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Advanced Concepts for Treating the Head, Neck and Shoulders
A 9 Step Protocol **********
Craniosacral. Neuromuscular. Myofascial
Advanced Concepts for Treating the Head, Neck and shoulders
Written by Ken DiPersio, LMT
KjD Therapy, Inc
2106 Bispham Rd
Sarasota, FL 34231
Web: kjdtherapy.com
Email: [email protected]
advanced
Introduction
evolve
evolve
grow grow
master
master
fields of knowledge
Quantum Physics
Biophysics
Biomechanics
Fluid Dynamics
Embryology Mindfulness
therapies
Biodynamic Craniosacral
original ordering forces, fluids
Myofascial Release Neuromuscular original the web of connection
movement is life
Biomechanical Craniosacral
the CNS environment http://www.stateofgracemassageandyoga.com/uploads/1/4/5/1/14511048/7967293.jpg http://www.paulmanley.co.uk/Musicians/Images/Upperback_posteriorview.jpg
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stuff
happens
train your body
There is a time for everything and a season for every activity under heaven.
ecclesiastes 3:1
how to
be
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train your mind
how
to
see
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train your hands
There is nothing better than for a man to enjoy his work.
ecclesiastes 3:22
how to do
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train your heart
how to connect
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9 Steps
Introduction
1.
2.
3.
4.
5.
6.
7.
8.
9.
Awareness exercise
Heart / fulcrum / mid‐line
Shoulder / trauma release
Thoracic fascia release
Shoulder muscles / trigger points
A/O muscles / trigger points
A/O release / myodural bridges
Occipital release
Still point induction
Case History
I recently worked with a young woman who was severely injured in a car crash. After seeing a
ladder in the road she swerved into another lane at 70mph and hit another car, causing her vehicle
to roll over several times. She became conscious as she lay upside down, half out of the car, with
her head resting on the road surface. Diagnosed with a head injury and multiple physical injuries,
her health continued to decline over three years. Her neck was unable to move at all for four
months and was in constant, excruciating pain. Neck range never improved beyond 50% in any
direction. It became increasingly difficult to manage family and work obligations. Emotional,
distressful states became common. She received treatment from MD, (pain medications, anti‐
inflammatories, anti‐depressants), from DC, (manual adjustments of the spine), physical therapy,
massage therapy, and other treatments to no avail. The headaches, neck pain, fatigue, depression
and other distress continued in a downward spiral.
During the evaluation it was clear that her body was overwhelmed, compressed in fight, flight
mode. Her right foot (which was stuck under the dashboard and prevented her from escaping),
right leg, right shoulder, heart, and cervical spine were severely compressed and lacking range.
These parts of her body were in “freeze” mode. She was oriented to trauma fulcrums rather than
the original vertical midline. Both shoulders were elevated toward the ears with immobile scapulas,
guarding her throat and neck, a common response designed to keep the head connected. She
recalled throwing her hands up in front of her face to protect it during the crash.
At first her system was so chaotic that “settling” the autonomics and getting connected was all that
could be done. I held her in the “pieta” position until much of the trauma energy dissipated. Next
we integrates at mid thoracic and sternum. Very shortly after contact she began to softly cry. Her
body began to tremble and then go into involuntary contractions. These came in waves with
periods of rest in between. At one point she reported that it felt as though a weight came off. After
30 minutes, we spent some time reorienting structures to the midline.
When she got up she was softer. She began tearing up again. When I asked her what it was about
she replied that they were tears of relief. Her body felt so much better. The constant pain in her
neck was reduced by around 80% and she could move her neck 50% further in flexion, extension
and lateral rotation both left and right were also greatly increased.
connect
Deepen
deepen
awareness
Awareness self
Self
Connect
love your neighbor as yourself
Jesus in Matthew 22:39
deepen
awareness others
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On Love
To truly advance in your desire to help others, to be the most effective therapist you can be, to take in information and use
it in a transformative way, there must be a basis or foundation in all that you do and all the ways that you be. This quote from 1 Corinthians is one of my favorites and speaks, in the most elegant way, about how we need to enter the treatment room.
1 Corinthians 13
If I speak in the tongues of men or of angels, but do not have love, I am only a resounding gong or a clanging cymbal. 2 If I have the gift of prophecy and can fathom all mysteries and all knowledge, and if I have a faith that can move mountains, but do not have love, I am nothing. 3 If I give all I possess to the poor and give over my body to hardship that I may boast, but do not have love, I gain nothing.
