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The six stages of Biodynamic Skeletal Therapy Treatment

This is an excerpt from Unwinding Bone by Scott Sternthal.

Six Stages of Biodynamic Skeletal Therapy Treatment

The six stages of BST treatment form the backbone (ahem) of the approach. In fact, their description and design were the main objectives of this book. For this reason, I want to spend ample time discussing and describing each one of them. Understanding each stage as well as possible puts the odds of success in our favor. Again, this may serve as more of a review for some of you. For others, it may be brand new. Review or new, take your time here—it will be well worth it once we start practicing.

Permit me to go back in time, again. People have been giving and receiving manual treatment for centuries. In Greek and Roman times, Aëtius of Amida, a physician, used massage for headaches, vertigo, and epilepsy. Based on hieroglyphic records, Egyptians used manual therapy to treat various ailments and injuries. Healers and shamans from these and other civilizations have claimed for thousands of years that healing forces can pass from practitioner to patient.

In the nineteenth century, “bonesetters” in England offered medical care for people who could not afford to see a doctor. Bonesetters soon began to attract the attention of the mainstream medical community. Sir James Paget, a physician, noted that bonesetters seemed to help patients who didn’t respond to traditional medical care. Eventually, bonesetters settled in the United States. The Sweet family practiced bonesetting in Connecticut and Rhode Island for nearly two centuries, and were likely among the earliest influencers of a visionary young medical doctor living in the southern United States named Andrew Taylor Still.

Still, whose ears must be ringing in the great beyond since we’ve been talking about him so much, is widely considered the founder of osteopathic manipulative therapy. After carrying out autopsies on cadavers retrieved from exhumed graves, as well as performing adjustments and other manual therapies on humans (both dead and living), Still was convinced that human anatomical structure was linked to health. A staunch opponent of pharmacology and wary of the medical doctors of his day with their often-barbaric interventions, Still believed that by nonsurgically manipulating body structure with the hands, function could be restored. As the first medical doctor known to have combined manipulative therapy with traditional medicine, Still believed that if a bone was precariously positioned, it could impact the function of the blood, lymph, and nerves. For instance, discussing ailments of the foot, Still said:

A partial dislocation of one side of the spine would produce a twist which would throw one muscle on to another and another, straining ligaments, producing congestion and inflammation, or some irritation that would lead to a suspension of the fluids necessary to the harmonious vitality of the foot. (Still 2004, 32)

Still famously never wrote a technique book, but his teachings have influenced much of modern-day manual therapy. His approach (now called the Still technique) has two parts: indirect and direct. The indirect part of the Still technique allows the myofascial structures to release. Then, the direct part improves range of motion by challenging the extensibility of the connective tissue.

Fast-forward to right now. With its multistage approach, BST reflects Still’s biphasic direct-indirect techniques. Instead of just two phases, BST has six, and they are:

1. Cocooning
2. Compression
3. Dialogue
4. Augmentation
5. Spreading
6. Integration
   

Stage 1: Cocooning

Cocooning is the first stage. To begin BST treatment, we surround the inertial tissue with our hands and fingers, providing a contained arena for potency to do its work. Becker referenced this:

I don’t impose any channels I want it to go in, but I give it a nice tight fit so it will keep going where there is work to do. I don’t let it just dissipate blindly, but I give it room to play in. I’m there to hold the stuff into focus so the work can be accomplished. (Becker 2023, 51)

Becker’s idea of giving the inertial zone a “nice tight fit” and giving potency “room to play” resonates nicely with BST. In a way, cocooning a compaction is like capturing fireflies in a jar. It’s a way of temporarily containing a kind of potent luminescence.

I mentioned before that, in nature, wind and water currents are invisible, but we still feel them. A similar phenomenon applies here. An osseofascial compaction is invisible, but we can still palpate it. During the cocooning stage, we surround the area of compacted tissue with the hands and fingers until we have the entirety of the compaction within our grasp. The compaction could be an entire bone, a dime-sized zone within a bone, or a sliver of connective tissue between two bones. If the compaction is within one part of a bone, we cocoon that specific area. If the compaction feels more diffuse throughout the entire bone, we cocoon it by grasping the bone at each end. If the compaction exists between two bones, we cocoon it from all sides.

Remember that the rhythms of primary respiration express themselves fully only through tissue that is healthy. At this very early stage, the compacted tissue is still “less healthy,” so some or all of the rhythms may be absent or weak.

Stage 2: Compression

Compression is the second stage. Compression exaggerates the compaction by compacting it even more, making it the main indirect portion of BST treatment. But even though we are squeezing the tissue, compression is also a way to create more space. This is counterintuitive, I know. But when applied with just the right amount of force and at just the right angle, compression “opens the door” for potency to enter the compaction and act. Like the frayed shoelace from earlier, axial compression—compression applied from the ends of and parallel to the collagen substrands—may create more micro-space between the strands. Of course, working this way with osseofascial tissue is not an exact science—we can’t see the actual collagen substrings to know if we are applying our compression exactly parallel to them. But this is where our orientation of compression becomes key. More on this soon.

