Craniosacral Therapy

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Craniosacral Therapy

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Craniosacral Therapy

JOHN E. DPLEDGER, D.O., F.A.A.O. AND JON D. VREDEVOOGD, M.F.A.

Eastland Press SEATTLE

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1983 by Eastland Washington 9811 L All Library of

reserved.

Card Number: 82-82505

International Standard Book Number: 0-939616-01-7 Printed in the United State s of America.

Photolithoprinted by Ann

Michigan, 1983.

Third Printing 1984

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To Our Families John Matthew, Mark, Mike and Rob and Kim and Jon

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Table of Contents

PH. D.

FOREWORD BY ELMER

xi

PREFACE

1

CHAPTER 1

Introduction to

5

CHAPTER 2

Concept: Basic Terminology

14

CHAPTER 3

Craniosacral Motion: Palpatory

26

CHAPTER 4

for Modification 39

Rhythm CHAPTER 5

Release of Transverse Restrictions Which Impair Mobility

46

CHAPTER 6

the ..... ".:UU.'-'0." ... " System: Diagnosis

Dural 60

CHAPTER 7

Dysfunctions

the

'-'H�UL.,U

Base

88

CHAPTER 8

Spinal

Mater and

. Complex

131

CHAPTER 9

and Dysfunctions

� ..,.",•• vuw

Osseous and Sutural the Cranial Vault

152 vii

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CHAPTER 10 167

The Occipital Condyles

CHAPTER 11 Temporal Bone Dysfunction

172

CHAPTER 12 The Mouth, Face and Temporomandibular Joint

185

CHAPTER 13 Extrinsic Neuromusculoskeletal System Dysfunctions Which Influence the

203

Craniosacral System

CHAPTER 14 Diagnosis by Evaluation of Craniosacral System Function and \Vhole Body Response

242

CHAPTER 15 Newborns, Infants and Children

256

CHAPTER 16 Specific Clinical Cautions and Applications

265

APPENDICES

APPENDIX A The Structures of Cranial Bone Sutures

273

Ernest W Retzlaff, David Michael, Richard Roppel and Fred Mitchell, Jr. ApPENDIX B Examination of the Cranial Rhythm in LongStanding Coma and Chronic Neurologic Cases

275

Z Karni, j. E. Upledger, j. Mizrahi, L. Heller, E. Becker and T. Najenson APPENDIX C Mechano-Electric Patterns During Craniosacral Osteopathic Diagnosis and Treatment

282

John E. Upledger and Zvi Karni APPENDIx D Management of Autogenic Headache

291

John E. Upledger and Jon D. Vredevoogd APPENDIX E Spontaneous Release by Positioning

Lawrence Hugh Jones

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300

ix

TABLE OF CONTENTS

APPENDIX F

Self-Induction of CR.!. Still Point Using Tandem Tennis Balls

310

james Ne/Jon Riley APPENDIX G

Diagnosis and Treatment of Temporoparietal Suture Head Pain

312

john E. Up/edger, ErneJt W Retz/aff and jon Vredevoogd APPENDIX H

Roentgen Findings in the Craniosacral Mechanism

317

Philtp E. Greenman APPENDIx I

The Relationship of Craniosacral Examination Findings in Grade School Children with Developmental Problems

329

john E. Up/edger APPENDIX]

The Reproducibility of Craniosacral Examination Findings: A Statistical Analysis

345

john E. Up/edger APPENDIX K

Holism, Osteopath y and Biomechanics

357

john E. Up/edger REFERENCES

359

INDEX

361

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Forew-ord

light on Craniosacral therapy, as explained and taught in volume, interface, or area of blending, that lies intervention medicine and self medicine, traditional allopathic-osteopathic psychophysiologic self

In other words,

"between

anisms when

"

book throws light on

an

differentiation between mind and

in

physics, biology, psychology and medicine. In

Preface to this book, John

"people ... continue to

they have care

in

health

world. Why?

has

recognize the existence of the significance.' , forceful statement about the ... ""M ..... .

.. "'klH'V"' ..... l.'U

are subscribed to by

some would say do not summarize

of

y"HJIU�U. texts. In

I am especially sensings and manipulations in Upledger's ��

••vu.[',v

and manipulations of "body electricity" in intervention

is not surprising, the visualization

self

It

of P .... .� ... "'''· should

common ground. At a number of physiologic correlates that

.... ['," ..a ......H .

xi

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xii

FOREWORD

remain without satisfactory explanation kind of "body electricity"

can

do not

the existence of a

"transferred" from therapist to patient (in the

technique) or can be self manipulated by a patient Since self-regulation placebo effect in drug after

in visualization

methods of psychophysiologic

one of the

almost

of intervention

u.��.�, ..

for instance), a crucial question is

reality of the"V-spread" data is accepted: Are the phenomena

merely result of psychophysiologic self-regulation, conscious or unconscious, the patient? that

It is a well

placebo effect, a body, is a subdivision

physiologic change in a effect (even though the

is completely unconscious of having generated it).

Much is known about how a patient consciously or unconsciously uses HU�F>',H"" change in biochemical and (visualization) to admittedly, much is not known. But one thing is certain: without mental imagery, conscious or unconscious, nothing can self-initiated or self-controlled. It is known that placebos and self-regulation methods not work with babies and dogs. Those creatures do not know what we are talking about. In mechanisms can not self-directed through visualization. But work with and Ius intermay handle the same energy in a way, but in both vention. the existence of a non-neurological and nonto cases we find it classical "body to account for results. of Often when the of the technique is used the patient

not know what is happening, and has no described by Upledger (and

what is "supposed to happen." The

which are observed by workshop students, including myself) take place without patient's own visualization. And since visualization is sine qua non of self'-F.'en....""" in its conscious or unconscious, self-regulation can ruled out as a satisfactory \.."'It''''--''''''wu'u In

8,

strange as described, you however, one who to mind team psychophysiology lab.

try it before

long been

it out

it may sound a hand." To me,

in this area, it rings a familiar note. It of yogis whom we (The Voluntary

in India in 1974 with a portable Foundation) self regulation adepts who were willing (and to

explain, maintained that everything they did "inside and outside the skin," however through to Western psychology and ""'",UlfJ''''''''v

uof a

which they called "prana." body's neurological

According to correlate, or reflection,

more of "nadis, " which are superphysical, but real, substance not yet detected by instruments.

filaments

are constructed, it is said, of "dense prana, " and they conduct a more subtle form of (meridians) are "prana" said to be

parts structure. In any event, ",,,-,.VLUHAj<, psychophysiologic phenomena are inside-the-skin or kinetic phenomena which, mediated by "prana" and directed by unconscious) are found inside and outside the skin. Thus, the former are

to yogic

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xiii

FOREWORD

"1J,0<..,,1<

cases of the latter. ". ....., ,.... .·u

that best accounts touch martial arts (kung fu, medicine, Philippine (Ayurvedic the

theoretical

the "vital physical body" characteristics similar to (which the"dense physical body" is said to servily obey), and is similar to body" of psychics, reported

days in "out of body"

It is interesting to note that in ...... O.• UIU. LU'':>VU

Puthoff and Russell (to name only a

with ultra-sensitive instrumentation indicate that an energy hypothesized to exist " is to

r!plrprtpr!

are talking about cosmos in which body, emotions,

I-'H_U�;<"I

of the same basic energy. many matter-bound thinkers by

word"spirit," then do not use of matter." If, however, you are not of as the densest form of uses the old"energy" in a this seem strange? Not to perhaps the most in medicine. LlUH"'J''''

for part of the of the

rhF'r",'h,

bind is to deny the this is a waste of time,

technique works." And I an effort,

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were directly funnelling divine healing power through their hands." Upledger's problem: how to talk about an intervention method that works though under the of your " how to separate from move boldly into UUJ1\..lnJWl fantasy, boundary of in such a way that him, and he vanish from sight, his work

frontier does not

up

to the land of" quackish

<J';;':HUU

" to use his phrase. a few more words energy."

hptnf'p

therapist in by cntlcs that

therapist. But to

is a "directing of mind of to

observer and experiencer, and

Upledger and other therapists who are working in many-leveled domain body are finding refreshing that support the idea of unity in medicine and yoga, body At

mind, conscious and unconscious. present state of knowledge and experience, perhaps it is

to

a

monist, remain rational, be undogmatic, be flexible, become intuitive, and continuously out and new We must not be like Soviet the new in the to " pounded area, on the scientists, however, gave Other, more open-minded are no new the energy a new name, "bioplasma," because of its apparent plasma-like properties, and started new To start new "direction of energy" craniosacral therapy.

projects.

projects is what we should the main work has just

the "V-spread" or

milieu from which it emerges, As Upledger says,

book

contains a "considerable amount of observation and theory that has not yet " stood rigorous scientific ELMER

PH. D.

The Menninger Foundation Topeka, Kansas 1982 August

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Preface

As in any new field of study, the craniosacral concept is changing rapidly. This book contains the most recent information available. amount of observation and We

your indulgence in

observation,

included is a considerable

that has not withstood matter. continued

application and

practitioner can begin to sort out the fact from the fantasy. Time

will demonstrate the

of craniosacral

that

the other hand, we do

potentially high-benefit

should be withheld from suffering of scientific seek to confirm or refute them. In other areas of care where the risk to and the potential dangers more formidable, our position on a

Moreover, number of

issue would quite different. potential of providing " "crocks"

whom conventional

has proved ineffective.

continue to suffer even though they have passed through the some of the health care facilities in the world. Why? This is so because orthodox to

the existence

significance. Although years

its

the

its

over 50 was possibility of such a It was unreasonable to seriously

doubt accepted instead concept of dynamic activity involving skull bones, meningeal membranes, cerebrospinal fluid, the intracranial body fluids, the

system, the development the brain, movement of the of total body connective tissues

as influenced by As our started to

1

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2

PREFACE

without a complete understanding of how it works or

it

when applied by these few, but appeared so as a that it became known to

It was

believed that they were directly funneling

ULIUHI;;H,

This obviated the need for an physiology. The work did not die .... ,',,:......,'-\..1

it as

continued to curious about results observed in response to therapy. own interest in the (Upledger)

I could not carry out position. I had no

were no

is a

our work, I heard a lecture by my co-author, Jon and an architect. The essence of his can

following quotation:

Nature makes the best

design in nature is for a purpose and is the most

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3

PREFACE

efficient way to accomplish a task. We should

the way nature does things and

try to emulate it, rather than clumsily and egotistically trying to invent our own. We cannot improve on natural

I

we need only understand it.

a disarticulated human skull and challenged him to explain to me why skull as it was, and to the function of the design of the six years, and I on

various

problems. is for the curious medical biologist or physiologist, On a general level, or anyone who has an interest in the integrated mechanical and physiological demystifies and provides a functions of the human body. craniosacral straightforward explanation for many observed but unexplained physiological phenomena and clinical <:""£1,.,, who is a "body worker"; On a more is, anyone in a healing profeSSion who uses as diagnostic or therapeutic tools. Included are medical and osteopathic physicians, dentists, chiropractors, physical polarity therapists, movement therapists, psychotherapists, and many, many more. Most of the people in have a background in In this book, we hope to help upon solid foundation an concept of dynamic anatomical and physiological function. encourage to improve their palpatory skills. I We by vistas which have opened for me since I began to (Upledger) am develop my own palpatory skills. The

is illustrated by the comment a who recently visited our He heard of to

supine

and instructed him treatment table, gently placed hands upon my At first he felt cardiovascular rhythm, then the to close eyes and breathing rhythm, and then very clearly the craniosacral Spontaneously and theatrically, he "Once you have found it, you'll never let it go."

who lowe the of this book to all of my in and me to and the things that my hands so often automatically. Outstanding among who put gentle prodders is the together into syllabus form my lecture notes and published articles, Sister Anne Brooks, now an osteopathic physician. I am deeply indebted to Stacy F. Howell, Ph.D. under whose tutelage I completed a three-year fellowship in Biochemistry at Kirksville College Medicine. Dr. Howell and a doctor a

pj-glTPp.n

attempted to teach me philosophy His

differ-

me into a naturalist observer. Louis Hasbrouck, D.O. and Anne

D.O. were both inspirational during

my first experience at a Cranial Academy seminar. Later on in my craniosacral development, Herbert C. Miller, D.O. helped me to trust in my hands intuition. l owe all of deal. to deCipher my handwriting and Ann and Laura turn manuscript into something readable. Charles Lincoln, D.O. (U.K.) concepts and tech­ and discuss my presentation was always there to niques. A prodigious amount of time was invested in the designing, typesetting,

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4

PREFACE

patient devotion to Patricia Lilian Lai and Catherine John and Dan of round of editing for which we are grateful.

Press did My wife Dianne offered encouragement and support whenever I needed it. Without this book would not have been written.

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Chapter 1 Introduction to the Craniosacral Concept

au.Av�'a.... uu rr.,nr,'nf"

is a

vision grounded upon certain

and treatment

utilize that

�>�>'VF,>�'U

therapy in diagnosis

the individual as an integrated totality. Unfortunately, for purposes we must therapy and discuss various

physiology

in reality is an

artificial, linear approach to certain of repetition.

and techniques

modified, or viewed from different angles at

points in

As a starting point, in Chapter 1 we will introduce the also as impulse. chapter, anatomical and physiological in Chapter 2, will serve as a remainder of the book.

THE CRANIOSACRAL SYSTEM AND ITS BODY SYSTEMS

TO The

may

physiological system. 1.

The meningeal membranes osseous structures to which the meningeal

2.

other non-osseous connective tissue structures which are intimately

3. 4. 5.

anatomic

The All structures related to production, resorption and containment of cereblrospinal fluid to,

uences. and is

by,: 1.

The nervous system

2.

The musculoskeletal system system The system The

3. 4.

5

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6

INTRODUCTION TO THE CRANIOSACRAL CONCEPT

5.

The endocrine system

6.

The

in structure or function of any of these ,,,,,,1-,,,,,,.,.. influence the craniosacral system. in structure or craniosacral will necessarily profound, frequently aeJ,en�r1()US development or function of the nervous system, especially the upon milieu" the development, system provides the growth and functional efficiency of the brain and spinal cord from time of embryonic formation until death. WHAT IS CRANIOSACRAL MOTION? The

system is characterized by rhythmic, mobile activity which primates, craniosacral motion occurs in man,

persists throughout ....., ...., ... .." felines, and probably all or most other from

physiological motions which are

It is distinctly different to breathing, and of, or closely

cardiovascular activity as well. It may be underlying phenomenon, which has related to, adequately explained. on the head. With practice

observed but not

rhythmiC motion can palpated most development of palpatory skills,

it can

be perceived anywhere on the body. The normal rate of craniosacral rhythm in humans is between 6 and 12 cyclesper

minute.

(This is not to confused with Alpha rhythm from the 12 cyc1esper second.) In pathological 8

which is

rhythmic rates of less than 6 and more than 12 During

per minute. summer of 1979, one of your authors (Upledger) had the privilege Institute for several long-term coma cases

We were in -anana, cases, coma due to anoxia motion. In most frequently of the cranial rhythm to as low as 3 or4 in a cycles per minute. A few coma cases due to drug overdosage resulted in a cranial rhythm above 12 cycles per minute. These rhythms were palpated on the patient's head. OBSERVATIONS OF CRANIOSACRAL MOTION Hyperkinetic children have observed to present with abnormally rapid from acute illnesses with craniosacral rhythmic rates, as have present with abnormally low patients will Moribund and improve, the rhythmic rates move toward rhythmic rates. As the clinical the normal In the rate of the motion is quite stable. It does not fluctuate as do the rates

the cardiovascular and

it appears emotion, rest, etc. respiratory systems in response to to be a reliable criterion for evaluation pathological conditions. Under normal circumstances this rhythmiC activity appears at the sacrum as a gentle rocking motion about a transverse axis located approximately rocking motion of the sacrum one inch anterior to the second of

to a

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transverse dimension

lNTRODUCTION TO T H E CRANIOSACRAL CONCEPT

of

head. As

7

the sacral apex moves in an anterior direction. This The the

head

of motion is referred to asjlexio1t

head narrows in its transverse of flexion is extension. During the extension phase, apex moves pos­ dimension. The sacral moves anteriorly while the teriorly. the flexion phase the rotates broadens. During

extension phase,

rotates and seems to narrow slightly. A complete motion is composed relaxation between the

is a neutrol zone or next of each as a slight pause which follows upon return

cycle. from the

and

extreme range of one phase

rhythmic

flexion and one extension phase. of one phase and the beginning

motion

the physiological

(ILLUSTRATION I-I-A).

Time

Neutral zone

Illustration 1·1·A Representation of Craniosacral Motion

Normal

in cases severance

to trauma. We were also able

in the cranium which were due to cerebral thrombosis and tumor.

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move into

INTRODUCTION TO THE CRANIOSACRAL CONCEPT

8

centers of the

nervous by palpating to determine of rhythmic motion change in the paravertebral musculature, the lesion or injury can determined. function is muscle above palpable change in

muscles move rhythmically between 20 30 cycles per innervated muscles move physiologically in correspondence with craniosacral rhythm. (6 to 12 per minute is rhythm "nU"-,,,-L<" amplitude of the patient's resistance is low, and the craniosacral rate, as palpated on energy which finding as membranes

is low; but We

rather restrictive and lacks accommodation to doubled while is reduced motion per minute

(ILLUSTRATION l-l-B). We

Illustration 1-1-B Representation of Craniosacral Motion Effect of Barriers

presently involve, situation in cases nervous system. We past involved mean that autism is find this clinical in autism. This meningeal a previous physiological problem which un;iUlH,Ul'",". and which rendered them less compliant. the body is rhythmic motion of symmetry in the any type which pathological which can be used to of physiological motion, as osteopathic musculoskeletal dysfunction), inflammatory responses, a.U.U",,'HVU;:). trauma with of motion will etc. While the .... l:,''''''. scars, vascular

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INTRODUCTION TO THE CRANIOSACRAL CONCEPT

9

what is, it will you you must upon other diagnostic methods exact problem. Restoration of pathological nature motion to the area motion can as a �L'VF.UV"U."" asymmetry is eliminated and normal physiological motion restored, you may confidently predict problem is being or has been resolved. ROLE OF

BODY FASCIA

may to-toe, laminated ....IUlLla.} all of the somatic it is apparent as an aid in

continuous from headbody fascia as a connective tissue invests in (between visceral structures of the human body. With this model any loss of mobility this tissue in any "l.n,p.rltlr of the process which system is nervous system, By some means, probably via normally kept in constant motion in correspondence with the rhythmic motion. By direct connections and common osseous anchorings, extradural interdependent in terms of their are interrelated and the motion. Therefore, prognostic which can mobility or restriction is from examination only by skill knowledge examiner. is directed to rate, amplitude, symmetry and quality of the craniosacral motion and its body. reflection throughout "'''-'''''...1.1.'''''

BACKGROUND

While the

craniosacral motion is still in theory that skull is in constant motion is not new. It was first profession more

50 years ago.

MODEL While a student at the American of Osteopathy in Missouri G. Sutherland became fascinated by the anatomical to him that were deSigned to human skulL It been taught the skulland one to the other by in impossible. only exceptions to this condition of human skull were said to found in the tiny mobile ossic1es of the ear and at the temporomandibular anatomists Sutherland, as many still teach only.! that the skull serves protective hematopoetic Possessing the became throughout to each and its sutures HU.U,-",t<;;;, Sutherland OJ ....'.<4>
..... L."'.....

1

that all nature's designs are purposeful, of the cranium must Certainly,

Italian anatomists in the 1900s, however, taught that cranial suture ossification was pathological in the mature human adult. teachings therefore contradict the British anatomists, who taught the doctrine of sutural ossification and cranial as a normal condition. (AII(Jtomi(J Umalla, Vol 1, p. 203.) 1931, by Professor

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10

INTRODUCTION TO THE CRANIOSACRAL CONCEPT palpating their crania of humans

cranium the sacrum on mater which firmly connects restrictive osseous attachments hpjh>T�'I'> the dural attachment of the nV:SlOlOIHe:al motion and vice versa, developed a model osseous cranium. The sphenoid the cranium via its

are influenced The sphenoid bones. From a mechanical with the sphenoid as the of motion at

•• au""uo

of the joint as a hypothesize as well as torsions, stalenena

I I'> V""""1_",.", "_u,,..v 11

motion patterns. torsions, sidebending occur if some flexibility is retained h"'m,�,.,,, between the sphenoid strain however, somewhat more is not, in fact, a Histologically, the sphenobasilar maintain some degree anatomical

Abnormal tensions to the various bones to

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to conceptualize as

in a

nCJ10!lOrosls. It more correct components of suture mater. Abnormal sphenobasilar f-1HJIJ.'''J .'Y

dural membranes are membranes attach.

circum-

INTRODUCTION TO THE CRANIOSACRAL CONCEPT

11

abnormal functional motion the sphenoid was

stance In

of

motion for the bones of the cranium. Inevitably, is the

force upon

sphenoid?"

moved in response to a circulatory upon the intracranial

system. He saw the falx

'-'-"" .... u.

the tentorium cerebelli and the falx cerebelli as parts o f a reciprocal tension of the cerebromembrane system which responds to circulatory by of motion at cranial in its rhythmic motion, Sutherland believed, was rhythmic contracventricular system of the brain. He regarded the brain as

tion and expansion of primary source motion. seems to

system and produces

the force which drives a phenomenal

of

supported this model. Sutherland's model is

PRESSURESTAT MODEL of a rhythmically pressure has the that the tissue difficult to adopt. We do not raises fluid pressure tensile strength to act as a hydraulic pump which the

within

rise and fall of

although glial cells in vitro are seen

semi-closed hydraulic system.

to move rhythmically, their motion is perhaps one-tenth "'''''V>J''''''''''''

in

rate that we

observasystem. It would not seem possible to draw a rhythmically contracting as movements for the

motion. It is true that motion of individual for in vitro may be much slower than those same cells in vivo; it may also be faster. We cannot

in vitro glial

An

to

movement into

rhythmically model one need only assume

, model. In production by the choroid plexuses within '-''''uu.�"..

than is the

significantly more

concept would be a cerebrospinal fluid

ventricular system of

the brain is

fluid back into the

by in

venous sinus

majority

occurs in the sagittal venous sinus. If production of cerebrospinal fluid is hypothetically twice as as resorption, the production is turned on a given period of time it will an upper pressure. When that upper threshhold is threshhold the production of fluid is

off by some

fluid is constant production of fluid is off.

The and after

of

when fluid production is off, the fluid

pressure will drop as a result of the constantly diminishing volume within the h}'draulic system. When a lower threshhold ,,,, ,,eV;),"'\.-L"'L

is reached,

fluid is again turned on and the cerebrospinal fluid system to rise In manner, a

fluid pressure is achieved which, in turn, causes the daries of the hydraulic system.

rtl,,·!"tl,m

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production of within the of

INTRODUCTION TO THE CRANIOSACRAL CONCEPT

12

'--r:"CD"'V"'j,U�'nL FLUID PREssuRE CONTROL MECHANISMS

At this time, there appear to

at

we now know that

1.

adults and other

two

U"';'-U<\U ...''' 1

sutures constantly move in normal human elastic

and since we have identified collagen

fibers as well as

within the suture

nerve

(APPENDIX A),

it

seems entirely possible that the suture contains a stretch reflex, When suture is gapped open

intracranial fluid pressure to a specific dimension, an

intrasutural stretch of

is activated which telegraphs to

to stop

of

ventricular the suture

ultimately to compress is relieved to come and its contents somewhat intracranial fluid pressure is reduced), a message is sent to

brain to resume production

fluid. This raise fluid pressure and reduce intrasutural

of fluid production will compression. With

model in mind, we

betl w€�en the suture

the

system

nerve axons in the monkey, meningeal

to

histological work provides us with

structures necessary to model described. sinus found in Groy's Anotom y (39thBRITISH EDITION),

2.

there is mention of an arachnoid granulation body which projects into the floor straight sinus at its of union with great vein. This body which ";>,r''''''''';> --';"'��'h-'contains a sinusoidal plexus of blood a ball-valve mechanism. mechanism may then control the

vein which, in turn, by

secretion of the cerebrospinal fluid drainage of

the choroid

of brain is from the ..... ...,,,... ,, . vein. which empty into great We would hypothesize the presence of these structures as supportive yet fluid is under another mechanism whereby production of homeostatic controL We that it is this the

and contract rhythmically,

some intrinsic contractile power human tissue in situ does

than

tissue itself. Observation of living

the rhythmic motion of brain tissue. of the it seems more reasonable to conclude the ventricular re�ipCIU(l1ng to fluid pressure, rather than it by contraction. Independently, E.A. Bunt, M.D., a South African neurosurgeon, has developed in the area of idiopathic, normotensive hydroa similar cephalopathy. Dr. Bunt lateral and third

us

taken through

of the brain which show approximately a 50% area change

during dilation and contraction of the la teral ventricles of

brain at a

of 6

cycles per minute in a normal patient. Dr. r"" ... .... � is viable. r"

work is in progress in conjunction with Dr, E,W. Retzlaff of the Michigan State University Department of

B,omechanics.

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INTRODUcnON TO THE CRANIOSACRAL CONCEPT

13

BECKER'S MODEL the model which Still motion was forth by Ph.D., an anatomist and previously a ... vu"'...J;<. ... '" in the Department Biomechanics at Michigan University. motion may craniosacral hypothesized of gravity. muscles to the tonic response of the provide either (1) a stimulus input into the nervous """". .,'''' which produces the cerebrospinal fluid pressure fluctuations, or (2) via fascial act directly upon voluntary muscles dural membranes, hydraulic of the cerebrospinal form the UUAu,;n... ", could cause a rise and fall of c"'cl,,,,", by rhythmically .........". "

craniosacral motion were not seem possible that quadriplegiC, ua.'u" IJH;J;<.La. cases, cranial ..... u'....", ... and in cycles per minute.

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in

ha ter'2 raniosacral once aSlc enninol

.. ..

..

Most readers of this text have a good background in anatomy and ever, many terms concepts in terms have conventional anatomy physiology courses. in which from those used in other Thus, upon main body of text, in this chapter we will survey the most important anatomical, physiological and therapeutic terminology used in therapy, as well as the language of anatomical position. Many of in

terms will

of the book.

detail in later

THE CRANIOSACRAL SYSTEM is a recently

own

physiological rhythmic nervous "v,:rp'TI related to the hydraulic system. autonomic nervous system, neuromusculoskeletal and endomembranes, most crine Its boundaries are formed by the specifically the dura mater. The system's fluid is via choroid which allows of fluid from the ventricular system of the brain.

plexus is

craniosacral system.

from blood into the

in its passage

fluid which passes

the choroid

is known as

cerebrospinal fluid. Cerebrospinal fluid is returned into the venous system by the in villae are most arachnoid villae. found in Significant

within

contents.

dural

is by the mater its is essentially impermeable to the cerebrospinal fluid

which it holds. Intake and outflow of fluid from

system is by means of specialized

tissue structures (choroid plexuses and arachnoid villae) which are under homeostatic These intake and outflow mechanisms qualify the hydraulic system as semiclosed. Homeostatic are self-correcting and nisms which rely upon loops. Biological """",pm" static

which enable

to effect

14

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15

THE CRANIOSACRAL CONCEPT: BASIC TERMINOLOGY

constant changes in both internal m€!ctlanllsrll in

external environments. An example of a

human body is

production of thyroid hormone

of the thyroid stimulating hormone receives about

gland, which is under gland. The pituitary

not to release more thyroid stimulating hormone into the bloodstream from level

is constantly monitored by

thyroid hormone in the blood, Blood sugar, body

blood pressure

other activi-

ties in

body are continuously by the dural boundaries of craniosacral As a hydraulic system, membranes, are given shape fluid pressure within the system and by its more bones to which the membrane is firmly lavishly rigid aspects, the within cranial vault. functionally as "hard in

allows us to dural membrane.

the

bones

hard

indicators in diagnosis and as handles in treatment. The

system obeys is like water. It is our

that although cerebrospinal fluid is the movement is of low velOcity and without much force.

we mechanics as

time

the

fluid

the

of fluid

LU'-'Y", U

Since fluids application of any

boundaries, the is transmitted equally in all directions.

Therefore, when we apply a pressure or force to an area of the boundary of equally via the system. This

the resultant

hydraulic fluid to craniosacral

rp'rPf\rO

types

We must also keep in mind that

hydraulic ",,<:tp'm

cerebrospinal fluid.

is more

pressure

is transmitted through relatively brain substance. to the more ""<;,PI"

MEMBRANES

the dura mater, the arachnoid membrane and The

mater is the relatively cord. It is a of the skull. It

the

the cerebellum respectively. It also tentorium cerebelli, bilaterally,

the relatively

separate the cerebrum

dura mater which contains the cerebrospinal fluid and thereby hydraulic . The arachnoid membrane is thin, dura

pia mater by

brane

subdural

not follow the

This

is also referred to as

and vascularized. It is separated from subarachnoid The arachnoid memof

brain.

arachnoid membrane from the dura mater exteroally, arc

with

This allows

dural

a

spaces which from

of In(let>enLoen

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pia mater inter-

16

THE CRANIOSACRAL CONCEPT: BASIC TERMINOLOGY

mater is the highly

delicate internal layer of the and the

It follows all of

<.I' <,u"'".

delivers blood supply. Since the

meningeal

are capable of independent motion, one of the

serve is to allow In cases of spinal

to rotate bend without where this ability is

and adhesion of

to

other

or due to intolerable

pain is produced during certain spinal movements. DURAL MEMBRANE

boundary of attachments act as anchors by (osseous) tensions are transmitted to connective tissues these common bony moorings between the dura and abnormal tension is

cross

boundary.

fact that via

connective tissues transmit tensions into tensions are transmitted to distant system. By way of dural continuity, hard-to-predict regions of the meningeal membrane system. vault

the and firmly

dura provides a

very

of endosteum which is

to

of the cranial vault are in constant motion as Contrary to common belief, they accommodate the ever changing fluid dynamics dural membrane tensions ..... "' ... O.LV

within the craniosacral other individual

the bones meet no matter what age the

The sutures or joints normal

not fuse

is

anatomical dogma, it is consistent with Mediterranean anatomical teachings. Our __ .. ___ .

..,_

dearly demonstrate

capability for continued

mobility

CRANIAL BASE

of the frontal bone and the

The cranial base is formed ethmoid contribution as it (ILLUSTRATION 2-1). It includes

bones and

body

notch in the frontal of

the sphenoid, the

base and condylar parts of the

for cranial vault. The in floor between the anterior posterior sphenoid body is referred to as the sphenobasilar joint. It is a

and

synchondrosis, which means that nous bone between

of somewhat flexible cartilagesynchondrosis accommobase

the out life. CoRE LINK

to the dural This is name and the sacrum. The name itself suggests

function of this

core link of spinal dural membrane is relatively free to move under of rest with

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THE CRANlOSACRAL CONCEPT: BASIC TERMINOLOGY

17

Occiput

Illustration 2-1

Cranial Base positIOn, the occipital and sacral motions mime each other. Unless abnormal restriction to mobility is present within the core link, the membrane transmits tensions imposed upon one of these bones directly to the other. SACROCOCCYGEAL COMPLEX This refers to the functional unity of these two bones. The meningeal mem­ branes enter the sacrum from above with the cauda equina. All three membranes blend together, and within the sacral canal there is firm bone attachment only at the level of the second segment. This is probably why the sacrum seems to rotate about an axis at this level as it conforms to the motion of the craniosacral system. In the sanaI canal, the dura blends with the terminal aspect of the pia, the filum terminale. The filum terminale exits the sacral canal through the sacral hiatus, which is usually at the level of the fourth sacral segment. The membranes are now quite fibrous, tough and blended together. They merge with and thereby contribute to the periosteum of the coccyx. From a craniosacral therapy viewpoint, it is therefore

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THE CRANIOSACRAL CONCEPT: BASIC TERMINOLOGY

18

advantageous to

Ull.;>aXCL

the sacrum and coccyx as a functional unit.

VENTRICULAR SYSTEM OF THE BRAIN

four

This system is composed while

third and fourth are

cavities within

(ILLUSTRATION 2-2).

hemispheres.

the communication Foramen of via Aquaduct of fourth ventricle of formed by pool and fourth congenital

Corpus callosum

brain with the subarachnoid space.

choroid plexuses within ventricular fluid via the duct system.

""<:j-""",,

with a resultant fluid

_

�r-

Midbrain

hp1,.",·"

_

Fornix

�:::...

_ _

��!!Io----....-+-------+_

\�:-

_

_

_

__

Illustration

2-2

Ventricles

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3rd ventricle

19

TI-IE CRANIOSACRAL CONCEPT: BASIC TERMINOLOGY

MOTION to people are involved in craniosacral motion is that motion which the whole body

Motion has a In this

rhythmically in response to

activity.

motion

of the craniosacral motion as

and short in range. We

is very

physiological because it is unconscious individual's are necessary for

continuation

Non-physiological motion may to abnormal adaptational result an obstacle or restriction physiological motion. It is a distorted motion pattern

is the result of restric­

tion. Non-physiological motion is also sometimes used to describe extrinsically in­ duced motion. However, this usage is less common and is not intended term appears in this book. Instead, we use the word movement for extrinsically motion. Passive movement is present when the therapist does the moving and the subject

no effort into the movement. Active movement

and

on the

of course,

opposite

of the to normal physiological motion within the body.

A restriction is an inherent energy

but is

causes physiological motion is

against the restriction. Usually, restrictions occur in the connective tissue or can result inflammation, adhesion, somatic dysfunction and neuroA release is

When a restriction dissipates, it is called a softening of

or restriction

which

The resistance melts is always a therapeutically nr,C"\r<'"rll",

rate

event.

through

per minute the

requires you tune into these motions, you can your own flexion-extension cycles as you stand or walk. After a time you will yourself in From

out to your own physiological body motion at will.

diagnostic, in a qualitative estimate

driving the physiological motion, of

doing to tune

and of

craniosacral

range quality A resistance barrier is a

of view, we are energy symmetry

extrinsic body connective tissues) , and in motion. Is it fighting a resistance barrier? point during the course of a normal motion

cycle at which the body motion either to pass at as either rigid or

body motion response

and exerts extra effort to pass, or is

Restrictions to motion and motion barriers can be characterized and restrictions bony Rigid

one bone cannot move in relation to another because

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20

THE CRANIOSACRAL CONCEPT: BASIC TERMINOLOGY

Elastic barriers and restrictions abnormal membrane tensions which prevent normal physiological motion. Abnormal membrane tensions often motion to but to this occur. When you encounter a has an

"give"

you

problem to

treatment, its restriction gently and directly it.

whole body response to craniosacral system is based upon concept of fascial continuity throughout the body. The motion of the body is probably related to the effect the fluctuation of the cerebrospinal fluid upon the nervous system, which in turn tonus of body tissues. PALPATION Palpation is typically defined as examination

touch. It is the development of

this skill to which this book is largely dedicated. Palpation is an art which is grossly neglected in only one palpators.

health care profeSSions. Even the "body of palpation and thus develop but a small part of

Most of you have been taught to palpate or touch with your This is preferred method the fingertips are SUl)O()Se<1 to your whole hand, of the hand. We, would urge you to palpate arm, stomach or

part of your body comes in contact with

body. The idea is to "meld" the palpating part of your body with the body you are occurs, palpating part of your body does what "" .... .'''..UH''O' As body is doing. It becomes synchronized. Once

and

tion occurred, use your to what palpating your own body is Your proprioceptors are those sensory receptors located in the muscles, tendons, and fascia that tell you where the parts of your body are without using your eyes. The to this of

pa."P"'UVH

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'"'''-''' '''''''''''1''0

and non-intrusive

21

THE CRANIOSACRAL CONCEPT: BASIC TERMINOLOGY

your hand. The

to success in using this type

palpation is your quiet, non-

intrusive melding with the patient. which should THere is one other as real information which your sensory receptors

you. As a

what seems to be without critical evaluation. After you develop the palpatory skill to some degree, you will have which comes into your

of time to critically appraise the information your senses.

in craniosacral therapy are usually non-intrusive indirect. In certain situations you may resort to direct treatment techniques applied against resistance barriers, but after the patient's body has demonstrated approach. need Anlndirect technique, as we define is one releases a restriction or "',-,HOJ'LUL"" to motion by encouraging motion in opposite to the direction of the

direction of ease (which is usually

"unlatching" principle. is sort Often, in to open a we must exaggerate the closure. same is true of indirect cranial technique. The therapist follows the restricted structure to its limit in the direction toward which it moves with ease, Le., the direction toward which it exhibits the range of motion. When structure extreme position, becomes immovable. of motion.

the structure or you simply to move. It is

limit of its easy range

motion structure as it attempts to return to neutral that pushes against you. As inherent you it will farther in the pushing motion of the structure direction of

easy range motion, often called "direction ease." As this you occurs, follow it, up but without pushing. the motion will move against you. more, this procedure through several more cycles immovable.

of inherent craniosacral motion. Ultimately, a tissue softening or release will occur. This is therapeutic which you have been waiting. The tissue has for ease motion and itself. Follow a few symmetry. As you perform this pathways of motion may rule is to allow the structure to move along any new pathway it desires. Do not let it return toward is what the same pathway it came. This technique. we mean by

Direct technlque is essentially the ron.,",,,,,, motion is to uunau" to pass through and restricted structure or restriction barrier.

assists abnormal

In motion testing, which is a primary method used in search for abnormal restriction barriers, the therapist induces the motion; as soon as structure begins . to move in the direction the therapist reverts to the role of what or restriction the monitor. purpose is to see how structure moves in response to inducement. The purpose is not to see how far how many the structure can be pushed. In the process pushing you may never find the true underlying problem, which may be compounded by

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THE CRANIOSACRAL CONCEPT: BASIC TERMINOLOGY

injury or restriction

causing

to develop.

We speak of the restoration of autonomic flexibility as a positive therapeutic of craniosacral therapy. Autonomic flexibility is a term used to describe an of the autonomic nervous system to res;polnct in the autonomic nervous system maintains and helps one survive without the need conscious thought. It has two major divisions: the sympat hetic and the parasympath etic. The dIvision causes the body to heart rate, by stress, anger and H,,"IJVUU to blood pressure, air and volume, b lood flow to which are needed to spring into action. The divisionmonitors body functions during times of rest, sleep, food digestion, elimination, etc. , when the body is not ready to into action. As stressful situations occur in daily life, the is Frequently, it cannot not allow opportunity system. Therefore, the increases

stress

body to spring into sympathetic nervous energy generated by a of tone or tonic activity of the sympathetic system

by day as we accumulate more energy from stressful stimuli than is This increase in

to tonus causes the to up, blood pressure to bowels to move Left toward spasticity and the blood flow to be diverted from vital organs to in this condition, the body would not survive very well. In order to counteract condition of readiness the

"fight or flight" instituted

nervous

the sympathetic hypertonus,

has to act more powerfully to slow the

processes and reduce the rate, lower blood pressure, of the bowels. The stress stimuli keep coming in. The balance sheet shows more stress stimuli than are

being

parasympathetic

tonus continues to rise. so rise in order to counteract the

a is reached at which parasympathetic nervous cope with nor effectively counteract increased energy in the heart rate increases, and one sympathetic system. The blood pressure can no

may develop spastic colitis and peptic

or any number of

We call these functional diseases. The autonomic flexibility. It can no longer effectively with the

dysfunctions. has lost

the out. A beneficial

therapeutic techniques

in

the autonomic nervous system is restoration of autonomic flexibility. body, when autonomic flexibility plays a large role in homeostatic activity is many homeostatic mechanisms are made more effective. There are a number of other words and phrases which it may be useful to define here so we can in the text. human body Fascial continuity is a phrase We the continuous the of head to the bottoms body as with invaginations and tubes the various organs and structures. It is largely oriented in a longitudinal direction and is to

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THE CRANIOSACRAL CONCEPT: BASIC TERMINOLOGY

You can

glide on the

when the body body to any other from any The term cross-restricting diaphragms suggests

"""tP ITl"

conceptual framework in which

structures. We regard these diaphragms as transverse They are an fascial for the longitudinally to its functional integrity. and are

the represent areas frequent sites of

stress within

body fascial

system dysfunction. term neuromusculoskeletal system is meant to between nervous system, the muscle system and skeletal

that

to tiona! point is artificial. Therefore, we use the word express the of A lesion is an area of localized or tissue. An osteopathic lesion is the term used to designate palpable paraspinal areas of tissue texture deviation a syndrome of dysfunction It tightness or swollen toward which includes hypertonus, tenderness to palpation, cord facilitation, dysfunction and autonomic somewhat localized at area Somatic dysfunction is a term

osteopathic

to by some of the osteopathic replace osteopathic lesion. Proponents of the term somatic dysfunction believe it is more scientifically osteopathic (meaning

or

internal milieu is

lesion." Opponents argue is much more than a somatic or body

dysfunction. environment inside the skin of the body, within which

all of your molecules, and organs function. It everything from interstitial fluid viscosity to hydrogen ion concentration in the urine. It also includes physical parameters such as pressure, as within cranial vault, we refer to several In our discussion below: Autism is a

of unknown etiology. The autistic child is

0V'.W.''' L

.......

preferring to interact with non-living things in the environment. The child is quently self-abUSing and will bite its hand and wrist or bang its head, etc. Autistic seldom display emotion other than They usually will not we have

eye contact or display many autistic children. They

intelligence, often display motor coordination. Since are of the cause of autism is unknown, there is much disagreement about diagnosis. and

to sit spans, an are those with been as such by the "system. " Our inclination was to as a convenient diagnosis attached to difficult-to-handle children. However, as in Chapter 15, many of

children our

drama tically to is that the behavioral

further

to

dysfunction, hyperkinesis to food and chemical intolerances, craniosacral and hyperkinesis due to emotional and psychosocial causes. similarly to description of Learning disabilities might be a significant number of learning disabled kinesis above. We have have favorably responded to craniosacral therapy alone.

