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)