4 Love is patient, love is kind. It does not envy, it does not boast, it is not proud. 5 It does not dishonor others, it is not self‐
seeking, it is not easily angered, it keeps no record of wrongs. 6 Love does not delight in evil but rejoices with the truth. 7 It always protects, always trusts, always hopes, always perseveres.
8 Love never fails. But where there are prophecies, they will cease; where there are tongues, they will be stilled; where there
is knowledge, it will pass away. 9 For we know in part and we prophesy in part, 10 but when completeness comes, what is in part disappears. 11 When I was a child, I talked like a child, I thought like a child, I reasoned like a child. When I became a man, I put the ways of childhood behind me. 12 For now we see only a reflection as in a mirror; then we shall see face to face. Now I know in part; then I shall know fully, even as I am fully known.
13 And now these three remain: faith, hope and love. But the greatest of these is love.
The Apostle, Paul
slow down… …see more
slow down… …see more
observe
Heisenberg’s Uncertainty Principle
The act of observing CHANGES the observed
To acquire knowledge one must study; but to acquire wisdom one must observe
Marilyn Vos Savant
orient the mind
attention in time
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orient the mind
Attention in Space
where
is
focus
orient the mind
settle
detach
observe
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1
mindfulness
awareness
perception
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1
Mindfulness Mindfulness is a moment to moment awareness of our current thoughts, feelings, sensations, and environment. From a perception of a neutral space we have a felt sense of all these things without engaging in judgement, belief systems and information from the past or future. From this perspective we settle into a place of acceptance rather than indulging in “right” or “wrong” attitudes. When we stay present and bring our attention to felt sensation, as the objective observer, we can see a bigger picture. In this mindful experience the “thought train” derails and myriad perceptual levels are seen. Mindfulness practices have been shown to provide many physical and mental health benefits.1 1. John Kabat‐Zinn, University of Massachusetts Medical School, beginning in 1979 zones of perception / attention Zone A
everything within the skin
Zone B
18”‐24” around body, personal space
Zone C
the room, immediate environment
Zone D
infinite space, the horizon
Zones of Attention In the biodynamic model much importance is placed on mindfulness during the treatment session. Where is your mind when you are working with the client? The way you be during the treatment session is just as, if not more so, valuable than what you do. Another way to say that is it’s not what you do but how you do it that matters most. The body is a complex, interactive processing organism that has its’ own individual way to be and act. According to Dr. John Upledger and others, the body also has an innate “inner physician” that knows how to heal itself. With all of the book knowledge and practical experience in the world, I still do not know enough to “heal” any body. So it falls upon us to pay attention, to listen carefully to that innate sense of health within us and within the client/patient. In doing so, we can then support the patients healing process in the direction that they need to go. The zones of attention are places we can place the mind and then observe phenomena from. Zone A is the structures, fluids and fields within the body. Zone B is the “energy body”, the 18‐
24” of personal space created by and surrounding the physical body. Zone C is the immediate environment and our connection to it. Zone D is the natural world to the horizon or infinite space. Many of us are taught to be present and relentlessly scrutinize zone A. How would you feel if someone was constantly scrutinizing and assessing you? Very often we need to get some distance to see the problem, to get information about the bigger picture or pattern. It is difficult
to see the forest when you’re standing directly in front of a large tree! So train your mind to move through the zones. Offer your ANS for processing, much like a parent will soothe a hurt child. Stay settled, calming the ANS. Allow the compression (trauma) in the body to expand into infinite space as you “hold” that space for them. Mindfully moving through the zones of attention will also benefit you. As you become more aware of and observe the true nature of dysfunction in your own body you can then process or metabolize your own imprinted trauma. This will help you to dissipate your pain and suffering. A
within
the
skin
B
around the
body
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C
the room
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D
infinite
Expand
space
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zones of attention
a
b
c
d
zone awareness exercise
Orient to the skin as your container
find your shape Settle into Zone A….your fluid body
perceive the midline
Move from midline to Zone B field
sense your personal frequencies and fields
Propriocept Zone C….the room
expand beyond the self
Expand into Zone D.... horizon
expand to infinite space
comfortable..or not?
