ABSTRACT Talking about his book Assessment and Treatment Methods for Manual Therapists (2023), Jeffrey Burch reflects on his years of studying and teaching manual therapy techniques. A lifelong learner, Burch discusses Dr. Rolf, osteopathy, and developing his manual therapy toolbox. Interviewer Jeffrey Kinnunen asks Burch to differentiate some manual therapy terms: direct/indirect, barrier, lesion, adhesion, and restriction.
Jeffrey Kinnunen: I want to express my gratitude for this opportunity to discuss your book, Assessment and Treatment Methods for Manual Therapists (2023). It’s a significant contribution to the structural integration field, and I’m eager to delve into the motivations behind it. Could you share what inspired you to write this book?
Jeffrey Burch: My pleasure to chat with you, and thank you for asking. It means a lot to me to pass on what I have learned from others and what I’ve developed myself. I’m not going to be here forever, but I can leave a book that will continue to speak to people in the future. This book provides opportunities for people to be more effective in their manual therapy work – to get more done with less effort. It’s beneficial for practitioners and for clients alike.
Starting with Still
JK: I wanted to talk with you for Structure, Function, Integration because I enjoyed the book – I find it to be a helpful tool. I enjoyed the infusion of the history of manual therapy and drawing everything back to Andrew Taylor Still1, [founder of osteopathic medicine, physician, surgeon, (1828-1917)]. I appreciate that you are willing to write all these things down. My understanding is that he was reluctant not only to teach, but then to document his techniques. Is that correct?
JB: That is correct. People were after Still for years to teach what he was doing. He developed some great ways of doing things, and he could make changes in the tissue happen quickly. He was known as the lightning bonesetter because he could quickly and efficiently get things done. But for a long time, people would ask him to teach and his response was, “I don’t know how.”
When he was in his later sixties, he figured it out. There was a transition where he was a little less physically able himself, he wasn’t practicing as much, and it meant a lot to him to pass it on. A parallel piece to this story is, as he began to teach, Andrew Still had been remarkably creative. He had lots of different ways of getting things done. There are stories about him lying awake at night, dreaming up new ways to do things. And he had an assumption and an intention that his students should be similarly creative. And indeed, since his time, people following him have come up with many new methods. But frankly, nobody was as creative as Andrew Taylor Still was.
So, he didn’t actually teach much technique. He said, “In our school, we’ve got three topics: anatomy, anatomy, and anatomy.” He would teach some general ideas about how you could change things and then say you figure it out for yourself. So, historically, that has been a problem. We’d like to know more about how he actually did things.
In my book, I described the one piece of film, a ten-second-long silent, grainy film clip of him doing something to somebody’s shoulder. He died in 1917, so there wasn’t much cinematography yet. So that’s the one piece we concretely have.
In this light, I’d like to mention the book by Welsh osteopath John Lewis [DO]. Getting to be quite a few years ago now, the Still family donated a large volume of Still’s personal papers to the archive at the osteopathic school in Kirksville. And so, Lewis went out there, and spent the next two years reading it. These pages added enormously to our understanding of Still. Lewis was able to write a new, more definitive biography of Still. I’ve read all the other existing biographies of Still, and Lewis’ book (2012), From the Dry Bone to the Real Man, is a much fuller depiction of Still and his life.
JK: That’s a great suggestion. I appreciated that in your book. You also mentioned where different techniques came from, where to go to find out more about them, and recommended follow-up reading. That is so refreshing because I’ve been in classes where techniques are floated out there, but it’s not necessarily clear where they came from if that is known. Not knowing makes it difficult to trace back, follow up, or refine the ability later.
JB: Thank you. Yes, that was important to me to chronicle and make available as much of the lineage as possible. As you suggest, for some techniques, the origin and history are better known than for others. For example, we just talked about this reconstructed Still technique. There’s also Harold Hoover’s technique, where we know right where it came from. Wherever I could, I provided that information.
Through the Osteopathic Annals
JK: In the July 2019 issue of Structure, Function, Integration, you wrote an article about the history of Rolfing® Structural Integration. You had said, as a paraphrase, that if you were running a structural integration school, you would be inclined to replace teaching the ‘Recipe’ of the Ten Series with a combination of the assessments that you’ve learned with your friendship and association with Jean-Paul Barral, DO, and his associates. I get the sense that you have supplemented all this knowledge with some of your own innovations from your own years of experience. Would you say that this is what your book is about?