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THE CRANIOSACRAL CONCEPT: BASIC TERMINOLOG Y

anatomical terms we have

are also

which may require

(ILLUSTRATION 2-3):

body.

Anterior-toward the front of Posterior-toward

back of

Cephalad-toward the head

of of

Caudad-toward the tail Pedad-toward the

body. body. body.

body. of Lateral-toward the Medial-toward the center of the body. Superior-above. Inferior-below.

L ateral s

T

oIII[ lIf--__

...

or

su

r

'

Inferior

Inferior

!

�

Pedad

Pedad

STANDING (SAGITIAL PLANE)

STANDING (ANTERIOR)

Posterior

SUPINE

Illustration 2-3 A natomical Directions

The

on the skull are given Asterton-junction

names:

parietal, and

Bregma-junction of coronal Inion-external occipital protuberance.

U'-'_HJj,UU

sutures.

Lamda-junction of the occipitoparietal and sagittal sutures. Pterion-junction of the frontal, parietal, sphenoid, and temporal bones.

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THE CRANIOSACRAL CONCEPT; BASIC TERMINOLOGY

The

Viscera-an organ which is not a muscle or

heart, lungs, etc., are

viscera. related to a viscera.

connective tissues

Thenar eminence- the

muscular part

the palm of the hand on the

thumb side. The hypothenar eminence is on the side of the fifth finger.

Internal rotation-the

rotation

the extremities.

the feet pigeon-

toe of

rotation.

Lymphatic pump- any treatment technique which assists the movement of lymphatic fluid through the body.

rationale for the use of the lymphatic pump the body, and to

is to enhance the removal of toxic waste substances improve the

of antibodies.

is

as treatment

and toxic conditions. lymphatic is usually performed in one of two ways, both the patient supine. In one therapist places his or palms over soles the are intermittently pushed at a rate approximately 180 patient's feet. for

times per minute seen to oscillate.

with an excursion of5-10 cm.

is

the

is continued 5-10 minutes. Alternatively, therapist the patient's with or hand on the patient's anterior

thorax. The patient is instructed to breathe slightly more deeply than normal. As the patient exhales

therapist follows the posterior-caudad motion

the

the ........ ,'''' ....... through immediately removed. A or 3 times.

to are suddenly can be repeated 2

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Chapter 3 Craniosacral Motion: Palpatory Skills the sciences and

Most of you have spent years upon your rational, reasoning

You probably have

convinced

information which your hands can give you is unreliable. You may consider facts to be reliable only sheet, projected on a screen or are printed on a electronic device. In order to use your and the as reliable instruments and the they can give

to trust

Learning to trust your hands is not an easy

treatment, you must You must

conscious, critical mind while you palpate for subtle

in

body you are

You must adopt an empirical attitude so that you may

without those come into your brain from your it is recommended Although attitude is unpalatable to most that you it a short trial. you have developed your palpatory skill, you can you criticize what you have felt with your hands. If you criticize to to use your effectively as highly sensitive you will never instruments which, in fact, they are. has been activities. This

divided into

may be

and right

but is

the purpose of developing a conceptual model upon which we can base a n understandable explanation. Consider the the

side of your brain as being the rational, thinking and critical the and intuitive side.

except in art, music and other creative activities. Often, of less value than

creative studies are regarded as left

of

brain has grown to

sciences.

a result, the

hyper-critical, self-centered, omniscient,

intimidating and almost autonomous. On the other hand, the is quiet, shy, which has hemisphere may carry a wealth

brain untapped right untapped,

because when an idea begins to emerge from the right of the into the consciousness, left side of brain immediately begins to tell you why that idea 26

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27

CRANIOSACRAL MOTION; PALPATORY SKILLS

is silly and irrational. In to develop the palpatory skills and to logical motions of it is necessary to your left brain for a while. Allow skills to without insists what you are message from your left brain consciousness isn't there, that it is your imagination. Ignore this criticism. Let your a chance to gain confidence. talents information you. Your right brain has brain may which are suppressed in your shy. probably intimidated for so it has become the right messages which you consciously may very them, draw them out, be kind and gentle with your tentative fleeting. intuition. It will develop quickly if it is a chance. Once you have followed your sensations for a while, as an empiricist rather than a scientist, skills

brain

in development and the information

of time to

that you arrest activity of from your senses. We do not mean to your left hemisphere. we want to give it a rest so that the remainder of you to develop. a Therefore, we make this plea in beginning: accept what you sense as real. Do not risk rationally to understand it. Give yourself a chance to the game trust my hands" is minimal to the potential payoff for those who

is

much greater

you can perhaps

right now.

Remember that the potential of humankind is limited only by its own concept that limitation. Relax and let it happen. We usually begin to palpate the by the human body. One of these motions with with the more obvious motions you should be is your time. Be comfortable. If you are not comfortable, stimulus input from your own tense muscles and discomforts will create an input noise level which will with your perception. With the obvious gradient. diastole? Is it

subject lying comfortably supine,

the radial pulses. Feel of the pulsation. in also to rise and fall of the pressure long is diastole? What is the quality of the rise of pulse pressure after sharp, gradual,

How broad is the pressure peak? Is the Memorize feel of rapid, gradual, smooth or

so that you can reproduce it in your mind body. You can physical contact the

you

broken

sing a song after you reproduce your

have heard it a times; similarly, you should be able to palpatory perception of the pulse after you have broken contact. Now palpate

carotid

Commit its of

as you memory wave morphology with Now palpate

carotid pulse waves simultaneously. Compare them. Are the sloping rises similar? Are the peaks the same? You are now learning to If you are aware of subtle with compare exist. For the time

not exist. to remember

of

pulses of your subject.

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CRANIOSACRAL MOTION: PALPATORY SKILLS

Illustration 3·1 Diagrammatic Representation of Pulse Wave Morphology: Cardiac, Respiratory or Craniosacral

compare them with another subject's pulses. It sometimes helps to draw a graphic representation of the pulse wave morphology to begin to make the connection between palpation and visualization of what you feel (IllUSTRATION 3-1). In the begin­ ning, you may be more comfortable at visualizing than you are at palpating, because you have been trained this way. Your palpatory perception may seem too intangible to be trusted. After you have concentrated upon the body pulses at the radial and carotid regions, simply lay your hands over the thorax of the subject and palpate the cardiovascular activity (ILLUSTRATION 3-2).

Illustration 3·2 Palpation of Thorax

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CRANIOSACRAL MOTION: PALPATORY SKILLS

After you focused upon cardiovascular characteristics to memory, shift your attention to the your

chest. Memorize those motions. Now

to cardiovascular,

then back to cardiovascular several times until you can

to

only what

you wish, keeping

other motions at an unconscious as "background noise." you must develop the ability to bring any part of that background motion into focus upon demand. Next, gently touch your subject's head (ILLUSTRA­ HL'-'U,-,''-L.

TION 3-3). We use

word "touch" because

amount of pressure

you and

Illustration 3-3 Palpation of the Head

upon your hands.

produced by the weight of the head is not a factor, your touch is very order

it is on the

Place your hands symmetrically with the weight of the occi-

resting upon

hypothenar

palmar

of the hand, as well as the 4th

UUi5"'Li>. Be comfortable (ILLUSTRATION 3-4).

eyes. As you gently

activity. Become aware

your subject's the arterial pulses as well as a generalized pulsation

the whole head in rhythm with the pumping action of your subject's heart. familiar with the After you have activity of the subject's to the breathing your attention upon motion of the head in head, and extension of You will notice a corresponds to rhythmiC activity of the subject's breathing.

which

Keep your eyes dosed. Once you are thoroughly familiar with the head motions corresponding to subject's cardiovascular and breathing discard them both from your conscious awareness. Become aware of other motions which were

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CRANIOSACRAL MOTION: PALPATORY SKILLS

Illustration 3-4 Position of Your Hands When

Craniosacral Motion at the Occiput

unknown to you. Let your

your subject's head as though the hands not

Use your whole hand to the head are welded or Feel what your hands are doing becoming aware of just

from the proprioceptors in your arms. As you continue this to seem as your hands with your subject's head with your eyes closed, it will and larger motions. Open your eyes and you hands are though your hands are will see moving at all, percepto ''''''5AA.<> tion. When happens, you are ceptive senses.

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CRANIOSACRAL MOnON: PALPATORY SKILLS

31

As you continue your exploration into the realm become aware that

palpatory

you

subject's head begins to broaden and narrow slowly and

its base rhythmically, about 6 to 12 cycles per minute. As the seems to move anteriorly, a transverse axis of motion approximately 2 inches anterior to inion,

protuberance. This

posterior

motion, as it arcs anteriorly, is the flexion After occiput the

of

I-1H-'''''''<:;

motion cycle of the cranioof motion returns to

position for an U"�'''L,:u c,,,,mAt'Y'>

motion in

occiput, with an arcing motion

With your in the same IJU"alUll. you can palpate some of the L<:;lU�'Ul mastoid and some of posterior of parietal During the extension

of craniosacral motion,

transverse dimension

these

narrows somewhat. Additionally, you can now extension motion phases as one the examination. You should also

aware

are moving independently of each motion.

the occiput, the temporals and

Allow your hands to remain in

a few minutes. Keep your eyes

and remain relaxed. Let your imagination run wild.

have probably been taught

that the

of motions you are feeling do not or if they did with instruments as crude as human impossible to

they would

are you feeling? Is it really your If this is the case, give your senses a chance to plenty of time to decide later. gain confidence. It will happen very quickly. you gentle motions of

palpated (or

person to person; your

UCVCIU

that you have palpated) the subtle

procedures. motions in one subject, As you

parietals allows for

The suture is the structure

among

examine other various physiological

those in other subjects. you

to note individual

will begin to store

from norms of per-

ceived physiological motions. you have successfully experienced the palpatory perceptions fOCUSing upon the the craniosacral .\.-.... n",,,,

by the motions

motions,

the

your

Become aware of physiological motions in your your own time

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CRANIOSACRAL MOTION: PALPATORY SKILLS

32

Illustration 3-5

Position of Hands for Self-Examination

the H",",-",-,-

necessary to enable you to palpate

(ILLUSTRATION 3-5).

you are vascular, breathing

confident that you have experienced craniosacral system motion on several subjects' from one physiological motion to

after you are able to shift your to move to other are It was

the head and body.

above

phase of

general, a broadening of the posterior slight narrowing. When describing transverse widening of whole

,-uuU'V"«\.,L,,, ,

of the a as i t

in its

the opposite, i. e. , a transverse narrowing accompanied by an '-H.",U�; "''' can be by various hand

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CRANIOSACRAL MOTION: PALPATORY SKILLS

33

ANTERIOR

ANTERIOR

"�����--���\�

I I , , ,

I

, I I , I I I \ \ \ \ \

\

I

\

\

I I I I I I I I I I I I I I

/ \

"

/

Illustration 3-6-A

Illustration 3-6-8

The Skull in Extreme Extension

The Skull in Extreme Flexion

placements upon the head. The palpatory touch is exceedingly gentle: 5 grams of pressure is too much. Imagine that you are feeling the hair move (ILLUSTRATIONS 3-6-A and 3-6-B).

In addition to the whole head continually changing shape in conjunction with the rhythmic movement of the craniosacral system, the whole body also moves physiologically and involuntarily in conjunction with the craniosacral rhythm. During the flexion phase of craniosacral motion, the whole body seems to externally rotate slightly and widen. During the extension phase, the body seems to internally rotate and narrow slightly. These motions can be palpated easily at the feet and ankles, thighs, pelvis, thorax, arms, neck and other parts of the body. The key to the discovery of this type of body motion is in the gentleness of your touch. If your contact with the subject's body elicits any tissue-guarding response, you will inhibit the very motion which you are trying to perceive. If you, the examiner, are not relaxed and comfortable, your own tension wtll inhibit your ability to perceive. Rest your hands gently upon the subject's body. Meld your hands with that body, and perceive proprioceptively the movements of your own hands. The next area of craniosacral system motion with which you should become familiar is the sacrum, which is attached to the caudal end of the dural tube. In order to palpate sacral motion, the sacrum sits in your hand so that the subject's sacral apex rests in the palm of your hand. The sacral spine should lie

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CRANIOSACRAL MOTION: PALPATORY SKILLS

Illustration 3-7-A

Palpation of Sacrum

Illustration 3-7-8

Sacral Spines Between Third and Fourth

fourth fingers. Your base to the level

will usually extend cephalad 4th or 5 th lumbar

(ILLUSTRATIONS 3-7-A and 3+B).

As

system moves into the flexion phase of its motion, the sacral During the extension motion;, are subtle and may

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the sacral apex moves synchrony with

35

CRANIOSACRAL MOTION: PALPATORY SKILLS

craniosacral motion of the

or may

or two, depending upon the

a

quality and quantity of restrictions which may be The subject can be in lateral the examination

motion (ILLUSTRATIONS 3-8-A,

3-8-B and 3-8-C).

Illustration 3-8-A Examination of Sacrum with Subject

Illustration 3-8-B Examination of Sacrum with uUU,,"'" in Lateral Recumbent Position

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sacral mobility. or prone position for to palpate In

36

CRANIOSACRAL MOTION: PALPATORY SKILLS

Illustration a-8-C Examination of Sacrum with Subject Prone

motion, you should their uses. Usually, novice examiners the sacrum when the subject is supine. However,

pressure paresthesia does not

reduce proprioception; as a matter of it enhances somewhat by noise. When sacrum of

sensitivity subject is supine on

your eyes and your hand your hand, lean heavily upon your elbow, what your is doing. familiarity with sacral motion is to motion between the sacrum and the to

sacrum, each examiner

occiput. This can palpates

while

flexion

extension

begin and end. It can also be achieved by placing one of your hands on sacrum and other on occiput the subject so that you can monitor u,. vu and extension motions at both the tube simultaneously. 1-'''...",<:1

.... ..

Simultaneous palpation of easily

sacrum and occiput by one examiner can be

the

(ILLUSTRATION 3-9).

In this

so that may

with the synchrony of movement between the occiput and sacrum. can be demonstrated having the the

interference as you palpate

the patient must have a proper pillow Crimping or sidebending of the is not crimped to one

With some notice

motions at the oCciput sacrum. living bodies as learning in range of motion,

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you will begin to motion and energy

CRANIOSACRAL MOTION: PALPATORY SKlLLS

Illustration 3·9 Examination for Synchrony of Motion Between Occiput and Sacrum

Illustration 3-10 Palpation of Paravertebral Musculature

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37

38

CRANIOSACRAL MOTION: PALPATORY SKILLS

Collect data. in your which drives motion from one subject to memory stores. Store about what is normal so that you will become aware of variations the norm. Ultimately, variations will on and pathophysiologic H1<;"'!jl1HJ�. paravertebral musculature is another area diagnostically the

palpation

the subject

(ILLUSTRATION 3-10).

motion in the sacrum. Keep the spinous processes h ",;hx,,, ., rhythm of the paravertebral regions can •

and motion

20 and 30

can nerve

used in the differential root compression. As with any skill,

development

palpatory sensitivity requires

time OJ"";'"'' is

small groups

practitioners

most your To reiterate, do not your obstruct palpatory skills. Develop familiarity with this extended use of your hands. After you can know on a "gut what your intellectually critical. Give your "right without this

your "left brain" continually Learn by doing.

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will then

plenty of time to its

Chapter 4 Techni ues for Modification of Craniosacral RbythIn motions and rhythms, Thus far you have with their normal activities. Your purpose has learn from state. You have body in its natural practiced the touch of the examiner (perhaps only should be no threat to which body might security to the subject. respond by guarding, or unconsciously. Now you should with and rhythmic which will modify discovery, diagnosis, treatment you have learned Compared with modify craniosacral motion may seem rather invasive. manipulative used by physicians We coax the we do not niques are still it, or even scare it. Approach it as you would a timid child or an system to make Do not force the animal whose trust you it from returning non-physiological motions. the goal is simply to pathway, and to encourage it to find a new from extreme into the route. Such system and its One of in" system motion As you to the external rotation (the flexion phase of "'"'''l'''< neutral, the excursion into internal rotation the rhythm repeats (ILLUSTRATION 4-1). As you motion, answer these Does the motion seem symmetrical? Do rotate externally or with more facility? As an than the right, and that foot rotates externally example, assume externally. In order to as easily or as as it neither foot rotates change this Situation, follow foot to the extreme range of this would mean it moves with the greatest ease. In our motion to has moved as far that you follow into external rotation. into external rotation as it go (in this case, rotates externally 39

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TECHNIQUES FOR MODIFICATION OF CRANIOSACRAL RHYTHM

\ Illustration 4-1 Palpating Craniosacral Rhythm at the Feet

than the right), resist the return to neutral by making your hands immovable. Do not push further into external rotation; simply resist the return to neutral by the feet from their extreme positions of external rotation. As the return to neutral is resisted or prevented by applying gentle force at the subject's feet, another examiner monitoring the head will feel a subtle resistance to the cranial bones' attempted return to neutral, and thence into the extension phase of craniosacral motion. The return to neutral and the move into extension will occur on the head, but with less/acility. This perceptible change at the head is due to the resistance you have caused by manipulating the subject's feet. As the craniosacral system again returns to its flexion phase, you will notice further movement into external rotation at either one or both feet. Follow this external rotation closely. Carefully take up the slack, just as you would keep a fishing line slightly taut when reeling in a fish, or as you would keep the front bumper of your automobile snug against the rear bumper of a car you are pushing. When the external rotation reaches the limit of its new range of motion and attempts to return to a neutral position, the hands of the therapist again become immovable. The rest of the craniosacral system will reluctantly return to neutral. Then, against the new and increased resistance, it will proceed into its extension phase. This occurrence can be witnessed by an examiner monitoring the activity at the subject's head. Each time the feet rotate externally a little further, carefully take up the slack and resist internal rotation. After some repetition (the number will differ, usually between 5 and 20), the total craniosacral system motion will "shut down," Le., become perfectly still. This is called the sttll point. The still point has been induced by the therapist's resistance to the physiologic­ al motion at the subject's feet. It is usually heralded by gross irregularities of the

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TECHNIQUES FOR MODIFICATION OF CRANIOSACRAL RHYTHM

motion

the

craniosacral system may

pulsate or wobble. As the

UH;UtIJ1"

resisting the return to the neutral position of the physiological motion at the craniosacral will ultimately shut down. We have still point electrically during some of our with Dr. Karni (APPENDIX C). As still point is approached, the subject will In our hypothetical subject, left leg excursion into external several rotation was greater

the

Both

externally further

they

correctly surmise that a somatic dysfunction was internally. Therefore, one in a position flexion sacroiliac joint. It is probably in the apex anterior. As the still becomes the will either an area or the recurrence an old,

involved low pain, currently

subject in breathing patterns, and probably some light persmooth by body spiration. Continue to resist until a against your (in this case, until internally also experience

During appears. The

relaxes.

still point, somatic

may spontaneously correct, V'-"\.
ly with a noticeable "pop." The breathing becomes very away.

may last a seconds to a few minutes. When it is over, symmetry and a will resume its motion, usually with a amplitude, After you have changes in

the still point, you should

quality and range of motion at

external rotations are now motion is improved, nothing not you may will

monitor. Notice

If the excursions into internal

to equality, If, in

the abnormality to patient. We have never done more than ten still point repetitions during the same

than extreme relaxa­ treatment session, However we know no tion and sleepiness, will occur, The stit! p01'nt is contraindicated in cases of intra­

cranial hemorrhage and aneurysm, where changes in intracranialfluidpressure might prove mental to patient, the technique described for induction of a With the nvurtlPf'P on the It is a tion ease range of physiological motion. this motion to its physiological end point, and resist its return. Take up the slack with each ensuing cycle until a still point of craniosacral system function is reached. the still and craniosacral activity is resumed, the new physiological motion induced from the head and sacrum. are usually more rapidly effective than of the body. The is simply to modify the activity

THE

TECHNIQUE

The still

achieved by application of the technique to the subject's occiput

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TECHNIQUES FOR MODIFICATION OF CRANIOSACRAL RHYTHM

is traditionally called a "CV-4" technique. CV-4 means compression of the 4th ventricle. In this case, 4th ventricle refers to the ventricle of the brain. Dr. Sutherland, the originator of this technique (SUTHERLAND 1939), believed that he was compressing the 4th ventricle of the brain and thus affecting all of the vital nerve centers located in and about the walls of this ventricle (ILLUSTRATION 4-2). Red nucleus

Nuclei of C.N. III Nucleus of C.N. IV Nuclei of C.N. V

�

rebellum

�"-4th

C.N.V

ventricle

C.N.VII Sa I'Ivatory nuc I eus C.N.VI Dorsal motor nucleus of C.N. X C.N. IX Nucleus of C.N. XII C.N. XII C.N.X"':::"-!IIO-.��./AA�-Nucleus ambiguus C.N. XII---Spinal nucleus of C.N. V Spinal part of C.N.XI Spinal nuclei of C.N. XI

Illustration 4-2 4th Ventricle and Related Structures

The occipital squama provide an accommodation to changing intracranial fluid pressures. The CV-4 technique significantly reduces the ability of these squama to accommodate. The intracranial hydraulic fluid pressure is therefore increased and redirected along all other available pathways when the motion of the occipital squama is extrinsically restricted. Thus, the CV-4 technique promotes fluid move­ ment and hence, exchange. The enhancement of fluid movement is always bene­ ficial except in cases of intracranial hemorrhage when clot formation is enhanced by stasis, and in cases of cerebral aneurysm where changing intracranial pressures could produce leaking or rupture. The CV-4 technique affects diaphragm activity and autonomic control of res­ piration, and seems to relax the sympathetic nervous system tonus to a significant degree. I have often used this technique to reduce chronic sympathetic hypertonus in stressed patients. Autonomic functional improvement is always expected as a result of still point induction. Clinically, this technique is beneficial in cases where a lymphatic pump tech­ nique is indicated (MAGOUN 1978). It has Significantly lowered fever by as much as4°F in

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TECHNIQUES FOR MODIFICATION OF CRANIOSACRAL RHYTHM

30-60 minutes. It connective tissues of acute and chronic lesions. It is processes, in both means of reducing The CV- 4 technique quite simply, an excellent multitude of problems in that it enhances tissue flexibility of autonomic response. As the therapist, cup so that the thumbs

restores (ILLUSTRATION4-3).

Illustration 4-3 Hand Position for Occipital CV-4

of the should be level with " formed by the apex cervical vertebra. or squama medial to, and totally avoiding occipitomastoid sutures (ILLUSTRATIONS4·4-A and4-4-B). As subject's occiput narrows in the extension phase of movement is followed by thenar eminences. As to widen during phase of the cranial cycle, you AU. .... H....!';. Your hands become immovable. You do not squeeze. As extension of the subject's occiput recurs, take up the slack by the subject's occiput. The broadening of the flexion "nc'r"."" motion is is ultimately stops, tembecomes reduced "'\-,",VB"

occurs in the will continue for a variable

the still point has been of seconds or minutes.

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44

TEOiNIQUES FOR MODIFICATION OF CRANIOSACRAL RHYTHM

perspiration will often appear on will occur. the subject's

Within a few minutes, you to broaden into cycle. When you feel a this broadening and motion. A point can also on the subject's head by applying same principles of following the motion to its extreme extension and resisting return to neutral until the rhythmic ceases.

Illustration 4·4·A CV-4 Hand Position

Illustration 4-4-8 CV-4 Relationship to Bony Structures

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TECHNIQUES FOR MODIFICATION OF CRANIOSACRAL RHYTHM

SACRAL STILL POINT INDUCTION When to the sacrum. whichever seems patient's sacrum

a still point the sacrum, therapist's is applied motion into the flexion or extension phase, the excursion. Resist the attempt by to

return

to

neutral

through

cycles

until

motion of craniosacral system ceases. The still point has been induced. on a patient's body the factors might be considered in selecting point should therapist is

induced. holding

the patient's body by monitor of the

may be based upon convenience position. It may

still point upon a given body

almost body

on the when area.

Manual contact

with practice, still points may be

with painful body parts is unnecessary induced

e.g. ,

and does not wish to disturb be based upon a desire to

body. desires to

motion the

palpated still

most convenient method of monitoring

or hands upon the area in

during the

body extremities when, e. g. , one is is an excellent means of one for

efficacious treatment can in developing a children.

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Chapter 5 Release of Transverse Restrictions Which IInpair Fascial Mobility The

of

in

longitudinal

motion is A small amount the transverse lStiC these fascial structures. This gliding mobility is therefore more the longitudinal than in the transverse. which, when hypertonic or Anatomically, in their longitudinal glide are located

act as areas

functional restriction to

the body's fascial

natural

structural/functional divisions

there is a predominance connective tissues which are transversely across the body. They can easily impair the longitudinal

glide of the majority of the fascial lamina.

potentially

transverse structures is the

(ILLUSTRATION )-1). This diaphragm

cavities. It is a diaphragm is the muscular part

arises

xiphoid process of the sternum, from the the aponeurotic lumbocostal arches, ribs, lumbar their diaphragm inserts into its affords passage to structures cavities.

traverse

structures include the

agus, the aorta, the vena cava, the azygos and the blood nerves and the usually pass through the nerve passage to the quadratus lumborum muscles. diaphragm from pericardium penetrate diaphragma tic The right crus of of the 1, 2 and 3, and

in and are contributory to the anterior longitudinal bodies of lumbar

46

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47

vena cava

Muscular part

of diaphragm-IF-+Central tendon

�A--Esophagus

Illustration 5-1 Respiratory Diaphragm - Inferior Oblique View

The left crus is smaller and attaches to the corresponding parts of the upper two lumbar vertebrae and the anterior longitudinal ligament. Fibers of the two crura extend anteriorly and medially where they cross to form the aortic hiatus. They then complete a "figure 8" to form the esophygeal hiatus. When the muscle of the respiratory diaphragm contracts, it pulls the central tendon downward, thus reducing the intrathoracic pressure and increasing intra­ thoracic volume. At the same time it increases intra-abdominal pressure and reduces intra-abdominal volume. A contraction of the respiratory diaphragm also exerts an inferiorly directed traction upon the pericardium which is transmitted via fascial continuity through the carotid sheath to the base of the skull. Hence, patients with chronic diaphragmatic hypertonicity frequently manifest less than optimal cranio­ sacral system mobility. The diaphragm is innervated by branches of the ventral primary divisions of thoracic nerves 9 through 12 and by the phrenic nerve, which arises primarily from the 4th cervical nerve but which may also receive contributions from the 3rd and 5th cervical nerves. ,An abnormal state of hypertonus or contracture of the respiratory diaphragm may occur unilaterally or bilaterally. It may occur from problems associated with any one or all of the lower four thoracic nerves on one or both sides. It may occur as a result of problems along the course of one or both of the phrenic nerves or from one or both sides of the cervical region at the levels of the 3rd, 4th and/or 5th seg-

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RELEASE OF TRANSVERSE RESTRICTIONS WHICH IMPAIR FASCIAL MOBILITY

ments. It may occur diaphragm, from

inflammation of

which spreads to hepato-biliary ",,<:tP,rn

and from inflammation and other related abdominal viscera. Dysfunction tion which

three lumbar the fasciae to inflammation

diaphragm may also occur six ribs, the sternum major muscle,

to somatic dysftmc­ process, the quadratus lumborum It may also occur secondary

structures

it, such as the aorta,

esophagus or the vena cava. The point is that abnormal common secondary finding in a vast number the diaphragm mary condition is the asymmetrical tension patterns and abnormal

h,rnp'rt"

then interferes not

dysfunctioning but also with patient is recurrent

1111,lt�• .:>t.:>,

of toxic wastes general The

quite

for our contention dysfunctions, therapeutic attention to the naturally occurring cross-restrictions of the human for releasing tension in the respiratory ,",U"P'''H'r,£H

(ILLUSTRATION 5-2). The

upon the treatment

III ustration 5-2 Hand Position tor Release of Respiratory Diaphragm

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49

RELEASE OF TRANSVERSE RESTRlCfIONS WHICH IMPAIR FASCIAL MOBILITY

sits comfortably next to thoracolumbar of the

your hands so

upper three lumbar vertebrae are in the anteriqrly, should cover

of

12

thoracic and

of your hand. Your other hand, placed

epigastrium, the xiphoid process and the anterior

costal firm

a

While using one hand under the

foundaplaced hand.

tion, apply pressure from anterior to posterior with the

the pressure very lightly, then slowly increase it until you feel a motion within this motion, follow it in any direction which it tends compression with just enough force to cause

patient. When you to go. Maintain the

this inherent motion to occur continue. The motion which you may be predominant in terior or

anterior regions

posthe patient's body, or it may appear to be uniform

throughout the body. You may palpate it as a shear, a torsion, a rotation or any which

combination these. Any hypertonic tissues occur.

the

of

of the diadirectional orientation of you phragm, it becomes apparent how various restrictions and distortions of tissue fibers, but by motion can occur. Not only are all transverse angles the variation of angle

to transverse is

stance provides a three-dimensional potential for Additionally, these the

of

This circumrestriction of normal mobility.

change as

diaphragm

and other be

your hands

As the tissues

change

the thoracic and abdominal cavities.

body. This new

within the tissues

Once

is readily

posterior

is gradually released and

freed and balanced. hand, wait 1 to 2 minutes hypertonus, a 1'r"·,,,,,·11

as from

diaphragm could

is treatment, an asymmetrical, in-

motion will be fel t as the appropriate amount of pressure is applied. The procedure can

as

as is necessary to obtain a

THE DIAPHRAGMS OF THE PELVIS Functionally

for our purposes,

pelvic and

together rather than separately. iJHl"' �'lH is composed of the levator ani coccygeus muscles and their l"-""LId.'C. diaphragm is composed the which traverse

(ILLUSTRATION )-3) may be

the bony pelvis. The diaphragm

across

pelvis like a hammock and

support to the pelvic viscera. It is traversed by the anal canal,

urethra,

of the superior ramus symphysis. It arises arise across two posteriorly from the inner surfaces of the spines the which is a '�'",'�'''V of it arises from arcus tendinus musculi levatoris ani arises The pubes bilaterally. It

not

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RELEASE OF TRANSVERSE RESTRICTIONS WHICH IMPAIR FASCIAL MOBILITY

Coccygeus m.

Levator ani m.

Urogenital d ia phragm----><...----"I,H\I/..-;:

�1I++'f+-\*:-;c----+-- Urethra

Illustration 5-3 Pelvic Diaphragms

thickened band of obturator fascia attached to the pubic bone and the spine of the ischium. The muscle fibers run medially and posteriorly and insert into the lower two coccygeal segments, the anococcygeal raphe, the external anal sphincter and the central tendinous point of the perineum. It is innervated by branches of the pudendal plexus derived from the 3rd, 4th and 5th sacral segments. The levator ani acts to support and raise the pelvic floor. It resists increasing intra-abdominal pressure. It draws the anus upward and constricts it. It is respons-

Coccygeus m.

---

tube Sacrum

Illustration 5-4 Coccygeal Hypertonus Inducing Flexion of the Craniosacral System

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51

ible in large part for vaginal tonus. The coccygeus is mixed muscle and tendon fiber. It arises from the ischial spine and the sacrotuberous ligament, and inserts into the sacrococcygeal junction. It is innervated by branches from the pudendal plexus derived from the 4th and 5th sacral segments. The coccygeus acts to draw the coccyx and sacral apex anteriorly, thus inducing an element of flexion into the craniosacral system (ILLUSTRATION 5-4). The urogenital diaphragm is composed of two layers of faSCia, the deep layer and the superficial layer. The deep layer spans the distance between the ischiopubic rami. It represents the fascial layers of the transversus perineal muscles, the levator ani muscles and the supra anal fascia. It is attached to the symphysis pubis anterior­ ly, and to the perineal body posteriorly. Laterally, it is continuous with the obturator fascia and attaches to the ischiopubic rami. It affords passage to the urethra and the vagina, and blends with their walls as they pass through. The superficial layer of the urogenital diaphragm attaches laterally to the ischiopubic rami from the arcuate pubic ligaments to the ischial tuberosities. It too affords passage to the urethra and the vagina and blends with their walls. Because of the intimate interconnections among these structures through common anchoring points and muscle attachments, any fragmentation of treatment or analysis would be illusory. Because of the powerful influence of the pelvic diaphragms, not only upon sac­ rococcygeal mobility but also upon longitudinal fascial mobility and the delivery of

)

Illustration 5-5 Hand Position for Release of Pelvic Diaphragms

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RELEASE OF TRANSVERSE RESTRK"TIONS WHICH IMPArR FASCIAL MOBILITY

fluid through these transverse structures, tension imbalances system and fascial mobility.

treated

The

similar to

is

nique used for

diaphragm. The

of the therapist's

course, different

Place one

(ILLUSTRATION 5-5).

under the supine

hold the sacral body so

palm. Your hand acts as a foundation which

the

resistance once you the anterior-posterior Place your upon the patient so that rest of the hand covers the covers the pubes and force with the Begin to apply a patient's pubes and resistance. As the

area. The hand is gradually

level at which point a

symmetrical pelvic

Ul<.",111"I'.

symmetrical spread tissues. If abnormal tonus will begin to show as a inherent motion tion. All of these motions <)1<'''U,e\.1 be followed without maintain

tissues exists, an torsion or rota­ but the therapist continue the self-

activity tonus is nique to determine which you have induced. to obtain the desired the amplitude and is mobilized. INLET transverse restriction which craniosacral system thoracic inlet. We blood and lymph cavity from the thoracic cavity is even inlet, cranial motion is vault.

fluid congestion

bony structures which are involved in the thoracic inlet the cervicothoracic upper ribs, the processes of the scapulae and

acromion

upper sternum.

of the neck are continuous 1"-"'-1""_

the verte­

of the

fasciae of the the platysma muscles. cleft which allows

deep fascia in this region. head and thorax. They

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53

Illustration 5-6 Neck Muscles Which Attach to the Thoracic Inlet from Above

At the thoracic inlet, the oblique courses of the sternocleidomastoid and trapezius muscles and their fasciae cause them to exert great influences upon the functional mobility of the bony structures of the thoracic inlet, as well as upon fluid flow and fascial mobility. The infrahyoid muscles and their fasciae also have great potential for interfering with the normal mobility of these regions (ILLUSTRATION 5-6). The investing layers of the cervical fasciae in the infrahyoid regions offer per­ fect examples of the concept of fascial sheets splitting into lamina to form pockets for the investment of muscles and other structures. In this region the fasciae are continuous across the midline. They form pockets which invest the sternocleido­ mastoid and trapezius muscles. These fasciae then fuse between the muscles into single sheets. These fasciae are also continuous with the investing fasciae of the pec­ toral and deltoid muscles. They attach at the superior nuchal line, the spinous process of the 7th cervical vertebra, the ligamentum nuchae, the hyoid, the achromia, the clavicles and the manubrium sterni. Since these fascial laminae form the investing fasciae of numerous muscles (and yet are truly parts of a single fascial sheet), contraction or hypertonus of any one or a number of these muscles affects the fasciae in such a way as to result in an imbalanced, hypertonic and restricted condition of the thoracic inlet. The external and anterior jugular veins are actually imbedded in the superficial layers of these investing fasciae. Thus, an increase in fascial tension due to muscle hypertonus may increase venous back pressure in to the head. Prevertebral fascia is the name given to the anterior portions of the vertebral fasciae which invest the vertebral column and all of its muscles. These fasciae are

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RELEASE OF TRANSVERSE RESTRICTIONS WHICH IMPAIR FASCIAL MOBILITY

levator

to coccyX.

scalene muscles and are

muscles.

the

fasciae of fibrous t1r\rrH'"

7th

These

as Sibson's

cervical vertebra and to carotid sheaths and are continuous axillary sheaths which cover the to axillary artery and vein) and axillary The through

thoracic can be anatomist. Suffice it to than a fluid flow, restriction of mobility

reduction

osseous

somatic dysfunction or restricted motion at the thoracic inlet is immense. Restriction of

interfere

thoracic

mechanisms. It must be

by

mobility

the craniosacral

as possible in order

as freely

system.

to allow for maximum

thoracic inlet incorporates techniques of pelvic diaphragms. These

The technique used to mobilize respiratory similar to those used

preceded by a general (but not osseous mobility region. at any thrust is not osseous restric-

thrust to The general

terloeo to mobilize the intervertebral articulations as well as the upper

tion but is It

the

general

by some

neural,

muscle tonus (APPENDIX D). sidebend

vided by your

patient's cervicothoracic

over the fulcrum pro-

Sidebend to extreme range motion. in the sidebending procedure.) Do not

or extension of the When

gentle to

at this point (ILLUSTRATION 5-7). proceeded to extreme of motion, the and hold as long as possible. exhalation occurs,

patient to the sidebending will go a little further. After this breathing exercise a few times until it no further movement into c>llJlCU'ClJUll rotate the head in the opposite to use only gentle to When

rotation has

been

while (ILLUSTRATION 5-8).

carried as far as it

go,

pro-

the

you for to see if further rotation will occur. the maximum of rotational movement, but very quickly thrust rotation. Usually, multiple "pops" will occur as the articulations of site direction.

inlet are mobilized.

the

in the oppo-

use more than 2 or 3 pounds of force.) Other

cervical

corrections can then be made if indicated. To cervical

and then your hands the upper

hand upon the

the transverse restrictions of patient. The

processes of

should

across your palm. Place your

thoracic upper

so that the sternoclavicular regions are covered. the hand on

supporting foundation,

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RELEASE OF TRANSVERSE RESTRICTIONS WHICH IMPAIR FASCIAL MOBILITY

Illustration 5-7 Introduction of Sidebending of the Lower Neck on the Upper Thoracic Spine

Illustration 5-8 Addition of Rotation of the Lower Neck on the Upper Thoracic Spine While Maintaining Sidebending

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RELEASE OF TRANSVERSE RESTRICTIONS WHICH IMPAIR FASCIAL MOBILITY

Illustration 5-9 Hand Position for Release of Thoracic Inlet

anterior surface force is releases

an anterior-posterior compressive until, under normal

lIL'Cn""CU

in a symmetrical manner on both

thoracic inlet (ILLUSTRATION

5-9).

If

r,-.",i"",rI

between

to cause motions to continue until a treatment can determined by repeating the DnJCI�m to see if

In

techniques for the

transverse restrictions the compressive motion should be followed minimal level required to cause continuation of the being adjusted according to motion. means the force used is will cause a defensive body tissue body's response to your pressure. Too much balancing motion which is the will obliterate the you are trying to abnormal motion to

Too much force is self-defeating. of balance so that in mind:

do not let the motion

you simply are allowing

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im-

57

RELEASE OF TRANSVERSE RESTRlCTIONS WHICH Th1PAIR FASCIAL MOBILITY

to recur. Let

tissues move anywhere they

which has just been traveled. After you have the meaning of these words will However, just remember apparent. For now, may seem a of your hands follows an anterior rotation in a clockwise direction, follow direction. Let it shear, let it torsion, let it

let it rotate in a Let it do anything

same path.

CRANIAL BASE In Chapter 13,

which attach to the cranial base are

described. They are

,,,,,'''''''''0

craniosacral systern present.

, .....",.'jH,

The cranial base is

with

hypertonus or contracture is of the cranial vault balanced and released

often obtained by the successan outlet. A congested thoracic with fluid drainage from the remedied prior to releasing


ful treatment inlet creates venous cranial vault. This cranial base restrictions and

its motion

(APPENDIX D).

The technique for

use of deep pressure into your fingers vertically so that

tissues of the suboccipital the tips act as a fulcrum upon which the 1.J"'.l"'l,''-'''U (ILLUSTRATIONS 5-IO-A

and

5-IO-B).

