a little more.” Asking for small, slow, active eye movements or conscious exhaling can also help when release is difficult.

Effects on the Vestibular System
Though it requires patience and sensitivity, this technique is procedurally very simple. So, how does it affect the vestibular system? The head and neck’s orienting reflexes are initiated by vestibular signaling. The small fluctuations in your client’s ability to let the head go are signs that his or her vestibular system and brain are renegotiating the habitual muscle tension related to orienting and righting the head. Your super-slow head lowering provides just enough rotational stimuli to evoke a vestibular response. The positions where you feel your client subtly stiffen may correspond to angles and positions where the inner ears’ semicircular canals are hypersensitive, or where they might be habitually accustomed to raising the “bracing needed!” alarm.

Waiting or subtly backing up in the places where you feel this slight stiffening allows a client’s nervous system to accommodate a new threshold of activation. By waiting and relaxing into each place where the slight stiffening starts, your client’s nervous system increases its adaptive range. This resets the stimulus thresholds that usually result in bracing. Your client’s nervous system is also being reminded that everything is OK; nothing bad happens in this position—the head does not fall off, get whipped around, experience pain, or any other subconscious catastrophic expectations  that may be coupled with particular head and neck positions. Of course, not everyone’s neck bracing is related to body memories of physical trauma; sometimes, it’s simply hard to let the head go. Tension, stress, eye or jaw strain, postural habit, illness, or, as described earlier, support or stability deficits elsewhere in the body, can all contribute to vestibular reactivity and bracing patterns.

As mentioned, this technique can often help clients who have preexisting dizziness or vertigo, as long as special care is taken to keep the eyes open (since vertigo, like motion sickness, is often activated by contradictory information from the inner ears and the eyes). It is also important not to lift the head so far or so fast that the dizziness is worsened. Once activated, vertigo may need some time to subside before attempting the technique again. A small minority of clients with vertigo will not be able to tolerate any head lifting or holding; this technique would be contraindicated for such clients, and for any clients with a very recent neck injury.

Lowering the head in the sagittal plane, as described here, stimulates two of the inner ears’ three canals related to rotational motion (the anterior and posterior semicircular canals). The third horizontal semicircular canal can be engaged with slow side-to-side rolling of the head, again feeling for your client’s ability to release the head at each step of the way.

Another variation is to carefully work with the client’s head off the table, or to use a drop-table to continue lowering the head posteriorly past anatomical position. This allows you to work with a larger range in the sagittal plane; however, keep in mind that having one’s head held off the edge of a table violates our earlier perceived-safety principle of making sure there is something under the head to support it. In addition, neck hyperextension itself can aggravate some neck conditions, so keep the neck long, use this variation with care, and use only with relatively healthy clients.

Whichever variation you choose, once you’ve lowered the head to the table, you’ve finished this technique and are ready to move on in your session. Patience is key. You can easily perform this technique too quickly, but I don’t think it can be done too slowly. Taking a full five or even 10 minutes to lower the head once will be time well spent.  

Notes
1. Yates et al., “The Effects of Vestibular System Lesions on Autonomic Regulation: Observations, Mechanisms, and Clinical Implications,” Journal of Vestibular Research 15 (2005): 119–29.
2. Moshe Feldenkrais, Explorers of Humankind, (San Francisco: Harper and Row, 1979).

Til Luchau is a member of the Advanced-Trainings.com faculty, which offers distance learning and in-person seminars throughout the United States and abroad. He is a Certified Advanced Rolfer and originator of the Advanced Myofascial Techniques approach. Contact him via info@advanced-trainings.com and Advanced-Trainings.com’s Facebook page.

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