Acupunture / Dry Needling Course

Cranial Osteopathy Introductory Course

Day 1 – Friday 10th September 2010
9.00 Registration & coffee
9.20 Introduction
9.30 Lecture - The Involuntary Mechanism – a brief review of osteopathic
principles, the history of the concept and an overview of the
involuntary mechanism in its ideal state
10.10 Participants’ histories
10.20 Introduction to practical –
10.40 Practical – distinguishing by palpation between bone, fascia and
extracellular fluid, introductory palpation of neurocranium
11.20 Coffee
11.30 Lecture – Reciprocal tension membrane and venous sinuses –
principle of reciprocal tension, anatomy, physiology and clinical
implications
12.10 Introduction to practical - reciprocal tension membrane -
12.20 Practical – palpation of reciprocal tension membrane – falx,
tentorium, spinal dura from sacrum
1.00 Lunch
1.40 Lecture – central nervous system and cerebrospinal fluid – principle
of CSF fluctuation, physiology and clinical significance
2.20 Practical – palpation of CSF
2.50 Tea/discussion in small groups (DSG)
3.15 Lecture – Analysis of patterns of motion
3.45 Tutorial – patterns of motion
4.15 Introduction to practical – inducing motion
Practical – observation and palpation of patterns of motion
5.30 Tutorial
Day 2 - Saturday 11th September 2010
9.00 Lecture – recapitulation of day 1
9.15 Lecture – principles of treatment (1) – directional strains and
balanced membranous tension
9.45 Tutorial – patterns of motion
10.0 Introduction to practical – balanced membranous tension
10.10 Practical – treatment methods- balanced membranous tension
11.20 Coffee/DSG
11.40 Lecture – principles of treatment (2) – tissue quality and CSF
12.00 Introduction to practical – CSF and CV4
12.10 Practical – treatment methods – CV4
1.10 Lunch
2.00 Lecture – the fascial system and transverse structures
2.40 Introduction to practical – fascial system
2.50 Practical – palpation of fascial system and transverse structures
3.30 Tea/DSG
4.0 Lecture – Sacrum and pelvis – applied anatomy, physiological
motion and clinical implications
4.30 Introduction to practical – sacrum
4.40 Practical – palpation of sacrum for physiological motion
5.10 Practical – treatment methods – BMT at sacrum
5.50 Tutorial
Day 3 – Sunday 12th September 2012
9.15 Lecture – recapitulation of day 2
9.30 Lecture/demonstration – bones of neurocranium – sutural anatomy
and functional significance, axes of physiological motion, clinical
implications
10.30 Introduction to practical – palpation of osseous cranial base
10.40 Practical – palpation of osseous cranial base
11.30 Coffee/DSG
11.50 Introduction to practical - palpation of osseous vault
12.00 Practical – palpation of osseous vault
12.30 Lunch
1.20 Lecture – temporal bone – applied anatomy, physiological motion
and clinical implications
2.00 Practical – palpation of temporal bone motion
2.40 Introduction to practical – treatment methods - disengagement
techniques
2.50 Practical – disengagement techniques
3.40 Tea/DSG
4.00 Lecture – introduction to the face and its’ functional relationship to
the neurocranium (the speed reducers)
4.30 Introduction to practical – palpation of facial motion
4.40 Practical – palpation of facial motion
5.10 Tutorial
5.25 Head checking
Day 4 – Saturday 18th September 2010
9.30 Lecture - review of first 3 days
10.00 Demonstration of facial bones – anatomy, applied anatomy and
physiological motion – all tutors
10.45 Coffee/DSG
11.15 Introduction to practical – palpation of individual facial bones
11.25 Practical – palpation of facial bones
12.20 Introduction to practical – treatment methods – peripheral
structures/balanced fascial tension
1.00 Lunch
1.50 Lecture- treatment and management of facial conditions including
TMJ dysfunction
2.40 Introduction to practical - treatment of face
2.50 Practical – treatment of face
3.45 Tea/DSG
4.15 Lecture/demonstration – application and integration of the involuntary
mechanism approach into clinical practice
5.00 Introduction to practical – treatment methods – sacrum BMT and
intra-osseous strains of sacrum
5.45 Tutorial
Day 5 - Sunday 19th September 2010
9.15 Lecture – recapitulation of day 4
9.30 Lecture – The cranio-cervical junction, birth trauma and intraosseous
strains of the cranial base
10.15 Demonstration of neonate skulls
10.25 Introduction to practical – intra-osseous strains of the cranial base
(the condylar parts of the occiput)
10.35 Practical – disengagement of the condylar parts of the occiput
11.35 Tea/DSG
12.00 Lecture – clinical application of the involuntary mechanism approach
to the treatment and management of infants and children
12.30 Introduction to practical – balanced membranous tension
12.40 Practical – balanced membranous tension
1.30 Lunch
2.30 Introduction to practical – CSF
2.40 Practical – treatment methods – CSF – CV4, lateral fluctuation, vspread
3.50 Plenary session – practical considerations of applying the involuntary
mechanism approach in clinical practice
4.20 Resume
4.30-5.15 Head checking (tea available from 4.15 pm

M.OST RESULTS !!!

