Accepted Manuscript

The biomechanical model in manual therapy: is there an ongoing crisis or just the
need to revise the underlying concept and application?

Christian Lunghi, DO, ND, Paolo Tozzi, MSc Ost, DO, PT, Giampiero Fusco, DO, PT

PII: S1360-8592(16)00005-X
DOI: 10.1016/j.jbmt.2016.01.004
Reference: YJBMT 1310

To appear in: Journal of Bodywork & Movement Therapies

Received Date: 2 October 2015

Revised Date: 4 January 2016
Accepted Date: 15 January 2016

Please cite this article as: Lunghi, C., Tozzi, P., Fusco, G., The biomechanical model in manual therapy:
is there an ongoing crisis or just the need to revise the underlying concept and application?, Journal of
Bodywork & Movement Therapies (2016), doi: 10.1016/j.jbmt.2016.01.004.

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 ACCEPTED MANUSCRIPT
The biomechanical model in manual therapy: is there an ongoing crisis or just
the need to revise the underlying concept and application?

Authors:
Christian Lunghi, DO, ND
Paolo Tozzi, MSc Ost, DO, PT
Giampiero Fusco, DO, PT

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Affiliations:

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School of Osteopathy C.R.O.M.O.N. Rome Italy
C.O.ME. Collaboration Pescara - Italy

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Mail address: pt_osteopathy@yahoo.it

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Keywords: biomechanical model, osteopathy, posture, manual therapy, fascia
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Abstract
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Different approaches to body biomechanics are based on the classical concept of ideal posture
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which is regarded as the state where body mass is distributed in such a way that ligamentous
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tensions neutralize the force of gravity and muscles retain their normal tone, as result of the

integration of somatic components related to posture and balance mechanisms. When compromised,
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optimal posture can be restored through the balanced and effective use of musculoskeletal
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components; however, various research findings and the opinion of experts in this field suggest a
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move away from the dogmas that have characterized the idea of health dependent on ideal posture,

to promote instead dynamic approaches based on the interdependency of the body systems as well

as on the full participation of the person in the healing process. Following these concepts, this

article proposes a revised biomechanical model that sees posture as the temporary result of the

individuals current ability to adapt to the existing allostatic load through the dynamic interaction of

extero-proprio-interoceptive information integrated at a neuromyofascial level. Treatments using

this revised model aim to restore the optimal posture available to the person in that particular given
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moment, through the efficient and balanced use of neuromyofasciaskeletal components in order

to normalize aberrant postural responses, to promote interoceptive and proprioceptive integration

and to optimize individual responses to the existing allostatic load. The latter is achieved via

multimodal programs of intervention, in a salutogenic approach that, from a traditional perspective,

evolves on an anthropological basis, to the point of centering its work on the person.

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Introduction

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The classical biomechanical model (BMM) analyses the relationship between body behaviors and

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gravity, as well as the organization of static and kinetic chains in relation to antigravity mechanisms,

spinal and vestibular reflexes. Efficient posture and good mobility of the entire musculoskeletal

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system have always been the central focus of BMM. In attempting to explain the emphasis in the
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approach of A.T. Still (the founder of osteopathy) that was placed on the spine and locomotor

system, Irvin Korr repeatedly referred to the musculoskeletal system indicating it as "the primary
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machinery of life" (Korr, 1976), where causal factors and factors responsible for the maintenance of
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different disease states can sometimes be established. In this sense, postural changes entail a
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substantial asymmetry of body volumes and kinetic functions, with the consequent modification of

body patterns, mediated by the sensory readjustment of specific neurophysiological mechanisms.

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Such postural changes may be found in the loss of harmonious relations between skeletal segments

in three spatial planes as well as in modifications of articular mechanisms and muscular synergies.
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This would cause changes in muscle strength and load distribution on skeletal segments. In the
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therapeutic field, different disciplines have developed interventions of a biomechanical kind with

the aim of dealing with possible deviations from the ideal posture. This approach is historically

rooted in the structural and biomechanical aspects of the body and seems to be attainable by the

correct response to linear mechanisms of compression, counterweight, tension, effort and balance.

However, osteopaths who, until a few years ago, while being anchored to the concept of the ideal

posture, were describing how difficult it was to detect in clinical reality, now claim that a well

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compensated body, regardless of asymmetry and postural adaptations that may be present, might be

considered as a balanced function (Kuchera, 2003; Kuchera, 2010).

In the light of these differences in interpretation and implementation of the concept of human

posture and biomechanics, the authors intend to explore here whether, to what extent and how we

should now move away from the concept of ideal posture. In recent years epistemological

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discussions have been initiated on the importance of osteopathic principles in defining the unique

characteristics of osteopathy (Fryer, 2011). At the heart of these discussions, much attention has

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been placed on how some approaches, such as the biomechanical-postural-structural model, have

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been overvalued in the past and what now needs to be changed (Lederman, 2011). In order to assess

these arguments with critical thought, in 2011 the Journal of Bodywork and Movement Therapy

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invited five leading experts from the world of manual medicine, osteopathy, chiropractics and
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physiotherapy to a debate on the subject (Chaitow, 2011). In particular, they replied to the thesis

that, according to Lederman (2011), the use of manual techniques to readjust, correct and stabilize
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misaligned structure cannot be justified. The experts argued that without restoring postural balance,

mobility, strength and resistance, normal functionality without pain may be much more difficult to
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achieve through rehabilitation strategies. Therefore, it is necessary to consider holistic approaches

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aimed at integrating body structure and postural function, such as osteopathic manipulative
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treatment. Taking up the discussion in this regard, the authors of this article propose a further step.

The multifactorial nature of biomechanical adaptations cannot but lead the operator towards a
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global approach that considers not only the assessment of the integration between the structure of an
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area and its related function, but also how this relationship might influence the allostatic load of an

individual, their personal adaptive capacity to the load, and how this is reflected on their posture.

This includes the continuous postural response of connective-fascial elements to internal and

external stimuli that the person is subjected to (Lunghi, 2015a), as well as the possibility that an

organism is well compensated from a postural standpoint and adequately functioning, independent

of the asymmetry and adaptations which may be present.

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Traditional view and critical review of the BMM

For some manual interventions such as osteopathy, the BMM considers the body as an integration

of somatic components connected to posture and mechanisms for balance (E.C.O.P., 2011a). Stress,

or imbalance of any kind within this mechanism, will have an effect on dynamic function,

provoking a major expenditure of energy, altered proprioception, changes in articular structures,

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impediments to neurovascular function, as well as changes in metabolism (Hruby, 1992).

Treatments within this model aim to restore optimum posture using efficient and balanced

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components of the musculoskeletal system (Rogers et al., 2002). Perfect posture was regarded as

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the state in which body mass is distributed in such a way so that the muscles maintain their normal

tone and ligamentous tensions neutralize the forces of gravity (Kappler, 1982). In this regard,

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Kuchera (2003) describes the osteopathic concept of ideal posture as an optimal posture for a
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given individual in the attempt to achieve and maintain a balanced configuration of the body with

respect to the force of gravity. However, in spite of being anchored to the concept of the ideal
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posture, Kuchera also reminds us how difficult it is to find it in clinical reality.

