OMM #13
Wed, 08/27/03 3pm
Dr. Fotopoulos
J. Uxer for Le Giang
Page 1 of 3
Compression of the 4th Ventricle Technique
I.
Effects of CV 4
 “By tempering the fluctuation of the cerebrospinal fluid, it is possible to induce
a balanced interchange of all the fluids of the body.”—Harold Ives Magoun
 CSF is very important to the vitality of living things.
 If there’s CSF blockage, you get into trouble just as you would with lymphatic,
arterial or venous blockage.
II.
Case Presentation
 You are consulted on a 75-year-old female patient whose physical status is
declining because of sepsis. (Sepsis: caused by a bacterial, fungal, or viral
infection. It’s the body breaking down → shock → ↓ blood pressure → death.)
 The patient’s respirations are quick and shallow and her mental status is unable
to be determined because of her hypersomnolence (lethargic, unresponsive).
 The patient is not currently intubated and she is maintaining a compensated
blood gas. Her body is compensating for her acidic content: Too much CO2
has built up, so she’s breathing faster to blow it off. When someone is
decompensated, they become unstable and have to be intubated.
 The attending physician wants to “pull out all of the stops” to see if this patient
can be helped before calling the family for approval to establish her “do not
resuscitate” status. MRI and CT of the brain are normal for a patient her age.
When in doubt and everything’s stable, use the CV4 technique. It’s one you can
always fall back on.
 Because the medical management of this patient has been maximized, you
decide to perform a CV4 technique on this patient in order to:
– Create a balanced interchange of fluids (and thus nutrients) in the vital
centers of the brainstem as well as the rest of the body.
– You try to move the CSF, forcing it into the venous circulation and through
the entire body.
III.
CSF Circulation
 Refer to the ppts for the picture of the CSF circulation.
 CSF produced in the choroid plexuses of the lateral, 3rd, and 4th ventricles
 CSF flows from the lateral and 3rd ventricles into the 4th ventricle via aqueduct
of Sylvius
 CSF exits 4th ventrical through 3 openings: midline via the foramen of
Magendie and two lateral foramina of Luschka
 CSF enters the cisterna magna, which lies behind the medulla and beneath the
cerebellum
 The cisterna magna is continuous with the subarachnoid space that surrounds
the entire brain and spinal cord.
OMM #13
Wed, 08/27/03 3pm
Dr. Fotopoulos
J. Uxer for Le Giang
Page 2 of 3

CSF ultimately flows into arachnoidal villi (forms arachnoidal granulations),
which project into the large sagittal venous sinus and other venous sinuses. It
enters the vascular circulation from here.
IV. Proposed Specific Effects
 THESE ARE IMPORTANT as to why we do this cranial treatment!
 From Osteopathy in the Cranial Field
1. Stasis of CSF, lymph, and venous blood is overcome due to the change in
the electro-biology of the fluids. Helps get fluid moving.
2. Vital centers are detoxified, nourished and stimulated because there’s no
stagnation. The circulation carries the wastes away.
3. Normalcy and efficiency in the vital functioning of the central nervous
system are restored because there are no waste products around.
4. Body metabolism is improved and immunity is enhanced.
5. In class he noted that this is VERY important: The pituitary-hypothalamic
complex is stimulated and influences involuntary adjustment to the
external environment and regulation of the body. Doing the CV4 indirectly
compresses the 4th ventricle. The pituitary gland lies near the 4th ventricle, so
doing a CV4 can have profound effects on the endocrine system.
V.
Contraindications
 These are absolute or relative. With absolute contraindications, you do NOT
want to attempt the CV4. With relative contraindications, use your judgment.
 Skull or neck fracture—absolute contraindication. An example would be
basilar skull fracture and/or fracture of C2.
 A pregnant woman in her 3rd trimester
– Absolute contraindication if she does NOT want to/ is not ready to go into
labor.
– Relative contraindication if she’s ready to deliver the baby. (Think last
week—Dr. Gustowski’s sister had this done and went into labor soon after.)
 A hypotensive patient—relative contraindication. When you do the CV4, you’ll
relax their body. This will further lower their blood pressure and cause them to
become more hypotensive.
 Cerebral Hemorrhage—bleeding in the brain.
– Unless it is during resolution and if the method of application is via the
sacrum.
– Must have sufficient time for the clot to become firm and ready for
resolution.
– Therefore, this is a relative contraindication determined by time and
clinical stability.
– Absolute contraindication if the patient is currently hemorrhaging or has
hemorrhaged in the recent past.
– Relative contraindication if the patient meets the 1st two points of this list.
OMM #13
Wed, 08/27/03 3pm
Dr. Fotopoulos
J. Uxer for Le Giang
Page 3 of 3
VI. Caution
 CV4 compresses the 4th ventricle, which is not far from the pituitary area
 The idea of the CV4 is to have a metabolic effect from the interchange of fluids
- lymph, venous/arterial and their contents (ie hormones, like pitocin)
 Labor may not ensue instantaneously just as the CV4 is done, however.
Remember that the body has to assimilate any treatment given. So, you may do
the CV4, and the patient may not feel the effects until 1 – 2 days later when the
body has adjusted to the change.
VII. CV4 Technique:
A. Hand Position
 Patient is supine.
 Doctor is sitting at the head of the table.
 Doctor cups one hand inside the other or laces fingers such that the thenar
eminences are about 1 – 2 inches apart.
 Patient lifts head and the doctor’s thenar eminences are placed on the
supraocciput and the thumbs point down the spinal column with the spinous
processes between them.
 Do Not Cross the Occipitomastoid Suture!!! You can cause nausea and
vomiting if you do.
B. Procedure
 The Doctor initially follows the occiput during flexion and extension to tune
into the mechanism. Know what flexion and extension feel like.
 Key step: Once tuned into the mechanism, the doctor encourages the
occiput towards extension. Maintain extension and resist flexion.
– Remember that in extention, the SBS drops and the occiput moves into
your hands. You’ll feel more pressure in your hands.
– In flexion, the SBS rises and the occiput moves away from your hands.
 The occiput is held until the still point (the mechanism will stop and you
won’t feel it anymore at this point.) Wait for the flexion/extension cycle to
begin; it may take 30 sec – 1 minute.
 Follow flexion/extension for a few cycles and then gently remove your
hands and place patient’s head gently on table
C. Caution!!!
 When your patient gets up off the table warn them that they may feel
lightheaded or may feel a little “funny.”
 This technique may produce and orthostatic response that should subside
quickly.
 Be there to prevent falls.