The Use of Seated Facet Release in Children

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1 The Use of Seated Facet Release in Children Karen M. Steele, DO, FAAO Professor Emerita, West Virginia School of Osteopathic Medicine Former AAO President

2 Outline of lab Pedigree Basic Principles Diagnosis and treatment with SFR Lumbar Thoracic Cervical First rib Questions Recognitions

3 One of the technique approaches used by Andrew Taylor Still Tell them your pedigree, child Adopted into the Still family September 10, 2009 With permission of Mrs. Roberta Still, widow of Richard H. Still, Jr, DO 3

4 Basic Principles of SFR Child is seated, either on the treatment table on the parent s lap Practitioner stands or sits behind the child Practitioner gently guides child into the position which matches the force within the restricted facet joint, then maintains gentle continuous compressive force at the facet, while moving the facet against the barrier The child is kept upright during the entire treatment, necessitating the perfect balance of forces at the restricted facet Children do not sit quietly. Move with the child while maintaining the force balanced on the restricted facet 4

5 Basic Principles of SFR First make a proper diagnosis. Determine if SFR is indicated and nothing else is contributing to the child s problem that needs medical or surgical attention. Indications & Contraindications Indications Facet joint restriction Contraindications Joint inflammation Fracture Severe osteoporosis Bony malignancy 5

6 Basic Principles of SFR: a different paradigm Not based on Fryette s Laws of physiologic motion but rather of facets restricted in opening or closing Pocket Manual of OMT 2010 Pocket Manual of OMT 2011 By permission, WVSOM 6

7 Basic principles of SFR: Lumbar spine The child may be seated on the table or on the parent s lap. Bring the child s back near you. Place the child s hands in their lap 7

8 Basic principles of SFR: Lumbar spine Gently guide the child into lumbar extension, by pushing anteriorly in the mid-lumbar area. Place your other hand on their shoulder

9 Basic principles of SFR: Lumbar spine Place knuckles over facets to be tested/treated, keeping the wrist straight and the elbow extended By permission, WVSOM

Basic principles of SFR: Lumbar spine Localize the knuckles of one hand over the restricted facet and provide an anterior force into the facet to be tested Place the other hand on the child s

10 Basic principles of SFR: Lumbar spine Localize the knuckles of one hand over the restricted facet and provide an anterior force into the facet to be tested Place the other hand on the child s shoulder and provide slight downward and medial compression into the facet to be tested Hyperextend the lumbar facets over your knuckles, individually Note motion characteristics during extension (facet closing) and recoil to neutral (facet opening)

Basic principles of SFR: Lumbar spine To treat the lumbar spine with SFR, exaggerate lumbar extension while pushing anteriorly into the restricted facet with your knuckles With your hand on the child

11 Basic principles of SFR: Lumbar spine To treat the lumbar spine with SFR, exaggerate lumbar extension while pushing anteriorly into the restricted facet with your knuckles With your hand on the child s shoulder, compress across the torso into the restricted facet and also compress inferiorly into the restricted facet. This provides localization in all 3 planes of restriction Pull the child into exaggerated extension while maintaining all forces localized to the facet being treated. Gently allow recoil at that facet by slightly reducing the forces into the facet Repeat this procedure until the facet moves freely in flexion and extension

12 Basic principles of SFR: Thoracic spine Sit/stand behind the seated child. Have the child come close to the edge of the table and rest their hands on their lap. Place your ipsilateral forearm anterior to the child s shoulder and your contralateral thumb on the facet to be palpated

the facet to be tested with your ipsilateral forearm and enough anterior force

13 Basic principles of SFR: Thoracic spine Place your torso into lumbar extension and have the child lean back onto your abdomen Provide inferior and medial force into the facet to be tested with your ipsilateral forearm and enough anterior force with your palpating thumb to be able to perceive facet movement. By permission, WVSOM

rotation and side bending toward you while maintaining all forces localized to the facet

14 Basic principles of control of the seated patient: Thoracic spine Control the child s ipsilateral shoulder by pinning it between your forearm and torso Pull the child into rotation and side bending toward you while maintaining all forces localized to the facet being tested Gently allow recoil at that facet by slightly reducing the forces into the facet By permission, WVSOM

Basic principles of SFR: Thoracic spine Palpate each facet joint with the thumb while inducing rotation and side bending toward you at that facet joint with your forearm on their shoulder Movement

15 Basic principles of SFR: Thoracic spine Palpate each facet joint with the thumb while inducing rotation and side bending toward you at that facet joint with your forearm on their shoulder Movement into the facet is controlled by your torso and lumbar movements, while holding the forces on the child s torso constant Note motion characteristics during extension (facet closing) and recoil to neutral (facet opening)

Basic principles SFR: Thoracic spine To treat the thoracic spine with SFR, exaggerate thoracic side bending and rotation at that facet level while pushing the facet anteriorly with your abdomen to

16 Basic principles SFR: Thoracic spine To treat the thoracic spine with SFR, exaggerate thoracic side bending and rotation at that facet level while pushing the facet anteriorly with your abdomen to induce extension at the facet to be treated. This provides localization in all 3 planes of restriction For a very young child, you can control side bending and rotation with your hand on their shoulder Gently allow recoil at that facet by slightly reducing the forces into the facet Repeat this procedure until the facet moves freely in flexion and extension

their lap Have the child drop their forehead into your

17 Basic principles of SFR: Typical cervical spine Stand behind the seated child, with their hands resting in their lap Have the child drop their forehead into your ipsilateral hand Have the child lean back onto your abdomen

the forehead hand, while palpating at each facet level with the contralateral thumb Note motion