Sutherland and Becker were fans of using compression, Jealous not so much. I certainly am. Sharon Wheeler, founder of the BoneWork approach, uses compression with both hands to create a “field of pressure” around compacted bone tissue, helping reanimate the traumatized tissue. Druelle and our teachers at the CEO were pro-compression, as well.

Becker believed that compression was a way of balancing the energy within inertial tissue. When he applied compression from the periphery toward the center—from the levers toward the fulcrum—the strain patterns would unwind, and he would achieve better results. “The compression is going toward the point out of which energy comes,” he explained (Becker 2023, 57). The key to therapeutic compression, according to Becker, is to apply just enough compressive force so that the energy applied from the outside matches the energy coming from within. By doing this, a kind of compressive “neutral point” is established, akin to two people pushing their hands together but remaining still. It’s at this moment of neutrality that the levers reorganize themselves, unwinding from a disordered state to an ordered one. This is exactly what we are aiming for during this stage. Below, Becker references Sutherland’s approach, discussing the latter’s accumulation of parameters with a compression toward the fulcrum.

The corrective principle in physiological biodynamics is more than mere exaggeration, direct action, opposing physiological action, etc. It is as Will Sutherland suggested when he was asked what to do with a convulsive case in a convulsive state: lock them up. Bring all the contributing factors present into the fulcrum, from the ends of all the levers, into physiological biodynamic focus or balance. This is the point of physiological and pathophysiological efficiency. This is the point at which entropy can modify its dynamic. (Becker 2023, 249)

While Sutherland and Becker used compression to unwind strain patterns, Jealous considered compression unnecessary and potentially detrimental to the cause. He reasoned that since all lesions still contain motion, why would we add compression and potentially stifle it? To this, I would argue that, indeed, too much compression applied too quickly and in the wrong direction can stifle it, but just the right amount of compression at the just the right speed and angle opens it.

Several kinds of manual therapy use indirect approaches, of course. Myofascial release techniques incorporate indirect work. In the Still technique, discussed earlier, the first part of the maneuver is the indirect exaggeration of the position of dysfunction to relax the myofascial elements. Counterstrain, a myofascial therapeutic approach developed by Lawrence Jones in the 1950s, uses compression to further shorten painful already-shortened tender points within muscles and tendons. These and other indirect manual approaches often impact the reflex loops between proprioceptive organs and the central nervous system. But Golgi tendon organs and muscle spindles are absent in bone. Could other mechanisms explain the impact of therapeutic compression on bone tissue? Well, as we well know, injuring a bone hurts. And when there is pain, the central nervous system can become sensitized, causing the pain to linger long after the acute injury has healed. This is aptly referred to as sensitization. This may seem obvious, but I think it’s worth saying anyway: the fact that we feel pain and experience sensitization is proof that the central nervous system is involved in bone pain. But during BST, we’re definitely not hurting anyone—the forces are just too small—and less is known about how nonpainful stimuli in bone are linked to the central nervous system. It seems that either (a) our impact on bony compactions is not mediated by the central nervous system, or (b) we just haven’t figured out how non-painful stimuli in bone are linked to the central nervous system. So what else is going on here?

But we do understand quite a bit about how bones respond to load. We know that, via fluid flow, osteocytes detect mechanical load and initiate bone remodeling. While BST doesn’t lead to bone remodeling in the classic sense (at least not in the duration of one or several sessions), perhaps the melting sensations we feel result from us temporarily altering the behavior of bone water. Another possible explanation for the changes we feel could involve electricity. Through compression, collagen emits an electrical charge, which leads to changes in its structure. We know from earlier that our bodies and cells contain bioelectricity, and that a bioelectric fabric may even govern our genome and evolution. We also learned how crystalline materials within collagen generate piezoelectricity when compressed or stretched, and how this electric charge contributes to mechanotransduction. It has been shown that electric impulses lead to changes in tissue sensitivity, symmetry, motion, and texture. Maybe our impact is fluidic and bioelectric.

A third possibility is that our therapeutic compression acts on the twisty nature of collagen itself, counterwinding it like a twisted rope. Once the rope is unwound (think of the frayed shoelace), more space is created within the compaction for potency to enter and act. My very-unproven-yet-plausible twisted rope theory may help illustrate this.