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transitions A‐D
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release / relief ?
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mid
line
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mid line ANS Tone?
active
still
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2
connection
deepen
awareness
client
2
The Embryonic Heart and its’ Fulcrum
Toward the end of the first week after conception, implantation occurs and a flow of fluid begins to move between germ layers, originating from the connecting stalk and continuing along the middle of the embryo. This “organizing” flow is called the Primitive Streak and its formation “orders” all subsequent growth in relationship to itself…. the MID‐ LINE.
Located along the Primitive Streak, the MID‐LINE, there is a collection of precursor heart cells called Henson’s Node or Primitive Node. These cells are differentiated and will eventually give rise to the heart. Because of the nature of the heart being first to form and its location on the MID‐LINE you might say that, as humans, we are HEART CENTERED beings.
The Primitive Streak along with its Node gives rise to the Notochord. Somites, or precursor vertebrae, appear as the Notochord gives rise to the Spine and Vertebral Column.
In the second week of growth the Primitive Node will expand and eventually locate at the third somite. In subsequent weeks, growth of the heart will use the third somite and then third cervical vertebra as its fulcrum or foundation for growth. In this way the third cervical vertebra could be seen as the MID‐LINE for the heart.
The Gesture of Humility
As the heart grows at C3 the brain begins to develop rapidly posterior and superior in relationship to it. Throughout development, the busy brain grows faster and faster, while the knowing heart grows slower and slower. In this way the heart regulates the growth of the brain. At a certain point the brain becomes heavy enough so that it “bows” forward bringing both the heart and brain into contact through the membrane of the pharyngeal arches, or what will become the face. This “gesture” of the brain bowing to the heart allows for connection and subsequent heart/brain communication through the face… before the CNS develops. This “avenue of communication” is present embryonically and throughout adulthood.
All this being said, it makes sense that in a culture where “hiding the heart” with a “stiff upper lip” and “using your head” to succeed, may be serving to break the heart/brain regulatory connection. We tend to hide what is in the heart or mind because it is unsafe to allow ourselves to be seen. When the heart ceases to regulate the brain properly the brain runs amok!
Often our clients’ TRAUMA is well hidden. Connection to the self and to the therapist in a safe environment is absolutely essential to ignite a healing process!
therapeutic connection
“ the first and only duty of the practitioner is to create safety in the treatment room” John E. Upledger
slow down be still be present attune…blend “The very stability of the nervous system depends on the support of a “safe” other.”
Peter Levine, In An Unspoken Voice
http://www.senseofspace.com/feng‐shui/wp‐content/uploads/2011/09/Safety‐First.jpg
biodynamic CST
Attune to:
Original
Ordering
Organizing
Forces
embryo / heart
primitive streak primitive node
Midline
heart centered heart
fulcrum
gesture of humility
heart
brain
http://blog.cranioschool.com/wp‐content/uploads/2013/11/6_weeks‐258x300.jpg
disconnection
wear
the mask
reconnect heart/fulcrum
Posterior heart…posterior C3
move attention through zones A‐D
support client in slow tempo
observe reconnection
3
Trauma
physical / emotional
response to shock
Inhibits craniosacral rhythm
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3
Trauma
Almost all, if not all, of the clients I see in my practice have been injured or “traumatized” in one way or another. They want relief from symptoms and want to “return to normal”. The body’s natural protective, guarding response around traumatic events is compression for relative safety. Compressive states generally activate the body system to fight/flight/freeze states. Michael Shea refers to the body’s activated state as “the autonomic festival”. It follows then, that most trauma requires decompression and therefore deactivation toward stillness of the body structure, fluids and fields to affect release and return the body to health. In his book Biodynamic Craniosacral Therapy: Volume 1, Michael Shea, PhD, defines trauma as “a physiological or psychic response to physical, emotional, or spiritual injury… usually the result of being overwhelmed by shock”. In An Unspoken Voice: How the Body Releases Trauma and Restores Goodness
by Peter Levine, PhD, describes trauma not as an external event that induces physical or emotional pain, or even pain itself, but a state in which the body becomes stuck in its synchrony to primitive survival responses. Trauma is not so much what happens to us but how our body responds to and organizes around events. In other words, how the body, through the organization of the autonomic nervous system, is holding itself in either a heightened sympathetic or parasympathetic distress mode. This indicates that trauma is a body reaction. Trauma resolution, with accompanying dissolution of symptoms, requires the therapist to work with the autonomic processes in the physical body rather than thought activities. We cannot think our way out of it. It is not surprising that people by the millions are turning to physical touch therapies to assist them in releasing trauma symptoms and to find health and balance.