Attendance Level of Electives

THE INTER-CONNECTIVE TISSUES - A practical approach to connective tissue TTT

Course by Valeria Ferreira and Alison Durant (01/05/10 - 02/05/10)



Wasn't too sure what the content of this weekends course was going to be ... but as I knew Valeria was leading it then I guessed that it would involve some of the following: structural realignment, soft tissue manipulation/ massage, visceral mobilisation, lymphatic drainage, cranial osteopathy, exercises and postural advice (taken from her web site).

Thankfully after the talk that the 4th Years had received from the Lead Tutor of 4th Year Technique about the general lack of fluidity in our soft tissue work ... this course was exactly what was needed as it concentrated on treating the superficial/deep fascia and muscles.

It has been said by myself on more than one occasion that the course at the BSO doesn't really emphasis much on its soft tissue work. It seems that after the basic cross fibre techniques have been shown in the Mixed Mode component then nothing further is done with soft tissue techniques until the 4th year electives of Strain Counterstrain and Visceral. This has also been suggested by various tutors in clinic.

Thankfully the course was going to look at myofacial release and soft tissue techniques.

CERVICAL AREA
After a revision of the anatomy of the different layers of fascia we moved on to the first practical elements of the course. I wont list every technique that we were taught, just the ones that are of a particular interest.

The first set of techniques we worked on were anterior neck structures such as sternocleidomastoid and scalenes. Having previously struggled with Scalene techniques Ive meet MET'ing then as shown by Linda Goddard (see entry dated 18/03/2001)with great success I hasten to add. But we were shown another technique which sounds quick aggressive however is in practice. It was to us the knuckles to hold back to superficial fascia of covering the scalenes and SCM and side bend the patients head towards and then ask them to rotate away. This technique is quite simple and quite effective ... looking forward to trying this one out.

Alison Durant was a massage therapist before she trained as an osteopath and still uses lots of deep massage in her osteopathic treatment. I was delighted when she demonstrated a number of techniques that she does with her elbow ... the reason why I was so delighted is that I too like to use my elbow as I find it a very effective tool, however it has often been criticised by clinic tutors due to the lack of proprioception in the elbow compared to the finger pads. What Alison does to improve this in her technique is to place the finger pads from her other hand next to her elbow to help her propriception of the tissues reaction of the techniques to ensure that she applies the correct amount of pressure on the tissues, this is what I now intend to practice in clinic to see how I can improve on my technique.

THORACIC FASCIA
To focus our understanding and to give us an opportunity to practice our newly acquired techniques Valeria got us to work on each others thorax. Valeria demonstrated her assessment techniques on one of the mixed mode students who was of a muscular build which helped identify muscular imbalances in his physique. She identified a tightening and pull in the fascia over his left pectoral region and she identified how on percussion of his clavicle there was a definite difference in the sound over the left dysfunctional shoulder/pectoral region.

The basis of the technique was to firstly work on the superficial fascia by creating a momentum the thorax and then treating with a pumping technique to mobilise the fascia. To work deeper was slightly more technical. Firstly we had to fix on the deep layer of fascia and then using functional movements either hold back on the fascia whilst the muscle glides underneath our fixed hold, or merely allow the fascia to move with the functional movements ... I'm looking forward to using and practising these newly found fascial techniques.



LYMPHATIC PUMP
Having been demonstrated a sinus drainage technique in the third year, finally I was given more instruction on a more general systemic lymphatic drainage technique during the course. Valeria demonstrated a quick technique which focus on all the major areas where lymph nodes are located and how to 'pump' them to encourage lymphatic flow and drainage.

Neuromuscular Re-Abilitation

30/04/2010

One of the students has just send a message saying she's selling her place on this course .... hence I hope Ive got in there first to buy it off her !!!



Well I'm now on a role with my Functional Approach. Prof Lederman's course was actually very informative ... not so sure I agree with the whole 'you don't kneed to know your anatomy approach, just the function of the body parts' ... but I definitely like his approach to rehabilitation through active movement apposed to passive static treatment on the plinth.

Have a Nigerian patient who's English isn't very good with a suspected annular strain. Due to the communication barrier Ive not been able to HVT here TSpine ... but I think functional active rehabilitation will be able to help her hence I tried it out for the first time ... it was only a matter of minutes til she tired and didn't want to participate any more ... not sure how to engage her in the activity but I'm determined to make it part of her recovery.


Prof. Eyal Lederman

Copyright 2009 Neuromuscular Rehabilitation in Manual and Physical Therapies

This workshop explores how manual and physical therapists can help individuals to recover their movement control. Musculoskeletal injury, pain experiences and central nervous system damage are all associated with diverse neuromuscular and movement control changes. The aim of this workshop is to provide the theoretical and practical basis for neuromuscular rehabilitation for these conditions.
This workshop is intended for manual and physical therapists of all disciplines, (physiotherapists, osteopaths, chiropractors, sports massage therapists, etc.) who work with patients whose conditions involve the neuromuscular system. The workshop will also be useful to Personal trainers, Alexander Method teachers, Pilates instructors, Postural Integration teachers, Rolfing practitioners, sports trainers and individuals who experience losses in movement control.
A functional approach in rehabilitation

A functional approach in rehabilitation is the key concept underpinning the management described in this workshop.
Functional movement is defined here as the unique movement repertoire of an individual. Some of this repertoire is movement behaviour associated with daily needs and demands such as feeding, grooming, going places, etc (general skills). Some of this repertoire is partly shared by others and some may be unique to particular individuals; they include physical hobbies, sports and occupational activities (special skills). For some people, their functional repertoire will include playing tennis, for another standing on their head (Yoga) or playing the piano and so on. Once a person learns a movement or a new skill it becomes a part of their movement repertoire and therefore, their behaviour. Movement which is outside the normal repertoire of an individual will be termed here as “extra-functional” (Fig. 1).