\ Illustration 5-10-A Release of Cranial Base

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upper cervical region is

58

RELEASE OF TRANSVERSE RESTRICTIONS WHICH IMPAIR FASCIAL MOBILITY

/ Illustration 5-10-8 Release of Cranial Base

pads of your

maintain contact with

The head of

the palms of your hands.

patient should be is The therapeutic tissues of the suboccipital patient's head will begin to at the suboccipital contact with the

only by the weight begin to relax to into the palms of your in a straight anterior Don't let the tissues move your

or caudad you will

Ultimately, as the tissues 'HJ;U"",-U

it seems

by a

the firmness

arch

to disengage from the

Slowly the atlas

sensation. As it floats, follow and the atlas anteriorly with

from the occiput, Move the occiput

minutely in a posterior

middle fingers. This further disengages decompresses the occipital condylar region. technique not only cranial base but also jugular foramena. This vault, thus

fluid drainage via the

tissues veins

fluid congestion. The reduction of

fluid congestion will glossopharyngeal, the vagus, foramena has a

joint is a potential cross-restriction to the free, gliding movement of oriented fascia. This hips, knees, ankles,

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59

RELEASE OF TRANSVERSE RESTRICTIONS WHICH IMPAIR FASCIAL MOBILITY

Illustration 5-1 1 Structures at the Cranial Base Which Are Favorably Influenced by Release of the Cranial Base

elbows, wrists and even the fingers and toes. Restriction in any of these regions drags upon the fascia which, in turn, to some degree impairs the free motion of the craniosacral system. Treatment is predicated upon locating the neutral position of the joint and holding until the tissues release. In osteopathic circles, this technique is commonly known as functional technique

(APPENDIX E).

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position and hold

Chapter 6

Dysfunctions of the Craniosacral Dural Metnbrane SysteDl: Diagnosis and Treabnent cause system system. The dural mem­ bundles are inter­ is made up of two layers venous sinuses are formed

are

them

(RHODIN 1974).

When

to abnormal tension in a certain time, the fibers within the

direction over a to

and

Dissection Study the fiber

displays these abnormally organized

orientation patterns may disclose direction of prinCipal tensions to which membranes were subjected during life (ILLUSTRATION 6-1). We

both human and the

preserves

falx Cerel)Clllt--

tentorium fibrous changes which (ILLUSTRATIONS 6-2-A

For

cadavers

the

and 6-2-B).

to the

of cranial vault simply as hard places in full-term infant skull,

the various under normal

is considerable distance between the edges of

vault bones. As we age,

spaces diminish in size but do not, life,

cranial vault bones do not

circumor ossify

though it may be, is always maintained (ILLUSTRATIONS 6-3-A

Once you the dural tensions

(RETZLAFF 1978)

and 6-3-B)_

the the ,,,,.HLU\.j

are merely hard places in cranial vault diagnosis and treatment abnormal dural and

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skills

easier to master.

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

61

Illustration 6-1

Fiber Orientation of Human Dural Membrane

Toward this end, think of the cranial bones and the sacrum and coccyx as levers which can be used to evaluate and treat dural membrane abnormalities. Following is a brief review of the functional anatomy of the dural membrane structure. The two layers of the dural membrane are tightly attached except where venous sinuses are formed. The outer layer is attached to the inner surface of the bones which form the cranial vault. At the sinuses the dura separates away from itself and from the bone (ILLUSTRATION 6-4). It affords space for the collection of blood and then adheres to the

dura from the opposite side of the sinus to form either a falx or the tentorium. It is this endosteal contribution of dural membrane to cranial vault bone which enables you to use these bones of the cranial vault as levers to diagnose and treat the intracranial membranes. The dural membrane forms the functional, if not the strict morphological boundary of the hydraulic system. The cerebrospinal fluid is the hydraulic part of the system (ILLUSTRATION 6-5). Remember, it is within the dural boundaries of this hydraulic system that the central nervous system must develop and function. Understanding the geometry of the dural membranes where they are not attached to bone offers the key to successful diagnosis and treatment of the cranio­ sacral system (ILLUSTRATION 6-6). The two falxes-cerebri and cerebelli-furnish the vertical component of the non-osseous-attached intracranial dural membrane system. The two leaves of the cerebellar tent furnish the component of this system which may be functionally considered as horizontal.

(There

is some deviation from the horizontal at certain

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62

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

Illustration 6-2-A

Human Dural Membrane

Illustration 6-2-8

Primate Dural Membrane

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63

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

Illustration 6-3-A Apparent Sutural Closure in Fetal and Adult Human Skulls

Sagittal suture

Two membrane layers of the falx cerebri

Illustration 6-3-8

Illustration 6-4

"Exploded" Adult Human Skull

Intracranial Venous Sinus

Demonstrating Non-Closure of Sutures

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64

DYSFUNCITONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

\'iOII�-----7Skuli bones

Dural membrane (spinal region)

Illustration 6-5 Semi-Closed Hydraulic System of the Cerebrospinal Fluid and Dural Membrane

anatomical regions of the tentorium cerebelli.) Dr. Sutherland spoke of this system as a "reciprocal tension membrane system." This is indeed the case (SUTHERLAND 1939) (MAGOUN 1966). The anterior-inferior extreme of the falx cerebri attaches to the floor of the cranial vault at the crista galli of the ethmoid bone and to the ethmoid notch of the frontal bone (ILLUSTRATION 6-7). The attachment then follows the midline superiorly inside of the cranial vault along the internal aspect of the metopic suture, under bregma, underneath the sagittal suture and under lambda to the internal occipital protuberance. It forms the sagittal venous sinus as it passes along the internal surface of the midline of the superior aspect of the cranial vault. The inferior and free border of the falx cerebri affords passage for the inferior venous sinus (ILLUSTRATION 6-8). At the extreme posterior attachment of the falx cerebri to the internal occi­ pital protuberance, its layers separate laterally to form the superior layer of the leaves of the tentorium cerebelli. The inferior layers of the leaves of the tentorium cerebelli come together medially to form the other vertical component of the reciprocal membrane system, tJ:1e falx cerebelli. There is a roughly quadrangular space where these membranes join. This space is the straight venous sinus which runs anteriorly and superiorly from the internal occipital protuberance to the union of the free borders of the falx cerebri and the two leaves of the tentorium cerebelli (ILLUSTRATION 6-9). The falx cerebelli extends inferiorly down the internal midline of the occiput from the inferior leaves of the tentorium cerebelli and the straight sinus to the foramen magnum. At the foramen magnum, it contributes to the very strong and dense fibrous ring which encircles this opening in the occiput (ILLUSTRATION 6-10). It is quite easy now to conceptualize the functional continuity between the

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DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

Falx cerebelli

Illustration 6-6 Dural Membranes

Illustration 6-7 Anterior- Inferior Attachment of the Falx Cerebri

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65

66

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

Superior sagittal sinus

Interior sagittal sinus

Straight--1-l1P!llij sinus

Illustration 6·8 Venous Sinuses within Falx Cerebri

Sagittal sinus

Cranial-�H bone

Dural membrane

."..-----tH- Straight sinus

,\"_-Transverse sinus

Illustration 6·9 Formation of the Straight Venous Sinus

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DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

and the frontal and ethmoid bones, and the posterior protuberance, as well as the Moving one step further, it is magnum and the sacrum and coccyx system. Hence, you can influence you can influence the sacrum and rr..,� r,,'� Carrying the concept just a bit tube

to influence the of the tentorium

sacral canal, except at the some movement of the dural tube or superior ends of this

'-""IJLV'-""

tentorium cerebelli will membrane system. are continuous with two superior walls of

venous sinus. From the

superior layers

of the tentorium cerebelli

incisura tentorii;

peduncles pass through are continuous with

of the leaves of the tentorium

two layers of the falx

the straight sinus

to each other after attach anteriorly to the anterior tentorium cerebelli attach tentorium encloses the is to the mastoid angle of the

sinuses (ILLUSTRATION 6-12). I t is now that there is within the cranial vault and continuous of directions.

through which tensions can (lLLUSTRATIONS 6-13, 6-

axes are: 1.

to

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68

DYSFUNCfIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

Fibers of the falx cerebelli

Dural fibrous ring around the foramen magnum

Cut end of spi nal cord

Illustration 6-10 Dural Ring Around Foramen Magnum

Frontal bone attachment of falx cerebri

I

Foramen magnum

Illustration 6-11 Dural Membrane Continuity

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Straight venous sinus

69

5FUNcnONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

""",na,nA'rI

clinoid attachments

Occipital attachments

Illustration 6-12 Osseous Attachments to the Tentorium Cerebelli

Superior-inferior a. sagittal suture to foramen magnum, and to

plate and notch of

ethmoid-frontal bone b.

3.

magnum to sacrum

coccyx

Horizontal or transverse a. temporal to temporal b. parietal to parietal c. occipital squamous to occipital squamous d. foramen magnum to sacrum Now

you can relationships functionally, you can attach as

use

to

membranes and their tissues. TECHNIQUES FOR BALANCING DURAL MEMBRANES The

is easily of the falx

its anterior tensions of the two light traction

hpl�"'P

processes and A frontal tension in

with traction is

technique most

to diagnose and treat

anterior-posterior direction of the falx cerebri. The traction is light

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70

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

and straight anterior. The weight of the contents of the cranium is enough to maintain the occiput in position on the table. The traction you apply to the frontal bone should not disturb the resting position of the occiput. The frontal bone is best grasped by the middle or ring fingers along the lateral ridges which form the anterior borders of the temporal fossae. The rest of the contact is with the palms and thumbs anterior to the coronal suture and bregma

(ILLUSTRATIONS 6-15-A

and

6-15-B).

SUtural restrictions will present firm resistance to the traction; the frontal bone may not move anteriorly because the sutures do not disengage. This resistance, if present, will be met first. Mter the sutures are disengaged (you may have to use direction of el1ergy techniques which are described below), you are ready to evaluate membrane tension. Excess tension in the falx cerebri will be experienced as an elastic form of restriction, not firm and immovable as is the sutural restriction. The further you lift the frontal, the more you will sense a tendency toward elastic recoil upon the bone. Specific areas of restriction can be localized with practice; that is, the recoil tendency may be strongest over glabella or above a bregma. Occasionally, you may sense an elastic restriction to your traction in the lateral aspect of the frontal bone. This probably means that the endosteal membrane which passes under the suture is restricted. In conditions of normal membrane tension, the frontal will lift easily and seem to float once the sutures are disengaged. The head shape will change as you lift. You will sense a floating, plastic quality rather than an elastic recoiling quality. When either sutural or membranous restriction is encountered, a correction can usually be made by patiently maintaining your traction. Seconds to minutes may be required to make the correction. The patient can be asked to take a few deep breaths and hold them as long as possible. These breathing maneuvers will often facilitate release of the restriction. The breathing maneuvers are usually more effec­ tive with sutural restrictions than they are with membrane tension problems.

ANTE RIOR

Sacrococcygeal complex

1\

= SUPERIOR

INFERIOR POSTERIOR

Illustration 6-13 Anterior-Posterior and Superior-Inferior Axes of the Dural Membrane System

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71

DYSFUNCTIONS OF TIlE CRANIOSACRAL DURAL MEMBRANE SYSTEM

Temporal

cerebelli Parietal

Parietal

Illustration 6-14-A Intracranial Horizontal Membrane System

Illustration 6-14-8 Horizontal Membrane System

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72

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

Illustration 6-15-A Hand Position on Skull

Frontal Lift and Traction

\

Illustration 6-15-B Frontal Lift and Traction - Hand Position on Subject

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DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

Illustration 6·16

Finger Placement for Direction of Energy Release of Falx Cerebri

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73

DYSFUNCfIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

technique which we

most

in

restrictions is the direction of energy, or "V-spread" as it has been one hand on side of a restriction consists of one to aU

hand on a

striction site.

that your

and forth between

opposite to or linked with the re-

are

and that

until a palpable softening

are passing energy therapeutic pulse are

restriction. of falx

to the

longitudinally on both cerebri. fingertips should be down over of nasal bones, the bases the fingers up near the coronal suture. About onehalf inch of space between these two fingers is adequate (ILLUSTRATION 6-16). one finger of below

other hand on the posterior occipital protuberance or immediately bu t on the

Pretend your hands are

energy cerebri to

the

and

on the back

anteriorly placed fingers. Usually within 1 or 2 minutes, you in the region; there may

a rapid pulsating activity (60±1 0 per a tendency

some

and

as though

is

itself

tension patterns. Follow but do not impede frontal freely in an anterior will seem to your treatment is finished. of energy technique can same membranous restrictions. Simply two fingers

a

the

other hand approximately one-half inch

affected part

suture. Point

restriction. Then wait

finger,

the release to occur. The

similar pulsating activity before it occurs

(ILLUSTRATION 6-17) (APPENDIX D).

for

tentorium ceretentorium cerebelli

use of

The

attachments to the internal OCcipital are

of which of

as

wings

2 cm.

to

contact points to apply an anterior

occiput. occiput is lifting decompression traction between sphenoid gently cradled in the hands while thumbs are applied to the tissue overlying wings of

to the

wings. All you do is maint<'lin a the surface of the patient's skin. Take up you lift the restrictions if

specifically

if they do not or The presence

of

sutural restrictions will

In this

(ILLUSTRATION 6-18).

anteriorly, you will are

spontaneously correct during

reliable treatment

must be

restrictions can be useful. Other

of tissues

indirectly applying traction or force upon the bone

balances

on its deep

sphenoid. Do not squeeze hard. The skin is

to connective tissue which ultimately

tension immembrane

cases, the V-spread techniques may be out. In techniques are described in Chapter 7. you are not only joint

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occiput you are

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

Illustration 6-17

Finger Placement for Direction of Energy Release of Subcoronal or Coronal Restrictions

Illustration 6-18

Hand Position for Decompression of Sphenoid

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75

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

Fron.a.

�

bone

"'---:;.-?::::....---+- Sphenobasilar

synchondrosis

....---'''''''<:----+--Foramen '""""' magnum

Occipital bone

Illustration 6-19 Diagram matic Representation of the Cranial Base

(ILLUSTRATION 6-19).

Those sutures are between the occiput

between the temporals and

sphenoid. Once the

tion or decompression of the cranial base is accomplished, simply and waiting

suspending the the tentorium membranous restrictions

corrections, the membranes

cerebelli can evaluated. resistance. occiput will

a suspended by strings from the sphenoid as membranous restrictions correct. You may or sutural, later to wait 5 to 10 minutes for all the corrections to occur. wIll occur if you wait. The weight the intracranial contents is enough to stretch the the cranial and to Bony by compression ilie fur conditions are described in 10. The lifting of the sphenoid, after osseous and sutural decompression is will free border the tentorium cerebelli. The induced tension is also through the straight venous sinus and has an prrln r'", effect upon

blood wiiliin

structure, much as though you were

sinus. of temporal bones also lend

tentorium cere belli upon the to use in the

membranes. As the sphenoid is lifted, a traction is imposed via

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77

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

from the clinoid processes to the petrous ridges of the temporal The temporals are affected through their sutural connections to the sphenoid. TECHNIQUES FOR BALANCING SUPERIOR-INFERIOR OR

DURAL MEMBRANES superior-inferior oriented part of the dural membrane system may above and below

divided into

dividing line

of the

mater at this anatomical in the makes the occiput a very useful vertical or on the from the superior attachments

axis above the the falx cerebri deep

suture and lambda to the inferior forms

as this

Anteriorly

fibrous

inferiorly, it involves

ethmoid and frontal bones. system above the

treat the vertical

border is applied

lifting the

traction is continued until you can feel the which attach

resistance of the

to the sagittal suture. As gentle trac-

tion is continued (beyond the parietal lift

described in Chapter

9),

the

through falx and the straight sinus. At this point in the treatment procedure, a horizontal balancing activity often allow any untwisting and/or lateral your

to occur while you continue

cephalad traction. This

correction

relief of abnormal tension patterns within

the

falx cerebri and the straight sinus.

lateral or horizontal balancing which occurs is largely due to the posterior-inferior of the parietal bones to the cerebellar tent leaves (ILLUSTRATION 6-20). Simply work with these factors until they seem to balanced. After the have been

the falx

and

JJHe"''''-U

in

are

a sense of direction.

sutures of the vertical

parietal bones have been mobilized. The technique

membrane systems is traction using the parietal bones as levers after a (APPENDIX D). lift has ReleaSing the dural membrane tube

the foramen magnum and the

requires that the cranial base, piratory

and the

diaphragm

somatic dysfunctions will

released of the

with the free

be

should therefore

With some experience, you will be able to discern with confidence whether or not restrictions from

diaphragms,

osteopathic somatic dysfunctions of

dural

An

thoracic inlet, the

indeed exist by simply

means of developing this skill is to

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base or the mobility the

78

DYSFUNctIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

Illustration 6-20 Parietal Lift with Traction

mobility of the dural tube base, When restrictions are found, reexamine the restrictions correct the mobility of

restrictions one at a time. After and note the

reexamine

which your correction or release of

restriction has had upon its mobility. At achievement of this skill may seem impossible; however, as you and to trust your you will find that you can the With you wiUbegin to impossible. reason it out: distinguish the feel kind of restriction another. Another useful exercise monitoring the dural and is to work in pairs, with one locating and correcting restrictions during the monitoring process. By practicing in how the corrections feel in the manner, the monitor tube mobility can be evaluation and treatment of complex. At the occiput, you must the occiput from disengage the occipital the tissues at the cranial atlas. These techniques are described in Chapter 5 of the diaphragms) and 10 (occipital After the

condyles are freed

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articular

of the

the

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

79

Spinal dural tube

�::::::�.-�; � ---�

+ ==;.-; -�;;== ==��;-

=.�:===�.---��g��

Illustration 6-21

Effect of Occipital Traction

on the Dural Tube and Sacrum

therapist begins a very gentle cephalad traction (ILLUSTRATION 6·21). The patient, of course, is comfortably supine upon the table. The first bit of traction will cause the occiput to further decompress from the cervical spine. The traction must be light so as not to cause the tissues to respond by guarding or contracting. Gradually, the occiput will move toward you. As it does, the spinal dural tube will begin to glide cephalad with it. Try to feel how far down the dural tube the traction force is reaching as the occiput continues to move gradually cephalad. As the dural tube gently follows the foramen magnum, you can perceive just when a restriction is met. If you know how far down the dural tube your force is reaching when the restriction presents itself, you will know where (i.e., at what segmental level) the restriction to dural tube mobility is located. Visualize, imagine and practice: you will be amazed at how rapidly you can develop this skill. Don't think critically or become anxious about it in the beginning. After all, what is the risk if the examination does not yield correct impressions at first? On the other hand, once you begin to get some correct impressions, your skills will develop rapidly. Often, when you note a restriction to the free gliding of the dural tube, it can be corrected by continuing the same traction for a few minutes. Otherwise, a particular technique may be required for a particular restriction. Post-operative adhesions affecting the mobility of the dural tube may be successfully treated by multiple repetitions of the CV-4 technique. Gradually, increased fluid pressure seems to break down the adhesions. The CV-4 in these cases can be performed daily. Either the patient or a family member can be taught to apply the technique (APPENDIX F). From the sacrococcygeal end of the dural tube, the technique is essentially the same. First, the sacrum and coccyx must be free to move in relationship to their adnexa and articulations. Commonly, the coccyx is restricted in an anterior position and may require gentle mobilization by placing a finger in the anal canal to release the coccyx posteriorly. Sacroiliac and lumbosacral joint dysfunctions are also common. Traditional techniques to mobilize the sacroiliac joint are usually satis­ factory (MITCHELL 1979). The common lumbosacral compression ordinarily requires a decompression technique which can be applied in combination with the examina­ tion (CHAPTER 8). Another frequent cause of sacral immobility is hypertonus of the piriformiS muscle (CHAPTER 8). This condition must also be resolved before good sacral motion, and hence free dural tube motion, can be obtained. Decompression of the lumbosacral junction is performed with the patient supine and the therapiSt's arm placed between the patient's legs. Rest the sacrum so

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80

DYSFUNCfIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

is between your should be placed above the sacral base. lumbar so that you are stabilizing Now lightly apply traction in a caudad lumbar spines

(ILLUSTRATION 6-22).

and S-l. The sacrum then attempt to apex. If the sacroiliac seem to impede patient apply pressure upon or her hands. This pressure will

to

(ILLUSTRATION 6-23).

disengage, the sacrum will begin to traction. As equina.

phenomenon occurs, it

you meet a restriction to

how far up the glide of the

an idea of where the restriction is. When two therapists are sacrum,

one on the

tube can be therapist on

by

traction on one

other. end.

steady. Do not elicit a tissue guarding time has just as much as a larger is that the force does resistance in the body, whereas against which the therapist must then work-usually without success.

does not resistance

TECHNIQUES FOR BALANCING HORIZONTAL DURAL The into four

oriented structures

divided

temporal to magnum to sacrum.

squamous; and to temporal

upon the two leaves

generous and extensive attachments ridges of the temporal bones and to the (ILLUSTRATION 6-24). At medial regions of that the anterior portions processes of the direct non-osseous functional connection in bones. We to this contact

tentorium of the of the

This

oriented structures is used to create traction in the

the in

temporal and treatment

the horizontal or transverse

leaves of the tentorium cerebelli, the first utilizes the temporomandibular joint in Chapter 12 (ILLUSTRATION 6-25). This te<:h!11Q upon the temporomandibular joints and the ternOOn)O�lncarried beyond its etal su tures (APPENDIX G). The cephalad traction upon the mandibular joints

then affects

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DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

Illustration 6-22 Hand Position for of the Lumbo-Sacral Junction

Illustration 6-23 Patient Assistance in the Disengagement of the Sacrum from the Ilia

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81

82

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

ANTERIOR

Temporal bone petrous ridges

Tentorium cerebelli

Occipital bone

Illustration 6-24 Attachments of the Tentorium Cerebelli

the

squama cephalad. This to spread

suture.

are moved

cephalad as a secondary functional sutural shear. As falx cerebri resists into external rotation around the axes When you

causes the temporal squama in their A nonphysiological shear is induced at the The falx, is now tractioned lift is induced by upward traction, the (ILLUSTRATION 6-26).

reached this point,

mandible and

to

as you gradually wobble the lateral of the tentorium cerebelli, the the falx as it affects and is parietal ment at sinus. A closed circle is now formed with tentorium If the traction is gently continued long magnum, the of the occiput, be obtained.

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information about

balance coccyx may

83

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

Illustration 6-25 Hand Position for Cephalad Mandibular Traction

Sagittal suture and sinus

x

'"

.

Cii

(2) '"

l.L..

.

"

(4)

'C .r:J

�

(��


U

� � (4)

,

.11

,

,,�

Temporomandibular joint

�����

-=��� Temporal bones

Illustration 6-26 Effects of Mandibular Traction

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"

Temporomandibular joint

84

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

seems to The membrane-balancing closest to the after osseous restrictions resolved. First tent is Icva""u. this will move fluid about the spaces above below it. After and and

horizontally, the presence of the

falx the

all the way to the sacrum can traction until you can feel whole

your eyes as you

membrane system balanced. been achieved using cephalad traction on the mandible, we After balance angles of the mandible (ILLUSTRATION 6-27). Use next use caudad traction over skin to placed on the enough pressure your Your fingers

not move relative to

skin.

over

is

caudad. underside ofthe skin is rooted to bone taken up, traction on the skin will be mandible. Once the slack has A0UALL'.�",

to the mandible. The

patient's temporal squamous

of your hands should gently rest over the to monitor subsequent activity.

caudad traction causes temporomandibular joints to disengage. will usually occur rather because the earlier stages of this technique

Illustration 6-27 Hand Position for Caudad Mandibular Traction

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85

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

and thus the way temporomandibular joints can your hand gently on side of the head.

engagement

mandible will and

balance

then

to sway side-to-side as it achieves a new

the temporals. As traction is

continued, temporal will often

temporoparietal sutures begin to disengage. Then the lateral temporal At this bones begin to move slightly to sway side-to-side, forming a parallelogram

in one direction, then in the

direction. As

new fluid is n;P'''--;P'''i',rI

if you will

bones must effectively a single instance when

in our own

parietal contact to balance the tentorium AnT"'''''''''

be aware

technique in case the

technique transverse sinuses. .u<"'(1'.H J.U� the tentorium

oCcipital squama is based upon to the internal occipital ridge. Usually the ocd--

..

the attachment of those

put has been subjected to undue tension by the tentorium cerebelli. upon one or the other

favorably

places

in a

force,

as cervical

tension upon the of cases, imbalanced tension

of the tentorium from within causes recurrent

extracranial oCcipital somatic dysfunctions. The extrinsic

must first It must be

of all tensions from any restriction with the

lambdoidal

(CHAPTER

free to move. These in the

to In order to hand and place the head. Motion is

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DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

The

you

hand

under the sacrum. The patient is pulley; the sacrum is the is tube (ILLUSTRATIONS 6-28 and 6-29). You must then a rotational motion in either on the other end. As you induce rotations in both

perceive and upon both

the system will seem to loosen up. As the loosening occurs, you will notice a quicker more other end of

transmission

You should also motion

rotational

induced at one end to the

system. to notice if "''''' ..., ...... ., loads are restricting the

the sacrum or the occiput.

Illustration 6-28 Hand Position for

of Sacrum and Occiput with Patient Supine

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Ultimately, when

87

DYSFUNCTIONS OF THE CRANIOSACRAL DURAL MEMBRANE SYSTEM

movement has been established for

occiput (foramen magnum)

sacrum, and when the message is transmitted without distortion from one end to

other,

whole

will seem to

into a

treatment is thus completed. it is now apparent to you and its related

of rOI!reSS10n of events is responses to your ministrations.

Occiput

Sacrum

Illustration 6-29 and Sacrum as Pulleys

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Chapter 7 Dysfunctions of the Cranial Base

of the

serves as the of the home in quality of physiological and by treatment which can most be environment The floor of the cranial cavity is a directed at craniosacral source craniosacral system Under moves freely and in response to, the rise fall of cerebrospinal fluid pressure. ethmoid, SOlnell01,(l cranial base are osseous components (ILLUSTRATION 7-1). occipital cranial cavity has a in modern homes, In common with most and durable, covering. This covering is dura mater. It is continuous up the sides cavity and its interior ceiling cover. The mater floor duplicates upon to form partitions: falx the falx which arises the and contributions to occiput, the which arises parietal bones and the temporal bones. It forms a "'-�.v,,,'U The dural membrane also attaches to bone. Through (ILLUSTRATION 7-2).

and its continuities indicates cranial base, AJ,-,-"""",- of its firm osseous this floor significantly to movements with some u.... """;'" interior of passage to the various venous sinuses: sagittal sinuses, transverse the occipital the petro us sinuses, and the straight sinus. The dural transmits tension from any source through itself in a direction dictated and its (ILLUSTRATION 7-3) . It is not difficult to "'""'1'>""'- abnormal tensions with normal with free blood this venous sinus system. with venous 88

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89

DYSFUNCTIONS OF THE CRANIAL BASE

Occiput

Illustration 7-1

Cranial Base

sinus drainage may result in increased intracranial venous back pressure, which will then reduce normal fresh blood delivery to the brain. It may also raise cerebrospinal fluid pressure slightly but significantly and thereby interfere with the normal move­ ment of this vital fluid through the ventricular system of the brain and through the various subdural spaces. THE CRANIAL BASE FOSSAE: ANATOMY The floor of the cranial cavity forms the anterior, middle and posterior cranial fossae. The floor of the anterior cranial fossa is formed by the orbital plates of the frontal bone, the cribriform plate of the ethmoid bone and the lesser wings and anterior body of the sphenoid bone. Its posterior boundary is the posterior borders of the lesser wings and the an terior margin of the chiasmatic groove of the sphenoid.

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DYSFUNCjIONS OF THE CRANIAL BASE

frontoethmoidal and frontosphenoidal sutures. is traversed support the of the brain. portion is the roof on both crista galli. The frontal crest, which ends at cecum, offers attachment to falx cerebri and a groove for the superior a vein passes from the which is afforded passage by this falx. to the superior sinus through the of the crista are located on the and afford passage to olfactory and TRATION 7-4).

cranial fossa traverses wings of These bony structures its lateral fossa are the margins of the lesser the anterior clinoid processes and anterior ridge of of the petrous posterior boundaries are the bones and sellae. The contains chiasmatic groove, between and the tuberculum UWUUJec;

posteriorly. ro{;es:;e:; which Immediately tentorium turcica, in which pituitary

----{ Falx cerebri ....'-... attachment

Illustration 7·2 Floor of Cranial Cavity with Osseous Attachments the Two Falxes and Tentorium Cerebelli

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of

91

DYSFUNCTIONS OF THE CRANIAL BASE

Illustration 7-3 Fibrous Changes in Dura

HoIc-------'.,.,.....- Cribriforum plate of ethmoid ��""'�--+P"" Clinoid processes

Illustration 7-4 Frontal Fossa

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DYSFUNCTIONS OF THE CRANIAL BASE

92

(hypophysis) is located. The posterior of the hypophyseal fossa, as the entire is called, is the dorsum sellae is a lateral plate oriented more or less superior lateral which are the clinoid processes. These processes offer attachment clinoid superior layers tentorium cerebellL nerve (C.N. V I). the notch for are the carotid grooves which extend of the anterior processes. The HHo.U;',is actually a petrosal nerve. great of 7-5).

the great superficial nerve has significant of the brain (OWMAN and supply to the and temporal bones dysfunction between lace rum may dynamic anatomy lobe circulation and, of the middle cranial are known as the temporal fossae. They support temporal lobes of the are grooved for the passage of the anterior and branches of the meningeal arteries and veins. The recurrent of the mandibular ( C. N. V) and located in the greater and lesser sphenoid These fissures afford passage nerve (C.N.I V), opthalmiC nerve (C. N. V I) as well as the the superior orbital fissure can (and ment of the eye. Also located in fossae, bilaterally, are which affords passage to division of the foramen ovale, which P""'"''''F.''' to the mandibular nerve ( C. N. V), the which affords passage to recurrent branches of trigeminal nerve ( C. N. V) which affords passage to with its "u...... ;.�

over The posterior cranial It is bounded by mastoid parts of the parietal bones. It is crossed by It houses the cerebellum, middle cranial fossa by bones. The tentorium cranial fossa. It is

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DYSFUNCTIONS OF THE CRANIAL BASE

(ILLUSTRATION 7-6).

In

becomes occipital

center, located in the occiput, is are the

side of are in rough passage to inferior medulla (as it spinal cord), the meningeal (the dura is firmly to magnum), the spinal accessory nerve (CN. XI), the at the ANTERIOR

Foramen magnum

Illustration 7-5 Mid dle Cranial Fossa

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DYSFUNCTIONS OF THE

ANTERIOR

Occipital contributions to the jugular foramena

Foramen magnum

Internal oO::lOltal protuberance

Illustration 7-6 Posterior Cranial Fossa

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CRANIAL

BASE

95

DYSFUNCTIONS OF THE CRANIAL BASE

posterior XII) and vertebral the arteries. foramen magnum is the Anterior to synchondrosis, occiput and posterior body of the sphenoid are joined by basilar part of cartilage. The oblongata rests over this sphenooccipital union. The foramena are between the petrous bones and lateral to the are located occipital base. These ly occipital They afford passage to X), and spinal accessory nerve ( C.N. (C.N. IX), vagus nefYe transmit inferior and transverse venous sinuses which drain veins. Meningeal vessels In of jugular are foramena can result from occipital condyles, cranial dysmuscle hypertonus, somatic dysfunction tube from and tension transmitted to foramen magnum via falx cerebelli and/or the tentorium of the foramena in intracranial congestion symptoms resultant to dysfunction of pressure, to venous XI and XII (APPENDIX D). nerves Also located in the posterior cranial superior to jugular are acoustic meati through which pass the the nerve (C.N. VII), the acoustic nerves internal auditory arteries. crest the occipital which support This crest is the attachment for cerebelli, which and the occipital venous sinus. through sinus. the free passage of venous grooves the transverse venous sinuses where attaches. These grooves are the posterior boundaries of the fossae. transverse venous sinuses through the foramena. good venous tension upon the tentorium cerebelli can within the drainage vault. From brief review of the pertinent anatomy, it should be apparent membranes or osseous structures of far-reaching and often of the nefYOUS, venous and endocrine CRANIAL BASE Originally, Dr. Sutherland held that base dysfunctions were predominantly osseous in nature. conceptual model works both in diagnosis and treatcranial base more is presented of not

membrane tensions which are significant cause may be suture tissue tensions and restrictions

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DYSFUNCTIONS OF THE CRANIAL BASE

Symphysis

Illustration 7-7 Comparison of Movements Possible at a and Synchondrosis

motion which we have come to dysfunction) of joint external forces on them. Therefore, we h""'U..,'''O, will cause a more IJL'UUVUlH.... and temporal which attaches more This difference of opinion teachings becomes clinically ''"5.<>''",'''UH causes underlying function is often temporary. identifies and successfully treats cause of abnormal soft tissue or brane tensions. This cause may ultimately found in the abdominal extremity or elsewhere in We cannot and should not scope of our of the craniosacral system We believe that it is a rare circumstance when the sphenobasilar motion aberration is nature. Rather, we prefer to base as a unit motion dysfunctions secondary to tensions or other soft tissue tensions. immobility, abnormal osseous anchorings from both within tensions are vertebral canal. Cranial without the d.U1U�,,,""'L,,"1 system fluid dynamics unidenti fied causes. EXAMI N A T I ON VAU LT

size and sensitivities technique modification which is develop

F O R T HE C RA N I A L B ASE: of pOSitions to evaluate two of these "vault holds," as by Dr. Sutherland (MAGOUN 1966). third is a modifiauthors has found to be most useful in view hands. We suggest that the system use of all three of vault and then develop a most satisfactory. We believe it is essential that you of the total approaches to each problem.

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DYSFUNCTIONS OF THE CRANIAL BASE

97

dysfunction is crucial. The or improvised individually for The most and serious errors are when the problem is to conform to a preconceived of the Th�>r£llnl In the first vault (ILLUSTRATION 7-8), your index areas external of the bilaterally. Your fingers rest IJUC... '-HU') to approximately one-half inch above superior nuchal line. Some slight may result if the has small in size. This will not interfere with however. The third and fourth (middle and ring) fingers of your hands are not in the information contact with the and do not participate in examination. Likewise, do not contact patient's head, but only touch each The thumbs serve to provide proprioceptive and cues about motion of the therapist's hands. Movements in one and the reciprocal movements in direction. The is positioned and usually on the. behind the your forearms tably on your elbows on table improves propriocepUsually, is more comfortable for therapist. Comfort for both yourselfandyourpatient When you are tense, you receive stimulus input from your own body is which becomes noise and interferes with inputs the the more presents an soft patient. A tense, uncomfortable tissues. This circumstance dampens the gentle which you are trying to craniosacral i t requires a with a tense And even a very experienced circumstances. hold was also The second therapist are Usually, the is held in one of your the thumb overlies the area opposite would advise against allowing the remainder of your hand to rest upon no patient's head. when there is we have In fact, with palm of frontal bone can be simultaneously both sphemotion when thIs contact is made. We that both methods be evolved third vault hold (ILLUSTRATION 7-10) is a modification It provides maximum amount of for one of your authors information whole amount of time. In the application of this vault is supine and therapist is out" and thumbs are at the fingers are in contact with occipital squama. fourth to occipitomastoid sutures. are in contact with occiput, just bones to the mastoid processes of the third fingers are

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DYSFUNC TIONS OF THE CRANIAL BASE

Illustration 7-8

First Vault Hold

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DYSFUNCTIONS OF THE CRANIAL BASE

99

/

Illustration 1-9

Second

Vault Hold

running inferiorly over the mastoid tips. Neither your fourth or third actually the occipitomastoid sutures. fingers the suture on both is straddled the space between your third index are allowed to rest anterior to the ear so their bilaterally, depending, placed over the

1.

14<>,'"

...."'1 sphenobasilar

(described below) occipital squama and my thumbpads

2.

occipitomastoid suture

3. 4. 5.

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DYSFUNCTIONS OF THE CRANIAL BASE

100

Illustration 7-10 Third Vault Hold

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DYSFUNCTIONS OF THE CRANIAL BASE

101

sutures, occipitomastoid sutures.

sutures

as

With experience, this hand application can provide excellent information than i n fragments. It is "'U�H"VVa."'Aa.,system as a whole, about the activity approach which many of the unique concepts of diagnosis For this reason, we encourage you to be treatment presented in and to original thoughts to attention to your C L ASS I C A L MOTI O N TES T I NG JOINT DYS FU N C T I O NS therapist initiates direction, then monitors You evaluate range movement and ease or restriction of motion. to patient's head is light, 5-10 grams in most are not oriented, that is about \JlJ,"-'"'''' of motion described below, vault bones in

resulting motion symmetry The force

craniosacral """'''PI'''' trying to evaluate not how it responds to outside outside threats such as heavy touch, traction or work with your is beneath this at a level of touch the so as to avoid you are attempting to observe. you will test using the vault hold, and The motions attributed to sphenobasilar joint or are:

Sutherland

1. or to the right. convexity to the great wing of high on the the posterior either uu,-, .•v, to base. the anterior Lateral strain with the posterior "IJU""uv body either of the 5. anterior 6. Compression or impaction of the joint/synchondrosis. joint Among five of these six to determine presence of "lesion" or motion dysfuncmotions are with the range extension range of flexion motion is by Dr. Sutherland states that when cranial concept as moves more into flexion and is more resistant to exsphenobasilar moves further a " flexion lesion." lateral strain it is called a strain than into is named for which moves facility. or impacted, examination will sphenobasilar joint is Ar nt,,,t·p,",or expansion or disimpaction. joint is resistant to reveal that use as a comparison. diagnosis must no real reciprocal motion is experience with on the basis of the and nonbe 2.

3. 4.

..

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DYSFUNCTIONS OF THE CRANIAL BASE

102

compressed patients. As your experience grows, you will gain confidence and your

acumen. flexion or

When

the therapist should

the inherent motion patient's body is itself moving into the flexion Do not to initiate a flexion movement patient is moving into extension, or to initiate an extension movement while the patient is moving into There is a or relaxed period of time and extension. is, before

reciprocal motion of of motion,

is

a brief time of relaxed neutrality following return from the extension phase and vice versa. It is the excursion from neutrality to motion which you, will You ":l,,: t Pltn boost as the craniosacral of the active ranges of motion. You evaluate response to the push or In

perfectly functioning craniosacral system, flexion and extension are the the motions which are

only normal sphenobasilar

,-"C"VJl<. It is how much of each of which is of interest to

described below. C ranial base motion patterns are positionally inducible. While you are the cranial motion, another person to raise or rotate one of your Observe what occur in subject's extremities (either upper or manner will begin to afford the therapist an motion. A little of of the human body and of the of connective tissue tonus and tension. SPHENOBASILAR/CRANIAL BASE FLEXION-ExTENSION

one of the vault holds above, exert a gentle force over the occipital squama and grea t wings of the sphenoid concurrently. This force is toward the patient's feet. When you use

first vault hold, the

are in contact with will cues so that your

and fourth

other and furnish applied as equally

proprioceptive and symmetrically as possible. After cranium has responded to the initiating (on the order 5 grams), you become passive follow cranial motion to its Flexion at sphenobasilar union is the postulated motion the angle by the sphenoid the more acute. follow

sphenoid

neutral balanced ease. To test reciprocal motion (extension) of

sphenobasilar joint/cranial

you apply a similar, bilaterally equal force in a superior cephalad direction and the your force is toward yourself. Once the motion is motion is passively followed to its restricted point. motion implies a "",,,,O>UH.1<> of

acuteness of follows the

angle at the sphenobasilar union. motion to a point of

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DYSFUNCTIONS OF THE CRANIAL BASE

103

may repeated several times until you are is reliable with respect to the relative ease or restriction direction toward which the motion is the induction of flexion is called an begin your testing force at the onset of versa. extension motion, and compare the result with normal motion. ,u"u",u,-, "-'HUH,,,.

postulated, and both the Sutherland Cranial Academy have traditionally taught, that on skull of the subject is the junction of these the sphenoid body and the occipital formed at the inferior surface of this synchondrosis is less than

superior surface of the angle is

1

motion, the number size Therefore, must increase. The reverse is true during two angle formed by \.lULUJ'l';

the flexion phase,

during the extension

is

a as to move slightly

(ILLUSTRATION 7-11), X-ray

studies by Greenman lend some support to SPHENOBASILAR/CRANIAL BASE SIDEBENDING Sidebending distortions of cranial an imbalance of tension placed upon the combination of factors. The result is

are maintained by by one or a between

the sphenoid great wing and its paired than on the opposite side, This means head is angulated slightly at the phases of craniosacral system motion When this lesion pattern is discovered, it is

orientation. with convexity either

left or right. The test for sidebending lesion of

vault holds described above, but

convexity bulging. At the beginning the therapist should attempt to ipsilateral great wing of the bulging of the convexity on other hand. The extent of this is passively URJlULVL to neutral again. As

next

side. The amount of approximation is

compared. The lesion is Ua.JlU"-'-' perceived (ILLUSTRATION 7-12). We repeat: the

10

grams) and initiatory only. induced force, you test to see how far natural origin of the inducing an

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DYSFUNCTIONS OF THE CRANIAL BASE

104

Sphenoid body

FLEXION

EXTENSION Illustration 7-11 Flexion and Extension Phases of Crani osacral Motion Depicted at the Cranial Base

BASE TORSION

lesion is named either moves cephalad

wing of side on which the for the most ease and excursion. A

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DYSFUNCTIONS OF THE CRANIAL BASE

105 orientation of the sphenoid is such that

more

All crania should

� �u� ��� of the torsion motion in response to your test. Lack of symmetry means a lesion pattern is in cranial base.

an axis

through (where the

To better understand torsion motion, simply the between the venous sinus ends) and anteriorly.

that is tilted slightly to one side upon this axis, and the occiput is tilted slightly in the opposite direction upon same axis ([LLUSTRATION 7·13). as usual, normal rhythmic flexion and extension motions are but the cranial To test

is operating from a torsioned orientation. the vault hold is applied. A torsional motion is sphenoid, while

at the

to

occipu t is stabilized

beginning of either any torsional movement. The motion test can initiated at force is of craniosacral motion. If your a flexion or extension more upon wing of the which is cephalad, initiation are concentratbeginning the extension phase. should be made of the sphenoid moving inferiorly, the beginning of

start

flexion

You are simply testing to tion of ease toward which cranial base torsion can induced.

test at the

CLINICAL SIGNI FICANCE AND TREATMENT OF FLEXION, SIDEBENDING AND TORSIONAL DISTORTIONS OF CRANIOSACRAL MOTION The clinical significance and correction of flexion, extension, sidebending and of the cranial are all discussed together for reasons:

torSional

are usually secondary to some somatic

1.

system.

which is extrinsic to the L,-"',LV"',

extension,

torsion

of the

by cranial treatment, but will often return problem is itself identified and treated.

the extracraniosacral cranial base dysfunctions are often self-correcting when the primary dysfuncWe use

"spontaneous" corrections as UH.U"'''''.H

abnormal flexion-

torsion

2.

