How do you like your ribs?

Ann Sleeper's Structural Rib Dysfunction Workshop

I was fortunate to be one of two teaching assistant for Ann sleeper this weekend.  The other TA was Harminder Sihota.  We had a good laugh at Ann and her funny sounding voice (she was battling a tickle in her throat).  

Structural rib problems are often overlooked by many therapists.  Often people that have a diffuse non-specific pain in there back is often a rib problem.  This is were the person knows where the pain is but can't seem to put their finger directly on it.  

Common symptoms of a structural rib dysfunction are:

• "poke in the back", chest and breast pain
• Pain in the neck (especially upper ribs)
• Pain in the shoulder and arm; decreased ROM especially ribs 1 and 2, Thoracic Outlet Syndrome symptoms
• Breathing issues
• Circulatory issues
• Lymphatic issues
• Autonomic balance (can even show up as focus, digestion etc)
• Low back pain.  Rib 12: everybody meets here.

Other common symptom include sympathetic irritations.  Remember that the sympathetic chain ganglia are running along the anterior of the vertebra where the rib heads join the vertebrae.  This can be like the "Wheel of Missfortune".  You don't really know what kind of autonomic issue you might end up with when you have a rib problem or if you will have a sympathetic problem.  Keep an eye out for rib dysfunctions when you see autonomic problems.  

Its always good reviewing anatomy and the movement that the ribs make. Typical ribs: ribs 3-10 have 5 joints per side.  Yes 5! There are 3 in the front and 2 in the back.  In the front there is the piece of chondral cartilage between the sternum and the bone of the rib.  This gives us the sternocondral joints and the costocondral joints.  In the back the rib joins to the vertebral body of the level it is named for and the vertebral body above by demi facets and also to the transverse process of the vertebrae it's named for.

The ribs are flexible and have a great deal of motion available to them.  We look for 2 distinct movements when we are assessing the ribs.  We look for pump handle and bucket handle movements.  It is easier to palpate the pump handle movement from the front and the bucket handle movement on the lateral aspects of the ribcage.

Realizing that the ribs are so flexible and mobile we come to the conclusion that there must be multiple ways they become dysfunctional.  Ann's course covers what the ribs will possibly do:

• anterior and posterior rib subluxations; 
• external and internal torsions; 
• superior subluxations of the top rib 1; 
• superior lateral rib flexion (bucket bail dysfunction); 
• lateral rib compression; 
• anteriorposterior rib compression; 
• inhalation and exhalation restrictions of rib 11 and 12.
• costocondral and sternocondral
• sternomanubrial joints

We also covered the clavicle too.  

• Sternalclavicular joint
• Acromioclavicular joint

It was a 2 1/2 day course and on the last day patients came in for the students to practice on.  I think this is such a valuable opportunity for the students.  It helps to get the order of things solid in their minds and get confirmation from the instructors about what is happening. Sometimes it is difficult to justify the extra time of work to do this but the result is you end up "owning" the material and integrating it into your practice right away.

I have been treating the ribs for over 20 years and it is always nice hearing the stories from Ann and Harminder to give me even more experience of what patients go through trying to find relief for problems caused by ribs.  I was also happy to see a full course of people that have learned to treat these overlooked areas.  Their practices will get busier and the clients will be happy.

I greatly encourage you to look into becoming skilled at Muscle Energy Technique (MET) especially for the ribs and sacrum.  Go to Ann's website: annsleeper.com.

Parting is such sweet sorrow

The final get together of the 2014 Mastering Cranial through Mentorship has ended.  I feel happy that it was such a great success but sad that I won't be getting together with these great people regularly.  I am hopful that we will still continue to meet throughout the year(s).

As I reflect back over the course I am amazed at what we covered.  The manual is over 260 pages almost equally split between academics (anatomy physiology) and practical (techniques.)  It has been a real joy to watch as each students palpation and understanding blossomed.  The excitement that was shared with me as they "got it" made my heart glow.

Initially we started with more biomechanical and fascial approaches to the cranium.  Using induction tests or motion tests to assess the sutures.   As experience is gained over the months by way of feeling and treating a number of heads, students were able to start seeing a three dimensional hologram in their minds eye.

This can really be shown by the feeling of the back of the head.  When palpating the cranial rhythmical impulse (CRI) initially you might feel a bit of a discrepancy in the symmetry between sides.  You would need to do more assessment to be able to isolate the area involved.  Is there an inferior subluxation of the petrobasilar articulation?  Is it the occipitomastoid suture?  Is it the upper or lower limb of the occipitomastoid suture?  Is it the hingemastoid pivot at the parietal notch?  Or several other possibles?  I was happy to have reported to me that students were able to better isolate the areas prior to any specific tests.  This was only a small example of the great strides they have taken.

The last days consisted of two important things:

1. Reviewing any material that they had questions on. This part is so valuable and something you just don't get in weekend workshops.
2. Having patients come in. Working in pairs through the history, assessment and treatment phases of a session.  This is a great opportunity to put into practice the whole package of the material.  

I had a little fun with one group by saying the person had a cranial base dysfunction which they didn't in fact have.  After I told them what I found they looked at each other quizzically.  They said they found something else.  Upon asking if they where certain, they both retested the head and said yes they are both sure.  I laughed and said "good job!"  This is a very good example of three individuals assessing something and arriving at the same results.  This is the certainty that you want to have when working with a person's head!

A big THANK YOU to the whole group and a WELL DONE!

Cranial Mentorship

I have been sitting in the sun thinking about the current mentorship program that is in progress.  We recently finished a "review" day.  This allowed everyone to bring and ask questions about what we have covered in the first 6 days of classes. 