JB: Yes, my book could serve as a textbook for such a curriculum. I’m going to add a little bit to that as well. Yes, I learned a lot from Jean-Pierre Barral, but also from other osteopaths, notably French osteopath Alan Gehin, Canadian osteopath Philippe Druelle, and some others along the way. As well as reading a whole lot of older osteopathic literature.
JK: Right. That’s what is interesting about your career as a Rolfer®, you dipped your toes into the tradition of osteopathic manual therapy. In my perception, I think of what we call Rolfing Structural Integration as a lineage that we can trace back to osteopathy, but it’s a branch. You dipped your toes into both. In the world of osteopathy, were you finding answers to questions from your structural integration side? Or were you discovering new things to consider?
JB: Both, and yes. I just had a great curiosity about the lineage, knowing that Ida Rolf [PhD, (1896-1979)] had studied extensively with osteopaths on the way to developing her work. Notably, Dr. Rolf studied with osteopaths Kenneth Little and Amy Cochrane, but also John Wernham and others. Having read some osteopathy, I recognized that everything in Rolf’s philosophy of therapeutics was part of the osteopathic cannon, except that she brought gravity to the foreground. Gravity is a lesser and sometimes forgotten piece in osteopathy.
So I would ask questions like, what are the roots of structural integration? Where did this come from? This led me not only back through osteopathy, but there have been traditions of manual therapy in peoples everywhere in the world since pre-history. These traditions are known by various names; in the United Kingdom they are called bonesetters, and indeed, they might have set broken bones. But they were also doing manual therapy.
In Portugal, there are people referred to as algebrista, which comes from the same root as algebra. And you know, in algebra, we reduce equations, so algebra is really reduction. It also reduces suffering or problems in the body. In Germany, Wundartz, literally, wound healer. In Mongolia, they are called Bariachi.
While there are, of course, differences between ancient manual practices, there are also interesting similarities throughout the world as well. I remember working with an American who had studied acupuncture and Chinese medicine, and he had actually practiced in China for a time. He told me about traditional bonesetters in China, who are not the same as the acupuncture lineage that we have now. It’s something other and older. He told me that, having received treatment from those people, my work was identical to theirs.
JK: Wow.
JB: Yes. I went looking for what has been written, what has been recorded about those traditions. The literature is thin. Part of the story is that manual therapy knowledge was passed along by apprenticeship, often in family lineages, and people guarding their knowledge. There’s limited literature about that.
Taking us back to Andrew Taylor Still, his father was a medical doctor, and although Still had been born in Virginia, his dad soon had a job in Kansas territory. The job was for a precursor organization of the Bureau of Indian Affairs, working on an Indian reservation providing healthcare to Native Americans. This led to a couple of interesting things. Still would go with his father on house calls. So, his medical education began before his elementary school education did. Also, he learned the language of the Native American people and studied with their traditional healers. Late in his life, he said that the core of what he was doing in osteopathy was what he learned from the Native Americans.
JK: And that would be the Shawnee tradition.
JB: Shawnee, yes.
JK: That is interesting because I did notice that you describe Still as the discoverer of osteopathic medicine, as opposed to being the founder. And that makes a lot of sense in this context.
JB: That was Still’s language, he described himself as the discoverer. Yes, an implication of that is he didn’t create it. He found it. It had already existed.
JK: Had always been there.
JB: Right.
Burch’s Take on Rolf
JK: So, to summarize, you have, throughout your associations, trained to a level where you could teach Barral techniques, visceral manipulation, and some of the nerve and vessel manipulations. You’ve developed quite an armamentarium of cranial types of techniques. You’ve also innovated over time; you have your own techniques and you’ve described your point of view on these things in your book.
JB: Yes, several pieces I’d like to comment on here. The training of Rolfers has varied a lot over the years, over the decades. Sometimes by official curriculum design, and sometimes by teachers doing whatever they wanted to do. In the era when I trained as a Rolfer [late 1970s] we were told repeatedly and with emphasis that there is no specific Rolfing technique. That absolutely anything you can do that will achieve the goals of Rolfing [Structural Integration] is Rolfing [Structural Integration]. There’s a somewhat famous story about a conversation between Ida Rolf and Emmett Hutchins [cofounder of the Guild for Structural Integration, (1934-2016)].
