Autism Spectrum Disorders have been before, the family must now prioritize caring for their child in a new way. AUTISM AND THE AUTONOMIC NERVOUS SYSTEM Activity of the spinal sympathetic chain, and/or dorsal vagal activity, can be physiological characteristics of the nervous system of people with various diagnoses on the autism spectrum. They might also have a physical issue arising from a dysfunction in their organs. Their family or caregivers might notice that people with autism some- times react with fear and panic even with no apparent reason. They may be hypersensitive, reacting to a stimulus in the environment that other people do not notice, or to something that reminds them of something in their past—or they might simply be imagining something dangerous. Other people looking at their behavior objectively find that these reac- tions are unfounded and feel there is nothing to be upset about. Sometimes people on the autism spectrum are trapped in states of fight-or-flight or shutdown, or shift between these two states. They may be in a state of shutdown, folded into themselves and apathetic one moment, then suddenly extroverted, afraid, or aggressive in the next. To others who do not understand their behavior, they react in seemingly strange, unpredictable ways that often make them seem asocial in their behavior. Many parents or caregivers are confused and surprised by these sudden shifts in behavior because they are not aware of anything that could be causing the emotional changes. Psychological testing for autism evaluates behavior and defines different kinds of autism, but does not consider the underlying physiological factors in terms of Porges's new interpretation of the function of the autonomic nervous system. As a result, treatments have mostly focused on training the parents to try to adapt their behavior to fit the special needs of their child, rather than improving the child's condition so that they do not have these special needs. The Polyvagal Theory presents a new biobehavioral model linking autistic behavior to specific physiological states of the autonomic nervous 165 EFTA00810167

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY system. This allows us the possibility to develop more effective strategies for treating autism. When we see that many of these individuals are being affected by their spinal sympathetic chain or dorsal vagal activity, or are vacillating between the two, we can simply say that they are not socially engaged. Then we can focus on using or developing interventions that help them to be socially engaged and improve the function of the ventral branch of their vagus nerve and the other four associated cranial nerves—resulting in more social behaviors. Stephen Porges chose to work with autistic children, and has had suc- cess in improving the behavior of many of them. He interpreted this as a verification that there was some validity to the model of the nervous system presented in the Polyvagal Theory. I was inspired by his work and have also been treating autistic individuals with some success. Hope for Autism: The Listening Project Protocol Important distinctions were made by Stephen Porges in his Polyvagal Theory and Listening Project that point to specialized functions of the cranial nerves that go to muscles in the middle ear, and to how proper listening enables social engagement.81 Porges made a breakthrough in our understanding of hearing, one of the problems affecting about 60 percent of autistic children. I heard Stephen Porges describe this in a lecture at the Breath of Life Conference in London (May 23-24, 2009). He described how problems associated with listening and processing human voices might be related to poor function of cranial nerves V and VII—rather than cranial nerve VIII, as in typical deafness—and how the mechanisms involved in listening may be an important part of autistic symptomology. People on the autism spectrum are a challenge in many ways to par- ents, teachers, and other caregivers. Anyone working with autistic children notices that they often do not seem to be able to understand what other people are saying, and cannot carry on normal two-way communication. Many people on the autism spectrum do not seem to understand the 166 EFTA00810168

Autism Spectrum Disorders meaning of what is being said to them, and many of them do not speak at all. This is especially challenging for psychologists and psychiatrists because autistic individuals usually have difficulty communicating ver- bally, so that verbally based therapies are not helpful. Therefore, as a standard practice, their cranial nerve VIII (auditory nerve), which has sensory fibers deep in the inner ear, is tested to find out whether their hearing is sufficient. Most individuals on the autism spectrum pass the standard hearing test, which is usually administered in a quiet room with no background noise, or with the subject wearing head- phones that eliminate all sounds other than the frequencies being tested. The problem with this test for individuals on the autism spectrum is that it only measures part of the auditory mechanism. Stephen Porges realized that for people to hear and understand what is being said, they need two other cranial nerves: the trigeminal nerve (cranial nerve V) and the facial nerve (cranial nerve VII). In order to learn to speak, we first need to be able to hear and under- stand spoken language. Porges found that many individuals on the autism spectrum have a dysfunction in cranial nerves V and VII, which interferes with their ability to hear and understand spoken language. These nerves originate in the brainstem, and each has several branches with different functions, two of which go to two muscles in the middle ear. CN WI goes to the stapedius, a tiny muscle in the middle ear, and CN V goes to the tensor tympani, at the eardrum. One of the many functions of cranial nerve CN WI is innervation of the stapedius muscle. When the stapedius functions properly, it helps to reduce the volume of sounds that are above and below the frequency range of the human female voice, to help a child focus on sounds in the frequency range of a mother's voice. When this muscle functions properly, a child can easily hear its mother's voice above background noise, learn language from its mother, and communicate with her and other people. CN VII, which innervates the stapedius muscle, has other branches as well, one of which controls the muscles of the face (which have been referred to as "organs of emotional expression"). When this nerve is not functioning properly, there is often a lack of facial expression. One 167 EFTA00810169

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY characteristic of both children and adults with a diagnosis of autism is a lack of natural facial expression; their flat facial affect makes it difficult for people to read their emotions in a conversation. Because of this, other people tend to think that the autistic individual lacks empathy. There is a neurological connection between proper hearing and the muscles that open the eyes. The flat ring muscle around the eye is inner- vated by the seventh cranial nerve, and people with hearing problems often have drooping eyelids. Lifting the eyebrows— the way we do when something just heard is an "eye-opener"—can help us understand spo- ken language. All these factors point to the importance to hearing of the proper functioning of the seventh cranial nerve. A branch of CN V regulates the tension in the tensor tympani muscle, which is involved in regulating the Eustachian tube that connects to the throat. The tensor tympani is similar to the stapedius, regulating the rigid- ity of the ossicles (small middle-ear bones). Tensing the ossicle chain increases the tension of the eardrum, diminishing the volume of low- frequency background sounds. One of the roles of the stapedius and tensor tympani muscles is to dampen sounds such as those produced by chewing. If the middle- ear muscles do not contract sufficiently, the perceived volume of low- frequency sounds can be extremely high, and even mask human-voice sounds. This condition is called hypemcusis. For people suffering from this condition, incoming sounds can be disturbing or even painful. Some autistic children put their fingers in their ears to block out sounds, especially low-frequency sounds. In this condition, a child processes acoustic information only within a restricted frequency range, so that sounds in the frequency band of human speech may be lost in background sounds, while lower-pitched sounds may be functionally amplified. Children with hypersensitivity to sound might overreact to other people's voices, especially the low-pitched voices of some men. And when they put their fingers in their ears, this may be misinterpreted to mean that the child does not want to listen to what is being said, when in actuality they are just trying to protect their ears from a painful experience. 168 EFTA00810170

Autism Spectrum Disorders Everyday noises that include low frequencies (e.g., vacuum cleaners, traffic, or escalators) seem unbearably loud to people with this condition. They cannot understand what is being said to them due to background noises that bother them tremendously, even though the same noises do not bother other people. One of my patients, an eleven-year-old boy, stuffed his fingers into his ears to reduce the sound whenever a train went by at some distance from my office window. I had never noticed the sound of the trains passing before, and my other clients never seemed to react to it. A different kind of dysfunction of the muscles and nerves can result in an opposite kind of problem with hearing and understanding what is being said. Muscle tone may be insufficient to amplify the sound adequately, so that not enough sound gets through, and the child can appear to be deaf to what is being said to him. This is often misinterpreted as a lack of interest in communication and social activity, or taken to mean that the child does not want to respond or do what is being requested of him. Sometimes children with these problems can become very skilled at reading lips and interpreting body language. They may appear to be able to carry on a conversation and to be sociable—but they have a problem if the person who is speaking is not directly in front of them so that they cannot read their lips. Some adults also struggle to understand what is being said unless they can see the other person's face. People who are lip-reading fixate their gaze on the other person's mouth, unlike a person with normal hearing who looks into the other person's eyes, or looks away while listening. Adults who have difficulty understanding if more than one person talks simul- taneously may avoid going to parties or crowded restaurants, preferring to meet people one on one. Or they may use another strategy—talking all the time, to avoid revealing that they cannot understand others. Children on the autism spectrum can have major difficulties func- tioning normally in a noisy classroom. When a child is overly sensitive to sound, a high level of background noise can be painful, while chil- dren with a normally functioning inner ear find the same level of noise acceptable. 169 EFTA00810171

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY For a child with severe hyperacusis, environmental sounds cause bursts of pain that they cannot escape. Going through the various soundscapes of daily life might feel like the experience of rats in a cage being stressed by electrical shocks at unpredictable time intervals. The children might not even realize that they have a problem; if they were born with hyper- acusis, they might not know that their randomly traumatic experience is not normal, and might just assume, "That's Imagine watching a movie with the soundtrack turned up full blast— the actors' voices are screaming at you, and you cannot wait to get out of the theater. You leave, holding your ears. But what if you were an autistic child who cannot get out of the cinema? In order to investigate the implications of cranial nerve dysfunction— and ultimately to prove the validity of the Polyvagal Theory—Stephen Porges designed his Listening Project Protocol for a research program that he carried out with subjects on the autism spectrum." In peer-reviewed research, he describes his empirical studies using the Listening Project Protocol with autistic children (see below). Porges's research and scientific articles over the last twenty years have broken new ground in treating autistic conditions. Identifying a physi- ological pattern that may be partly responsible for autistic behavioral patterns is a significant breakthrough in our understanding of autism, and has opened possibilities for new forms of treatment. The method that he developed has already helped many people to improve their com- munication skills and social behavior. Porges hypothesized that the reason many children on the autism spectrum have difficulty in using language to interact is dysfunction in the neural regulation of their middle-ear muscles, described above. CN V and CN VII, two of the cranial nerves necessary for social engagement, originate in the brainstem and have branches that go to those two muscles in the middle ear. Porges treated a large group of children with a diagnosis of autism using an ingenious therapeutic intervention. In Porges's Listening Project Protocol research, all of the children tested had diagnoses on the autism spectrum, and many of them also had hyperacusis. All of the children, 170 EFTA00810172

Autism Spectrum Disorders after receiving extensive hearing tests, received five forty-five-minute sessions daily for five days. In one publication, Porges and his group demonstrated that spe- cially computer-altered music improved auditory processing skills and increased ventral vagal regulation of the heart.89 A second publication describes two trials conducted by Porges's team. One trial contrasted a group of children wearing headphones only with another group receiving computer-altered music, processed with an algo- rithm to enhance the acoustic features of prosody. In the second trial, one group received the computer-altered music and the other group received the same music, but unaltered. In both trials, only the group receiving the computer-altered music exhibited a reduction in auditory hypersensitivity.9° I had a chance to hear the special music myself. After I listened for a few minutes, I felt as if my middle-ear muscles had been stimulated and exercised. My eardrum itched, and the structures in my middle ear felt as if they were hopping, dancing, and vibrating. More importantly, I experienced an improvement in my hearing and in my ability to hear speech more clearly. At his lectures, Porges presented inspiring videos showing some of the changes in the children and how, when they could understand what was being said, they emerged from their previous social isolation and began to relate to others. Porges is constantly working on improving the acoustic stimulation that he uses, and the means of delivering it. At the time of this writing, in 2016, he was conducting registered clinical trials in Melbourne, Los Angeles, and Toronto. The Role of Hearing in Autistic Spectrum Disorders In order to be sociable and carry on a two-way communication, people have to hear and interpret the meaning of words spoken by others. As described above, problems with hearing and understanding character- iztemany individuals on the autism spectrum. This phenomenon is well 171 EFTA00810173

