ABSTRACT This case study is of a client who had bilateral mastectomies and then had a five-session series of Rolfing® Structural Integration, a fascial-focused therapy. The client, JD, was a thirty-nine-year-old breast cancer survivor who had had six surgeries and radiation to treat breast cancer. The treatment protocols included scar tissue release, proprioceptive mapping, and fascia release techniques in the Rolfing paradigm. Positive results were observed with regard to an increased range of motion in humeral flexion returning to a normal range, and the pain was alleviated.
Introduction
The process of transforming from a bodyworker into a Rolfer® involves a paradigm shift in perceiving, thinking, and practice. This shift involves not only our own relationship to the vertical ‘Line’ of the gravitational field but also our relationship with our clients, their presentations of pain and discomfort, and the reality that is concretely observable in their bodies versus their subjective reality, that is their senses, thoughts, and ideas about their bodies. With the gap between perception and reality, are we all living in a carnival’s house of mirrors?
In May of 2023, I became a freshly minted Rolfer™ in the United States from Rolfing Instructor Libby Eason’s first Atlanta regional training of the Dr. Ida Rolf Institute®. Learning to deliver the Ten Series pioneered by Ida Rolf, PhD (1896-1979) is like being gifted the keys of a Ferrari (Sultan and Hack 2021). Rolfing® Structural Integration is defined by its beauty and elegance in how it works with fascia. It offers layers of possibility for many types of research; if we think of the Ten Series as a protocol, we can evaluate the outcomes for the clients. During my Phase III of this Rolfing training, I felt eager to embark upon case studies to harness the potential of the Rolfing
Ten Series.
When an established client from my massage therapy practice, let’s call them JD, came for their session with me as a Rolfer-in-training, I was eager to create and implement a multi-session series to meet their functional goals. JD stated, “I’m now ready for you to dig out my scar tissue, as I am finally healed from my last [breast] surgery. I know it’s going to hurt, but I need my arm to move above my head.” My science mind leapt for joy – at last – an opportunity to have concrete and measurable data about my execution of Rolfing Structural Integration. JD gave consent to documenting the process and publishing the findings. I realized I could measure this client’s humeral flexion before and after delivering fascial-focused sessions, to investigate the effects of fascia work in the gravitational field. This was an opportunity to observe and document this profound system I was studying. At the same time, my inner-blossoming Rolfer cringed at the thought of ‘digging out scar tissue’. I was walking away from the idea of ‘fascia mashing’ and forward into the ‘must get in-there’, address the layers and their relationship for effectiveness. This article is a summary of my findings.
Client History, Goals, and Five-Session Series Framework
JD, a thirty-nine-year-old mother of two, was diagnosed with breast cancer in April 2020 and underwent several breast surgeries and radiation:
March 2020 – Right lumpectomy.
March 2020 – Bilateral mastectomy five days post lumpectomy.
May 2020 – Right breast surgery to remove methicillin-resistant Staphylococcus aureus (MRSA) infection [type of staph bacteria resistant to antibiotics].
June 2020 – Expander in the right breast.
August 2020 – Radiation regimen for five days per week, for five weeks on the right breast. Target zone from twelfth rib to clavicle including axilla.
October 2021 – Reconstruction on the right breast, removal of expander, and replacement with implants. Also did abdominal liposuction and fat transfer.
September 2022 – Reconstruction and replacement on the left breast to reattach netting around the breast from the initial reconstruction in 2020.
When JD came for her sessions, she was cancer-free and was working with continual hormone control therapy under the supervision of her oncologist. The oncologist also granted permission for this fascial therapy and encouraged JD to work with personal trainers, physical therapists, massage therapists, and any other resources to regain her normal function and lifestyle.
JD’s main goal was to “get the scar tissue out” on the right side, specifically under the right breast, which was inhibiting the motion of her right arm when lifting above her head. Her secondary goal was to have her right breast drop back down in position, and continue manual therapy work with the lymphedema that was gathering in her right arm.