As the body and the fields it generates holds the stress responses, the normal, self regulating mechanisms break down. As manual therapists it is our response‐ability to assist the client in their own ability to self regulate and come to balance. To allow for the decompression of trauma and compensation patterns we, as therapists, must develop conscious attention or mindfulness, along with an appropriately regulated ANS, empathy,and compassion. These therapeutic states are the template that we use, foundation for physical touch techniques that support release of trauma from the body. In his latest book “ In An Unspoken Voice: How the Body Releases Trauma and Restores Goodness” Peter Levine writes about the essential qualities necessary to work with trauma. Empathy and compassion “help to create an environment of relative safety, an atmosphere that conveys refuge, hope and possibility” In my own training with Dr. John Upledger he was often heard to say that it was essential to instill hope in the client during the treatment, something that western medical philosophy often abandoned.
craniosacral system
Nutrient bearing CSF is produced by choroid plexus in the brain’s ventricular system as an extract of blood.
CSF is distributed to the brain and spinal cord through the sub arachnoid space and central canal.
After delivering nutrients depleted CSF returns to blood supply through arachnoid villi.
Movement of sagittal suture controls production of CSF through pressure and stretch receptors http://www.youtube.com/watch?v=K9BYEO9725k
craniosacral anatomy
Cerebrospinal fluid motion
Trauma Creates
Fulcrums
Vectors
Compression
Inflammation
Compensation
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force
vectors
Encapsulated Forces/ Fulcrums and Vectors
In studies at Michigan State1, Dr. John Upledger and Dr. Svi Karni, measured changes in electrical potential while assisting and holding the patient in specific positions. In the “correct” position” pain relief was accompanied by the softening of tissue, relaxation of the whole body, reduction of respiratory rate, increase in fluid and energy flow and a release of heat.
Why did specific positions relieve pain and suffering?
Pathways of Traumatic Force
As traumatic energy enters the body, the tissues and fluids attempt to dampen or absorb those forces. Energies are moving in straight lines. As the body moves with impact the straight line trajectories are “bent”. Since energy is divided into packages or “quantum packets” many trajectories or vectors of force may be injected into the body during one traumatic event. The result may be a problem with many “bending” imprinted trajectories that cannot be easily dissipated. These often interfere with efficient function and full range of motion. In response, the body often creates inflammation that further compounds the problem and leads to pain and suffering. Let’s help the body dissipate encapsulated force vectors by following the arm and then holding it in a position that will allow
force to metabolize or discharge from the system.
compensation patterns
Imprints
As the twig is bent so grows the tree.
Alexander Pope
interference waves
disturb ANS regulation
require energy to “hold” chaos in place
http://manifestedharmony.com/wp‐content/uploads/2013/10/tree‐bent‐by‐wind.jpg
Most Therapies
Too
Fast
most therapies
craniosacral therapy
slow… to the
speed
of Health
craniosacral therapy
shoulder release technique
Support arm out of gravity
Palpate CSR
Follow… slow movement to vector (tension)
Hold position at stop(no CSR)
Wait….Release
4
fascia
metabolic fields – self organizing activity in fluid body
retension field / matrix
fast / slow growth tissue
elastin
flexibility…recoils
collagen
fibrous support…no recoil
4
Metabolic Fields
From Michael Shea’s, Biodynamic Craniosacral Therapy: Volume 1, metabolic fields are defined as “patterns of self organizing activity in the fluids of the embryo that form the matrix for the subsequent differentiation of structure”.
Dr. Erich Blechschmidt identifies eight metabolic fields in his book “The Ontogenetic Basis of Human Anatomy”. These are Corrosion, Suction, Densation, Contusion, Distusion, Retension, Dilation, and Detraction fields.
Metabolic fields have two defining principles. First, submicroscopic fields of fluid activity relate to adjacent fields in a way that creates the growth resistance necessary for proper development of individual structures and their relationships to other structures. Second, metabolic movements in the fluids are motivation for morphological characteristics, gene transcription and cell differentiation.