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY recognized; Stephen Porges initially pointed this out in his presentation of the Polyvagal Theory, and I have confirmed it in my practice. However, these hearing problems are most often related to a dysfunctional CN V and CN VII (as Porges discovered) and not CN VIII, the auditory nerve, often incorrectly assumed to be exclusively responsible for hearing. When an autistic, Asperger's, or otherwise challenging child comes to my clinic, I ask the parents about their child's hearing. Invariably, they say that their child's hearing was tested by an ear specialist who reported that it was normal. Most autistic children have their hearing tested in the usual way: they wear headphones, and respond when they hear the varied volumes and frequencies of sound from the headphones. The parents are almost always told that their child has good hearing, but this misses the core of the autistic child's hearing problem. It is not a question of the child hearing single tones in a test, without background noises. The question should be: can the child hear the human voice in the presence of background noise? Does the child have the ability to filter out background sounds, especially low-frequency sounds? One mother brought her nine-year-old son to me because of his aggressive behavior at school. I usually do my own simple test to check such a patient's ability to hear well. I ask the child to turn around, so that their back is turned and they cannot read my lips. Then I give them a simple task to perform—for example, to put their coat on. Often the parent will protest, saying that this puts the child at a dis- advantage since it's easiest for them when they can see the speaker's face. This particular mother said something similar. So I asked her what hap- pens when her son is in the next room or does not see her face, and she tries to get him to do something that she wants. "If he does not answer," the mother responded, "I stay calm and tell him again:' "If he still does not answer, what do you do?" She replied, "I tell him a third time. If he still does not do it, I know it is because he doesn't want to answer me. Sometimes I get so irritated that I slap him." 172 EFTA00810174

Autism Spectrum Disorders From her son's point of view, he was occupied doing something and was not aware of the mother's message because his fifth and seventh cranial nerves were not functioning sufficiently to filter out background sounds. He was probably not even aware that his mother was talking to him. Then, all of a sudden, without his understanding why, his mother would slap him, and yell at him in an angry voice. Even though she had told him something three times, he had been unable to hear and understand what she said. In her own frustration at not being heard, she then slapped him, but from his perspective this was without warning; he did not know what led up to the slap. So he might logically interpret his mother's message as,"If you want another person's attention, hit them, and then give them your message?' Sometimes, when the boy was in school and asked one of the other children to do something, and if the other child did not do it right away, he would slap them without warning to get their attention. It is no wonder that this child had a hard time playing with other children. His mother had inadvertently taught him this antisocial pattern herself. In my clinic, when children turn their back to me and do not respond to my simple request to put their coats on, I do not assume that they heard and understood it just because I said it. Instead, I suspect dysfunc- tion of CN V and VII. If this is indeed the case, and autistic individuals cannot understand what others are saying, they will of course have a hard time recognizing how to use language to get others to understand and help them. THE EVOLUTION OF HEARING Early in the evolution of Earth's creatures, large predators including the dinosaurs and other great lizards roamed the land, often preying upon small mammals. The largest animals that could threaten these dinosaurs and lizards pounded the earth with their feet when they walked or ran, producing low-frequency percussive sounds. The dinosaurs registered these low-frequency vibrations in the nerve endings wrapping their large skeletal bones. 173 EFTA00810175

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY Information about the approach of a potential predator was crucial, especially for protection of their offspring. But these large creatures could not hear sounds in higher frequencies. Paleontologists have found that their middle-ear bones were attached to the jawbone, unlike those of later species. Thus it is speculated that dinosaurs "heard" by registering low-frequency vibrations in the bones of their skeleton, but could not hear higher-frequency sounds made by mammals. Mammals have evolved ears that allow us to hear higher frequencies; our middle-ear bones, detached from our jaws, vibrate based on sonic waves in the air. Mammalian "voices" are in a higher frequency range than the rumblings of the dinosaurs and large lizards. Therefore early mammals were able to communicate with each other without being detected by the larger and faster animals that were their predators, and this was a potential advantage in their struggle for survival. However, if mammals indiscriminately let all the sounds of their envi- ronment into their ears, including both very high and low frequencies, we would experience a confusing cacophony. The higher and lower fre- quencies would drown out the mammalian-voice sounds. For humans, sounds in the vital frequency range of the female voice might convey information from the mother that is crucial to a child's survival in a dangerous situation. So how does our hearingexusion these important frequencies? The ability of mammals to filter out sounds depends on varying levels of ten- sion in the stapedius and tensor tympani muscles in the middle ear. These effectively block out both high- and low-frequency sounds, leaving only the sounds roughly in the range of the human voice. A well-functioning stapedius muscle can filter out sounds above and below the range of the human voice—even otherwise deafeningly loud noises?' The evolution of the structures of the ear and the sense of hearing is well documented in the field of evolutionary biology, from the time of the early dinosaurs starting 190 million years ago until today. In mammals, three small parts of the jawbone became separated from the rest of the jaw. These three small bones as a group are called the ossicles. (The root os- means "bone," and ossiele means "tiny bone.") These three bones are 174 EFTA00810176

Autism Spectrum Disorders called the hammer (maliens), the anvil (incus), and the stirrup (stapes) because they resemble these shapes. They are enjoined in synovial joints, and held together by a ligament in a flexible "chain." Movement of the ossicles is controlled (either facilitated or restricted) by adjustments in the tension of the tensor tympani and stapedius mus- cles, which attach to the ossicles at opposite ends of the chain. These muscles affect the hearing in different ways. The tympanic membrane (eardrum) is round in shape, like a drumhead; the tensor tympani muscle connects it to the malleus, one of the ossicles. Changes in tension in the tensor tympani muscle determine how much the eardrum can vibrate. Sounds are louder with increased tension. The tensor tympani is innervated by a branch of the fifth cranial nerve, and acts as a kind of volume control on how much sound gets passed on to the receptors of the acoustic nerve deep in the auditory canal. The stapedius, about one millimeter long, is the tiniest muscle in the entire body. It is innervated by a motor branch of the seventh cranial nerve, which changes the level of muscle tension. The stapedius is also a very thin muscle. It originates in a small cavity surrounding the bones of the middle ear, and inserts into the neck of the stapes (one of the three ossicles). The stapedius only transmits certain frequency ranges as it tenses and relaxes. With normal hearing, the sound frequencies of the human female voice get through easily, while sounds above and below these frequencies are largely filtered out. To register the changes of frequency when someone else is talking requires a well-functioning stapedius muscle in order to separate out the range of sounds needed for us to hear, understand, and communicate with each other. This function is crucial for a child in learning vocabulary and the melody of language. TREATING HEARING IN AUTISTIC CHILDREN A characteristic common to people who are socially engaged is that we usually have a melodic voice that can communicate feeling. This voice melody, or prosody, makes it easier for other people to understand us. In 175 EFTA00810177

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY contrast, people with autism often have a flat, monotonous voice, which can verge on sounding mechanical and robotic. Perhaps the reason that they lack prosody in their voice is that they cannot hear it in other people's voices due to a dysfunctional CN VII. If a child cannot hear and appreciate, or feel the emotions communicated by, the melody in the voices of others, they cannot comprehend the benefits of using melody in their own voice, much less learn to express it. This quality of the voice is not primarily a vocal problem per se. As soon as we help people on the autism spectrum to a state of social engage- ment through improved function of their cranial nerves, the quality of their voice changes; they immediately have more prosody, and it is easier for others to understand what they are saying. Sometimes hearing can be improved with the Basic Exercise by increasing the flow of blood to the brainstem, where cranial nerves V and VII originate. The Basic Exercise can also release tension between the base of the cranium (where the nucleus of CN V is located) and the first three vertebrae. The Neuro-Fascial Release Technique can also be suf- ficient to reset the function of these nerves and improve social behavior. With the understanding gained from my study of the Polyvagal The- ory, I developed my own approach to autism spectrum disorders. I evalu- ate the function of cranial nerves V, VII, IX, X, and XI, and then I use a selection of specific biomechanical cranial techniques to release restric- tions and enable proper function in these nerves. Based on my clinical experiences and the feedback of my students, I have confirmed that it is possible to improve the communication skills of some people with a diagnosis of autism. Several of my patients who originally came to me with an autism diagnosis were evaluated again after I treated them and were found to be no longer autistic. I have learned over the years to be careful about saying "cure autism," usually simply stating that I have helped some people with a diagnosis of autism to improve their hearing and achieve more empathy and better communication skills. Many professionals working in the field believe that autism cannot be cured and are more receptive to a claim that it is possible in many cases to improve communication. 176 EFTA00810178

Autism Spectrum Disorders Treating Autism Over the years, I have successfully helped many children and young peo- ple with a diagnosis on the autism spectrum. Many such children have problems with normal social behavior; they do not seem interested in other people, avoiding looking at them or making eye contact. They seem to lack empathy, and would rather spend time alone or playing on their electronic devices. Their parents may designate other young people as "friends" if they can sit together in the same room for periods of time. However, the child- ren do not really interact with these friends, but sit in their own worlds, playing alongside each other but by themselves. Some autistic individuals lack verbal communication skills, and can- not take part in a meaningful two-way conversation. They do not seem able to listen or understand what is being said, and they are not playful. Some do not speak at all; others, when they do speak, may repeat like a parrot what was just said by someone else, or repeat sentences from a movie. Sometimes they continue speaking without pausing for the other person to respond. To start to make sense of all the various behaviors exhibited by indi- viduals on the autism spectrum, I have observed that such individuals are not socially engaged, and have faulty neuroception. I have been able to help some of them by getting them into a state of social engage- ment. In several instances, I have brought about normal vagal function and improved the function of the other four cranial nerves involved in social engagement. This brought the individuals out of states of stress or dorsal vagal withdrawal and spontaneously improved their com- munication skills. Perhaps one of my most unexpected discoveries in doing body ther- apy is that I have found tension in the right sternocleidomastoid (SCM) muscle—and an accompanying deformation of the skull called "flat back of the head" or plagiocephaly—in every client diagnosed with ADHD or a diagnosis on the autism spectrum. Research published in the journal Pediatrics reported that this deformation of the skull, usually only on one 177 EFTA00810179

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY side, is present in a higher percentage of children with autism and ADHD, compared to normally functioning children.91 The sternocleidomastoid muscle is attached to the base of the temporal bone, on the side of the skull, so that chronic tension in the SCM muscle noticeably deforms the shape of the skull in a particular way. Although this client group consists mostly of children and young people, this deformation of the skull is not confined to children; I also see it in many adults who have had difficulties being socially engaged. This same approach can achieve similar improvements in adults. Can certain characteristic shapes of the skull put pressure on certain blood vessels or nerves inside the skull? A baby's cranium is made up of several plates, connected by tough connective tissue. A constant pull on the temporal bone from chronic tension in the SCM muscle can pull the baby's cranium out of shape. If the tension in the muscle is not released, the skull remains out of shape as the child matures. Many parents come to me because they already know that their child has a flat back of the head. If the parents were not already aware of it, I show them how to feel the shape of their child's head, and to notice any asymmetry there before we start the treatment. Relaxing the tension in the sternocleidomastoid muscle on one side often gives a noticeable improve- ment in the shape of the child's head within a few minutes. Technique for Rounding a Flat Back of the Head I start by feeling the two sternocleidomastoid muscles, and I work on the side that is tighter. I take the top of the child's SCM muscle on that side firmly but gently between my thumb and index finger. This must not cause pain. (SeeSternocleidomastoid" in the Appendix.) I ask one of the parents to hold the foot on the side where we are going to release the SCM, and to gently bend their child's foot down at the ankle joint with one hand, and then with their second hand to bend their child's toes up. After a minute or two, the child relaxes and the sternocleidomastoid muscle is much more relaxed and pliable. When the SCM no longer pulls on one side of the back of the cranium, the part that was flat fills out, becomes 178 EFTA00810180

Autism Spectrum Disorders rounded, and the two sides become symmetrical. The rationale behind this technique is found in Tom Myers' book Anatomy Trains, in which he describes the-superficial front linen Then the parent and I evaluate the back of the child's head again. It has always become more symmetrical. When the child comes back for another treatment, I observe that the changes have held. AUTISM: A CASE STUDY As exciting as it was for me to see the changes in the children that I treated, and to hear about their improvements, the next step was to find out whether other people could learn the approach and have similar suc- cess. In my school in Copenhagen, we offered a two-year program based on the biomechanical cranial techniques I had learned from my teacher, Main Gehin. For many years, I started the first day of the first course teaching students my Neuro-Fascial Release Technique (see Part Two). In this way I began to realize how simple and powerful this technique is. On the second day, I asked whether any of the students had tried the techniques they learned and, if so, what they experienced. One young man named Thor told the class of his success. He had gone home with the idea of reviewing the techniques that he had learned that first day, and treated his younger brother, William, who had had a diagnosis of infantile autism and was then seventeen years old. William was asocial, and sat in his chair looking down at his Play- Station or playing with his keys. He did not speak or make eye contact with anyone. He could also be moody; if he was upset about something, even though it might seem trivial to other people, he would withdraw into himself and sulk. Thor told of one mute episode that lasted for three months after William was made to wear a T-shirt that he did not want to wear. Even though he only wore T-shirt for one day, he sulked in silence for three months. After Thor did the Neuro-Fascial Release Technique on him, William sat back and looked Thor in the eyes, which he had not done before. Then he stood up and balanced on one foot. Like many people with autism, 179 EFTA00810181

