1. HVLA cervical spinal manipulation is contra-indicated with acute concussion symptoms!
[fragile patients]
Avoid the type of spinal manipulation for which the risk seems greatest: forceful manipulation of the upper spine with a rotational element
"Spinal manipulation: its safety is uncertain". Ernst E (January 2002). CMAJ 166 (1): 40–1. PMC  PMID 
the potential to expose patients to vertebral artery damage can be avoided with the use of mobilization (non-thrust passive movements).
Di Fabio R (1999). "Manipulation of the cervical spine: risks and benefits.". Phys Ther 79 (1): 50–65. PMID 

2. Neurophysiology of Muscle Dysfunction
Fuzz (adhesions) -
interlayer fascia bonding
Fascial entrapment of the sural nerve and its clinical relevance.
Anat Cell Biol Jun;47(2): doi: /acb
Paraskevas GK1, Natsis K1, Tzika M1, Ioannidis O1. PMID:
- the nerve was observed to take a course within a fibrous fascial tunnel 3.1 cm in length that caused nerve fixation and flattening

3. How can we reduce adhesions?
Myotonic Facilitation Technique
How can we reduce adhesions?
1. Stretching
Use Cross-plane Oscillations (Wiggle at end of free motion)
2. Manipulation
Use Perpendicular lines of force
(Addresses Muscle Spindles)
[Fuzz = interlayer fascia bonding]
Copyright 2018, Dr. Todd Turnbull

4. Addressing Muscle Fiber Adhesions
Myotonic Facilitation Technique
Addressing Muscle Fiber Adhesions
Goal: Restore normal filament sliding action [Eliminate adhesions]
Muscle Spindles
Negative stimulation
- causes muscle fibers to shorten and become more guarded
- excess use of force, grinding, stroking, cross fiber
Positive stimulation
- allows muscle fibers to adapt to stretching and lengthening
- Perpendicular lines of force helps to separate muscle fibers
Copyright 2018, Dr. Todd Turnbull

5. Muscle Activation Deficits
Myotonic Facilitation Technique
Golgi Tendon Organs
1) detect tension in myotendinous junction
2) transmits sensory input to spinal cord
3) synapses with alpha motor neurons
4) inhibition of alpha motor neurons causes muscle relaxation and reduction of tension
Muscle Activation Deficits
- altered sequence of muscle firing
- delayed initiation of contraction
- termination of muscle contraction
Copyright 2018, Dr. Todd Turnbull

6. Correcting Muscle Activation Deficits
Myotonic Facilitation Technique
Correcting Muscle Activation Deficits
(neuro-muscular dysfunction)
Golgi Tendon Organs
Negative stimulation
- causes muscle fibers to increase tension and guarding
- pulling tendons away from insertions, grinding, stroking, cross fiber
Positive stimulation
- decreases muscle tension to a lower level
- Line of drive is into the insertion at the point/angle of most tenderness
Injuries occur at connection sites
Copyright 2018, Dr. Todd Turnbull

7. Neuromuscular Integration Protocols
Myotonic Facilitation Technique
Neuromuscular Integration Protocols
1. Search for the primary cause
- Scan major muscles first
- Determine which bones are most distorted
2. Check origin & insertion regions for tenderness
- If belly and one end are tender then correct into osteo-tendon jctn.
- If both ends are tender, both ends need correction
3. Evaluate muscles above and below for serial {kinetic chain} distortions.
Acute pain - gentle press and hold
Chronic pain - play piano, pin and stretch
Muscle cramps - squeeze spastic fibers
Copyright 2018, Dr. Todd Turnbull

8. Muscle Memory Patterns
- Nociceptors produce muscle guarding reactions when tissues are stressed or injured.
- Muscle guarding leads to abnormal joint position and limits range of motion.
- Local tissue response reinforces nociceptor activity.
- Long term guarding causes changes in connective tissues (degeneration/ossification).
- Stretching injured tissues can re-stimulate nociceptor activation. [stretch slowly]
J Am Osteopath Assoc Sep;90(9):792-4, Nociceptive reflexes and the somatic dysfunction: a model. Van Buskirk RL.
West Virginia School of Osteopathic Medicine, Lewisburg.
Chronic muscle hypertonicity is the result of trained, protective muscle memory patterns.
Repetitive corrections are necessary to create new muscle memory patterns.

9. Neurophysiology of Muscle Dysfunction
[Autogenic Inhibition Reflex]
A sudden relaxation of muscle in response to an overloading force.
An automatic feedback lengthening reaction that protects muscles against damage by “sharing the workload” among the many muscle fibers..
Retrieved March
A dysfunctional muscle will produce less output than a healthy muscle.
Copyright 2015, Dr. Todd Turnbull

10. How do we develop healthy Muscle Memory patterns?
1) Muscle Belly - compress perpendicularly into the muscle fiber adhesions first
2) Insertions - press directly into the osteo-tendinous junction at the site and angle of most sensitivity and tenderness
3) Repetitive Correction
- builds healthy muscle memory patterns

11. Where/How do concussions irritate nerves?
C1 dysfunction affects:
1)Vagus nerve
(CNX - heart and digestive)
2) Spinal Accessory
(CNXI - SCM and trapezius)
3) Hypoglossal nerve
(CNXII - swallow and voice)
4) Auricular nerve
(hearing, tinnitus)
5) Occipital nerve
(headaches)
Symptoms - dizzy, foggy, balance loss, earaches, vision, blood pressure, etc.