Strain and compresa.\.-,.aU.Lv"a.\.-L,,, system origin within the craniosacral system. sion of the cranial base often have transient. is not true Craniosacral motion pattern abnormalities are more severe cranial base strain and compression problems, which are distransient nature of many of to

problems may be due neuromusin

changes are usually the result of traumas and

3.

everyday stresses. Although the dysfunctions of flexion-extension, sidebending and torsion of the are seldom seriously

cranial base may and! or

4.

11 ..... <1.1-'..... 1

strains the

of

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can usually

106

DYSFUNCTIONS OF THE CRANIAL BASE

NOR MAL

�=!=�I(!l-+- Sphenobasilar synchondrosis

Occiput

SI DEBENDING WITH CONVEXITY LEFT

SIDEBENDING WITH CONVEXITY RIGHT

I

I

Illustration 7-12 Sidebending Lesion (Top View)

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DYSFUNCTIONS OF

THE

107

CRANIAL BASE

Illustration 7-13 Cranial Base Torsion

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108

DYSFUNCTIONS OF THE CRANIAL BASE

be of by strain The correction of more difficult may sometimes require more individual modification in order to Flexion-lesion That will often

TRATION 7-14}.

numerous dysfunction, recurrent sinusitis and nasal allergies. use of indirect This type of cranial lesion is often temporarily correctable by That is, it has been determined flexion is dysfunction, that motion into its extreme range flexion, and hold When the craniosacral to return to the neutral

Illustration 7-14 Whole Body Habitus of Chronic Craniosacral Flexion

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DYSFUNCTIONS OF THE CRANIAL BASE

109

position, the therapist becomes Do not against to exhibit barrier: prevent the cranium returning to neutral. If it torsion or sidebend, or proceeds into any other motion that to you are lesions you have not which will probably return of to its neutral correct as you cranium will go further into the flexion You are a passive a partial release of this occurs, you have range of motion. Pd.LL';; 'U. As this movement into further flexion occurs, you follow, but not it. may occur once or times. staying range of motion will be movements of the accompanied by a sense that the patient's head "softened." We cannot what has occurred; but once you have perceptually enced softening of your head, you will we mean. dura will not likely forget the experience either. It mater was contracted suddenly cranial vault bones a more movement. speak of as the Once has occured, you should follow the motion back to craniosacral system cycles then into the extension phase. Three or passively monitored. The phases of motion can then be reevaluated to determine whether or not been ranges of the Usually, it seems as though extension of motion is about corrected when a full therapeutic achieved. When you perceive this amount of improvement, it is barrier not move for a considerable Occasionally, the time, even though you do not allow a return to by the craniosacral by the patient's When occurs, therapy can often inhale and hold their breath as long as cooperation. Simply have the If this work, the exhale forcefully and possible hold their as possible. correction, or usually occurs as of patient must resume normal inhalation and/or exhalation breathing assistance by the patient is found that it is inhalation or exhalation in a series of steps.) necessary to enlist you are probably If none of these neuromusculoskeletal somatic dysfunction which even a temporary correction of the lesion can achieved. heads are usually in their extremities are and The rotated (ILLUSTRATION 7-n). When headache is a problem the extension head the pain is usually Many more severe incapacitating than in patients have extension heads coupled temporal bone dysfunctions. endocrine have tells us that extension head discomfort, have a tendency to work it out although it. may themselves by the use of exercise. The correction of the extension is also accomplished by the use of in-

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DYSFUNCTIONS OF THE CRANIAL BASE

1 10

Illustration 1-15 Whole Body Habitus of Chronic Craniosacral Extension

You use the same approach as you

the

u,-.,uv·u

correction,

that you follow the motion to its extreme range of extension and a return to resist the return to neutral. The craniosacral system will your resistance. With each little further into extension. You take patiently as As you develop which every person is endowed, the

will go a motion the each time this occurs and wait as in with patience" will

process with easier.

you will find this period of waiting for the skills as your release to be fascinating and instructive. Ultimately, the release occurs and the correction has been You may of course the patient's breathing assistance if you grow of waiting. As in the of motion technique for flexion leSion, you evaluate the flexion-extension the range of A 50% after you feel the correction been motion indicates that a has been achieved. therapeutic We the of and torsion motion dysfunction

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DYSFUNCTIONS OF TI:lE CRANIAL BASE

111

of physical evaluation. The clinical

diagnosis should be made strictly on should not be used to Patients with sidebending

<",,,,,,",;tl

base motion distortion.

torsion

of the cranial

may have both} frequently pain syndromes, headache, motor disturbances, sinusitis, problems, dental U«"''',-,-J'UC>Hn,l, are they incapacitating.

are annoying

Corrections for sidebending indirect

the motion in its direc­ wait through several cycles, of motion after each breathing assistance However, we repeat, waiting and correction. A 50% a correction of the cranial base which are primary of cranial base.

BASE LATERAL STRAIN strain lesion" patterns of the cranial and incapacitating than flexion-extension, sidebending terns. They are more likely to be primary craniosacral are secondary to extracraniosacral "ncr",.""

more severe pat­ dysfunctions than Lateral

the result of trauma. It may head injury. a forehead which been displaced. This is

(ILLUSTRATION 7-16).

a strain, apply one of the vault holds. at the beginning of either a flexion or an extension

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DYSFUNCTIONS OF THE CRANIAL BASE

Left side bulging forehead

�f.tI-----,F-- Axis of rotation for sphenoid body

--;;::t::�H� Sphenobasilar synchondrosis

Direction of fo r motion strain left

....!-----lc-... - Axis of rotation occiput

�1

for

TOP VIEW

Illustration 7-16 Left Lateral Strain

of craniosacral is matters little which it is better not to motion phase which is purposes same manner. right and then to test both beginning of a or an extension phase. force is on order of 5 grams. It is applied in an anterior direction ipsilateral occipital squamous and great at cranial groups teach abnormally positioned around vertical axes, being rotated to produce strain lesion. It is assumed this at the sphenobasilar joint. this model sphenobasilar joint were indeed a that However, this is not case. Rather, we the result cranial base are

..:;'" on one side, then on restriction length of excursion u...........

h",m,�,.,

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strain motion is head. The freedom, is compared. The is

113

DYSFUNCTIONS OF THE CRANIAL BASE

which moves furthest anteriorly with the ease. For strain cranial base is one which allows on the left side (ILLUSTRATION 7-17). of lateral strain response to motion testing is symmetrical in both ease and range of motion. of testing for lateral strain lesion of the and/or frontal bone laterally, first to one is held stationary during this more direct; however, it has one pitfall. you to diverge from a straight transverse test you are strain motion. With sidebending, probably combined with two can be overcome. sidebending, almost left or TION 7-18).

correction of lateral strain lesion exaggeration, as by torsion. The indirect barrier is followed in step breathing) may perceived. Breathing assistance (inhalation, exhalation than also required. Correction of this lesion pattern will usually take correction of those patterns described It a more extensive adjustment of the motion characteristics It usually

TOP VIEW

....--\--....� ..;: _+--�---::--... Direction of motion testing '"

........ ... Complication of added side-bending

Illustration 7-17 Motion

for Left Lateral Strain

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DYSFUNCTIONS OF THE CRANIAL BASE

Frontal

,

Occiput

Illustration 1-18 Cranial Base Sutures in Lateral Strain

of the a mobilization of some or all the cranial base sutures and, perhaps, sutures of the vault. As you lesion position, all of necessary corrections one at a time or simultaneously. Be let it patient, take your time Occasionally"after the correction been exploited to its indirect technique extent, it may become necessary to apply butgentle force the That the force direct is applied in the direction should used only fully have Clinically, those patients with lateral strain patterns of the sphenobasilar more severe problems. joint/cranial The of the:; th and 6th cranial nerves pass base strain of the tension upon tentorium cerebelli. with motor eye. We many cases of of in children by of abnormal tensions within tentorium treatment aimed at

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DYSFUNCTIONS OF THE CRANIAL BASE

cerebelli. These patients, some of whom were already scheduled for surgery, were able to avoid the invasive surgical technique. Also, the motor nerves to the eye pass through the superior orbital fissure, which is formed by the greater and lesser wings and the body of the sphenoid in conjunction with the frontal bone. The tensions imposed by lateral strain lesion patterns of the cranial base can easily be visualized to interfere with the free passage of these nerves through that bony orifice. Severe head pain is very common with lateral strain lesion of the cranial base. The first patient on which I (Upledger) used cranial osteopathy was a case of unrelenting headache of fourteen years' duration. The severity was such that the patient had been medically discharged from the U.S. Navy twelve years prior to our encounter, after having spent two years in a naval hospital. He had received disability pay since his discharge. The headaches had begun after a blow to the head inflicted by a shell casing during shipboard gunnery practice. The patient had been referred by a neurosurgeon for a therapeutic trial by acupuncture. Cranial examination revealed a severe lateral strain pattern of the cranial base. This problem was corrected during the first treatment. Neither the lesion nor the headache returned during a seven-month follow-up period. Since that first patient there have been many similar cases; most have resulted from trauma to the head. The direction of force of the trauma was usually oblique. In such cases, the head usually appears as a parallelogram when viewed from above. Personality changes frequently accompany the head pain. We have a tendency to say that the personality changes are of emotional or psychiatric origin. Often the head pain is attributed to a psychiatric cause. We have found that both head pain and personality disorder spontaneously correct when the lateral strain lesion pattern of the cranial base is successfully corrected. Occasionally, we have found personality disorder which improves upon correc­ tion of cranial base lateral strain and which has not been accompanied by head pain. This situation is less frequent but should be considered when personality change fol­ lows either mild or severe head trauma by as much as several months. After all, the examination for cranial motion distortion is quite innocuous when properly performed. Lesions, when found and corrected, can only work for the patient's good, whether or not they seem related to the chief complaint. Very often, lateral strain lesion patterns of the cranial base are imposed at birth during the delivery procedure. Our studies and research experience indicate that in children the most common result of the birth-inflicted lateral strain lesion is a learn­ ing disability, usually in the area of reading (APPENDIX I). Correction of the lateral strain has resulted in dramatic improvement in reading skills in several cases. We continue to collect data in this area and plan to publish the results by 1985. Of necessity, this type of study requires longitudinal observation of several children. The mechanism for the reading problems may be that lateral strain of the cranial base creates pressure upon the great superficial petrosal nerve as it passes through the foramen lacerum. This foramen is a fibrocartilagenous opening between the sphenoid great wing and the petrous part of the ternporal bone. This nerve (the.great superficial petrosal) has been shown to possess the capability of influencing occipital lobe blood flow in primates by 50% of total volume delivered (OWMAN and EDVINSSON 1977). If it is compressed in the human, it seems reasonable that visual association skills could be affected. Our preliminary clinical results support this concept.

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DYSFUNCTIONS OF THE CRANlAL BASE

In con junction dysfunction in lesion of the cranial parietal and frontal cases of cerebral palsy. to permit almost Remember that continue even when a ,",u"""'''' the tude

cases

S P HE NO B AS I L A R/ C R A NIA L BASE VER T I C A L The vertical strain significance and quently incapacitating sidebending and torsion. within the craniosacral ",,':rp'rrI trauma.

of the

are comparable in clinical are much more flexion-extension, .1". '- etiologically I-'"",-LU to result from ........

of the bulging slopes posteriorly inferior vertical strain strain and inferior strain to the (at the sphenobasilar union) in relationship to it contributes to that union (ILLUSTRATIONS 7-19-A, 7-19-B and 7-19-C).

If the sphenobasilar joint were a symphysis capable osseous shear, it is that vertical strain lesions from the joint which joins these two earlier, it is a upon it by

Illustration 7-19-A Sagittal Section through Human Skull Normal Anatomical Position

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1 17

DYSFUNCTIONS OF THE CRANIAL BASE

c Illustration 7-19-8 Vertical Strain

c Illustration 7-19-C Inferior Vertical Strain

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118

DYSFUNCTIONS OF THE CRANIAL BASE

sutural problems by a secondary strain pattern in its "'11,,"'\.)111 an aberration in its anatomy to if ever, within the union Therefore, cause must be the subject of a search through the membrane system and cranial sutures. Diagnostic motion utilivertical strain the vault holds therapist should conceptualize through axes points are eccentric to postulated axes of rotation of rotation about these transverse axes can induced All normal systems will tolerate some inferior strain. Lesion presence is motion in two directions. strain motions in cranial are two methods of inducing One is to stabilize to the sphenoid wings. The other and apply and the is to move both the when force is applied only to great vertical In testing for an anterior "nose-dive" wings of the sphenoid the eccentric contact points when wings of motion. A motion is induced at testing vertical strain. When force is to both occiput sphenoid in course of motion for superior strain, the occipital squama are encouraged to move sphenoid wings are moved inferiorly. motions are vertical strain. to the to the correction of vertical strain lesion is in the correction of lateral strain lesions since the two problems are clinical in physiological by use exaggeration to indirect If you find that the sphenoid moves easier in which indicates superior vertical strain, you should hold, but Take up barrier at the end of the motion in direction release or wait through as many cycles as are correction. reverse of technique is by this method, patient satisfactory paH"LU". If you cannot assistance may be If the correction is still not achieved, you may then resort Gently, to continuous ly, hold the against until a rection occur. You should improvement in motion symmetry. mobiliZing the strain lesion of cranial base, rn"rr'l£"r a search for the "v,v,,,,,,- factors which the extension rhythmic movements of craniosacral by vertical strain lesions, are to the presence a vertical strain is a system. motion of the results similar to those induced by strain patterns. may seem until one that craniodysfunction is the common source for unrelated

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DYSFUNCTIONS OF THE CRANIAL BASE

The vertical strain pattern of the cranial base correlates to, and may be the cause or effect of, undue tension upon both the falx cerebri and the tentorium cere­ belli. The falx (cerebri) is attached to the frontal bone, both on the cranial base and at the forehead. A bulging forehead, as found in superior vertical strain, will obvious­ ly stress the falx cerebri

(ILLUSTRATION 7-20).

The tension thus created is necessarily

transmitted to the tentorium cerebelli and the sagittal and straight venous sinuses. Dysfunction of the sutures of the cranial base also occurs when vertical strain is present. Especially affected are the sphenofrontal and sphenopetrosal sutures. This sutural dysfunction may then interfere with the function of nerves and blood vessels which pass through the various foramena which are formed along the paths of these sutures. Included among the affected foramena is the foramen lacerum, which passes the great superficial petrosal nerve. This nerve has a strong influence upon the blood supply to the occipital lobes of the brain. Also affected by vertical strain is the superior orbital fissure, which affords passage to the visual motor nerves. This anatomy may account for the frequent occurrence of visual problems which accompany the vertical strain lesion patterns of the cranial base. It must also be kept in mind that the anterior attachments of the tentorium cerebelli are to the clinoid processes of the sphenoid bone. The diaphragma sellae is strongly influenced by this double-layered membrane. The orifice of this dia-

Illustration 7-20 Membrane Model Demonstrating Tension on the Falx Cerebri with Superior Vertical Strain

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DYSFUNCTIONS OF THE CRANIAL BASE

120

hypophyseal infundibulum, which suspends of hypothalamus. The diaphragma sellae also "U'_''-',J,,'' sinuses. It is common for correction of vertical strain ,-L",.HAC''"''

base to result in "serendipitous" and concurrent improvement of endocrine function.

severe

strain patterns of the cranial base, severe head and personality disorders are the rule rather than the

pvrp,r.t.r.

disorder is one which manifests violent outbursts of been a fantasy of one of the authors to examine strain lesions; however, to date, time

not

cranial base dysfunctions described earlier in this problem. In both its clinical Slj.?;:nlIllcallce it is Significantly more severe. The clinical it can

are extremely varied

may seem

consistently occurring clinical manifestations of cranial sion of mood. I t is often diagnosed as an enaogeno It may also be an underlying etiologic agent childhood "autism" and allergies. We have tomical of cranial base compression the head.

"1'>"<>""#>£1

Illustration 7·21·A The Axes of Cranial Base Motion Distortion Extension and Transverse Axes for

-

Vertical Strain

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DYSFUNCTIONS OF THE CRANIAL BASE

Illustration 7-21-8 The Axes of Cranial Base Motion Distortion­ Vertical Axes for Sidebending and Lateral Strain

Illustration 7-21-C The Axes of Cranial Base Motion Distortion Longitudinal Axis for Torsion

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DYSFUNCTIONS OF THE CRANIAL BASE

122

Our point is simply that the thorough physician should always look for cranial base compression, no matter what the patient's complaint nor how unlikely it may seem that the clinical symptom or syndrome could be etiologically related to cranial base compression. Traditionally, the Cranial Academy and the Sutherland Cranial Teaching Foundation teach that compression refers to anterior-posterior impaction at the sphenobasilar joint between the sphenoid body and the occipital base. We would expand this concept to include any compression of the cranial base components in any direction, whether due to osseous impaction, sutural dysfunction or membran­ ous restriction (ILLUSTRATIONS 7-22-A, 7-22-B and 7-22-C). In our investigations of craniosacral system function in severely disabled children (cerebral palsied, autistic, seizure-disordered, learning disabled and the like), we came to the conclusion that careful physical examination of the cranio­ sacral system can differentiate osseous from membranous restrictions of the cranial base. In fact, we carried out a double blind study involving 63 children with Dr.

Temporal

Occiput

Illustration 7-22-A Cranial Base Bones Normal Relationship

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DYSFUNCTIONS OF THE CRANIAL BASE

Behavior Research in San in the field of child autism on the basis The child who rates Early Infantile Autism. Intermediate School that the more classi­ from a membranous (dura floor covering compression which was around the compass. restriction is elastic in quality as rigid quality of osseous restriction. we examined under who had Dr. Rimland. Only 5 had been diagnosed point. These children his +20 score as

Frontal

Occiput

Illustration 7-22-8 Anterior-Posterior Compression

of the

and Occiput

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DYSFUNCTIONS OF THE CRANIAL BASE

were rated on a scale 1 to 10 in terms of membranous and osseous restriction. A the most severe restrictions were as 10. normal mobility was A positive higher scores on and our own restriction to motian . •;;:La.uvu was significant at a 0.01 level of This is a P"�U'UA<'U4L that further investigation would be worthwhile. llI<1Ll'UH it is that

transmission of tension from a It can result antero-flexed coccyx, or from lumbosacral

Frontal

Temporal

Occiput

Illustration 7-22-C Lateral Compression of the Cranial Base

(Note the Occipitomastoid Suture Compression)

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125

DYSFUNCTrONS OF THE CRANIAL BASE

condyles

compression

articular

from emotional trauma, although we cannot

It also seems somehow to how this might occur.

E V ALUATI ON OF A NTE RI O R- P OSTE RI O R C OM P RESSI O N OF THE CRANIA L BASE vault patient using one is to compress the patient's head gently in an anterior-posterior

procedure is performed upon holds. The first

to

quickly treat transient or insignifiheld is induced

cant cranial base until a lateral }..HIJ"".l""lHJ'¥,

head is

during this phase such as torsion, motions of the

while continuing

point of release with its palpable lateral in response to your com-

lesion patterns are actually present and are pressive force.

compressive

The

is used?" Each

a different amount of compressive thought will to your hands.

happens in very gradually increase your force may be a flexion, a a strain force motion begins, that is occurs. will occur without any other lesion would seem to be the you find nothing the patient's slowly, \-vU'-''-U'cu,

presenting

a thing. If cranial base, if compressive force (Y:i to 1 pound) and not allowed for force more changes which

force too rapidly

"''''11'''111.11'', a closed

tell you

to receive and

feedback or

back to you. phase of the you are ready to attached to that

although vault hold, You should "�J'''';'':1VJ:Uso that, by and the skin of your

A gentle anterior ae'COln this force will be amount of lifting decompressive force is posteriorly.

lifting of the to further lighten

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the occiput sphenoid wings is to settle again.

126

DYSFUNCTIONS OF THE CRANIAL BASE

anterior decompression is

process repeated until the occiput

though it is free and balanced to problem cases, this one treatment,

totally achievable

who is monitoring it

as In

and the sphenoid may not may require several treatments.

As you perform the deICOlrnp'rel5S11{e

of

become aware that various cranial As you suspend the occiput patterns will often during the decompression sections of this ",'''CAH,;U

base is

traction effect cranial base sutures are of the brain and the internal hydraulic correction. Second, the attachments cesses of the sphenoid bone serve

You may have guessed by now that we use described above

occiput does not drop " you are dealing with a compression lesion means of learning to evaluate

the floor after "lighten­ cranial base. Experience is the time

When the occiput seems does decompress, but offers an you are dealing with a When you have applied this technique to many, like. The same is true in F- F--....,., ••

or in auscultating lungs and

reservoir of information in your cerebral data bank in of what you have no numbers can be You must evaluate on the basis judgments for which you are performing decompression is very forgiving.

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of lightening versus follows the anterior

of the occiput. If sphenoid as you raise it

'-A'-",".U",

127

DYSFUNCTIONS OF THE CRANIAL BASE

EVALUATION FOR

CRANIAL BASE COMPRESSION

with autism that concept, test treatment It was during our compression were developed. In an attempt to mobilnique lateral cranial ize many internally rotated temporal what we half-jokingly called the technique. It is a in almost have with temporal sutures. each ear is ultimately attached by collagen fiber to the bones. When you apply traction upon the the the traction U""'-VI.l! temporosphenoidal suture, ture and the medial junction hp'h"�>An basilar ears (pinnae) are gently rather than that of an irate manner

OCCiput

Illustration 7·23 upon the The Effect of the "Ear Pull" Sutures of the Cranial Base

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128

DYSFUNCnONS OF THE CRANIAL BASE

Posterior lateral traction is gently applied in as

bilaterally, as sion of the osseous ear canal. The traction is motions that come into turning or possible. Any interfered

they are passively

Gradually,

bones

ears will begin to move laterally. Continue your traction

as anchors of the

on both sides. If,

or release is has not

a reasonable

you may

at

the release will occur. powerful, period of time is or traction over a which will yet it does not invoke the tissue resistance guarding by the occur if your is too great and you are You can move a 1�O-foot yacht in the water and, for

to apply your

one finger if you are

period of time.

same is true in

over a prolonged

of

matter, in dealing with all

system

connective tissue

which does not stimulate tissue

body. Gentle, reaction is the rule

for maximum success.

would indicate that discussed above is so familiar to engineers. is essentially a is dependent solely upon

state of deformation.

to the the spring a

.... ,,� . '"'a.'".H'''

force. A constant amount

which which will result

Stiffness means resistance to deformation. Strength refers to

and stiffness should maximum load the spring will carry before it breaks. a spring, the rate of application of load When not amount load upon it is dashpot

load. The spring will return to its original rate of application of the

rp,",,,' p ':I'

imposed load is the important factor,

resultant

(ILLUSTRATION 7·24-A).

connective tissues

as muscle,

faScia, etc. ,

a combination of these two elements, the spring and the dashpot, as were in series. Bone, behaves as though spring and the in (ILLUSTRATION 7·24-B). research by Dr. and our department to date would 'H�U'-'''' ''-

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DYSFUNCnONS OF THE CRANIAL BASE

DASH POT

Time SPRING Il lustration 7-24-A Spring and

SERIES

3.

4.

PARALL E L Illustration 7-24-8 Effect of Loading on the Spring-Dashpot in Series and Parallel

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5.

1 30

DYSFUNCTIONS OF THE CRANIAL BASE

spring load is first accommodated by the stretch of the spring. Then, more slowly, the dashpot begins to move, taking the load off the spring as time passes. The tissue, therefore, has memory for the pre-loaded state as long as the spring continues to feel the load. When the dashpot has totally accommodated the load, and the spring is no longer on stretch, the tissue no longer remembers what it was prior to the deforma­ tion imposed by loading. This model illustrates very nicely the type of corrections made in the craniosacral system as we described the techniques above. From this model, it is apparent that all dashpots must accommodate all loads imposed in order for permanent corrective change to occur. This movement of the dashpot requires time. When the spring is no longer under load, the release is palpably perceived by the physician. In the parallel model, the dashpot (viscous element) requires time to respond to the load. But when the load is imposed over time, the dashpot responds by deform­ ing. This circumstance begins to place a load upon the spring. The transferrence of this load from dashpot to spring continues through time until the load is finally and completely transferred to spring. Later, if the load is removed, the return to the normal, undeformed state is carried out by the spring with resistance to this return initially being imposed by the dashpot. As the spring continues to load the dashpot, the undeformed state is finally reached and the load no longer exists. In the series arrangement, there is permanent deformation when the load is removed after sufficient time has passed. In the parallel arrangement, the material returns to its original state after some time has passed. The lesson to be learned from these models is that when dealing therapeutically with connective tissues, consider both the spring and the dashpot characteristics of the tissues. Collagen usually exists as a wavy, relaxed configuration. It does not assume a load until the elastin has been stretched by initial loading. The ground sub­ stance collagen contributes greatly to the viscous or dashpot response of the connective tissues. Careful attention to the feedback from the patient's response to your loading will successfully guide you through therapeutic techniques. The results you obtain will more often be permanent, and the accuracy of prognosis will be improved.

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Chapter 8 The Spinal Dura Mater and Sacrococcygeal COInplex occiput with the sacrococcygeal

dura mater, which connects through the �'-'��"'� Within this canal

where it is also known as

... "'.'u ..'u

forms a loose sheath for mater is represented below the

endosteal layer of the magnum by the vertebral

which

this canaL

membrane is considered to intracranial dura mater. Within the vertebral

osseous

mena, they are blending into the nearly transverse at the prolongations results in a

transmission of tension into the dural

(caudad) regions than orientation allows for more rn�eClOtn are when these ,

The subdural space

tubular dura mater is much

Most of this excess space is filled by the subarachnoid space, the spinal cord and the dural independent motion the dural sheath and The space bral canal

interval. This space contains venous 131

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THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

Dural tube

Horizontal cervical sleeves

Vertical lumbar and sacral sleeves Illustration 8-1 Directional Orientation of Dural Sleeves

tissue. and to the cranial dural restful conditions, functional anatomy of the dural connections between the occiput and the of

complex are such that movements

occiput are duplicated at the sacrococcygeal end; conversely, movements of sacrococcygeal

longitudinal

dura mater within

of

are duplicated at the occiput. This occurs

the

which is

of the

vertebral canal.

same dural the occiput or symptoms at both ends

are

restrictions to motion sacrococcygeal complex

are

the spinal dura mater. It is often by this mechanism

head and lower back pain occur concurrently. It is also by virtue of the attachments of the spinal dural bodies of the 2nd and 3rd cervical vertebrae that

upper cervi-

and regions of osseous

at any one dural

With

the

it will fre-

quently spread as symptomatic pain and dysfunction to all three regions of the body. somatic dysfunction of significant In addition, any spinal or can restrict dural tube mobility and thus as secondary any or all

of osseous dural attachment.

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THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

Given

functional conditions

above, it is easy to understand

importance and usefulness of techniques which the spinal dura mater. mobility of this dural

the freedom of motion of can be

somatic dysfunctions

upper

sacrum, the coccyx

sheath mobility can

be

for various ,.uO'''"�'
with the continued hydraulic

motion of the latter techniques the spinal dural membrane. Hence, the

imposed upon osseous
when attempting to mobilize the spinal dura mater. EVALUATION O F SPINAL DURAL of the

MOBILITY

tube is best evaluated

simultaneously
occiput and the sacrum. This can best

accomplished by one to have two

person; however, when learning and gaining experience, it is therapists together on a When alone, the comfortably about 2-4

or on an air mattress. You sit side so that one of your hands can the patient's sacrum

tabletop foam padding or air other hand cradles the occiput. The purpose of gluteal and sacral mattress is to allow your hand and arm to pass under the on the tabletop.

upon the

areas with

It is important when evaluating dural tube mobility within the vertebral that

factors

by That

examination the examination

in a tissue response of and must

not in an alteration osseous motion of occiput or the complex. Artificial alterations in motion can only too easily induced; and incorand, ultimately, to

rect information to incorrect diagnostic cannot treatment. We comfort

the

connective tissue

the examination

physiological motion as it

sacrum extension motions of these two

not as it

correctly placed one hand under the you can evaluate and sacrum seem to move in syn-

system. axes of chrony and parallel in response to the rhythm the rotational movement of occiput sacrum are transverse (ILLUSTRATION 8-2). The tube connectors Remember

probably the anterior

longitudinal

two osseous flexion and extension are rhythmically

of the craniosacral system. During

act as movements

flexion phase the anterior dural

anterior longitudinal ligaments are

and

in a cephalad direction. This results in the sacral apex moves rotational movement of the sacrum, as illustrated, in and During the extension phase of motion the posterior posterior longitudinal ligaments are tensed cephalad while the anterior connectors

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THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

SACRAL OCCIPITAL

Flexion ---Dural membrane ---­

Flexion

Axis of rotation

\/

Illustration 8-2 Mechanism of Occipital-Sacral Synchrony

are relaxed. This results in an anterior movement of the sacral base as it rotates about the postulated axis in the illustration. As you tune in to the movements of the occiput and the sacrum at the same time, there are several questions which must be answered: 1.

Are the sacrum and occiput moving freely and in synchrony with each other?

2.

Is one of these two bones lagging, or moving in time, slightly behind the other?

3.

If there is a time lag, does the movement of the lagging bone seem to be coming from a restraint or drag imposed upon it from outside the dural membrane? Is it coming from your hand or from an extrinsically attached muscle or ligament?

4.

Does the lag seem to be coming from somewhere between your hands?

5.

If you sense a dural tube drag, can you locate the position of drag? Is that area tender to palpation? Is it within the dural tube, or on one of its spinal nerve sleeves? As you answer these questions after experience with more patients, you w!ll

develop skill in localizing the causes of restriction to the free mobility of these two bones, which represent the osseous attachments of the extremes of the spinal dural tube. As a learning experience it is beneficial to slightly inhibit the motion of either the occiput or the sacrum with one of your hands, and then to note the effect of this artificial restriction upon the motion perceived by the other hand. When two therapists are working together to evaluate the mobility of the spinal division of the craniosacral system, one examiner uses the occiput while the other uses the sacrum. For the therapist at the head end of the patient, it is often beneficial to use a vault hold (CHAPTER 7) so that the effect of the sacrococcygeal complex can be perceived not only upon the occiput, but upon the whole cranial vault. This is an excellent learning experience.

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THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

1 35

The therapist at the sacrococcygeal end of the patient should place the arm between the supine patient's legs and the hand under the coccyx and sacrum. The sacrococcygeal complex is situated so that the sacral apex is in the therapist's palm; the sacral spine is between the therapist's third and fourth fingers, and lies parallel to them. The therapist's finger tips may be at the level of the transverse processes of the 4th or 5 th lumbar vertebrae, depending upon individual hand and sacral size. It seems that the more weight which the sacrococcygeal complex therapist places upon his or her elbow, the better-so, lean on it. Do not try to feel with the hand which is under the sacrum. Try to meld your hand with the sacrum and allow your hand to move with it. When this has been achieved, observe what your hand is doing, that is, what the sacrum is doing. This application of the hand to the sacrococcygeal complex is identical to that which is used when there is only one therapist (ILLUSTRATION 8-3).

After both therapists have tuned in to the patient in this manner, they should communicate what is happening at the two ends of the spinal dural tube. The same questions should be answered by both therapists. One of the therapists should then impose artificial restrictions to gain perceptual experience about what a sacrum feels like when an occiput is restricted, and vice versa. The therapiSts can also impose deep paravertebral pressure upon the patient to perceive the effect of paraspinal somatic dysfunctions upon the function of the craniosacral system. CAUSES AND TREATMENT OF RESTRICTIONS TO SPINAL DURAL TUBE MOBILITY Causes of dural tube motion restriction which originate within the intracranial membrane system have been discussed previously. Suffice it here to say that each

Illustration 8-3 Hand Position for Palpation of the Sacrum

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1

THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

restriction pattern

its tube occipital motion include all of muscles, to this pivotal of the In most

is more than one inch thick.

muscles may

individually (CHAPTER 13). For our present purposes, however, considered in When mobility is by the dural therefore

the

throughout

craniosacral

"uC'�""cn

understand that abnormal connective tissue an dealt with effectively

at the occiput must accurate evaluation of craniosacral The technique release of the

motion can base (CHAPTER 5) is our usual

general tension placed upon the occiput its connective tissue attachments. This also the atlanto-occipital joints, of the frequent source of occipital restriction. cause system

to use dysfunctions which are influencing to use

sensitivity required to

sitting or while the of the neck into maximum relaxation or are beginning, you will to resor t to a to

maximum relaxation of

pOSitioning is necessary. After patient's itself to

proper

As some

the head. In the and error. In gentle it will seem as (APPENDIX E).

the optimal position changes.

is a dynamic,

not a static treatment

Our with connective tissue has shown such tissue literally posseses memory (CHAPTER 7). As you been

or stressed, the strain or stress I-'''''''"''U as correction occurs, you will heat emanating

area you may notice a rather rapid, pulsating activity. The pOSition

of involvement;

until both heat emanation and pulsation cease. If the position is to the end achieved.

corrective

are many

full

somatic dysfunctions (MITCHELL

1979); in expert hands, most of these

described is noninjurious. with effective. are most yet to encounter a transient nature which

effect

The method which we this method is extremely Use

technique you

proper

effect.

somatic dysfunction of more

not express itself as a drag upon the spinal

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tube.

THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

137

/

Illustration 8·4·A Position and Hold Technique for the Neck Patient Seated

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138

THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

Illustration 8-4-B Position and Hold Technique for the Neck Patient Supine

can be of spinal When found, significant its motion restriction. in to and which is effective is Once again, any technique at which you are The correction of the somatic restriction; dural therapeutic success. are three

methods, all

will

are

and

remove the

mobiliz-

ing the spinal dural tube and correcting contributing paraspinal problems. The is to exercise dural tube motion both but and sacrum, gently, but encourage the the motion encourage an increase in the way; as you

of motion through 30-50

Frequently, you can overcome dural membrane restriction the paraspinal somatic dysfunction will paras pinal !eSlOflS

method

function is the of CV-4 (CHAPTER 4). As patient progresses rhythm, they in the somatic dysfunction as they approach

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THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

139

pain will usually disappear. As long as the pain can be induced by CV-4 application, the somatic dysfunction is present. When the pain can no longer be induced, you have corrected the somatic dysfunction. The third method of mobilizing paraspinal somatic dysfunction is simply the "direction of energy." This technique is based upon the fact that all living human beings are batteries, generators and capacitors in the literal, electrical sense. Your skin is the insulator which holds in your electricity and which protects you from environmental electrical phenomena which could interfere with your electrical health and functioning. When you place your skin into intimate contact with the skin of another human being, some of the resistance of these two insulator skins seems to be lost. Ultimately, the two capacitors (you and your patient), by virtue of the increaSing conductivity of the skin, become one. Although this may sound rather romantic, it can also be used therapeutically. When a paravertebral somatic dysfunction is discovered, you need only place one finger over each of the transverse processes of the involved vertebra, and the other hand very gently upon the top of the patient's head so that the parietals and their sutures are mostly covered by this hand

(ILLUSTRATIONS 8-5-A

and

)j

Illustration 8-5-A Correction of Somatic Dysfunction by Direction of Energy - Patient Prone

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8-5-B).

140

THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

Illustration 8-5-8 Correction of Somatic Dysfunction by Direction of

Patient Seated

you will a motion is autonomously beginning to move. though involved occurs, gently follow the motion while maintaining your contact over the transverse processes. Usually next occurences will be heat pulsating at locus of the somatic dysfunction. Continue your until motion, heat and pulsation are all no The somatic dysfunction has at this time. OccaSionally, a somatic dysfunction involves a

problem this technique to totally correct. In such cases, a simple joint correction. to complete after the direction of energy may be of energy somatic dysfunctions which seem to corrected by the severe

are those

are maintained

soft tissue contracture rather

craniosacral system dysfunction is

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by of the

141

THE SPINAL DURA i\l1ATER AND SACROCOCCYGEAL COMPLEX

attempt at (ILLUSTRATlONS8-6-Aand

Bring your

patient. It is sometimes hand in from the patient's

vertebrae are between your spines with the fifth finger in space

which are

spines of the 5th lumbar

rc:� \ .

Hand supporting sacrum

Lumbosacral

Illustration a-6-A - Hand Placement for and Treatment

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142

THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

p ��------�-

Illustration 8-S-8 Lumbosacral Decompression - Position for Examination and Treatment

the 1st

finger is between the spines of the 4th and The rest of your fingers support the lumbar

5th lumbar vertebrae. spine. Now stabilize

with one of your hands. the sacrum, apply a caudad traction upon the sacrum. This traction very small

and is

The 5

lumbar

a and 1st

you will tissues

to contract against you. This tissue

reduce traction. localized osseous

the

you should

no separation of the lumbosacral junction occurs, you have a For treatment, hold the force that

your traction

of tissue response until

may several minutes. the same treatment until

is some separation but still some occurs. The restriction very seems to correct pulled in a ratchet-fashion, alternating from side-to-side like a drawer that is out when stuck. When

must be Repetitions of correction are usually

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THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

branes possess memory and require repeated reeducation sessions. It is

if two therapists can the lumbosacral

on these cases. One the other simulta-

head. This can provide a treatment which we have

useful, and which we

decompression of the as levers (ILLUSTRATIONS lumbar vertebrae and

have been

,,.",UA''''''' U

8-7-A

junction, is to flex and 8-7-B). The patient's body is applied. the fulcrum

added to the suprapubic area to This technique 1-''''''''''''' lumbosacral compression

-----

---

;/

Jf

Direction of traction to the sacrum

Illustration 8·7·A Use of

as Levers in Lumbosacral

DecompreSSion - Hand Position Relative to Bony Structures

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144

THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

Illustration 8·1·8 as Levers in Lumbosacral Added Suprapubic Force

a slow application of If the pelvis tends to tissue relaxation permits more

n,.(�r"·"'11

legs should be

allowing the tissues to or rotate as you flex, allow this to more flexion, continue to take up the slack. the knees should not back off a

is painful, you are use this technique initially.

we use it after rU1.rn-,I>" locally at the lumbosacral junction. It is often benefiCial to have a second is performed. LU';l ...�">L UiUi:lLll\..C: the cranium as

"'-',",VA.U

factors

sacrum's ability to muscles and ligaments

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145

THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

joints. arise from the anterior sacrum from the grooves lC;�LUlHJ=; sciatic foramen and Insertion of the piriformis sciatic foramen is via a tendon into through the greater trochanter of posterior to tendon of the internus and the gemelli. branches of the 2nd and sometimes of the 1st muscle acts to

rotate

Cut end of gluteus maximus m. _fl--
... '"' with is innervated by ." . ....

n

lumbar nerves. The It may also have some

,...---'<--+-- Piriformis m.

