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Dr Steve Sandler PhD DO

TREATMENT TECHNIQUES FOR THE CERVICAL SPINE, THE THORACIC SPINE, THE RIBS, THE DIAPHRAGM AND THE MEDIASTINUM DURING PREGNANCY . . Dr Steve Sandler PhD DO. The sitting position to treat the pregnant patient with cervical and thoracic techniques. Soft tissue techniques.

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Dr Steve Sandler PhD DO

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  1. TREATMENT TECHNIQUES FOR THE CERVICAL SPINE, THE THORACIC SPINE, THE RIBS, THE DIAPHRAGM AND THE MEDIASTINUM DURING PREGNANCY . Dr Steve Sandler PhD DO

  2. The sitting position to treat the pregnant patient with cervical and thoracic techniques

  3. Soft tissue techniques • Sitting Technique for the cervical spine and the sub occipital muscles. • Soft tissue technique for the neck and shoulders patient sitting • A modification of the periscapular techniques

  4. Sub Occipital soft tissue techniques patient patient sitting

  5. The thumbs pass over the Trapezius muscle as they pass down the spine

  6. Mable Stable on the Table Hips and shoulders vertical and at 90 degrees Small pad or pillow under the belly to support the bump

  7. Modified Periscapular Technique

  8. Cranial Techniques • CV4 supine • Side lying for the volumetric approach to the horizontal compartments

  9. CV4 patient supine • It is perfectly acceptable to have the patient supine as long as it is not for too long. You need to avoid compression of the IVC with the weight of the gravid uterus.

  10. VOLUMETRIC ASSESSMENT OF THE PRIMARY RESPIRATORY MECHANISM WITH THE PATIENT SIDE LYING both you and the patient form parts of a greater circle The base of the sacrum fits into the palm of the hand Both occipital condyles fit into the palm of the hand operator

  11. Volumetric assessment of involuntary motion with the patient sidelying

  12. Cranio Sacral Palpation in Pregnancy

  13. Ribs and diaphragm • Sitting rib stretch • Sitting upper thoracic flexion/ extension • Specific techniques for the diaphragm from behind

  14. Sitting rib stretch

  15. The right arm and hand are employed supporting the patients right arm and shoulder which are draped over the osteopaths shoulder. • This is very important because the anterior aspect of the gleno-humoral capsule is weak and if allowed to drift forward an anterior tear or dislocation can happen.

  16. The hand holding down one rib whilst the other moves away from it thus stretching the inter space.

  17. Sitting upper thoracic flexion/ extension

  18. The index and middle fingers fix the transverse processes The osteopath lifts his arms to create an arc of movement in the AP plane

  19. Techniques for the diaphragm from behind

  20. The osteopath steps back as he “gathers the flesh” with the ulnar borders of is hands • The movement into extension opens the ribs and allows the diaphragm to descend

  21. A word of caution is important here. The osteopaths hands are very near to the breast tissue, which apart from being tender are a sensitive area as far as ethics and patients comfort are concerned. • The osteopath must explain very clearly to the patient what he intends to do and why in order to ensure that the patient is clearly informed as to the ambition of the technique and is in a position to give her informed oral consent. • If English is not her native tongue then the use of an interpreter must be considered. • Once the explanation has been given and accepted then the technique can proceed.

  22. The ulnar border of the hands is under the costal margin

  23. The thenar eminences pushing gently downwards on the ribs at the end of expiration .

  24. A Myofascial release for the thorax and the mediastinum • There are many techniques to release the fascia in this region however in pregnancy it is better to have the patient sitting in order once again to reduce the pressure of the gravid uterus on the inferior vena cava. • Also, because the ambition of the technique is to release tension within the mediastinum that might be impeding venous return from the lower extremities, techniques that are performed sitting are better than those done supine .

  25. Myofascial Release for the mediastinum • Standing at her right side one hand on her sternum and the other on her upper thoracic spine. • The same note of caution regarding ethics and the breast tissues mentioned above will apply here too. • The normal axis of the heart is from the right shoulder to the left hip and so your hands must reflect this by being angled in the same axis. • If needs be the plinth must be very low to allow this to happen.

  26. Use the usual vectors of flexion/extension/ rotation left and right, and side bending left and right. • In addition add the vectors of translation of anterior posterior motion, and laterally motion, and a final vector of cepheled motion (towards her head) and caudad motion (towards her sacrum).

  27. Balance your weight on your heels so as not to put weight into your hands. Think of your belt buckle as being the centre point of motion with this approach. • Very gently allowing the flexion/ extension parameter to enter your consciousness try to perceive which vector is dominant, i.e. which of the two vectors of motion does the tissue between your hands prefer to move in. Hold that vector and adds the next vector of rotation to it.

  28. Then side bending and so on. • Stack each vector of ease on to the next and when you have each of the ease directions or vectors in place hold the point of minimal tension for around 90 seconds. • At this time you should perceive warmth or softening in the tissues under his fingers as the tension within the myofascial chain in the thorax releases.

  29. CONNECTIONS OF THE PERICARDIUM dura mata at the base of the cranium interptergoid fascia inter pterygo maxilliar fascia palatine fascia pharngeal fascia mid cervical fascia pleura PERICARDIUM diaphragm endothoracic fascia transverse fascia peritoneum

  30. HVLA techniques • Sitting HVLA techniques for the cervical spine with minimal levers • Sitting Lift Off techniques • Modification of the Dog technique

  31. High Velocity thrust ( HVLA) technique with the patient sitting

  32. Sitting techniques again are better than supine or Dog techniques • Remember the “Lift off “ technique does not mean you lift the patient off the plinth • It refers to the fact that one vertebra is lifted off from the one below.

  33. Classic position for upper thoracic lift off techniques • The problem here is that the enlarging breast tissue is tender and she will not like compression of the breasts towards her own chest wall. • Also if her breast expansion is sizeable then it might be difficult for her to interlace her fingers behind the neck especially for the upper thoracic vertebrae.

  34. The V and the W positions of the elbows

  35. The use of a pad between the osteopath and the patient helps to focus the tension as well as protecting the osteopath from injury

  36. Cupping the bottom elbow The force is directed straight back towards the osteopath with a bilateral pectoral contraction

  37. Modification of the dog technique The open hand variation for the dog technique

  38. The cepheled forearm The force through the shoulder from the cepheled hand

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