Metabolic fields are the basis for and are an underlying imprint in every structure of the embryo and are carried forward through adult life.
You might compare them to a blueprint out of which the structure complies.
Fascia‐ Fields of Origin/ Development
In embryological development the inner tissues arise adjacent to and are contained within limiting tissue. In inner tissue, a watery, intercellular matrix accumulates between cells creating intercellular spaces and a loosening field . Cells can then move away from each other forming a net‐like or reticular arrangement.
Where the intercellular matrix shapes the cell groups in a particular way, tension resistant fibers arise called collagen. The collagen fibers form lattices with variable mesh size. The larger the interstices or mesh size the higher degree of loosening occurs and the more deformable the fascia, e.g. pleura. The smaller the interstices or mesh size the less deformable the fascia, e.g. ligaments.
Retension Field
Loose inner tissue and limiting tissue act in relationship to each other under the direction of the retension
field. The retension field allows for adjacent tissues to grow at different rates. Slower growth tissue acts to “retain” or limit the adjacent faster growth tissue creating tension. The more fast growth tissue tries to stretch against the retaining slower growth tissue the stronger the collagen fibers will become in the adult form.
Retension fields bring into effect a biomechanical resistance to stretching. Trauma will generally create biomechanical compression, thus activating retension field strength. The body response to trauma is to protect by binding, decreasing the mesh size between fibers and creating less deformable fascia.
All fascial release or connective tissue therapy techniques should be applied with metabolic field principles in mind. It is not a matter of biomechanical stretching alone. The therapist should “hold” tension end ranges, not merely waiting for a increase in length, but also a change in the loosening, suction and densation field patterns that began embryologically and continue to shape and change the body in response to life events. Fascia Anatomy & Physiology
Fascia is communication network that integrates the structures, fluids, fields and all body systems into the whole. Its main components are collagen, elastin and a support matrix.
The fascia is tough, yet flexible, connective tissue that touches and influences bones, muscles, organs, nerves, and vessels.
Fascia is a continuous three dimensional web of fibers that functions to support, protect, divide, connect, and communicate with all structures in the body. Fascia is classified as superficial, deep or core level. Superficial fascia is just under the skin. It provides pathways for nerves and vessels. It also stores fat and water that insulate and protect. Deep fascia is an extensive
network of intercommunicating fibers that blend with muscles, bones, nerves, vessels, and organs down to the cellular level. The deep fascia functions to support, protect, separate, deliver nutrients, eliminate waste and promote ease of fluid flow. The core or deepest fascia is the intracranial membranes and spinal meninges. The core fascia encloses the brain and spinal cord. It serves to protect, provide fluid pathways for inflow of nutrients and outflow of waste, and provides a barrier between the central nervous system and the rest of the body.
Imagine a three dimensional web, all one piece, shaping, cradling, attaching and communicating with all structures in the body. Now imagine that every single structure, down to the last cell, is held in perfect balance by this amazing, intelligent
tissue which is constantly changing, responding to information from metabolic fields. Imagine that perfect balance disrupted by physical force trauma, environmental influences, genetic influences, disease, or emotional trauma. The resulting distortion in the whole system will change the body’s internal balance, triggering responses in the metabolic fields in an effort to bring the body into balance in relationship to the retained trauma. This often creates symptoms of varying degree. Biomechanical and other stress placed on fascia cause the fascia to organize to meet the stress. fascia
fluid dynamics
small pressures transmit equally
potentially large effects
fascial diaphragms
Cranium
Atlas/ Occipital
Hyoid
Thoracic Inlet
Respiratory
Pelvic
The Thoracic Inlet
It is especially important to release the thoracic area when treating the head, neck and shoulders. The thoracic inlet/outlet
consists of the outer container of the skin. The skin contains the rib cage and sternum, the bony layer, which in turn contains fascia which creates the containers of the pericardium for the heart and pleura for the lungs. Add to that all the blood vessels to and from the heart, between heart and lungs, complicated joints and related muscles to move the body, negative air pressure creating “lift” on the abdomen, and it gets quite complicated. It is a wonder that these structures all function
together efficiently with a high degree of mobility. This high degree of mobility is necessary to insure safety. We need to be flexible under normal circumstances. We must move. Move with work, to play to see around us, to escape danger, etc.