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Osteopaths, chiropractors and many other manual therapists have given different explanations to
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malpositions of body structures, thus developing different approaches to treatments. A recent

current of thinking and modality of intervention in the chiropractic field Chiropractic Biophysics
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(CPB) - proposes avoiding short treatment sessions focused on the symptomatic area, while

promoting long-term therapeutic programs instead, with the objective of improving the general
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patients wellness as well as the balance of the individuals posture (Harrison et al., 2000). CPB is
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intended to be a systemic scientific model for the global care of the individual and goes beyond the

concept of correcting a local subluxation. For instance, if the patients spinal curves are far from

their ideal balance, the suggested treatment involves weekly-based sessions of mirror image

adjustments, neck and low-back extension traction, and mirror image exercises with the aim of

restoring the structure and function of spinal curves within 6 months to one year (and then to shift

to a monthly-based maintenance program). A study from Paulk and Harrison (2004) suggests that

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the CPB method can restore lumbar lordosis and in some cases reduce symptoms in patients

suffering from chronic low back pain, following an accurate analysis of postural deviations and a

careful assessment of the spinal curves. Furthermore, this approach has been reported to be effective

in normalizing cervical lordosis and improving symptoms within a year during the follow-up study

of a 41 years old patient with syringomyelia (Haas et al, 2005). Despite further research being

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needed in this field, it is obvious that some authors within the chiropractic community are shifting

their therapeutic choice from structural manipulation aimed to normalize a local subluxation

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towards a multimodal approach to posture based on the use of bioengineering principles and the

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human ability to maintain an erect posture in a painless and comfortable manner with low energy

expenditure (Harrison et al, 2000). Harrisons spinal model, in particular, is proposed not only as a

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diagnostic but also as a predictive model for the development of back pain when the spinal curves
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lose their optimal geometrical relationship and functional balance.

The concept that an altered or impaired function in a specific body region may potentially influence
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other areas or the posture itself is not a new topic in the manual therapy field. In 1955 Steindler

proposed a mechanic bioengineering model that interprets the human body through a series of
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kinematic chains and interconnected junctions by means of which any movement can potentially
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involve and influence the whole system (as for instance the dorsiflexion of the tibiotalar joint
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producing ascending biomechanical compensatory changes at the knee, hip and lumbar spine

articular complexes). Nowadays, some authors (Sueki et al, 2013) observe that most of the
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impairments identified by manual therapists in their patients are not limited to the biomechanical
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system itself but include altered processes originating from the overload of other systems that, in

turn, influence the musculoskeletal function and clinical presentation. These considerations are

linked to the concept of regional interdependence according to which a dysfunctional unit in a

system may deliver abnormal stresses to different segments in the same system or in other related

systems, hence favouring the establishment of new dysfunctions elsewhere (Erhard and Bowling,

1977). In other words, the aberrant mechanisms initiated and maintained by the primary

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dysfunctional area may induce an allostatic response involving interdependent physiological

processes of neural, somatic, visceral and biopsychosocial nature. Therefore, in the attempt to

preserve the state of health, we must rely on various adaptive strategies of different kinds:

physiological, cognitive, affective, psychosocial etc. (Bialosky et al, 2008). Selye (1956) described

the local adaptation syndrome (LAS) as a chronic inflammatory reaction to stressful factors such

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as chemical, physical, biological, environmental, psychological and emotional stimuli. The latter

trigger a local tissue reactive response that may impair the blood flow and thus accumulate

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metabolic wastes even causing changes of tissue texture. The stress load is a variable that moment

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by moment may lead the body either to adapt or to activate the intrinsic self-regulatory and self-

healing properties. Therefore the LAS represents the tissue response to a given stressor that surely

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prompts the local function to readapt to the new contextual request but also may promote a general
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adaptation of the whole system (Chaitow, 2006). The adaptation process allows us to understand the

concept of health in biological terms but also the concept of somatic dysfunction currently defined
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as impaired or altered function of related components of the somatic (body framework) system

(E.C.O.P., 2011b) and classified with the code M99.00 in the International Classification of
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Disease, ICD-10 (2010). This is considered to be one of the main factors affecting the economy of
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the body and the root of many disturbances even in remote areas from where the dysfunction is
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located; the normalization of which is considered central to restoring the normal mobility and

function of the entire musculoskeletal system. Therefore both the concepts of regional
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interdependence and somatic dysfunction support the possibility that an altered musculoskeletal
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function may influence the impairments of other related body systems. In addition, despite the fact

that the treatment of the symptomatic area is considered as the primary objective of many

therapeutic programs, in the light of the concepts described above, it is necessary to apply different

multimodal strategies which address the functional interdependency of the body systems, especially

in the case of a recurrent pain pattern that persists even after the intervention has been delivered in

situ (Sueki et al, 2013). Thus can the treatment of the body posture be considered a valid

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intervention? Eyal Lederman, an osteopath and doctor of research, is one of the authors critical of

the BMM, which he has defined as the postural-structural-biomechanical model (PSB). Following

Ledermans reasoning, and the related debate, it is time to lay the foundations for a new concept of

BMM from a neuromyofascial and postural biotensegritive perspective.

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The JBMT debate on the BMM

Using back pain as an example, Lederman has stated that the PSB model does not work, in that

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there is no demonstrable or credible relation between back pain and postural and biomechanical

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configurations. As a consequence, attempts to treat and normalize these configurations are

meaningless and a waste of time and resources.

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Lederman reports that manual therapists still cannot justify using manual techniques to readapt,

correct, or balance a misaligned structure (Lederman, 2011). The suggestion is that a multi-
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disciplinary rehabilitative strategy, focusing on functional motor re-education, behavioral

methodologies and psychological, cognitive and therapeutic exercise approaches, is the best way to
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resolve and prevent dysfunctions such as back pain. The effects of manual techniques are, in the
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best cases, short-lived and are largely redundant (Lederman, 2011). It can, however, be argued that

manual techniques permit the recovery of force and resistance, mobility and postural balance. This
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makes it easier to restore function without pain, through a multi-disciplinary rehabilitative strategy
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(Chaitow, 2011). Ledermans statements bring into question the methods of many manual therapists.
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He suggests an expansion of the PSB model, proposing individualized treatment for each case,

based on the identification of the processes generated by the actual state of the patient.

Subsequently stimulation / signals / management / care that will support / assist / facilitate change

must be provided (Lederman, 2011). All this Lederman defines as the process approach. This

argument is in itself not controversial, in that it suggests that passive manual treatments where the

subject is not addressed cognitively, proprioceptively and interoceptively, are of little value in the

process of healing and recuperation. At the 7th Interdisciplinary Congress on Low Back & Pelvic
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Pain in 2010 many lecturers echoed and sustained Ledermans position in many ways. There were

also lecturers who proposed alternative ways of breaking the impasse, as in the case of OSullivan

who presented a biopsychosocial approach to back pain, paying particular attention to the

mechanisms at the root of the changes that can cause pain (OSullivan, 2010). The cognitive and re-

educational healing strategies OSullivan suggested are less extreme than those of Lederman.

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In order to critically evaluate these arguments, The Journal of Bodywork and Movement Therapy

invited five authoritative world experts in manual medicine, osteopathy, chiropractic and

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physiotherapy to respond to Ledermans thesis (Chaitow, 2011):

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1. Gary Fryer (PhD, BSc Ost, ND) states that although evidence connecting posture with lower

back pain is lacking, there exists a strong rationale explaining how posture can generate pain.