The story goes that one evening Ida was having dinner at Emmett’s house, and after dinner he said, “Ida, I have a question. If I was working with a client and a lot of things had improved, but it wasn’t quite right yet. And I could see that if I could get the periosteum on the hip to breathe, that things would be better. And if could get that periosteum to change by making a magic incantation or whistling a popular tune, would that be Rolfing?” And Rolf’s response in her inimitable style was, “What do you think?” Emmett said, “I think it would.” And Ida said, “I think so, too.” So, if it would be legal to achieve the results of Rolfing [Structural Integration] by making a magical incantation, that leaves the field quite open for how we could do things.
Rolf studied with osteopaths, but she learned mostly philosophy theory from them and not so much technique. She came up with her own early technique, which frankly, was clunky, and a lot of force to get things done. When I was learning more of the available osteopathic techniques, I found that I could get things done more quickly and easily. Less effort for me, more comfort for the client, quicker results.
And as I learned techniques from various directions, I started to see some little patterns on my own. Just like Still was creative and had lots of ways of doing things, it occurred to me maybe I can figure out some more ways to do things. One of my techniques in the book, for example, is what I called the ‘accordion technique’. I invented it on an airplane flying to Boston, Massachusetts, to teach a class. I was fiddling with the tissue on my arm and came across it. I initially was going to call it ‘the Boston technique’, but I like names that are more descriptive. There’s a certain thing that’s done with it that resembles how one would handle an accordion. So I called it the accordion technique. Later a colleague suggested I rename it the alternate-decompression technique, which is even more descriptive.
JK: Who were your Rolfing Instructors? You were at the then Rolf Institute® [now the Dr. Ida Rolf Institute®] when Rolf was alive, but it doesn’t sound like you ever had the opportunity to meet her.
JB: Back in 1977 when I was training, when I was an auditor, Michael Salveson [Advanced Rolfing Instructor] was the instructor, assisted by Neal Powers [Structural Integration Instructor]. And then my practitioner phase with Peter Melchior [cofounder of Guild for Structural Integration, (1931-2005)], assisted by Caroline Widmer, who was a Rolfer and a psychologist from North Carolina.
In the era when I trained, we were repeatedly told, with emphasis, illustrated with teaching stories, that the Ten Series was only for the benefit of beginning Rolfers. It was something to allow you to do good enough work for the early years of your practice so that you could get enough experience to start to perceive what each client really needs. We were sent out into the world as Rolfers with a mandate to move beyond the series at a certain point of experience, perhaps after five years of practice.
And Ida Rolf was still alive at the time that I trained, but she was seriously ill with cancer and had recently stopped teaching. She died about eighteen months after I completed my training, so I did not have the pleasure of meeting her.
Clarifying Osteopathy
JK: We should clarify what it means to be an osteopath; it can be confusing. Some people have the credential of DO, a doctor of osteopathy. In the United States, a person with a DO has a license to practice medicine equivalent to an MD or medical doctor. In Canada, osteopathy graduates call themselves DOMP, Diplomate in Osteopathic Manual Practice, which means they do not have a medical degree like their counterparts in the United States. And then, some practitioners know osteopathic techniques from weekend continuing education courses, which is very different from being an osteopath.
JB: I’ll give you a little synopsis of some of that history. Andrew Taylor Still was a medical doctor, he continued to use the MD designation throughout his life. He never put the DO credentials behind his own name. Initially, he wanted what he was doing to stand alone as a manual therapy practice and not be a part of medicine. When he was first teaching, that’s what he was doing. Early on at his school, John Martin Littlejohn (1865-1947) was an English medical doctor, who also had two other doctorates, heard about Still and came to be treated by him. Littlejohn had a problem with his breathing and Still fixed him right up. Littlejohn got enthusiastic about the work and enrolled in Still’s school.
Because of Littlejohn’s experience in academics, he was also made the dean of students at the same time that he was a student. Upon graduation, Littlejohn was immediately faculty in Still’s school. They had a trade where Littlejohn taught physiology in exchange for his tuition for learning the osteopathic work. After a couple years of teaching at Still’s school, there was some kind of big disagreement between Littlejohn and Still, the exact nature wasn’t recorded well, just that it was very hot. So, we Rolfers don’t have any monopoly on that kind of drama.