When trauma imprints the body, the body reorients off the mid‐line to varying degrees. As a result the body tends to compress and compensate in a cascade of events designed to “hold” the body safe until the trauma force can be dissipated. In this way compression becomes “safe”. If the trauma forces are not released the body priority will be to remain compressed. The thoracic inlet is especially vulnerable to this scenario. Compression inhibits movement of joints, muscles, breath, and blood flow and creates a seemingly “life or death” crisis. This further activates the sympathetic nervous system response creating more stress in an overstressed, unregulated system.
Remember, the heart parasympathetically regulates the nervous system. When we discharge or dissipate trauma force from the thoracic inlet it will have beneficial effects for the heart, lungs, shoulder girdles, neck and head.
thoracic inlet release
thorax
bones
muscles
fluids
Newton’s third law of motion
every action has an equal and opposite reaction
lighten
up
cascades
Diaphragm Release Technique
Posterior hand…C7, T1, T2 Anterior hand…sternum, clavicles, ribs
rest on surface, settle, connect
follow movement to fulcrum…stop
hold support….wait….release
thoracic inlet release
Posterior : C7‐T3
Anterior : inferior clavicles, sternum
release signs
Lengthening
Softening
Spreading
Heat
Sigh sign
Rapid eyelid motion
Twitching
Settling
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5
neuromuscular therapy
muscle hypertonicity
ischemia
muscle bellies…along the fibers
muscle attachments
5
Neuromuscular Therapy
Developed from the earlier work of Janet Travell, MD and further developed into therapy protocols by Paul St. John and Judith Walker Delaney, Neuromuscular Therapy (NMT) is a specialized form of deep tissue massage that helps to re‐educate and improve communication between nerves and muscles. During NMT the therapist, having an intimate knowledge of muscles, their attachments and innervations, will first locate areas of ischemic tissue and then work with strokes along the fiber orientation to bring much needed fluid into the area.
As the muscle becomes more fluidic, specific points known as trigger points are revealed. Trigger poinst are areas of ischemic tissue that irritate nerve fibers and nerve endings. This continual irritation overwhelms the nerve pathway to the point where the excess stimulus “escapes” through fairly predictable pathways. This causes another area of the body to experience pain even though the “trigger” is remote. These “other pathways” are known as Travell’s trigger point pain patterns.
An example of a trigger point pattern would be a client that has frontal head pain every time there is hypertonicity or contraction of the sternocleidomastoid muscle.
Many commonly known trigger points are found in the muscle “bellies”, however, since approximately 75% of nerve endings are found in muscle “attachments” it is wise to know each muscle origin and insertion, searching them for trigger points as well.
Treatment is done holding “static pressure” on specific points until pain is relieved. It is believed that the pressure drives out toxic debris, such as lactic acid, relieving the ischemic condition and allowing new, nutrient rich blood to flow in. Adding biodynamic principles to the work would allow the therapist to move much more slowly into the tissues and triggers. To avoid defense reactions from the body we do not want to initiate pain responses. If you find pain return to neutral and start again more slowly. Allow the body to invite you in rather than fighting to keep you out.