Based on the client’s goals, schedule, and budgetary constraints, it was decided to work consistently every one to two weeks to complete a six-session series [became a five-session series when one session was canceled due to illness] of fascia-focused manual therapy to free her arm, breast, and thorax.
The series format scheduled was as follows:
- Measurement of humeral flexion (via goniometry) and subjective information gathering before and after each session (Physiopedia 2024).
- The initial session was sixty minutes, the second thirty minutes, then sixty minutes, thirty minutes, and sixty minutes, and the final session was sixty minutes.
- Five sessions were completed (one session was cancelled due to illness).
- Dates of appointments: January 3rd, January 11th, January 17th, January 25th, and February 7th, 2023.
Observations
At the beginning of the first session, JD reported that the left arm was “more free and capable” than the right arm, with more movement above the head and in external and internal rotation. The right arm felt constricted, and there was a distinct pulling sensation under the right breast in movement. JD felt the right arm could not accomplish strength training exercises and could not feel fluid while swimming. Some discomfort and pain were experienced under the right breast while moving; the pain and discomfort would come and go. JD was surprised by the initial measurements of the right arm having more and the same range of motion (ROM) as the left arm (see below for initial measurements).
JD presented with an anterior pelvic tilt and an anteriorly shifted pelvis. When standing, her femurs were rotated internally, with a slight counterrotation of the lower legs. She held her arms close to her body, hugging them tightly to the ribs. The left side of her thorax was rotated to the right, including her belly button. Her neck was shortened at the occiput and on the left side, and her head had a forward chin and a sharp right angle of the jaw to the sternum.
When breathing, JD exhibited little movement in the lower ribs, both front, back, and either side. Breath was more inhibited on the right side of the thorax. Breath also appeared restricted throughout the upper ribs, and the lumbar spine appeared not to move with respiration either. The expected continuous pattern of breathing was more inhibited on the right side of the body than on the left.
Her right breast was notably more elevated than the left breast, and the left breast seemed to be rotating toward the midline.
Standing wall goniometry was performed to measure humeral flexion. With the client’s back completely supported by the wall, each arm was raised above the head, and the placement of the goniometer was centered at the axilla region. Then humeral flexion was performed and measured by the degrees of movement at the shoulder. The optimal range is 180 degrees or 180° (Physiopedia 2024). Each measurement was done twice (first measurement = M1; second measurement = M2).
Initial measurements:
Left arm M1 = 170°, M2 = 175°.
Right arm M1 = 175°, M2 = 173°.
JD’s personal resources included her spiritual practice as a Christian and her consistent participation with a local church. She’s an owner of a local retail business in a busy tourist town, and as a mother of two, her nervous system was continuously stimulated by meeting her deadlines, raising her children, and spending time with her community. Her strong character and natural leadership were visible in her stalky powerhouse presence, and her energy would reach every corner of a room when she entered. She’s the kind of person that quickly analyzes a situation, calculating all options, and pursuing what needs to get done efficiently.
Working Goals
The goals of this case study were to restore the full range of humeral flexion and increase proprioception at the surgical sites. While the range of motion appeared to be restricted only a few degrees away from the expected 180 degrees of humeral flexion, there remained the opportunity to restore the range of motion to ‘normal’ despite the multiple layers of scar tissue from the several surgeries and the radiation that occurred at the right breast region.
My main intention was to rebuild JD’s proprioception of this region with manual techniques and movement suggestions. The goal was to induce greater fluidity within the scarred layers, restore a sense of ownership of the breast prosthetics, and integrate the sensation of these regional layers into the client’s sense of the rest of her system.
Working with our well-established therapeutic relationship, JD and I had built a therapeutic alliance before this case study investigation began, as I had been her massage therapist through many parts of her recovery process during her oncology treatments. I had already delivered massage therapy, lymphatic drainage, and overall stress relief treatments; this built a rapport that was beneficial to this research project, whereby we were able to dive into this fascia-focused series with precision and depth.
