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Manual Medicine Workshops in the Philippines for 2009

TOPICS for INCOMING WORKSHOPS:
Greetings!
We were wondering if you could help us sort out suggested "sharing" topics for 2009..

The intent is for us to finish all our major events by midyear so we can prepare for when we bring to the Philippines an international certification for structural rehabilitation via the nice folks at the Center for Intergative Manual Therapy (CIMT). The certificate will be issued by Westbrook University regardless where the courses were taken.

Off the top of our heads, we thought you might be interested in:

1.
Advanced L-D Myofascial Releases (Local, Direct):
CTM - Connective Tissue Mobilization (Based on 2007 Protocol)
IASTM - Instrument-Assisted Soft-Tissue Mobilization
SASTM - Sound-Assisted Soft Tissue Mobilization
Pre-Requisite: Practitioner level for direct local myofascial release

Workshop director is a licensed SASTM Practitioner. He has been successfully using Gua-Sha and CTM techniques in a clinical setting with great results from 2005.
His favorite IASTM tool is a Hartmann Tool.

2.
Module II:
Viscero-Somatics II: Visceral Manipulation for Visceral and Somatic Functional Gains
as applied to:
1. Post-operative Ileus
2. Somatic Dysfunctions of Visceral Origin
3. Visceral Dysfunctions of Somatic Origin

Visceral Manipulation has been a part of the Workshop Director's clinical practice from 2005. A functional overlap between three main schools of VM practice will be presented.


3.
A Manual Medicine Approach to Central and Peripheral Lymphatic Drainage
Thoracic-access techniques to lymphatic drainage will be highlighted, with the intent of filling in a gap in widespread local LD practice.


4.
A Manual Medicine Approach to Pelvic (other foci: Hip / Lumbar) Complaints
(Includes Pelvic Visceral Manipulation)


5.
Dyspahgia Management
Though largely regarded as an OT / SP concern in the Philippines, a Manual Medicine approach to treatment will be presented.


6.
A Brief Introduction To Manual Medicine Techniques (A demonstation of Every Major Proven technique)
Since a plethora of techniques exists, a way of synthesizing a flow of techniques into Manual Medicine Practice will be presented.


7.
Neuro-linguistic Programming in Manual Medicine: Improving the Mind-Body Link

The Workshop Director is an NLP Master-Practitioner, A Clinical and Medical Hypnotherapist, and a Pain Management Consultant.


8.
Advanced Spinal Mechanics: Beyond HVLA
Yes, there is life beyond HVLA.


You'll let us know what you're interested in, right?
Harold can be reached at 09274515589 and via this site.

Thank you for exploring visceral manipulation with us

We's like to thank the manual practitioners who joined us for our super-fun visceral manipulation study group. The size of this class proved ideal for the amount of palapatory sensitivity that had to be gained extremely quickly. Early feedback is that learning this new heightened level of palpatory sensitivity felt nothing short of evolutionary. We'd have to agree. It isn't every therapist that can visialize and feel the motility of the spleen and pancreas. Should we say we're proud? Of course we are! Everyone was hands-on this time, bar none! Everyone tried everything! The entriely new set of tools our little group got for access to the thorax alone was well worth the extended hours of paractice. Thanks for joining us again, kids! 'Till again.

Oh, you missed it? It was on 14 December 2008. We missed you, too. You'll join us next time around, through? There you go. See you then!

Yours in Manual Medicine Evolution,

Assessment of Lumbar Spine Flexibility

Tom Hewetson
MSc. BSc. (Hons) Ost. Med. D.O.

Introduction
Flexibility is generally agreed to be, the ability to move a joint or combination of joints through a range of motion (ROM) for which they were intended. It may be said that flexibility encompasses two components, joint mobility and soft tissue stretch-ability. An individual lacks flexibility if they are unable to reproduce the normal ROM for that joint or combination of joints. One of the roles of the physical therapist working with sports people is the assessment of flexibility. The normal functioning joint has two barriers to motion, (1), the physiological barrier, a point to which an individual may actively move any given joint(s), and, (2), the anatomical barrier, the point to which the joint(s) may be passively moved beyond the physiological barrier (DiGiovanna, 1991). A third barrier of joint flexibility is the pathological barrier caused by trauma or disease. For the purpose of this essay, pathological barriers of lumbar spine motion are not discussed at length.

The need for lumbar spine flexibility is dictated by the sport in which an individual participates, for example, a formula 1 driver would need less flexibility than a gymnast. As well as inter-sport differences there may also be intra-sport variations, for example a rugby prop forward (whose primary role is strength through short ROM) would conceivably need less flexibility than a scrum half (whose primary role is passing the ball which requires the player to have good all round flexibility of the lumbar spine). The questions being asked are: how valid and reliable is subjective lumbar spine flexibility assessment in clinic (what would seem to be normal clinical practice, certainly normal osteopathic practice)? and, is an objective assessment, such as goniometry (a method of measuring the range of motion or position of a joint, either actively or passively) more valid and reliable? For something to be valid it has to be well grounded on principles and or evidence. As a measurement concept this means that it has to measure what it is supposed to, in this case, joint ROM (flexibility). Reliability means that the measurements are consistently repeatable or reproducible. The following are the cases for subjective assessment, followed by objective and finally the discussion and conclusions.