Littlejohn departed, he went up to Chicago, Illinois, and opened the American School of Medicine, Surgery, and Osteopathy to teach what he’d learned from Still, along with all of medicine and surgery. Exactly what Still did not want to have happen. With that competition, and with pressure from students, Still ended up doing the same thing with his school in Kirksville, Missouri, teaching medicine and surgery right along with osteopathy.
After about ten years of operating the school in Chicago, Littlejohn decided to close the school and went back to London, United Kingdom, and opened the British School of Osteopathy, where he taught manual therapy only. It’s ironic; this was how Still originally wanted osteopathy to be. The British School of Osteopathy still exists in London and has become the mother of all osteopathic schools in the world outside of the United States.
In the United States, it’s the only place where osteopaths are trained to do medicine and surgery, all components of a classic medical degree, MD. Everywhere else in the world, osteopathy is only manual therapy, no pharmacology, no surgery, none of that. That’s one, not the only, but one of the great divides in osteopathy. Successively, Littlejohn fostered both sides of this divide.
For a long time, the entrance requirements for osteopathic schools in the United States were slightly lower than for medical schools. So, a lot of who they were getting as students were people who couldn’t quite get into medical school. Osteopathy became a side door into medical practice, and most of them didn’t care about manual therapy. This decreased the manual therapy component of osteopathic education in the United States to the point that in the 1970s, it was possible to graduate from some DO schools without ever taking a manual therapy course. John Upledger [DO, (1932-2012)] is an example of an osteopath who graduated from one of those osteopathic schools, he said he learned all of his manual therapy skills postgraduate after he got his doctorate.
JK: That’s a good synopsis. I got into this work from a formal science-based education before I got into doing manual therapy, my bachelor’s degree was in clinical nutrition and my master’s degree is in exercise science. I wanted to become an osteopath for the manual therapy training aspect. I’m based in Michigan, so I was looking at Michigan State, and in their program, it was four years of medical school and osteopathic school, and then three years of residency. In those seven years of training, there are only three weeks of manual therapy training specifically. So I found the same thing as what you are saying, with that route I was going to have to figure it out on my own afterwards. I decided not to do that.
JB: That makes sense. In our time, osteopathy has diversified, people have figured out different techniques and developed different philosophies. Another major division among those who actually do manual therapy is between the structuralists and the energetic practitioners. The energetic types think that people who actually get in there with their hands and work on things physically are just incredibly crude dealing with gross matter that way. Whereas the structuralists wish the energetic types would actually touch the body and do something.
With each division of manual therapy, there are orthodoxies of insisting what they know is the right way and everybody else is wrong, and they will tell you why. That kind of thinking is ordinary human behavior. Whereas the truth is, there’s a place for all of it. Sometimes you need one way and sometimes you need another way.
The Future of Manual Therapy
JK: I’ve gone back and read older articles by Rolf and her students; there is a range of points of view, like you just said. And from reading your writing, it seems you concur that Rolfing work is defined by the goals and the kind of relationship that our bodies have with our environments – including the planet we live on – and
the resultant gravity pulling down on us. With your experience teaching and writing, what are the next gaps that need to be filled in our manual therapy knowledge? How are you hoping the work will advance?
JB: Fascinating question. First, I want to say that the idea you just said, that Rolfing [Structural Integration], in particular, is described only by goals and not by method, was explicit in my basic training. That’s the way we were trained. So, like everybody else, I know that my way is correct, and that’s the way we were trained back then.
I am very interested in Hiroyoshi Tahata’s writing recently about spatial relationships between people (2018). We all know how you sit or how you stand with respect to another person or a group of people affects dynamics there. Apparently, as I’m learning from Tahata’s writings, there is actually a word for that in Japanese. It’s very easy, one syllable, ma. [See page 34 for article by Tahata about ma.] This is something that Japanese people are very aware of. Working in this way is significantly outside the box for me. I think there’s a frontier here to create structural and functional changes with spatial relationships and how we relate to each other.
As structural integrators, we’re interested in spatial relationships within a body, to the earth and gravity, and Hiroyoshi introduces interpersonal space as another dimension. It would be very interesting to explore this further.