Scott’s very-unproven-yet-plausible twisted rope theory

We covered the basics of collagen structure earlier. Remember that collagen is mainly responsible for the viscoelastic properties of bone and fascia, and the ability of collagen fibers in osseofascial tissue to ease under compression allows us to enter into a special therapeutic dialogue with the osseofascial continuum. We saw how the hierarchical structure of the collagen fibril makes it similar to a twisted nanoscale rope, and due to structural imperfections in the collagen triple helix molecule, the twisted rope is flexible. Similar to actual ropes or cables, collagen fibrils are naturally loaded with tension and are prone to buckling when compressed. Like multistrand ropes when they are compressed or counterwound, Bozec demonstrated that pure collagen displays “birdcaging,” a separation of individual substrands. Notice how more (not less) space is created between some of the strands (figures 11.1 and 11.2).

This idea helps explain how pure collagen behaves, but what about collagen in bone? Is the same birdcaging phenomenon present? It kind of feels that way, doesn’t it? Due to the staggered arrangements of hydroxyapatite crystals within the collagen fibrils, there is much less room for collagen in bone to buckle than it would on its own. After all, if the crystals didn’t resist compressive load, bone just wouldn’t be bone. But Stock showed us that some collagen distortion in bone is not only present but necessary for optimal load transfer to occur. This tells us that there is still room for collagen in bone to act like pure collagen. Even though bone is rigid, under just the right amount of compressive force at just the right angles, an unmistakable softening occurs. And when we fine-tune the compression—making microadjustments in the amount and angles of force—we seem to enhance the release even more.

We can now envision an invisible yet palpable scar-like bony imprint composed of tiny, twisted collagen molecules arranged into disorganized tangles of larger, bunched-up collagen fibrils, all of which are bungled up in a frazzled, scar-like mess. Then, under just the right amount of compression and at just the right angles, the disorganized pattern of collagen “slackens” (at least temporarily), creating more space between (some of) the individual twists of collagen. More research is needed to substantiate this, but I think that the twisted rope theory is compelling. Combined with picturing the squishy viscoelastic cushion of the collagen “accordion” described earlier, the image of unwinding the twisted rope may serve as a helpful visualization. It does for me.

Okay, enough chit chat—back to our subject waiting patiently on the table! We’ve already cocooned the compaction. Now, we need to figure out how to apply that tricky axial compression that will open the system. I have found that the best way to do this is … well, there is no best way, actually. Our best bet, I think, is to find where the compaction feels most rigid in tension, and then compress the bone directly back into that line of rigidity, twisting a bit here and a bit there, fine-tuning our contact. We may have to play that mini-accordion (described above) to find the best angle. If we use too much compressive force, the spring of the collagen bottoms out. But, if we carefully remain within the fluidic cushion of the bone, collapsing the twists and tensions, counterwinding the collagen like a twisted rope or shoelace, we seem to create more space for potency to enter and act. Again, this is far from an exact science. As in all the stages of treatment, listening to the tissues in our hands is paramount. The tissues tell us what to do.

If the compaction is within one part of a bone, compress that specific area. If the compaction feels more diffuse throughout the entire bone, compress it from each end. If the compaction exists between two bones, compress it from all sides.

Stage 3: Dialogue

The third stage of BST treatment is dialogue, and is very much about listening. This is when we begin to feel (listen to) and decipher the rhythms of primary respiration as they emerge from osseofascial tissue. In my opinion, manual dialogue should unfold like verbal dialogue between two people. Through verbal dialogue, we listen to words and observe other nonverbal cues to understand how we can help. During manual dialogue, we listen and observe with our hands. We interpret tactile sensations to understand how to best offer support. During a verbal conversation, nonjudgmental listening is sometimes enough for a patient or friend to find a solution for themselves. Listening on its own provides an empowering opportunity for self-healing. Through manual dialogue, when we listen using a similar nonjudgmental presence, we offer the body a chance to lean on us so it can change. Both verbal and manual listening can be profoundly therapeutic, since they invite meaningful change to occur from within.

During this stage of BST, as we continue to maintain the compressive dialogue from earlier, the inertial fulcrum itself may come into focus. The inertial fulcrum feels like stillness—a calm, vital presence—within the somewhat chaotic inertial fulcrum-lever system of the compaction. We are not only dialoguing with the levers, here, but also with the fulcrum. The fulcrum is hard at work, balancing the disorganized patterns of osseofascial tissue swirling around it. As we dialogue in compression, creating and holding space for potency to enter and act, primary respiration should begin emerging from the bone, manifesting more strongly from within the compaction. It manifests more strongly because the tissue is getting “healthier” in our hands. We may begin to feel the rotations and movements of the CRI, then the welling up and receding of the mid-tide, and finally the steady presence of the long tide. Remember, if the long tide is hard to perceive, focus on the CRI and mid-tide. Eventually, we may sense a shift when the rhythms coalesce, inhaling and exhaling the bone in one resultant rhythm.

