Subtle Work and Motilities: An introduction to Advanced Visceral Manipulation and Cranial-Sacral Therapy

The biggest question at the last workshop seems to have been this one:

How does it all fit?

The truest, yet probably the least helpful answer at the moment is: "It depends."

The point is that we have been moving as far from the box as possible.

The perspective that being out of the "box" of standard Physical Medicine has given us is this:
The box is hardly useful, often ineffective, and sometimes harmful.

If you doubt the last statement, consider this:

Picture a time-sensitive lesion, for which early proper intervention is curative.
Now, picture a delay in proper treatment because only unproven traditional care was delivered.
You now have perpetuation of a dysfunction that could have been quickly resolved.
Plus, you may have a summation effect: acute somatic dysfunctions piling up on top of a primary somatic dysfunction that is "accidentally" pushed into chronicity.

Now, picture a nerve root lesion that could have been solved in a few sessions with manual medicine.
Now, picture that same lesion resulting in pain, disability, and lots of lost man-hours under unproven "Box" technology.

So, what do we use, and when? It depends. That's why you've been given a swiss knife rather than a hammer. Because really, a hammer doesn't work that well on screws.

As an overgeneralization, however, we have found this treatment flow to be particularly effective:


Check for pain and dysfunction.
Isolate the primary dysfunctions.
Turn off the "guarding" patterns evidenced by somatic dysfunctions and nociceptive reflexes.
Switch to parasympathetic using Reflexive De-Afferentation, Cranial OMT, or any similarly effective technologies you may have at your disposal.
Check if the Zink patterns indicate that generalized or focal treatments would be best.
Improve circulation and lymphatic drainage to the treatment areas first.
Treat the primary dysfunctions and turn off their guarding patterns.
Go superficial to deep.
Engage a system, not just a location.
Use active techniques whenever possible, with as much proprioceptive, verbal, and non-verbal feedback.
Integrate biofeedback to lock in your gained neurologic "rest and recover" blueprint.
While active techniques can not be used yet, use passive techniques with as much harmonic resonance, circulatory improvement, and neural-proprioceptive feedback as possible.
Pain-free ROM movements are best. 
Correct sacrum.
Free bony locks up to the thoracic at CT junction.
Free soft tissue dysfunctions in the cervical area.
Rest the sub-occipital area.
Demonstrate again that the complaint dysfunctions have been resolved.
Engage another parasympathetic shift.
Encourage improved water and electrolyte balance.
Incorporate exercises and active interventions whenever possible, and on each follow-up.
Engender a new lifestyle whenever possible.

Keep in mind, however, that even the best treatment flow protocols should be modified by your skill and confidence level, patient rappor, patient consent, and time considerations.

That's where your training, practice, and support systems come in. Seek out your colleagues. Invest in evaluation. That'll give you the initial confidence with your new skillsets.

If you feel you need perpetual certifications on paper can give you skills, the only real way to assess that will be to go to the clinics and see your patients.

If you can deliver the results your patient deserves, then whatever ritual you used to get to that proficiency was useful for you. Do more of that.

We could, at the end of the day, be proven wrong re all of the above. Thing is, we'd love to be proven wrong. We like that because it shows us how to correct our course -- how to do things better each time.

That's why the only super-strong rule for Manual Medicine is this:

"Use what is useful.

Use what works."

Next Workshop:

May 16, 2010:

Subtle Work and Motilities

An introduction to Advanced Visceral and Cranial Manipulation