Subjective
Osteopaths are taught to use observation and palpation to ‘look’ for restrictions of motion (Vickers, 1999). It is normal practice in both orthopaedics (Hoppenfeld, 1976; Bates, 1991; Magee, 1992), and Osteopathy (Chun, 1991; Kutchera et al. 1997), to subjectively assess flexibility of the lumbar spine. ‘Normal practice’ does not necessarily mean that it is the best or most effective. These types of assessments are carried out both actively and passively. According to Magee (1992), the archetypal lumbar spine should be able to flex forward 40˚ to 60˚, extension is normally limited to 20˚ to 35˚, lateral flexion, left and right approximately 15˚ to 20˚ and rotation is normally 3˚ to 18˚. The key words here are ‘normally’; this means that there will be individuals that produce more, or less movement through the lumbar spine (presumably abnormal movement), and ‘approximately’, which means that this is a guess at the ROM. Others like Kapandji (1974) and Fitzgerald et al. (1983) are a bit more specific with their reporting of degrees of motion, but still report them to be ‘approximations’. Those that have done research in this area such as, Maher, et al. (1994), Binkley et al. (1997), Maher et al. (1998), and Van der Wurff, et al. (2000), all agree that there was poor demonstration of reliable outcomes of mobility testing in clinical practice, and that physical therapists should be cautious when making clinical decisions based on subjective evaluation of movement. The general consensus was that there was a need for more research. In contrast to these findings, Boline et al. (1993) reported that there was good to excellent inter-examiner concurrence using observation and palpation and that palpation for pain was the only spinal procedure to show consistent reliability.




Objective
Unfortunately there is relatively little research on lumbar spine flexibility testing using goniometry. In order to maintain continuity, examples of goniometric research on elbow, ankle, scapula and lumbar spine are used. Goodwin et al. (1992) did a comparative study on 3 different types of goniometer. The results showed that, not only was there significant difference between goniometers, that there were also significant differences in tester replication. Their advice was that “interchangeable use of goniometers (and presumably the therapists using the goniometer) was inadvisable”. In a single practitioner clinic this is not a problem, but it could become a problem if one works in a multi-practitioner practice, or as part of a (sports) medical team. Youdas et al. (1993) compared goniometry with visual estimates of ankle joint ROM. They reported “considerable inconsistencies” between 2 or more physical therapists making repeated goniometric and visual measurements. Youdas et al. (1994) reported that goniometer-positioning techniques for scapulohumeral rotation were “clinically unacceptable”. The same holds true for these study’s as the first; interchanging therapists to take readings of the same subject is probably not a good idea, this could create a problem if one is a member of a medical team. Boocock et al. (1994) used a flexible electrogoniometer on the lumbar spine. The outcome was, that this was a good measurement for biomechanical investigation, and would be helpful for the sporting (and ergonomic) fields of study.

Discussion
The questions asked were: how valid and reliable is subjective flexibility assessment of the lumbar spine? and, is an objective assessment such as goniometry more valid and reliable? From the evidence it would seem that neither subjective or goniometric lumbar spine flexibility assessments are completely valid or reliable, but each method has its advantages and disadvantages.




Advantages to subjective assessment are:
• No equipment needed
• No expense
• Normal practice (relatively easy to explain to colleagues, everyone uses this system)
• Easy to do
• Can assess tissues quality (palpation)

Disadvantages are:
• Unreliable
• Not conclusive
• Easy to misinterpret
• Guesswork
• Lack of research in subjective assessment

Advantages of goniometric assessments are:
• Objective measurement
• Can be reproduced / repeated (if done by the same practitioner using the same equipment)
• Acceptable for research
• Good for baseline measurement

Disadvantages are:
• Poor inter-tester reliability
• Poor interchange-ability of equipment
• Can be expensive
• Can be difficult to use
• Lack of research on lumbar spine

A possible reason for the contrast in research for the subjective case is, we are only told that they are “physical therapist”, we are not told what kind of physical therapist they are, or, if they carry out this type of assessment on a regular basis in their respective practices. In the case for Boline et al. (1993), we know that the study was carried out on chiropractors; perhaps they had favourable outcomes and good inter-tester reliability because they are more practised at employing these techniques. Maybe one should employ a combination of subjective expertise and objective measurements. Some form of goniometry could be employed for a baseline measurement for athletes as guidance for when they become injured. As to the possibility of an athlete being assessed and treated by a single practitioner, this may be impractical, especially when seeking a second opinion.

It would be reasonable to assume that an athlete would seek advice from a physical therapist, on treatment of pain, and or rehabilitation from an injury, and that they would seek advice on flexibility from a coach or trainer. It is imperative that we not only understand flexibility training and the ramifications of it, we must also understand the strength training for this region as well, in order to comprehensively assess flexibility. Poor techniques can lead to joint and soft tissue damage. The soft tissues have two main properties, elasticity and plasticity. The elastic tissue returns to their normal length post stretch, while plastic tissues remain elongated. This may be one of the reasons for increased flexibility in many sports people, however, flexibility without stability is worthless and both should be encouraged when training.

Here are some questions to ponder for the future. If both methods are not completely valid or reliable why are they still used? What, are the alternatives? and how expensive are they? Is spinal flexibility assessment in clinic an art or a science? Does it matter what technique one employs to assess the flexibility of the lumbar spine as long as the athlete recovers?








References

1. Bates, B. (1991) The musculo skeletal system. In: A guide to physical examination and history taking pp. 459 – 500. J. B. Lippincott Company.

2. Binkley, J., Stratford, P. W., Gill, C., Maber, C. (1995) Interrater reliability of lumbar accessory motion mobility testing. Physical Therapy, 75 (9): 786 – 795.

3. Boline, P. D., Haas, M., Meyer, J. J., Kassak, K., Nelson, C., Keating, J. C. (1993) Interexaminer reliability of eight evaluative dimensions of lumbar segmental abnormality: Part II. J. Manipulative Physiol. Ther., 16 (6): 363 – 374.

4. Boocock, M. G., Jackson, J. A., Burton, A. K., Tillotson, K. M. (1994) Continuous measurement of lumbar posture using flexible electrogoniometers. Ergonomics, 37 (1): 175 – 185.

5. Chun, L. R. (1991) Motion testing. In: An osteopathic approach to diagnosis and treatment (eds. DiGiovanna, E., Schiowitz, S.) pp. 164 – 175. J. B. Lippincott Company.