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An asymmetric posture can create the overloading of ligaments and other structures, may

contribute to the exhaustion of an individuals reserve of energy, which translates into tension
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and pain. Fryer concludes by stating that the BMM was overvalued in the past, but that it is best

to consider the multi-dimensional nature of pain to establish a patient centered holistic

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approach.
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2. John C. Hannon (DC) believes that the criticisms of Lederman are too simplistic. He states that
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the psychological aspect of the patient should be considered essential in the care of the

individual. He reports the effectiveness of traditional massage that is able to obtain immediate
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results on pain through the use of heated and padded tables, longer duration of treatment and the
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consequent deeper relaxation of the patient. He believes that manual therapy should not be

based solely on the commitment of the operator to make a diagnosis, but to unite the

psychological state of the patient to the treatment, thereby combining art and technique to make

each individual an active and not a passive part of the treatment.

3. Irvin (DO) responds with a more complex postural pattern based on three fundamental systems:

the feet, the sacrum, and the central nervous system (CNS). In the case of an imbalance in one

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of these three systems, a modification of the entire posture with a resulting onset of pain may

occur. It is not always possible to demonstrate a direct relationship between the BMM and the

presence of pain, but tissue modifications which are a consequence of incorrect posture can

maintain or aggravate a pre-existing imbalance. The BMM is not considered in decline, but

thanks to study and research, is in development, revision, and integration.

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4. Lee (BSR, FCAMT, CGIMS) criticizes Ledermans way of approaching the BMM, in as far as

lower back pain cannot be classified from a single cause. The cause of back pain must be found

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in a more global approach which also takes into consideration the clinical experience of

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operators. In this pattern it is not possible to isolate a BMM which would be the same for every

patient with lower back pain. Therefore, the BMM described by Lederman is not considered

accurate or reliable.
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5. McGill (BPE, MSc, PhD), finally, strongly criticizes Ledermans BMM approach, in that back
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pain is a subject so vast that it cannot be schematized into a protocol. Every individual will need

a personalized therapeutic approach. Studies by Lederman are therefore of little applicability in

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that they treat this subject from a monodimensional perspective and do not take into
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consideration the actual evolution of back pain (from the dehydration of discs, to modifications

in the functions of the articular facets and the consequent passage of the transference of pain
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from disc to articular facet). The central sensitization will influence the connection between
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pain, mechanical and functional factors and the correction necessary for the patient to finally
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reduce the neuronal response. Thus the connection between pain and biomechanical factors is

variable within the natural process of back pain. McGill observes that Lederman had omitted

particularly important research cited in his article, particularly those which tend to favor a

relation between a BMM and the probable development of lower back pain, such as the

neuromuscular asymmetry which anticipates an eventual episode of lower back pain. Lederman

seems to have confronted the arguments without taking into consideration the multiple inherent

aspects of back pain such as incorrect posture, the mechanism of therapeutic exercise and its
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effectiveness, the kinematics of movement, neurological function, the mechanism of pain,

damage to the spine, patient classification, the loading of tissues, etc.

Even though it seems the work was inappropriate and without rigor, this discussion can be the start

of more accurate and specific scientific research. These findings do not seem to have been

conceived in relation to the clinical practice of manual therapists and osteopaths, still busy today

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correcting misaligned or asymmetric structures. In spite of this, a more modern idea of posture

can be identified with the strategy adopted by the neuromyofascial system to react to the force of

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gravity and proprioceptive and interoceptive afferent stress or allostatic load.

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Innovation and current evidence on human biomechanics and posture
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Mans adaptation to the force of gravity and the erect posture seems to be achieved through

complex evolutionary mechanisms in myofascial and skeletal tissue with the purpose of improving
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stability with minimal energy expenditure (Zavarella et al., 2015). In the erect position, normal
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muscle tone maintains the body standing with the minimum of energetic expenditure (almost 7%
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more) compared to the supine position (Masi and Hannon, 2008), often for prolonged periods

without causing fatigue. Modern research (Masi et al., 2010) suggests that human muscle tone at
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rest is related to the passive or contracted muscoloskeletal tissue. This would result from its intrinsic

viscoelastic properties, which is the base level of passive muscle tension and its resistance to
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passive stretch which contribute to the maintenance of postural stability. Myofascial tone is defined
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by Masi and colleagues (2010) as Human Resting Myofascial Tone or Tension (HRMT). Conversely,

the co-contraction of muscle is under active neuromotor control, which provides higher levels of

tone for better stability. Functionally, the HRMT is integrated with other networks of passive

tension, such as fascial and ligamentous tissue to form a biotensegritive system (BOX 1).

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[BOX 1. Biotensegrity and its implication in manual therapy and research. Through the

principle of biotensegrity, the body is able to integrate different stimuli from mechanical forces,

which are distributed nonlinearly across the structure, thus translated into biochemical signals, to

finally maintain the functional and structural integrity of the system (Swanson, 2013; Chaitow,

2013). From molecule to cell, and eventually to tissue and organ, the biotensegrity structure is, at

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each level, intimately connected into a hierarchical organization. This helps us understand how

forces applied by a manual therapist on the skin bring about responses either at a cellular level,

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arriving at changes in gene expression (Maas and Sandercock, 2010), or at a global level, leading to

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postural adaptations (Cao et al., 2013). The principles of biotensegrity can thus be used to bridge

the divide between researchers and clinicians, in addition to assisting research into the active

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mechanisms of manipulative medicine. In fact, the mechanotransduction, or rather the process of
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converting mechanical energy into chemical energy through specific cellular and molecular

transmitters could represent one of the mechanisms of interaction between manual intervention and
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tissue response (Tozzi, 2015a). END OF BOX 1]

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Evidence suggests that the transmission of tension is a basic property of the surface of muscle cells,
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and that the specific morphologic junctions are the result of a dynamic interaction between muscle

cells and the tissues they adhere to (Trotter, 1993). The sites most studied in the transmission of
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tension are the distal portion of muscle fibers, where in fact they are in contact with both connective

and epithelial tissue. The morphological and molecular similarities of muscolotendinous junctions
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in different animals suggest that the challenge to create a strong adhesive junction between muscle
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fiber and tissue with different physical properties is essentially the same for all muscles. In most

animals, aside from phylum, the distal portion of muscle fiber is typically folded, producing a

junctional interface which significantly reduces the absolute value of the tension on the cellular

membrane (Trotter, 1993). This assures that the principal stress vector on the cellular membrane

will be tangential to the tension, minimizing the concentration of stress.

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Thus, muscoloskeletal tone at rest is an intrinsic viscoelastic tensile property, which expresses itself

within the kinematic chains of the body, organized tensegratively. This function is inseparable from

the corresponding fascial components and the tendino-ligamentous structures. In other words, the

HRMT is a passive myofascial function, which operates within the tensile network of tissues. This

passive tension is independent from CNS activity, and is derived from the intrinsic molecular

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interaction of actin and myosin filaments in the repeating units of sarcomeres; however, muscular

contractions activated by the CNS generate much more tension, and are transmitted by the

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contractile elements of fascia (Masi and Hannon, 2008). Nevertheless, myofascial tissue generates

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integrated layers and networks of passive and active tensile forces, which provide stabilizing

support and control for body movement (BOX 2).