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY William had been unable to balance well enough to stand on one foot. Then he shifted his weight to the other foot, and stood on that. That one technique was enough for William to be brought into a state of social engagement. He started to communicate with his family and other stu- dents at school, and started making friends. Thor asked me to also treat William, and I treated him four or five times. But most of the work on his nervous system had been done by Thor's treatments before William ever came to me. Over the next few months, William made many friends, traveled to other European countries on vacations, got involved in theater, took yoga classes, and started dating. He went on to finish a bachelor's degree from Copenhagen University in the Study of Media, and then to receive a mas- ter's degree. The last time I saw William, he told me that he is doing very well, and proudly related that he had taken a vacation to Amsterdam with three of his friends, also young adults with challenging diagnoses. They had handled the whole trip themselves—booked a hotel, found restaurants, visited museums, and had a good time together and enjoyed the trip. William had attained ranking as a chess master, and he had beaten several other international chess masters. He is also just starting an apprentice- ship as a sound designer for a Danish software company that produces video games. You can see Thor tell William's story on You'Ibbe (Search "autism, William, Stanley"). SPECIAL CONSIDERATIONS IN TREATING AUTISTIC CHILDREN Treating children (especially those on the autism spectrum) with hands- on techniques has its special challenges. Even children without autism will usually not lie still on a massage table for very long. Those with medical histories have often had a history of countless visits to doctors and hos- pitals, where they have been forced to lie still for an examination, or to receive painful injections. 180 EFTA00810182

Autism Spectrum Disorders It is hard to imagine how a child with negative experiences like that can feel safe, especially on the first treatment—lying on her back in a position of total helplessness, in an unfamiliar room, and being approached by a complete stranger who towers over her and starts doing something to her. Resistance is understandably triggered by this, and it takes patience, skill, and experience on the part of the therapist to help these children feel safe. Many autistic children, furthermore, do not like being touched. A treatment is often an improvised dance of the child, the parent, and me before I can gain the child's confidence enough for him to relax on the table and allow me to get my hands on him so that I can treat him. I find that succeeding with an autistic child, however, is always deeply rewarding. If you are treating autistic children, there are a few things that you should know. When they come into your space for the first time, it is natural for them to feel unsafe. They do not know you, and they often react with fear upon seeing the massage table, which looks like a medical examination table. You may have the best of therapeutic intentions, but they do not know that. If you or their parents hold them down, it is coun- terproductive; they will feel even more threatened, and perhaps violated. All children can be wary of being touched, especially by a stranger. A lot of these patients have pain in their head and neck, where I want to work. Perhaps they will allow me to touch their knee or elbow, but push my hands away when I try to touch their head or neck. The techniques that I choose must therefore be highly effective, since there is such a small window of opportunity in which I can touch these children, especially at the start of their very first session. I must first make them feel safe, and this might not happen at all on the initial treatment. I might give the child toys to play with, and wait until they have their attention on the toy, or I'll have their parent lie on the table next to them, maybe even with the child on their stomach. I keep eye contact with the child, and when I see any expression of pain or discomfort, I pause in what I am doing and let the child relax before I go further. 181 EFTA00810183

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY My cardinal rule in treating children, especially autistic children, is that they must feel safe, and must be respected, every step of the way. This is a prerequisite to certain techniques in particular that help the child's nervous system. In my clinic, when I schedule a child for their first treatment, I like to talk with one of the parents on the phone first; I do not like to talk about the child's "problems" in front of the child. I tell parents not to have high expectations for the first session, and that I might not even be able to touch their child, much less do a technique, the first time. I inform them that my practice is to respect the child's resistance on the first session, and not push beyond their comfort zone. Also, I tell the parents that they should not try to help me by forcing their child to lie still. If the child has a good first or second session with me (including attaining a more symmetrical and rounded back of the cranium—see "Technique for Rounding a Flat Back of the Head" on page 178) he will more readily accept another session and be more willing to lie still and allow me to work on him. Rather than reacting to me with fear and panic, he will often look at me and smile. I feel that this is significant, since one of the characteristics of children on the autism spectrum is that they usu- ally avoid looking at others, making eye contact, or smiling. One problem for autistic individuals who lack normal two-way verbal communication is that they cannot understand the spoken word well enough to know what to expect in a therapeutic encounter. While the value of the therapy may be obvious to their parents or to health care professionals, autistic children may have no understanding of why they are there, or the value they might gain from the treatment. They most likely have no idea that there is even anything wrong with them, or that their life can be better. Their behavior changes, however, when they realize that they are safe with you, especially once your treatment makes them feel better. 182 EFTA00810184

Autism Spectrum Disorders Concluding Remarks While the Polyvagal Theory has given me increased clarity and under- standing in regard to treating various difficult emotional, physical, and mental conditions, the insights I've gained into treatment of individuals on the autism spectrum have quite possibly been the most profound. A common characteristic of people on the autistic spectrum is that they have difficulty communicating normally, not only with people in their everyday life, but also with their caregivers and with people trying to treat them. These communication difficulties limit the possibilities in their lives, as well as the efforts of others to communicate with them and to treat them. This causes suffering for them and their families. Under- standably, their caregivers often feel helpless, challenged, and not up to the task. Helping individuals on the autistic spectrum is a journey into a vast, uncharted area. For caregivers and therapists, trying to grasp the idiosyncrasies of behavior exhibited by those on the autism spectrum may only add to the confusion. However, when we observe autistic individuals from the point of view of the Polyvagal Theory, we realize that we may be able to help by simply improving the person's ventral vagal function. At any given moment, a person can be in only one of the three auto- nomic states. Autism-spectrum individuals can suddenly shift between states of stress and withdrawal without others understanding why. Enabling the state of social engagement by improving the function of cranial nerves may have the potential to stabilize these shifts, and reduce some of the difficulty that these individuals commonly experience. Furthermore, correcting auditory issues by improving the function of the fifth and seventh cranial nerves often leads to dramatic improvement in a person's communication skills, social behaviors, and empathy. Positive changes of this nature tend to build on themselves, further aiding the person's development. When two people are socially engaged and communicating face to face, they pass information about their emotional states by small move- ments of facial muscles. This also stimulates the nerves in the muscles of 183 EFTA00810185

ANATOMICAL FACTS OLD AND NEW: THE POLYVAGAL THEORY each person's own face, so that their fifth and seventh cranial nerves give them ongoing feedback and a clear idea of what they are feeling them- selves and what they feel about the other person. Our society increasingly relies on emails and text messages. TV anchors often have deadpan faces, or assume put-on expressions. More and more people deaden their faces with Botox, or reduce their expres- siveness with plastic surgery. However, the more we communicate without seeing each others' faces and hearing the changes of tone in each other's voices, the more impersonal the interchange will be, and the less we are able to communicate anything emotionally. We can talk, but with words alone we are just passing data. Telephones are a step up in communication from emails because they capture changes in vocal expression. Skype and FaceTime give us both the sound of the voice and the facial expressions—but nothing beats face-to-face communication. The less children relate to adults who communicate fully using a melodic voice and an expressive face, the more the children's facial expres- sivity will be underused and underdeveloped. Is it any wonder that we have increasing numbers of children with autism, ADHD, and other com- munication disorders? Beyond relating to autistic people, similar difficulties arise from time to time relating to anyone else in any one of our "normal" relationships. Our interactions with other people would be so very easy if both we and they could be socially engaged all of the time. First, it is helpful to realize that we are not in a ventral vagal state all the time—and neither are they. Second, we now know that we can do something to bring ourselves or the other person into a state of social engagement. It is my feeling that we have just begun to explore the potential of the Polyvagal Theory not only to help people on the autism spectrum but to help each of us in all of our relationships with others. 184 EFTA00810186

PART TWO EXERCISES TO RESTORE SOCIAL ENGAGEMENT ler PartInexplores the healing power of the vagus nerve. Optimal health is possible only when we have a well-functioning ventral branch of the vagus nerve. The exercises and techniques in this part should help most people to move from a state of either chronic spinal sympathetic chain activity (stress) or dorsal vagal activity (shutdown) to a state of social engagement. These exercises can also be used to prevent problems in the autonomic nervous system from developing, and to maintain a general level of well-being. When you begin to do these exercises for the first time, I suggest that you start a simple journal. Write down any symptoms or issues that bother you. Also, take a look at the many symptoms listed in the "Heads of the Hydra" list at the beginning of Part One. You might want to add one or more of these to your list. Note how often a given symptom has appeared. For example, your symptom may present "all the time;' "every morning," "once a week," or "once a month." If you have a migraine headache every day, your goal is certainly to be totally free of migraines; however, any improvement would be welcomed as a positive result. Also note how strong your symptoms are. You might write that "They bother me, but I get through the day anyway,""They require me to take medication,""They are so strong that I cannot go to work or take part in normal social activities:' "I cannot sleep," or "I cannot get out of bed in the morning:" You might prefer to evaluate the pain or symptom using a scale from one to ten. 185 EFTA00810187

EXERCISES TO RESTORE SOCIAL ENGAGEMENT After you have been doing the exercises, you can look back at your list and note any changes—for example,"The migraines are less frequent: "The pain is less severe," or "I spend less money on painkillers every month:' Focus on how the exercises have helped—that you do not have the symptom(s) so often, or that the problem is not so severe. Perhaps whatever symptoms remain will diminish or disappear as you keep doing the exercises. You might also notice other positive changes—for example, are you sleeping better? Breathing better? Is your appetite more normal? All of these contribute to better health and resiliency. The Basic Exercise The goal of this exercise is to enhance social engagement. It repositions the atlas (Cl, the first cervical/neck vertebra) and the axis (C2) and increases mobility in the neck and the entire spine. (See "Atlas" and "Axis" in the Appendix.) It increases blood flow to the brainstem, where the five cranial nerves necessary for social engagement originate. This can have a positive effect on the ventral branch of the vagus nerve (CN X), as well as on cranial nerves V, VII, IX, and XI. The Basic Exercise is effective, easy to learn, and easy to do, and takes less than two minutes to complete. I usually teach this exercise to my clients in their very first session. BEFORE AND AFTER DOING THE BASIC EXERCISE Evaluate the relative freedom of movement of your head and neck. Rotate your head to the right as far as it goes comfortably. Then come back to the center, pause, and rotate your head to the left. How far do you rotate to each side? Is there any pain or stiffness? After doing the exercise, make these same movements again. Is there any improvement in the range of your movement? If there was pain when you rotated your head, did the exercise reduce the level of the pain? 186 EFTA00810188

The Basic Exercise Most people I have treated are surprised to experience an improvement in the range of movement as they rotate their head to the right and left. Better movement of the neck often accompanies an improvement in the circulation of blood to the brainstem, which in turn improves the function of the ventral branch of the vagus nerve. You or your client will probably want to repeat the exercise as needed. BASIC EXERCISE INSTRUCTIONS The first few times that you do the exercise, you should lie on your back. After you are familiar with the exercise, you can do it sitting on a chair, standing, or lying on your back 1. Lying comfortably on your back, weave the fingers of one hand together with the fingers of the other hand (Figure 4, 5, and 6). Figure 4. Fingers interwoven 187 EFTA00810189

EXERCISES TO RESTORE SOCIAL ENGAGEMENT Figure S. Hands behind the head Figure 6. Lying on the back 188 EFTA00810190

The Basic Exercise 2. Put your hands behind the back of your head, with the weight of your head resting comfortably on your interwoven fingers. You should feel the hardness of your cranium with your fingers, and you should feel the bones of your fingers on the back of your head. If you have a stiff shoulder and cannot bring both of your hands up behind the back of your head, it is sufficient to use one hand, with the fingers and palm contacting both sides of the back of your head. 3. Keeping your head in place, look to the right, moving only your eyes, as far as you comfortably can. Do not turn your head; just move your eyes. Keep looking to the right (Figure 7). 4. After a short period of time—up to thirty or even sixty seconds— you will swallow, yawn, or sigh. This is a sign of relaxation in your autonomic nervous system. (A normal inbreath is followed by an outbreath, but a sigh is different—after you breathe in, a second inbreath follows on top of the first inbreath, before the outbreath.) Figure 7. Looking to the right 189 EFTA00810191

