SEATED INNOMINATE AND PELVIC BOWL BALANCED LIGAMENTOUS TENSION 1. The physician is seated behind the child with both hands, each contacting an innominate and the sacrum. The fingers contact the ASIS bilaterally while the thumbs cross over the PSIS s to contact the sacrum 2. The innominates are then gently taken into opposite directions in rotation, inflare and outflare, using the thumbs to control the motion of the sacrum to accommodate innominate motion. This is done until the fulcrum of tensions within the tissues of the pelvic bowl is in balance. 3. Once balance is achieved, the physician maintains the positioning until a correction of the mechanical strain or improvement of tissue motion is noted. SEATED ABDOMINAL DIAPHRAGM RELEASE 1. The child is seated with the physician behind them and supporting their back with their hip or leg. 2. The physicians fingers anteriorly contact the inferior border of the rib cage and gently hook posteriorly and superiorly to engage the abdominal diaphragmatic fascia. Posteriorly (see bottom picture) the thumbs are engaging the thoracolumbar junction, including the 11-12 ribs and T12- L1. 3. The child is gently encouraged to slump into the fingers while the entire diaphragm is brought into ease or bind, whichever feels more conducive to treatment, until the passive breathing of the child is felt easily. This is balance. 4. This position is held until a release of the mechanical strain or improvement in tissue motion is noted. Heather Ferrill DO, MS March 2014 Convocation Page 1
SEATED OR STANDING RIB BALANCED LIGAMENTOUS TENSION 1. The child is seated or standing with the physician behind them. 2. One of the physician s hands is placed on the anterior and posterior aspect of the rib(s) to be treated, noting that with young children that the rib runs in a more horizontal plane than in older children and adults. The other hand stabilizes the vertebra attached to the rib being treated. 3. Using gentle pressure, the rib and its surrounding tissue is engaged by using a pincer grasp. Then the physician brings the area into balance by bringing the entire rib up or down, internal or external rotation, and inferior or superior inclination. OMT for the child with ENT problems 4. Once balanced tension is achieved, the physician maintains that position until a correction of the mechanical strain or improvement in the tissue motion is noted. SEATED OR STANDING THORACIC INLET MYOFASCIAL RELEASE 1. The child is seated or standing with the physician behind them. 2. The physician contacts the first and second ribs and possibly the manubrium anteriorly, and the costotransverse junction of T1 posteriorly. The focus of treatment is on the fascial connections of the thoracic inlet. 3. The area is engaged by gently lifting superiorly. Balance is sought by bringing the area into ease or bind through engaging flexion/extension, sidebending and rotational barriers. 4. When the breath is easily felt coming through the tissues, the position is held until a correction of the mechanical strain occurs or improvement in tissue motion is noted. Heather Ferrill DO, MS March 2014 Convocation Page 2
SEATED OR STANDING CERVICAL FACILITATED POSTITIONAL RELEASE: Lower cervical, Occipito-Atlantal (OA) and Atlanto- Axial (AA) joints 1. The child is seated with the physician to the side for best control of the head. 2. One hand is used to monitor tissue response to treatment at the level of the dysfunctional segment(s). The other hand is placed on the head. 3. The child s head is gently placed in relative flexion until the cervical spine is in a postural neutral position. 4. A gradual and gentle axial compression is applied until there is a softening of the tissues just under the monitoring hand. Force used should be no more than 2.5kg. 5. While maintaining the axial compression, the segment monitored is then brought into is position of ease, or into the position of diagnosis. For example, if the diagnosis was C4FRSr, than C4 would be gently brought into a flexion, sidebending and rotation to the right using the head as well as translational motion of the monitoring hand. 6. This position is held for 3-5 seconds and then released and the area is re-assessed. This procedure can be reapplied as many times and the child allows. BALANCED LIGAMENTOUS TENSION: CRANIO-CERVICAL JUNCTION 1. With the child in the seated position, the physician contacts the occiput with one hand so that one finger stabilizes C1 near the opisthion. Two fingers (thumb and middle finger in this example) then are placed slightly lateral to midline to approximate the plane of the occipital condyles. 2. The other hand monitors the frontal area. 3. A gentle traction is then applied to bring the occiput into relative postural flexion, while at the same time stabilizing C1 and C2. 4. A balanced ligamentous tension is sought between the occiput, C1 and C2. 5. This position is maintained until there is a change in tension, a correction of the strain pattern or improved motion is felt. Heather Ferrill DO, MS March 2014 Convocation Page 3