Functional rehabilitation is defined here as the process of helping a person to recover their movement capacity by using their own movement repertoire (whenever possible). Hence, for a person who has motor losses at the knee and is unable to walk or run, the rehabilitation will be in walking, then running, jumping and stair-climbing, etc. If this person plays tennis, this activity will also be used in the rehabilitation programme.
However rehabilitation is likely to be less effective if the remedial movement patterns or tasks are outside the individual’s experience (extra-functional). For example, it would be less helpful for a tennis player with a leg injury to be given rehabilitative exercise such as football, or leg presses in the gym or leg exercise lying on the floor (Ch. 2). For this particular patient, rehabilitation that incorporates tennis tasks is more likely to be useful. For a person who is suffering from lower back pain and enjoys Yoga, a functional rehabilitation would consist of the shared functional activities but may also include some of the upright postures from Yoga. A less suitable rehabilitation approach would be to prescribe tennis to this individual. This may seem obvious, however, movement rehabilitation often prescribes extra-functional tasks such as core stability training on the floor, bracing the trunk or strength training with equipment. The question is how effective these activities are in recovering functional movement.
The Introduction of extra-functional activities during rehabilitation raises some problems. Extra-functional activities or exercise require learning a new task at a time when the patient is experiencing pain and/or loss of movement ability. This might not be the best time to enter a new exercise regime. Learning requires set-aside time, intense mental focus and physical effort. Often it means the patient has to be dependent on others for instructions and guidance during the training. A functional approach which aims to use the patient’s own movement resources does not require additional learning; the cognitive demands are less taxing and do not require protracted training. Also the set-aside time for practice is more manageable for the patient. Furthermore, the rehabilitation programme seldom relies on any specialised exercise equipment. The remedial movement challenges are an integral part of the person’s daily activities and therefore, can be practised anywhere and at any time. A functional approach is easy to apply and it empowers the patient to self-care.
There are exceptions to the functional approach in rehabilitation. There are circumstances where the patients will require specific exercises for particular motor losses, challenges which are not provided by their functional repertoire. There are also situations where the individual is physically unable to perform functional activities. When and why the rehabilitation should stray from this model will be discussed throughout this workshop.

Rehabilitation levels: Skill and ability level rehabilitation

Movement rehabilitation and motor normalisation following injury occurs naturally for most individuals. Following injury most humans will take physical actions that will support their spontaneous and unaided recovery. This would happen without any special knowledge or understanding of the underlying physiological principles underpinning their recovery. In this form of rehabilitation the individual is attempting to, partially or fully, execute the movement that has been lost. Attempting to walk becomes the rehabilitation for the person who lost the ability to walk. Similarly, if an individual with an arm injury is unable to reach; their repeated attempts in that pattern would often be their rehabilitation. The focus in this form of movement recovery is on the overall skill of performing the particular movement. This will be loosely referred to as skill rehabilitation.
However, this approach does not always lead to the intended results. Individuals who are in pain or have motor losses may develop movement patterns that circumvent their losses. A patient may present with walking difficulties due to losses in the control of balance and coordination. Using the similarity principle, one would imagine that by encouraging the patient to increase their walking, “walking would train balance and coordination during walking”. However, what may happen is that the patient will get better at using their compensatory pattern; walking slowly, using wider gait, shorter steps, rather than truly improving their control of balance and coordination during walking.
Balance and coordination are part of several control building blocks that make up skilled movement. These building blocks are called sensory-motor abilities. A therapeutic approach that targets the various motor abilities will be termed in this text as “Re-Abilitation”. At this level of rehabilitation the aim is to recover control losses associated with particular abilities. Hence, in the walking scenario described above, the rehabilitation would aim to challenge balance and coordination in dynamic and upright postures (Fig. 2).
Skill rehabilitation and re-abilitation are both clinically important and are often used in combination. However there may be a shift of focus towards one of these particular approaches depending on the individual’s condition and their phase of recovery.

The code for neuromuscular adaptation

Neuromuscular rehabilitation is a straightforward process – anyone can do it. Indeed, we all do it all the time. Every day we take actions that result in movement and behaviour changes; we can self-modify our motor control. Furthermore, the neuromuscular system has the capacity for self-recovery and to reorganise in response to injury. It means that within our behaviour there are certain elements that facilitate the recovery of movement control.
In functional rehabilitation we identify five such elements that optimise neuromuscular adaptation: cognition, being active, feedback, repetition and similarity (Fig. 3). Hence in order to learn a new task, modify our behaviour or help our system recover we need to be aware of what we are doing (cognition) and we have to actively perform the action that we aim to recover (being active). In order to correct our movement we rely on internal information from our senses or depend on guidance by someone (feedback) and we have to practise the task many times (repetition). Furthermore, the practice has to closely resemble the movement we aim to recover (similarity). Hence, to play the piano a person needs to practise the piano. However, strength training with finger weights or practising push-ups is unlikely to benefit playing the piano. The practice has to be task-specific.
The recovery of motor control can be facilitated by introducing the adaptive code element into the rehabilitation programme. It will promote a functional recovery that is more likely to benefit the patient in their daily activities. The results are more likely to be maintained in the long term and could help to reduce the overall duration of the treatment programme.