trigger points
ischemia
specific points
hyper‐irritated trigger remote pain, sensation
facilitations
shoulder girdle
Shoulder
Shoulder Joints
glenohumeral
acromioclavicular
Strenghth
sternoclavicular
Flexibility
Scapulothoracic
http://www.figurerealm.com/userimages/customs/44500/44482‐1.jpg
Muscles
anterior muscles
http://logon.prozis.com/images/chest_muscles.jpg
posterior muscles
http://classconnection.s3.amazonaws.com/160/flashcards/1189160/jpg/muscles_of_the_back1329203605243.jpg
pectoralis minor
Origin: anterior rib 3‐5
Insertion: coracoid
process
Action: abduction and anterior/inferior scapula rotation
H
pec minor
pec minor triggers
symcheckercdn.triggerpointproducts.com/img/pectoralis01.jpg
pec minor tx
anchor ribs anterior/lateral
bring arm to end range..support
wait…release
compress trigger
wait release
serratus anterior
Origin: lateral ribs 1‐9
Insertion: under scapula to medial border
Action: abduction http://upload.wikimedia.org/wikipedia/commons/6/6c/Serratus_anterior_muscles_lateral.png
serratus anterior
serratus triggers
serratus anterior tx
Anchor ribs lateral
Continue to hold arm up and back
Wait for release
Gently compress trigger
Wait for release
latissimus dorsi
Origin: T6‐L5 vertebrae, sacrum, medial ilia
Insertion: anterior humerus
Action: shoulder extension, arm inferior and external rotation
http://tptherapy.files.wordpress.com/2010/03/lats1‐258x300.jpg
latissimus dorsi
lat triggers
http://www.myorehab.net/articles/article‐images/article%20graphic%20‐%20what%20april%20showers%20bring.jpg
lattissimus dorsi tx
Anchor latissimus tendon lateral scapula
Continue holding arm up and back
Wait for release
Gently compress trigger point
Wait for release
pectoralis major
Origin: medial clavicle, lateral sternum, superior abdominal aponeurosis
Insertion: anterior humerus
Action: arm anterior, medial, internal rotation
http://www.rad.washington.edu/academics/academic‐sections/msk/muscle‐atlas/upper‐body/pectoralis‐major/atlasImage
pec major
pec major tx
anchor pec major at sternum
45’ traction
wait for release
compress trigger
wait for release
pec major triggers
clavicle
Allows free movement
absorbs force
guard the heart
Stabilizes scapula lateral
Rotates on horizontal
http://rozeklaw.com/wp‐content/uploads/2013/03/clavicle‐injury.png
clavicle
clavicle tx
contact superior/inferior
follow movement to stop
wait for release
The Clavicle
The clavicle is the first structure to begin ossification in the embryo during weeks 5‐6 and finishes ossification at age 21‐25. It is made up of trabecular or spongy bone surrounded by a compact bone shell. The clavicle articulates with the sternum medially and the scapula laterally at the acromioclavicular joint. This horizontal long bone is a strut support that keeps the scapula away from the rib cage allowing for free movement of the scapula on the thoracic wall and maximum shoulder flexibility. Because of its early embryo position in relationship to the the heart, brain connection, the clavicles act as “guardians” of the heart. The clavicle rotates along its axis as the shoulder abducts. The clavicles are the most often broken bone in the body. The spongy character is able to absorb tremendous forces and then often break rather than let those forces invade the body. The spongy character also allow the clavicles themselves to imprint or hold forces. To release those forces hold the superior and inferior aspects of the clavicle after releasing the sub clavius muscle. Hold and wait for the underlying fascia to release. Continue to hold until you feel a lengthening or softening and de‐rotation of the bone itself.
sub clavius
Origin: superior aspect first rib
Insertion: inferior/distal clavicle
Action: depress / stabilize clavicle
http://o.quizlet.com/i/c8d‐ebuWAxwzj7LrIU0Ofg_m.jpg
sub clavius
sub clavius triggers
http://abbottcenter.com/bostonpaintherapy/wp‐content/uploads/2010/02/subclavius‐trps.jpg
sub clavius tx
thumb contact inferior clavicle
fingers contact superior clavicle
apply gentle deep superior pressure into subclavius
wait for release
trapezius
Origin: occiput, ligament nuchae, sp process C2‐ T12
Insertion: distal clavicle, acromium process, spine of scapula
Action: upper…elevation
middle… elevation, adduction, upward rotation
lower… depression, adduction, upward rotation
http://4.bp.blogspot.com/‐CZLO6K‐t9Vg/TyTaDiVntWI/AAAAAAAAAK8/Y0BMQAZ1aYY/s1600/diagram%2B1%2BFLAT.jpg
occiput
lateral clavicle
thoracic spinous process
trapezius trigger
trapezius tx
Occiput
trapezius tx
C2‐C7 lateral spinous process
trapezius tx
cervical/upper junction
trapezius tx
cervical/upper junction
trapezius tx
cervical/upper junction
Sternocleidomastoid
Origin: sternum, medial third of clavicle
Insertion: mastoid process
Action: head extension, lateral rotation and flexion
tp://www.jaypeejournals.com/eJournals/_eJournals%5C118%5C2011%5CMay‐August%5Cimages/7_img_1.jpg
SCM mastoid SCM sternum
SCM clavicle
SCM trigger Points