Anchoring into Anatomy
JK: Your direction as an author feels anatomical to me, where you describe things in anatomical terms. As a manual therapist, I tell myself that if I can imagine the specific anatomy I’m contacting, then I can determine what it is trying to tell me. Usually, something interesting happens. Is it too narrow of a box to focus our ruminations exclusively on anatomy?
JB: That’s very comfortable for me. Down here to my left is the eight-foot-long shelf of anatomy books that I spent many, many, many hours pouring over along the way. I set myself a goal of building an internal hologram of the body so I could zoom into structures in my mind, travel through them, and rotate with them. And I pretty well accomplished that. This has been very useful in figuring out what’s going on with the person, where I am, and what I need to do.
Returning to the division in osteopathy between the structuralists and the energetic people, I’m solidly a structuralist.
Defining Terms
JK: That reminds me of another thing I deeply appreciated in your writing, you take the time to be very clear about what you mean by different terms. That often is not the case, as I know you’re aware.
JB: Yes, I point out some of that in the book and give some examples of murkiness in terminology out there.
JK: You wrote that sometimes you feel the speakers are not always clear about what they mean with different terminology. That’s difficult for me because I do have a solid biomechanical and kinesiology background, and so it feels off when experts say something inaccurate in a video. I’m sure you sometimes get that feeling.
JB: I do. An example of that, which I mention in the book, is people talking about osteopathic or osteopathic-related techniques. People will reference direct techniques and indirect techniques.
One version of that is if you’re working right at the site where you want to change something – that’s direct. If you’re using leverage from a farther away location in the body – that’s indirect. But there are more meanings of it, such as, if you mobility test something to the end feel, and you have to go farther to get to an end feel in one direction than the other. Then, going in the longer direction, which seems like it’s a little easier – this is indirect. Whereas, if you go against the barrier or something, you’d run into resistance sooner – that’s direct. Except for the people who reverse that terminology.
Whenever somebody uses the terms direct or indirect, your immediate project is to find out exactly what they mean by that terminology. Most cases, they’re not very clear within themselves, partly because they live in this environment of terminology mud. It is essential to know what they mean by those terms. The use of the terminology in the first place is muddy enough that I avoid those terms altogether.
JK: Sure, I can appreciate why you’d say that. What do you think about posture versus alignment?
JB: The way we were taught back in 1977 at the Rolf Institute® was that structure is where the person’s body is in space when they’re not making an effort at all. It is the least effortful place for them to be. Whereas posture has the same root as the word pose, and refers to a way that a person will more or less consciously hold themselves. That seems like a useful distinction.
JK: Great, that is very practical. How about the terms: barrier, lesion, adhesion, and restriction?
JB: Oh, well, that’s a fine collection of terms.
Barrier
JB: Let’s start with barrier. This has to do with mobility testing of tissue at any scale, from tiny little things to big movements. And it turns out that if you mobility test something slowly, you get to notice things that you don’t notice, can’t notice, if you’re moving too quickly. It’s related to this. If I’m holding something made of a single consistent material, like a rubber band made out of synthetic rubber, then when I stretch it, it becomes longer to a certain point. That part happens easily. If I were to pull more, it takes more force, but it goes farther. And eventually, you get to a place where the pull isn’t going to stretch any further.
If you have a mixed component, for example, a fabric that’s mixed fibers like linen and spandex. You’re going to see a new behavior. You’ll have that initial length where change is easy as you’re putting on more force. But all of a sudden, you have to step up how much force you’re using to get more change – so it feels like you ran into a little barrier there. If you keep going, you’ll get a succession of those as you run into the next material nature and stretch. In a composite material, there are several transitions as the force pulls through one fiber and then the other, or it’s the relationship of one material to another.
Human tissue has got a lot of stuff in it: several kinds of collagen, several kinds of elastin, and more. So, guess what? Our tissue exhibits a stepped force deformation curve, and we call each of those inflection points a barrier. As you stretch, bend, or compress tissue, you feel like you are running into barriers in there.
Various treatment techniques are oriented to particular places in the forced deformation curve, specifically certain barriers. Or, in some cases, the space between barriers. To organize a treatment, you need to know where you are in the forced deformation curve. Some techniques are first barrier techniques. There are middle barrier techniques. There are end-feel techniques. I mentioned Harold Hoover’s technique already, which is actually a less-than-first barrier but a very specific force level.