EXERCISES TO RESTORE SOCIAL ENGAGEMENT 5. Bring your eyes back to looking straight ahead. 6. Leave your hands in place, and keep your head still. This time, move your eyes to the left (Figure 8). Figure 8. Looking to the left 7. Hold your eyes there until you notice a sigh, a yawn, or a swallow. Now that you have you have completed the Basic Exercise, take your hands away, and sit up or stand up. Evaluate what you have experienced. Has there been any improvement in the mobility of your neck? Has your breathing changed? Do you notice anything else? NOTE: If you become dizzy when you sit up or stand up, it is probably because you relaxed when you were lying down, and your blood pres- sure dropped.This is a normal reaction. It usually takes a minute or two before your blood pressure adjusts and pumps more blood to your brain. 190 EFTA00810192

The Basic Exercise CERVICAL VERTEBRAE AND VENTRAL VAGAL DYSFUNCTION When I test clients and find that they have ventral vagal dysfunction, I also observe that they have an upper cervical misalignment—i.e., a rotation of the vertebrae Cl (the atlas) and a tipping of C2 (the axis) away from their optimal positions. Using the Basic Exercise almost always brings my clients back into a better alignment of Cl and C2, and when I test them again I find that they have proper ventral vagal function. A rotation of CI and C2 can put pressure on the vertebral artery, which supplies the frontal lobes and the brainstem, where the five nerves necessary for social engagement originate. From my clinical observations, I believe that it only takes one negative thought to bring Cl and C2 out of joint, affecting our posture and physiology. I demonstrated this a few times in my advanced craniosacral classes. First, I had the students observe the position of my CI. I lay on my back, and my students could determine the position of my Cl by gently plac- ing the pads of their thumbs on its transverse processes. If there was no rotation of Cl, their thumbs would be close to horizontal. However, if one thumb was higher than the other, that would indicate a rotation of the vertebra. At the start of the experiment, a student observed that his thumbs were horizontal. Then I simply thought about something that was disturbing to me. Immediately, the transverse processes of Cl moved; one side went up and the other went down. The position of Cl felt like it had rotated approximately forty-five degrees away from the horizontal, with one side up (anterior) and the other side down (posterior). (Though this obser- vation is counter to the actual anatomical possibilities for Cl alone to rotate, it is what leechlike under your thumbs if you have them lightly monitoring the transverse processes of CI. The only explanation I have is that the rotation must be a complex combination of the repositioning of Cl, C2, and C3 taken together. Cl must somehow slide out of the joint so that it can turn even further.) I found the experience highly unpleasant, since I had to undergo a change of state away from social engagement. The other students in the 191 EFTA00810193

EXERCISES TO RESTORE SOCIAL ENGAGEMENT class could see a change in my breathing, and a loss of color in my face. Then I had my student perform our hands-on technique for myofascial release (see "Neuro-Fascial Release Technique," on page 195) to realign my CI and C2. These vertebrae did not come back into place as quickly as they had come out of position. He had to repeat the technique several times until C1 was again horizontal. Finally, I felt more like myself. The rotation of C1 and C2 has evolutionary survival value; it puts pressure on the vertebral artery, reducing blood flow to the brainstem, which affects the function of the five nerves necessary for social engagement. This puts us into a non-ventral vagal state, which in cases of danger can help our survival by shutting off the higher functions when we have to fight or to flee, or when we cannot face the present situation physically or emotionally. If our neuroception suddenly registers signals from the environment indicating that we are threatened or in danger, this change in our physiol- ogy should be instantaneous—and it is. Interestingly enough, although our nervous system is quick to be upset, it takes a longer time to settle down when we are safe again. It does not require a trauma to affect C1 and C2; the memory of a past event can do the same thing. Brain-scan studies in women with post-traumatic stress disorder show a reduction in blood flow to their brains' frontal lobes when they hear a re-telling of the traumatic events.cm Why would a trauma, the memory of a trauma, or even just a negative thought lead to a structural change such as a rotation of Cl and C2? Ten small muscles connect the occipital bone at the base of the skull with C1 and C2. Eight of these muscles are called the suboccipital muscles, and lie on the posterior (back) surface of the vertebrae. Two other muscles, the rectus capitis latemlis and the rectus capitis anterior, lie on the anterior (front) surface of these same two vertebrae. They are innervated by the occipital nerve, located on the scalp at the back of the head. (See “Suboc- cipital muscles,""Vertebral arteries,""Suboccipital muscles with vertebra:' and "Suboccipital nerve" in the Appendix.) Inappropriate tensions in any of these ten muscles are enough to shift and hold Cl and C2 out of joint. 192 EFTA00810194

The Basic Exercise The transverse processes of each cervical vertebra have openings (called foramens, or foramina) to accommodate passage of the vertebral arteries. Rotation or tipping of the vertebrae can twist or put pressure on these arteries, reducing the flow of blood, as in a plastic garden hose; if you put a bend in it, you reduce or shut off the flow of water. The amount of blood passing through these vertebral arteries depends on the position of the upper cervical vertebrae in the neck. When we do the Basic Exercise, we lie with the weight of our head on our fingers. This pressure is enough to stimulate the occipital nerve, causing these muscles to relax and to come into balance with each other. When we do the Basic Exercise, the first two cervical vertebrae move into a better position relative to each other. When Cl and C2 come back into place, it relieves tension on the ver- tebral arteries, providing better blood flow to the brain and brainstem, and allows us to return to social engagement. Adequate blood supply to the cranial nerves, brainstem, and brain is necessary for proper function of the social nervous system as well as other bodily functions. Concurrently, therefore, with realignment of Cl and C2, there is relief of many of the symptoms that we earlier described as the 'Heads of the Hydra:' WHY DO WE MOVE OUR EYES IN THE BASIC EXERCISE? The Basic Exercise involves movement of the eyes because there is a direct neurological connection between the eight suboccipital muscles and the muscles that move our eyeballs. We can directly experience this connection between eye movement and changes in tension of the suboccipital muscles if we place a finger across the back of the head, just under and parallel to the lower edge of the skull. Leaving the head in place, if we move our eyes right or left, up or down, or diagonally, a light finger pressure should detect a slight movement of the upper cervical vertebrae, or a change in the levels of tension in the muscles of the neck under our finger along with every movement of our eyes. 193 EFTA00810195

EXERCISES TO RESTORE SOCIAL ENGAGEMENT In my clinic I have observed that people who are socially engaged have a well-positioned Cl and C2. They also have a well-functioning auto- nomic nervous system that is flexible and able to respond appropriately to a variety of situations and internal states. Social engagement is not a fixed state, nor should the position of Cl and C2 stay fixed after doing the Basic Exercise. These bones move the instant that our psychological state shifts in moments of happiness, sat- isfaction, fear, anger, or withdrawal, or when our physiological state shifts among social engagement, dorsal vagus activation, or spinal sympathetic chain activation. Our autonomic nervous system is constantly scanning both our external and internal environments. When everything is good, Cl and C2 come into place, and we get adequate blood flow to the brainstem. When there is a dorsal vagal state, or activity of the spinal sympathetic chain, Cl and C2 rotate out of position, reducing blood flow to the origin of the five cranial nerves in the brainstem and to some areas of the brain. This physiological mechanism takes us away from social engagement, but it also enables us to react when we are challenged or endangered. This mechanism is instinctive, immediate, and bypasses conscious thought. Usually we are not aware of the change. One of the cornerstones of my treatment of stress and depression is to realign Cl and C2 using the Basic Exercise, or with a hands-on myo- fascial release technique (see "Neuro-Fascial Release Technique" on page 195). These interventions release imbalances in the tension of the small muscles that hold the skull and the first two vertebrae in relation to each other, and this repositions the atlas and the occiput. Improved alignment of the vertebrae, especially CI and C2, improves blood flow to the brain and usually brings a rapid improvement in the function of the five nerves necessary for the state of social engagement. There are other forms of manual therapy that use short-thrust, high- velocity manipulative techniques designed put Cl in place. However, I prefer to use a gentle technique. If I can give the body the right information with a soft touch at the right place, the body will balance itself. Because we cannot put Cl and C2 into place and expect them to stay that way 194 EFTA00810196

Neuro-Fascial Release Technique for Social Engagement permanently, we should repeat balancing techniques frequently, or as needed. Since there is no such thing as a fixed state of balance, it is more useful to think of balancing, an ongoing process. Neuro-Fascial Release Technique for Social Engagement Before I ever heard of the Polyvagal Theory or treated a patient on the autism spectrum, I managed to develop a hands-on healing technique on the base of the cranium that I would fortuitously be able to use later to help many people improve their communication and social skills. Some- times I choose to use this technique in my clinic rather than the Basic Exercise. I've named it the "Neuro-Fascial Release Technique." I developed this technique based on my understanding of the principles of biomechanical craniosacral therapy, osteopathy, and connective-tissue release (Rolfing). I have used it with great success for at least twenty-five years, and I have taught it to a few thousand therapists. This technique takes less than five minutes to perform, requires no physical effort, and is highly effective. You can use it on yourself, or to treat someone else. WHEN TO UTILIZE THE NEURO-FASCIAL RELEASE TECHNIQUE The Basic Exercise is a simple self-help method, and an easy and effective way to achieve better function of the ventral vagus nerve. However, if you are a body therapist, you may prefer to use your own hands rather than give people exercises to do; or you may want to combine the self-help exercises with hands-on techniques. The Neuro-Fascial Release Technique can serve as an alternative to the Basic Exercise. It is especially valuable for treating babies, children, and adults on the autism spectrum who lack the necessary verbal com- munication skills to absorb instruction about the Basic Exercise, when it might be difficult to communicate with them and have them follow your 195 EFTA00810197

EXERCISES TO RESTORE SOCIAL ENGAGEMENT instructions. Using your hands in this way gives you a nonverbal method for bringing about beneficial changes in another person's nervous system. If you practice massage or other hands-on modalities, I suggest that you do this technique, or have your client do the Basic Exercise, when you start your sessions. This recommendation is in line with the research of Porges, Cottingham, and Lyon (see earlier section), and will ensure that your client's autonomic nervous system will be flexible and that he will gain the most he can from your treatment. I also suggest that you end your sessions with this technique. NEURO-FASCIAL RELEASE TECHNIQUE INSTRUCTIONS If you are used to doing massage, you will need to use your hands in a new way in order to have success with this technique. Practice this technique on yourself and learn how to achieve a release before you try it on some- one else. To bring about social engagement with this technique, you need to stimulate reflexes in the nerves in the loose connective tissue just under the skin over the base of the skull. This balances the levels of tension in the small muscles between the base of the skull and the vertebrae of the neck It will be easier to learn this technique if the person is lying on his stomach, so that you can easily see your fingers. Start with one side of the back of his head. I. Push gently at the base of the skull on one side, and feel the hard- ness of the occipital bone. Test the "slide-ability" of the skin on one side of the occiput. Gently slide the skin over the bone to the right. Then let it come back to neutral. 2. Then slide the skin to the left, and let it come back to neutral. In which direction was there more resistance? 3. Slide the skin in the direction of greater resistance. Go very slowly, and be ready to stop at the very first sign of resistance. It may only have moved an eighth of an inch or less. Stop there, and hold that position. Continue to feel the slight resistance. In the pause when 196 EFTA00810198

Neuro-Fascial Release Technique for Social Engagement you are doing nothing, the person will sigh or swallow, and the resistance in the skin will melt away as it releases. 4. When you test again, the skin should slide easily in both directions. 5. Repeat the technique on the other side. When you test the vagus nerve again (see Chapter 4), it should be functioning properly. Also, there should be greater freedom of movement when turning the head to the left and right. TWO-HANDED NEURO-FASCIAL RELEASE TECHNIQUE INSTRUCTIONS Once you have practiced with one hand, you can use two hands. 1.Place one finger of one hand on the occiput at the base of the back of the head on one side. Test the slide-ability of the skin over the bone, as described above. The skin should slide more easily in one direction than the other over the bone. 2. Place a finger from the other hand at the top of the neck on the same side. If you push a little deeper, you should be able to feel the muscles. Use this finger to test the slide-ability of the skin over the muscles at the top of the neck. It should move more easily in the direction opposite to the direction that the other finger is slid- ing over the skull bone (Figure 9). 3. After you have tested, lighten your pressure. Let the fingers of your two hands slide the skin in opposite directions until you feel resistance. 4. Stop there, and hold that slight tension; wait until you get a sigh or a swallow. 5. Release your fingers, and allow the skin to return to its original position. 197 EFTA00810199