6. Fitzgerald, G. K., Wynveen, K. J., Rheault, W. et al. (1983) Objective assessment with establishment of normal values for lumbar spinal region range of motion. Physical Therapy, 63 (11): 1776 – 1781.

7. DiGiovanna, E. (1991) Somatic dysfunction. In: An osteopathic approach to diagnosis and treatment (eds. DiGiovanna, E., Schiowitz, S.) pp. 6 - 12. J. B. Lippincott Company.

8. Goodwin, J., Clark, C., Deakes, J., Burdon, D., Lawrence, C. (1992) Clinical methods of goniometry: a comparative study, Disabil. Rehabil., 14 (1): 10 – 15.

9. Hoppenfeld, S. (1976) Physical examination of the lumbar spine. In: Physical examination of the spine and extremities pp. 237 – 263. Appleton & Lange.

10. Kapandji, A. I. (1974) The lumbar vertebral column. In: The physiology of the joints: the trunk and vertebral column pp 72 – 126. Churchill Livingston.

11. Kutchera, W. A., Jones, J. M., Kappler, R. E., Goodridge, J. P. (1997) Musculoskeletal examination for somatic dysfunction. In: Foundations for osteopathic medicine (eds. Ward, R. C. et al.) pp. 489 – 509. Williams and Wilkins.

12. Magee, D. (1992) Lumbar spine. In: Orthopaedic physical examination (ed. Biblis, M.) pp. 247 – 307. Saunders & Co.

13. Maher, C. G., Adams, R., Shields, R. K. (1994) Reliability of pain and stiffness assessment in clinical manual lumbar spine examination. Physical Therapy, 74 (9): 801 – 811.

14. Maher, C. G., Simmonds, M., Adams, R. (1998) Therapist conceptualization and characterization of the clinical concept of spinal stiffness. Physical Therapy, 78 (3): 289 – 300.

15. Van der Wurff, P., Hagmeijer, R. H., Meyne, W. (2000) Clinical tests of the sacroiliac joint. A systemic methodological review: part 1. Manual Therapy, 5 (1): 30 – 36.

16. Vickers, A. (1999) The manipulative therapies: osteopathy and chiropractic. Bmj.com

17. Youdas, J. W., Bogard, C. L., Suman, V. J. (1993) Reliability of goniometric measurements and visual estimates of ankle joint active range of motion obtained in a clinical setting. Archives of Physical Medicine and Rehabilitation, 74 (10): 1113 – 1118.

18. Youdas, J. W., Carey, J. R., Garrett, T. R., Suman, V. J. (1994) Reliability of goniometric measurements of active arm elevation in the scapular plane obtained in a clinical setting. Archives of Physical Medicine and Rehabilitation, 75 (10): 1137 – 1144.

HVT is not everything (again)

Facilitated Segments: a critical review



Key words: Facilitated segments, manual therapy, osteopathy

The concept of spinal facilitated segments has dominated osteopathic
neurophysiology for over half this century. This concept has been at the
heart of osteopathic teachings and is often used both in clinical diagnosis
and as part of the rationale of treating different musculo-skeletal and
visceral conditions. Surprisingly, such an important subject has never been
criticised: the existence of facilitated segments and their relevance to
manual therapy or osteopathic medicine has never been questioned. This
article re-examines the original studies of Korr, Denslow and their
co-workers, aim to identify what has been demonstrated in these studies and
to reinterpret their findings in the light of current knowledge of
neurophysiology.

The spinal facilitation concept
In principle, the facilitated segment was described as a specific area of
the spinal cord that was capable of organising disease processes. It was a
very simplistic model: it had two input and two output routes. The input
routes were sensory from musculo-skeletal and viscera. The output routes
were the motor efferents to muscle and autonomic motor to sweat glands,
blood vessels and viscera. Inside the spinal cord it was suggested that
abnormal activity in one area of the spinal cord could spread to adjacent
areas. The facilitation process would be initiated when aberrant sensory
information from an area of damage or pathology (muscle or viscera) was
conveyed via the afferents to the spinal cord. This would alter the neuronal
activity at the same segmental level and might spread to adjacent areas of
the spinal cord affecting spinal centres not directly related to the
original injury. For example, a musculoskeletal injury could reach the
spinal cord through its afferent connection causing spinal facilitation or
sensitisation to take place. Because of the anatomical proximity of the
motor and autonomic spinal centres, this spread of excitation would
eventually involve these lateral centres. This in turn would alter the
segmental autonomic activity leading to changes in vasomotor, sudomotor and
visceral activity. The reverse could happen too: through the same
neurological mechanisms a pathological condition in the viscera could end up
affecting skeletal muscle activity.
Even before examining the original research, we can see that there are
several problems with the facilitated segment model:
a. The descending influences from higher centres were not included in the
model, although they have profound segmental influences. This omission is
unrealistic - the spinal centres do not work in isolation from the higher
centres. Both movement and autonomic activity are heavily organised from
above the spinal cord (Sherrington, 1906; Folkow, 1956; Bard, 1960; Brown,
1968; Ganong, 1981; Schmidt, 1991).
b. Outside the spinal cord afferent and efferent connections are,
anatomically, highly segmental. However once in the spinal cord all
anatomical specificity is lost (Luscher & Clamann, 1992). Motoneurons of
several muscles are intermingled within the ventral horn and distributed
over several segments up or down from the point of exit (efferent peripheral
nerve). Similarly afferents from one area or muscle, once in the spinal
cord, tend to diverge up and down over several segments terminating on many
different motoneurons and interneurons (Luscher & Clamann, 1992). For
example, spindle afferents from one muscle connect with motoneurons of other
muscle groups (Eccles et al, 1957; Eccles & Lundberg, 1958). This implies
that if lateral spread of sensitisation does take place, it will not
necessarily be segmentally specific.
c. The facilitation model creates a biological paradox which is not
supported either by research or by clinical observations. If damage in
muscle caused spinal facilitation and consequently visceral dysfunction, it
would mean that each time we damage our muscles it would automatically
result in some visceral dysfunction. In this scenario common conditions,
such as delayed-onset muscle soreness which is associated with muscle damage
(Bobbet et al, 1986; Ebbeling & Clarckson, 1989), would inevitably lead to
visceral dysfunction. Yet, 'viscerally' speaking, most sports people are
fairly healthy. They do not seem to develop visceral dysfunction in response
to acute or chronic musculo-skeletal conditions.