Lesion
JB: And then there’s lesion, which is a broad and sometimes confusing term. That can mean a gross wound where you’ve just been slashed and need to be stitched up. That’s a lesion. We can have an infectious lesion. If somebody comes in and has a boil, that’s a lesion. The way we often deal with that word in our kind of work is – the tissue has lost its elasticity in a particular area. Or, in some cases, it’s lost its integrity and actually is too elastic. So, it’s the idea that something’s not quite right here. A fairly broad definition of a lesion is a localized area of tissue dysfunction in the body. Unfortunately, that definition falls apart because everything in the body is connected and all of the various lesions are linked to each other through the connective tissue matrix, through the nervous system, and so forth. So, it’s a fairly soupy term for places where stuff ain’t quite right in the body.
Adhesion
JB: The term adhesion is interesting. There are two companion terms: contracture and fibrosity. Fibrosity is the more general term. Some areas of the body have gotten roughed up in some fashion, tissue damage from a direct injury, overuse, or an infection. The fibroblasts are trying to repair the area, and so they’re ripping out damaged fiber and laying down new fiber. They tend to get a little over-excited about that sometimes and lay down too much fiber, resulting in stiffness.
Each bit of connective tissue in the body needs to have the right mix of elastin and collagen and the right total fiber content in order to have the biomechanical properties to do its job. The more damaged something is, the more excited the fibroblasts seem to get about the whole thing, and they lay down too much fiber and are also biased toward collagen. Once an area has lost elasticity, that is excessive growth and placement of fiber is fibrosity.
There are two useful ways to describe variations of fibrosity. One of them is called a contracture, which is a kind of fibrosity. For an example of this, consider the kind of tissue in the body that is a membrane, like a pleura inside the chest wall. If this tissue acquires some kind of wear, it gets roughed up, and too much fiber grows in there. That’s called a contracture, which is a bit of a misnomer because contracture suggests that it’s pulled short, which it might be. But, essentially, it’s not that it’s pulled short, but rather that it’s lost its elasticity. It’s now more difficult to elongate it.
We also have areas in the body where we have membranes facing each other with a lubricant in between. There shouldn’t be any mechanical connection with them. There are lots of examples of that in the body. For example, between the outer surface of the lungs, the visceral pleura, and the lining of the chest wall, the parietal pleura. The only place the lung is supposed to be attached physically to anything in the body is a small upside-down, teardrop-shaped area on the medial surface of the lung, the hilum of the lung. Everywhere else, there should be a well-lubricated glide plane of the lung to the chest wall. But you get a bash to the chest wall or a lung infection, and the fibroblasts do their usual number. In repairing the individual membranes, some of the fiber grows across the formerly lubricated space, and now they’re stitched together. That is an adhesion. Think adhesive. In other words – glue.
Recently, both verbally and in writing, I’ve encountered people referring to contractures as adhesions. That muddies the waters here, so I routinely remind people of these distinctions. People are using adhesion loosely, kind of replacing fibrosity as the more general term. It’s useful to think about and know what you’re dealing with.
Often, the techniques for treating adhesions and contractures are similar. But there is a difference in the result we wish to achieve. If you have an adhesion, we wish to take it apart, disrupt that fiber, and restore the lubricated glide plane. Whereas, if you have a contracture, we wish to restore its elasticity. No, please do not take it apart. It’s supposed to have structural integrity there.
Restriction
JB: So, restriction is an area where there’s a limitation in movement. And obviously, that could, by the earlier definitions, be either a contracture or an adhesion. You can also have a smooth muscle cell making a persistent contraction that creates a reduction in the mobility in an area.
That brings up an important distinction between a smooth muscle cell and striated muscle cells. Striated muscle is meant for intermittent contraction and actually cannot maintain a contraction for any considerable length of time. Just try holding your arm up – how long is that going to last out in front of you?
Smooth muscle cells, as long as you supply it with food and oxygen, you can potentially have a cell or cluster of cells contract for the rest of your life. It can’t make as powerful of contraction as striated muscle, but a lot of little smooth muscle cells together can create some stiffness in there. So that’s an arena where some of the work we do with people’s nervous systems is fruitful.