During the dialogue stage, we remain active yet nonjudgmental listeners—volunteering support when necessary, making subtle suggestions here and there, offering encouragement when needed. Our role here is to keep the levers of bone tissue in contact with the fulcrum, bathing them in stillness. As we hold the entire ocean of primary respiration in our hands as the tissue continues to unwind, we fine-tune the pressure to encourage it even more. Like a dependable friend, we reassure the tissue that it can lean on us while it changes.

If the compaction is within one part of a bone, dialogue with that specific area. If the compaction feels more diffuse throughout the entire bone, dialogue with the whole bone from each end. If the compaction exists between two bones, dialogue with it from all sides.

Stage 4: Augmentation

Augmentation is the fourth stage of BST treatment. Like a proud parent running beside their child learning to ride a bike, or like a drama teacher mouthing the words as their student recites them during the school play, the augmentation stage of treatment is when we support the phenomena unfolding before us. We’re not interfering, but we’re still right there, offering encouragement.

Now that primary respiration is breathing the bone beneath our hands, we should be able to recognize the maximum amplitudes of the phases. At the height of the inhalation phase, a natural disengagement of the bone tissue occurs. Here, it’s as if the compaction is expanding, stretching its wings, creating more space for itself as it shifts to a more natural state. We remain in contact with the tissue as it does so and until primary respiration has reached a maximum amplitude for a few complete cycles.

If the compaction is within one part of a bone, augment primary respiration from within that specific area. If the compaction feels more diffuse throughout the entire bone, augment primary respiration within the entire bone from each end. If the compaction exists between two bones, augment primary respiration within it from all sides.

Stage 5: Spreading

The spreading stage is the fifth stage and is the direct part of BST treatment. Once potency has unwound and expanded the inertial bone tissue as much as it can on its own, and the expression of primary respiration is robust, spreading the bone will encourage the tissue to expand a little bit more. As we saw earlier, the expansion occurs within the relaxation phase of the collagen tensile stress/strain curve. Our role here becomes more active again, reversing the direction of our compressive force by applying a spreading action directly against the most rigid torsional shape or pattern of compaction. Here, the term spreading is used instead of stretching or tension, since the idea is to slowly spread the bone as if it were made of taffy. The “taffy” image is another visualization that works quite well. Remember, the spreading stage is slow, gentle work.

Earlier, we learned that in pure collagen, very low tensile loads lead to an unkinking of the collagen molecules. The unkinking leads to a kind of re-jigging of the collagen-water relationship, or a molecular hydroplaning within the tropocollagen, causing a “relaxation” of the collagen. If the tensile force continues to increase, the higher load shifts from the viscosity of the collagen-water relationship to the elasticity of the solid collagenous matrix. Since we’re interested in engaging the same fluids responsible for the formation of the dysfunction, we use very low tensile forces. I’ve put this in bold type because it is important. During BST treatment, it helps to view bone tissue as a fluidic medium. Regardless of the stage of treatment, we are always working within the fluid body of osseofascial tissue. Also, remember that viscosity is rate dependent, so the effectiveness of this stage depends not only on the amount of force applied but also on the rate at which it’s applied. If we spread too hard and too quickly, we’ll bypass the fluidic cushion of the bone, and the taffy will resist. It is worth repeating that this is slow, gentle work.

A helpful way to avoid applying too much spreading force is to simply imagine spreading the bone, and wait for a very subtle relaxation to manifest from deep within the bone matrix. We’re not “lengthening” bones here. Rather, we are waiting for quiet “sigh of relief” texture change from deep within the tissue. When we’re at the right level, sometimes it feels as though two conflicting things are happening at once: the collagen relaxes while the crystal reinforcements hold. So, with our fingers and hands, we cover as much of the surface area of the tissue as we can, and then we just imagine spreading the bone like cold honey on toast.

During the spreading stage, primary respiration sometimes fades temporarily. Once it reemerges, we remain in contact with the tissue for a few complete cycles.

If the compaction is within one part of a bone, spread that specific area. If the compaction feels more diffuse throughout the entire bone, spread the entire bone from each end. If the compaction exists between two bones, spread it from all sides.

Stage 6: Integration

Once the spreading stage is complete and primary respiration is being more robustly expressed from the once-inertial site, we integrate our local work into the global human system. Here, we remain in contact with the once-inertial tissue, expanding our perception to include the entire body and sensing primary respiration breathing within it. We wait for this larger ocean of primary respiration to recognize the local mini-ocean in our hands and then carry it away with its tide. We stay with this sensation for a few complete cycles of primary respiration until the local structures become almost indiscernible from the rest of the body. Once this occurs, we remove our hands or transition to other modalities, if necessary.

More Excerpts From Unwinding Bone

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