Developing a neuromuscular rehabilitation programme

Much of the rehabilitation promoted in this workshop is the marrying of the three concepts discussed so far:

1. The focus on functional movement,
2. The principle of skill/ability level rehabilitation
3. The code for motor adaptation.

Through a simple three steps process the therapist decides which level of rehabilitation will be used and applies the motor adaptation elements to the treatment programme. Many of the remedial challenges are selected from the patient’s own movement repertoire. It really is that simple.
The beauty of it all is that these principles can be applied to any condition in which the neuromuscular system is implicated:
Conditions with an intact motor system
• Neuromuscular changes associated with musculoskeletal injuries, sports injuries, post surgery, back pain and other musculoskeletal pain conditions
• Conditions where certain behaviours impede recovery or may lead to injury or pain
• Non-traumatic pain conditions such as trapezius myalgia, chronic neck pain and painful jaw
Conditions where there is damage to the central nervous system (CNS):
• Stroke, head trauma and post CNS surgery and all the degenerative conditions

The main difference in managing these conditions is in the magnitude of losses, the duration of recovery and extent of potential recovery.

Summary

• Neuromuscular rehabilitation aims to help the individual recover their movement control
• Functional movement is the movement repertoire of an individual
• Functional movement is individual-specific
• Functional rehabilitation uses the patient’s own movement repertoire to help them recover their movement losses
• The rehabilitation promoted in this workshop has three basic recurring concepts:
1. It aims to be functional
2. It uses the skill/ability level rehabilitation concept
3. It uses the learning/adaptation code to optimise motor control changes

A Patients Gratitude

Received a present today from a patient. He is the author of the Poetry. So busy with revision etc at the moment .... however I will make the time to read some of his poetry, especially the poem entitled 'Osteopath' ....

Professor Lederman's Harmonic's Technique

Yet again Manus Sinstra has come up good with the talk by Prof Lederman. I attended his presentation of his Harmonic Approach to treatment.

Without sounding two sceptical (i.e. that the Manus Sinstra lectures are just trying to sell us their courses) I was actually impressed with what Professor Lederman had to say. Unfortunately I won’t be able to explain what he had to say so eloquently, but basically harmonic techniques work on 3 organisational levels:

1. The local tissue organisation
The reparative processes following tissue damage
The physical and mechanical properties of the tissues
Fluid dynamics (blood, lymph and extracellular and synovial fluids)

2. The neurological organisation
Increasing proprioceptive stimulation
The gating of pain

3. The psychophysiological organisation
A generalised reduction in motor tone
Generalised autonomic changes
The modification of pain perception and tolerance
Body-self and body-image integration
A relaxation response

(You can tell I was that impressed that I bought the books hehe)


So have I used Professor Lederman's Harmonic Technique in clinic ... the simple answer is yes .... but the true is I’m not sure as to how effectively I have utilised it. In the true sense of reflection of my actions I think that I have used it as more of a stop-gap between techniques ore when I’m feeling stuck or waiting for the tutor to arrive after examination as opposed to a first line treatment.

One think that stuck in my mind was the Professor Lederman said that he would spend all of his time with his patients treating them with harmonics, i.e. that he would literally oscillate the patient for hundreds and hundreds of times in a session. I think that I would have trouble trying to justify to any of the clinic tutors why I had spend the whole of a treatment session waggling a patients limb in the air as I haven’t spend enough time reading the texts. Hence in reality I question how effective my attempts at Harmonics have been as I just have not repeated the motion enough times to have a therapeutic effect.

I have used harmonics on a few patients with success however !!! One example has been whilst treating a 64 year old lady with degenerative changes of her spine. Part of the treatment was using Harmonics on her Lumbar Spine to show her that her spine is able to move and move in a pain free range, hence to try to reinforce to her that staying active and mobile is good for her back and that she can actually do it. The other types of patients that I have used it for is for patients with Adhesive Capsulitis. I have found it an excellent way of increasing the range of movement within the pain free barrier and to increase the range of motion slowing but surely whilst the treatment remains pain free or at least a low level of pain as the restrictive barrier is reached whilst the angle/degree of oscillation is increased. It is also a good way and well documented way of patients self-treating Adhesive Capsulitis in between treatments.

Me demonstrating the self-treatment of the GH joint with Harmonics (I really need to smile hehe)

Cranial let down - and then up again

Well this has proved that I don't have good karma after all lol

Obviously changing from IMS to the Advanced Spinal Manipulation has a come back ... I can no longer attend the post-registration OSTEOPATHY IN THE CRANIAL FIELD PRELIMINARY 5-DAY COURSE run in September as quote "Please note that, from 2003, attendance at a foundation course, satisfactory completion of IMS at undergraduate level or completion of a previous SCTF-approved course (e.g. BSO or SCC) will be a pre-requisite for enrolment on this course".