JK: I appreciate your patience in allowing me to put you on the spot like that, while some of our readers will know these details, we also have readers who read our pages to know about structural integration. These are some of the elements we are dealing with.
Assess, Treat, and Reassess
JK: There’s a certain temptation for those of us who work as manual therapists to really focus on technique. Your book had more of an emphasis on assessment, and not just stopping with one assessment, but allowing a total presentation to come to you versus getting right to the technique. Is that accurate?
JB: Yes, that is very accurate. There are lots of ways of assessing. Rolf asserted that you can learn everything you need to know by the contour of a person’s body, looking visually, and she got a lot of mileage out of that. That was the best assessment method she had. Since her time, a lot of other assessment methods have been developed, so we can now do a more thorough and finely graded assessment of what’s going on.
Each assessment method can show us something, no one assessment method can show us everything. And each assessment method also has an error rate. So, if you use a second similar test, you can learn more. I suggest, in many situations, it is best to do more than one test, because each one gives you an important part of the picture with an overlap in what information will be provided. For example, there are at least three different ways to assess inflammation in the body; some of them give you a more ‘in the moment’ picture, and others are longer-term picture information.
I routinely use the nineteen assessment methods documented in my book. I don’t use all of them at every moment with every client. Some of them I use quite routinely, and others are kind of like the funny little tool over in the corner of your toolbox that you use once in a while when you need it. I recommend to people when you’re working, always use more than one. Generally, using four or five to figure out what you’re working on will give you a much more complete picture. These are the physical tests, which will combine with your interview of your client when you start to get their history and their impression of the whole thing. Rolf looked at the contour in the body; yes, that’s valuable information, but just by itself, it is not sufficient.
JK: My impression of your philosophy is to assess, treat, and reassess. You don’t stop until you’ve reassessed and see what happens.
JB: Absolutely. Jan Sultan [Advanced Rolfing Instructor] brought this home in a continuing education course that I took with him and when I did my Advanced Training with him. Assess before you treat. And immediately after treating, assess again. This gives you immediate feedback on what happened with your treatment. As Jan pointed out, this is an important part of how we grow as therapists, as it helps us to get immediate feedback on each action that we make.
You may observe when you’re treating something and think to yourself, Wow, we achieved everything we wanted. Other times, none of what we wanted, or somewhere in between. When you know you have gotten none of the changes you wanted, maybe a different technique will be in order. One of the reasons we have so many techniques is that each moment, each of them will be useful for some people to achieve the desired results. And you might make a call like, yeah, that’s nice. It changed in the direction we wanted, but let’s do a little bit more here today.
Here’s another piece to understanding assessment and treatment, particularly if you’re working with something that’s very fibrotic, don’t try to make it perfect in one day. There comes a certain point at which you are trying to soften things up, yet you’re actually doing injury. And although you may make it freer at the moment, then the fibroblasts are going to have their way with it, and a few weeks from now, it’s actually going to look worse. There are distinct signals the body will give that a manual therapist can interpret as the tissue has reached a saturation point for the day.
People’s bodies will always continue to change for weeks after their sessions. And they like it better if you let them do it rather than trying to do everything for them.
JK: Right, the integration happens at home. What other references do you consider essential reading for Rolfers?
JB: In the back of my book, there are several pages of suggestions, and among those are some books on orthopedic testing about how to learn to be able to do that. And I want to mention, again, John Lewis’ definitive biography of Andrew Taylor Still, From the Dry Bone to the Real Man, is particularly valuable.
Lots of books come to mind, in particular, the books of Rene Cailliet [MD, (1917-2015)], who authored a set of seven books in which he takes on different body parts and different kinds of syndromes. That is worth looking at, it gives us a lot of valuable assessment perspectives about each of those.
JK: That’s great. After more than forty years of practicing Rolfing [Structural Integration], can we dispel the myth that Rolfing sessions have to be painful?
JB: Yes. That’s interesting you bring that up. I had a poll taken a few years ago; I had people asking questions of members of the public about their awareness of an experience of dentistry, acupuncture, and Rolfing Structural Integration. Of course, most people had been to a dentist and had a pretty good idea of their scope of practice. Less was known about acupuncture. And for Rolfing work, about 10% of the population surveyed had ever heard of the word, and it was down to 1% of the people who could describe something about it. And what they said was, “It was expensive and hurt a lot.”