The original research
Korr, Denslow and their co-workers were the first to describe the
facilitated segments in osteopathic medicine. The original research
consisted of several studies which were carried out on a large number of
normal healthy subjects. They used different experimental set-ups and were
able to demonstrate the following findings:

1. Varying motor thresholds - pressure over the spinous processes produced
reflex muscle contraction at and close to the segment. In some segments this
response was exaggerated (Denslow et al, 1947). Every person had an
individual pattern of response.
2. Varying levels of skin conductivity - there were differences in the
sweating pattern of the backs of all normal individuals (Korr et al, 1958).
This suggests increased activity of the sweat gland, implying altered
sympathetic activity.
3. Varying levels of vasomotor activity - using temperature and light
sensors they were able to demonstrate that all normal subjects have
individual vasomotor activity which is changed in different parts of the
back (Wright et al, 1960).
4. Viscerosomatic changes - sometimes, known visceral pathologies manifested
segmentally as increased skin conductivity (Korr et al, 1964).
5. Each individual had a unique thermal pattern with some common patterns
shared by all normal subjects (Wright & Korr, 1965).

Contrary to commonly held belief, they did not demonstrate the following:
1. They did not show facilitation - most of the studies were carried out on
normal healthy subjects. In all subjects they found varying levels of
neurological activity at different segmental levels. This is a complex
situation to begin with: if the subjects were healthy how come they all
displayed a supposedly neuropathological state of facilitation? If the
biological norm is that healthy subjects all show signs of facilitation, it
implies that the regional changes observed probably represent the normal
variability of a highly complex system rather than a facilitation
phenomenon. Such variability can be demonstrated anywhere in the body. For
example, if you prod different parts of your own leg, you will find some
areas are more tender, with the muscles feeling stiffer, and if you press
hard enough you may make the muscle contract to evade pain and discomfort.
When this procedure was applied to the spine, as Denslow et al (1947) did,
it was very attractive to view it as segmental facilitation.
Spinal facilitation does occur and can be seen following musculoskeletal
injuries. It is well established that inflammation produces both peripheral
sensitisation of the afferents (such as free nerve endings) and central
sensitisation within the spinal cord (Dunbar & Ruda 1992, Hylden et al 1989,
Cook et al 1987, Woolf & Walters 1991). This sensitisation means that the
threshold of different neurons is reduced, so they respond to mechanical
stimuli to which they were impervious before injury. This process tends to
spread laterally in the spinal cord but in a selective way; not all neurons
are sensitised. The selectivity of the spread seems to be functional in
character supporting the process in some way. For example, lateral
sensitisation has been shown to spread to the motoneurons which supply the
muscles in the affected area (He et al, 1988). This may have a functional
role in the muscle guarding often observed at the site of damage. It is very
difficult to imagine what would be the functional role of a lateral spread
to autonomic-visceral centres in musculo-skeletal damage. It should also be
noted that the sensitisation process seems only to take place when
nociceptors are excited by pain or inflammation and not when proprioceptors
are stimulated, such as during a manual treatment.
A similar sensitisation phenomenon was demonstrated by Korr and his
co-workers (1962), by introducing chemical insults to different spinal
structures. They demonstrated that this lateral spread could alter
sympathetic activity to the segmental sweat glands. This change only took
place when pain was inflicted. However, the spread was not always 'neatly'
segmental; some of the changes were general or remote from the segmental
distribution. This finding is not surprising in the light of what has been
discussed about afferent divergence within the spinal cord. These changes in
sympathetic activity may not necessarily have been due to facilitation. They
may arise as a secondary functional physiological process, e.g. to support
changes in muscle activity or the inflammation process at the site of
damage. Furthermore, such sympathetic changes in sudomotor activity have no
clinical relevance to osteopathic practice. More important clinically are
changes in motoneuron threshold by spinal sensitisation as described by He
et al (1988).
When Korr et al (1962) introduced postural insults, such as heel lifts on
one side, or having the subjects sit on a tilted chair, they observed
changes in the pattern of sweating. The changes were general but sometimes
more noticeable as an exaggeration of the pattern observed before the
insult. Again, they concluded that these changes were due to facilitation.
However this is also doubtful: the changes were probably due to whole body
adjustments to changes in posture rather than a locally organised change in
the spinal cord. Here too the leg can be used as an example. If you ask a
subject to stand on one leg there will be considerable differences in the
muscle activities of the two legs. Naturally the blood supply and sweat
gland activity will also vary considerably between the two legs with an
increase in activity in the balancing leg. These are whole body postural
adjustments incorporating complex patterns of neuromuscular and supportive
autonomic changes. These patterns of recruitment are organised within the
whole system rather then segmentally by the limited and local processes of
facilitation.
All the changes that were demonstrated were during separate studies on
different individuals: one study showed that in normal subjects there may be
a variable pattern of muscle response to pressure (Denslow, 1947). Another
showed changes in skin conductivity (Price & Korr, 1957), and a third showed
variability of vasomotor tone (Wright & Korr, 1960). They never took the
logical step of examining all three phenomena of facilitation in the same
group of subjects! This is equivalent to seeing three different patients,
one with joint pain, one with conjunctivitis and another with urethritis,
and diagnosing them all as having Reiter's Syndrome! Eventually they did
examine the three manifestations of facilitation in a group of subjects with
musculoskeletal injuries. However, for some reason not all subjects had the
full test procedure, e.g. some had skin conductivity but not EMG
examination. In this study they claimed that "frequently" the exaggerated
patterns were segmentally related to the site of injury. This suggests that
the nervous system does not respond in a stereotypic manner to injury.
Unfortunately no statistical analysis was carried out on the data and their
use of terminology such as "frequently" is not very helpful; does it mean