Not really sure how I'm now meant to get my Cranial palpation skills at this level .... I guess I just need to concentrate on getting through the course at this stage and will explore my options later .... at least Ive saved £945 hehe




Just received another email from Gayda ... the cranial course in Sept is back on ... now where am I gonna find that £945 ... hehe

London Marathon 2010

Well it is the first time for Virgin to host the London Marathon and it was my first time to treat Marathon runners post event.

Having met the others at the tube station and then taken a short walk to the Imperial War Museum (http://www.iwm.org.uk/) where the Spinal Injuries Association - SIA (http://www.spinal.co.uk/) were hosting their post Marathon Runners event ... we set up the room ready to treat the runners. We had a bit of a wait till the runners came in so after a talk of what was expected from us, a chat from a young guy with a C6 spinal cord injury and some lunch we were ready for action.

Excitement rose as the first two of the 69 runners entered the new treatment room. Seeing as there were about 20 BSO students there is was probably a bit over whelming for the runners having us all gather round them whilst Danny and Robin set about showing us how it was done .... not longer had the tutors started was it the student turn.

I started treating Andy a 42 year old guy who had just completed his first marathon in 4 hours and 4 minutes .. he was over the moon (as I would be to have merely completed a marathon let along in 4 hours). It wasn't long after my treatment had started that the muscles in his legs went into spasm.

Never have a felt a muscle spasm with such violent aggression. Andy was in agony !!! Having tried to stretch out the offending muscles Andy had to hop off the table and take matters into his own hands ... or rather his own legs by stretching out the muscles himself.

Robin joined us to show us some simple techniques to help Andy out .... but the key was to reduce the amount of pressure that I was applying to his muscles in order to not allow his muscles to react in such a manner. It was however quite nerve racking treating these spasms as during his run they never once went into spasm ... again with some reassurance from the tutors I was feeling confident to carry on.

The good thing about the day is that wasn't merely offering the runners a massage we were allowed to treat them with true osteopathic style and flair ... which included manipulation. Danny obtained consent from Andy and proceeded to show us how to perform a 'Sphinx' technique to the TL and how to do a prone CT Danny style leaving some very easy Dorsal Springing with multiple cavitation's to me.

Soon more runners had entered the treatment room hence it was time to wish Andy well with some post event advice on stretches and heat/ice therapy. Andy thanked us for our work and reassured me that he definitely benefited from his treatment.

Next on my plinth was Gemma a 45 year old hairdresser who had just completed her first Marathon in 5 hours 15 mins. Gemma was complaining of tightness in here lateral thighs. After and assessment and a consultation with Robin it was agreed to mobilise her TL and to work into her ITB. Gemma had never had Osteopathic Treatment before and neither had her husband seen osteopathic treatment hence he filmed me treating Gemma for prosperity lol

Having got Gemma into a wind-up position for a TL side lying rotation thrust on a very very high table and with no pillows I prayed that I would manage to mobilise her TL .... bilateral success was achieved and with some Dorsal Springing I realise how the muscles and the joints in the body react to such a onslaught of trauma such as a Marathon and how easily they gave themselves up to Osteopathy.

More and more runners had now started flowing through the doors hence the treatments needed to be fast and effective for all. A range of aches and pain were treated with hip flexors appearing to be the number one offender ... hence lots of side lying psoas MET's were performed by all. A few very ugly looking and bleeding feet were seen and a couple of twisted ankles and swollen knees were treated.

I thoroughly enjoyed the day and it really had spurred an interest to compete in a Marathon .... but more importantly has encouraged me to think about a career in Sports Osteopathy ....

Grayinstitute - Dr David Tiberio

http://www.grayinstitute.com/

Applied functional science for prevention, rehabilitation and performance enhancement.
David Tiberio PhD Physical therapist, is a faculty member and the Academic Dean of the Gray Institute. He is a former Associate Professor at the University of Connecticut. David teaches in the area of kinesiology, therapeutic exercise and musculoskeletal dysfunction. His research interests include muscle activity during functional exercise and the relationship between foot and leg function. David has published several articles and is the editor for the Function Junction website.



Well I know that the BSO is very 'structural' ... and I understand what that means for osteopathy ... but Ive never really understood what 'classical' and 'functional' osteopathy was, after yesterdays Manus Sinstra I now understand what functional osteopathy is about.

However I don't really understand how I can apply that to my current practice. I definitely need to go on some further courses to really understand how to apply functional assessment and functional treatment ... I'm hoping that next weekends course (Neuromuscular Rehabilitation - Prof. Eyal Lederman) will help bridge some of this gap.

What I need to do is try to arrange a practice visit with someone like Matt Harris who uses lots of functional work, I'm even going to try to arrange to watch Jon Singleton a fellow fourth year who uses a functional approach alot.

Ive also arrange to do extra hours in the Sports Clinic to see Robin Lansman work as he talked to us in the third year about a functional squat test which forms part of his assessment of the patient.

Clause 20 - what you need to know

www.osteopathy.org July.August 2008

WOW Strain-Counterstrain really does work!!‏

Well having not had good results with S-CS it's kind of fallen off my radar of late, but this was flagged up during my CCA feed back as one of my Tutors was Jo Holmden the S-CS lecturer.