EXERCISES TO RESTORE SOCIAL ENGAGEMENT Figure 9. Sliding the skin over the occiput with two hands 6. Do the same thing on the skin on the opposite side of the skull and the neck. When you test the vagus nerve again, it should now be functioning properly. There should also be greater freedom of movement when turn- ing the head to the left and to the right. PROPER APPLICATION OF THE NEURO-FASCIAL RELEASE TECHNIQUE The key to success with the Neuro-Fascial Release Technique is getting the skin to slide, and stopping at the first sign of resistance. Use your fingertips to connect with the skin using the lightest touch imaginable. Then slide the skin a very short distance over the underlying layers of muscles, bones, and tendons. This technique differs from techniques used in other forms of mas- sage, which primarily target the muscular system and therefore push into the body. Please take the time to read the step-by-step instructions so that you can learn to do it properly. 198 EFTA00810200

Neuro-Fascial Release Technique for Social Engagement This hands-on technique stretches the loose connective tissue just under the skin. (To get an appreciation of how fine and delicate this tissue is, go to YouTube and search "Strolling the Skin:") This connective tissue is rich in proprioceptive nerve endings. When you gently slide the skin a very short distance over the muscles and bones, you create a slight traction in this loose tissue, which is enough to stimulate these nerves. You slide the skin only a short distance, until you feel the very first sign of resistance, and because you are working directly on the proprio- ceptive nerves you do not need to use the force required by most forms of massage that focus on the muscles. If you use unnecessary force and keep pushing after the first sign of resistance, or if you slide the skin too rapidly, the muscles and the ligaments will actually tighten. You cannot cause any damage this way—the release just takes a longer time. At worst, you might not get the desired changes. You may find that sometimes you are pushing so lightly that the other person reports that they cannot feel anything. That is good feedback! As you progress with the treatment, you will notice palpable improve- ment in the slide-ability of the skin. The Salamander Exercises The following "Salamander Exercises" progressively increase flexibility in the thoracic spine, freeing up movement in the joints between the individual ribs and the sternum. This will increase your breathing capacity, help reduce a forward head posture by bringing your head back into better alignment, and reduce a scoliosis (abnormal spine curvature). Eighty percent of the fibers of the vagus nerve are afferent (sensory) fibers, which means that they bring information back from the body to the brain, while only 20 percent are efferent (motor) fibers that carry instructions from the brain to the body. Some of the afferent fibers from parts of CN IX and CN X monitor the amount of oxygen and carbon dioxide in the blood. By improving our pattern of breathing with these exercises, we tell the brain (via the afferent nerves) that we are safe and 199 EFTA00810201

EXERCISES TO RESTORE SOCIAL ENGAGEMENT that our visceral organs are functioning properly. This in turn facilitates ventral vagal activity. But which comes first? Is a limited breathing pattern the result of a dysfunctional ventral vagus, or is a lack of ventral vagus function caused by feedback from a less than optimal breathing pattern? If there are ten- sions in the respiratory diaphragm and the muscles that move the ribs, feedback from the afferent vagal nerves monitoring those movements will report abnormal breathing, which may prevent a state of ventral vagal activity, just as restoring ventral vagal activity can improve the physi- ological condition; in practice, improving either one is helpful, no matter which came first. A forward head posture reduces the space in the upper chest that is available for breathing. The Salamander Exercises can create more space in the upper chest for both the heart and the lungs. Reducing a forward head posture will also take pressure off of the nerves that reach from the spinal cord to the heart, lungs, and visceral organs. By improving the alignment of the cervical vertebrae, the Salamander Exercises also relieve pressure on vertebral arteries, and can relieve some back pains between the shoulders. When you do the Salamander Exercises, you bring your head to the same level as the rest of your spine. This posture is similar to that of a salamander, which does not have a neck, so that its head is like an extra vertebra at the top of the spine. A salamander cannot flex, extend, rotate, or side-bend its head separately in relationship to the first vertebra of the spine, or lift its head above the level of the spinal vertebrae, as reptiles and mammals can. This exercise is done with the head in line with the spine. In terms of your spinal movements, these exercises put your head in a position that is neither up nor down. The thoracic (chest portion of the spine) can now side-bend better, somewhat like a salamander. You can utilize side-bending movements in your thoracic vertebrae in order to release muscular tensions between your ribs and thoracic spine. This contributes to the freedom of movement of your ribs and promotes optimal breathing. 200 EFTA00810202

Neuro-Fascial Release Technique for Social Engagement In the extension and flexion of the human spine, there is usually greater flexibility in the neck and lumbar vertebrae, and less flexibility in the thoracic spine. However, the flexibility of the thoracic spine increases dramatically with side-bending. The facet joints of the thoracic vertebrae are unlocked, allowing the thoracic spine to side-bend more freely. LEVEL 1:THE HALF-SALAMANDER EXERCISE To do the first part of the Salamander Exercise to the right, sit or stand in a comfortable position. 1. Without turning your head, let your eyes look to the right. 2. Continuing to face straight forward, tilt your head to the right so that your right ear moves closer to your right shoulder, without lifting the shoulder to meet it (Figure 10). Figure 10. Half-Salamander with eyes to the right 3. Hold your head in this position for thirty to sixty seconds. 4. Then let your head come back up to neutral, and shift your eyes to look forward again. 201 EFTA00810203

EXERCISES TO RESTORE SOCIAL ENGAGEMENT 5. Now do the same on the other side: let your eyes look to the left, and then side-bend your head to the left. After thirty to sixty seconds, return your head to an upright position, and your eyes to a forward direction. THE NALF-SALAMANDER—A VARIATION In this variation on the Half-Salamander Exercise, follow the same instructions above, but let your eyes look to the right while tipping your head to the left (Figure I I). This movement of your eyes in the opposite direction before you move your head increases your range of motion; you should be able to side-bend your head even further to the left. Hold this for thirty to sixty seconds, and then reverse to do the same thing on the other side. Figure 11. Half-Salamander with eyes to the left LEVEL 2:THE FULL SALAMANDER EXERCISE The Full Salamander Exercise involves side-bending the entire spine rather than just the neck. Also, we use a different body position. 202 EFTA00810204

Neuro-Fascial Release Technique for Social Engagement 1. Get down on all fours, supporting your weight on your knees and the palms of your hands. You can rest your hands on the floor, but it is better if you place the palms of your hands on a desktop, a table, the seat of a chair, or the pillows of a sofa. Your head should be on the same plane as your spine (Figure 12). Figure 12. Salamander on all fours 2. In this exercise, your ears should be neither lifted above nor dropped below the level of your spine. In order to find the right head position, lift your head slightly above what you think is right. You should be able to sense that your head is slightly raised. Then lower your head slightly below what you think is right. You should be able to sense that your head is lower than it should be. Go back and forth between the two positions. Take your head up a little and then take it down a little. Try to find a position in the middle where your head does not feel too far up or down. Although you may never find this position exactly, you can begin to zero in on it. 203 EFTA00810205

EXERCISES TO RESTORE SOCIAL ENGAGEMENT 3. Once you have found a good position for your head relative to your spine, look to the right with your eyes, hold them in that po- sition, and side-bend your head to the right by moving your right ear toward your right shoulder. 4. Complete the movement by letting the bend in your side continue beyond your neck, all the way down to the base of your spine. 5. Hold this position for thirty to sixty seconds. 6. Bring your spine and head back to center. Figure 13. Salamander with head to the left 7. Repeat all steps above, but on the left side (Figure 13). Massage for Migraines In the Appendix you will find drawings of four different patterns of migraine headache pain, shown in red. (See "Headache" illustrations.) The X's in the drawings indicate the location of trigger points on the surface of the muscles that can be massaged in order to release tension in the affected muscles. 204 EFTA00810206

Massage for Migraines The four drawings show the four typical patterns of migraine pain. Find the pattern of pain that fits your symptoms. Once you identify the headache pattern, you can see which part of which muscle has been tight, and where to massage it. The trigger points, each marked with an X in each drawing, are areas on the surface of a muscle where there is a high concentration of nerve endings. Some of them will feel more thick or hard than the rest of the muscle. People often find that trigger points that need to be released are painful when pressure is applied. FINDING AND DEFUSING TENSION IN TRIGGER POINTS Because you are working on nerves on the surface of the muscle, a light touch is usually sufficient to release the tension in the entire muscle. Rather than massaging the entire muscle, as in ordinary massage, it is usually enough to simply massage the trigger points. You do not need to work hard or press deep into the body. Massaging trigger points deeply or with a lot of force is usually pain- ful, and can be counterproductive. Under excessive pressure, the body does not feel safe, and the autonomic nervous system is put into a state of sympathetic activation or dorsal vagal withdrawal. This is not harmful, but it is inefficient because it takes time for the body to settle down again. Make a few small circles on the trigger point. Then stop and wait until you notice a nervous system reaction in the form of a sigh or a swallow. Within a few minutes, the intensity of the pain should start to dimin- ish or disappear. You can repeat the treatment whenever relief from a migraine is needed. Not all the X's on the drawing need to be treated. Even if an X indicates a trigger point for a particular pattern of pain, if you do not feel anything hard or painful at that particular spot on the surface of the muscle, that trigger point is not active. Don't waste time trying to release it, but focus on the trigger points that do feel hard, thick, or painful. 205 EFTA00810207

EXERCISES TO RESTORE SOCIAL ENGAGEMENT SCM Exercise for a Stiff Neck This exercise will extend your range of movement as you rotate your head, alleviate symptoms of a stiff neck, and help to prevent migraine headaches. It is similar to the very first movements that we made as infants lying on our stomachs, propped up on our elbows, with our heads free to move so that we could look around. 1. Lie on your stomach (Figure 14). Lift your head, and bring your arms under your chest. Rest the weight of your upper body on your elbows (Figure 15). Figure 14. Lying on the stomach ft al PAI 111 Figure 15. Lifting the head.jpg 206 EFTA00810208

SCM Excercise for a Stiff Neck 2. Rotate your head to the right as far as it comfortably goes. Hold that position for sixty seconds. 3. Bring your head back to center. Figure 16. Turning the head to the left) 4. Now rotate your head to the left as far as it comfortably goes, and hold that position for sixty seconds (Figure 16). If you have improved the rotation of the head with this exercise but the movement is still not as good as you want it to be on one side, then the restriction is probably coming from another muscle, the levator scapulae, which is innervated by spinal nerves C3—05. This kind of stiff neck will not be eliminated solely by improving the function of CN XI and the trapezius and sternocleidomastoid muscles. (See "The Levator Scapulae Muscle" on page 104). Part of the stiffness may also come from a hiatal hernia and shorten- ing of the esophagus, since the vagus nerve wraps around the esophagus. (See "Relieving COPD and Hiatal Hernia" on page 89.) n 207 EFTA00810209

EXERCISES TO RESTORE SOCIAL ENGAGEMENT Twist and Turn Exercise for the Trapezius The Twist and Turn Exercise improves the tone of a flaccid trapezius muscle, and balances each of its three parts with the other two parts. It also helps to lengthen the spine, improve breathing, and correct forward head posture (FHP). This in turn often alleviates shoulder and back pain. This exercise can benefit anyone, not just those with FHP. It takes less than one minute to do, and the feeling of positive change is immediate. It is a good idea to take a moment to do this exercise whenever you have been sitting for a while, and to repeat it regularly from time to time. I do it almost every time that I get up from sitting at my computer. Every time you do the exercise, you will experience an improvement in breathing and posture, and its positive effects are cumulative. The idea behind this exercise is neither to strengthen nor to stretch the trapezius muscle. The assumption is that the muscle is strong enough and just needs stimulation of the nerves to flaccid muscle fibers. You are waking them up so that they can take over their share of the work, as they did when we were babies and crawled on all fours. When a baby is lying on its stomach, it uses all the fibers of the three parts of the trapezius muscle to keep the shoulder blades together, lift the head, and turn the head to look around. Later, the baby also uses all these muscle fibers when raising itself up on all fours to crawl and to look around. However, when a baby stands up, all the fibers of the trapezius are no longer used evenly. Some become more tense, while the energy goes out of other fibers so that they become flaccid. The head is no longer supported in the same way by all three parts of the trapezius muscle. Over time, the head tends to glide further forward, so that the centers of the ears are in front of the center of the shoulders. The shoulders then exhibit a tendency to pull forward and down toward the midline. After doing this exercise, you will have a more even tone in all the muscle fibers of the three parts of your trapezius. Then, when you stand or sit, your head will glide back and up naturally by itself, reducing FHP and improving your posture. 208 EFTA00810210