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[BOX 2. The myofascial skeleton and its function in body movement and posture. Passive
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myofascial tension, independent of CNS control, furnishes a basic stabilizing component to aid and

maintain a balanced posture. In this regard, Wood Jones (1944a; 1944b) demonstrated that muscles
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and tendons, which find a diffuse insertion on the fascia, use these extended sheets as a homologous
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function as in the ectoskeleton of invertebrates. This refers to a skeleton of soft tissue for muscular
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insertions called ectoskeleton. Tendon networks display a distinctive feature in the hands and feet.

On the back of the hand, for example, there is a series of flat extensor tendons, which expand
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themselves from underneath the extensor retinaculi in the direction of the fingers. The tendons are

connected to each other by highly variable fibrous bands known as juncturae tendinum (von
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Schroeder and Botte, 1997). Together with the tendons themselves, and their associated fascia, these
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fibrous bands contribute to the formation of a complex network of tendinous tissue on the back of

the hand, which was probably developed from one embryonal blastoma. The bands are probably

important in the spacing of the extensor tendons, channeling forces between them, and coordinating

the extension of the finger (von Schroeder and Botte, 2001). This structure represents a key to the

extensor surface of the hand, thanks to its integrated function of the internal tendon network. As

such, any particular function and its single elements serve this primary role. Contemporary

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anatomists use the term super tendons to describe a network of tendons and closely related

structures (articular capsules, tendon sheaths, pulleys, retinacula, fat pads, and bursae) where the

complex internal function is superior to each singular structure (Benjamin et al., 2008). Recently,

the complex interaction of various digital tendons has been evaluated in the context of the co-

evolution of the body and the brain, allowing the principle of non neural somatic logic to emerge,

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on the basis of cellular function (Valero-Cuevas et al., 2006). END OF BOX 2].

A complex analysis of HRMT is in the evolutionary phase and has, through electromyography,

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identified silent signals of lumbar muscles in an erect, relaxed position. The HRMTs passive role in

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contributing to the maintenance of a balance posture is sustained by the biomechanical principles of

elasticity, tension, stress, rigidity, and myofascial tensegrity. More research is necessary to

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determine the molecular base of HRMT in sarcomeres, the transmission of tension between fascial
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elements which envelop the micro and macro anatomical structures involved, and the way in which

the myofascia help to maintain an efficient, passive and balanced posture. Interestingly, a
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significant deficiency or excess of postural HRMT may lead to symptoms of musculoskeletal

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disturbances and pathologies. For instance, axial myofascial hypertonicity can be a predisposing
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factor in ankylosing spondylitis (Masi et al., 2010). This deforming, often progressive, condition

leads to rigidity and bony lesions localized at the osteotendinous junctions, with consequent
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excessive concentration and transmission of force, up to tissue micro-lesions and maladaptive

inflammatory reactions.
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Considering such an evolution of the concept of posture and biomechanics, and evaluating the role

in which HRMT can influence postural balance, we have encountered several factors, each different

yet intertwined. Each one of these responses is significant in bringing about the final result; the

storage, or memory, of responses in fascial tissue and the consequent individual postural patterns

(Tozzi, 2014). A dysfunctional tissue memory could therefore take place during the infiltration of

fibrous tissue and meshwork collagen in the nodal points of fascial bands, along with a progressive

loss of elasticity. Alterations on the fascial level related to architecture, contractility, viscoelasticity,
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fluid dynamics, acid/alkaline balance, somatic and autonomic neuro-fascial interactions, metabolic,

piezoelectric and epigenetic factors, can interact in the onset of somatic dysfunction, as suggested in

the neuro-fasciagenic model (Tozzi, 2015b). It is proposed as a model unifying much explored

neurogenic aspects with mechanisms related to the fascia underlying the genesis and maintenance

of somatic dysfunction (Figure 1). Changes in the relation between the connective structures and

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their functionality, also detectable by palpation, would be the result of changes involving the tissues

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from the cytoarchitecture as far as the extracellular matrix, resulting in structural, chemical,

hydrodynamic and bioelectrical repercussions over the whole fascial network of the body. This

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would require a tissue adaptation to local stress through a global connective reorganization (Tozzi,

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2015b). Consequently, these changes in myofascial tissue can alter the activity of the related higher
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centers responsible for both proprioceptive and interoceptive sensorial integration, and motor and

postural control (Schabrun et al., 2013; Tsao et al., 2008).

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Hence the evolution of a new concept of posture is emerging, leading to a revised concept of BMM,
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which transcends the idea that posture is solely compressive, static and linear. Yet the operating
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assumption of many operators seems to be firmly tied to the classic BMM, even though this would

not be accepted by many authors and theories, as anything more than a holistic idea.
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The proposed revision of the BMM

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Principles and aims

The BMM frames the patient from a structural or mechanical perspective. The structural integrity

and the function of the musculoskeletal system are interactive, interdependent with neurological,

circulatory, respiratory, metabolic and behavioral systems (Hruby, 1992). Fascia and connective

tissue can serve as a unifying characteristic of all these elements (Tozzi, 2015b), playing an

integrative role on mechanical forces throughout the whole body. According to Zink and Lawson
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(1979), by exploring posture through myofascial patterns, the operator is able to discern the signs of

the functions and dysfunctions from an anatomical, physiological and psycho-social point of view.

In fact, the concept that the perception of the body, environment, emotions and psyche affects

posture (Sypher, 1960) is intrinsically related and integrated in the BMM (Irvine, 1973). Individuals

suffering from mood disorders manifested rigid and imbalanced postural patterns. In contrast, in a

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healthy individual, the posture tends to show a soft quality and good body flexibility. This implies

good adaptability and homeostasis. The BMM assesses the individual by taking into consideration

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that the body is a unit and that the adaptations are parts of a tensegrity system, in which a minimal

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change in any body region can cause global biomechanical changes, at both tensional and

ergonomic level. Biotensegrity is the ability of the musculoskeletal system to adapt itself to

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different elements of continuous tension and discontinuous compression, in order to maximize
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efficiency and comfort (Swanson, 2013). An imbalance in this relationship can influence the

function of all other physiological systems. In the same way, changes to postural mechanism and
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related connective tissue often influence vascular, lymphatic, neurological function, metabolic and

behavioral responses, independently of etiology. This process compromises the individuals

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capacity to adapt to various stressors or to recover from injuries, and to prevent further damage.
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In the first place, posture can be considered as the result of the dynamic and constant interaction of
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two groups of forces: the force of gravity and the force of the bodys reaction to the environment. A

postural deterioration indicates the individuals loss of ability to efficiently counteract gravity.
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Respecting the rules of economy, comfort and pain, the optimal posture for a given individual at a
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given chronobiological moment will be "the best attempt" that the body makes through the

integration of sensory information and the best distribution of body mass. This decreases muscular-

postural energy expenditure and harmonizes the compressive forces on the weight-bearing

structures through a balanced ligamentous tension. If the body presents structural changes, the

operator will identify if this change is subject to an increase in energy demand or obvious pain. In

this case we can define the "postural imbalance" which stresses the soft tissues sensitive to pain and

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is affected by events and/or structural changes, such as somatic dysfunction. This will create a

predisposition to gravity-related tissue strain and pathophysiological responses resulting in various

symptoms such as fatigue, back pain, headaches, etc. (Irvine, 1973).