She commented that she hadn't seen much S-CS from me and was curious as to why. I explained that the real reason was because I've be concentrating on techniques that I would likely use in a CCA and that S-CS wasn't one of them as I would really struggle to justify the physiology as to how the technique works. She appeared to understand my point of view, however suggested strongly that I made the most of the tutors whilst I still had them at my disposal.

One morning whilst in clinic a gentleman presented with pain and muscle hypertonicity around his first rib among other things. Having previously had a diving accident and an X-ray showing spondyloarthoris and spondylosis it was agreed that HVT to allow the first rib to rise in inspiration more smoothly wouldn't be the most appropriate technique .... what was I to do?? Well the answer was to see Miss Holmden and ask her to demonstrate S-CS for the first rib. Miss Holmden was more than pleased to show me the technique.

After the obligatory 90 secs the pressure was released from the tender point and the patient was unwound from his position of ease and then pressure was reapplied in order for the patient to report how tender it was now, the answer was "it wasn't tender at all". Still dubious that the disappearance wasn't due to the application and reapplication of some inhibitory pressure I was keen to objectively reassess the inspiration of his first ribs, to my delight they were moving bilaterally.

I was looking forward to this gentleman returning next week to see if this movement had been maintained. Next week soon came around and I was pleased to find that the ROM had been maintained and that the patient reported a 80% improvement in his symptoms.

OSPE Nightmare !!!!

Oh my word ... I'm embarrassed with myself after today's fiasco!!!

Well it was time to take my OSPE. This year the format was slightly different as in you don't move along different lanes to different examiners but stay at the one station for a 20 minute OSPE with two examiners .... I was being examined by Chris Thomas and Valeria Ferreira (good news as they put me at ease).

So it was two questions with a part A and a part B for each of the two questions.

Question number one was concerning the examination of the upper ribs, and a treatment of the soft tissue and a HVT. So I start off my technique. I go straight into treating the upper ribs with articulation. Okay so I'm a fourth year now so I thought I should do some fancy articulation of the upper ribs ... so with the patient supine I I palpate the rib angle with the one and and the anterior portion of the rib with my other hand and start to gently articulation the models ribs ... feeling rather pleased with myself I was then asked to demonstrate another technique to work on the the upper ribs .... so I ask my patient to turn on his side ... I pause and then pause some more and pause even longer ... I cant remember what to do.



By this stage the panic has set in and I barely remember where the ribs are let alone how to work on them. The tutors try to put me at ease and suggest that there may be an easier position to have the patient in .... so I ask the patient to lay prone .... again after some more pausing I still cant do it.

Okay I get a breather by the examiners, they instruct me to carry on with the second part of the question but tell me that we will return to the question as they will need to see another technique. The second part of the question was to demonstrate how to perform a HVT to rib 2. Thankfully I can demonstrate this and even more thankfully I don't have to perform the thrust on the model ... phew lol.

Okay question two and I'm still a nervous wreck as I still cant remember how to articulate the upper ribs with another technique but I need to focus with the question at hand.

Okay question two is about working on the LS facet. Okay I know this one. I start working on the soft tissues particularly the Glutei. Having been asked the attachments of the Glutei I start to reel them off ... did I just say that Gluteus Maximus is attached to the Great Trochanter ??? I start to back track and as I do I start to get myself even more confused ... how many gluteal lines are there ... how many did I say ... oh hell I not sure what I said at this point and I still have to demonstrate how to articulate those damn ribs (I feel sick). I manage to demonstrate how to HVT the LS.

Okay come on now Steve you can do this pesky rib. Okay I get the patient side lying again and I'm sure I have to life his arm somehow .. after some fumbling with his arm I'm asked to demonstrate it with the position prone ... hence the model turns onto his back for me ... again I fumble some more with his arm. Finally as the bell rings to finish the exam I remember the technique and quickly adopt the position ... I the examiners and the model all take a big sigh of relief .... cant wait to get the result of this exam !!!!!

Oh no look at that photo ... not only am I lay on top of a skeleton in my bedroom ... but look how thin my hair is getting :-(((

UPDATE 29/04/2010

OSPE Grade

Well it wasn't all that bad ... Picked up the result of my OSPE today
and I got a C high. I'm pleased with the grade as I thought it would
be a lot worse. The feed back wasn't unexpected however. I knew that
my nerves got the better of me and that this effected my ability to
recall simple muscle origins and insertions.

The most interesting part of the feedback was that I always tried to
show the most advanced techniques that we had been taught instead of
going for the simple but effective ones and building up to mire
complicated manoeuvres when prompted to by the examiners.

The head of 4th year technique gave the group some general feedback
also that after reflection I feel applies to myself. He advised us
that we really need to make our techniques and particularly our soft
tissue work the most effective and smooth as in today's current
climate patients won't allow for us to still be learning and
developing our techniques once were qualified as the patients will
simply see other practitioners if our treatment isn't effective from the
onset.

MET Scalenes

Having been having trouble with my approach to work on Scalenes we were taught a new method of treating them (along with all other anterior neck muscles) using an MET.