It started very informal with us discussing techniques and application in different settings.  It has been a wonderful experience so far for me as an instructor to see practitioners think, practice and think again on topics that have been presented.  It leads to a much deeper understanding.  I believe that when you have an opportunity to revisit topics and techniques again and again you start to master the material.

After the discussion period we moved on to do practical review.  It was evident to me the improvement that was being made.  All started to get a much deeper grasp on the methods.  When you distill all techniques down in our profession you come to the realization that the refining of one's palpation skills is the most important element to what we do.  Everything is based on this skill no matter how fine or gross the technique.  With cranial it is even more obvious.  After over 20 years of practice and constant honing of my palpation I am still making improvement to how I palpate and what I am able to feel.

I am looking forward to our next 6 days (spread out through June) before our next review day.  We will be looking at more of the cranium in close detail.  We will continue to look at the fascial systems and joints (we have already learn to treat the facet joints 2 different ways other than Muscle Energy Technique) in both a biomechanical and functional method. 

With the next sessions taking place in June I am wondering about holding class outside.  Maybe that is just the nice spring day talking...

CSF and Sleep

This is a really interesting and thought provoking interview.

http://www.cbc.ca/video/news/audioplayer.html?clipid=2421296702

In the first 10 - 30 minutes of sleep a mouse brain increases the exchange rate of cerebrospinal fluid (CSF) into and out of the brain having a complete exchange of fluid in the brain.  This is a 10 - 100 fold increase in circulation compared to an awake mouse.  This seems to "sweep" out the brain of metabolic wastes.  This could be helpful in the prevention of Alzheimer's disease.

Just another good reason to be getting a good nights sleep!

Simply TMJ

It was a very successful workshop on November 2nd and 3rd.  It was a slightly larger group than I usually teach and presented the opportunity to use Lesli Smith as my Teaching Assistant.  I always enjoy having a colleague to work and practice with because it further challenges me to be exacting with our presentation of the hands-on techniques.

I also upgraded my audiovisuals to include a projector and screen.  Now I can have anatomy pictures up on the screen so everyone can be "on the same page."  I think with more practice with my new AV equipment the courses will be even better in the future.  The feedback would suggest the students liked it too.

I must congratulate the class on great work.  Some of the hands-on can be challenging; both to the patient AND therapist.  This was clearly demonstrated when we treated the back of the tongue and going down the throat to treat the pharyngeal constrictor muscles.  Yes there was some discomfort at the time but afterward it seemed that everyones tongue waggled much easier!

Thank you all who attended for making the class so much fun!

How Muscles Really Work

Lets look at how muscles really work.  This might come as a bit of a surprise to you, I know it was for me.

In 1951 Feneis took samples of the flexor muscle in the finger and he made cuts over a huge distance doing about 1900 slices.  He traced single cells and what he found was that one cell starts and ends then another starts with gaps in-between.  They are lined up but they are like a series of tiny "little worms" but they don't necessarily touch each other.  They are all independent worms all scattered longitudinally through the muscle.  See the photo below.

Muscle fibres (cells) are discontinuous; however, its collagen is continuous.  In other words the muscle fibres don't run from one end of the muscle to the other.  The below picture is misleading, and its also how most of us have been taught to think of  a muscle.  The muscle cells are long but are not more than a few millimetres at most, not centimetres.  In other words one muscle cell of the sartorius muscle does not run the whole length of the muscle.

So each "little worm" muscle cell doesn't pull directly on the next cell.  It does it by pulling on the collagen.  The collagen is spread throughout like an unbroken fabric in the muscle, a molecular continuum from one end to the other that runs around twisting and making spirals connecting each of the muscle cells.  The collagen holds the muscle together like a unit and transmits the force from one little worm to the next, to the next and so on until it reaches the tendon and then the bone.

A muscle like the drawing above (or in the top diagram of the below photo) that had each fibre running from tendon to tendon could not work.  When the muscle contracted and hardened it would cut of its own blood supply and compress its own nerves and render the whole action useless.  The interesting thing is Niels Stensen wrote this in 1667, and yet I wasn't exposed to this view until now.

The true architecture of a muscle is a parallelogram where the tendon plates are offset to each other and the muscle fibres run between them on an angle.  Where the tendon plates are K, M, D, C and E, F, O, N and the muscle fibres are A, B, F, E and C, D, H, G in the below diagram.

On the below picture you can see the representation of the collagen fibres as a cross hatching that is molecularly continuous from one tendon plate to the other and around all the muscle fibres.  As the muscle fibres (1 and 2) shorten and thicken (1' and 2') it preserves constant volume.  One tendon is fixed (the top) and the other is free to move.  The space between the fibres is not compromised, in fact there is a slight increase in the available space so that more blood can be drawn in, or lymph can flow and nerves aren't squashed.  You can see a blood vessel between the fibres as a red dot.  This is a simple representation in two dimensions, whereas real muscles are complex and have a spiral to them.

Here is a representation of the orientation of fibres in the deltoid muscle.  It is aligned like a chevron.  Somehow this type of explanation is missed in texts I have read.  It certainly seems a very logical setup.

Unfortunately modern textbooks don't talk about this it would seem.  Somehow science has overlooked this contribution from long ago.  When we look at muscles in this way it does explain so much.

This material was taken from a lecture by Dr Brian Freeman PhD, Embryology from a Biodynamic perspective; in Bath, UK July 2010.

2013 Course dates!

Yes finally the dates are set.

Advanced Cranial: Front of the Head
March 23, 24, 25 and April 6, 7 and 8th, 2013. 
FYI Easter is on the 31st of March.

Advanced Cranial: Back of the Head
September 21, 22, 23 and October 5, 6, and 7th, 2013.
FYI Thanksgiving is October 14th.

TMJ
November 2nd and 3rd, 2013.

I hope to see you then.

Check out dynamictherapies.com for more detailed info on the courses or call me at 604-418-8071