10% or 90% of subjects? Furthermore they never compared the findings of this
study (subjects with musculoskeletal injuries) to the extensive control
group of the previous studies (normal subjects). Interestingly, when one
compares the photographs of skin conductivity of subjects with injury (Korr
et al, 1964, pages 68-70) to those of normal subjects (Korr et al, 1958,
pages 35-37), they don't seem to be different. The results in this study
could be interpreted like the results of their other studies - they
demonstrated individual variability rather than facilitation.Overall, given
that the studies did not exclud the influences of higher centres and made no
direct recordings from the spinal cord it can be argued that all the changes
observed in the studies were not due to local segmental facilitation but
were in fact organised by the total nervous system (with the prominent role
of supra spinal centres).
2. They did not demonstrate somatovisceral reflexes - These early studies
did not show that abnormal muscle activity or skeletal abnormalities will
spread to affect the viscera by the process of facilitation. This is a very
important point: they assumed (along with many generations of osteopaths)
that sympathetic changes to sweat glands of the skin mean that the whole
segmental autonomic system has been affected including the autonomic centres
controlling visceral activity (Korr, 1948; Korr et al, 1962; Korr 1978).
This conclusion is a fantastic hypothetical leap, one which was never
demonstrated in humans with intact nervous systems. Furthermore, they did
not show that stimulation of mechanoreceptors (proprioceptors) would cause a
change in visceral activity. They simply observed the triad of muscle tone,
local tenderness and local sympathetic changes (skin conductivity and
vasomotor). The generally held belief that stimulation of different groups
of proprioceptors can alter visceral activity was never demonstrated in
these studies. They have demonstrated the reverse: that sometimes, known
visceral pathologies manifested segmentally as increased skin conductivity.
However, that does not mean that the reverse is true, i.e. that stimulation
of the soma will alter the activity in the viscera. This would be comparable
to suggesting that since we reflexively close our eyes during sneezing, we
would sneeze each time we close our eyes.
3. They failed to demonstrate relevance to osteopathic manual therapy -
Another interesting point is that there is no mention in all these studies
of which form of manual technique could bring about autonomic changes. The
logical next step of these studies was never taken and was totally
side-stepped in the articles, i.e., testing the effect of different forms of
manual techniques on spinal facilitation. Without discussing techniques, the
concept of facilitated segment has no meaning to an osteopath. The osteopath
needs to know how to change the activity of the facilitated segment. So many
generations of osteopaths have assumed that high velocity thrusts (HVT) are
the most appropriate form of manipulation for normalising or resetting the
facilitated segment.
Recent studies into the effects of manual techniques on neuromuscular
activity have strongly suggested that passive manual techniques are unlikely
to affect this system (Sullivan et al, 1991; Kukulka et al, 1986; Leone &
Kukulka 1988; Belanger et al, 1989; Goldberg, 1992; Sullivan et al, 1993;
Lederman, 1997; Newham & Lederman, 1997). They only produce a transient
artefact event that has no permanent influence on, or ability to bring about
functional changes in overall motor processes. Even if one accepts the
possibility of facilitated segments as described by Korr, Denslow and their
co-workers, it is extremely doubtful that passive stimulation of the soma
would result in the resetting of neurological activity (Lederman, 1997). All
neuromuscular activity is organised centrally to spread centrifugally to the
periphery (Schmidt, 1991). The peripheral receptors (proprioceptors /
mechanoreceptors) provide feedback rather than control the motor system.
Fascinating segments
The criticism in this article is not about the quality of the research but
the interpretations of the results and the far-reaching conclusions that
were drawn. Overall in their studies, Korr, Denslow and their co-workers did
not demonstrate the facilitation phenomenon. In the light of our current
understanding of neurophysiology it is doubtful whether the facilitated
segment model as described by Korr, Denslow and their co-workers has any
neurological basis or clinical application.
An interesting question arises: what was and still is so attractive in the
concept of facilitated segments? The answer I believe lies in the high
velocity thrust (HVT) and segmental adjustments. The concept of the
facilitated segment provides the justification for performing a very
accurate HVT on particular segments. It gives the HVT a physiological depth
beyond the biomechanical structural fixing of the spine. The osteopath is
now able to reach deep into the interior of the patient to affect visceral
pathologies. This was done at a great cost to osteopathy - osteopathic
understanding of neurophysiology has starts and ended at the facilitated
segment. In my view, the principle of the facilitated segment has stifled
the development of osteopathic neurophysiology for the last 50 years.
Important issues such as neuromuscular rehabilitation following
musculoskeletal injuries, central nervous damage, posture and movement
guidance, the psychodynamics of touch and psychophysiological processes and
pain management have never been addressed in depth. Some of these issues
and their relevance to osteopathy and manual therapy have been discussed in
detail by Lederman (1997).

The way forward
There is a need in osteopathy to develop a better understanding of
neurophysiology; to see the wider picture rather than concentrate on a
single fraction of the total system / person. There also needs to be a
better understanding of how osteopathic manual approaches can be developed
to become effective therapeutic processes for treating the nervous system.
This is essential for working with a wide range of clinical conditions which
have a neurophysiological element in them. Some of these are common clinical
conditions that osteopaths see in daily practice such as postural and
movement changes, neuromuscular changes following musculoskeletal injuries
and the neurophysiological aspects of pain.
In order to influence the nervous system treatment should imitate natural
processes that bring about changes in the nervous system. Most important is
the use of cognition, volition and repetition and avoiding the use of
reflexive type treatments that have been demonstrated to have no long term
effects (Lederman 97, Newham & Lederman 97). Lederman (1997), has discussed
in detail how these elements of neurophysiology can be incorporated into and
expand osteopathic practice enabling the treatment of a wider range of
conditions. Some of these points will be discussed in future articles.