18 Basic principles of SFR: Typical cervical spine Place the contralateral thumb on the ipsilateral facet joint to be tested Induce ipsilateral cervical side bending and rotation with the forehead hand, while palpating at each facet level with the contralateral thumb Note motion characteristics during extension (facet closing) and recoil to neutral (facet opening) By permission, WVSOM

Basic principles of SFR: Typical cervical spine To treat the cervical spine with SFR, stabilize the facet to be treated with the thumb at that level and exaggerate side bending and

19 Basic principles of SFR: Typical cervical spine To treat the cervical spine with SFR, stabilize the facet to be treated with the thumb at that level and exaggerate side bending and rotation at the facet to be treated Gently allow recoil at that facet by slightly reducing the forces into the facet Repeat this procedure until the facet moves freely in flexion and extension

Have the patient seated with their hands in their lap Stand behind

20 Basic principles of SFR: Rib 1 Make the diagnosis of elevated or depressed rib 1 in the usual manner. Have the patient seated with their hands in their lap Stand behind the patient and place the ipsilateral hand over the first rib to be treated. By permission, WVSOM

21 Basic principles of treatment SFR: Rib 1 Have the child drop backwards against your abdomen, and drop their forehead into your contralateral hand, as you did for cervical treatment. Press inferiorly on the restricted first rib with your ipsilateral hand to stabilize it.

Basic principles of treatment SFR: Rib 1 To treat the first fib with SFR, maintain a stabilizing inferior pressure on the rib to be treated From flexion, take the child s head to contralateral side

22 Basic principles of treatment SFR: Rib 1 To treat the first fib with SFR, maintain a stabilizing inferior pressure on the rib to be treated From flexion, take the child s head to contralateral side bending and rotation, allowing the head to rest in your hand and the child to rest on your abdomen Using your hand on the forehead, localize a distraction force into the restricted costotransverse facet Maintain downward pressure on the first rib and anterior and upward distraction into the restricted facet with your abdomen All planes of force are localized at the restricted facet

pressure on the first rib and anterior and upward pressure into the restricted facet with

23 Basic principles of treatment SFR: Rib 1 Maintain your distraction force into the restricted costotransverse facet from your hand on the forehead, as well as downward pressure on the first rib and anterior and upward pressure into the restricted facet with your abdomen Rotate the child s head away from the restricted rib, still maintaining a distraction force

24 Basic principles of treatment SFR: Rib 1 Maintain your downward pressure on the first rib and anterior and upward pressure into the restricted facet with your abdomen Extend the child s neck while still maintaining all other forces at the restricted costo-transverse facet

Basic principles of treatment SFR: Rib 1 Maintain your downward pressure on the first rib and anterior and upward pressure into the restricted facet with your abdomen Side bend

25 Basic principles of treatment SFR: Rib 1 Maintain your downward pressure on the first rib and anterior and upward pressure into the restricted facet with your abdomen Side bend the child s neck, now creating compression at the restricted costotransverse facet with the hand on the forehead, while still maintaining all other forces at the restricted facet

Basic principles of treatment SFR: Rib 1 Finally, while still maintaining your downward pressure on the first rib and anterior and upward pressure into the

26 Basic principles of treatment SFR: Rib 1 Finally, while still maintaining your downward pressure on the first rib and anterior and upward pressure into the restricted facet with your abdomen, allow the head to gently fall forward into flexion You will commonly feel/hear an articulation Recheck rib 1 motion in the usual manner

before, pull the child back against your abdomen and create a lumbar lordosis so that you can create an upward and forward force into

27 Basic principles of SFR: Alternative control of torso for upper thoracic and Rib 1 SFR treatment Have the child put their hand behind their neck so that their arm is at about a 90 angle Place your arm under their triceps area and grasp the arm against your torso As before, pull the child back against your abdomen and create a lumbar lordosis so that you can create an upward and forward force into the facet being treated This will require more lordosis on your part, as your are localizing to the upper thoracic and first rib areas

28 Basic principles of SFR: Alternative control of torso for upper thoracic and Rib 1 SFR treatment For a younger child, simply grasp their elbow

Basic principles of SFR: Alternative control of torso for upper thoracic and Rib 1 SFR treatment Maintaining the forces from the abdomen into the treated facet, induce a lateral pressure from your

29 Basic principles of SFR: Alternative control of torso for upper thoracic and Rib 1 SFR treatment Maintaining the forces from the abdomen into the treated facet, induce a lateral pressure from your arm through the child s arm and into the restricted facet Translate the child either toward or away from the restricted facet Gently allow recoil at that facet by slightly reducing the forces into the facet Repeat this procedure until the facet moves freely

30 Thank you to my models: Brendan 13 yo Mason 4 yo Ellie the elephant 2 yo Joanna 9 yo

31 Thank you most of all to Dr. Richard Still, who mentored me in my early years and later welcomed me into his home and family during the last few years of his life. His wish was that this treatment approach be carried forth in its most pure and unadulterated form for the benefit of future generations of osteopaths, osteopathic physicians and patients. With permission of Mrs. Roberta Still,

32 References Beatty D, Li TS, Steele K, Comeaux Z, Garlitz J, Kribs J, Lemley WL. A Pocket Manual of OMT 2nd Edition. Lippincott Williams & Wilkins, Baltimore

OMT Without An OMT Table Workshop. Dennis Dowling, DO FAAO Ann Habenicht, DO FAAO FACOFP

OMT Without An OMT Table Workshop Dennis Dowling, DO FAAO Ann Habenicht, DO FAAO FACOFP Cervical Somatic Dysfunction (C5 SR RR) - Seated 1. Patient position: seated. 2. Physician position: standing facing