JD’s faith and commitment to reaching her functional wellness goals presented as a great asset in her adaptability for change despite the layers of trauma her body had incurred.
Strategies
The manual and movement work during each of the five sessions followed the Rolfing Principles of Intervention (Sultan and Hack 2021). What follows is a specific description of the series I designed to meet the client’s goals:
Session 1:
- Address fascial layers of the shoulder girdle,
- Work to increase adaptability in the axial complex.
Sessions 2, 3, and 4:
- Work with superficial and deep structures of the thorax and axial complex,
- Enrich sensory awareness of support structures of the lower body,
- Teach the palintonicity principle, with arms and axial complex especially.
Session 5:
- Work to integrate the regional work done in sessions 1 through 4 into broad, multi-segment awareness for the client,
- Bring closure themes into the work and support JD in feeling the changes that have occurred.
Within each of the sessions, JD was receptive to working to enhance her proprioceptive awareness by following the sensation of my contact points while doing the scar tissue release work and direct fascial manipulation. Proprioceptive awareness was invited for both her right and left shoulder structures and her thoracic movements with breath and gestures. We worked together for her to feel my contact mapping each of her ribs and moving her shoulder girdle passively.
Scar tissue release approaches were performed focusing on the meticulous separation of adhered layers using manual shearing, compression forces, and imagery of gently separating cellophane-type tissues. The focus was to restore the adaptability of JD’s thorax by working superficial structures then deep structures in the general areas of constriction – both axilla and lower ribs under the breasts.
Direct fascial manipulation was applied to address the thoracic rotation by working with the rectus abdominis, pectoralis major (especially at the sternal attachments), serratus anterior superior, intercostals, and diaphragm specifically. Related soft tissues associated with these structures were directly and indirectly included.
Results
Initial measurements revealed minor inhibition of the humeral flexion range of motion for both the right and left shoulder. By the end of the five-session series, both arms were measuring the full range of motion, which was restored to 180 degrees. Throughout the series, JD reported an increase in her range of motion and felt “less restriction” in moving her arms above her head. She was able to return to weightlifting and swimming without feeling “stuck” at her surgical sites and without feeling pain while moving.
At a follow-up session on April 5th, 2023, JD reported that her arms, chest, and ribs remained pain-free and mobile, and that she was able to increase her exercise program as part of her goals for the summer of 2023.
Conclusion
JD’s humeral flexion improved both objectively by measurement and subjectively through self-reporting during a focused five-session series using the Rolfing® Principles of Intervention and strategies taught during my Rolfing Certification Program. After the fifth session, JD’s range of motion returned to the normal 180-degree humeral flexion, and she reported feeling more mobile with her shoulders and pain-free two months after the conclusion of the five series.
The implications of these positive results during this case study suggest that further research would be beneficial to understand how Rolfing Structural Integration, and structural integration in general may be a significant benefit for people recovering from mastectomy procedures.
H. Ro Irwin-Mayberry is a Certified Rolfer® passionately playing and working in the magnificent mountains of Breckenridge, Colorado. She also holds a Colorado massage therapy license since 2006 whereby she specialized in chronic pain management, injury recovery, and athletic performance. After racing mountain bikes at the professional level in 2021, she hung up her race helmet, became a Certified Rolfer, and amateur triathlete. Irwin-Mayberry is also a certified yoga instructor and has a BSBA in Marketing and Management. She joyfully anticipates completing her Certification in Rolf Movement® integration in June 2024.
References
Sultan, Jan H. and Lina Amy Hack. 2021. The Rolfing SI Principles of Intervention. Structure, Function, Integration 49(3):16-24.
Physiopedia. 2024. Range of motion normative values. Available from https://www.physio-pedia.com/Range_of_Motion_Normative_Values?utm_source=physiopedia&utm_medium=related_articles&utm_campaign=ongoing_internal.
Keywords
fascia; mastectomy; scar work; humeral flexion; case study; fascia manipulation; five session series. ■
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