Cranial

and Cervical Spine

Facilitated Posi3onal Release
Osteopathy in the Cranial Field

Denise K. Burns, D.O., F.A.A.O.

Program Director NMM Program
RPSOM
Southampton Hospital

F.P.R.
Developed by

Stanley Schiowitz, D.O., F.A.A.O.

NYCOM

Type of Technique
Passive - the pa3ent does nothing
Indirect - Treatment is directed primarily away
from the barriers
(Direct - barriers can be challenged aJerwards)

A form of
Myofascial Release
Counterstrain & Func1onal techniques are posi3onal
techniques
FPR relies on both the posi3onal component and a
facilita3ng force
Similarity to the S1ll technique
wriNen about by Richard Van Buskirk, D.O., F.A.A.O.
Derived from wri3ngs of Dr. S3ll and Charles Hazzard, D.O.

MECHANISM of ACTION
Works to normalize the muscle spindle res3ng
length
AJer normaliza3on, restores range of mo3on
to the joint
Decreases tension and pain from the joint
Decreases abnormal propriocep3ve ac3vity
Decreases Gamma gain

TECHNIQUES WITH MUSCLE

SPINDLE AS PROPOSED
MECHANISM OF TREATMENT
COUNTERSTRAIN
FACILITATED POSITIONAL RELEASE
STILL TECHNIQUE

I.O.
INSTANT OSTEOPATHY

Muscle Spindle
Modify small motions

Respond to proprioceptive information

Prevent tears to muscle bodies by limiting or
preventing
too rapid stretching
stretching too far

Muscles are involved in ALL

somaKc dysfuncKons
Causing

OverexerKon
Underprepared muscles

Maintaining

Strains
SplinKng
Reexes someKmes maintained longer than is necessary for protecKon

Ini3a3on of Soma3c Dysfunc3on

Proposed Neuromuscular Mechanism

FPR

Stretch of the whole muscle

Initiates stretch of the spindles
nuclear bag & chain region gets stretched
Annulospiral fibers become stimulated
Stimulus travels along Ia fibers/Type II
fibers through dorsal horn
At ventral region, stimulates alpha
motor neurons
Causing extrafusal muscle to
contract decreasing ROM

Muscle Spindle
with increased
gamma
stimulation
&
STRETCH

Increases tension on
Muscle Spindle spindles
- increase firing
10
with gamma
GAMMA

MOTORNEURONS
SET THE
SENSITIVITY OF
THE SPINDLES

Stimulated
Stimulates
Gamma
Alpha
motorneuron
motorneuron

Stimulates extrafusal
muscle CONTRACTS

LESS TENSION OR
STRETCH IS
NECESSARY TO
ACTIVATE
THE
SPINDLES

Gamma activity causes the two ends of

the muscle spindle to contract
The relatively non-contractile nuclear bag &
chain region gets stretched MORE
Annulospiral fibers become stimulated
MORE

Stimulus travels along Ia or II fibers

through dorsal horn MORE
At ventral region, stimulates alpha
motorneurons MORE
Causing extrafusal muscle to contract MORE
Additional mechanical stretch

MAINTANCE OF SOMATIC
DYSFUNTION

Basic Rules of F.P.R.

Diagnose
Put region/joint into Neutral (aNen
curves)
places joint into idling posi3on

Monitor con3nuously
Add facilita3ng force (usually compression
or torsion)
reduces propriocep3ve noise

Add freedoms in all three planes (Flexion/

Extension, Sidebending, rota3on)
reduces muscle spindle ac3vity
allows reduc3on of gamma gain

Basic Rules of F.P.R.

Hold posi3on for three-ve seconds

Determine altera3on of 3ssue tension
Return to Neutral
Reassess

Barriers can then be challenged
Reassess

ContraindicaKons
Localized pathological 3ssue condi3ons
Infec3on
Celluli3s
Osteomyeli3s
Cysts

Tumors

Fracture
Increase or signicant altera3on of symptoms
Inability to tolerate posi3on

LAB
Diagnosis Cervical Spine

FPR TREATMENT
for the
CERVICAL REGION
Specic Single somaKc dysfuncKons
OA
AA
C2, C3, C4, C5, C6, C7

SoZ Kssue

Anterior
Posterior
Specic Muscles

Diagnosis Cervical Spine

Observe
ROM
Palpate
Special Tests

OA MoKon
Loss of symmetrical coupling is clinically
signicant!

Sidebending component is ~ 5
Rota3on is ~ 5

OA Coupling
of rota3on and sidebending is to opposite
sides!

Occipito-Atlantal ( C0-C1 ) Test in

Neutral, Flexion, & Extension

Sidebend Left/Rotate Right

Sidebend Right/Rotate Left

AA MoKon
Primary mo3on is rotaKon!
Cephalad to caudad translatory
movement accompanies rota1on!
Smaller amounts of
Forward and backward bending
Sidebending

DysfuncKons are interpreted as

rotaKonal!

Atlanto-Axial (C1-C2)

Rotation Left

Rotation Right

Rota3on LeJ @ C1 on C2

C1

Sidebending Right- Transla3on LeJ

C2/3-7

Index Finger
over articular
pillar

C3-7 SomaKc DysfuncKon

Tends to be Type II
Single segment , non-neutral
Several segments may be
dysfunc3onal!

Sidebending LeJ-Transla3on Right C2-7

Index
Finger over
articular
pillar

Sidending and Rota3on LeJ

Rotate Left
Sidebend Left

Transla3on LeJ/Sidebending Right

Right

Left

Rota3on LeJ @ C1 on C2

Regional TesKng
(Clinical Pearls)

If exion-extension limita3on with less sidebending/

rota3on loss, think

OA
If a pa3ent presents with neck pain and on physical
exam demonstrates only rotaKonal limita3on, think
A-A dysfuncKon
If mostly sidebending limita3on with some limita3on
of rotaKon, think
C2-7

CERVICAL
F.P.R.

Flatten curve
(add a slight
amount of
flexion down
to the
monitoring
finger
Add
compression
down to the
monitoring
finger

For extension
dysfunctions,
add extension
and then the
sidebending
and rotation
Hold for 5
seconds
Return to
neutral or
challenge into
barriers
Reassess

Cervical FPR

CRANIAL TECHNIQUES

Common Indica3ons CV4 Technique

Headache
Systemic Illness
AJer Childbirth
Fluid homeostasis
Increasing Cranial Rhythmic Impulse
End of life care

CV4 Technique
Since structures
related to
processes of
respiration,
circulation,
digestion, etc., are
located in floor of
4th ventricle,
treatment directed
there encourages
general relaxation
of these processes.

 Hand placement is
MEDIAL to the
Occipital-Mastoid
suture on both
sides. Compression
on or lateral to the
sutures will cause
dysfunctional
movement of the
temporals, causing
symptoms of
Vertigo: N/V/
Dizzy/Foggy.

 GENTLE compression of Occiput,

compressing medially with Flexion,
followed by allowance of extension.
You MUST perform this technique within
the Flexion & Extension phases in order to
be successful.
Properly performed, this technique will
cause general relaxation of the body and
CNS. Decreased BP also occurs.

CV4 TECHNIQUE

OA DECOMPRESSION

Common IndicaKons

OA Decompression Technique

Parasympathe3c tone normaliza3on

Headache
Visual correc3on
Low back pain
Neck pain
Cranial venous drainage enhancement
Depression

OA Compression
Diagnosis:
Reduction of motion
at OA joint
(Compression).
Treatment is directed
toward general
decompression after
c-spine-related
somatic dysfunction
has been successfully
treated.