'''+I�- Femoral head

Knee

I \

il\ Illustration 8-8 Piriformis Muscle

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146

THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

Contracture of this muscle is common in patients suffering from lower back pain and sciatica. It will always serve to drag upon the sacrum, and therefore the mobility of the craniosacral system is at least partially compromised when the, piriformis is abnormally hypertonic. This deleterious effect upon the craniosacral system may explain the general malaise and personality change which frequently accompanies piriformis muscle problems. The piriformis muscle, when unilaterally hypertonic, has a tendency to pull the sacrum to one side. This situation of sacral position will be duplicated at the occiput. There are many techniques for correction of piriformiS muscle hypertonus. One of the most effective in our experience makes use of the principle of reciprocal innervation. The patient must perform an exercise which tightens the opposite piriformiS for 3 to 5 minutes, at least three times daily and whenever the affected muscle is painful (ILLUSTRATION 8-9). The exercise is performed by having the patient lie on the floor parallel to and with the good (non-painful) side next to the wall. Under your direction, the patient must be taught to palpate the tight piriformis_ Then, while lying on the floor, the good leg is flexed at the hip with the knee comfortably flexed, until the tissue change is palpable in the contracted piriformis. While maintaining this degree of thigh

Knee pressing directly against wall

t

+

Hypertonic piriformis

Illustration 8-9 Self-Help Exercise Used to Relax Hypertonic Piriformis Muscle

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THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

the tight piriformis with a non-involved side against the wall in a and continued until the tight when this relaxation is times daily will cause the chronically contractured over a period of days to weeks. As more efficiently. muscles are the flat, triangular arise from the superior two-thirds of the anterior sacroiliac and iliolumbar The fibers converge as the

inserts into the hip joint and

psoas major, the lesser femur. The iliacus muscle is nerves, H'�W�"�

of the femoral

originate from the 2nd acts to flex the thigh and tilt the in a state of abnormal contracture,

extension corresponds to motion (ILLUSTRATON 8-10)_ Unilateral contracture which is mimed by the occiput.

-'r"If\--

Quadratus lumborum m.

Iliacus m.

Illustration 8-10 Iliacus Muscle (Arrows Indicate How This Muscle Can Interfere with Free Sacral Mobility)

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148

THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

extension

in the occiput and

cranial

in the whole

are numerous. It is our experience that

mobilization

by the direction of energy techniques

described

Reciprocal innervation

flex the thigh muscle. The lines, sacrum throughout its entire length, the dorsum

dorsum

masses, coccyx and the

They insert into the gluteal tuberosities

sacrotuberous the iliotibial

the fascia lata.

the femur and

innervation of the

the inferior 1st and 2nd The of the thigh. muscle

sacrum and rotate it

the

away from

sacrum, which causes a drag upon

the craniosacral The gluteus maximus can be relaxed

utilization of the

of recip-

rocal innervation or by means of deep pressure upon the motor

(ILLUSTRATION

8-11).

Deep pressure can be performed by a thumb, a knuckle or even an elbow. until at the locus of maximum

Pressure should the muscle is

to have up of fasciculi which grooves vertebrae from axis to sacrum. The

The multifidus processes

on both sides of

on the vertebrae, processes above

two to four segments

insert into

(ILLUSTRATION 8-12).

is innervated by

branches of the it extends the spine acting laterally. Multifidus hypertonus contributes to sacral immobility, when bilaterally craniosacral system When

sidebends the spine

it promotes base as Hypertonus of described The

.... CJeAUlHh or

motion patterning. multifidus is effectively treated by the position hold in this chapter decompression of lumbosacral the supine you will

are flexed toward multifidus relaxation.

The complex of the pelvis all sacral motion in a state of unbalanced tension. These tensions are treated by mobilizing the pelvis

the pelvic

ments which must It must also be attachments (as do in the appro priate sacrum. Two very common injuries which are often

underlying cause

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As you

149

THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

��"""'M�P �rn- ressure point

Illustration 8-11 Gluteus Maximus Muscle

sacrum between of the sacrum between where

ilia, and anterior ilia occurs from a fall upon

downward motion of

a hard surface, and the momentum

ischial

tuberosities is suddenly halted

the sacrum and

ilia. Seldom sacrum drive it caudad so is usually a sidebending

structures above sym-

this occur

lesion

TION 8-13).

The

treatment for grasp

condition is to

sacrum between the index

finger inside the the and thumb. the ilia

other hand and move the sacrum cephalad until it "floats 1-'<1','''' ',«

is best placed in toward the

exert posterior

" or mobil-

lateral recumbent position with the by h�ving

Patient assistance may be upon both anterior

of the ilia spread laterally and aid in

so that the

iliac

impacted sacrum.

is another very common cause of Anterior flexion of the coccyx due to autonomic dysfunction. Anteroflexion of the coccyx causes cephalgia and tension to be transmitted through

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of

dural tube to

150

THE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

Illustration 8-12 The Multifidus Muscles

the

magnum. It can then

transmitted via

falx rp.'rp.I",'"

falx as a sinus, to and may, on occasion via the flax rp"pn,.; show headache. More often, tension disseminates it reaches the occiput results in of

The treatment for position. Insert

the patient in a lateral

coccyx is to

in the rectum. Gently grasp

coccyx

finger, gently but firmly mobilize it. between the thumb and the ilia anteroflexion both in cases of sacral impaction of

coccyx, the headache can immediately and

""""..,,&,<>'"

sacrococcygeal

This circumstance

and

by lesion ex-

a cause

somatic dysfunction and head pain. Similar cause can often be pelvic

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sacrococcygeal com-

TIlE SPINAL DURA MATER AND SACROCOCCYGEAL COMPLEX

Illustration 8-13 Sacrum and Ilia (Arrows Indicate Direction of Compacting

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151

Chapter 9

Diagnosis and reatment of Osseous and Sutural Dysfunctions of the Cranial Vault In

cranial base, which is chapter we will

,,,,,,, .. ,,.rt

in Chapter 7.

is its sides and roof.

Embryologically, the

sides and roof from vault which do

squama and are

lambdoidal, the sphe­

sphenosquamal, "nnpnn �<:;l'H<:;·'" to cranial vault have

discussed pre12, which

or will be discussed temporomandibular

suture determines the type has taught that Traditionally, Western or synarthroses (PRICHARD 1956,)ACOB and FRANCONE have been regarded as Uld.LlUH

joints. The are united by

in which contiguous demonstrates that sutures component bones

small

(RETZLAFF 1978, APPENDIX G,

contain connective tissue, In our we

vascular traced a single into brain. I

through the third as in the sagittal suture.

as are the teeth suture.

work

is presently in progress by Retzlaff, et . • 1.

152

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saw. An example

153

OSSEOUS AND SUTURAL DYSFUNCTIONS OF THE CRANIAL VAULT

Frontal

Parietal

Illustration 9-1 Types of Sutures on Exploded Skull

3.

Sutura lumbosa: in addition to the interlocking, there is a beveling so that the bones overlap one another, as in the coronal suture.

4.

Sutura squamosa: formed by the overlapping of contiguous bones with very broad, beveled margins. An example is the temporoparietal suture.

5.

Sutura plana: simple apposition of contiguous rough surfaces, as in the inter­ maxillary suture.

6.

Schindylesis: a thin plate of one bone is received into a cleft formed by other bone(s). Examples of the schindylesis can be seen between the vomer and the ethmoid, and between the vomer and the maxillae-palatines as they form the hard palate.

7.

The synchondrosis is not strictly a suture. It is illustrated by the cartilage bridge formed between the occiput and the sphenoid. Our own impressions suggest that in the sutures which present interdigitation,

the longer the digital projections, the greater the motion in that region of the suture (ILLUSTRATION 9·2-A).

The squamosal suture components are beveled and grooved. This morphology indicates the direction of motion which these sutures perform

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(ILLUSTRATION 9-2-B).

154

OSSEOUS AND SUTURAL DYSFUNCTIONS OF THE CRANIAL

V AULT

IIIustration 9-2-A

Varying Lengths of Digits at Sagittal Suture

Dr. Sutherland and his followers postulate specific movement around specific axes for each of the cranial vault bones. When you consider the cranium as a mechanical model, it does indeed become obvious that movement of one bone induces movement in other, related bones until the whole cranium is seen to move in response to the initial driving force (MAGOUN 1966). Our contention is that the driving force is the changing fluid pressure: the cranial bones move to accommodate these subtle changes in cerebrospinal fluid pressure. When one suture or bone of the cranial vault becomes restricted in its motion for any reason, it causes a distortion in the motion of the whole cranial vault as adjustment is made for this localized motion restriction. The CV-4 technique is an example of iatrogenically induced restriction of occipital bone motion. The result is a small but Significant increase in the motion of all other sutures and bones of the craniosacral system. If the CV-4 technique were to be continued long beyond its therapeutic usefulness, it could become a severe restricting lesion to the cranio­ sacral system, as in occipital somatic dysfunction.

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OSSEOUS AND SUTURAL DYSFUNCTIONS OF THE CRANIAL VAULT

155

Illustration 9-2-8

Beveled and Grooved Temporoparietal Suture

ACCOMMODATIVE MOVEMENTS OF THE CRANIAL VAULT BONES In order to gain a view of the accommodative movements of the bones of the cranial vault, we shall consider these bones individually. Although we present postu­ lated axes of motion for each bone of the vault, you should keep in mind that the best way to discover the typical movements of the cranial bones is not to learn them academically but to experience these movements perceptually. The movements vary from one patient to another. The norms vary for each vault bone. The movement is dependent upon many factors, not the least of which is head shape. We are most interested in the quality of the motion, whether the per­ ceived movement is smooth, whether the bone is moving against resistance, whether the range of motion is abnormally limited, etc. If a vault bone seems to be moving freely but in a motion pattern which deviates from the model which we shall pro­ pose here, you should catalog this fact in your mind but do not necessarily attempt to "normalize" its motion pattern, or even consider it as abnormal for that patient. In order to understand the movement of the cranial bones it is essential that you experience the motions of many crania. You may not be able to verbally describe what you feel, but you will perceptually understand the movements and, ultimately, their meanings and related symptoms. SPHENOID

As the sphenoid moves into the flexion phase of the craniosacral motion cycle, its posterior aspect moves cephalad, and its anterior parts take an anterior-inferiorly directed "nose-dive." The transverse axis of rotation is approximately halfway between the anterior and posterior borders of the body, when cut through the mid­ sagittal plane. It is horizontally level with the bottom of the sella turcica TRATION 9-3).

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(ILLUS­

156

OSSEOUS AND SUTURAL DYSFUNCTIONS OF THE CRANIAL VAULT

FLEXION

EXTENSION

Illustration 9-3

Sphenoid and Occiput (Note Transverse Axes)

As the sphenoid bone rotates about this axis during cyclic flexion and exten­ sion of the craniosacral system, the great wings have a significant effect upon the vault bones with which they articulate, namely, the frontal, temporals and parietals (ILLUSTRATION 9-4)-

Additionally, it must be kept in mind that the sphenoid in the

cranial base works in conjunction with the occiput, the ethmoid, the vomer and the petrous temporals

(ILLUSTRATION 9-5)-

When you consider the effects of the sphenoid

upon the other bones of the floor, sides and roof of the cranial vault, you must also keep in mind the secondary concurrent effects of all of these bones upon other bones with which they articulate. The eccentrically placed great sphenoid wings rotate anteriorly at their superior borders during flexion. The sphenoid, via the sphenofrontal suture, therefore induces the inferior part of the frontal to move anteriorly. Since the axis of rotation of the frontal is above the bone margin affected by the sphenoid wing, the frontal rotates in the opposite direction. At the same time the ethmoid, influenced by the sphenoid body, is helping to carry the transverse axis of the frontal bone anteriorly and may thereby act against the effect of the sphenoid wings upon the

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OSSEOUS AND SUTURAL DYSFUNCTIONS OF THE CRANIAL VAULT

Illustration 9-4 Vault Articulations of the Sphenoid

Axis for ethmoid rotation

Axis of rotation Axis of occipital rotation

�t)

Illustration 9·5 Interrelated Movement of the Cranial Base Bones During Flexion

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157

158

OSSEOUS AND SUTURAL DYSFUNCtIONS OF THE CRANIAL VAULT

frontal. Our impression

frontal motion during flexion is

rotation about a transverse translatory axis which is

a posterior in an anterior

direction. The

margin of the

anterior

of the

wing

sutural contact

therefore,

wing is very to the axis of rotation of the is probably more to inhibit to activate influenced . The

the

sphenoid

squamous. This

temporal bone, effect upon

occiput, in turn exerts a

suture, with its in bevel, (ILLUSTRKflON 9-6). a wobbling motion between these two bone

",uu,-uv'"...

Illustration 9·6 Among the Sphenoid, and OCCiput

TEMPORAL BONES

about bilateral axes which are ex· auditory and internally pass U'�''"''''' '

bones to

medial junctions at

as they and cause a wobbling rotation of the craniosacral system motion, the superior This broadening

of the temporal squama increases the transverse between

paired temporal squama, ...... I'1, ... ,J, is referred to as movements are during motion: the transverse distance

with the anterior rotation of the temextension

of cranio-

the superior of the bones decreases as these margins move posteriorly. This movement is internal rotation ly rotate during

the temporal system

(ILLUSTRATION 9-7).

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All paired bones internally rotate

body externalextension

OSSEOUS AND SUTURAL DYSFUNCTIONS OF THE CRANIAL VAULT

159

EXTERNAL ROTATION

INTERNAL ROTATION

Illustration 9-7 Temporal Motion (Note Axes and Difference in Distance Between Squama)

OCCIPUT

During the

phase of craniosacral system motion,

anterior occipital

base (basiocciput) moves cephalad; the squamal part moves inferiorly and anteriorly the foramen magnum, approximately in an arc about a transverse axis located with line. As the occiput moves into in fluid pressure, it drives bevel

temporal into external rotation.

is at the point

the

of the occipitomastoid suture (ILLUSTRATION 9-8). BONES

to glide squama are other as long as they don't This means that when rotation, superior margins move anteriorly into also move forupon

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160

OSSEOUS AND SUTURAL DYSFUNCTIONS OF THE CRANIAL

Illustration 9-8

Relationship Between Occiput and Temporal (Note Axis)

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V AULT

OSSEOUS AND SUTURAL DYSFUNCTIONS OF THE CRANIAL VAULT

161

This anterior motion is allowed by the lambdoidal sutures. The of

sagittal suture.

THERAPEUTIC TECHNIQUES FOR THE CRANIAL PARIETAL LIFT

parietal bones are mobilized by a technique called parietal To perform this seated above the patient's head. Your you should lateral are placed gently in contact The fingerpads of the fingers are in the lambdoid sutures and of hand are

of the

above the temporoparietal sutures. about one centimeter apart and must

temporoparietal sutures (ILLUSTRATION 9-9). Your thumbs are now crossed upon each above the head. They not touch scalp. Then, after finger pressure is exerted to compress the lateral (ILLUSTRATION 9-10).

will not work and may, in

temporal

are

precipitate a worsening of

clinical

symptoms. The amount of pressure exerted on the parietal bones is on the order of5 the hands. This grams. The thumbs, in contact with each other, are used to pressure on only theparietal bones is 5 minutes will suffice). As the

Illustration g-g Finger Placement for Parietal Lift

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3as

162

OSSEOUS AND SUTURAL DYSFUNCTIONS OF THE CRANIAL VAULT

Illustration 9-10 Hand Position for Parietal Lift

though the

bones are very slightly-allow horleS. Do it gradually; this to happen. Do not suddenly release your pressure on you may cause the this release is felt, to worsen. Usually, the patient will remark that pressure within the head has been relieved (APPENDIX DJ. FRONTAL LIFT

The frontal seems to rotate posteriorly while its axis moves anteriorly; it also seems to broaden as As we

during the flexion

of craniosacral system

suture was still patent. at

beginning of the

ments

vault bones of the cranium is to tion in normal motion of frontal bones from

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way to learn the movethem with your Variais

OSSEOUS AND SUTURAL DYSFUNCTIONS OF THE CRANIAL VAULT

carries

motions

them; a1l

examiner should do is

motion as much as possible, then study the motions that are is that frontal bones do. When a frontal bone

of it

UHO.-.CH

not seem to be

frontal lift (ILLUSTRATION 9-1 1). With frontal

so that your third or lateral to orbits of eyes. An anteriorly bone, traction is then applied until frontal bone is felt to restriction becomes are Frequently,

in order to mobilize below. or

frontal seems to be

cerebri. This type of restriction

an elastic resistance to your lifting

show

the

traction. When this occurs, simply use a direction of energy technique cerebri placing one fingers of

is perceived (ILLUSTRATION 9-12). The energy is best directed at

of

occiput pointing at the anterior falx

other hand should be laid

to, and on side of will first heat, activities then pulsating, then some movement as the releases. When all you may the frontal lift the direction of energy technique.

anterior falx

attachment to the

to evaluate your results. Specific corrections

sphenoid

occiput

been

Illustration 9-11 Hand Position and Direction of Traction for Frontal Lift

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in

7

164

OSSEOUS AND SUTURAL DYSFUNCTIONS OF THE CRANIAL VAULT

>-I'--+-:A ::::i--t-- ffected area

Illustration 9-12 Hand Position for Direction of Energy Technique to Falx Cerebri

and will be further considered in Chapter 10. Specific techniques for temporal bone dysfunctions are described in detail in Chapter 11. SPECIFIC SUTURAL RESTRICTIONS Specific sutural restrictions (APPENDIX D) are best treated by the direction of energy technique. To perform this technique, place the pad of one of your fingers upon the restricted suture and point across the greatest diameter of the cranial vault. Gently palpate the part of the cranium toward which you are pointing with your whole hand. After a few seconds you will perceive a pulsating motion with your palpating hand. When you feel this pulsation, place one finger of your palpating hand upon the center of the pulsating area, and point directly across the cranium at the restricted suture. Then gently place two of your fingers on either side of, and approximately parallel with the restricted suture. It is as though you will receive the energy between these two fingers which you are sending from the other side through

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165

OSSEOUS AND SUTURAL DYSFUNCTIONS OF THE CRANIAL VAULT

Illustration 9·13 Hand Position for Direction of from Hard Palate

you will

heat

pulsation at

Technique

restricted area, then

finger) will begin to move independently of each other as if motions very struggling to loose. You should encourage these correction been gently. Finally, when you feel release and are

by

of the <-.del'li,u

energy from the

palate (ILLUSTRATION

the directing finger patient's mouth, point at receive with your other fingers placed parallel to the

9-13).

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restriction suture on

166

OSSEOUS AND SUTURAL DYSFUNCTIONS OF THE CRANIAL VAULT

Illustration 9·14 Finger Placement for Receiving Energy at Junction of Three Bones

external surface of the patient's head. If the restriction involves the juncture of three bones as it would at the bregma, three receiving fingers may effectively be used, one on each bone, while the energy is directed with the other hand (ILLUSTRATION 9·14). Although we do not know the mechanism of action of this technique, it has been very effective in our hands and in those of many of our students. Try it before you reject it as being too esoteric.

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Chapter 10 The Occipital Condyles

occupy a critical position in

system at dysfunction of the occipcranium and the is never without serious consequences. Do not overlook the possibility ital of occipital as the cause of a multitude syndromes. Although it

said that a chapter devoted solely to one of one bone is we hope that by upon the occipital

not in the best

to better understand their

condyles you will

EMBRYOLOGICAL DEVELOPMENT OF THE In to get a the embryological skull are found in

in the body as a whole.

'-J'-''-'.U.

for the occipital condyles, we must r. .... ,,..p,,,t

area up and This vessels are

look at

of the skull itself. The region and brain the membra-

is interrupted by spaces nerves and blood passage into and out of this membranous vault.

Before develop into

is completed above, so that the cranial base is cartilagenous

By the end of the fourth of the cranial vault are cranial vault enclosure is usually completed. The cartilagenous of the base of mesodermal growth centers located on both sides of the of the foramen will ultimately form the anterior occurs. Lateral growth occipital condyles are of the occipital primitive brain to

centers will form the from these centers. It is its nuchal plate develops of the

Occipital encounters cartilage basilar synchondrosis is As the occipital capsules. The

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area begins to and roof the

168

THE OCCIPITAL CONDYLES

the foramena lacerus and the sutures which separate the occiput from the petrous temporal bones. The cartilagenous ossification centers give rise to all of the bones of the occiput (except the interparietal squama), the petrous and mastoid parts of the temporal bones, the sphenoid (except for the pterygoid plates and the parts of the great wings which are most lateral), and all of the ethmoid bone. The rest of the cranium is formed from membrane. At birth, the condylar parts of the occiput are not ossified completely; there is still cartilage present. The presence of this cartilage allows for some flexibility. If and when the condylar parts of the occiput are forced anteriorly during hyperextension of the head on the neck as a phase of the delivery process, they may become wedged into the narrowing receptacle formed by the articular surfaces of the atlas. If the self­ correcting hydraulic force of the craniosacral system fails to correct this circum­ stance, and if craniosacral treatment is not effectively performed, the condylar com­ pression may persist (ILLUSTRATION 10-1). Since cartilage is somewhat malleable and bone grows in the direction of lesser resistance, this compression or jamming of the occipital condylar parts between the receiving articular surfaces of the atlas can easily result in abnormal growth and

Illustration 10-1

Inferior View of Fetal Skull (Arrows Indicate Direction of Condylar Compression)

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169

THE OCCIPITAL CONDYLES

morphological development of the occiput. This will contribute to asymmetry of the skull and its dural membranes (ILLUSTRATION 10-2). As a result, malformation of the foramen magnum, the occipital condyles, the hypoglossal canals, the foramen lacerum and the jugular foramen may occur. The clinical implications of these mal­ formations are extremely varied and may be very serious. Through the foramen magnum passes the caudal end of the medulla oblongata, the meninges and their blood vessels, the vertebral arteries, the accessory nerves, the anterior and posterior spinal arteries, the tectorial membranes and the alar liga­ ments. Abnormal pressure about the foramen magnum which results in its deformation can therefore indeed set the stage for problems resulting from pressure on any of these structures. Compression of the condylar parts can easily result in hypoglossal canal mal­ development. This condition gives rise to clinical symptoms relating to dysfunction of the hypoglossal nerve, e.g., motor coordination problems, atrophy or mal­ development of the tongue. The compression of the occipital condyles between the articular surfaces of the atlas may also interfere with normal function of the suture between the occiput and the petrous temporal parts of the base of the cranium. This interference will appear as clinical syndromes relating to deformation and/or dys-

Illustration 10-2 Floor of Cranial Vault Viewed from Above Showing Asymmetrical Dural Membrane

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170

THE OCCIPITAL CONDYLES

the joints

Since

the age of six years, have an extremely

lacerum

the atlanto-occipital approximately

occiput is not completely ossified

on the occipital condyles can

correction of abnormal effect upon the health

child

or her life. Through the

jugular foramena passes jugular venous drainage of blood vault. deformation or dysfunction of foramena

such as brain dysto intracranial fluid 11 th the 9th, 1 nerves pass through function or head Dysfunction of these nerves can result in gag reflex problems, taste problems speech and swalposterior third of the cardiac arrythmias,

and

relating to

of stomach and lower bowel, and abnormal tonus of the sternocleidomastoid and trapezius The lacerum is partially filled with fibrocartilage. It is also

related to great Symptoms related to the auditory

auditory

petrosal nerve and the often from

related to impairment of blood supply to compression, as do lobes brain. This flow is influenced the superpetrosal nerve (OWMAN and EDVINSSON 1977). DIAGNOSIS AND TREATMENT OF OCCIPITAL CONDYLAR SOMATIC "'",.>LV"""

and treatment is simply a pos­ is not to spread the

u.,.,,,.,.,-,,",

from the

comes as a follow-up to described in

tissue restrictions of the cranial as extradural connective tissue restrictions must be re-

leased before reliable and accurate evaluation of the

of the occipital

condyles can be accomplished. diagnostic cradled upon are allowed to

with palmer

patient

of your hands and

as far as is comfortably possible

the patient's occiput in an anterior direction. You then its of the inferior (ILLUSTRATION 10-3).

The traction or

patient's tissues will react by the connective tissues made of contraction. If the

condyles are not

atlas, the occiput will seem to float are

articular

occiput will resist the motion you are trying to When the motion tests indicate that the condylar parts are restricted at the

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171

THE OCCIPITAL CONDYLES

.\ .

•

___ Transverse axis of occiput

Illustration 10-3 Hand Position for Diag nosis and Treatment of Cond ylar Compression

atlas, the first step of the treatment is instituted without changing the hand positions on the occipital region. Simply continue the gentle urging of the occipital condyles to disengage themselves posteriorly from the wedge formed by the articular surfaces of the atlas until you gradually perceive a posterior gliding of the occipital base in response to your traction. If traction is too forceful, nothing good will happen. After disengagement has occurred, induce a lateral spread into the condylar parts. This phase of the treatment technique has a tendency to help decompress the foramen magnum. It will also help release restriction at the jugular foramena. In order to achieve this lateral spreading of the condylar parts, slowly approximate your elbows using your arms as levers, and your hypothenar eminences and palms as the fulcrum. If you can imagine projections from your fingertips into the condylar parts, you can see the projected effect of bringing your elbows closer together. Continue this second phase of the treatment until the release is perceived. Compression of the condylar parts is often accompanied by cranial base and lumbosacral compression. Based upon the observations of numerous practitioners of craniosacral therapy, this problem is causally related to "hyperkinetic" behavior in children (APPENDIX I), to severe cephalgia in adults (MILLER 1972) and to various respiratory distress syndromes in infants and newborns (FRYMAN 1966). We have often wondered whether severe dysfunction of the occipital condylar parts is not contributory to sudden infant death syndrome.

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Chapter 11 TeDlporal Bone Dysfunction paired temporal

to the

by

petrous portions their squama, tympanic and mastoid parts (ILLUSTRATIONS II-I-A, 1l.I·B, ll-1-C and 11-I-D). Projecting are the from inferior part of

processes, which articulate with the processes are quite bone dysfunction.

bone is ossified from Embryologically, the temporal bone of newborn infant is in three tympanic ring (ILLUSTRATION 11-2). The tympanic ring,

offers

the squama shortly before term. The temporal bones unite during the year of life. temporal articulate with the occiput, and

mandible

PHYSIOLOGICAL TEMPORAL BONE MOTION Our findings and impressions

respect to temporal bone motion largely

described by Dr. Sutherland (MAGOUN 1966). He postulated that the

concur

temporal bones rotate around axes which to the

ridges

a line

which enter the

ear

the

squama move

the is in move medially following the

(auditory the upright

The axes angle of the temporal of the petrous During the flexion phase of craniosacral

1 centimeter

".,<:,..,0,,,,,

Because of

also move laterally; squama is temporal bones. As the

the zygomatic At

172

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TEMPORAL BONE DYSFUNCTION

173

Squama

process

Illustration 11-1-A Temporal Bone - Internal View

Squama

Mastoid process

External auditory canal Illustration 11-1-8

Temporal Bone - External View

whole picture is therefore somewhat like that of a wheel or gear moving in a small arc on a bent axle. These wheels or gears move back and forth during flexion and exten­ sion describing very small arcs. Dr. Sutherland has described this movement as similar to that of a "wobbly wheel." Since the petrous ridge attachment of the tentorium cerebelli is above the postulated axis of temporal bone rotation, the external rotation phase of temporal

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174

TEMPORAL BONE DYSFUNCTION

Zygomatic process

Squama

Illustration 11-1-C Temporal Bone - Superior View

Petrous portion

Zygomatic process Illustration 11-1-0 Temporal Bone - Inferior View

bone motion causes the anterior borders of the tentorium cerebelli to move slightly anteriorly. The effect is to tighten this membrane. The membrane acts as a diaphragm, causing a fluctuation of cerebrospinal fluid. Granted the movement is small, but small movements in extremely sensitive areas create large effects. The movements of internal rotation of the temporal bones are just the opposite of those described above. Temporal bone internal rotation corresponds to the extension phase of craniosacral system motion. The squamous part of the temporal bone is part of the site of origin of the powerful temporalis muscle. This muscle inserts upon the ramus and angle of the

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TEMPORAL BONE DYSFUNCTION

175

Illustration 11-2 Fetal Temporal Bone - Note Membranous Aspects

mandible and is used in the chewing process. It exerts a strong force upon the temporal squama, causing them to externally rotate during muscle contraction. The zygomatic process of the temporal bone offers attachment for the masseter muscle, another powerful muscle used in chewing. The effect of masseter muscle contraction upon the temoral bone is external rotation via its levering action upon the zygomatic process. The superior border of the zygomatic process provides attachment for the temporal fascia which descends from above. This fascia moderates the force of external rotation exerted upon the temporal bone by the temporalis and masseter muscles during the process of mastication. The articula­ tion of the anterior end of the zygomatic process of the temporal bone with the zygomatic bone of the face is in the nature of a serrated suture. The effect of this relationship is to transmit zygomatic process movement into the zygoma. The mastoid process of the temporal bone is strongly influenced by the attachment of the sternocleidomastoideus muscle, which crosses the occipitomas­ toid suture and also attaches to the occiput. The splenius capitis, longus capitis and digastricus muscles also attach to the mastoid processes of the temporal bones. Abnormal tonus of any of these muscles tends to pull the mastoid process inferiorly, thereby internally rotating the temporal bone. The postulated axis of rotation of temporal bone motion is approximately through the external auditory meatus. The axis angles forward (anteriorly) as it extends medially; therefore this force, imposed upon the mastoid process, tends to rotate the temporal squama posteriorly. This movement is referred to as internal rotation of the temporal bones. It corresponds to extension of the cranial base, and causes the transverse dimension of the cranial vault at the superior borders of the squama to decrease. The actions of the muscles which attach to the mastoid processes are countered by the actions of the masseter and temporalis muscles which attach to the zygomatic

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TEMPORAL BONE DYSFUNCTION

1

(ILLUSTRATION 11-3). temporal attachments for stylohyoideus bone styloid processes muscles. contraction, these muscles inhibit temporal

and

act much as an anchor which

for surfaces of Because the extensive the temporal

varied is in constant jeopardy.

sutures, fasciae, membranes and bone

as well as equilibrium

proper

unfavorable influences of

structures are

HU'''_' '::;'' .

potential sources of

(ILLUSTRATION 11-5).

Clinically,

to

bone dysfunction can best be blood pass

appreciated by and are intimately NERVES PASSING THROUGH THE TEMPORAL BONES acoustic

BLOOD VESSELS PASSING THROUGH THE TEMPORAL BONES internal carotid artery

chorda

artery

facial

internal jugular vein of internal

carotid semilunar

occipital artery inferior middle

of trigeminal

(eN.

sinus vessels

tympanic branch of internal auditory branch of

tympanic branch of g!c'SS()ptHI

artery internal cochlear branches to jugular

IX) auricular branch of vagus (eN. X)

to many syndromes. in the autistic passed imately 100 autistic children of autistic behavior which are discussed in

consistent

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TEMPORAL BONE DYSFUNCTION

177

Mandible Mastoid process

Illustration 11-3 Balance of Muscle Action on the Temporal Bone

temporal bone decompression is successfully performed. EVALUATION AND TREATMENT OF TEMPORAL BONE FUNCTION AND DYSFUNCTION There are three major techniques which we have found most useful when deal­ ing with the temporal bones. MASTOID TIP TECHNIQUE

This technique is used for motion evaluation and treatment. Interlace your fingers to support the supine patient's occiput. Place your thumbs so that they cover the mastoid processes and tips of the temporal bones. Then gently apply medial pressure bilaterally, upon the patient's mastoid tips. This pressure has the effect of

springing the superior borders of the temporal squama laterally. From the description of physiological motion above, you can see that you are encouraging one component of external rotation of the temporal bones by medially compressing the mastoid tips. As the other component (the rotational component) comes into play, you should simply go with it. Do not impede or inhibit the rotation about the transverse axis in any way. Evaluate the symmetry of temporal bone motion. Asymmetry, when per­ ceived, can often be successfully treated by rocking the temporal bones. Rocking is accomplished by applying pressure first to one mastoid tip and then the other in rhythm with the craniosacral system. This encourages external rotation first in one temporal bone, and then the other. Several cycles of this type of movement will usually free the restricted temporal. One or the other temporal bone will thereupon become still for one-half cycle and then begin moving in synchrony with its mate on the opposite side. If this treatment technique is unsuccessful, it will often make obvious a specific sutural restriction. Sutural restrictions involving the temporal bones are quite common. They are successfully treated by the direction of energy techniques described in Chapter 9.

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TEMPORAL BONE DYSFUNCTION

178

Sphenotemporal suture

Temporal-+--' styloid process

Occiput

Illustration 11-4 Cranial Base - Inferior View

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TEMPORAL BONE DYSFUNCTION

179

Illustration 11-5 Effects of Muscle Action (Arrows) on Temporal Bone (Fulcrum Is in the External Ear Canal)

CIRCUMFERENTIAL MOTION TESTING AND TREATMENT TECHNIQUE

Apply this technique by inserting your middle fingertips in the supine patient's ears in such a manner that your fingers act as extensions of the axis for the rotational component of temporal bone motion (ILLUSTRATION 11-6). Then lay your fourth fingers in contact with the mastoid processes of the temporal bones, while keeping your index fingers in contact with the zygomatic processes of the temporal bones. Evaluate rotational movement around your middle finger extensions of the temporal bone axes for symmetry and ease of motion. Motion testing is always per­ formed in synchrony with the patient's own craniosacral system rhythm. As you per­ ceive this rotational motion, the broadening and narrowing of the temporal squama will also become apparent. When you encounter restrictions to the motion, induce alternate movements; carry one temporal bone into external rotation and the other into internal rotation. This treatment has an excellent therapeutic effect upon the sutures related to the petrous parts of the temporal bones in the cranial base, especially those sutures between the occiput and temporal bones. When you feel the release of the restricted temporal bone, be alert to one of the bones tending to stop for one-half cycle so that the other bone will catch up, restoring synchrony of motion between the two temporal bones. Always leave the temporal bones in neutral. Never take your hands off the patient when the bones are in either extreme internal or external rotation. Never leave the temporal bones out of synchrony. Otherwise, you may cause nausea, vomitin� vertigo or even seizure activity.

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TEMPORAL BONE DYSFUNCTION

180

Illustration 11-6 and Treatment Circumferential Motion (Arrows Indicate the Direction of Force for Encouragement of External Rotation)

TEMPORAL BONE DECOMPRESSION:

TE CHN IQUE

THE "EAR

Through our

extensive

with autistic

children, we have bones. type of

logical

of medially compressed allows some physio-

bone motion. It is the quality

motion which seems abnormal. as if in a highly viscous medium. Put When only one with

The perception is that these

is "gunked simply, it is as though bones is so involved, of course, the lack On the

when

motion symmetry is present; but temporal

temporal

symmetry

motion is

are medially

rrum,""rp"

quality of motion is abnormally

seem to drag on the whole system. Considering the extensive funcbones have throughout the craniosacral system,

tional influences that the that It was more or

indeed affect

out of frustration

the diagnosis and treatment of that something was impeding or these bones

other severe behaviorly

the bone

VH_n... ... ....

efficiency of

we developed the "ear pull" bone

on be medially compressed

compression. We knew mobility. The thought that It then

the direct

approach to a problem would be most efficacious. Since that time, our experience with the ear pull technique has very positive.

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TEMPORAL BONE DYSFUNCTION

The ear less approximates "h"<';;11,-,"

by fibers to osseous temporal The

place

of the ear canal more or

direction of the petrous part of the temporal

anteromedially into

would

181

traction

as i t

the ear pull technique,

cranial base. To

ears in the direction

on both

be an extension

bones (ILLUSTRATIOl': 11-7). Once traction is begun,

directions will become

determining. Begin traction equally and bilaterally, allowing the direction of movement to be determined by the inherent of the tissues. This will as the

It is our habit to grasp the cartilage of the external ear on a transverse level with, and ears

to the the

auditory meatus lying

traction very lightly and gradually increase it

canal).

both

Begin

of

you feel a motion response. If

ears want to turn or slide in one direction or another, go these movements. Do not impede any movement. If you should in advance that the ear must move along

Occiput

Illustration 11·7 Direction of Traction for the "Ear Pull"

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182

TEMPORAL BONE DYSFUNCT10N

a certain vector, you will become a Continue your T\",�t""r" traction,

to the correction. Be

LU'",-''''U,'''''''

to any

vector modification

which seems to If the

to your

sion was present.

no compres-

and if necessary, gently increase

your traction until a Since we

the majority of our

technique, we have

many otherwise undetected medial

temporal bones. that "if you It can surely be we would counter that if you

you

It is

a few minutes.

medial

and corrected,

are great. In view of these L. it would seem somewhat remiss not to test and treat your patients for temporal bones. SUTURE Because this suture is a particularly

we will

of clinical

it independently. are or contracture This muscle is

which tempor-

contracted under conditions of

stress, dental malocclusion and/or temporomandibular joint dysfunction. anatomy of is

muscle shows

of producing

during its

of the

attachments of the anterior border of the ramus to

fossa and

duce the mandibular ramus of the temporal bone. suture are beveled and

surfaces such a way

a sutural shearing

may longitudinally stress collagen It may also cross-sutural

muscle (lLLUSTRATION 11-8). This fibers

is generated by contraction of the narnn,.-.r'.l

appear to be

dimensions and produce

IJUv.;H'I.."'L

as disrupt normal receptors. It may

activity normal nerve DIAGNOSIS AND TREATMENT OF

resulting

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TEMPORAL BONE DYSFUNCTION

183

Temporoparietal suture

Illustration 11-8 Bevel of the Temporoparietal Suture

dysfunction of the temporoparietal suture is usually straightforward. Sutural com­ pression, when exaggerated, will quickly increase symptom severity if the examina­ tion is done during an exacerbation. If the patient's condi hon is quiescent during the examination, the symptom complex can often be induced in a matter of minutes (APPENDIX G).

The technique for diagnosis of temporoparietal sutural dysfunction is per­ formed with the patient lying comfortably supine. You should be seated cephalad so that you can comfortably grasp the patient's mandibular angle with your crooked fingers. Your elbows should rest comfortably upon the table so that the distal parts of your palms overlie the patient's temporomandibular joints, and the more proximal parts of your hands cover the temporoparietal suture. Exert a light cephalad traction with your crooked fingers (usually the index or middle fingers) which are grasping the mandible in the notch just anterior to the angles. Apply the traction on both sides as equally as possible. As you very gradually increase the traction force, you will perceive compression at the temporomandibu­ lar joints. A swaying and balancing activity by the mandible may ensue as these joints impact. Follow any of these motions and let them achieve a balance for you. After the temporomandibular joints are compressed and balanced, the temporal squama will usually activate, moving side to side as they begin to balance. Follow and continue your traction. The shearing effect at the temporoparietal sutures will next occur. It is when this shearing occurs that the symptomatic patient will let you know. As stated above, the existing pain will worsen; the quiescent, clinical syndrome will recur. Once you are satisfied that the diagnosis involves a compression of the

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184

TEMPORAL BONE DYSFUNCTION

temporoparietal suture, the treatment is to directly decompress the suture. The technique for decompression of the dysfunctioning temporoparietal suture is to reverse the traction on the mandible so that the temporomandibular joints decom­ press or disimpact first. The temporal bones then balance, and finally the tempo.ro­ parietal sutures are opened and mobilized as the temporal squama glide inferiorly. This sutural mobilization can be palpated by the palms of your hands which overlie the sutural regions. The caudally directed traction on the mandible is accomplished by gently grasping the skin over the angles and rami with just enough force so that you have a non-sliding friction between your fingers and the patient's skin. The skin is attached on its deep side indirectly to the bony surface of the mandible. Once the slack is taken up, the skin traction exerts a force upon the patient's mandible which is ultimately applied to the temporoparietal sutures. Continue traction to the point of palpable release or restoration of sutural motion. Another very effective technique for the mobilization of the dysfunctional temporoparietal suture is the direction of energy or V-spread technique which was described in Chapter 9.

Copyrighted Material

Chapter 12 The Mouth, ace and TelDporolDandibuiar Joint The mouth,

together in most or the maxillae

"'''1'>''''''''

In our

this chapter clinical problems and vomer. Such

with the

sphenoid, and th��reror'e Ordinarily, the

when

temporal, maxillary, ally, a nasal, palatine or make this point Oecallse correct secondary problems corrected until joints, described in same time that

joint

bony structures of the The interrelationships complex (ILLUSTRATION 12-1). to these structures simplifies

\_U,".�llV"

therapist to develop rational '_U�LF.LJ'V"'.i.O Without the mechanisms are thus more effectively used. Problems which primarily

nasal and

sutures are usually the

trauma. These problems, the rest of the compensatory dysfunctions.

PALATINES, AND complex functioning unit

We consider these bones as a more or less to the sphenoid comprise the major part of the hard be regarded as inserts or maxillae. When,

(ILLUSTRATIONS 12-2-A and 12-2-B).