VENOUS SINUS TECHNIQUE Venous sinus technique as used in small children is very similar to the one learned by most in our schools and cranial osteopathy courses. This version is a seated version. The biggest difference is the tissue you focus on treating. Young children do not have the same cranial sutures found in adults; therefore it is important to shift attention to treating the membranous restriction rather than bony restriction. Treating the cerebellar falx This is an intraosseous technique, not intra-articular. 1. With the child seated, the fingers of one hand (usually two or three in young children) are placed along the region of the cerebellar falx, inferior to the inion and superior to the OA junction. 2. A gentle force is applied in the direction of the crista galli, accompanied with a gentle spreading motion of the fingers until a change in the membranous texture is appreciated. Treating the tentorium and transverse sinus 1. With the child seated, the fingers of both hands contact the region of the transverse sinus and tentorium. 2. A gentle anterior-medial force is introduced, approximating inclination of the tentorium, while at the same time the fingers spread gently. 3. This distracting pressure is held until a change in tissue texture is noted. Treating the Falx Cerebri and Sagittal Sinus 1. With the child seated, the hands may be placed in a modified vault hold with the thumbs aligned parallel with the sagittal suture. 2. A gentle distraction motion is applied laterally until a change is tissue texture is felt. 3. The thumbs are walked along the suture until the entire suture has been addressed. Heather Ferrill DO, MS March 2014 Convocation Page 4
4. Remember, in the young the metopic suture has not fused. This technique may be modified to address restrictions all the way through to the forehead. angles of the occiput. THE SPHENOBASILAR SYNCHONDROSIS (SBS) The sphenoid of a young child is not fused; it still has three bony growth centers connected with cartilage. In children less than one year old, the lesser wings and sphenoid base form one unit, and the greater wings with their associated pterygoid plates form the other two units of the sphenoid. Therefore, it is best to contact the SBS through the lesser wings, not the greater wings. We can contact the lesser wings of the sphenoid by contacting the anterior dural girdle (ADG). The ADG is an embryological remnant of thickened dural tissue that runs along the coronal suture. Contact with the occiput is made at the inferior lateral 1. One hand is placed in the region of the coronal suture/anterior dural girdle. Two fingers of the other hand are placed on the lateral angles of the occiput. 2. The SBS pattern is assessed, either through observing inherent motion or gentle motion testing. 3. The SBS is brought into balanced membranous tension through the reciprocal tension membrane and the SBS so that membranous and osseous mechanics are addressed. 4. This position is held until there is a change in the quality of motion at the SBS. Some of my favorite resources: All techniques described above are adaptations of things I have learned from these outstanding physicians though direct contact or through their writing. And many thanks to my patients and their parents who allowed me to take a bunch of pictures while treating! Carreiro, J. Pediatric Manual Medicine, An Osteopathic Approach. Churchill, Livingstone, Elsevier 2009. Carreiro, J. An Osteopathic Approach to Children, 2 nd ed. Chruchill Livingston Elsevier, 2009. Frymann, V. The Collected Papers of Viola M. Frymann, DO. Legacy of Osteopathy to Children. American Academy of Osteopathy, 1998. Sergueef, N. Cranial Osteopathy for Infants, Children and Adolescents: A Practical Handbook. Churchill, Livingstone, 2007. Arbuckle, B. The Selected Writings of Beryl Arbuckle DO. American Academy of Osteopathy Heather Ferrill DO, MS March 2014 Convocation Page 5