12. Non-thrust Correction of C1
Contact Point - Anterior portion of the transverse process. The point of maximum tenderness is the area of most dysfunction.
Line of Drive - Press A-P, L-M, I-S
Pressure - Hold 3 to 5 seconds at patient tolerance
Results - reduces symptoms of dizzy, foggy, balance, hearing, swallowing, vision, blood pressure
Copyright 2014, Dr. Todd Turnbull

13. A-P Cranial Compression
[Reduces symptoms of sinuses, dizzy, foggy, balance, vision]
Patient Position
- seated or standing with head slightly flexed
Doctor Stance
- side of patient
Contact Hand
Frontal bone above glabella
Occiput bone below EOP
Line of Drive
Squeeze gently and hold for 1-3 seconds then release.
Repeat 3 times.
Patient response = muscles relax, sigh/exhale, “that feels good”

14. Temporalis/Masseter Correction
- Muscle tension and guarding create jaw clenching
- Reduces symptoms of headache, confusion, ear pain/tinnitus, fogginess, balance,
Contact Point - The point of maximum tenderness is the area of most dysfunction.
Line of Drive - Press into the insertion points
Pressure - Hold 3 to 5 seconds at patient tolerance

15. 1 3 2 Suboccipitals 1) Obliquus Capitis superior
Origin - Transverse process of C1
Insertion - Occiput
Action - extension, lateral rotation
2) Obliquus Capitis inferior
Origin - Spinous process of C2
Insertion - Transverse process of C1
Action - Rotation around the Dens
3) Rectus Capitus Posterior Major
Action - extension, rotation and lateral flexion 1 3 2

16. Trapezius and Sub-occipital correction
Occipital Traction
Trapezius and Sub-occipital correction
- Pull the occiput away from C1-2 using a series of gentle traction and release movements with slight flexion of the skull.
- Minimally add lateral and rotational moves to enhance release of tension.
Patient response = muscles relax, sigh/exhale, “that feels good”

17. Sub-occipital and Trapezius correction
Occipital Nodding
Sub-occipital and Trapezius correction
- Open the occiput-C1 junction using gentle nodding motions
- Progress thru each cervical level by flexing the head to the chest
Patient response = muscles relax, sigh/exhale, “that feels good”

18. Platysma
Origin -
the fascia covering the upper parts of the pectoralis major and deltoids
Insertion -
the mandible and the corners of the mouth
Action -
depresses the lower jaw and pulls the corners of the mouth down (grimace)
Grimace, then pin and stretch with side to side motions
the external jugular vein is underneath the platysma
Copyright 2014, Dr. Todd Turnbull

19. http://www.seeing.org/techniques/palming.htm Palming Technique
Cup each eye with the palms of your hands in such a way that there is no pressure on your eyeballs and no light enters the eye.
- Palm until your eyes are relaxed
[Take 3 to 10 slow breaths. Rest elbows on the table while sitting.]
Do you see nothing, or shapes, lights and colors?
Techniques to help the eyes be free and fluid
[Whole body sway, Body Rotations, Head Rotations, Color Days]

20. How Do You Correct Cranial Nerve Entrapment?
Do 'sliders' slide and 'tensioners' tension?
An analysis of neurodynamic techniques and considerations regarding their application.
Coppieters MW, Butler DS Manual Therapy Jun;13(3): Epub 2007 Mar 30. PMID
Correcting Nerve Entrapment
- Nerve fibers have elastic properties and should slide freely through bones, muscles and fascia.
- Use mechanical nerve gliding exercises [dental floss approach]
- Activate eyes, tongue, swallow, vocal, facial muscles, scm/traps to pull on cranial nerves and mobilize them.

21. Crazy Brain Stretch
Neuroplasticity - connect as many neurons as possible, without overloading an injured/fragile system.
floss cranial nerves to reduce concussion symptoms
Activate:
1) traction eustachian tubes
2) vocal [say “aaah!”]
3) facial [squeeze muscles]
4) tongue [wiggle side to side]
5) eyes [circumduct both directions]
- Begin with strongest functions
- Slowly add weaker functions
- Progress to do all simultaneously
*Perform for 5-10 seconds
*Repeat 1-3 times per day

22. A comparison of two home exercises for benign positional vertigo: Half somersault vs. Epley maneuver.
Foster CA, Ponnapan A, Zaccaro K, Strong D.  Submitted to: Audiology & Neurology EXTRA 2012
DOI 04/29/2015

23. Hallpike positional test
(peripheral vs. central cause of vertigo)
1) Patient lays supine on the table with eyes open.
2) Support patient's head while it extends over the edge of the table.
3) Lower head down, rotate to one side and look for nystagmus.
- Perform bilaterally at a moderate pace (not fast)
[Positional changes cause maximal stimulation of the semicircular canals]
Peripheral lesions
- usually a delayed onset of nystagmus and vertigo.
- The nystagmus is horizontal or rotatory and does not change directions.
- nystagmus and vertigo fade away within about a minute. [Adaptation]
Central lesions
- nystagmus and vertigo may begin immediately with no adaptation.
[Vertical nystagmus, nystagmus that changes directions, or prominent nystagmus in the absence of vertigo are seen only in central lesions]