Secondly, the concept of posture needs to be integrated within the whole context of the individual.

In fact, remembering the unity of the body, this leads to an evaluation of the integration between

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structure and function to understand the connection between how two people who have the same

dysfunction can take different paths: compensation/adaptation or failure/inability to adapt. The

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human body is capable of adapting itself to several environmental or internal changes. What does

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this mean in biological terms? Today allostasis seems the most precise response, defined as the

capacity of physiological systems to maintain stability by means of change and adaptation

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(Schulkin, 2003). It is a metasystem of regulation which maintains the stability of essential systems
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for life (homeostatic systems). The function of allostasis is the consistence of systems through

various homeostatic controls, but actually the fitness of the system in respect to the environmental
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demands on the organism by natural selection (Selye, 1956; Schulkin, 2003). Adaptation is the main

element of stress response, by which a biological mechanism restores balance and minimizes the
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effects of variables, through the interdependence between structure and function. Therefore, posture
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can be interpreted as the temporary result of the individuals current ability to adapt to the present
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allostatic load through the dynamic interaction of extero-proprio-interoceptive information

integrated at a neuromyofascial level.

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Zink proposed that myofascial compensation pivots on four anatomical transitional areas
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(lumbopelvic, thoracolumbar, cervicothoracic, craniocervical) that play a major role not only in

defining the spinal curves, but also in compensating regional patterns, both during the periods of

development and learning but also in adult life. The concept of the common myofascial pattern is

accepted in osteopathy as it, thanks to palpatory tissue tests, and can furnish a quick look at the

interrelationships existing between body, mind, spirit, and the allostatic load of a person (Zink and

Lawson, 1979). This compensatory myofascial pattern represents a useful, functional, and

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beneficial response without manifesting evident symptoms on the part of the musculoskeletal

system, as in, for example, the consequences deriving from allostatic overload, structural

asymmetry, that of lower limb discrepancy and its overuse. Postural imbalance, however, describes

the same phenomenon with the difference that the changes of adaptation are dysfunctional,

symptomatic, and therefore highlight the failure of homeostatic mechanisms.

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In discussing the modalities for applying the BMM, the authors therefore advance the following

proposal: the multifactorial nature of the adaptations and biomechanical allostasis. The term posture

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has inherent ideas of movement, fluidity, action and reaction, integration, reciprocity, tensegrity,

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economy, self-organization, adaptation, complexity, and multi-sensory experience. And this makes

it so "complex" that a systemic perspective is necessary to gain a comprehensive understanding.

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Furthermore, in posture we find the same features that are found in complex systems, such as the
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non-linear thermodynamics and the ecology of autopoietic systems (Zhang et al., 2014). This

multifactorial nature requires a comprehensive approach that considers:

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1. the evaluation of the integration between a structure and its related function, in order to observe
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to what extent this relationship could influence the allostatic load of an individual as well as their
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ability to also adapt through postural reflexes;

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2. the neuromyofascial component in the continuous postural response to internal and external

stimuli which the body receives and integrates through the interoceptive and proprioceptive senses;
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3. the biopsychosocial influences on a given person at a given time, that makes the adaptive
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response much more individual and unique.

From this follows the complexity with which this adaptation manifests itself, in a non-linear way,

permutable, unpredictable, but observable. This, today, according to the authors, is the necessary

revision to guarantee the evolution and viability of BMM (Table 1). The complex relationship

between inputs (visual, vestibular, occlusal, somatoemotional, proprioceptive) and outputs (postural

and adaptive compensation) manifests itself in the myofascial tone (Masi and Hannon, 2008; Masi
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et al., 2010) in a perennial search for new dynamics of balance. The revised BMM thus proposes a

posture to be read and not corrected, interpreted and not judged. An ideal posture to be reached at

all costs, therefore, does not exist. Instead a posture is an epiphenomenon: the efferent result

(musculoskeletal) of an underlying afferent complexity (neuromyofascial). The treatment

possibilities offered by this proposed revised BMM do not then work on the efferent reflex arc

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(motor), but on the afferent reflex arc (sensory), aiming to identify and treat altered integrated

somatic information that has caused the postural alteration (Zavarella et al., 2015).

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For example, we can find a reduction of movement in an ankle caused by post-surgical adhesions

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which, independent of the applied surgical procedure, may become traceable in the underlying

levels (from skin to bone, from fascia to nervous tissue). The information coming from the scarred

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area comes not only from the skin, but from any and all tissue involved in the trauma and the
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intervention. The same changes will be observed in the efferent system when the messages return to

the ankle and motor system, thus altering the global postural response. Along the pathways of
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various messages, a symptom can emerge, probably in the area least capable of compliance
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(Bordoni and Zanier, 2013), as, for example, in the spinal control of the ankle which can become
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symptomatic with relative hypertonia in the paraspinal muscles, painful to the touch. When

stimulated in this way, the sympathetic nervous system can produce local vasoconstriction of the
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ankle and again disturb the postural balance (Macefield, 2005; Mouchnino and Blouin, 2013).

Frequently, the patient develops sensory symptoms, even in the case of a small, aesthetically
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acceptable scar, because the adhesion can create entrapment along the course of the nerve (such as
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the peroneal nerve, citing the ankle as an example). Trapping will not only be of mechanical origin,

but also in response to the afferent postural system which induces involuntary local and segmental

contraction (Gilbey, 2007; Raju et al., 2012). As a result of the constant stimulation of the pain, the

CNS and peripheral nervous system adapt and change their structure, creating a vicious cycle

(Zwerver et al., 2013; Day et al., 2012). Even the visceral nociceptive stimulus and the interoceptive

protopathic pain, carried by the C fibers, produces the same effect, as the central sensitization is

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established at a subcortical level (brainstem and/or spinal cord) and does not need to come to

consciousness (Jnig, 2013). The neurologists who work on scar tissue with prolotherapy and neural

therapy found the same mechanism of altered afferent information (field of interference) which can

create the basis for more serious organic and postural disorders (Gary, 2011). Therefore trauma,

scarring and adhesions at any level from teeth to feet can alter the dynamics of walking, chewing,

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and the proper distribution of load (Rowe et al., 2005; Skraba and Greenwald, 1984; Harrison et al,

2005); as in the case of a scar on the elbow that can cause postural problems related to the gait,

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cervical and lumbar pain (Bordoni and Zanier, 2014). In addition, some authors, hypothesize that

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the presence of a dysfunctional vertebra may develop pain, increased muscle tone and altered

weight bearing with consequent postural changes, because of a dysfunctional autonomic efferent