In the majority of cases, the lateral "n,,,r.t,r

palatine restrictions are 185

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186

THE MOUTH, FACE AND TEMPOROMANDIBULAR JOINT

Frontal

Mandible

Illustration 12-1 Exploded View of the Bones of the Face

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THE MOUTH, f'ACE AND TEMPOROMANDIBULAR JOINT

187

may The vomer provides hard palate at flexible

midline and

sphenoid (ILLUSTRATION 12-3). This

often falls victim to intraosseous piece of

the vomer component must always satisfactory and result. When the functional d.HdC\JHl hard palate

of the

the sphenoid are

many previously

become

rnrn1,\r.,

with each 4), frontal, ethmoid, zygomatic,

..;.. �.'H.ll"',

and inconstantly directly with can see

via the always normalizing maxillary

mobility

and normalcy of the majority muscles which attach to the

11"".... """.'-0

obliquus maxillae will eye movement. Nerves

are intimately related to

include

infraorbitals,

the maxillary divisions of the trigeminal nerves, the nasopalatine, the palatine the anterior, middle and alveolar nerves. rhinitis,

and the also pass

are symptoms which frequently are infraorbital, anterior and

superior

palatine blood vessels. MAxILLARY BONE MOTION EVALUATION AND TREATMENT

and

supine

upper molars.

monitored other

simultaneously the thumb The biting moves into flexion.

as the sphenoid transverse dimension between molar biting

narrows as the sphenoid enters the extension phase often moves a One maxillary restriction somewhat by indirect by applying maxilla will not move as far as the during the of cranial base motion (called external rotation of the maxillae), follow both maxillae and resist the next of rotation. When internal rotation occurs again, follow and rotation is again After or five cycles, a will usually perceived. release seven or further resistance to external cycles, do not does not occur rotation maxillae. of the felt a release Whether or not you your

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188

THE MOUTH, FACE AND TEMPOROMANDIBULAR]OINT

Illustration 12-2-A Anterior View of Hard Palate

technique, you should next apply direct technique. Gently force the affected maxilla through the restriction barrier until it seems as though both maxillae are moving evenly. Your corrective force should be gentle, bu t firm and constant. Remember: a small force over a longer period of time is as effective and much less traumatic than a large force. After making this correction, the maxillae should always be restored to synchronous movement with the sphenoid before terminating the treatment. Other maxillary problems we have identified include sphenomaxillary torsion, shear and impaction. SPHENOMAXlLLARY TORSION

In sphenomaxillary torsion, it is as if the hard palate and the sphenoid are rotated in opposite directions about a vertical axis which passes approximately through the point of intersection of the sagittal and coronal sutures on the vault. This area is referred to as bregma. To test for sphenomaxillary torsion, use the same hand positions described

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THE

MOUTH, FACE AND TEMPOROMANDIBULAR JOINT

189

Illustration 12-2- B Lateral View of Maxilla, Palatine and Sphenoid

above in testing for normal maxillary internal and external motion in relationship to sphenoid flexion and extension. Through your finger contact with the biting surfaces of the upper molars, the hard palate is rotated about the vertical axis (ILLUSTRATION 12-�), first in one direction, then in the opposite direction. Stabilize the sphenoid with your other hand. Sphenomaxillary torsion is not a normal physiological motion, but all normally functioning patients which we have examined possess enough motion tolerance to allow for some torsion of the hard palate in relation to the sphenoid. The force you apply should be very gentle, but sustained for 10 to 15 seconds to allow time for the hard palate to follow your lead. The amount of torsion should be bilaterally symmetrical. If the movement is not equal in both directions, a spheno­ maxillary torsion restriction is present. This restriction is corrected by lesion exaggeration for 10 to 15 seconds or until release is perceived. This initial step is

always followed by direct correction. Direct correction is applied gently but firmly against the abnormal restriction barrier until the barrier is felt to yield. You should then wait 3 to 5 minutes and re-evaluate.

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190

THE MOUTH. FACE AND TEMPOROMANDIBULAR JOINT

Illustration 12-3 Medial View of Vomer and Maxilla

Illustration 12-4 Maxilla and Nasal Bone

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THE MOUTH, FACE AND TEMPOROMANDIBULAR JOINT

19 1

Illustration 12-5 Sphenomaxillary Torsion

Following correction of a sphenomaxillary torsion dysfunction, the palatines and vomer mIlS! always be evaluated and treated as described later in this chapter. SPHENOMAXILLARY TRANSVERSE SHEAR

Another problem which we have discovered in the sphenomaxillary relation­ ship is that of transverse shear. As the name implies, sphenomaxillary transverse shear means that the hard palate has been abnormally moved on a transverse plane to either the left or right in relation to the sphenoid. To test for this problem, you must maintain the sphenoid in a stable pOSition in the tranSverse plane. Then move the hard palate laterally on a transverse plane parallel to the plane of the sphenoid. Neither the hard palate nor the sphenoid should be allowed to rotate when perform­ ing this test (ILLUSTRATION 12-6). The sphenomaxillary shear is not a normal physiological motion. When the test is performed gently with persistent force, some transverse shear motion will occur. Place the palmar surfaces of the third and fourth fingers of one of your hands against the biting edges of the upper molars on the supine patient. Stabilize the sphenoid with the thumb and index or middle finger of your other hand. We find it useful to contact the thumb of the hand which is examining the hard palate with the dorsum of the other hand so as to provide relative motion cues. Urge the hard palate to move parallel to the sphenoid, without rotation, first to one side and then to the other. Enough time should be allowed in both directions to permit the patient's bony structure to follow the force you are applying. The motion response should be symmetrical; if it is not, a tranSverse shear restriction of the sphenomaxillary complex is present.

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192

THE MOUTH, FACE AND TEMPOROMANDIBULAR JOINT

It-!--+-V' -+-- omer

NORMAL RELATIONSHIP

SHEAR (Note intraosseus strain in vomer) Illustration 12-6 Sphenomaxillary Shear

technique to loosen the restriction toward which it most easily for 10 to 15

SPHENOMAXILLARY IMPACTION 1-''''�,L1U'" of the

is uncommon, but until it is

impaction HAC."",,,«

and sphenoid are

the together,

(or bones)

It also often involves the impaction clue to this problem is na,etJ�erJla(':nt motion

sphenoid. a lack of

the sphenoid and

the maxilla seem to move as a unit. Vomerosphenoidal impaction is

is described later in when testing vomer motion, your suspicion been aroused, by using light traction. The patient is

crl"""t"",/i

open.

the anterior of gauze is helpful to of the behind the

between your

chapter. affected comfortably fingers. A above

slipping. with the

and the sphenoid bone. Place your regions fingers

sphenoid. are grasping

anteriorly-directed traction. The hard well-lubricated manner. this does

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THE MOUTH, FACE AND TEMPOROMANDIBULARJDINT

193

\ \ Illustration 12-7 Hand Position for Release of Sphenomaxillary Impaction

resistance to the anterior midline. Unilateral resistance

not seem to occur, you should be able to decide other both or glide is

Bilateral resistance with the cates bilateral sphenomaxillary impaction. Midline resistance indicates vomer impaction with

sphenoid, the

or both.

When the treatment is

the palatines and vomer should free mobility and techniques

receive individual attention to are described below. PALATINE

treatment is to continue

and the hard palate glides freely in a

anterior traction until you U"-;,
MOTION EVALUATION AND

palatine bones interpose as functional connecting links between the maxillae and the lateral pterygoid plates of the sphenoid bone (lLLUSTRATION.IZ·S). to forces from both sources, to either with the

become

ethmoid, maxillae, inferior nasal (ILLUSTRATIONS 12·9-A and 12·9-B).

the tensor veli palatine, the musculus uvulae and

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muscular

194

THE MOUTH, FACE AND TEMPOROMANDIBULAR JOINT

Illustration 12-8 Palatine Between Sphenoid and Maxilla

Palatines Illustration 12-9-A

Illustration 12-9- B

Hard Palate - Inferior View

Hard Palate - Sagittal Section

pterygoideus. Nerves which are intimately related to the palatine bones are the greater and lesser palatines, and sensory fibers from the palatine, nasopalatine and glossopharyngeal nerves. Blood vessels which pass through these bones include the descending palatine branch of the maxillary artery, the ascending palatine branch of the facial artery and the palatine branch of the ascending pharyngeal artery. Frequently, correction of maxillary and sphenoidal restrictions will result in a more or less spontaneous correction of the palatines; however, they should always be evaluated individually and mobilized when necessary. We usually do this evaluation and treatment after maxillary and sphenoidal corrections have been completed, since the successful corrections of these problems often obviates the need for specific palatine corrections.

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THE MOUTH, FACE AND TEMPOROMANDIBULAR JOINT

195

The technique for evaluation and treatment of the palatine is the same. The diagnosis is made only as the treatment is performed. Slip one finger along the medial borders of the upper molars of the patient, just past the last molar but still on the hard palate. Keep this finger about one-quarter inch medial from the molar borders. Exert gentle pressure upon the palatine bone in a cephalad direction until the bone is felt to disengage from the maxilla and to glide sligh tly cephalad. After the bone moves as far cephalad as it will move with ease, exert gentle pressure upon it in a lateral direction. Hold this pressure until the bone rotates externally. Repeat the procedure on the opposite side of the patient's mouth. Resistance to motion, of course, indicates abnormal restriction. Easy and early compliance to your pressure means no restriction. To correct restriction, hold gentle pressure until there is compliance. VOMER MOTION EVALUATION AND TREATMENT

The vomer is a trapezoidally-shaped bone. It is very thin, and is situated vertically in the sagittal plane (ILLUSTRATION 12·\0). The posterior and inferior part of the nasal septum is formed by the vomer. The posterior superior border of the

III ustration 12·10 Position of Vomer

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THE MOUTH, FACE AND TEMPOROMANDIBULAR JOINT

and a furrow; it receives the rostrum the alae of the vomer articulate with the of the sphenoid and the sphenoidal processes of the palatine bones. The inferior border of

vomer is sphenoid.

vomer articulates with the crest on the superior by the maxillae and the palatines. anterior border is of the

hard palate formf?d

and fuses with above. The posterior border is and

(ILLUSTRATION 12-11). The vomer moves about a transverse axis located in its mid-region, as illustrated. The anterior inferior aspect of goes into flexion. As the contact with the hard palate, moves coordination

vomer moves superiorly as sphenaspect the vomer, which is in in extension. the is one finger on the midline of sphenoid movement (ILLUSTRATION

and 12-12). Use

technique to correct vomer restrictions, which interfere with coor-

dinated motion between the vomer and

sphenoid.

VOMER TORSION torsion and transverse shear, we have on In the sections vomer correction following sphenomaxillary correction. correction of vomer torsion, use your finger in the patient's mouth to torque the vomer about a vertical axis as the sphenoid is stabilized with the thumb and index or performed for 1 0 to 15 hand. Indirect of your "Ha'''''',",,'

seconds or until a

then direct vomer. The

is applied against the sustained

Frontal bone

Sphenoid bone

_....+-... Palatine

Illustration 12·11 Sagittal Section through Anterior Skull Position of Vomer

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bone

vomer

THE MOUTH. FACE AND TEMPOROMANDIBULAR JOINT

197

Illustration 12-12 Finger Position for Evaluation and Treatment of Vomer

follows. You will notice a release of resistance when the correction is completed. The contact points for the finger applying the torque in the patient's mouth are the posterior midline of the hard palate with the tip of the finger, and the back of the front incisors and the posterior surface of the alveolar ridge anteriorly. We cannot overemphasize that a gentle force over a long time is the proper method of correction.

VOMER SHEAR To correct intraosseous vomer shear resulting from sphenomaxillary trans­ verse shear, use the same application of your hands to the patient's head as for vomer torsion. The only difference is that the forces applied are not torquing; they are lateralward in two parallel planes. Move the sphenoid and vomer in opposite directions on parallel and transverse planes. Indirectly loosen first, then follow with the direct approach to correct the intraosseous strain. For all diagnostic tests and corrections of the hard palate in relation to the sphenoid, the sphenoid is stabilized and the testing or corrective force is applied to the hard palate. If the sphenoid is not stabilized, the testing or corrective forces will be transmitted into the cranial base through the sphenoid. Iatrogenic cranial base dysfunctions may be introduced in this way.

ZYGOMATIC BONES The zygoma has three articulating or sutural surfaces. These surfaces are ser-

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THE MOUTH, FACE AND TEMPOROMANDIBULAR JOINT

the zygoma articulates

rated so that the movements of the

Its

influence its mobility. is with the

is with the and its anterior articulation is with the

zygomatic process of ZVI!Olna.nc process of During

phase

motion, the zygoma

rotates about a diagonal axis which passes through and the angle of the mandible. During rotation between the superior

of

glabella

transverse dimension two zygomata increases slightly (ILLUSTRATION

12-13).

Functionally, the they aspects of the orbits

bones act as connectors to

They contribute eyes.

of frontal, temporal or

Zygomatic dysfunction can either be a

Temporal suture

ANTERIOR VIEW

Frontal suture

Maxillary suture

Temporal suture

Maxi IIa ry---'l_..... suture

POSTERIOR VIEW

LATERAL VIEW

Illustration 12-13 Zygoma

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THE MOUTH, FACE AND TEMPOROMANDIBULAR JOINT

It is seldom dysfunctional trauma can produce secondary which it articulates,

UUAL .... U

by placing the

and grasping the zygoma between technique are applied to

NASAL BONES The nasal

in shape. They articulate bone above (just below the glabella). laterally. The nasal cartilage meets rotation the nasal bones runs in a borders

flexion phase of craniosacral We have only found nasal

to result from trauma.

sutural dysfunction is made on

of tenderness to palpation

bone motion in response

activity.

dysfunction is of course deloerlde sutures between the frontal the nasal bones, using the

nature of the trauma. can be corrected by the nose as the vehicle,

stabilized (ILLUSTRATION 12-14), In order to mobilize intranasal bone sutures or the nasomaxillary sutures, you can attempt to encourage external rotation phase of motion using two finger as would use magnets, to draw anteriorly. direction energy with V-spread technique can also We frequently use is applied at glabella on bones; this arrangement from the midline just method very fine (high .., . ,.., _, in sutural mobilization in a matter __

TEMPOROMANDIBULAR JOINT EVALUATION AND TREATMENT The technique

evaluation and treatment of the telJlP.orOlJrlallal

(APPENDIX G) is performed with the patient lying supine. Seat

patient's head. extending patient's palms. The

rest your arms and hands upon head. Lay your hands gently over ears and temporal regions are joints will almost be

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a tripod external

200

THE MOUTH, FACE AND TEMPOROMANDIBULAR JOINT

Illustration 12-14 Direction of Force for Release of Frontonasal Impaction

fingers. We like to hook our middle fingertips under the angle of the mandible so that they fit into the notch. A gentle cephalad or superiorly directed traction is then exerted on both sides of the mandible as equally as possible. The force is gently and slowly increased until you perceive action or change at the temporomandibular joints as those joints are impacted by the traction. Usually, the mandible will then tend to swing back-and-forth or from side-to-side. Follow this motion without offering any resistance. At the same time, continue your superiorly directed traction. Lateral or anterior-posterior motions of the mandible reflect the inherent balancing process induced by your traction. Once this balancing process is completed, the lateral or anterior-posterior motions will stop.

H you continue traction in a cephalad direction, you will feel activity in the temporal bones. We do not believe you can have temporomandibular joint dysfunction without temporal bone dysfunction. The mandible will exert a force in the mandibular fossae of the temporal bones (ILLUSTRATION 12-15). This cephalad­ directed force causes the temporal bones to move cephalad and begins to disengage the temporoparietal sutures, as described previously in Chapter 11. Since the level of these sutures is angled superiorly and externally, and since it is at an acute angle, the temporal squama are forced to move laterally by the cephalad traction. This phenomenon can easily be felt at the palms of your hands. It causes a shear at the suture as the lateral borders of the parietal bones also attempt to move cephalad. The parietals are restricted in their cephalad movement by the falx cerebri and are forced into external rotation by your traction (ILLUSTRATION 12-16).

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THE MOUTH, FACE AND TEMPOROMANDIBULAR JOINT

201

Illustration 12-15 Hand Placement for First Phase of Temporomandibular Joint Technique

During this time the temporal bones, through their petrous ridges, are stretching the tentorium cerebelli, which is now acting as a diaphragm. This changes the fluid pressure inside the cranial vault. You will feel a considerable amount of fluid motion, membranous change and balancing in the course of this procedure. The temporal bone will move and balance in many directions. Let this happen; simply continue your cephalad traction. Finally, all the activity will stop and you will perceive a balance. The point of balance is the end of this part of the technique. The next step is to apply caudally directed traction to the mandible. Apply enough pressure with your hands against the mandibular rami to exert this caudad force. Because the skin is attached indirectly on its deep side to the bone of the mandible, by simply taking the slack out of the skin and then continuing to apply traction, the force will thereby be transferred to the mandible. Do not try to actually grasp the mandible. During your caudally directed traction, the temporomandibular joints will dis­ engage and balance. Then the temporal bones will move inferiorly in response to mandibular traction. This will again activate the dural membranous diaphragm and cause a movement of cerebrospinal fluid inside the cranial vault. The temporo­ parietal sutures will disengage and shear in the opposite direction, and the parietals

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THE MOUTH, FACE AND TEMPOROMANDIBULAR JOINT

Axes of external rotation

\J

I

Shearing force at suture

I of temporomandibular joint

Mandible

Illustration 12-16 Ce phalad Traction Phase of Temporomandibular Joint

will move

,"-,U'HL.un.<;

until all

UI:I..11:1.1,LI-<;

completed, you joints, but you

not only

the caudally

traction

has been treated

temporomandib-

also corrected the temporal bone involvement,

temporoparietal sutures, in the vault

mobilized the

excellent "holistic technique"

bones,

\..a" .." .... y

the dural membranes. This is truly an the craniosacral and all that it

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Chapter

3

Extrinsic NeuroDlusculoskeletal SysteDl Dysfunctions Which Influence The Craniosacral SysteDl are extrinsic to craniosacral may cause restrictive structures effects that system. chapter is designed to deepen your awareness of ligaments, fasciae, scars articular somatic awareness dysfunctions may on of problems. to a more complete of your description of specifi c treatment techniques is beyond scope of this such methods as positiot:l and which are described recall and used to treat many of the here. It is will also apply other treatment modalities in You will notice a great deal muscle and its action is described in connection attach t o at least two Because most o f at twice. We all been page to page to perhaps by having to flip back and chosen to text. We have in difficult areas of a fluency narrative so as to provide a more useful reference guide.

tonus or directly to the exerts a osseous bo undaries of influence upon delicate movements ofthe craniosacral imbalance impairs the b ones sk ull, "PI·j-pl",." of the bones involved in this coccyx. to o ne o f the muscle hypertonus which does not dampening owing to is and the 203 Copyrighted Material

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EXTRINSIC NEUROM USCULOSK ELETAL SYSTEM DYSFUNCTIONS

of the muscles mobility of system are the bones to which they attach.

of the limited but free below according to

The seems to be bone most system dysfunction due to abnormal muscle tonus. is probably UC'I..a.'-,,,,, occiput is the many muscles which respond with hypertonicity to the upon the dural memtensions o f daily living. The effects of by brane are immense. Occipital borders of the occiput tentorium cerebelli, the and inferior aspects of falx {,,,,,rpM,., ments, straight venous sinus, the transverse venous sagittal the confluence sinus occipital sinus. dysfunction can thereby interfere venous sinus function. Fluid congestion in the venous sinus system system (arachnoid villae), which is located v".nH,;u fluid is a an (GRAY'S ANATOMY, 39th British projects i nto the floor of the straight sinus near its junction Edition, pp. 693-94). cerebral vein. It contains a sinusoidal plexus blood vessels which control engorged blood. Under the outflow of great vein which, in turn, fluid into venous system. extremely firm attachment of factor which must must affect accommodative function mobility of Note that dura mater is firmly attached to the the second and third cervical vertebral bodies within the occiput and may thus as a Single u nit. attachments. Muscles which attach "UH"'...... of the occiput its function are Longus Capitis

transverse processes of C3, basilar part of the occipital

4, 5

Capitis Anterior

inserts upon to

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EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

205

Both of these muscles act to forward bend or flex the head on the spine since their insertions are located anterior to the occipital condyles. The innervation of these muscles is from branches of the 1st, 2nd and 3rd cervical nerves. Hypertonus of the longus capitis and the rectus capitis anterior acts upon the occiput to inhibit the physiological flexion motion of the occipital base (ILLUSTRA­ TION 13-1). Bilateral hyper tonus of these muscles would tend to produce an extension lesion pattern of the cranial base, while unilateral involvement contributes to a torsion lesion pattern of the cranial base.

capitus anterior

....----' .. �Longus capitus

Illustration 13-1 Anterior Aspect of Cervical Spine and Occipital Base

Rectus Capitis Lateralis This short, flat muscle arises from the superior surface of the transverse process of the atlas and inserts into the inferior surface of the jugular process of the occiput. It laterally side bends the head. It is innervated by a branch from the loop formed by the 1st and 2nd cervical nerves. Unilateral hypertonus of the rectus capitis lateralis contributes to a torsion lesion pattern of the cranial base. The proximity of this muscle to the jugular foramen is also of great importance. When these foramena become partially opstructed by tissue contracture, the result is increased venous back-pressure within the semi-closed cranial vault, contributing to intracranial congestion and cephalgia (APPENDIX D) and many other conditions. The glossopharyngeal (CN. IX), vagus (C.N. X) and spinal accessory (C.N. XI) nerves also pass through the jugular foramena. Increased muscle tonus in this area can therefore produce dysfunction of

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EXTRINSIC NEUROMUSCUL OSKELETAL SYSTEM DYSFUNCTIONS

"'J.�UH.CU

nerves,

below.

in turn may result in other problems set Xth CRANIAL NERVE

IXth CRANIAL NERVE

Loss of gag reflex

Aphonia or

Slight dysphagia

Dysphagia

Loss of taste to posterior

Regurgitation of fluid

Sternocleidomastoid muscle dysfunction

through the nose

third of tongue Uvular deviation

muscle dysfunction Hypertonus of cervical

P haryngeal and

Loss of sensation to

Xlth CRANIAL NERVE

musculature (which

spasms

pharynx and

Esophageal spasms

further compounds the

tongue

Cardiospasm

problem at the jugular

Pylorospasm

foramen)

Loss of motor control of

of soft palate wall

or

Increased salivation

of pharynx, larynx or external auditory meatus disorders Salivary disorders Cardiac arrhythmias Gastric

Posterior Major arises from the spinous process of the inferior nuchal

of the

medial border of by branches of the nerve and from muscle extends the head and rotates it to the same side. the attachment of these to the occiput is to the occipital condyles, hyperto extension of head on the neck and to tonus of these muscles base. Unilateral hypertonus contributes to torof the sion lesion

Rectus Capitis Posterior This muscle arises from the widens as it inserts into the medial of

on the of the inferior nuchal line. It is

suboccipital nerve.

the arises transverse processes of the nuchal and lateral to and inserts into the occiput posterior to rectus capitis posterior. It is innervated by branches of the suboccipital nerve and serves to extend and sidebend the and torsion

Ob/iquus

Therefore, hypertonus

the

of the cranial base through its

Inferior

This muscle does not attach to

occiput

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but does form the inferior

207

EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

border of the suboccipital triangle. Therefore, it greatly influences the occiput via its origin upon the spinous process of the axis and its bilateral insertion upon the transverse processes of the atlas. It too is innervated by branches of the sub occipital nerve. It serves to rotate the atlas on the axis, and turns the head ipsilaterally. Hypertonus of this muscle will affect occiput function through its influence upon the mobility of the axis and atlas, and upon the condition of the tissues of the suboccipital triangle. One must also keep in mind the dural attachments between the occiput and the axis. The suboccip ital triangles are bounded laterally by the obliquus capitis superior; inferiorly by the obliquus capitis inferior and medially by the rectus capitis posterior major (ILLUSTRATION 1 3-2). All of these muscles are innervated by branches of

Occiput Superior nuchal line

+-+- Parietal bone

Obliquus -�-f-;"" capitis superior

Obliquus----.; capitis inferior

I l l u stration 13-2

Posterior View of Upper Cervical Spine and Occiput

The suboccipital triangles are bounded laterally by the obliquus capItIS the suboccipital nerve. The innervation fibers co ntribute to the contents of the triangle. Muscular hypertonus of the walls of the suboccipital triangle can produce irritation of the suboccipital nerve which will, in turn, produce further hyperto nus of the walls of the triangle, etc. This is a self-perpetuating problem which will ultimately cause dysfunction of the cranial base via the occiput, and dysfunction of the dural tube through its attachments to the posterior bo dies of the upper cervical vertebrae. The posterior atlanto-occipital membrane and the posterior arch of the atlas form the floor of the suboccipital triangle. The posterior atlanto-occipital mem­ brane is broad and thin; it connects to the posterior margin of the foramen magnum and the posterior arch of the atlas. The membrane covers the groove in the atlas, which permits passage of the vertebral artery and suboccipital nerve. Anteriorly, it adheres tightly to the dura mater. Stress on this memb rane due to abnormal neuro­ musculoskeletal fu nction may interfere with proper function of the vertebral artery and subOCCipital nerve.

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EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

cover of the suboccipital triangle is capitis

by the semispinalis

and a layer of dense fibro-fatty tissue which lies just beneath

muscle. Semispinalis This articular

head toward

arises from Cl 5 and

C7), and from the

6.

inserts by means

its tendon to the

inferior and superior nuchal lines. It is innervated by branches the cervical nerves. This muscle is a rotator of the base dysopposite side and can significantly to

function by immobilizing the occiput in a flexion lesion stricted, and by contributing to a torsion

if bilaterally re-

the superior nuchal

of the clavicles, borders of the

muscle inserts into medial margins of of the scapulae

protuber-

of the occiput. the spinous processes of C7 and all

ligamentum thoracic

hypertonic.

posterior borders acromion processes

(ILLUSTRATION 13-3).

Superior nuchal line /"Il'l'r-ri1'r-",.-.j-

T-12

\ Illustration 13-3

Trapezius Muscle

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lateral third

EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

209

Dysfunction of the trapezius immobilizes the occiput in a flexion lesion pattern. The trapezius must often be restored to a normotonic condition before the cranial base can be functionally corrected. Innervation of the trapezius muscle is by the spinal accessory nerve

(eN.

XI), which passes through the jugular foramen.

Trapezius hypertonus can cause dysfunction at the jugular foramena, which irritates the spinal accessory nerve

(eN.

XI) and causes further trapezius hypertonus,

another self-perpetuating neuromusculoskeletal problem. Sternocleidon1ostoideus This muscle arises from the sternum and clavicle (ILLUSTRATION 13·4). It inserts into the lateral surface of the temporal mastoid process and the lateral half of the superior nuchal line of the occiput. The muscle is innervated by a branch of the

�

mporal bone

/ Mastoid

c./

process

� Occipitomastoid suture Occiput

Sternocleidomastoideus m.

Sternum

Illustration 13-4 Sternocleidomastoideus Muscle

spinal accessory nerve

(eN.

XI) as well as by branches of the 2nd and 3rd cervical

nerves. Therefore, it participates in the pathophysiological condition of dysfunc­ tional self-perpetuation via the effect upon the jugular foramen described earlier under the trapezius muscle. . The sternocleidomastoid muscle offers more severe cranial problems than does the trapezius. This is because the sternocleidomastoid crosses the occipitomastoid suture which, when jammed or restricted in its motion, can create severe and incapacitating symptoms. It also can cause temporal bone dysfunction which, through its influence on the tentorium cerebelli, may cause severe problems.

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210

Constrictor Pbaryngeus Superior

sphenoid, the pterygomanp late This muscle arises from the It mandible and the of the dibular raphe, the alveolar process inserts into the occiput by an aponeurosis to spine on basilar plexus. It assists in The is by deglu ti tion. of is to but from a The clinical point view its struc ture would indicate that hypertonus may conto sphenobasilar flexion compression Occipitalis

This arises the la teral of the nuchal line and posterior inserts into the galea aponeurotica. It is innervated branches auricular branch of facial nerve. Although a weak muscle, we are sure that hypertonus this can to occipital ClViJFVIV1.L

BONES

The

function. The numerous and varied sutural recdy to insure proper equilibriu m, and the temporal to the apparatus, and nerves with which it is connected make it extremely numerous b lood significant clinically. ab out temporal bone function; is always more to you something new. when you closely, each contact will Sternocleidomastoideus

This suture bone.

insertion across the of the

or contracture in severe dysfunction of the temporal normal axis of rotation that bone, posterior rotation temporal a the transverse dimension of the superior aspects of the temporal squama, i.e. , internal rotation. Clinically, dysfunction of the bones etiologically to any motor This occurs IVth, Vth and VIth cranial nerves pass the the tentorium cereb elli. Rotational dysfunction of the temporal bone increased tension into anterior cerebellar tent at the petrous ridges. The tentorial attachment is posteriorly Correction of this anatomico-physiologic from clinoid processes of the dramatically corrects rapidly bone

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EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

bone of the tissues of the jugular foramen and XIth cranial nerves. It

in

foramena, and a secondary increase in venous vault and thus into the cerebrospinal

of venous outflow pressure within effect is created

of resorption of cerebrospinal fluid into in

of events often

distress or visual disturbances for a good clinical The occipitomastoid suture dysfunction, which may be caused

accompanied by the temporal bone dysfunction is

.

.1.'-<:;1<;:<"";;;

hypertonicity of the sternocleidomastoid, is often related clinically to disabled children. It may

cause head pain, nausea and

f.',-,.'",u'ua"

the temporal fossa, which parietal squama, the the frontal bone.

temporal nerve, muscle after arising The temporalis Its anterior fibers ly. The gross and that when the

m.

Maxilla

Mandible

IIIustration 13-5

Temporalis Muscle

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EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

Illustration 13-6

Effect of Temporalis Muscle Contraction on the Temporoparietal Suture

draw the parietal

downward

(ILLUSTRATION

1 H).

classified as a squamous each other. pressed or suture then perivascular compressed. result in chronic bone dysfunction. The latter resorption of bone of mild to moderate dysfunctions of the

These

parietal and temporal DigaJtricus consists of an anterior and a of the mandible near The two bellies

belly which arise rp<,nl"rt, and from the mastoid join inferior to body stylohyoideus muscle and hyoid bone (ILLUSTRATION

13-7).

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EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

o

...... Mastoid process of temporal bone Anterior belly of digastricus m. L-_\-'"

Posterior belly of digastricus m. Hyoid bone

I l l u stration 13-7

Digastricus Muscle

This muscle raises the hyoid bone and assists in opening the jaw when the hyoid is stabilized from below. It is innervated in its anterior belly by branches of the mandibular trunk of the trigeminal nerve (CN. V) and in its posterior belly by branches of the facial nerve (CN. VII). A frequent variation is that the posterior belly of the digastricus may arise partially or entirely from the styloid process of the sphenoid bone rather than from the temporal. The digastricus often is involved in anxiety and hysteria. It contracts and interferes in a subtle manner with temporal bone motion. It creates a tendency toward internal rotation of the temporal. It produces an elastic restriction which is easily overlooked by the clinician. Digastricus dysfunction in the posterior belly will also result in hyoid tightness. This may be the only clue a less experienced clinician will perceive. Anterior digastricus hypertonus causes a tenderness to palpation along its course on the inferior region of the mandible. Digastric hypertonus should always be suspected in cases of hoarseness or loss of voice, and in pain around the hyoid bone. Occasionally, temporal bone dysfunction will be the apparent cause of digastricus contracture. Correction of temporal bone dysfunction will correct and release the digastricus muscle. Longissimus Capitis

This muscle arises from the transverse process of the 1st through the 5th thoracic vertebrae and from the articular processes of the 4th through the 7th cervical vertebrae. It inserts into the posterior margin of the mastoid process of the temporal bone deep to the splenius capitis. The muscle is innervated by branches of the middle and lower cervical nerves. It serves to extend the head and to sidebend and rotate the head ipsilaterally. When in an abnormal state of contraction, it can result in temporal bone dysfunction by causing posterior internal rotation of the bone and immobilizing it in that position.

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EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

This

half of the ligamentum nuchae and from the

arises from the

through the 4th

spinous processes of the 7th into

process of

vertebrae. It inserts

bone and into

occipi tomastoid suture.

it

muscle also is neck and to

cervical nerves. It serves to extend

bones and crosses system. Contracture or hypertonus of the petrous

It induces

causes the temporal

splenius capitis

bone to go into posterior rotation of H<::AI'Ull

rotation of to the cranial

squamous portion of the occipital head" with internally

base and

of the

roots. Masseter Some

inferior surfaces

zygomatic

of the muscle crosses the suture of the bone. The masseter nerve. to an anterior rotation of temporal

as the bone moves about its

diagonal axis (ILLUSTRATION 13-8). Clinically, of emotional stress and tension which

POSTERIOR

in chronic

ANTERIOR

7r(

process al

Mastoid process

Illustration 13-8

Effect of Masseter Contraction on

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Direction of force exerted upon temporal 7\1rlr.nn!>t.i"' process by masseter muscle contraction

EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

215

clenching the jaw and den tal contribute to a chronic rotation of temporal b one. When cranial examination reveals conof mastication. look at the tonus the dition, Stylohyoideus Hn""",!lo; arises the tempora l b one. It inserts into

sacral symptom can

anterior lateral surfaces I t p asses between inserts into longitudinal part which the hyoglossus The styloglossus hypoglossal nerve (CN. XII). It draws the tongue up than a cause,

cranio-

sacral Auriculus Posterior

This muscle arises into the

the temporal and inserts by surface the ear. I t is the the facia l nerve (CN. VII). external ear posteriorly and the in moving the Abnormal tonus of muscle sometimes may resu l t from dysfunction of tembone and may be considered a system problems. SPHENOID "keystone" The sphenoid accommodative motion of the which, their abnormal tonus, may inhibit or interfere with sphenoid function or motion are of considerable of the sphenoid are with the The major osseous frontal, no great to that if inhibited in its mobility, will place significan t drag on the motio n of the whole craniosacral system. The muscles which attach to sphenoid are discussed Pterygoideus

pterygoid p late of This of the sphenoid, pyramidal process of the IJ",'e"''''H'- bone and the tub erosity maxilla. It inserts into inferior and posterior parts of the ramus of the mandible. The muscle is innervated

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21 6

EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

'--",I-'T,pn."noideus medialis m.

Illustration 13-9 Pterygoideus Muscles

by the medial pterygoid nerve from the mandibular division of the trigeminal nerve. Its position medial to the mandible is similar to the masseter on the outside. It is divided and offers passage to the lateral pterygoid muscle (ILLUSTRATION 13-9). The medial pterygoid muscle is powerful; it acts with the masseter to close the jaw. Chronic problems, such as dental malocclusion, tension, anger and anxiety, which cause hypertonus of the medial pterygoid muscle, result in significant dysfunction of the craniosacral system. It is difficult to predict the symptoms which may result from chronic medial pterygoid hypertonus because the physiological effect of the muscular dysfunction is upon the "keystone" of the craniosacral system. There will always, however, be dysfunction which involves the relationship between the sphenoid, maxillary and palatine bones. The temporomandibular joint is also a frequent focus of difficulty when the medial pterygoid muscles are in a state of hypertonus. Pterygotdeus Latera/is

This muscle arises from the inferior part of the lateral great wing of the sphenoid, the infratemporal crest and the lateral pterygoid plate. It inserts into the anterior part of the condyle of the mandible and the articular disc of the temporo­ mandibular joint. The muscle is innervated by the lateral pterygoid nerve from the mandibular branch of the trigeminal nerve (CN. V). It opens the jaw, protrudes the mandible and moves the mandible from side to side. Our clinical experience indicates that contracture or hypertonus of the lateral pterygoid muscles is frequently involved in dysfunction of the temporomandibular joints. Owing to the powerful nature of the muscle and its generous attachments to the sphenoid, this muscle is often etiologically related to craniosacral system dysfunction. It contribu tes to reduced mobility of the sphenoid, usually holding it in the extension position. Lateral pterygoid hypertonus is often overshadowed by other lesion patterns and is difficult to discover until many layers of adaptive lesion patterns have been

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removed. It is a frequent cause of recurrent craniosacral and temporomandibular joint problems. Temporalis This muscle has firm attachment to the external surface of the great wing of the sphenoid as this bony surface contributes to the temporal fossa. These anterior temporalis fibers run almost vertically, deep to the zygomatic arch, and attach to the anterior coronoid process of the mandible. By this mechanism, temporomandibular joint problems and temporalis muscle contractures cause dysfunction of the sphenoid. This abnormal tension imposed by the temporalis upon the sphenoid wing, if unilateral, can contribute to torsion and sidebending dysfunction of the cranial base. If the increased tension imposed by the temporalis is bilateral, it may immobilize the sphenoid in a vertical strain position which, because of its immobility, may be mistaken for a sphenobasilar compression. You must also keep in mind the attachments of the temporalis muscle to the frontal and parietal bones. These multiple attachments of the temporalis muscle to the various bones of the cranial vault make it a prime suspect when searching for the principal cause of osseous immobility. Tensor Veli Palatini This muscle arises from the sphenoid fossa at the base of the medial pterygoid plate, the spine of the sphenoid and the lateral wall of the cartilage of the auditory tube. It then descends vertically between the medial pterygoid plate and the medial pterygoideus muscle. It ends in a tendon which passes around the pterygoid hamulus, from which it is separated by a small bursa. The tendon then inserts into the palatine aponeurosis and the horizontal part of the palatine bone. The innervation to the tensor veli palatine is usually from the accessory nerve (CN. XI) via the pharyngeal plexus. The muscle classically tenses the palate during the process of deglutition. The muscle is significant in clinical craniosacral work because sphenoid bone dysfunction can cause change in its tonus. This change in tonus may increase tension on the auditory tube and become the hidden etiology for difficult-to-define sympto­ matology of the auditory system. It may also be the cause of recurrent middle ear problems related to impaired fluid drainage via the auditory tube. Constrictor Pharyngeus Superior This muscle arises from the inferior posterior surface of the medial pterygoid plate and its humulus, from the pterygomandibular raphe, the alveolar process of the mandible and, by a few fibers, from the side of the tongue. It inserts into the median raphe and an aponeurosis which leads to the pharyngeal spine of the occipital base. The muscle is innervated by branches from the pharyngeal plexus. It participates in the act of deglutition. It is partially by this muscle that the cranial base may cause difficulty with swallowing. PARIETAL BONES

The parietal bones form much of the sides and roof of the cranial vault. The point of maximum convexity on the external surface of each parietal bone indicates the origin of ossification of the bone. If this point is abnormally prominent, it

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EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCfIONS

to peripheral tension. The important in the sagittal sinus

venous

absorption of

venous

The nature

suture

contents include blood vessels, nerves suture resulting from shearing of intrasutural neurogenic may become

(ILLUSTRATION 13-10).

connective tissue

into the

ventricular

intrasutural An extreme

produce connective tissue

':lTtronJ-",rn"

Additionally, work in progress continuous single axon fibers traverse dural membrane as it

parietals allows

temporal squama

for a gliding motion between these two bones

all of

fJ«,lA\C ••,..,:)

strongly

in monkeys, suture through the

falx

tissue itself, and

of innervation may represent a mechanism whereby sagittal suture function, cerebrospinal fluid production by (ILLUSTRATION 13-11).

Ternporalis surfaces of

This muscle abnormally

parietal bones. tension

Illustration 13-10

Suture Bevel

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Suture narrows during extension-----_�

-.. -::::::: : ::::==;�� := ��::::::==----. Suture widens during flexion

I l l u stration 13-11

Sagittal Suture in Flexion and Extension

across the temporoparietal suture. This shear frequently results in both local and referred pain. Many recurrent temporal headaches are caused by this mechanism, which is activated by temporalis muscle hypertonus. This hypertonic condition may be chronically caused by ongoing emotional stress or dental malocclusion. The innervation to the temporalis muscle is from branches of the mandibular division of the trigeminal nerve (C.N. V). It normally acts to close the jaw. Its pos­ terior fibers contribute to mandibular retraction. It arises from the whole of the tem­ poral fossa. The muscle inserts into the coronoid process and the anterior ramus of the mandible (ILLUSTRATION 13·12). FRONTAL BONE

The frontal bone contributes to the anterior cranial vault by its squama, and to the floor of the cranial vault (which underlies the anterior brain) by its horizontal formation. These horizontal plates also contribute to the superior aspects of the orbital cavities and to the nasal cavities. The muscular attachments to the frontal bone are rather sparse. Temporalis

This muscle attaches to the posterior, lateral and inferior aspects o f the frontal bone as it contributes bilaterally to the anterior portions of the temporal fossae. The temporalis muscle fibers which arise from the frontal bone i nsert into the anterior ramus of the mandible and are therefore almost vertical. Abnormal tonus of the temporalis muscle does not interfere to any great extent with frontal motion. Our impression is that frontal bone motion is compound and includes an anterior rotation of the superior aspect ab out a transverse axis during

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Illustration 13-12 Temporalis Muscle

the flexion phase of motion. In addition, this transverse axis translates anteriorly and inferiorly. Frontalis

This muscle does not attach directly to the frontal bone and has minimal effect upon its motion. However, by indirect effect through the corrugator and orbicularis oculi muscles which do attach to the frontal, it can, if chronically hypertonic, inhibit the flexion phase of cranial base motion. The frontalis is innervated by temporal branches of the facial nerve (C.N. VII). MAXILLAE

These bones powerfully influence the function of the craniosacral system via their articulations with the frontal, ethmoid, palatines (which articulate with the sphenoid), vomer and zygomatics. The maxillae also have important articulations with each other. Articulations with the lacrimals, the nasals and the inferior nasal concha have less influence on craniosacral system function but can be symptomatic when dysfunctional. The maxillae have inconstant articulations with the orbital surfaces and the lateral pterygoid plates of the sphenoid. Muscles which attach to the maxillae are quite numerous. Those which we consider clinically Significant in maxillary function are described below.

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�If-----+-==- Bucci nator

m.