http://www.nhlakesidesportsmedicine.org/portals/47/Images/content_photos/scm‐trigger_11.jpg
SCM trigger points
SCM
turn head toward work side
Compress triggers
Wait for release
release attachments
6
The atlas occipital joint
The atlas/occipital joint, or AO, is located where the occiput or base of the head meets the
atlas or first cervical vertebra of the neck. The inferior aspect of the occiput has two boney
prominences called condyles. These condyles fit into corresponding grooves in the superior
aspect of the atlas called superior facets. When the condyles move anterior and posterior in
the facets, flexion and extension of the head occurs. This is the “yes” motion. The second
cervical vertebra, called the axis, articulates with the atlas at the facet joints and also sends a
boney prominence upward called the dens. The atlas rotates around the dens allowing lateral
rotation or “no” motion. The occiput, atlas, and axis are supported and moved by
strong but highly flexible fascia and musculature. Because of the need for flexibility here the
joint is inherently less stable and is therefore more susceptible to stress and strain. Muscular
and fascial strain may lead to compression of the boney structure, nerve entrapment and
dysfunction. There are three cranial nerves and one vein that exit the cranium at the a/o joint by way of two
openings in the base of the skull. These openings are called jugular foramina, are located just
lateral to the foramen magnum, and are formed as the occiput and temporal bones meet. The
cranial nerves are lX glossopharyngeal, X vagus, and Xl spinal accessory. Superior
compression of the atlas may cause these nerves to malfunction. The jugular vein which
carries waste blood out of the head may also be adversely affected. 6
atlas occipital joint
occipital condyles
C1 atlas… facets
C2 dens
Compression
loss of : flex/ext
: rotation
atlas occiput
atlas occipital joint
helical fluid flow
All life grows in spirals
william seifritz, the protplasm of a slime mold
A/O muscles A/O muscles
finger pads against base
finger tips toward eyes
head rests on thenar eminances
wait for release
7
A/O nerves / jugular foramen
IX glossopharyngeal
tongue, taste, speech
X vagus
gut, parasympathetic
XI spinal accessory
upper trap, SCM
myodural bridges
posterior: C1 dura
anterior: sub occipital muscles
A/O decompression / myodural bridges
stabilize atlas
apply 1‐2 gram traction
pinkies‐superior
8 The Occiput
The occiput is a fairly thin bone at the base of the cranium. It allows for the brain stem to meet the spinal cord through the foramen magnum. It also allows for the outflow of blood, CSF, and important cranial nerves through its articulation with the temporal bones at the two jugular foramina. The shape of these openings is vital to the functions of blood supply and nerve conduction. Compression from injury and ensuing long term, sub occipital muscle hypertonicity, tend to medially compress the occiput, distorting the shape. This, in turn, may have a profound effect on direction and vitality of the fluid flow, inhibition or excitation of nerve conduction and overall sympathetic distress.
To treat this we will place the hands posterior to the occiput and settle. Then, in a very gentle manner, laterally spread the occiput, using care to keep traction load at 1‐3 grams. Follow the movement that presents without moving beyond end range. This should feel very fluidic. If not, wait until it does.
8 occiput release
Laterally
Spread
Condyles
occiput release ‐ bilateral 9
Still Point Induction
The central nervous system is designed to normally “settle” into stillness throughout the day. When the nervous system is extremely activated, still point can cease to occur.
Still point induction is a technique designed to still point a sympathetically charged nervous system, allowing the ANS to come into balance. Dr. Sutherland would compress the occipital condyles medially having the effect of compressing the fourth ventricle. This would inhibit CSF flow and within a short time the ANS would go “still”.
Dr. Upledger, while trying to create safe, effective ways to induce stillness, found that inhibiting the medial, or extension phase of the craniosacral rhythm, would also achieve “still point”. In so doing, he took the “compression” out of the technique and found it as effective. Still point allows the central nervous system to rest, reorganize and then “reboot”. Dr. Upledger also found that still point induction redirected fluid forces and increased fluid exchange in the cranium, allowing much needed fluid to move into deprived areas. Biodynamically, I have found that still point induction helps the body to return to the original vertical midline.
9
still point induction Settle ANS
Reorganize fluid body
Reorient to midline axis
Redirect fluid pressures
Promote fluid exchange / movement
http://www.desktop4ipad.com/wp‐content/uploads/2011/05/Beautiful‐NatureLandscapes.jpg
CV‐4 still point
follow CSR lateral‐medial
hold medial barriers
wait for stillness