ILIAC CREST
Sidelying with the legs at 35° of hip and knee flexion.
Kneeling, if working on the floor, or standing – at the level of the shoulders in both instances, in front of the client.
Use a blunt elbow, making contact on the ulna, distal to the olecranon process. Sink into what will generally be the very thin layer of tissue over the crest at
the midline of the coronal plane. Contact this tissue directly atop the superior surface of the ilium. Direct the force in an inferior direction with the deliber- ate intention of engaging the periosteum as well as the covering tissues.
With this version of releasing the iliac crest there is no line of tension devel- oped. The inferior pressure is simply maintained until the pelvis drops away from the rib cage as part of the change in tone that this release will encourage (Fig. 7.13).
Movement Comments
Figure 7.13
MFR to the iliac crest, suitable for the pediatric population.
Client Therapist
Nothing specific for this release.
While this release is covered in the section on the lower extremities (p56), it deserves special consideration in the pediatric pelvis because ‘hip hiking’ is so common in the cerebral palsy (CP) population. This technique, in conjunction with other releases (hamstrings, hip flexors and adductors), will make a child (or CP or post-CVA adult for that matter) much more available for neuromotor and sensory integration approaches to pelvic stability and positional awareness.
The goal is to be visible to the child while working on them. Although this is not absolutely essential, I favor this relationship with the child whenever possible. However, doing this release from behind the child is also acceptable. Certainly, once deep release has occurred and the child is clearly in a more relaxed and trusting state, then positions other than ‘therapist’s face visible’ can be utilized more readily.
TENSOR FASCIA LATA Sidelying.
Kneeling, if working on the floor, or standing – at the level of the waistline in both instances, in front of the client.
Use the fingers, a soft fist or an elbow. The pressure should be sufficient to steadily maintain depth without over-exertion. Wait for softening – tone change – and then go more deeply into the tissue. Again, maintain a consistent degree of pressure at that level. If the tone shifts again, follow the opening it makes into the tissue and repeat.
Once the tone has noticeably dropped, a distal line of tension can be intro- duced that will further lengthen the tissue. This line of tension can be carried anterior to the greater trochanter (Fig. 7.14).
Figure 7.14
Fingers used for MFR to the tensor fascia lata, suitable for the pediatric
population. Movement Client Therapist Technique Comments
Once flexor tone is reduced, the other hand can be used to passively take the pelvis through a range of anterior–posterior motion.
This release is also covered in the section on the lower extremities (p58). It also deserves special consideration in the pediatric pelvis because tight hip flexors are extremely common in the cerebral palsy population.
Once again, the goal is to be visible to the child while working on them.
PSOAS Supine.
Kneeling on the floor at the level of the child’s knees and facing toward their head. Or standing at the same level and facing toward the head.
Hold the leg to be treated in the air to about 30° of hip flexion. Use the index and middle fingers of the other hand to sink into the anterior abdominal wall 1 cm lateral to the ASIS. Angle the contact toward the lumbar spine (Fig. 7.15). Technique
Once the psoas is engaged the pressure should be appropriate to maintain a con- sistent depth – nothing more.
Initially, the raised (treated) leg is held in a static position. Once some releas- ing response is detected in the psoas, the leg can be put through a range of motions. These can be internal–external rotation and increased extension as well as abduction–adduction or a combination of all of the above. These are done slowly and the response in the psoas is monitored throughout. The movements should augment the release. A contracted, guarded response would be a sign to reduce the velocity and/or amplitude of the movement. Many CP children have hypertonicity in the abdominal muscles as well as the deeper hip flexors. In those instances, the focus should be on releasing these superficial and mid-layer muscles before contact is attempted with the deeper psoas. The lower abdominal release described earlier in this chapter can be eas- ily adapted for a child. Also utilize the upper abdominal release shown in Chapter 8.
With any release in the pediatric population, the position of the child is open to modification. Clearly, where there is a high degree of gamma gain with hypersensitivity of the stretch receptors, attention should be given to finding positions that at the very least do not generate further hypertonicity. For example, it may be necessary to bolster the legs to 90° of hip and knee flexion to make the underlying tissues accessible.
I speak from first-hand experience when I say that any time a treatment starts to develop the feel of a wrestling match, the Law of Diminishing Returns will set in. Yet what defines a wrestling match is also open to modification and reinterpretation based on the situation. For example, I have also found that firm, controlled leaning with parts of the body other than those at the site of the active MFR assists with a general lowering of tone in the high-tone child. This is not a wrestling match. When wrestling develops it is usually at the site of the MFR. It involves a ‘you push, I’ll push back harder’ scenario. With leaning,
Figure 7.15
Utilizing MFR to the psoas with mobilization of the hip and deep prevertebral fasciae.
Figure 7.16
Making contact with many parts of the body during MFR to the tensor. A leg is resting firmly against the child’s back.
there is a deliberate attempt to deliver a firm, friendly background pressure as well as the local MFR (Fig. 7.16). It can serve to pacify a hyperarousal state as well as take attention away from a more specific contact that may border on noxious if allowed to stand out on its own.