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pathway, influenced by electrical and biochemical afferents (Brumagne et al., 2008; Shirzadi et al.,
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2013). Every tissue can potentially become a source of aberrant afferent stimuli that in turn can

elicit autonomic efferent reflexes with consequent changes in posture via the influence on
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myofascial bands (Kumka and Bonar, 2012; Benjamin, 2009) or myofascial tissue in general, such

as the subcutaneous, aponeurotic fascia, dura mater, perimuscular, perivascular and perinevrial
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fascia. In addition, the fascial system of the limbs should be considered as communicating with the
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whole body, in particular through the thoracolumbar fascia (Benjamin, 2009). The latter, if
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undergoing dysfunctional processes, causes arthrokinematic abnormalities to the back or shoulder

regions (Willard et al., 2012). In fact, when the fascial tissue is not in its normal physiological
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condition, the fascial receptors such as Pacini and free endings may become nociceptors and
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promote the onset of a symptomatic complex (Benjamin, 2009; Kumka and Bonar, 2012). By

applying this model in treatment, the neuromyofascia may be primarily involved and activated so

that it can respond to postural realignment (Dunnington, 1964). The treatment of fascial

compensation patterns, also thanks to interventions in transitional areas and the corresponding body

diaphragms (pelvic/thoraco-abdominal/superior thoracic/tentorium) has produced positive

physiological changes in "healthy" people, such as decreased respiratory and heart rate, increase in

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tidal volume and decreased skin resistance (Ortley et al., 1980). This approach may also be useful in

planning preventative treatment for a general population not affected by a manifest disease or

musculoskeletal disorder, as in the case of the subjects enrolled in the study of McPartland and

colleagues (2005), where cannabimimetic, anxiolytic, sedative and analgesic effects were

found. This study suggests that osteopathic manipulative treatment, and, in particular, the work on

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fascial compensation patterns, can be associated with and mediated by the endocannabinoid system.

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Examples of the application of the revised BMM in evaluation and clinical decision making

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processes

The revised biomechanical viewpoint guides the operator in the evaluation of somatic dysfunctions

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related to the patients posture, as well as in the treatment of structural, vascular, neurological,
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metabolic and behavioral function by re-informing the neuromyofascial component. The objective

is to optimize the patients adaptive potential by restoring structural and functional integrity. Some
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evidence supports the possibility of improving dysfunctional postural patterns through osteopathic
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manipulative treatment (LeBauer et al., 2008; Brooks et al., 2009), although further research in this
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direction is still necessary (Posadzki et al., 2013).

The postural evaluation process, should firstly inform the operator if the patient is able to respond
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positively to postural treatment in terms of time, cost and effectiveness. Subsequently, it should
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inform the operator if the persons posture:

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1) plays a role in the revealed clinical picture;

2) represents a significant risk factor for current or future pain, dysfunction or disease;

3) is the result and the best possible adaptation to pathogenic causes and damage on a

neuromyofascial level;

4) is the manifestation of local, segmental and/or global imbalances in the interdependent

relationship between structure and function.

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In the evaluation process (Figure 2) the operator assesses global (myofascial compensatory

patterns) and local (somatic dysfunction) tissue adaptability that are clinically relevant for postural

adjustments. For this purpose, the BMM implies:

1. Enlistment of the person for manipulative treatment, through a differential diagnosis and an

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objective evaluation. This requires the operator to assess the underlying causes of pathology in

order to understand the influence that the disease has on energy levels and body mechanics. Some

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diseases, in fact, can affect posture on specific levels and can have specific consequences. An

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example would be a spondylolisthesis at L5-S1, which affects most of the sagittal plane, having the

effect of anterior postural displacement, resulting in iliolumbar strain, as well as aggravation of

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lower back pain and nerve root compression. This kind of presentation could lead to the referral of
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the person to their doctor (Tozzi, 2015c);
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2. Verification of the presence of postural compensation and decompensation (Chaitow, 2009). In

this phase, the operator observes the person to assess their individual adaptive ability, through
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postural tissue responses (Lunghi, 2015c.). Using a specific test of tissue preference in terms of
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quality of motion for the four transitional areas, Zink and Lawson (1979) argue that it is possible to
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classify myofascial patterns in a clinically useful way (BOX 3);

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[BOX 3. Zink myofascial patterns (Lunghi, 2015c.)

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Ideal fascial patterns (craniocervical/cervicothoracic/thoracolumbar/lumbosacral transitional

areas show a minimal alternating preference for sidebending-rotation): minimum load

adaptation transferred to other regions, the condition of tissues that can also indicate the

capacity of the individual to maintain the alternation of homeostatic/allostatic processes;

Compensated fascial patterns (craniocervical/cervicothoracic/thoracolumbar/lumbosacral

transitional areas show a clear alternating preference for sidebending-rotation): which alternate

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direction from one area to another and usually with some kind of adaptation. This tissue aspect

can be an indicator of a compensated allostatic state;

Uncompensated fascial patterns (craniocervical/cervicothoracic/thoracolumbar/lumbosacral

transitional areas present with a non-alternating preference for sidebending-rotation): which do

not alternate, and which are usually a result of an allostatic overload, or a macro trauma or

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repeated microtraumas. A condition that exceeds the capacity of the individual to cope with

adversity; a condition of allostatic overload which corresponds to the phase of resistance or

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exhaustion in the theory of the general adaptation syndrome of Selye. It is when the allostatic

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load is superimposed on exceptional or unforeseen disorders, resulting in an unnecessary and

harmful overload. END OF BOX 3]

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The operator may proceed with more comprehensive screening tools which indicate current levels

of functionality and can be also repeated to assess progress during treatment:

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Crossed syndrome patterns: are indicators of relative postural alignment (Frank, 2009) (BOX 4);
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[BOX 4. Crossed syndrome patterns (Chaitow, 2009). Relative postural alignment indicators that

occur with:
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- Upper crossed syndrome, which concerns the shortening and tightening of the pectoralis

major and pectoralis minor muscles, the upper trapezius, the elevator scapulae, erector
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spinae and sub-occipital muscles, as well as the lengthening and weakening of the deep
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flexors of the neck, the serratus, middle and inferior trapezius muscles. These functional

changes favour conditions of cervico-thoraco-brachial pain;

- Lower crossed syndrome, which indicates muscle tension in the quadratus lumborum, psoas,

lumbar erector spinae, hamstrings, tensor fasciae latae and piriformis muscles, which is

associated with a lengthening of the gluteal and abdominal muscles. This can induce a

combination of lumbopelvic stresses which can lead to conditions of lower back pain.

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The operator proceeds with palpation of the areas affected by the functional changes

described above, after requesting active movements of the patient, to evaluate the sequence

of activation of different muscles of the limb. For example, hip abduction movements may

be requested to verify if this movement takes place using the ideal sequence of contraction

(tensor fasciae latae, gluteus medius, and after 20 to 25 of abduction the quadratus

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lumborum), or if hyperactivity is manifested (e.g. tensor fasciae latae and quadratus

lumborum which would denote a weakening of the gluteus medius) END OF BOX 4]

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Assessment of the balance in monopodalic load with eyes open and closed (BOX 5): this is a

neurological indication of the integration between exteroceptive and interoceptive input, as well

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as of the efficiency of central processing and motor control (Bohannon et al., 1984);
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[BOX 5. Assessment of balance in monopodalic load. The monopodalic balance test evaluates the
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function of postural control, which correlated with muscle coordination, motor control (Winters and
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Crago, 2000) and basic myofascial tone (Masi et al., 2010), is expressed through a complex

relationship between balance and interoceptive, proprioceptive and exteroceptive sensory

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mechanisms. They involve somatic and visceral motor efferents, which are in turn related to
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emotions and physiological responses (Charney and Deutch, 1996).