Twist and Turn EIS) ise for theTrapezius TWIST AND TURN EXERCISE INSTRUCTIONS There are three parts to this exercise. The difference between the three parts is the position of your arms. 1. Sit comfortably on a firm surface, such as the seat of a chair or a bench. Keep your face looking forward. 2. Fold and cross your arms, with your hands resting lightly on your elbows (Figure 17). You will be rotating your shoulder girdle briskly, first to one side and then to the other, without stopping, and without shifting the hips. Figure 17. Hands on elbows 3. For the first part of the exercise, let your elbows drop and rest just in front of your body. Rotate your shoulders so that your elbows move, first to one side and then back to the other side. When you rotate your shoulders from side to side, your arms glide lightly over your stomach. This activates the fibers of your upper trape- zius (Figure 18). 209 EFTA00810211

EXERCISES TO RESTORE SOCIAL ENGAGEMENT Figure 18.Trapezius twist 4. Do this three times. Do not strain, and do not stop your move- ment. Move your shoulders without forcing them or holding them; your movements are easy and relaxed. 5. The second part is just like the first; the only difference is that you lift your elbows and hold them in front of your chest, at the level of your heart (Figure 19). Rotate your elbows first to one side and then to the other (Figure 20). Do this three times. This activates the muscle fibers of your middle trapezius. Figure 19.Trapezius twist with elbows lifted 210 EFTA00810212

Q Twist and Turn Excercise for the Trapezius Figure 20. Trapezius twist to the right 6. For the third part, raise your elbows as high as you comfortably can, and repeat the exercise above (Figure 21). Rotate your elbows from side to side, three times (Figure 22). This activates the muscle fibers of your lower trapezius. Figure 21. Elbows raised high 211 EFTA00810213

EXERCISES TO RESTORE SOCIAL ENGAGEMENT Figure 22.Trapezius twist with arms lifted After you have done the exercise, you might notice that your head feels lighter and has moved back and up, away from the forward head posture. It is not uncommon for someone with significant FHP to become an inch or two taller the first time they do the exercise. If someone has been look- ing at you from the side, she will see that your head has moved partway back from its original forward position, if you had that tendency. A Four-Minute Natural Facelift, Part 1 Benefits of this gentle and pleasant treatment include relaxing the facial muscles and leaving a more natural smile in place by improving the function of cranial nerves V and VII. You can do it for yourself and share it with others. This exercise: improves the circulation to your skin puts life into the muscles of expression of the middle third of your face, in the area between the corners of the mouth and the corners of the eyes 212 EFTA00810214

A Four-Minute Natural Facelift, Part 1 • improves blood circulation to the skin of your face • brings a youthful quality of liveliness that you can feel and others can see • helps you smile more naturally and more often • makes your face more responsive to interactions with others, and thereby increases your sense of empathy • makes flat cheekbones a little more prominent and makes very high cheeks a little flatter. Before you do this technique, look at your face in a mirror. If you are doing the technique on someone else, give theta hand-held mirror so they can watch their face and follow the changes. Look especially at the area of the skin around the cheekbones. Do one side of the face first. Then check whether you can see or feel a difference between the two sides. The differences are usually obvious when you talk or smile. Then do the other side. There should be more symmetry again. WHERE TO DO THE TECHNIQUE There is a point on the face that is the endpoint of the Large Intestine acupuncture meridian, called LI 20. (See "Acupuncture points" in the Appendix.) It is a beauty point in Chinese, Japanese, and Thai Massage. In Classical Thai Massage, this point is called "Golden Bamboo." In Traditional Chinese Medicine, this point is called "Welcoming Fragrance and it opens the nostrils, improving the breathing. This point in Chinese medicine is interesting in terms of Western anatomy. It lies directly over a joint between two bones of the face, the maxilla and the pre-maxilla. The two bones were separate entities long ago in the evolutionary development of our species, but they calcified together into a single bone at an early stage. In modern anatomy, the maxilla/pre-maxilla is referred to as one bone, called the maxilla. 213 EFTA00810215

EXERCISES TO RESTORE SOCIAL ENGAGEMENT The endpoint of the Large Intestine meridian is easy to find. Just lightly touch the skin about an eighth of an inch to the side of the top of the supra-alar crease (the fold between the cheek and upper lip), near the outer edge of the nostril. If you explore the area with your finger, you will find this point easily because it is more sensitive than the rest of the surrounding skin (Figure 23). Figure 23. Massage at LI 20 HOW AND WHY TO DO THE TECHNIQUE The surface of the facial skin is innervated by branches of the fifth cra- nial nerve. Lightly touching the skin of your face stimulates these nerve endings. 1. With a very light contact, brush the surface of the skin at acu- puncture point LI 20. Then let your fingertip melt together with the skin. 2. Slide the skin up and down to find which direction presents greater resistance. Push lightly into that resistance. Stop. 3. Hold at that point, and wait to feel it release. 214 EFTA00810216

A Four-Minute Natural Facelift, Part 1 4. Slide the skin inward toward the midline of the face, and out toward the side to find the direction of greater resistance. 5. Stop there, and push lightly. Hold and wait for the release. The muscles of the face are innervated by branches of the seventh cra- nial nerve (VII). There are two layers of facial muscles just below the skin. 6. Let your fingertip sink gently into the muscle layers beneath the skin at the same point. Let the first muscle layer adhere to your fingertip as if it were Velcro. 7. If you are careful not to push too hard, and if you feel what is happening under your fingertips, you can slide these layers of muscles; first slide one layer on top of the other, making a small circle. 8. As you go around the circle, you may notice that there is more resistance to sliding the skin in one direction. Keep pushing lightly in that direction, and hold until there is a release in the form of a sigh or a swallow. 9. Next, push slightly deeper. Now the deeper layer of muscles sticks together with the top muscle layer and the skin. You can slide both layers together over the surface of the bone. 10. As you go around the circle, you may notice that there is more resistance to sliding the skin in one direction. Keep pushing lightly in that direction, and hold until there is a release in the form of a sigh or a swallow. All bones have a connective-tissue covering called a periosteum (peri- means "around," and osteurn means "bone"). This tissue is very rich in nerve endings from spinal nerves or, in this case, cranial nerves. 11. Let your fingertip sink even deeper into the face until you rest lightly on the surface of the bone. 12. Massage on the surface of the periosteum has a profound effect on the autonomic nervous system. Press lightly, but hard enough 215 EFTA00810217

EXERCISES TO RESTORE SOCIAL ENGAGEMENT to reach the surface of the bone at Large Intestine 20. Let your fingertip move from side to side on the surface of the bone, then hold a light pressure on the bone and wait until you get a release. In the embryo, this bone was two bones, the maxilla and the pre- maxilla. Even though these have fused into one bone, it is still possible for most people to sense that there were once two separate bones. This massage of cranial nerves V and VII stimulates the nerves to the skin and muscles of the face. It does not erase all the wrinkles, but it relaxes the muscles of the face, reduces some wrinkles, and leaves the face looking younger and more refreshed. And there are no negative side- effects such as scar tissue from a face-lift operation or toxic accumulations of Botox. More importantly, this massage helps the face to be more expressive, communicative, and responsive—more socially engaged. Our face should be flexible and able to express different emotional responses in various situations. Facial expressions are a vital part of our communication with other people. In addition to expressing our own emotions, facial flexibility is impor- tant for social engagement. When our face is relaxed and we look at some- one else's face, our own face automatically makes micro-movements that mirror the other's facial expression. These movements are very small, and change very quickly. These changes in tension in our skin and our facial muscles then feed back to the brain via the afferent pathways of cranial nerves V and VII, to give us immediate subconscious information about what others are feeling. This is a prerequisite for us to have empathy for another person. If facial muscles under the skin are generally relaxed, a person usually has a smooth, pleasant, and what is seen as a beautiful or handsome face. Unfortunately, many people get stuck in the same emotional and facial pattern for years. Their facial muscles pull on the skin, creating wrinkles or a double chin. If the person stays in the same emotional state and does not relax his or her facial muscles, these wrinkles become deeper with time. 216 EFTA00810218

A Four-Minute Natural Facelift, Part 2 In addition to this technique, a light stroking of the skin of the face stimulates CN V and reduces tension in all the facial muscles. A Four-Minute Natural Facelift Part 2 Part I is focused on 1.120, an acupuncture point on the Large Intestine meridian at the side of the nostril. Stimulating this point improves the balance and tone of the muscles of the lower face around the mouth and the nose. Part 2, in turn, focuses on the eyes. The actual technique is similar in many ways to the first facelifting technique that you did at Large Intestine 20. You will find the-sensitiw-pleeton the inside corner of the eyebrow. People often rub this point naturally, without thinking about it, when they are tired. Massaging the skin and muscles of the face here is often self-soothing (Figure 24). Using your thumb or one finger, connect to the-aenpunc-tufe-peirkt B2. This-peint-is-lecated-at-the-medifil4imer4-enil-ef-the-eyebrew, At B2, work your way down each of the layers: the skin, two layers of muscles, and the periosteum. Figure 24. Massage at B2 217 EFTA00810219

EXERCISES TO RESTORE SOCIAL ENGAGEMENT This point is also a trigger point for the orbicularis oculi muscle, a thin, flat muscle that surrounds the opening of the eye. The eyes are sometimes called the mirror of the soul. Before we work on B2, the muscle might be too tight, leaving the eye somewhat closed or it might be undertoned, leaving the eye too open. When we finish, there will be an improved balance between looking outwards and looking in. You will see another person more clearly, and this person in turn will have an easier time making eye contact with you and will experience seeing you differently . At a deeper level, this acupuncture point is at the edge of a tiny facial bone called the lacrimal bone. The word "lacramal" refers to tears. Sometimes a person's eyes can be dry and appear lifeless. Someone can also experience an annoying flow of tears By touching this bone at B2 and holding your contact on the Mal bone, you will balance the flow of moisture to the eyes and leave them bright and sparkling. The goal of the facelifting massage is leave a smile on your lips and a twinkle in your eyes. I. Find the place at the inner corner of the eyebrow that is more sensitive than the surrounding areas. 2. First use your fingertip to brush the skin lightly a few times. 3. Let your fingertip rest lightly on the skin at point B2 (see above), and hold that contact with the surface of the skin until you get a release in the form of sigh or a swallow. 4. Next, press gently down to the layer of the facial muscles. This is where the flat, round orbicularis oculi muscle, which goes around the eye, attaches to the bones of the face. Let the skin stick to your finger and make a small circle, sliding the skin lightly and searching for the direction where there is resistance. 5. Hold your finger on that resistance until you get a release in the form of a sigh or a swallow. 6. Then go even deeper until you feel the surface of the bone. Rub that a few times. 218 EFTA00810220

Severing all the Heads of the Hydra 7. Then hold the contact with the bone, and wait for a release. If the orbicularis oculi muscle is too tight, closing the eyelids into a squint, this should open the eye more normally. If the eye was too wide- open, this technique should firm it down a bit but still leave it open. This is the second of two beauty points in Classical Thai Massage. Severing all the Heads of the Hydra The purpose of all of these self-help exercises and hands-on techniques is to help bring people out of a dorsal vagal state, or help them out of chronic activation of the sympathetic chain, and bring them home to a ventral vagal state. Only in this way can weeever all the heads of the Hydriand restore our capability for physical and emotional health. 219 EFTA00810221

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NOTES 1 Jerzy Grotowski, ed. Eugenio Barba, Towards a Poor Theatre (New York: Routledge Theatre Arts, 2002), 27. 2 Ida P. Rolf, PhD, Rolfing Reestablishing the Natural Alignment and Structural Integration of the Human Body for Vitality and Well-Being, rev. ed. (Rochester, VT: Healing Arts Press, 1989). 3 "The Nobel Prize in Physiology or Medicine 1937," Nobel Media AB 2014 (Oct 4, 2016), www.nobelprize.org/nobel_prizes/medicine /laureates/1937/. 4 There is another aspect and medical definition of stress that refers to pushing our muscles and/or organs with sports training and other physical regimens such as fasting, and it has been said that a certain level of this kind of stress is good for an organism. 5 Main Gehin's definitive book on his technique is called The Atlas of Manipulative Techniques for the Cranium and the Face (Seattle: Eastland Press, English translation, 1985). In this book, Gehin teaches more than 150 biomechanical techniques, and describes which techniques to choose when attempting to improve the function of the individual cranial nerves. 6 Ronald Lawrence and Stanley Rosenberg, Pain Relief with Osteomassage (Santa Barbara, CA: Woodbridge Press, 1982). 7 CN VIII is the coccleovestibular nerve. There are two specialized organs in the bony labyrinth of the temporal bone. "Cochlear" refers to the auditory component of CN VIII, which transduces sound into electrical impulses to the brain. "Vestibular" refers to the part of CN VIII that translates information from the movement of a thick fluid in three semicircular canals embedded in the temporal bone. As we change the position of the head in relationship to gravity, fluid in these canals moves, pushing on hairs that stimulate nerves to give us information about the position and movement of the head. 8 Harold Magoun, DO, Osteopathy in the Cranial Field, 3td ed. (India- napolis, IN: The Cranial Academy, 1976). 221 EFTA00810223