Illustration 13·13 Buccinator Muscle

Buccinator

This is the principal muscle of the cheek. It forms the lateral wall of the oral cavity. The buccinator muscle arises from the maxillary alveolar processes above, the mandibular alveolar processes below and the pterygomandibular raphe. The fibers run anteriorly and insert into the deep layer of fibers of the lips (ILLUSTRATION 13-13).

The motor innervation of the buccinator is by the buccinator branch of the facial nerve (eN. VII). The sensory fibers are from buccal branches of the tri­ geminal nerve (eN. V). Abnormal tone of these muscles is rare in our clinical experience; however, the common origin should be kept in mind when looking for causes of temporoman­ dibular joint disturbances and for problems involving the pterygoid process of the sphenoid. The effect on the cranial base of anterior force upon the pterygoid would be to discourage the flexion motion of the sphenoid and to encourage the extension motion as this bone participates in the normal rhythmic activity of the cranial base. Masseter

This thick muscle consists of two portions. The larger is the superficial portion, which arises by a tendon from the zygomatic process of the maxilla and from the posterior two-thirds of the inferior border of the zygomatic arch. It inserts into the angle and inferior part of the lateral ramus of the mandible. The deep portion is smaller. It arises from the posterior third of the inferior border and from the entire medial surface of the zygomatic arch. This deep portion inserts into the superior half of the mandibular ramus and onto the lateral surface of the coronal process (ILLUSTRATION 13-14·A).

The masseter muscle is innervated by branches from the mandibular division of trigeminal nerve (eN. V). The masseter muscle closes the jaw. This muscle is often involved in problems with dental occlusion and in chronic jaw-clenching due to emotional problems. It contributes to ongoing temporoman-

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Illustration 13-14-A Masseter Muscle

problems and to te mporal bone dysfunction, encouraging anterior and exte rnal rotation that Pterygoideus

to the masseter. I t arises muscle is deep in This thick, from the U".'.u,,,, surface of lateral pterygoid plate sphenoid, the the p alatine and the tuberoSity of maxilla. It is mandibular ramus and angle the mandibular V). The mandibular branch of the the (ILLUSTRATION 13-14-B). is often to dental i njury emotional p roblems. Hypertonus or contracture the medial pterygoid always system dysfunction of some type. PALATINE BONES

with palatines form posterior fourth the hard palate. each other, the maxillae, vomer, inferior nasal concha, sphenoid and ethmoid osseous communication between They occupy a key nose and bones those Tensor Veli Pa/atini

medial muscles arise bilaterally from the scaphoid fossa at walls of the auditory and from the pterygoid plate the to the transverse posterior of the longitudinal palatine bones. Their innervation is from the acc essory nerve (CN. The muscles tense the palate degluti tion. or hypertonus bute to via to This hypertonus may result from sphenoid

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Illustration 13-14-8 Pterygoideus Medialis Muscle

normal condition of these muscles with p hysiological mo tion. The palatines are small and light. are not often .�'''�.�V.� which with system ful dysfunction may from immobility is result of trauma and is an osseous lesion, but con tripallaLl'''''' bone pattern by the tensor veli palatini may significant. bution to the Pterygotdeus Medialis

These muscles arise partially from processes of the palatine b ones. Another slip to bones. tendon into ramus and mandible. to the tensor veti palatini a nd to the superior are by the division of trigeminal nerve (C.N. these muscles can stro ngly impair the physiomotion and function the palatine bones thus contribute to pain which involve the palatine bones via tensor veli palatini musc les, to syndromes which i nvolve auditory BONES

to the cheeks. They form the walls and floors of the orbits and to parts the temporal and infratempo ral (ILLUSTRATION 13-15). The only attachment which afford is ongm the masseter These muscle the fibers insert i nto the mandible. Masseter innervation is the division V). The masseter closes jaw. Hypertonus o r of the trigeminal nerve contracture the masseters will cause zygomatic dysfunc tion. may result i n

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Parietal

Zygomatico­ maxillary suture

Zygomatico­ temporal suture

Illustration 13-15 Relationships of the Zygoma

facial or orbital pain and a drag upon the nr"''''''''{1 cheekbones are often a sign of

motion of the maxillae and temporals. bone dysfunction.

MANDIBLE

bone is l ower and it carries the teeth. It consists a horizontal body two vertical or perpendicu lar rami. It has bilateral articulation bones. mandible is a with cause of craniosacral system then tentorium muscles of to mandible. There are numerous muscular mastication or are affected by imbalanced tensions which involve the relate to temporomandibular jawbone. There are many clinical problems jOint dysfunction . Although the temporomandibular is often co'nSl.oelcea the the muscles of mastication to the etiology of lightly. We regard manproblems cannot be as an u nstable anchOring system for soft tissues which attach to it. The articulations the mandible with are, bones are very vulnerable to tensions which tend to move mandible from midline. muscles which to below. mandible are

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arises from the fascia which covers It inserts into the parts of the body pectoralis major mandible. The innervation of nerve (eN. is by branches of the

Vm·

We are unaware of any cases o f platysma hypertonicity which from a strictly to craniosacral system dysfunction. point of view, the possibility exists a relatively platysma in a state of \"l1.1V',U\.. would cause hypertonus muscles which in motion of craniosacral system. which close the jaw a ttach to the temporals, maxillae, zygomatics, parietals, sphenoid frontal. A constant hypertonicity of these muscles, even at a low level, indeed cause amount o f system to This in the Mylohyoideus

muscle arises the length of the mylohyoid line mandible. by mylohYOid nerve, hyoid The muscle is It inserts into which arises the inferior branch the mandibular branch of the trigeminal nerve (eN. V). The mylohyoid muscle raises the hyoid U\..,;HH.}H, deglutition, sucking and of chro nic hypertonicity of this will mandible, but also upon infrahyoid Once the hyoid by the antagonistic action of the infrahyoid muscles, the mandible will subjected which tends to open it. will counteracted by the muscles to the bo nes of the vault to zYJ�Olma.t1cs. It is by this mechanism that mylohyoid may and contribute to temporomandibular craniosacral joint dysfunction. DigastricuJ

This

under the discussion the belly of muscle arises mastoid notch o f the temporal. anterior belly arises fro m inferior in a bellies end in a tendon which depreSSion on the inner of the mandible. passes through a fibrous loop attached to side and cornua the u ..._�"u" of temporal bone and are produced via can act as a transmitter from hyoid bone, or i t may b e i n a state o f abnormal contraction we have found the infrahyoid muscles to be the cause of temporal and mandibular dysfunction transmitted by the digastricus. from hyoid to innervation o f is b y mylohyoid nerve, which i s a of nerve (eN. V); the nerve (eN. muscle normally raises the hyoid and assists i n opening the jaw. The anterior belly from the mandible draws the hyoid up and (ILLUSTRATION 13-16), The posterior belly draws the hyoid up and

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Mandible

Origin of the m.

Illustration 13·16 Section of Mandible

Pterygoideus Medialis

the

This

system joint dysfunction of the sphenoid-palatine-maxilla temporal bones through its sphenoid and maxillae, thus sacral the the tonus pterygoideus is pathological condition of the or trauma to the long the trauma has forgotten. Pterygoideus Laterali!

This muscle arises from the sphenoid, the pterygoid plate. It inserts into a and into of the tempo romandibular joint. It is the mandibular division of arises opens the mandible

of

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to and acute system dysfunction and to temporomandibular joint dysfunction. Its hypertonicity is usually caused by trauma, dental malocclusion and chronic hyperemotional states such as anger, tension or stress. Masseter

This muscle arises from the zygomatic process of the maxilla and from the and into the It inserts into angle and the ramus the zygomatic lateral surface of the process. It is innervated of the the jaw. nerve (eN . V). muscle Clinical to abnormal tonus of the masseter muscles include dental malocclusion, states trauma. masseter muscle contributes to ongoing temporomandibular Hypertonus of joint dysfunction. It encourages anterior and rotation of the around an axis which is approximately through the ear canaL Temporalis

muscle arises from temporal includes temporal, parietal, frontal sphenoid It inserts into mandible at its anterior coronoid as far forward as the and into its anterior ramus, last tooth. is innervated nerves which arise trigeminal nerve (eN. V). muscle

city of one o r malocclusion, chronic hyperemo tional s tates and physical trauma. problems, Temporalis muscle hypertonicity can underlie temporoparietal suture dysfunction, pterion dysfunction and b one dysfunction. The results are always dural membrane tension as well as osseous and sutural p roblems. Temporal bone may be for many recurrent neck, shoulder and arm Buccinator

This arises outer of the alveolar p rocesses the It inserts into the deep and the pterygomandibular maxillae, the It derives mo tor innervation from the facial layers of the muscle fibers the trigemi nal nerve (eN. V). VII), and sensory innervation compresses the in mastication. Significantly to craniosacral this muscle has not In our probably it has no firm insertional place. Constrictor Pharyngeus Superior

third of posterior margin the medial muscle arises from the pterygoid plate, the raphe, the alveolar of the mandible and the of the I t inserts into the pharyngeal spine in basilar of the by branches of the pharyngeal plexus. I t assists in anatomical relationships of this muscle would that in a hypertonic

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state it might significantly contribute to sphenobasilar flexion and compression dys­ in our own clinical experience, we have found little to support function.

HYOID BONE

Although the hyoid bone is not strictly a part the craniosacral system, it has such generous muscular and fascial to the cranium that it cannot as a to and The hyoid acts like a floating .:.><::<.-aJll\..llUl connecl:ea by attachment for the cranium above it (ILLUSbelow TRATION 13-17).

Suprahyoid muscles

I Infrahyoid muscles

I

I

Illustration 13-17 Suspension of Hyoid Bone The hyoid bone consists of a body, two greater cornua and two lesser cornua. which runs to it. First is the stylohyoid Two major ligaments are tip styloid process of the bone to the cornua. ligament, to the hyoid is lateral thyrohyoid ligament. This ligament runs the tip of superior cornua the cornua of the hyoid bone. It is a round, of cartilage to the elastic ligament which forms the posterior border of the thyrohyoid membrane. The

which

attachment of the hyoid to the cranium are

below. GeniohyozdeuJ This muscle arises from the inferior mental spine on the inner surface the the hyoid. the mandible. It inserts into the anterior

symphysis menti The

by branches the 1st cervical nerve via the geniohyoid muscle draws the

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EXTRINSIC NEUROMU SCULOSKELETAL SYSTEM DYSFUNCTIONS

and hyoid bone anteriorly. I t in and U"""'LULL hyoid is fixed, the geniohyoid depresses the mandible. is related to this

229

When the the

Digostricus

inner side The anterior b elly arises arises as two the mandible; the posterior belly arises from mastoid notch of temporal bone. Both b e llies insert into a tendon which connects the two bellies passes through a fibrous loop arises cornua of the the hyoid is anterior b elly by mandibular the trigeminal nerve (CN. V). posterior belly is innervated by a branch facial nerve (CN. VII). The muscle raises hyoid bone and assists in opening jaws. hyoid forward and the posterior belly draws it

Stylohyoideus

This muscle arises from the posterior and lateral surfaces styloid process the temporal with It inserts into hyoid body at its cornua. It is VII). It draws by a branch of facial nerve and Mylohyoideus

arises from the whole length mylohyoid inserts into body the hyoid bone. It is mandibular division of the trigeminal nerve V). muscle raises hyoid and the tongue, and assists in mastication, deglutition, sucking and blowing. nerve (eN. V) or with division of the Problems of the facial nerve (eN. VII) can the appropriate referrable to the hyoid Craniosacral dysfunction itself as an abnormal tension of the hyoid bone referred down from above. In order to balance abnormal fixing fro m below the hyoid must react by becoming is tightening throat which is usually attributed to can result of craniosacral "'''·''A.� dysfunction. the hyoid bone from below are described below. muscles which SternohyoidCUJ

arises fro m the posterior "TP'TnOrl sterni It inserts into the suprahyoid body the hyoid. This stabilizes hyoid muscles and draws the hyoid inferiorly. It is innervated by branches the 1st, 3rd cervical nerve roots via the ansa cervicaHs.

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Thyrohyoideus It thyroid arises the oblique line of the lamina This Functioncornua of hyoid inserts into the inferior border of the ally, it seems to be an extension the sternothyroideus muscle, which arises the manubrium sterni (dorsal to the origin of eus) and

1st and sometimes 2nd ribs. thyrohyoideus draws the hyoid inferiorly or the thyroid cartilage superiorly, depending upon the degree of fixation of two structures. It eus muscle, direct connection between the 1st (and sometimes the 2nd)

with the sternothyroidsystem, via hyoid bone, found this to be a clinically

1st, and sometimes

2nd, cervical

nerve roots. OmohYOideus contains inferior and superior bellies, by a central are tendon. The inferior belly arises from the cranial border of the scapula. This inferior is bound to the clavicle by a fibrous band, then passes deep to the sternocleidomuscle.

belly then inserts into and more cephalad. tendon in the superior belly cranium and inserts into of hyoid body. cervical nerve root branches via ansa 2nd

It is innervated The omohyoid draws

hyoid inferiorly. It offers further connection between

cranium via hyoid to the clavicle and then on to the scapula. It whereby dysfunction can influence thoracic inlet vice versa.

connection is a frequent clinical finding

to abnormal tonus of the omohyoid We have devoted attention to

often may

hyoid bone and its relationships to the

craniosacral system in order to emphasize its importance in many clinical syndromes anatomy. Many until one considers the which seem craniosacral-hyoid, thyroid-thoracic inlet dysfunction help before anatomy which

are referred for the

explored and evaluated, much less treated. SACRUM

AND

C OCCYX

The sacrum and coccyx are the osseous structures .which end

mater

spinal canal between the 3rd cervical

and

no osseous 2nd

attachment to the 2nd and 3rd cervical vertebrae is only at anterior aspect of bodies of C2 C3. It is that is, tube attaches to the firmly attached within the canal

only at

out to filum terminale as arrangement allows for gliding movement of the posterior fibers the

magnum and the coccyx. dura mater is inelastic, circumstances which undue tension upon the sacrum and the coccyx will have a upon the funcsystem as a the tion and <>rn""",,",n

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which, by abnormal tonus, may therefore cause

are discussed below.

Piriformis This muscle arises bilaterally as three digitations from the anterior the sacral bone 1st through the 4th segments, margin of the greater sciatic

anterior surface of sacrovia the greater sciatic foramen

tuberous ligament. It passes out inserts by a round tendon into femur (I LLUSTRATION 13-18). Its insertion is the common tendon innervated by

surface of the greater trochanter of to, and may partially muscles. The

UU�H'_U'_"

the thigh.

sacral nerve. This muscle serves to In our experience,

is by the 1st

is a common cause of craniosacral

-'<:-�:-'I-t-+- Piriformis m.

Greater trochanter

Illustration 13-18

Piriformis Muscle

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,;:u�:t.>,n

and torsion dysfunction. When in a state of hyper tonus, i t sacrum. I t may this unit. this occurs, it causes concurrent s idebending torsional tendencies at the then at the sphenobasilar joint. Recurrent cranial are due to tension paired sacral results in of reflects u p the dural mobility c ranial base. ,-, u ,,,,, ,,",,",,

two-thirds of the This is a flat, triangular muscle which arises from the iliac fossa, the i nner lip the crest, the anterior and iliolumbar and the sacrum. converging, its insert into lateral the psoas and onto femoral nerve derived from (ILLUSTRATION 1 3- 19). It is innervated by fibers 2 nd and 3 rd lumbar spinal nerves. The muscle the thigh. by hypertonus will con tr ib u te to dysfunction lesion) cranial b ase. Unilateral iliacus muscle hypertonus will cause torsion dysfunction of the craniosacral '''''' TP ,rn

-\'!IIIr--- Quadratus lumborum m.

nguinal lig.

Illustration 13·19 Iliacus Muscle (Arrows Indicate How This Muscle Can In terfere with Free Sacral Mob il ity)

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233

Maximus U-"",\.. l C'"

of

gluteal region. I t arises from o f that (including

maximus is

Illustration 13-20 Gl uteus Ma ximus M u scle

are passed to their spinal nerves. and 1 st and destination via the inferior gluteal nerves. muscle extends and laterally rotates the the gluteus hypertonus causes a maximus causes a reduction of sacral mobility. bending torsional dysfunction sacral Bilateral hypertonus causes a reduction of sacral mobility in position of flexion. These with sacral mobility are transmitted to the cranial base via dural Multifidus

lie in tendinous fasciculi muscle consi s ts grooves on both of spinous processes from sacrum to axis. In the posterior sacrum from the4 th segment upward, fasc iculi arise above. That is, spinous processes two to insert into the arise fro m the level of the 4 th sacral mul tifidus generally which arise insert into the spinous process the 5 th lumbar from sacral segment usually insert into spinous p rocess o f the 4th and so on u p to axis.

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arise laterally medially as ascend, Since the unilateral contraction p roduces a rotation wi th a tendency towards extension multifidus contraction backwards the involved spinal lumbosacral

in membranous upper is back cervical head pain, mental of depression. This depression is considered to be endogenous and is blamed the head, neck and low back of lumb osacral junc tion, the usually remarkable A in the craniosacral system motion is detected immediately. Unilateral lu mbosacral region multifidus contrac ture system dysfunc tion. usual result is one of cranial torsion dysfunction. this is the case, base torsion dysfunction will often correct abnormal lumbosacral spo ntaneously Coccygeus and Levator Ani

the These by generous to coccyx. a hammock. the pelvic diaphragm is in a s tate of hyperto nus or contracture fo r reason, the coccyx is pulled into anterior This condition of anterior position transmits tension up dural tub e coccyx (which has dural to its the occiput. Such tension causes occipital and pain in addition to in ab normally hyperto nic diaphragm. and restored normal craniosacral system pelvic diaphragm tension and LIGAMENTS

membrane In this section we will only consider those which are extrinsic to the of craniosacral When things happen to the normal one should always consider an imbalance tension to Injury , s tressful voluntary problems. for stylostyloid p rocesses of the temporal b ones offer hyoid ligaments, which connect p rocesses the lesser cornua the hyoid which connect these probone b ilaterally; and for s tylomandib ular

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I l l u strati on 13-2 1

Styloid Processes of the Temporal Bones

cesses with the angles of the mandible (ILLUSTRATION 1 3- 2 1 ) . Imbalanced tension of these ligaments will interfere with normal temporal bo ne motion. The styloid processes serve as levers which affect temporal bone motion. A slight tension upon the lever has an exaggerated effect upon the motion of the whole bone. The sphenomandibular ligament co nnects the spine of the sphenoid bone to the lingula of the mandibular foramen. Imbalanced tension from the mandible can therefore cause dysfunction of the sphenoid bone as it moves in response to the urging of the craniosacral system. Ligaments which, when imbalanced or under abnormal tensio n, interfere with normal occipital motion include the ligamentum nuchae, the fibrous raphe of the pharynx, the lateral atlantooc cipital ligaments and the oc cipitoaxial ligaments, which pass through the foramen magnum. There are also nu merous ligaments which can easily impair the free mobility o f the sacrum a s i t participates i n the motion o f t h e craniosacral system. These ligaments include the anterior and posterior lo ngitudinal ligaments whic h co nnect occiput to sacrum. The intervertebral disc between L5 and Sl may be considered a ligament and can certainly impair the sacrum's ability to move. The ligamentum flava connects the lamina of L5 and Sl . Imbalance of tension in these ligaments is most likely to produce a sidebending or torsional craniosacral system dysfunction pattern. The articular capsules which connect the articular processes of L5 and Sl can likewise interfere with free sacral motion when these capsules become inflamed or stiffened for any reason. One must also consider the iliolumbar ligamen ts, which connect the sacral base to the transverse processes of L5 ; the interspinal and supraspinal ligaments; the

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EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

ligaments of the sacroiliac articulation (ventral, dorsal and interosseous); the liga­ ments which connect the sacrum and the ischium, usually the sacrotuberous and sacrospinous; the sacrococcygeal ligaments (ventral, dorsal and lateral); the inter­ posed fibrocartilage; and the interarticular ligaments. Postural imbalances, athletic stresses, injuries and the like will cause tension imbalances in these ligamentous structures. These imbalances are manifested as abnormality of motion in the craniosacral system; bizarre syndromes are frequently the result. FASCIA Fascia is a connective tissue which is derived embryologically from mesoderm. It is composed primarily of collagenous and elastic fibers. Fibroblasts and fibrocytes are always present. Fascia exists in dynamic equilibrium. Collagen fibers are glistening white. They are composed of reticular fibrils which are visible with the electron microscope. These collagenous fibers form the bulk of fascia, tendon and ligament. Collagenous fibers are pliable and extremely tough, with little extensibility. Elastic fibers are stretchable. They vary in length and thickness depending upon the tension placed upon them. They are not known to be composed of smaller fibrils but rather are homogeneous proteinaceous material. Electron miscroscopy suggests that a unit (which we shall call the "elastocol­ lagenous complex") may account for the contractibility of fascia. This unit is innervated. It may serve as the mechanism by which fascia exhibits the ability to contract and relax. It may also relate to fascial "trigger points." In our proposed "elastocollagenous unit" the elastic fiber is the core. The collagenous material is coiled around the elastic fibers. The collagen and elastic fibers have common attach­ ments at the extremes of the " elastocollagenous complex" (ILLUSTRATION 1 3·22). Innervation of the " elastocollagenous complex" is both sensory and motor. As the complex reaches its limit of expansion, stretch stimuli produce a reflex elastic contraction as well as the subjective sensation of pain. There is also a ground substance present in fascia which may vary in constituency from fluid to solid. This substance transports metabolic materials throughout the body. (We refer here to both anabolic and catabolic materials.) Our research, both independently and in conjunction with Dr. Zvi Karni, Professor of Biological Engineering at the Technion Institute in Haifa, Israel, suggests that fascia may serve in an electrical conduction capacity and therefore that fascial contraction may interfere with its electrical conductivity coefficient. Local-

�

·/ f· b �

EI astlc = I

I

ers

�

';b L ::

� 1

Relaxed complex

�

Collagen

.-=:==:=-a,

==

Stretched complex I l l ustration 13-22

" Elastocollagenous Complex"

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EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

237

ized pain and tissue devitalization may b e produced a s a result. Fascia may vary in character from predominantly dense and fibrous (which may be organized or disorganized) to loose-fibrous, fibroelastic, areolar or reticular. The organized dense fibrous tissues in the extreme are the aponeuroses, ligaments and tendons. These tissues are largely inelastic; they can withstand great unidirectional stretching and tensile strains while still remaining pliable. The disorganized dense fibrous tissues have their collagen fibers arranged in an interwoven manner, rather than in parallel bundles like the organized tissues of aponeuroses, ligaments and tendons. The disorganized dense fibrous tissues form most of the fascial mem­ branes, the dermis of the skin, the capsules of organs and the periosteum of bone. These tissues can resist strong stretching tensions in any direction. In this character­ istic they differ from the organized dense fibrous tissues, which best resist stretch­ ing in only one direction. The latter tissues easily tear when stretched at right angles to their direction of fiber orientation. Some membranes, such as the dura mater, have their bundles of collagen arranged in layers rather than in interwoven networks. Continuous abnormal tension on these tissues in a given direction will cause the fibers to organize. Fiber orientation is parallel to the direction of maximum tension to which the membrane is subjected (ILLUSTRATION 1 3-23). Microscopic study of fiber orientation patterns in normally disorganized fascia and the dural membrane may indicate the presence of abnormal fiber patterns. From a functional point of view, the bOdy fascia may be regarded as a single and continuous laminated sheet of connective tissue. This laminated sheet extends without interruption from the top of the head to the tips of the toes. It contains

I l l ustrati o n 13-23

Orientation of Dural Membrane Fibers in Response to Stress

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EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

pockets which fo r the presence the visceral which allow for skeletal s tructures. I t also contains concentrically the verteb ral column demands placed upon i t mater invests the b rain and s pinal cord. I t i s a fascial memIts blood vessels serve throughout the majority its The brain and exit pia mater contrib ute to the perineurium of the nerves pia mater blends with dura mater at the exits of these nerves spinal fro m the Its ou ter blends wi th the villae co me into intimate contact wi th it. as it follows the fissu res ventricular system of the brain. It travels with embryologically. the by the subarachnoid space, or adherent, is arachnoid with cerebrospinal fluid. is p ro mi nent at the The it is separated from the dura mater the subdural space, whi ch contains a th in layer o flubricati ng fluid. There i s functionally Significant independent mobility the mater, the arachnoid and the pia mater. arachnoid with pia mater occurs, do not restrict a small trabeculae, where of motion between two At the the brain subarachnoid space considerably to form cisternae. The cisternae are with cerebrospinal fluid and are named for their anatomical locations. dura mater is outermost of concentric invest It is fib rous connective tissue composed b undles arranged in interlacing layers. It two layers, an inner meningeal layer and an outer layer. These layers are blended into continuity at the foramen fo ramena, as du ral layers invest blend with coccyx. The of skull. It is continuous the periosteum the uncalcifled and m obile skull bones su tures. concepts o f concentric cervical region i s an excellent example o f and concentric tubes ( the contained , together with the within the spinal the ,,"'.c�"'h"" another tube column and i ntervertebral its conte n ts, in addition to invests the many i mportant It connects the w i th the thorax anterior is complex of anterior is continuous from the skull to the coccyx. I t invests the longus colli and the rectus anterior and to tips the vertebral transverse nt',,. r,,, ,,,, of the extends over the scalene muscles and beco mes the

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EXTRINSIC N E UROMUSCULOSK ELETAL SYSTEM DYSFUNCTIONS

Sibson's fascia, which

is continuous with the n t,") r,'pr! by striate

over the cupula of each This fascia is on the deep muscle fibers on occasion. It is continuous with The carotid sheath contains the carotid artery, vagus nerve (CN. X). Medially, it is continuous with esophagus and t rachea.

Laterally, it is continuous The carotid

'>LAO"aLU o. . La'''£Jl''

sternum the scalenes. It is continuous with the pericardium cervical sympathetic neural tissue is imbedded in sheath; therefore, tension on the carotid sheath affects autonomic function. descends from

fibrous pericardium is continuous with the carotid penetrate the

base. Below, many of the inferior surface

the diaphragm. We have

the crura of the

they become

with the fascia skull to pelvis, with

continuity nerve function in

muscles. upon

are hundreds

in the human body

illustrate

continuity of fascia from may regard the in the body to any other HU.UU.U.>

of fascia attach to of the craniosacral fascial continuity, an injury which results in fascial contracture o r the craniosacral which, in turn, can

central

This may cause bizarre and

is based on are normally traction. Areas of injury immobility. One must carefully Fascial quality of motion in to rule but feel compelled to use to find an because we do not subscribe to dogmatic and absolute r r. nr.". ",r" to be learned with viscera has carried its own that it is a localized the fascial

to

are these: that it is it during embryologic

mobile connective tissue mobility; and that such

dysfunction or mobility produces a

which m anifests as abnormal

in craniosacral t reatment and

whether it be clean, or post-traumatic lIUJ'CH1" in fascial mobility.

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than sterile, can create

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EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

Drag upon fascial mobility, which is induced by cicatricial formation, may result in craniosacral system dysfunction. The resulting clinical syndrome may only be traced to the fascial problem as you observe a successful therapeutic result. One of the best examples of this rather bizarre and far-fetched idea was the case of a '36year old woman whose migraine headaches of 20 years' duration were ended when her appendectomy scar was mobilized. The appendectomy was performed when the patient was 1 2 years of age. The menarche occured at age 1 3. The headaches began at age 1 6. This patient had visited several clinics of good reputation, exhausted most other therapeutic modalities and was in the process of accepting her incapacitating problem as the result of a deep-seated, psychoneurotic disorder. Examination of fascial system motion integrated with craniosacral system motion led us to the appendectomy scar. Deep pressure medially on the scar produced the headache; deep pressure laterally caused relief of the headache. Mobilization of the scar was performed by sustained and deep but gentle pressure. At this writing, there have been no headaches for approximately 1 8 months. Spontaneous relief of low back pain, menstrual disorders and chronic and recurrent cervical somatic dysfunction also occured following cicatrix mobilization. We have found similar, apparently bizarre relationships between headache and suspension of a right kidney, surgical removal of a right medial knee cartilage, coccygectomy and ganglionectomy of the left wrist. We have seen dysautonomia as a result of craniosacral system dysfunction which arose from surgical procedures. We have also observed the relief of " endogenous depression" as the result of mobilizing scar tissue which caused cranial base compression. We believe that scars which significantly contribute to craniosacral system dys­ function are most easily found by the blind evaluation of craniosacral motion, both within the craniosacral system and as it is reflected throughout the total body fascia. We search for the locus of immobility while the patient is dressed in loose clothing. Only after we find the locus do we look for the presence of a scar. The movements under investigation are so subtle that we do not wish to have the visual observation of a scar or cicatrix suggest the locus of immobility. We feel much too suggestible to accept the approach of a prior visual observation or verbal history from the patient. Palpation is used first, followed by confirmation upon direct observation and patient history. ARTICULAR SOMATIC DYSFUNCTION Somatic dysfunction of the spinal column anywhere throughout its length will result in craniosacral system dysfunction. This probably occurs through several mechanisms: 1 . Somatic dysfunction which reflects at one or more intervertebral foramena may cause tension or abnormal change in the character of the dural sleeve, which follows the spinal nerve root out to the affected foramen. This condition may produce a "dural drag" upon the free motion of the craniosacral system. Func­ tionally, the sacral hiatus may be regarded as another foramen which has a similar effect of "dragging" upon the free mobility of the craniosacral system; therefore, any articular dysfunction of the sacrum will produce a change in the craniosacral system. 2 . Facilitated spinal segments are almost always detectable b y examination o f the craniosacral system. This may be due to a neural mechanism from that segment

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EXTRINSIC NEUROMUSCULOSKELETAL SYSTEM DYSFUNCTIONS

3.

241

which produces craniosacral dysfunction. Somatic dysfunction usually adversely affects the craniosacral system by way of its effect on fascial mobility and muscle tonus. It is very rare when these conditions cannot be detected by their effect on the free mobility of the craniosacral system.

Many muscles and connective tissues external to the craniosacral system can have a deleterious effect on that system. This chapter has taken you on a short tour of these tissues and described the possible mechanisms of their adverse effects. We hope that you will keep these possibilities in mind whenever you diagnose or treat craniosacral dysfunction, as this attitude will definitely enhance your ther­ apeu tic abilities.

""

...

" "

,.

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Chapter 14 Diagnosis by Evaluation of Craniosacral SysteIn Function and Whole Body Response rhythmic motions of .... ,.�,,.,,.

�u

in

human body can be used

In this chapter, our attention will be focused primarily

the

craniosacral system rhythm, mobility system, the response rest the body to rhythmic motion. Because we are focusing attention upon this system

not mean that we

craniosacral rhythm is the most signifi-

cant body

(It is probably the most

explored the use rhythms.

this body rhythm and mobility more

It does mean that we have of the

mobility have

so It would seem that we

have

to your As a professor in a college osteopathic and as a teacher some I (Up\edger) have allopathic medical by the observation that 3rd and 4th year students are reticent to human being during an examination It seems 242

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CRANIOSACRAL SYSTEM FUNCTION AND WHOLE BODY RESPONSE

243

untenable that a health care professional may carry a neurotic aversion to touching another human being. After overcoming the aversion to touching (which we do by touching), you can begin to obtain information about the patient with your hands. Use them. The cost of health care can decrease considerably if" touching skills" are developed and used by health care professionals (APPENDIX K). Accurate diagnosis by the use of craniosacral system motion requires that you accumulate examination/touching experiences with many healthy and many less­ than-healthy human beings. As you accumulate a data base of experience, you will be surprised, if not amazed, at the diagnostic inSights you can receive from your hands. You will notice the person-to-person variations in quality, symmetry, rate, rhythm, restriction, etc., of the craniosacral motion. The methods we have developed for use in palpatory diagnosis are described below.

QUALITY OF CRANIOSACRAL MOTION Very gently apply your hands to the patient's body. The application of your hands can be anywhere on the body. We suggest the vault hold, the thoracic inlet, the respiratory diaphragm, the pelvis, the thighs and the feet as good "listening stations" for starters. Your touch should be too light to stimulate a perceptible body response. Note the quality of the motion which you perceive. Is it free and easy, as in good health? Is it labored, as in a rigid container fighting against its boundaries? Is the motion lethargic and lacking in inherent energy, as in states of physical or mental exhaustion? Correlate your impression of the quality of motion with other information about the patient. Keep this in your memory for future recall and comparison. SYMMETRY OF CRANIOSACRAL MOTION

Is the motion symmetrical on the head? At the various "listening stations" listed above? Is there a lack of symmetry? Where is that lack of symmetry most pronounced? Where is the restriction that produces it? RATE OF CRANIOSACRAL MOTION

Is the rate normal (between 6 and 1 2 cycles per minute)? If the rate is high, you may suspect an acute problem against which the patient is fighting very hard. Hyperkinetic children present with elevated rates. (For those of you interested in traditional Chinese medicine, an elevated rate suggests a Yang malady.) If the rate is below normal, it suggests a chronic, debilitating (Yin) problem against which the bodily defenses are failing. Resistance is flagging. This could be due to emotional exhaustion, malnutrition, metastatic malignancy or anything in between. CRANIOSACRAL SYSTEM MOBIUTY ABOVE AND BELOW THE FORAMEN MAGNUM

Any lesion or dysfunction may place a drag on dural membrane mobility. Lesions which affect the occiput and above will interfere markedly with the free mobility of the intracranial membrane system. These lesions are either intracranial,

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CRANIOSACRAL SYSTEM FUNCTION AND WHOLE BODY RESPONSE

cranium and in turn have maximum effect system.

intracranial

upon

Lesions below including the

affect the

mobility of

you what the cause presence place one examining head over

system,

under the

the other on top of the

parietal or frontal bones. Is

hands? Next,

cephalad

and

your two

occipital squama. How whole ,,,,,: r... ,CT1

dural tube compare with that

of the motion of the under

place one motion

motion

under

occipital squama and one on

your two hands compare with that

does the motion of the intracranial the spinal dural tube? division

system

frontal. How does

the whole

How

compare with or

moves with least ease is the one you should further examine to more precisely

INTRACRANIAL MEMBRANE RESTRICTION LOCALIZATION

restriction

In system,

within cranial motion anything to modify the Look for asymmetry of motion within

asymmetry, visualize a three-dimensional Answer A

intersection to an infinite number arcs

to discover

involved. lesion, and its relative realize

you are

motion restriction. As move more symmetrically. Another difficult to diagnose circumstance is presented by the midline lesion. The I-L",,",o.1 midsagittal

Here, the motion restriction is located on but of a Ui0'1J"''-''' system moves.

amplitude of the

localize this lesion, place your fingers

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that of the dural about which the median

of the

CRANIOSACRAL SYSTEM FUNCTION AND WHOLE BODY RESPONSE

245

lIIustraion 14-1 Cranial Base with Examples of Arcs Secondary to a Point Restriction

head from the glabella to the external occipital protuberance. Be sure your fingers are spaced out along this median sagittal line. Rest them very lightly so as not to impede the inherent motion. The system should be moving in flexion and extension about a moving fulcrum located in the anterior straight sinus region. If the fulcrum (or axis) is immobile or fixed, where is the fixation point? The lesion is located at this point (ILLUSTRATION 14·2). If the arcing is around the normal pivot point in the straigh t sinus, but is not mobile, the problem is in the straight sinus. The key is the loss of normal mobility of the pivot point which moves rhythmically back and forth along the intersection of the falx cerebri and the tentorium cerebelli (the straight sinus). Practice in locating the intersection point of the radii of the arcs which your hands describe will pay large diagnostic dividends. The resolution of the abnormal arcing during the healing process is a valuable prognostic indicator. LOCALIZATION OF RESTRICTIONS OF THE SPINAL DU RAL T U BE

Probably the most difficult techniques to describe are those which we use to localize restrictions imposed upon the spinal dural tube. The techniques are not difficult once you have experienced them, but they are nonetheless difficult to describe. It is somewhat like trying to talk about how you know which direction a sound is coming from; you have stereophonic hearing, but how do you know that a sound is coming from 5 o'clock over your right shoulder?

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CRANIOSACRAL SYSTEM FUNCTION AND WHOLE BODY RESPONSE

Illustration 1 4-2 Localization of Midline Point Restriction

We have used two separate techniques to localize dural tube restrictions. The first is very passive monitoring, and the second is very light traction. We continually change back and forth between these two approaches in deciding the location of the restriction. Perform the passive technique after clearing any restrictions of the cranial base and the other transverse diaphragms. Gen tly rest the patien t' s occiput in your hands.

A clear, unrestricted dural tube will give the impression that its longitudinal move­ ments are free of impediment. The occiput easily rotates with the phases of cranio­ sacral system motion (ILLUSTRATION 14·3). The two squama of the occiput feel like handles attached to the superior end of the dural tube. The handles and the tube should move freely and easily in synchrony. If they do not, there is a restriction somewhere. Often, there are minor restrictions which clear up after a few cycles of motion, so you should monitor 10 to 1 2 cycles before making a decision about the presence of restriction. You are monitoring the normal inherent craniosacral system motion as it manifests in the spinal dural tube. Pretend your fingers extend all the way down the tube; experience what these imaginary prolongations of your fingers are doing and what they encounter. The traction phase of this examination is performed by gently applying a cephalad or superiorly directed traction upon the occiput so that you are causing the mobile dural tube to glide gently toward you. When you meet a restriction to the free glide of the tube, try to answer the question, "How far down the tube was my traction effect when I felt the restriction?" With practice, you will be able to answer this question.

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CRANIOSACRAL SYSTEM FUNCTION AND WHOLE BODY RESPONSE

Dural tube

... -

t

Sacrum

Occiput

Illustration 14-3 Dural Tube Continuity (Easy Motion Should Follow Traction from Either

tube closest to you,

upper

traction is gently and slowly increased, you can move at a time. Often your patient will be able You

This is most valuable feedback and potentially constructive game. The cost

error

applied from the sacrum, with the filum terminale; then, as your traction force is moves cephalad. At what level do you meet which we use to sharpen perception of the in terms

from you is performed with polyethylene

(ILLUSTRATION 14-4). Flatten a long sheet of the film on top of a

adhesion of the polyethylene film to the table top will offer to its movement across the table top. Gently pull on the film amount of traction which you must use to move place an object (such as a water glass) on the resistance to your traction is increased by the weight of the film to several different locations. Perceive response to your traction is restricted in a given locus. use multiple objects. Once you are familiar with the the effect of the various objects Have a friend place the objects for object after you have done your testing with how quickly you can develop accuracy at restriction to your traction while you are blind-

RESTRICTIONS TO THE FREE

OF FASCIA

to toe. You can travel malleolus without ever

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CRANIOSACRAL SYSTEM FUNCTION AND WHOLE BODY RESPONSE

248

Restricting object

Illustration 1 4-4 Training Method for Localization of Restrictions

dysfunctions all interfere with the free gliding of the fasciae. Use the same principles for body fascia which we have described above for testing the mobility of the dural tube. You can practice with the polyethylene film on the table top to develop your skills. The only difference now is that you are attempting to localize extradural problems by the use of gentle fascial traction, rather than by traction directed at the spinal dural tube. Apply gentle traction. As your force is gradually increased, the effect moves further away from you. We apply the traction at several places because the closer you are to the restriction, the more apparent it becomes. We usually begin with the upper cervical region and direct the traction cephalad. From the neck, you can usually sense as far down as the pelvis. You can then use the heels. Gently pick the extended legs up from the table and apply traction directed pedad. From the heels, you can generally sense as high as the respiratory diaphragm. When you wish to clarify your impressions, symmetrical placement of the examining hand upon the thighs, abdomen and thorax is helpful. Fascial planes of both the anterior and posterior regions of the body are used. Improvise and locate the restriction. PALPATING DENERVATED MUSCLE ACTIVITY

While I was a visiting professor at the Technion Institute in Haifa, Israel, I was asked to perform examination of several neurological patients at the Loewenstein Neurological Institute in Ra'ana, Israel (APPENDIX B). I had no clinical knowledge of the patients except that they were all neurological cases and had longstanding

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CRANIOSACRAL SYSTEM FUNCTION AND WHOLE BODY RESPONSE

Cases of both coma and paralysis were included. with the craniosacral system rhythmic activity at a rate of 6-12 motion can be palpated anywhere on the body. While Institute, Professor Nachansohn, I discovered moves at

25 cycles per minute. The character of the motion is

rate is significantly increased (not necessarily twice cranial in the paravertebral We found patients cord injury on all in at which rate of craniosacral rhythm, as elevated from the patient's cephalad norm to the more 25

per minute. The spinal cord vertebral level at which the in these cases were quadriplegias and paraplegias was one case of poliomyelitis and one case of Guillian-

several cases LC�lU'-"CU

post-anoxic coma and found

to 3 or 4 cycles per minute. In cases of hemiplegia due to muscle response to the craniosacral system rhythm of the body, and elevated on the paralyzed activity in the unaffected side of the head was usually and chaotic on the affected side. Further work along

WAVES OF INJURY AND DISEASE

the whole body motion as it responds body will move into internal and set up

",u.v"a. ... ,,,,. rhythm. Injury and disease areas seem to waves like those that occur when one drops a pebble into a quiet

waves created by the pebble you can tell

pond. If you can see

water; the waves form arcs, the radii of which intersect

where the at exactly the point activity which you the natural,

","vrp",,'1

into the pond. The same is true of the wave in

human

wave motion of

You are using your hands to body. A restriction lesion sets up an itself upon the normal physiological where source

problem. restriction or interference waves, gently place your inferior costal margins, allow your hands

positions as you of concentric

need to make globes around the

is the center of

all the concentric hand on

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CRANIOSACRAL SYSTEM FUNCTION AND WHOLE BODY RESPONSE

250

Your two intersection gives you perfect. Using Practice

(ILLUSTRATION 14-5).

we have been able to

the secondary consequences many physicians

many which had been unsuccessfully

years. seem to interfere in proportion to

are two restrictive

severity. Where there are two lesions of equal severity,

one

Illustration 14-5 Use of Arcs in

if there are most pronounced. For ovary, you will probably be unaware of the ovarian if you examine if you examine from you will probably find the ovarian problem not the pericardial one. On the problem i s more severe than the ovarian the as well as from pericardial problem

if the pericardial you might find the might experience only during

some confusion right ovarian problem and palpation of pelvic motion. Or, you may only find the ovarian the intensity of its pericardial diminished. We distance and Degree of abnormal motion

this situation as an inverse

oe

SOMATOEMOTIONAL RECALL AND RELEASE

Another we have observed and our therapeutic armamentarium we have called somatoemotional

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as the

CRANIOSACRAL SYSTEM FUNCTION AND WHOLE BODY RESPONSE

251

connective

seem that body tissues

From our possess a memory. is changed.

an injuring force occurs,

tissue which receives the

it retains the energy of

A

is set up in the impaired area.

activity or

increased kinetic human body then either localizes the

dissipates that energy and returns to normal; or impact energy and

it

during the

much as it walls

effectively After the energy inactive state of the Qi or your area. Energy (electrical, isolated, the body this area ra ther than own personal then through it. no clinical In some cases cost adaptation is so small that it In cases the cost of adaptation, or of energy if you will, is so the original injury for us, usually

The is often very

the resulting clinical impossible to discover

knowledge. It does

reason, given our present

seem, however, that

the patient's body will

which underlies discovered, the rPTlrP,",""'(1 and concurrently

chief

you to the original

When the

accident which was

recall and release (also know as "un-

technique begins quite

the patient takes over very

it until the release occurs.