The test consists of the following stages (Chaitow, 2009):

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1) The patient is asked, barefoot in an orthostatic position, to lift one foot (the raised foot

should not be resting on the supporting limb). The knee should be raised as high as possible

within the limits of comfort;

2) The patient is asked to maintain their balance for 30 seconds with eyes open;

3) The test is then repeated with the contralateral limb;

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4) After having carried out the test with eyes open, the patient is asked to identify and visualize

with eyes closed a point in front of them to then attempt to maintain their balance for 30

seconds.

Based upon their observation of the patient during the test, the operator gives them a score

corresponding to the time of maintaining balance achieved by the subject, i.e. the time of the

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occurrence of one or more of the following conditions:

- The raised foot touches the ground or rests on the other foot;

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- The limb supporting the load jumps, moves or fingers are raised;

- The hands touch something other than the body.

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N.B. The test may also be recommended as a daily exercise, sometimes using tables or swinging

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sandals, in order to increase the time maintaining balance with eyes closed. END OF BOX 5]
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Assessment of core stability (Norris, 1999; Chaitow, 2009): indicator of the relative importance
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of muscles (transversus abdominis, obliques, diaphragm, erector spinae, multifidus, etc.) that
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protect the spine. For instance, the ability and coordination of the patient in maintaining the
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lumbar spine stable during the phase of loading allows an assessment of the core stability. In a

bent limbs test the patient, in supine position with the knees and hips also flexed, places a hand
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between the lumbar region of the spine and the supporting surface. Once becoming aware of the

pressure of the column on supporting surface, the patient is asked to bring the navel towards the
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spine by contracting the transverse muscles of the abdomen and the multifidus muscles. The
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patient is then encouraged to gradually extend a leg, sliding their heel along the supporting

surface. If the eccentric contraction of flexors of the hip exceeds the stability of the pelvis, an

increased lumbar lordosis will manifest before the limb is completely extended, indicating

insufficient core stability.

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3. Verification, by both local and global testing, of the presence of somatic dysfunction, that is an

altered interrelationship between structure and function affecting joint or soft tissue (viscera,

connective tissue, muscles), with an influence on the postural pattern (E.C.O.P., 2011b). However,

somatic dysfunction is nowadays described as a manifestation of local adaptation syndrome, or a

mechanico-physiological somatic response with the purpose of reacting, adapting to exogenous and

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endogenous stresses which may be acting upon us (Fusco, 2015). Tissue reactions would allow the

survival or the optimal function at a given context of the individual through the modification of four

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main parameters: change in tissue texture, positional or functional asymmetry, reduction of range

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and/or quality of movement, and tenderness or sensitivity to palpation (usually referred to by the

acronym TART).

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4. Application of the inhibition test

The assessment can identify different somatic dysfunctions, when the severity, the accessibility, the
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clinical relevance of the subject to the disorder is needed to be understood. This can be determined

by the detection of one or more of the qualitative parameters of the TART acronym in the
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dysfunctional area, but also from the anamnesis, and the outcome of specific tests, including the
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inhibition test. It consists in the application of manual vectorial induction stimuli for a few seconds
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on an area of somatic dysfunction, while the immediate response is evaluated at a distance on

another dysfunctional area, and/or on a compensation pattern, and/or on a related function (e.g.
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postural control). So, for example, the temporary inhibition of a disturbing influence in
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dysfunctional tissue, by a slight manual pressure in situ, can determine if there are outcome

variations of functional tests, such as the time of maintaining the balance in monopodalic support,

or semeiological tests such as the Lasgue or Soto Hall tests. Any variation in the response of the

test after or during the inhibition of a dysfunctional area, suggests the dominance of the

dysfunctional structure over the postural function. On the contrary, the absence of such a variation

suggests the dominance of the postural function over the dysfunctional structure.

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5. Selection of the therapeutic approach:

If the evaluation reveals a decompensated myofascial pattern, a positive crossed syndrome test,

a monopodalic load test that does not change when the somatic dysfunction is inhibited, a

positive core stability test, it suggests the dominating influence of the postural/biomechanical

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function is undermining salutogenesis with respect to the dysfunctional somatic structure. A

maximalist approach is then the recommended modality of intervention in this case. In the

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maximalist approach, adaptogenic global techniques (such as CV41 or total body unwinding2)

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are usually used, even if sometimes, however, the operator can use an integration of different

approaches of a global nature (such as the General Osteopathic Treatment3 or the balancing of

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the diaphragmatic system), in order to reduce the allostatic overload (represented in this model
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by postural overload), to normalize any aberrant neuromyofascial reflexes, to improve postural

asymmetries, to optimize the synergy of musculoskeletal elements and to favour the integration
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of somatic dysfunction in an optimal neuromyofascial postural function.

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If the evaluation reveals a compensated (or minimally uncompensated) myofascial pattern, a

negative crossed syndrome test, a monopodalic load test that does change when the somatic
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dysfunction is inhibited, a negative core stability test, it suggests the dominating influence of the

somatic dysfunction (structure) in undermining salutogenesis with respect to the

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postural/biomechanical function. In this case, a minimalist approach or any technique

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specifically addressing the dysfunctional somatic area may be the best choice of intervention.

1
Abbreviation for compression of the fourth ventricle; a cranial technique applied to the occiput
that seems to produce global body effects such as enhancement of fluids movement, influences on
the immunity response, changes in the autonomic output.
2
An indirect dynamic fascial technique that consists in the unfolding of the whole body
dysfunctional pattern enclosed in the inherent fascia motion.
3
Maximal treatment approach based on a specific routine of articulatory techniques applied
throughout the body as a whole.
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6. Ongoing management of the case:

In the debate concerning the BMM (Chaitow, 2011) the necessity of "opening" the biomechanical

model to include social activities, occupational and recreational activities emerged, in order to

provide a comprehensive and permanent correction of postural and structural factors. So, as

suggested by Lederman (2011), it proposes a 'process approach', whose purpose is to identify the

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processes underlying conditions of patients and to provide stimulation, signals, management and

care that will support, assist and facilitate change. To give an example, nutritional advice and

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physical activity exercises that fill the gap that a passive manual treatment (without the subject

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being cognitively and proprioceptively involved) leaves in the healing process and in the recovery

of the person. For the effective implementation of dietary advice a progressive approach may be

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useful tailored to the needs of the individual patient (Walker and Reamy, 2009). As regards physical
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activity, however, until now, most sports training, be it amateur or competitive, has placed emphasis

on the classical triad of muscle strength, cardiovascular conditioning and neuromuscular

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coordination, perhaps leaving out certain aspects related to movement. Some researchers together
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with bodyworkers nowadays suggest training which works on the fascial network, considering it
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might be of great importance to athletes, dancers and common people wanting to benefit from

movement (Schleip and Mller, 2013). Schleip and his colleague Mller, argue that if the fascia is
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well trained, that is, in such a way as to make it elastic and resilient, then it may be relied upon to

perform effectively, with a high degree of prevention as regards injuries and their recurrence. In the
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osteopathic field, on the other hand, exercises have been described and used to the management of
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local adaptations, such as the prevention of recurrent musculoskeletal (De Stefano, 2010) as well as

visceral dysfunction (Brazzo, 2011). Finally, global exercises have been proposed dealing with

individual energy management (Fulford and Stone, 1997).