ACCESSING THE HEALING POWER OF THE VAGUS NERVE 9 The idea that the cranial bones move is contrary to almost all teach- ings in anatomy and physiology. The commonly held belief is that the bones fuse together at different ages, the last of these growing fast to the rest of the skull at the age of thirty-eight. However, I saw collec- tions of separate human skull bones from an older adult in an anatomy lab; the bones had been separated by filling a prepared skull with rice and submerging it in a bucket of water. As the rice absorbed the water and expanded, it pushed the bones apart from each other. If the bones had fully grown together, as is taught in many anatomy classes, this separation of bones would not be possible in an adult of this age. 10 Lauren M. Wier, MPH (Thomson Reuters) and Roxanne M. Andrews, PhD (AHRQ), Statistical Brief #107: The National Hospital Bill: The Most Expensive Conditions by Payer, 2008, Healthcare Cost and Utiliza- tion Project Statistical Brief #107 (Rockville, MD: Agency for Health- care Research and Quality, 2011), www.hcup-us.ahrq.gov/reports /statbriefs/sb107.pdf. 11 M. Widen, "Back Specialists are Discouraging the Use of Surgery," American Academy of Pain Medicine, 17th annual meeting, Miami Beach, FL (2001). 12 Markus Melloh, Christoph Roder, Achim Elfering, Jean-Claude Theis, Urs Muller, Lukas P. Staub, Emin Aghayev, Thomas Zweig, Thomas Ban, Thomas Kuhlmann, Simon Wieser, Peter Juni, and Marcel Zwahlen, "Differences Across Health Care Systems in Outcome and Cost-Utility of Surgical and Conservative Treatment of Chronic Low Back Pain: A Study Protocol," BMC Musculoskeletal Disorders 9, no. 81 (2008). 13 Lumbar Spinal Stenosis, American Academy of Orthopaedic Surgeo (2010), www.knowyourbackorg/Pages/SpinalConditions/Degene tiveConditions/LumbarSpinalStenosis.aspx. 14 Michael Gershon, The Second Brain (New York Harper Collins Publishers, 1999). 15 B. Zahorska-Markiewicz, E. Kuagowska, C. Kucio, and M. Klin, "Heart Rate Variability in Obesity," International Journal of Obesity and Related Metabolic Disorders 17, no. I (Jan 1993): 21-23. 222 EFTA00810224

Notes 16 Gemot Ernst, Heart Rate Variability (London: Springer-Verlag, 2014), 261. 17 Stephen W. Porges, "Orienting in a Defensive World: Mammalian Modifications of our Evolutionary Heritage—A Polyvagal Theory," Psychophysiology32 (1995): 301-18. 18 Fischer, Philip, MD, "Postural Orthostatic Tachycardia Syndrome (POTS)," Mayo Clinic podcast (Apr 23, 2008), http://newsnetwor mayoclinic.org/discussion/postural-orthostatic-tachycardia -syndrome-pots-24cc80/. 19 P. J. Carek, S.E. Laibstain, and M. Carek, "Exercise for the Treatment of Depression and Anxiety," The International Journal of Psychiatry in Medicine 41, no. 1 (2011): 15-28. 20 For a list of health issues that can develop, at least in part, from a dys- functional ventral branch of the vagus nerve, see the table at the begin- ning of Part One listing the "Heads of the Hydra?' 21 Stephen W. Porges, "Neuroception: A Subconscious System for Detecting Threats and Safety," Zero to Three 24, no. 5 (May 2004): 19-24. 22 Ben Hogan, Five Lessor's: The Modem Fundamentals of Golf (New York Simon and Schuster, 1957). 23 Vasilios Papaioannou, loannis Pneumatikos, and Nikos Maglaveras, "Association of Heart Rate Variability and Inflammatory Response in Patients with Cardiovascular Diseases: Current Strengths and Limitations:" P osomatic ne 67, suppl. 1 (2005): 529—S33. 24 B. Pomeranz, acauley, Caudill, I. Kutz, D. Adam, and D. Gordon, "Assessment of Autonomic Function in Humans by Heart Rate Spectral Analysis," American Journal of Physiology 248 (1985): H151-H153. 25 U. I. Zulficiar, D. A. Jurivich, W. Gao, and D. H. Singer, "Relation of High Heart Rate Variability to Healthy Longevity," American Journal of Cardiology 105, no. 8 (Apr 15, 2010): 1181—85, doi: 10.1016/j.amj -card.2009.12.022 (epub Feb 20, 2010), erratum 106, no. I (Jul 1, 2010): 142. 223 EFTA00810225

ACCESSING THE HEALING POWER OF THE VAGUS NERVE 26 P. Jonsson, "Respiratory Sinus Arrhythmia as a Function of State Anxiety in Healthy Individuals," International Journal of Psychophysiology63 (2007): 48-54. 27 P. Nickel and F. Nachreiner, "Sensitivity and Diagnosticity of the 0.I - Hz Component of Heart Rate Variability as an Indicator of Mental Workload;' Human Factors 45, no. 4 (2003): 575-90. 28 J. F. Brosschot, E. Van Dijk, andlErhayer,"Daily Worry is Related to Low Heart Rate Variability During Waking and the Subsequent Nocturnal Sleep Periar International Journal of Psychophysiology 63 (2007): 39-47. 29 A. J. Camm, M. Malik, J. T. Bigger, G. Breithardt, S. Cerutti, R. J. Cohen, P. Coumel, E .L. Fallen, H. L. Kennedy, Kleiger, F. Lombardi, A. Malliani, A. J. Moss, J. N. Rottman, G. Schmidt, P. J. Schwartz, and D. H. Singer (Task Force of the European Society of Cardiology and the North American Society of Electrophysiology), "Heart Rate Variability: Standards of Measurement, Physiological Interpretation, and Clinical Use," Circulation 93 (1996): 1043-65. 30 Arpi Minassian, PhD, Mark A. Geyer, PhD, Dewleen G. Baker, MD, Caroline M. Nievergelt, PhD, Daniel T. O'Connor, MD, Victoria B. Risbrough, PhD, and the Marine Resiliency Study Team, "Heart Rate Variability in a Large Group of Active-Duty Marines and Relationship to Posttraumatic Stress," Psychosomatic Medicine 76, no. 4 (May 2014): 292-301. 31 Vasilios Papaioannou, loannis Pneumatikos, and Nikos Maglaveras, "Association of Heart Rate Variability and Inflammatory Response in Patients with Cardiovascular Diseases: Current Strengths and Limitations:" Psychosomatic Medicine 67, suppl. 1 (2005): S29—S33. 32 Masari Amano, Tomo !Cando, U.E. Hidetoshi, and Toshio Moriani, "Exercise Training and Autonomic Nervous System Activity in Obese Individuals," Medicine and Science in Sports and Exercise 33 (2001): 1287-91. 33 Amelia M. Stanton, Tierney A. Lorenz, Carey S. Pulverman, and Cindy M. Meston,"Heart Rate Variability: A Risk Factor for Female Sexual Dysfunction," Applied Psychophysiology and Biofeedback 40 (2015): 229-37. 224 EFTA00810226

Notes 34 Ji Yong Lee, Kwan-Joong Joo, Jin Tae Kim, Sung Tae Cho, Dae Sung Cho, Yong-Yeun Won, and Jong Bo Choi,"Heart Rate Variability in Men with Erectile Dysfunction," International Neurourology Journal 15, no. 2 (Jun 2011): 87-91. 35 Jacqueline M. Dekker, PhD, Richard S. Crow, MD, Aaron R. Folsom, MD, MPH, Peter J. Hannan, MStat, Duanping Liao, MD, PhD, Cees A. Swenne, PhD, and Evert G. Schouten, MD, PhD, "Clinical Investigation and Reports: Low Heart Rate Variability in a 2-Minute Rhythm Strip Predicts Risk of Coronary Heart Disease and Mortality from Several Causes: The ARIC Study," Circulation 102 (2000): 1239-1244. 36 Robert M. Carney, Kenneth E. Freedland, and Richard C. Veith, "Depression, the Autonomic Nervous System, and Coronary Heart Disease," Psychosomatic Medicine 67 (May—Jun 2005): S29—S33. Studies of medically well, depressed psychiatric patients have found elevated levels of plasma catecholamines and other markers of altered ANS function compared with controls. Studies of depressed patients with coronary heart disease (CHD) have also uncovered evidence of ANS dysfunction, including elevated heart rate, low heart rate variability, exaggerated heart rate responses to physical stressors, high variability in ventricular repolarization, and low baroreceptor sensitivity. All these indicators of ANS dysfunction have been associated with increased risks of mortality and cardiac morbidity in patients with CHD. 37 M. Malik, P. Barthel, R. Schneider, K. Ulm, and G. Schmidt, "Heart- rate Turbulence after Ventricular Premature Beats as a Predictor of Mortality after Acute Myocardial Infarction," The Lancet 353, no. 9162 r 24, 1999): 1390-96. 38 epartment of Health and Human Services, National Center for Health Statistics,"Health, United States 2015: Special Feature on Racial and Ethnic Health Disparities" (accessed June 2016), www.cdc.gov /nchs/hus/. 39 A. B. Kulur, N. Haleagrahara, P. Adhikary, and R S. Jeganathan, "Effect of Diaphragmatic Breathing on Heart Rate Variability in lschemic Heart Disease with Diabetes:' Arquivos Brasilieros Cardiologia 92, no. 6 (Jun 2009): 423-29, 440-47, 457-63. 225 EFTA00810227

ACCESSING THE HEALING POWER OF THE VAGUS NERVE 40 Peter Levine is a leading shock and trauma therapist. He uses verbal techniques, combined with a close observation of the client in terms of subtle changes in their autonomic nervous system, as the client regresses to the time of a traumatic event. He wrote Waking the Tiger (Berkeley: North Atlantic Books, 1997). Since then, his teaching has grown into a form called Somatic Experiencing. 41 Stephen Porges developed, patented, and marketed a vagal-tone monitor to measure HRV through a small company called Delta- Biometrics, Inc. That company no longer exists; however, there are now many vagal-tone measuring devices manufactured by other companies. 42 James Oschman, PhD is a research scientist and author of the bestselling book Energy Medicine (London: Churchill Livingstone, 2000). 43 The Listening Project Protocol is now available through Integrated Listening Systems as the "Safe and Sounds Protocol: A Portal to Social Engagement," 44 John T. Cottingham, Stephen W. Porges, and Todd Lyon, "Effects of Soft Tissue Mobilization (Rol ling Pelvic Lift) on Parasympathetic Tone in Two Age Groups," Physical Therapy 68, no. 3 (Mar 1988): 352-56. 45 D. Buskila and H. Cohen,"Comorbidity of Fibromyalgia and Psychiatric Disorders," Current Pain and Headache Reports 11, no. 5 (Oct 2007): 333-38. 46 P. Schweinhardt, K. M. Sauro, and M. C. Bushnell, "Fibromyalgia: a dis- order of the brain?" Neuroscientist 14, no. 5 (2008): 415-21. 47 A systematic review of antidepressant efficacy failed to demonstrate superior effectiveness compared to psychotherapy, alternative therapy such as exercise, acupuncture, and relaxation, or active intervention controls such as sham acupuncture or therapies not specific to depres- sion. Arif Khan, Charles Faucett, P. Lichtenberg, I. A. Kirsch, and W.A. Brown, "A Systematic Review of Comparative Efficacy of Treatments and Controls for Depression:' PLOS (Jul 30, 2012), http://dx.doi .org/10.1371/joumalpone.0041778. 48 My primary biomechanical craniosacral teacher is Main Gehin, the French osteopath who wrote The Atlas of Manipulative Techniques for the Cranium and the Face. (See note 5 above.) 226 EFTA00810228