References:
Bard P 1960 Anatomical organisation of the central nervous system in
relation to control of the heart and blood vessels. Physiological Reviews
40:4:3-26
Belanger AY, Morin S, Pepin P, Tremblay M-H, Vacho J 1989 Manual muscle
tapping decreases soleus H-reflex amplitude in control subjects.
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osteopathy for all

Learn Structural Integration in the Philippines

This is a special first call to Manual Medicine Specialists / Manual Therapists / Physical Therapists deeply interested in pursuing an American University-issued Certification in Structural Rehabilitation possibly starting September 2009 in the Philippines.

Please signify your intention to join us at:
assist@truecaremed.com
www.manualmed.bravehost.com
www.manualmed.blogspot.com

You may find Harold's mobile number on our websites.

Stay well and Stay blessed.

The problem with HVLA

Great post Ben, and quite appropriate.

The problem with HVLA (and I'm a frequent user), if it goes wrong you
seldom get a chance to put it right. HVLA is an art-form that gets
little appreciation because most people are not that good at it. And
if you are not so good its probably best you leave the neck well alone.
Over the years my respect for the neck has grown considerably, and I now
have a policy of not manipulating on the first visit, and not at all if
I can get good enough results without it. Most cranio-cervical joint
and C1/2 problems can be treated remotely. Always leave room for
nature to do some of the rebalancing work. The concept of "minimum
interference" comes to mind here - a concept first relayed to me by Jon
Leigh in the 1980's. Thanks Jon.

Kevin

--- In OsteopathyForAll@ yahoogroups. com, Benjamin Katz
wrote:
>
> Dear Howard,
>
> Your take on the mechanisms involved in this is most interesting and
> I'm sure there's a lot to what you say. I appreciate your contribution
> and I hope that you will continue to share your clinical knowledge and
> experience as it is clearly both deep and extensive. However, I am not
> so sure about your admonition to:
>
> > "steer clear of anyone who tries to treat this cranially."
>
> Not all osteopaths who use cranial techniques believe that osteopathy
> begins and ends in the head. Most of the teachers I have studied under
> that work with this approach see it as a mode of treatment that in no
> way affects the fact that success with our patients still relies on
> the appropriate application of osteopathic principles and many of them
> have learned these from Mr Wernham, one of the more senior amongst
> them having been his apprentice for many years.
>
> All of these osteopaths and most that I have met that use this
> approach seriously understand that there is a place for local
> treatment as well as a global approach to the body, are familiar with
> the complex and dynamic interrelationships that exist in the body and
> are well aware that if one is going to address the tissues that are
> currently causing the symptoms, one had better make sure that one also
> addresses the factors in the way this patient's body works as a whole
> that have predisposed these tissues to get into this state / are
> maintaining it, if one doesn't want to see the problem return in the
> future or degenerate into something worse.
>
> There may be osteopaths that treat palliatively and osteopaths that
> understand that the whole body is a dynamic whole that must be
> addressed as such but they cannot be easily divided into "cranial" and
> "classical" or exclusively identified with any other camps that we may
> recognise in the profession. There are osteopaths that have never
> heard of Wernham that work with osteopathy in a manner that does just
> as much justice to the tradition passed down to us from AT Still as
> yourself and I am quite certain that some of them use structural
> techniques, others cranial approaches and others still the whole body
> treatment approach that Mr Wernham taught you.
>
> The great beauty of osteopathy is that the power is in the principles
> and one may apply these successfully in any way one chooses if one
> does so faithfully. This is, presumably, why Dr Still did not teach
> his students techniques but encouraged them to learn for themselves to
> listen to the body itself and "find the health," as I have no doubt
> that you yourself do in your own way.
>
> So, if you meant that Sue should be wary of anyone who looks
> exclusively at her head, I would have to agree with you wholeheartedly
> and apologise for going on at such length for what is in fact a small
> clarification. If, on the other hand you were indeed suggesting that
> she should avoid practitioners that use "cranial techniques," I hope
> that this may have gone some way to convincing you that some of us
> might not be so narrow minded as you had thought.
>
> By the way, I thoroughly enjoyed the conference on Sunday and will
> look forward to future events.
>
> Regards,
>
> Ben

visceral manipualtion workshop philippines

A Solution-seeking Approach to

Manual Medicine for

Viscero-somatic Dysfunctions

Why learn visceral manipulation?

Would you believe you can do more with less effort? Again! Even more with even less effort! Oh, come on!

For those who have been with us a few times or from the start, what was it like when you learned the UBER-POWERFUL seated lumbosacral-pelvic super-stacking for removing restrictions from the pelvis to the LS-spine and TL junction? Shockingly amazing, wasn't it? How such a simply elegant thing could do so much used to be beyong our imagininings -- yet there it was. You learned it. And now you're using it to deliver results very few practioners can (even with their best effort, sadly).

But first, a secret: I'm sorry. We've only been using this stuff for the last 3 years. I can't say we're experts. Unlike NLP, for which i can complete Trainor's Trainer level this year (with effort, time, and Grace), i can't say i have 30 years of experience here, nor VM-D (doctoral) certification yet. So, we're only calling this a "sharing." Then again, you've seen how many tons of uuuuusefuuuul stuff we throw in during our simple "sharings," right? And no, we are NOT related to the Energizer Bunny.

My publisist insists we fit this in first:

WHAT: a life-changing experience? VISCERAL MANIPULATION SECRETS workshop. Revealing the hidden links to improving somatic dysfunctions with tiny moves. Yup. You don't have to be huge to make profound impacts on patient well-being. And yes, you can rest those strained pained thumbs, now.