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Conclusions

The approach to posture through the revised BMM focuses on the person, understood in their full

range of psychosocial and physical expressiveness. This is expressed in the promotion of the

inherent capabilities of self-regulation, mostly through the use of the musculoskeletal system as a

key tool for adaptation and intervention (Rogers et al., 2002). The centrality of this apparatus is

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definitely one of the components that has produced an expansion in the use of BMM on the part of

the community of many manual therapists. Experts who have examined the issue of BMM and its

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increased use, concur with the need to move away from the dogmas that have characterized the idea

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of health dependent on ideal posture, to promote dynamic approaches through which the person

"participates more fully" in the healing process (Chaitow, 2011). In the field of osteopathy,

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specifically, use is made of the five models (biomechanical, neurological, respiratory-circulatory,
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metabolic, biopsychosocial), five forces of activation/adaptive capabilities (Tozzi et al., 2015), both

in the evaluation phase and in that of the intervention, drawing on the correlation between the
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corresponding body elements. Nevertheless, it is possible to organize manual therapy with a

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specific emphasis on one or more models, directing the therapeutic stimulus to a chosen structural
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and functional component, according to the type of allostatic load of the person in care. Therefore,

through the integration of traditional principles and contemporary scientific evidence a rational
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biomechanical intervention emerges based on the adaptive concept of health (Tozzi et al., 2015), in

which postural disorders are a reflection of a lack of dynamic interaction, within and between
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adaptive systems, recognizable by changes in the relationship between structure and function, even
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more than damage to single system. The treatment has the objective of interacting with the adaptive

function (Lunghi, 2015a), whether respiratory, circulatory, metabolic-energetic, psychological or

biomechanical, the one which is described in a particular way in this model.

Posture thus becomes:

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1) one of the ways of assessing adaptive ability, namely health, particularly when the person

manifests an overload of the biomechanical function;

2) one of the forces of activation, to be evoked in treatment, both in approaches to clinically

relevant dysfunctional structures and in adaptogenic approaches addressing a function (in this case

biomechanics) (Lunghi, 2015b).

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Interventions on posture and the application of BMM should therefore be based on a multimodal

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approach that makes the person a participant in the process also through active everyday gestures

connected with their lifestyle, in a salutogenic approach that, from a traditional perspective, evolves

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on an anthropological basis, to the point of centering its work on the person (Tozzi, 2015c).

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Captions

Figure 1. The fasciagenic model of somatic dysfunction (Tozzi, 2015b): the diagram shows two

main interacting fascial changes structural and functional that may underlie somatic

dysfunction and account for its palpable features (tissue texture changes, asymmetry, restriction of

motion, tenderness). They may occur through various types of interactions and under different

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kinds of influences. Several dysfunctional events may produce different forms of forces and

responses in the fascia with consequent dysfunctional processes.

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Figure 2. Evaluation and clinical decision processes of the revised biomechanical model: the

operator finalizes a clear picture of the global and biomechanical postural condition of the patient

through the application of a process of evaluation and selection of the most appropriate therapeutic

approach.

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Evalua on of myofascial pa erns
Anamnesis, Differen al Diagnosis, - Ideal

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Physical Examina on aimed at Test of ssue
- Compensated
quan fying possible impacts of preference
- Uncompensated
pathogene c factors on body
mechanisms and energy levels

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-Assessment of Crossed Syndrome Pa erns
Screening test for
-Assessment of monopodalic load
Enlistment of pa ent levels of body
-Assessment of core stability
func onality

Checking for the presence of

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postural compensa on/ Global/Local tests for
decompensa on: Evalua on of the presence of soma c dysfunc ons as
soma c dysfunc ons altered interrela on between structure and func on
Assessment of the individuals
adap ve capacity (Local Adapta on Syndrome)
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Inhibi on test on the dysfunc onal area

The test reveals an actual The test reveals no varia on:
checking for possible varia ons of body func onality
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varia on: dominance of the dominance of the postural

levels, uncompensated myofascial pa erns and/or
dysfunc onal structure over func on over dysfunc onal
semeiological parameters
postural func on structure
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Use techniques focused Use global

on resolving soma c adaptogenic
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dysfunc ons techniques

Minimalist Approach Maximalist Approach

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Progressive individual approach:

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integra on of nutri onal and

physical care with social and
occupa onal ac vi es

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Table 1. Main features of the classic BMM and the revised BMM

Classic BMM Revised BMM

Concepts
Perfect posture is regarded as the
state where body mass is
distributed in such a way that the
muscles retain their normal tone
Posture is an adaptive function of a
multifactorial nature, an indicator of the
individual adaptive capabilities in dealing
with stressors of various origin and nature. It

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and ligamentous tensions manifests through variations that can be
neutralize the force of gravity. "seen", but "not predicted", independent of
asymmetries which may be present.
Efficient posture permits good

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mobility and performance of the Posture is seen from a neuromyofascial
musculoskeletal system. perspective and in terms of biotensegrity. It
is identified through the strategy adopted by

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the neuromyofascial system aimed at
reacting to the forces of gravity and to
stimuli given by extero-proprio-interoceptive
afferents, as well as to the allostatic load of

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the individual.
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Implications Body adaptation to the force of The postural balance is achieved and
gravity and to the upright posture maintained through a dynamic tensegritive
is the result of the integration of relation between neuromyofascial and
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somatic components related to skeletal components aimed at improving

posture and balance mechanisms stability with the least possible expenditure
(receptors). of energy.
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Stress or postural imbalances can The muscular tone of the neuromyofascial

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affect functional dynamics system not only depends on neuromotor

causing a greater expenditure of control but also on intrinsic viscoelastic
energy, impaired proprioception, characteristics of muscular tissue at rest
joint disorders and impediments (HRMT) integrated into a complex, passive
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to neurovascular and metabolic tensional metasystem composed of fascia,

functions. muscles, ligaments, capsules and articular
elements. Excesses or reduction of HRMT
can lead to disorders and pathologies in the
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musculoskeletal system.
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The minimum change in any part of the body

may cause a global biomechanical re-
adaptation that is both ergonomic and
tensional which may influence neurological,
vascular and lymphatic functions as well as
behavioural and metabolic responses,
independent of etiological factors.

Applications Analysis of the relationship Observation of posture by means of an

between body attitudes (body assessment process which considers the
volumes) and the force of integration of related structures and
gravity. functions and how this relationship
influences the allostatic load and the
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Analysis of the organization of
kinematic and static chains in
relation to antigravity
mechanisms and spinal and
vestibular reflexes.
individuals adaptive capacity; postural
imbalances consequently are identified by
assessing structural variations which
increase the energy requirements of the body
or cause/favour the onset of pain.

Tracing the loss of harmonious The neuro-muscolo-skeletal components, the

relationships between skeletal myofascial patterns and transitional areas are
segments causing alterations in used for:
muscular strength and load o Restoring optimal posture (not
distribution on skeletal segments ideal posture) of the individual in

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on three spatial planes. that given moment;
o Balancing aberrant postural
Restoring optimal posture responses;;

through the balanced and
effective use of musculoskeletal
components.
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o Favouring the integration of extero-
intero-proprioceptive afferents;
o Optimizing individual responses to
the existing allostatic load through a

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salutogenic process which involves
the active participation of the person
in healthy daily activities and
lifestyle.

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