The technique is really effective, but you do have to chose the patient carefully as the technique requires the patient to support the weight of their head laying supine with their head off the table, you take some of the support away by asking the patient to take the weight of their head instead of you hence you engage all of the anterior neck muscles to perform the MET, then you stretch them with a posterior shift of the head and a nodding action opposed to extension.

Ive been using this technique a lot since it was shown to us with great results. Its important to provide an appropriate and individual amount of assistance with supporting the head during the isometric phase of the technique depending on the patients strength, fitness, age, condition, presenting symptoms and diagnosis. It is also paramount that the patient fully understand how to perform the technique before it is attempted, I often found that it was a good idea to perform an MET to another muscle such as hamstrings prior to attempting it on the anterior neck muscles (even if it was only for demonstration purposes opposed to treating the hamstrings).

March CCA Success

Criteria Title Description
Criteria 1 Case History Taking
Criteria 2 Examination Skills including clinical testing
Criteria 3 Osteopathic Evaluation and Clinical Reasoning
Criteria 4 Patient management and treatment plans
Criteria 5 Professionalism

Well I cant believe my grade ... I knew that it went well and I was confident that I passed ... but a A low !!!

Having received my feedback I finally feel that my experiences as a nurse have paid dividends as it appears that I received credit for my communication and therapeutic relationship building.

The pressure is off for the final CCA ... however I now feel that its actually still a pressure but in a different way as everyone is expecting me to do well and don't seem to be giving my any support for my worries and concerns !!!

CCA Summary

Technique - Knee and Ankle

13/11/09 - Kiera Kinch Tutorial - Knee Examination

It wasn't until Keira Kinch gave us a tutorial that I really appreciated how observation is the first key step to assessment. When a fellow student was asked to perform a knee examination to the rest of the tutorial group. She did as I would ... stand the patient up and look at their knees etc and then get them straight onto the table to perform a passive examination.

When the tutor repeated the examination she look at the patient in greater detail and got the patient to do active movements. She asked the patient to engage their quads whilst standing to see how the patella tracks and she asked the patient to do squats to see how the different muscle groups engaged.

24/02/10 - Knee examinations were okay, could not explain which bursae were for which conditions need to revise those.

Technique - Hip

17/02/10 - Good examination, think of more ways to ttt than supine.

15/04/10 - Treated my first OA Hip patient today in the Royal Free Hospital. His presentation was exactly as it says in the text books. I really struggled to treat him has his limb was so heavy ... I understand now why it is so important to make techniques effective and easy to perform else there is no way the osteopath will have longevity in the profession.

Strain Counterstrain Treatment Mind Map

Technique - OA Joints

25/11/09 - During a technique tutorial in clinic today I was shown another approach to manipulating the OA. The technique is basically the same as we are shown in technique class but with full rotation, then you take off half, then you put on full side-bending, test your levers, add on side bending and shift if required and then thrusts. Ive tried it a few time now when practising, but Im not sure its C1-2 that's cavitating.

10/02/10 - After practising technique with Nandeep it was apparent that occasionally we loose the rotation when side bending is put on.

11/04/10 - Today I had a patient that I needed to thrust their OA joint. I don't know why but the thought of doing this panicked me as I haven't had the opportunity to practise my thrust as the students that I practice technique with don't want to practice OA thrusts hence I didn't feel confident. The tutor thrust the patients OA for me. He used a different technique which was a combination of a cradle and a chin hold. The technique worked for him. It heiglightened to me how techniques can be adapted to suit the individual practitioner as long as good anatomical knowledge and a clear idea of what your trying to achieve is used.

CPR Training

Well as an ITU Nurse with a certificate in Advanced Life Support (ALS) this is something I would have done well in if it was examined.

ADVANCED SPINAL MANIPULATION

05/01/10 - Had our first ASM lecture today. I'm really excited about this module as having seen tutors who are able to use this technique in clinic look so professional and slick, they make it look effortless and the patients say that it is so comfortable to have it done to them.

12/01/10 - Okay so this week we revisited the principles of ASM. I'm still struggling with doing HVT with long levers that I don't think I'm at the stage where I can learn minimal leverage yet.

19/01/10 - Today we discussed junctional areas and looked at mobilising the T/L and L/S. Now normally I can manage to cavitate a T/L as the rotational element of the joint means it is an easy joint to cavitate with rotation, but with ASM I just cant feel the tension in the joint.

What has been good about today is the discussion of the L/S and that its plane of movement can vary quite considerably hence why is a standardised approach to winding up the L/S then it may not be possible to cavitate it, but the direction of the plane needs to be tested before hand.

26/01/10 - Today we looked at side bending as the primary lever to HVT. It would be extremely advantageous to be able to mobilise the LSpine or CSpine with side bending. I can think of numerous occasions where if I was proficient at side bending thrusts it would have been more comfortable for the patient. I can also think of alot of patients whereby side bending as the primary lever in the LSpine would have been beneficial when there has been the possibility of discal involvement hence why rotation isn't suitable hence Ive opted not to mobilise the LSpine.

09/02/10 - Sitting CSpine thrusts are something that I like and something that I find relatively easy to perform, however I'm still struggling to apply minimal leverage. One really important thing that Daryl mentioned to us today is that he thinks we possible are so used to feeling the tight tension of a locked joint pre thrust that we are missing the tension of a wound up joint, I think he is right here but I just feel that I don't have enough experience to establish if the joint is wound up. I guess the only way it to attempt the trust, but that goes against everything we have been taught about not delivering the impulse unless we feel the joint is wound up.