WHEN: right now, you can sign up for our little sharing on: 14 december 2008 (9am to 4pm, or until the doc notices how many times he's been told to stop the sessions becuase everyone's silly-happy-saturated already.

WHERE: AICA (the Academy for International Culinary Arts), our beloved gastronomic home (Good food = opiates and endorphins and Alpha-Gamma-Theta learning states = better brain absorption, too). Our AICA family has a website, too. And physically, it's in pasig, next to the Valle Verde clubhouse and Bagaberde (gimmicks, good vibes). We're a stone's throw from the ULTRA.

WHY: you can join us for all of your own internal right reasons, or merely for how useful this stuff is. It's up to you, really. Can you see yourself there? You can? Why not make that wonderful dream of healing potential come true?

HOW: can you invest in yourself and your skills today? The man to contact is THE Harold Boy Cacao and his mobile number is on the websites at www.manualmed.bravehost.com and www.manualmed.blogspot.com. Our clinic manager is at assist@truecaremed.com

Now, back to why we want you to see what we're sharing for a limited time only!

Have you ever noticed how sometimes the seemingly smallest things have such remarkable effects? This often holds true of visceral manipulation. Personally, the fact that small moves can make profound neuromusculoskeletal and sometimes emotional shifts for patients has continued to inspire me to keeping looking for and developing manual techniques and protocols.

Is this material so different from the rest of Manual Medicine?

For anyone that’s been with us a while, RDTs now make sense, and all of Manual Medicine looks rather like the same banana, peeled differently left and right, and savored in a multitude of ways. The pressure involved is vastly different, however. Plus palpation skills are forced into jumpstarted evolution. Either of these is good news: (1) less physical effort, strikingly good somatic and visceral results, and (2) there’s a tendency for palpatory skills to get exquisitely good.

If you’ve been with us for thoracic and cervical, you’ll be pleased to know that you’ve already learned a few things that profoundly affect viscera and lymphatics. So now it’s time to learn to do the reverse also: how do you work with the visera to affect the somatic systems? It’s also a good time to answer other questions, such as “how do we work with the nervous system,” and “how do we influence autonomic regulation to bring about homeostasis. RDTs already show us we can affect the ANS profoundly. Visceral Manipulation and the cranial techniques show us another part of the puzzle. They tell us “what else” there is that can be done to help our patients.

This workshop will hopefully serve as a gateway. Some therapists may choose to specialize in Bowen Work, Visceral Manipulation, or in Cranial Techniques. Others may choose to just seamlessly integrate the parts of visceral Manipulation that aid Somatic Recovery.

OF course, what better place to learn at than a Chef’s institute? Who better to learn this with than with friends and colleagues who know how deeply you need to help your patients, and how passionately you want to have the best skillsets and mindsets?

Now that you’re ready, sign up to join us for a day of fun learning on the 14^th of December, 2008 at AICA in Pasig. Let’s Go! Uy, excited na!

Oh, did we fail to mention that, sometimes, you can just push lightly on the tummy in a certain way and sometimes the entire LS spine relaxes?

Curious, aren’t you?

So you know where to sign up now, We are at www.manualmed.bravehost.com and www.manualmed.blogspot.com and our clinic manager is at assist@truecaremed.com

Until then, Stay Blessed.

With the best warm regards,

Sincerely,

Doc Strix

FEEDBACK!

Whether you are familiar with Manual Medicine or are just learning about it now, have you ever found yourself asking "what should I do, and when, and why?"

This workshop will help you on the path toward resolving those questions. It’s been successfully argued to me this way: You know the answers. All you've ever lacked is the certainty and the experience.

What if we could download our years of experience into your practice? Would that be extrmely useful?

If you've been with us a while now, you can completely understand why we constantly get feedback like:

· "Amazing material. I didn't think you could do that."

· "T.I., 'yun lang pala yun."

· "I wish i knew this before i started to work professionally with patients."

· "Now it makes sense."

· "Pwede pala yun?"

· "Bakit di inexplain sa amin yun dati?"

· "saan ba kayo nagtago e naghahanap kami ng ganito ang tagal na?"

· "Kakainis ka, doc. Sana tinuro mo na dati sa amin yan?"

· "May napulot na naman kami sa inyo. Tagal ko nang hinahanapan ng sagot yan, e kyo lang pala makakasagot niyan!"

· "Langya, marunong ka pala nyan?"

· "Paturo naman."

· "Ha? Paano nangyari yun?"

· "Ay, bakit ganoon? Nawala yung pain!"

· "Uhmm.. Are you pressing the same way? Why doesn't that hurt anymore?"

· "Oo nga, no?"

· "Wow, can you see my family next week?"

· "Ang galing!"

The succeeding entry is courtesy of the The Upledger Institute, Inc. They are at www.upledger.com

Explore Visceral Manipulation

The Therapeutic Value of Visceral Manipulation

Life and motion are intertwined. Although we can have motion without life, we cannot have life without motion. Of particular importance and interest are those motions -not ordinarily visible -that take place within the human body. They are linked to many levels of activity, from cellular pulsations of unknown origin to rhythmic contractions of the heart and diaphragm - and even the CranioSacral system.

The visceral system relies upon an inter-connected synchronicity between the motions of all the organs and the other structures of the body. When health is at an optimum, this harmonious I relationship remains stable through the body's endless varieties of motion.

When one organ cannot move in harmony with its viscera due to abnormal tone, adhesions or displacement, it will work against not only the organs but the muscular membranous, fascial and osseous structures. A source for chronic irritation is set up and the way is paved for disease and dysfunction. In addition, this disharmony creates within the body walls fixed and abnormal points of tension that the body is forced to move around.

Imagine, for example, an adhesion around the lungs. It creates a modified axis that demands abnormal accommodation from adjacent body structures. The adhesion can modify rib motion -which in turn creates imbalanced forces on the vertebral column and with time can create a possible dysfunctional interrelationship of additional structures. This scenario is just one of hundreds of possible ramifications of such a small dysfunction -magnified by thousands of repetitions daily.