Notes 49 Monica J. Fletcher, Jane Upton, Judith Taylor-Fishwick, Sonia A. Buist, Christine Jenkins, John Hutton, Neil Barnes, Thys Van Der Molen, John W. Walsh, Paul Jones, and Samantha Walker, "COPD Uncovered: An International Survey on the Impact of Chronic Obstructive Pulmonary Disease [COPD[ on a Working-Age Population:' BMC Public Health Journal 11, no. 612 (2011), www.biomedcentral .com/1471-2458/11/612#B1, doi :10.1186/1471-2458-11-612. 50 The 10 Leading Causes of Death in the World, 2000 and 2012, World Health Organization Fact Sheet No. 310 (Geneva, Switzerland: World Health Organization, 2013). 51 Robert I. Miller and Sterling K. Clarren, "Long-Term Developmental Outcomes in Patients with Deformational Plagiocephaly," Pediatrics 105, no. 2 (Feb 2000): e26. 52 David G. Simons, MD, Janet G. Travel', MD, and Lois S. Simons, PT, Myofascial Pain and Dysfunction: The Trigger Point Manual, 6i° ed., vol. 2 (London: Churchill Livingstone, 2008). 53 Ida P. Rolf, PhD, Rolfing: Reestablishing the Natural Alignment and Structural Integration of the Human Body for Vitality and Well-Being, rev. ed. (Rochester, VT: Healing Arts Press, 1989). 54 John T. C.ottingham, Stephen W. Porges, and Todd Lyon, "Effects of Soft Tissue Mobilization (Rolfing Pelvic Lift) on Parasympathetic Tone in Two Age Groups," Physical Therapy 68, no. 3 (Mar 1988): 352-56. Their experiment is discussed in detail in Chapter 4. 55 C. C. Lunardi, F. A. Marques da Silva, Rodrigues Mendes, Marques A. P. Stelmach, and Fernandes Carvalho,"Is there an Association Between Postural Balance and Pulmonary Function in Adults with Asthma?" Clinics 68, no. 11 (Sao Paulo, Brazil: Department of Physical Therapy, School of Medicine, University of Sao Paulo, Nov 2013). 56 D. M. Kado, M. H. Huang, H. S. Karlamangla, E Barrett-Connor, and G.A. Greendale, "Hyperkyphotic Posture Predicts Mortality in Older Community-Dwelling Men and Women: A Prospective Study," Journal of the American Geriatric Society 52, no. 10 (Oct 2004): 1662-67. 57 Mayo Clink Newsletter (Nov 3, 2000). 227 EFTA00810229

ACCESSING THE HEALING POWER OF THE VAGUS NERVE 58 Alf Breig, Adverse Mechanical Tension in the Central Nervous System: An Analysis of Cause and Effect: Relief by Functional Neurosurgery (Stock- holm: Almqvist 8c Wiksell International, 1978). 59 Roger W. Sperry, "Roger Sperry's Brain Research," Bulletin of The Theosophy Science Study Group 26, no. 3-4 (1988): 27-28. Also see Sperry's review of The Formation of Nerve Connections by R. M. Gaze in Quarterly Review of Biology 46 (Jun 1971): 198. 60 A. I. Kapandji, The Physiology of the Joints, 6th ed., vol. 3 (London: Churchill Livingstone, 2008). 61 T. A. Smitherman, R. Burch, H. Sheikh, and E. Loder, "The Prevalence, Impact, and Treatment of Migraine and Severe Headaches in the United States: A Review of Statistics from National Surveillance Stud- ies," Headache 53, no. 3 (Mar 7,2013): 427-36. 62 L. D. Goldberg, "The Cost of Migraine and its Treatment," American Journal of Managed Care 11, no. 2 suppL (Jun 2005): S62-67. 63 David G. Simons, MD, Janet G. Travel', MD, and Lois S. Simons, PT, Myofascial Pain and Dysfunction: The Trigger Point Manual, 0 ed., vol. 2 (London: Churchill Livingstone, 2008). 64 M. S. Robbins and R. B. Lipton, "The Epidemiology of Primary Head- ache Disorders," Seminal Neurology 30 (Apr 2010): 107-19. 65 Jes Olesen, Headaches, 3rd ed. (Philadelphia: Lippincott, Williams 8c Wilkins, 2006), 246-47. 66 R. C. Kessler, W. T. Chiu, O. Demler, K. R. Merikangas, and E. E. Wal- ters, "Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication," Archives of General Psychiatry 62, no. 6 (Jun 2005): 617-27. 67 Phil Barker, Psychiatric and Mental Health Nursing: The Craft of Caring (London: Arnold, 2003). 68 Michael Passer, Ronald Smith, Nigel Holt, Andy Bremner, Ed Sutherland, and Michael Vliek, Psychology (UK: McGrath Hill Higher Education, 2009). 69 The National Intimate Partner and Sexual Violence Survey (Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 2017), www.cdc.goviviolenceprevention/nisys/. 228 EFTA00810230

Notes 70 M. J. Breiding, J. Chen, and M. C. Black, Intimate Partner Violence in the United States-2010 (Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Preven- tion, 2014), www.cdc.gov/violenceprevention/pdf/cdc_nisys_ipv report_2013_v17_single_a.pdf. 71 T. Frodi, E Meisenzahl, T. Zetsche, R. Bottlender, C. Born, C. Groll, M. Jager, G. Leinsinger, K. Hahn, and H.J. Moller,"Enlargement of the Amygdala in Patients with a First Episode of Major Depression:' Biological Psychiatry 51, no. 9 (May 1, 2002): 708-14. 72 Bruce S. McEwen, "LI Stress Induced, Hippocampal, Amygdala and Prefrontal Cortez Plasticity and Mood Disorders," Behavioral Pharmacology 15, no. 5-6 (2001): Al. 73 There was no published report from this treatment project. This sum- mary is condensed from personal conversations with psychologist Marc Levin over several years. 74 Thomas Insel,"Antidepressants: A Complicated Picture," The National Institute of Mental Health Directors Blog (Dec 6, 2011), www.nimh.nih .gov/aboutIdirectors/thomas-inseUblog/2011/antidepressants-a -complicated-picture.shtml. 75 Peter Wehrwein, "Astounding Increase in Antidepressant Use by Amer- icans," Harvard Health Blog (Oct 20, 2011), www.health .harvard.edu/bloglastounding-increase-in-antidepressant-use-by -americans-201110203624. 76 Andreas Vilhelmsson, "Depression and Antidepressants: A Nordic Perspective Frontiers in Public Health 1, no. 30 (Aug 26, 2013), doi: 10.3389/fpubh.2013.00030. 77 Craig W. Lindsley, ed., "2013 Statistics for Global Prescription Medications," ACS Chemical Neuroscience 5, no. 4 (Apr 16, 2014): 250- 251, www.ncbi.nlm.nih.gov/pmc/artides/PMC3990946/, doi: 10.1021 /cn500063v. 78 Jay C. Fournier, MA, Robert J. DeRubeis, PhD, Steven D. Hollon, PhD, Sona Dimidjian, PhD, Jay D. Amsterdam, MD, Richard C. Shelton, MD, and Jan Fawcett, MD, "Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-analysis," Journal of the American Medical Association 303 (2010): 47-53. 229 EFTA00810231

ACCESSING THE HEALING POWER OF THE VAGUS NERVE 79 Mark Olfson, MD and Steven C. Marcus, PhD, "National Patterns in Antidepressant Medication Treatment," Archives of Genera! Psychiatry 66, no. 8 (2009): 848-856, doi: 10.1001/archgenpsychiatry.2009.81. 80 IL C. Kessler, R A. Berglund, O. Demler, R. Jin, K. IL Merikangas, and E.E. Walters, "Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replica- tion," Archives of General Psychiatry 62, no. 6 (Jun 2005): 593-602. 81 See Chapter 5, "Relieving COPD and Hiatal Hernia;' for more about hiatal hernias and their treatment. 82 Centers for Disease Control and Prevention, "Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years—Autism and Developmental Disabilities Monitoring Network," Surveillance Summaries (Mar 28, 2010): 1-21. 83 Centers for Disease Control and Prevention Autism and Developmental Disabilities Monitoring Network Surveillance Year 2010 Principal Investigators, Jon Baio, EdS, corresponding author, "Prevalence of Autism Spectrum Disorder among Children Aged 8 Years—Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2010," Morbidity and Mortality Weekly Report 63, no. SS02 (Mar 28, 2014): 1-21. 84 Ariane V. Buescher, MSc; Zuleyha Cidav, PhD, Martin Knapp, PhD, and David S. Mandell, ScD, "Costs of Autism Spectrum Disorders in the United Kingdom and the United States," Journal of the American Medical Association Pediatrics 168, no. 8 (Aug 2014): 721-28. 85 Tara A. Lavelle, PhD, Milton C. Weinstein, PhD, Joseph P Newhouse, PhD, Kerim Munir, MD, MPH, DSc, Karen A. Kuhlthau, PhD, and Lisa A. Prosser, PhD, "Economic Burden of Childhood Autism Spectrum Disorders," Pediatrics 133, no. 3 (Mar 1, 2014): e520-29. 86 Nicole Ostrow, "Autism Costs More Than 2 Million Dollars over Patient's Lifetime:' Bloomberg Business (Jun 10, 2014), -than-2-million-over-patient-s-life. 87 Also see Erik Borg and S. Allen Counter, "The Middle-Ear Muscles," Scientific American 261, no. 2 (Aug 1989): 74—80. 230 EFTA00810232

Notes 88 The listening project protocol is now available through Integrated Listening Systems as the "Safe and Sounds Protocol: A Portal to Social Engagement," 89 Porges, S. W., Macellaio, M., Stanfill, S. D., McCue, K., Lewis, G. F., Harden, E. IL, and Heilman, K. J.,"Respiratory Sinus Arrhythmia and Auditory Processing in Autism: Modifiable Deficits of an Integrated Social Engagement System?" International Journal of Psychophysiol- ogy 88, no. 3 (2013): 261-270. 90 Stephen W. Porges, Olga V. Bazhenova, Elgiz Bal, Nancy Carlson, Yevgeniya Sorokin, Keri J. Heilman, Edwin H. Cook, and Gregory F. Lewis, "Reducing Auditory Hypersensitivities in Autism Spectrum Disorder: Preliminary Findings Evaluating the Listening Project Protocol," Frontiers in Pediatrics 2, no. 80 (Aug 1, 2014), doi: 10.3389/ fped.2014.00080. 91 This is based on conversations with Stephen and his lab assistant, who tested the function of my stapedius musde on two different visits. See also Erik Borg and S. Allen Counter, "The Middle-Ear Muscles," Scientific American 261, no. 2 (Aug 1989): 74-80. 92 IL I. Miller and S. K. Clarren,"Long-Term Developmental Outcomes in Patients with Deformational Plagiocephaly," Pediatrics 105, no. 2 (Feb 2000), http://pediatrics.aappublications.org/content/105/2/e26.short. 93 Thomas W. Myers, Anatomy Trains: Myofascial Meridians for Manual and Movement Therapists, 3rd ed. (London: Churchill Livingstone, 2014). 94 J. Douglas Bremner, MD,"Neuroimaging Studies in Post-Traumatic Stress Disorder," Current Psychiatry Reports 4 (2002): 254-63. 231 EFTA00810233

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ABOUT THE AUTHOR Stanley Rosenberg is an American-born author and body therapist. A Rolfer since 1983 and,practicing craniosacral therapist since 1987. He studied biomechanical craniosacral therapy for many years under Main Gehin, trained in craniosacral therapy at the Upledger Institute and in biodynamic craniosacral courses with Giorgia Milne, studied applica- tions for treating children with Benjamin Shield, and took courses in osteopathy with Jean-Pierre Barral. For many years he led a school in Denmark, teaching structural integration, myofascial release, release of scar tissue, biomechanical craniosacral therapy, visceral massage, and biotensegrity. He is the author of four books, published in Denmark: Nevermore Pain in the Back, Nevermore Stiff Neck, Pain Relief with Osteomassage, and Hwa Yu Tai Chi. In addition to his work as a body therapist, he has worked in theater— training actors in yoga, acrobatics, and voice—at various institutions, including Yale University, Brandeis University, Swarthmore College, and the National Theatre Schools of Denmark and Iceland. More information about the techniques presented in this book can be found on his website. EFTA00810237

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