He also demonstrated how to perform sitting LSpine thrust as side bending .... he's very good !!!

My struggle with the CT junction continues but today we were shown a seated CT thrust. As always Daryl made it look so easy, but its not. The beauty of the technique is that apart from having your head held and vision slightly obscured it was a really comfortable position to be in during the thrust. This one definitely needs some practice so I can utilise it on my patients.

23/02/10 - Rib thrusts are interesting thrusts. But as I'm struggling with my Dog technique I'm also struggling with my rib thursts. If I'm honest I don't feel today's session added anything to my rib thrust technique ... perhaps I'm just feeling rather despondent at the moment.



09/03 - Having the same old issue here with the SI thrusts as I'm having with all the other thrusts, i.e. if I cant feel the wind up with long levers how am I supposed to feel it with minimal short levers. Daryl's SI thrust is interesting as he delivers the impulse to the SI closest to the table opposed to the SI closest to the operator. I'm not sure what to think about this technique. I know Daryl is expectational at HVT's so I can see how it would work for him but I really struggled to establish where my force was being applied into the patients pelvis so I really could not say if I was feeling tension in the correct SI !!!

What Is Cranial Osteopathy?

Even though Im no longer taking the cranial elective, I still feel its important for my learning that I have a greater understanding of what cranial osteopathy is. Hence after some research this is what I have found out.

Cranial Osteopathy - The five fundamental principles of the cranio sacral mechanism
The cranial concept is a system of therapy that is being used widely throughout the world and I will try to explain the fundamental principles that apply to it. The cranial concept was first developed by an osteopath called William Garner Sutherland in the early 20th century and he was the first to coin the phrase cranial-osteopathy. Since Sutherland, there have been practitioners like Upledger who have further developed the theory and other branches have developed such as cranio-sacral therapy (craniosacral). The system of cranial osteopathy and cranio-sacral therapy is becoming more and more popular in Israel and in Jerusalem specifically patients are beginning to benefit from it due to greater awareness.

Whether an osteopath uses cranial osteopathy, structural osteopathy, classical, visceral or functional osteopathy, the same principles of diagnosis are used which are based on a system that applies anatomy and physiology in order to prevent disease. The osteopath considers the whole body as a unit all of whose parts need to be properly nourished by its internal fluid environment in order to function, heal itself and thus combat disease.

When the osteopath considers the body as a whole, inevitably this includes the cranium and all of it components; it's bone, cartilage, membranes and internal environment that is nourished by blood-vessels and nerves.

5 fundamental principles exist in cranial osteopathy:

1) That an inherent mobility exists within the brain and spinal cord.
The neural tube develops in the embryo with 2 anterior sections that invaginate and curl up like a ram's horn to form the cerebral cortex. Since it is believed that there is inherent motility within the brain, the pulsating motility responds by curling and uncurling in the way it was developed.

2) Fluctuation of the cerebro-spinal fluid.
There are a number of theories as to how the CSF fluctuates and what the basis of its movement is. For the osteopath however, the important factor is that changes in pressure can be palpated along the route of the CSF and any existing restrictions may alter the CSF fluctuation and have consequences on the body.

3) Motility of intracranial and spinal membranes.
The spinal membranes that form the structures of the intracranial membranes are the falx cerebri and the 2 tentorium cerebelli. These sickle-shaped structures arise from a common origin at the straight sinus known as "The Sutherland fulcrum". The insertions of these membranes are along various points around the cranium. The falx cerebri originates at the internal occipital protuberance, travels upward and forward and eventually insert into the crista galli of the ethmoid bone. The 2 tentoria cerebelli pass along the transverse ridges and the two converge on the body of the sphenoid and insert onto the anterior clinoid process. Together, these membranes constitute the reciprocal tension membranes linking the cranium to the sacrum, functioning as a unit around a common fulcum - the Sutherland fulcrum.

4) Mobility of the bones of the skull.
Whilst the skull may appear to be a solid structure in fact it has zigzag edges which grow together to form movable sutures. These joints evolve from smooth-edged plates of membrane in the newborn and eventually evolve into articulations with slight movement according to the contours of the two surfaces.

5) The involuntary mobility of the sacrum between the ilia.
Not to be confused with movement of nutation and counter-nutation of the sacrum between the ilia, the cranial-osteopathic concept considers the sacrum having an involuntary, respiratory mobility. We have already mentioned the mobility of the intracranial and spinal membranes and it is the lower attachment of these membranes to the sacrum that results in the direction and containment of the sacrum's movement. The movement is a physical extension of the primary respiratory mechanism and allows the sacrum to flex an extend at the level of the second sacral vertebra.

It is with the comprehension of these five fundamental concepts that the cranial osteopath starts to understand the craniosacral mechanism. With a knowledge of the anatomy of the cranium, the physiology of the respiratory mechanism and the cranio-sacral rhythm the osteopath embarks upon a path of therapeutics that are applicable to all kinds of ailments experienced by patients.

(http://osteopathy4osteopaths.blogspot.com/)