The reputation for pain is a reflection of Ida Rolf’s early, rather blunt-force treatment methods. We are still living down that reputation from those days. Today there are ways of achieving all of the results that we want that will involve no pain.
JK: Yes, and it’s fair to say that sometimes people are dealing with chronic pain and any amount of touch or movement or contact may be uncomfortable. But, that’s discomfort that was already present and they wouldn’t be aware of that being a part of the work, even though a practitioner may work gently.
JB: That’s true. Also, when you run into something like that, this may be a place for long lever techniques, instead of touching it directly. If you use some other part of the body as chopsticks to get to it and affect things, there are ways the process can be more comfortable.
You know, you’ve drawn out of me a lot of important aspects about the book and our work doing manual therapy. I have a parting message for the readers of this article and the book: as you’re moving into working more gently, or even just as an experiment, be as relaxed in your body as you can when you do this work with people. This wisdom comes from a recent teaching experience.
This book was developed from teaching materials that have evolved over many years, for a series of courses that I teach titled “Functional Methods.” In those classes I basically teach this book and most of these treatment techniques are rather light force. There are a couple of them that can use end feel, but even then, it’s a comfortable end feel. When I observe people learning this material, because they are used to working with a lot of force, they’ll often come into the technique with a lot of bracing in their shoulder girdles, trunk, and so forth, which makes things not respond as well.
It’s an interesting experiment to make; coming back to mobility testing, if I’m as relaxed as possible in my body when I mobility test a wrist, let’s say, for example, I’ll see a certain range of motion. If I intentionally tighten up my toes on one of my feet and try it again, the apparent range of motion will be less in the wrist. Model in your own body what you want things to be like for the person you are working with, and be relaxed in your own body as you work.
JK: That is a whole topic on its own. Any closing statements for us?
JB: I’ll just come back again to that image of – the more you know, the more you’re in contact with things that you don’t know, and so look outward as well as inward. And just enjoy the splendor and wonder of the world as we continue to discover it.
JK: That’s beautiful, thank you so much for your time.
JB: You’re most welcome, Jeff. My considerable pleasure. Thank you.
Endnotes
1. For more information, the Museum of Osteopathic Medicine has an extensive collection of articles (https://www.atsu.edu/museum-of-osteopathic-medicine/a-t-still-papers-american-school-of-osteopathy-aso).
Jeffrey Burch received bachelor’s degrees in biology and psychology, and a master’s degree in counseling from the University of Oregon. He was certified as a Rolfer in 1977 and completed his advanced Rolfing® Structural Integration certification in 1990. Burch studied cranial manipulation in three different schools, including with French osteopath Alain Gehin. Starting in 1998, he began studying visceral manipulation with Jean-Pierre Barral, DO, and his associates, completing the apprenticeship to teach visceral manipulation. Although no longer associated with the Barral Institute, Burch has Barral’s permission to teach visceral manipulation. Having learned assessment and treatment methods in several osteopathically derived schools, he developed several new assessment and treatment methods that he now teaches, along with established methods. In recent years, he has developed original methods for assessing and releasing fibrosities in joint capsules, bursas, and tendon sheaths. He is also beginning to teach these new methods. Burch, as the founding editor of the IASI Yearbook, regularly contributes to it, as well as to other journals.
Jeffrey Kinnunen is a Certified Rolfer, American College of Sports Medicine Certified Clinical Exercise Physiologist, and American Council on Exercise Certified Health Coach. Kinnunen strives to facilitate positive outcomes with his clients by raising awareness of the possibilities for living.
References
Burch, Jeffrey. 2023. Assessment and treatment methods for manual therapists: The most effective and efficient treatment every time. London, UK: Handspring Publishing.
___. 2019. The recipe in history and considerations for the future. Structure, Function, Integration 47(2): 43-47.
Lewis, John. 2012. A. T. Still: From the dry bone to the living man. Self-published: Dry Bone Press.
Tahata, Hiroyoshi. 2018. Working with Ma. Structural Integration: The Journal of the Dr. Ida Rolf Institute 46(1): 44-51.
Keywords
manual therapy; treatment methods; Andrew Taylor Still; osteopathy; Rolfing Structural Integration; lineage; Ida Rolf; Ten Series; direct/indirect; barrier; lesion; adhesion; contracture; fibrosity; restriction ■
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