Through the dedicated work of Jean Pierre Barral, an osteopathic physician and registered physical therapist, healthcare practitioners today have the rhythmic motions of the visceral system available as important therapeutic tools. Dr. Barral's research and clinical work with the rhythmic motions of the viscera led to his development of a form of manual pressure that focuses on the internal organs and their environment as well as their potential influence on many structural and physiological dysfunctions. The term he coined for his therapy was Visceral Manipulation.

This therapy relies on palpation of normal and abnormal forces within the body. Through manual pressure, the therapist can evaluate abnormal interplay, overlap and effect on the normal forces at work in the body. The goal of Visceral Manipulation is to assist the body's normal forces in removing abnormal effects, whatever their source. The effects of Visceral Manipulation can be global, encompassing many arenas of bodily function. It is used by a wide variety of healthcare professionals today; practitioners include osteopaths, medical doctors, doctors of chiropractic medicine, physical and occupational therapists, massage therapists, acupuncturists and other licensed body workers.

How Does Visceral Manipulation Help You?

Visceral Manipulation is used to locate and solve problems. It encourages your own natural mechanisms to improve the functioning of your organs, to dissipate the negative effects of stress and to enhance your general health and resistance to disease. How Is Visceral Manipulation Performed?

Visceral Manipulation is based on the specific placement of manual force to encourage normal mobility, tone and inherent tissue motion of the viscera and their connective tissues. These specifically-placed manipulations have the potential to effect normal physiological function in individual organs, the systems the organs function within and the structural integrity of the entire body.

Due to the delicate and often highly reactive nature of the visceral tissues, gentle precisely directed force reaps the greatest results. As with other methods of manipulation, such as Cranio-Sacral Therapy, that enter very deeply into the body, trained Visceral Manipulation therapists work only to assist the forces already at work. Thus, they can be sure of benefiting the organism, rather than adding further insult, injury or disorganization within the body.

Both dynamic functional actions and somatic structures that perform individual activities are assessed by Visceral Manipulation therapists. In addition, they evaluate the quality of the somatic structures and their functions as they relate to an overall harmonious pattern -with motion serving as the gauge for determining quality. Harmony and health exist when motion is free and excursion is full and when motion is not labored, overexcited, depressed or in conflict with neighboring structures and their mobility.

What Is the Origin of the Visceral System and Its Therapy?

Methods such as Visceral Manipulation have been part of the medicinal cultures of peoples in Europe and Asia since pre-recorded times. Historically and currently in Oriental medicine, manual manipulation of the internal organs is a component of some therapeutic systems. It is no surprise that practitioners in many parts of the world have devised and incorporated into their therapies manipulations designed to work with the internal organs and their functions.

Dr. Jean Pierre Barral became interested in biomechanics and its influence on the tissues while he worked as a registered physical therapist at the Lung Disease Hospital at Grenoble, France. At the hospital he made the acquaintance of Professor Dr. Arnaud, a recognized specialist lung diseases and a master of cadaver dissection.

Working with Dr. Arnaud, he followed patterns of stress in the tissues of cadavers and biomechanics in living subjects. This provided Dr. Barral with an introduction to the visceral system and the notion that tissues have memory -fundamental to his subsequent development of Visceral Manipulation.

In 1974, Dr. Barral earned his Diploma in Osteopathic Medicine from the European School of Osteopathy in Maidstone, England. Working primarily with articular and structural manipulation, his development of Visceral Manipulation began during an unusual session with a patient whom he had been treating with spinal manipulations.

During the preliminary examination before treatment, Dr. Barral was surprised to find an appreciable improvement. The patient confirmed that he felt relief from his back pain after going to an "old man who pushed something in his abdomen." The incident piqued Dr. Barral's interest in the relationship between the viscera and the spine. He began exploring stomach manipulations with several patients. Successful results led him to the gradual development of Visceral Manipulation.

Between 1975 and 1982 Dr. Barral taught spinal biomechanics at England's European School of Osteopathy. In collaboration with Drs.Paul Mathiew and Pierre Mercier, he published Articular Vertebrae Diagnosis. Using his work with Dr. Arnaud as a foundation, Dr. Barral continued to investigate how the thickening of tissues creates areas of greater mechanical tension which in turn, pull on surrounding tissues. The discovery led him to the theoretical and practical development of "general" and "local listening" techniques.

The development of "manual thermal diagnosis" began in 1971 during another treatment session. While turning a female patient, Dr. Barral felt a strong emanation from her mammary gland to his hand. Questioning her, he learned she had been operated on for a tumor in that area. Researching this phenomenon with other patients, he learned just how accurately areas of stress in the body could be located by palpating the associated energy -which proved to be thermal. Consequent research in this arena has added manual thermal diagnosis to the practitioner’s diagnostic tools.

With Dr. Serge Cohen, a Grenoble radiologist, Dr. Barral documented changes in the viscera before and after manipulation; they employed x-ray fluoroscopy and ultrasound to record changes in position, motion and fluid exchange and evacuation. Later research with a team of electronic engineers and technicians was conducted using infrared emissions from the body.

Dr. Barral began teaching Visceral Manipulation through The Upledger Institute, Inc., in 1985; today he teaches the Advanced Level Visceral Manipulation courses. In addition, he continues research and development in manual medicine while maintaining a very full clinical practice. He has also written Visceral Manipulation, Visceral Manipulation II, Urogenital Manipulation, The Thorax and Tubo-Ovarian Manipulations. In several European countries, as a result of Dr. Barral's pioneering work, a rigorous test in Visceral Manipulation must be passed in order to earn an osteopathy diploma.

This information is courtesy of the The Upledger Institute, Inc. For further information please see their site at www.upledger.com