You must stay

may take five minutes or it may take an hour. If this technique, your patient may benefit

your schedule is tigh t and you an appointment

you have adequate time.

With the patient seated, we usually begin with one hand on head and the other on

upper thoracic region force is

A slight, inferiorly-directed cervical and upper of the pressure on

is necessary to and can be monitored on the you reach a position in movement will

As

body

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25 2

CRANIOSACRAL SYSTEM FUNC110N AND WHOLE BODY RESPONSE

Illustration 14-6 Seated Position for Beginning S omatoemotional Recall and Release

move into a and easy motion pattern. If an CU'Ul.'U> it before the with the somatic to follow wherever

leads you. U4'4"C<'::

move more and more

seems to inhibit your patient

points will present

_,.".."

rule is when the

,.., on their body movements. into a rut of continually

Do not

...

movement, usually circular.

a pattern of

repetition may continue for an interminably long placed on the motion by will reveal time. A very slight, point, the an exit point where the motion will take a new direction. From drag. This is a motion is followed process, and the

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CRANIOSACRAL SYSTEM FUNCTION AND WHOLE BODY RESPONSE

movement to movement events and changes are your patient will experience. When

253

What is predictable treatment session is over the

movements occur significantly. No further autonomous you attempt to resume the session. But arm goes up into the air during the gently grasp it and follow. Significant restrictions may

localized in the

as the first example below method we frequently use is to

anterior ilia of the own body move­

and compress slightly Then follow through, release

(ILLUSTRATION 14-7). The

f

Illustration 14-7 Position for Beginning Somatoemotional Recall and Release

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CRANIOSACRAL SYSTEM FUNCTION AND WHOLE BODY RESPONSE

with the be lying supine. In case, the introduced to start grasped a slight traction or compressive process. Each release which occurs during any of these is like

process can

layer

away to discover what is in assume

occured. You will know will shut down. Often

center.

body posture in which

is correct

craniosacral system

patient will spontaneously comment that "this is exactly

accident a " All you have to wait until the release time to complete. Completion is by breathing cessation of emotional outpouring,

body

more even

and a motion.

awareness of completion of higher-amplitude

describe at least a hundred examples in which difficult problems have

We

may not seem at all in this way. The the but when it is illuminated the can almost

been

the connections

by about 20 minutes wrist and the

was due to two years since this treatment. Another

is

continued to experience

man with

stress tests who

pain. Multiple recurrent upper thoracic and

somatic dysfunctions were present. He had

extensive

treatment some years. He was upper thoracic rib problems were lflJUry 10 years when he of the scaffolding planks fell on his head

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from an

scaffolding. Several

he hit the ground.

255

CRANIOSACRAL SYSTEM FUNCTION AND WHOLE BODY RESPONSE

During the somatoemotional recall and release session he relived a football 45 minutes which had occurred at age 16. He been unconscious amnesia the events just injury. Until treatment session and the He had that the unconsciousness blow to the head,

During the treatment session he went into extreme and upper thorax. He actually

the frontal region. As this position was maintained became and his pain

the blow in

began to release, the In

year since his

somatic dysfunctions initial treatment, he has had little The lastingly to treatment. He can more freely. He says he is much more relaxed As

easy going.

examples demonstrate, you should be these of recall and

for the unexpected H:;l",a"",

Don't

recall

your patients.

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Chapter 15

' New-borns, Infants and Children

Newborns, infants and children present special craniosacral system problems. '* As the newly-delivered child develops, the character of the cartilage, membrane and bone which comprise the cranial vault undergoes considerable modification. Under normal conditions, the skull of the term fetus is truly a membranous sac filled with cerebrospinal fluid. This fluid contributes an internal pressure to the semidosed system. An hydraulic system is thus created which obeys all of the physical laws applicable to a semidosed hydraulic system. Inside the membrane boundaries of the system are the visceral structures: the brain, the pituitary gland, a complex vascular system, the brain's ventricular system and innumerable others. The bony developments in the fetal and infant skull may be thought of as "hard places" in the membrane; they contribute to its shape and functional integrity. As maturation occurs, the distances between these bony hard places are reduced. The ratio of flexible membranous cranial vault to more rigid osseous cranial vault changes in favor of the latter

(ILLUSTRATION 15-1).

It is therefore easy to understand

how the misconception arose that the adult skull eventually becomes totally rigid. Due to the extreme flexibility of the newborn skull, the techniques for examination and treatment of the newborn craniosacral system are quite different from those applied to the adult. Thus, as the human being develops from newborn to adult, the techniques of craniosacral examination and treatment must be gradually modified. Craniosacral system motion in the newborn and infant is more difficult to perceive than in the adult. The range and amplitude of motion are much less in the newborn. The inherent energy which drives the system also seems much less than in the adult. Moreover, the levers (cranial vault bones) with which we perceive much of the motion are Significantly smaller, and the movement of the membranous regions more subtle.

'It is recommended that any of you who intend to work with newborns, infants and children, familiarize yourselves with the work ofBeryl E. Arbuckle, D.O., F.A.CO.P. Dr. Arbuckle, working with Angus Cathey atthe Philadelphia College of Osteopathy, pioneered a great deal of work with the anatomy of the intracranial membranes of stillborns. She also worked intensively with cerebral-palSied children. Her concepts are published in The Selected Writingso!Beryl E. Arbuckle,

D. 0., F.A. Co.P.

This book is available through the American Academy of Osteopathy in Colorado Springs, Colorado.

256

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NEWBORNS, INFANTS AND CHILDREN

257

Illustration 15-1

Adult and Fetal Skulls We suggest that in learning to examine and treat infants, you should first become very familiar with the craniosacral system activity of adults. Then extend your experience to adolescents, younger children and finally to younger and younger infants until you reach the newborn child. The developmental changes which occur are rapid in early life, but are on a continuum. You should experience many and various points along the continuum so that you are capable of adapting to the level of development of the craniosacral system at any given age. In examining and treating newborns, we have developed a routine which we have found to be helpful and efficacious. We present it here only as a way to begin. Each of you, we hope, will develop your own individualized approach which best utilizes your particular skills. This routine is as follows: 1.

Observe the cranial vault and face for asymmetry.

2.

Observe the torso, including the neck, for torsion patterns between the head

3.

Observe the roof of the mouth and the strength of the sucking reflex.

and the pelvis. These observations are best made in the resting or sleeping newborn. The examination and treatment techniques are largely inseparable and are therefore presented together. EVALUATION OF CRANIAL BASE MOBILITY

After quickly making the above-listed observations, insert your little finger in the newborn's mouth. It is helpful to use a fingercott from which you have washed

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258

NEWBORNS, INFANTS AND CHILDREN

is milk-improvise.)

is

palmar

facing

of the distal

suckle on your finger. As this occurs, encourage so that When

of child sucks in, your

suckling. Place your

of the by

is

is gently monitored. action the

palate. The hard palate is encouraged to move cephalad. in turn moves the vomer. The vomer rocks the sphenoid. Mobility of the entire cranial is thus encouraged by the suckling action. As the sucking proceeds, you should feel this total throughout cranium. If you do not rhythmic the mouth in rhythm movement, very gently encourage the with

child's

the total

activity.

vault begin

to does not

on your finger, wait

will not occur, then gradually andgently begin to

action

upon the child's hard Once you have attained mobility of the cranial vault by movement of

cranial base,

symmetrical. If

with

the movement until it seems reasonably

is an obvious sidebending or torsional distortion the to correct it by approach. attention to sphenoid during the course this balance

sphenoid as

Follow in exaggerated by your cycle gently guide the movement pattern a little subtle in infants they are frequently asymmetry,

movement is cycles of motion; with each

to symmetry. Releases are so do a

cycles

then leave it alone. You will usually see

response to what you have almost Following this you may observe at a partial correction of previously noted asymmetries of the of head or face. a note of these and of remaining Re-evaluation on the following will if your correction has

sucessfully made.

DECOMPRESSION OF OCCIPITAL CONDYLES

Next,

the occipital head Hyperextension

of condylar parts of the forceps, or even by significant manual traction. which have been assisted by the passage of the This condition occurs as obstetrical person anterior child's the birth canaL These dissipated for the optimal

and of you must move the occiput posteriorly in relationship to

technique used to decompress and correct is the same

in

for

one holding 4th fingers are <>"1"<>".,,

Your 3rd fronta-sphenoid occiput as far as allowed by the suboccipital and cervical tissues. The

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NEWBORNS, INFANTS AND CHILDREN

259

fingers are

Hold

gently

allow the

back same time, your other

away

should gently encourage the fronto-sphenoid complex to sort of "nose-dive," as though rotating through

and inferiorly around a transverse

As you

gently the 3rd and 4th effect of spreading the condylar parts of

slightly away occiput as

approximately

squamous

are decompressed.

that your fingers are into parts; your objective is to spread parts laterally.

occipital REMOLDING THE

face for the shape,

pressure <;;1<",-"0>,,,,_,

that a very small an atraumatic

correctly, you should see an immediate change in is shape. If the asymmetry and then returns a hours or later, you

the cause of the

not identified and

in spinal dural tube. This of osseous tensions, in

Frequently, the cause is in an abnormal torsional may inherent in itself or may the sacrum and pelvis. BALANCING THE OCCIPUT AND

"'''''"'''UN!

The next technique we apply to the sacrum. In order to do this, hold the occiput in of the Movements of the be dural pressure against dural

which can

C3. restric-

observed upon when you

torsion. It is best pelvis in one direction and the sacrum in the other. The dural is not the case, a gentle,

in both directions at the restriction barrier

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ends; if a few

260

NEWBORNS, INFANTS AND CHILDREN

minutes will correct the dural torsion. for and sacrum should in both for flexion and extension in anterior-posterior directions and torsions. All of these motions should free, symmetrical and synchronous between occiput and sacrum. If they are not, direct force over an period of a few minutes produces correction. BALANCING THE SACRUM AND PELVIS

The last procedure in our routine is to balance the sacrum and pelvis. Think of iliac crests as sides a pubes and rami as the the sacrum as floor. It has newborn child has just "'">r',,,ro to of not responsible of the"guy wires," which are the ligaments pelvic symmetry. One can see how a a parallelogram. can Hold with one hand below the sacrum and the other over pubic or thumb just to the pubic symphisis and the sacrum cradled in the fingers. the pelvis for parallelogram left and right. If you meet a restriction barrier, hold gentle shear in both force against it until the abnormal barrier is dissipated. correction has been for an returns in a few days, explore If the underlying cause. in many ways. Clinically, the crying to excess, poor hyperirritability of the nervous we seen muscle tonus (floppy baby), respiratory distress, excessive regurgitation and bowel dysfunction. We have seen many dramatic within minutes following correction of system BEHAVIORAL AND LEARNING DISORDERS

Probably the most common problem we have found in school is of the occipital condyles. problem is inability to concentrate hyperkinetic behavior, abnormal periods time. Correction of the is by immediate and dramatic relief of symptoms. hyperkinetic child will frequently fall asleep on the treatment table within a minute or two been In our a recurrence the syndrome. results in a return of the Hon of the dysfunction. We never had to correct a obtain a lasting result. longest case in our files is a little over years without recurrence of either hyperkinesis or occipital condyle compression. We have treated more than fifty hyperkinetic cases to date and are presently compiling the for publication. Further, I have a group of of Osteopaths) in the to do similar treatment children. far, confirm our own. It is true that some hyperkinetic behavior improves with dietary restrictions and approaches. We would respond to fact in two ways: 1. we are making no claim that is cause of all behavioral

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NEWBORNS, INFANTS AND CHILDREN

261

physiological the of cranioon the vagus nerve, the pituitary gland, etc.), it seems

2.

"'L�"WU"'<''''L"usystem dysfunction may be the underlying cause of and the like. From our the

is

to

to abnormal In any case, the treatment is We have

it can't hurt to try it

a

of

such as dyslexia.

ages in

from range as high as 26

group of

years, with an average age of about 12 years. We occipitomastoid sutures to be

found the temporal bones and

in over half of

size is approximately 65 dysfunction

in about half of the cases. four treatments and correction of internal rotation of the

old boy,

temporal bone, remarked that he was enjoying reading now. He explained that he now read whole words. This

began bone was partially mobilized. He could only see the words in

treatment,

the first treatment when the that, prior to to four letters

this boy to

education

His

treatment sessions and

confirmed progress. We do not contend that can and may

to

improvement in

are,

function following physiological correction is usually little doubt that there is a cause and effect relationship.

and dramatic. It CEREBRAl. PALSY

date, we have treated 14 cases

spastic cerebral palsy. We use multiple restrictions at same time

11::,<:;1;1,,"11"14 body fascia and

restrictions. We

to at

cases. most dramatic cases involved almost total recovery from spastic side was spastic and these was a 3 �-year-old boy whose sidefloor, His means of locomotion was to crawl about on left a He could use left arm his first

side

He would abduct

arm

then adduct to move

left. He had strabismus. He could not chew, so all of his food was pf()ce:ss�:d blender. We found out later that and in his diaphragm area. After

3rd treatment, he

constant

in his head,

up and

treatments, he was released good upright locomotion motor skills and coordination of all the extremities. He chews same food that the rest told us that all some

return of

30 good fine

eats regularly the attention. He family eats. He requires no more my body who made the pains" have gone. He of right eye All

progress has occurred in the year following the first treatment.

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NEWBORNS, INFANTS AND CHILDREN

The key correction came from left coronal suture, which was severely and inwardly. During 3 treatment this suture mobilized, depression came out. The following his at 4:00 a.m., mother that wanted to walk. He He now and is dancing ''-'"''V.LA''' The second case was a 9-year-old girl. Spasticity of the her most severe symptom. leg was spastic to a and was ",u,,,,,,' in in the upright }Jv"n'VH and circumference than the left. She was but with difficulty. A problem with left coronal suture similar to that noted in the in spasticity Dramatic case was found and immediately She now has a short and right leg to cope with. Her fine motor coordination of the right hand is excellent. She is under pelvic dysfunction osteopathic to the short and underdeveloped right quadriplegia. third dramatic case was a She was suture (the frontal or the anterior borders of the parietal bones were overriding) bone was produced dramatic relief of spasticity. 8 treatments, child was crawling and standing. is now walking and climbing. The other 1 1 cases in our have all improved. We have when we are able to find that some will dramatically "key lesions."

At the present time, we have treated 108 children who have diagnosed as autistic by one profession or another. We have no illusion that all of these are autistic. sense seem to autistic in the who are more similar system. suspicion led of restriction in the me (Upiedger) to do an 63 children who have National Association been called autistic and most whose parents belong to for Parents of Autistic Children. children whom I examined "blind" were all by Dr. Rimland, of the Institute for Child The California. I the children on in San and osseous restrictions of to 1 0 (0 signifying no restriction L(UUU',,,'\,uu system on an extreme restriction). The third measured the inherent energy of the craniosacral system -3 to +3. more "schizophrenic" in their behavior do not Children who In high energy Significantly, but do not seem to is or no perceptible craniosacral rhythmiC movement. you actively motion-test, the system complies with your induced motions but has rate what I little inherent motion characteristic its own. I would child in the lower range of membranous restrica considered to tion (0, 1, etc.), and inherent energy in range restriction, and a +3 in more autistic child was rated as a +9 or + 10 in as osseous restrictions inherent motion. Other behavior disorders usually

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NEWBORNS, INFANTS AND CHILDREN

restrictions are springy testing force. They spring

in to your into restriction as you reduce your

of this work, I postulate

autistic child

more severe membranous

restriction

the craniosacral system. I

sense that these children have a

inherent energy within this membranously restricted system. outcome of the study was that the Dr. Rimland's rating scale my of membranous restriction positively at a 0.01 but the results seem This is preliminary work and will not feel that schizophrenia is Autism, on autism also leads us to As the autism

treatment series in more

autistic children are as follows:

pattern of correction. 1.

it is or how distorted

system that is moving, no To the novice it may seem

whole craniosacral Expand the

1-',,"'"''''''

Trust us: there is motion locale where you find it. parts of the system will

mobile region to move a little. (It is very

in pairs with autistic children.) Get your every motion you can get. 2. 3.

in the door and

anterior-posterior will eventually prove to a junction. If you are the cranial base is in between.

4.

as head-banging in severity. This long-standing, internal may well have been but controllable

fYlt",A'"''''

pressure on the cranial has been a

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264

NEWBORNS, INFANTS AND CHILDREN

attitude toward craniosacral treatment and will sometimes indicate

very where

should

or her

during treatment. They are almost

compression restrictions have

5.

released

balanced, it seems that we have not progress until somatic

restrictions

been as

body

the team treatment approach 14.

deal of CaeJlHLUJ-'" or ,.,."',.,....,.,..orl

whole gamut to terminate or

treatment involves ears as your and move the temporal bones

... <",,,<,;1.1

base. then

(CHAPTER II).

accomplished, you above corrections have sacral system of the au tistic child as you would take

treat the cranio-

you find. It may treatments for a year to reach this of correction. are sensitive to, and the It is important their may pass through. As creative activities appear,

emotion must be

how far the autistic child can advance once the craniosacral system is functioning on rn ... .. ,.."r"" llevel, but our observations would lead us to believe there is reason a need

concerted

among

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and

Chapter 16 Specific Clinical Cautions and Applications The clinical applications discussed in this chapter are those with which we have had the most experience. We can only our own and functional mechanisms which responses. It is not meant to is far your trials of techniques in various unmentioned situations. Rather, it is you an area in which to start craniotherapy has little, if any, serious, irreversible or sacral examination and therapy. It does aim at the improvement in function of a physiologic­ is seldom contraindicated. Although

may be more, we can think of only four contraindications for craniosacral treatment: 1.

Acute intracranial hemorrhage: The may Significantly .... u,.u". ....

to the craniosacral

in that it may prolong duration of the tenuous progress of dot formation. 2.

in intracranial fluid pressure dynamics pro-

Intracranial aneurysm: The

duced by craniosacral treatment may of a 3.

4.

already

to

intracranial aneurysm.

is more of a caution: A very The applied in recent skull fracture, an increase

should motion

precipitate bleeding or membranous tear. magnum is a Herniation 0/ the medulla oblongata through the threatening situation wherein you would not wish to alter fluid pressures within the craniosacral

by

use of manipulative

rather extensive .... UAU'"'.. The areas in which we craniosacral treatment to be efficacious and often curative are discussed below. Under no circumstances should

treatment b e

modalities. It should be

with all treatment

of which

case. A truly in your mandatory except in clinical research We should not is develop loyalty to an approach or to any specific system to the exclusion of any 265

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266

SPECIFIC CLINICAL CAUTIONS AND APPLICATIONS

approach or Our loyalty is to the patients we treat. We must our selection of treatment modalities.

in

CONDITIONS

well to the CV-4 techniques described in Chapter4. "still usually lower pass through phase of an is usually seen within an hour after treatment, and is continued effect indicates a reversal of the tide of battle and If bodily technique treatment session is

is more own autonomic nervous system. In conjunction with treatment and will CV-4 fluids, acute onset to the recovery <::A''-'Ut"l','"

LOCALIZED

of by boils are helped a the improvement is techniques, as in Chapter 9. Once prompt and dramatic. You can direct energy from the parietal region (crown) on both by placing of the head to a area will first area. moves through. Then, as in effect occurs, perceptibly. patient will usually jJHtU\;,,,, The area of involvement will comment upon an improved feeling or sensation, and the treatment is complete. treatment may once or twice daily if the the as We think If we see

have no problem quite how many at a subject and wish to discuss the situation which occurred.

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SPECIFIC CLINICAL CAUTIONS AND APPLICATIONS

267

ACUTE SPRAINS AND STRAINS

is direction of energy techniques. of energy is combined with tissue tension­ of tissue tension will cause chronologically the of injury. motion will stop. As the energy pattern of the position is achieved, all the tissues will release locally. Craniosacral system Be to and treat at the same time. They may

CHRONIC PAIN PROBLEMS

OF VISCERA

are secondary to autonomic nervous system amenable to craniosacral treatment. conditions biliary dyskinesia, the problems of inflammatory and the bowel, paroxysmal tachycardia, asthma and numerous other comfor restriction patterns a thorough For these and autonomic and treat what you functions. AUTONOMIC NERVOUS SYSTEM DYSFUNCTIONS

treating what be taught to the

as Raynaud's phenomenon are often find after examination. The CV-4 performed on

RHEUMATOID ARTHRITIS

to daily This is to be physicians. We experience only a few out of the wheelchair for about years now. on both when we In beginning, this in a Boston hospital for suffered severe pain. had approach, we used a combination of with our osteopathic manipulative treatment, craniosacral treatment nutritional treat­ ment. Together the patient, we believe that acupuncture gave pain relief for the in the treatment and that craniosacral treatment is duration. We have three remission over seven

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SPECIFIC CLINICAL CAUTIONS AND APPLICATIONS

268

who

benefited, but none as dramatically as

one

CV-4 technique daily teaching a family to do We less dangeroils accomplishes several positive things. It is an innocuous positive aspects of of anti-inflammatory drugs. Among the fluid <01I..,u",u/,\ treatment are physiological of !U'JUJlUL. of nutrients removal of family a of and often cements LCUIUl1<1.1 severely strained by chronic pain and invalidism. EMOTIONAL DISORDERS

more than one treatment. or have had We have yet to examine a case of or it that has not shown severe anterior-posterior compression of the cranial base. yet to see the case which has not responded favorably and usually to of It does not seem to matter of a one or is "post- partum technique dramatic We wonder if perhaps the obstetrical delivery process might not result in lumbosacral compression, which to the cranial and causes depression. v ""'" "COA v "v,

Always correct tbe lumbosacral problem whicb

accompanies

base compression

(CHAPTER 7).

the had is other area in which we as consistent and characteristic a anxious patient does not seem to present craniosacral restnction as does the depressive patient. In treat what Restrictions will have a tendency to recur. Treat over a the Occasionally, a crisis will level seems to to occur as corrections are carried out. Be patient through the crisis. It usually Signals the of some repressed emotional matter which will ultimately beneficial to

Among the causes of scolioSis, we should list the craniosacral system. The base must mobilized balanced in all cases of cranial and scoliosis. The reasons must identified and between cranial be kept mobile so that normalization of the curves can occur. which we have found The most common causes of cranial base include trauma, trauma, sphenomaxillary or torsion, trauma, orthodontic braces which one maxilla in internal rotation and in rotation, vomer dysfunction to intraosseous strain, the unilateral occipital condyle many extrinsic problems. cranial base and locate the cause for the imbalance.

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269

SPEClFrC CLINICAL CAU110NS AND APPLICATIONS

VISUAL DISTURBANCES

6, we wish to restate discussed in amenable to release of Nystagmus also respond patterns of tentorium problems dural membrane tensions. Visual acuity and treatment; however, the site of dysfunction is not predictable. It region. the

these

AUDITORY PROBLEMS ear problems are well treated

and

CEREBRAL ISCHEMIC EPISODES application of the parietal lift released. We

technique have seen memory loss treat what you

through craniosacral therapy. We taken you on a long structure and function this relatively and certainly under-appreciated gentle system described. Previously terms and a human body physiological to the ailments and You have have been touch and to or stubbornly unresponsive clinical you expand your understanding of the body as a unit of the fasciae, the and the body in concept craniosacral has helped you to a deeper awareness and If this toward your patients their problems, it will have

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Appendices

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Appendix A

Structures of Cranial Bone Sutures ERNEST W. RETZLAFF, Ph.D., DAVID MICHAEL, D.O., RICHARD ROPPEL, Ph.D., FRED MITCHELL, D.O, Department of Biomechanics, Michigan State University-College of Osteopathic Medicine, East Lansing, Michigan"

There are few studies on cranial bone sutures which have utilized modern histotechniques. One of the most informa­ tive studies on the structure and the devel­ opment of mammalian cranial sutures was done by Pritchard, Scott, and in 1 95 6.1 Their primary concern was development of the suture, so there was limited discussion of the adult structure. this report provided us with a for our investigation. Much of the initial work on this has been the development of in a paper tologic methods. This is Popevec, Biggert, and Retzlaff. Previously reported studies on cranial bone mobilitf"; Annual NaResearch tional March 1 5- 1 6 , 1 974) were based on nh'''''''-'the logical studies Saimiri sciureus. performed on the same animal. It is of particular interest to note that in the 10 adult from which the bone tissue was there was no evidence of suture ossification. The general pattern of the suture was by Pritchard et aLI similar to that the sutures displayed of cells and fibers between of the bones. The

outermost layer is a zone of connective tissue which bridges the suture and is nated the sutural ligament. The next consists cells. These two appear to be continuous with that periosteum of the skull bones. This modified is periosteal layer, the sutural found on both the o uter the inner surfaces of the suture. The space between filled with fibrous the ligaments is connective tissue. is The reticular connective tissue seen in the space with extensions into the an inner sutural ligament. This may and outer binding structure which serves to some hold the sutures b ut still movement of the skull bones. In addition to the connective tissue seen in the central space, b lood vessels and nerve fibers are evident. The function of these nerve fibers is not known but it is possible that they may be involved in the physiologi­ cal effects of cranial The ��.:,�- Wll."U"'" by ever occurs in man cannot We do know that be answered by this the sutures between the bone and bones i n the squirrel monkey show no evidence of closure in the speci­ mens we have studied. � ..

Osteopathic ASSOClO!ioll UAOA), Vol. uJ{,?f)pallJlcAss()ciafiOl1, 212 E. Ohio 51" Chicago,

IL

75,

Feb. 1976,

pt.

607-608, by permission of Ihe

60611.

273 Copyrighted Material

2 74

APPENDIX A

J.J. , Scott, JH., and Girgis, F.G.: Structure a n d development o f cranial and facial sutures. J Anat 90:73-86, Jan

56

O.K.: The compliance and resistance to 6, May 75

2

]1,Hchael, O.K., and Retzlaff, E. W.: A preliminary study of cranial bone movement i n the squirrel monkey.JAOA 74:866-9, May

n

E.W., Michael, O.K., and Roppel, KM.: Cranial bone mobility. JAOA 74:869-73, May

n

Supported by AOA research #T73-91, "Cranial Motion and Intracranial O"namics," through the AOA Bureau o f Research.

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Appendix B

Examination of the Cranial Rhythm in Long-Standing Coma and Ch ronic Neurologic z. KARNI,].E. UPLEDGER,J MIZRAHI, L HELLER, E . BECKER, AND

INTRODUCTION , a case of a child who In an earlier had been treated with cranial by Dr. Upledger, F.A.A.O. (Assoc. Professor ,� .... at the Biomechanics Department, of Osteopathic Michigan State Michigan, and a Professor at the Department of Biomedical Engineering, Technion-Israel Institute of Technology), his recent summer visit to this country, was described. Here the results of a cranial examination per­ formed by Dr. on patients in the intensive care units of the Loewenstein Neurological Institute, are reported. The purpose of the examination was to establish whether or not these some of them comatose for iods of time, still possess a cranial and if the rhythm is retarded i n and frequency in compar­ both ison with normal values. The cranial rhythm was evaluated by Dr. Upledger m eans o f of the cranium or the extremities per in some of minutes (cpm.). the cases, a strain plethysmographic measure­ menr was carried out which correlated very clpsely with the values ob tained palpa­ tion for those In the following, the results of the exam.. ....v . w

•

NAJENSON*

various cases are It is, nA'n"'''llPr "r.'rp· r1pr1 by a short account of the nature of cranial rhythm and the role it cue which directs the the dan in and during cranial treatment. THE CRANIAL RHYTHM The cranial contents-nerves, ar teries etC.-is and veins, soft tissue, memin a fluid s ta te within the brane of the dura mater. The inner structure and shell like, divided Beneath the dura mater bou nded below the which r u ns almost arachnoid to the d u ra. Further down is the subarachnoidal space between the mem­ branes of the arachnoid and the pia mater, the latter covering the cerebral cortex. I n flows the cerebrothe subarachnoidal spinal fluid the subpial space contains the interstitial fluid-that extracellular fluid ou tside and be tween the nerve cells. The fluid structure is, primarily biphasic with the more viscous and stationary interstitial fluid as the inner core which is bordered externally the lighter, almost non-viscous CSF. to The hydraulic contents are system, the pulsatory motions of the the venous system and the pulmonary sys-

Repril1ter/ with permission of t.he putbors.

275 Copyrighted Material

APPENDIX B

tem which transmits its effect to the dura mater the vertebral connections the cervical section of the column, The lateral all these systems induce upon the fluid sets the latter into motion, the nature of which d epends upon the fluid properties and on the mechanical b ehavior of the container.j, 6 The classical Monro-Kellie theoryl' side red the the skull bones-rigid, and the inner incompressible. The immediate implication o f was that any induced these to another motion resulted in compartment of the so that the total volume remained intact, While this seemed the Monro-Kellie doctrine pre­ of assu mption was the fluid was assumed com­ and measurements were made to find the gross bulk m od ulus of the entire and the moduli of each o f its namely that of the CSF and of the intersti10 tial The modulus, defined as ratio of the increment o f in volu m e pressur e t o the relative of a closed deformable was also measured in problems hydrocephalus,I!, 12,13 Even with the assumpindicate tion, the values of the bulk in volume cannot all be tha t the the "absorbed" o f the fluid, Deformation of skull bones has also to be taken into account although that deformation may b e small in conditions magnitude. Thus the of the shell should no some zero lateral displacement. should occur and calculations that it is on the order o f a few microns. This is in agreement with dial gauge measurements which, with the of against the the gauges parietal side There remains still a considerable between values of the free motion cranium that feel duri ng a cranial

examination for mobility and those of the a mechanical dial gauge, The ratio of the two sets of values is about a hundred to one and this is morphology of the by the cranial bones. arrangement of the large The it as a n "open bones the cranium structure." Such structu res, composed of a finite number of elements o r of an infinite number of infinitesimal elements are characterized by elements contrib u ting their small incre­ mental motions along a com mon direction thus in a finite value motion. The of the "''''Ullp'.''' of an open structure is the coiled Here, each infinitesimal element of the coil torsion which contributes a component to the axial elongation of the spring. Each elongation is itself. an infinite infinitesimal number of them are summed u p the same direction altogether, a value for the total of the The skull bones are joined soft- tissue su tures and the architecture of the complex is such that a small angular motion of each to inter­ which are of the nal pressure changes, ment component the integral of is noticeable and measurable. This is what the physician feels as a motion of the cranium and its cranial rhythm, Sutherlandl5 regarded the cranial rhythm He called as a pivot of Cranial the cranial articular structure "a which functions "in conjunction with the the and the intracranial membranes" and con­ sidered the physiological of the respiratory and cardiovascular systems as to the cranial rhythm, It only was further postulated that in a normal human all skull suture articulations remained m ob ile throughout life. abor normal force upon this system by any of its related which structures could cause were otherwise often idiopathic or the result of neurotic malady. The was to trace of the ary constrained motion measured

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277

APPENDIX B

Patient in chronic state.

JI!. Patient H s., male, age 17. Admitted-

stored to its natural state of equilibrium. The normal cranial is

of

of the

spastic tetraparesis,

28.1.1979.

per minute

Bowel and bladder in­

(cpm). This rate is slower than the respira­

continence, contracture of lower limbs.

tory rate in the relaxed state by almost a identified third. The normal

Connected to a Bennett respiration machine.

of the parietal with the lateral bone, may reach 1-1 Yz mm. Changes of frequency, have been

a reduction with

dromes!6 and when the

Still in age 11. Admitted­

IV.

epilepsy, coma, tran­

26.6.1979.

to 40%,

viral

synrestored

of ups and downs.

the rhythm to its normal level the syndromes

V. Patient

age 27. A UNIFIL

subsided and vanished.'6 Mechanical mea­

soldier. Admitted-lO.6.1979. As a result

have also

of a gun shot wound: diffuse peritonitis;

surements of the cranial

been carried out and found to be in good

mography

resection

17.

agreement with the !·Of the various

of

liver,

Fracture of right femur, left olecranon and humerus. After a cardiopulmonary

means

in anoxchronic vegetative

trical reSistance

ic coma,

sensitive and effective

state. Released 5.10.1979 to be flown home

elsewhere.2

to the Fiji Islands. VI. Patient

The Loewenstein

1 8.7.1979. AJl"!,;l"V<>'''.

which is the country's rehabilitation, accommodates in its inten­ sive care units severe cases of brain some of which are in coma for several

A cranial examination of the )J""LlClIl:>

offers a wide variety of cases from which

age 17. Adrnitted-

comparative data can be accumulated. For

20.10.1975. Injured in a road accident.

his

Fraction in T10 and in the base of the skull. Diagnosis: disturbances from

that purpose, Dr.

recent visit, performed a cranial examina­ tion on eight

who

a

T8 downward, bowel

cross section

ence. Blindness of the

that hospital. The results

24.6.1977. Returned for two-week

don are shown below.

are accom-

by a brief account of the and a description of their present state.

of hospitalization in May '78 and August in '79. Services himself and wheel chair.

VIII. Patient

Ad-

M.O.,

mitted-12.10.1975. Fell

RESULTS OF CRANIAL RHYTHM

and fractured T8. �'�,.., ' with sensory disturbances ..�'_.�.

EXAMINATION I. Patient H

eye. Released

Sh., male, age 22. Admitted-

oo'wnW:'lro;;: bowel and bladder incontinence.

30.11.1975. Still in retention

venomous sting of scorpion on 14.10.1975.

Released 27.6.1976.

Patient in a chronic vegetative state. PatientM.

male, age 18. Admitted-

13.11 1977.Still in

IX. Patient I.M., female, age 24. Admit­

as a stem

following an anasthesia for an oral surgery. Diagnosis: status post cardiac

lesion. Later course: respiratory arrest; re­

arrest with brain damage due to anoxia,

moval of left epidural hematoma and

coma, tracheostomy, contracture of limbs.

Copyrighted Material

278

APPENDIX B

Patient LM. passed away on

7 . 1 2 . 1 979.

The above patients, except for patient

the estimate of the percentage ratio of the pulsatory amplitudes of the cranial rhythm

I.M. (IX), were cranially examined by Dr.

to the normal values. These ratios were

1 979, some of them in

measured-when possible-at three places:

Dpledger in August,

their beds and some while sitting in their

the head, the upper extremities and lower

wheel chairs. The examination consisted of

extremities. The following table shows the

the count of the cranial rhythm in cpm and

results obtained:

Tahlc - Count and amplitude ratio of cranial rhythm of patients with brain damages.

Crania! Rhythm «(pm)

Patient

Sex

Age

Head

Oia�nosis

I

H.Sh.

M

22

Venomous sting of scorpion. Chronic vegetative state

Amplitude Ratio

Upper

Lower

e);(rem-

ext rem-

itieS

iries

Head

(%)

Upper

Lower

extrem-

I..'xtrem-

iril;'S

itics

10

NR

50

]I

M.Y.

M

18

Severe brain stem lesion. Chronic ve,getative state.

III

H.S.

M

17

Spastic terraparesis

2.5

IV

A.E.

M

11

Epilepsy. Transitnt terra paresis.

2.5

V

R.)

M

27

Anoxic coma. Chronic veF:etatlve state.

60 2.j

NR(')

4()

6

)0

)0

)0

NR

NR

)0

NR

NR

VI

G.S.

M

)5

Polyneuroapathy (Guillain-Barre).

25

70

50

)0

VII

S.H.

M

17

Paraplegia.

18

50

50

50

VIII

M.O.

22

Paraplgia.

16 (Rt)

100

I.M.

24

IX

45 (It)

(,()(Rt) 10(1.,)

Anox:c coma. Chronic vegetative state.

(t)NR - No Rhythm detected.

Measurements were later performed on

thumb of patient G.S. (VI).

patient G.S. (VI) and patient LM. (IX). The

A time indicator marked each second by

technique-a strain plethysmography-by

a small spike of the needle and every ten

means of high-extension, electrical resis­ 2

seconds by a large spike. When the gain

tance strain gauges is described elsewhere.

sensitivity was doubled (Fig.

The strain gauges were applied at the upper

amplitude of the cranial rhythm. The fre­

1 b),

so did the

and lower extremities and picked up the

quency count for that patient was 5 -6 cycles

pulses, of course, superimposed on the

per minute and the amplitude ratio esti­

much slower waves of the cranial rhythm.

mated, in comparison with a normal pattern,

With respect to the latter, the frequency

as

40%-5 0%.

could immediately be determined. As to the

When the gauge was applied over the

amplitude ratio, it could be assessed from

right ankle the frequency pattern changed

22-25

the ratio of the average pulse amplitude to

conSiderably to

that of the rhythm and compared with the

The pulse amplitude was much weaker and

normal values. Assuming the pulse ampli­ tude to be practically constant with respect

could not be made. When the gauge was

to the same patient, over a short period, the

moved to the right great toe, the pulse

amplitude ratio of the cranial rhythm in

record was even weaker but the frequency

reference to the normal pattern could also

remained in the

be assessed at least to a general approx­

recordings are all compared with the cor­

a fair assessment of the amplitude ratio

20-25

cpm range. If these

responding results in the table, the confor­

imation. Figure

cycles per minute.

1a

shows a section of the strain

mity is indeed striking.

record measured continuously over the

Copyrighted Material

Figure

2

shows a section of the strain

279

APPENDIX B

- 7 CPM

....+II1I . 1-I 8'12

-

CPM -Il10+'''--- 5V2 CPM

----11....1-.. ---

6V2CPM-

TIME

+STRAIN

. -+ 4 ---J1IlI!o+....----

(a)

CPM ----5 -__II!o.j.ollI--- CPM ------...;IIIJooI..--

TIME

+STRAIN

(b)

Strain-time plethysmography record over patient sensitivity. (b) double

G. S. 's

Copyrighted Material

with (a) standard gain

280

APPENDIX

B

---'1---- 4'12 CPM �---liIoo�----

�

PULSE

+STRAIN

2

Strain-time plethysmography record over the

pertaining to the right hand thumb I . M, the of the c ranial wave was a round 5 cpm and the amplitude ratio assessed as 30-40%. The strain record also picked up bursts of slow dilatati ons The at that of the time, was in a few days later. OBSERVATIONS No conclusive results may as ye t be de­ duced from the cranial examination of at the Loewenstein from Nor are the measure­ ments sufficient to corroborate to the the­ cranial mobility and some observations can be made which support the fundamental theories of cranial and indicate how to L

in is a slow-down of the these cranial rhythm to abou t one half of the normal level-i n frequency and ampli­ tude-when measured at the head. Th is level o f i s lower than t h e one measured in cases of psychiatric dis-

2.

hand

I.M.

orders 1 6 where the rhythm was still in the range of 60-70% of the no rmal values. The c ranial rhythm is measurable all over the body and retains a constant This conforms with a value respiratory to the very end of

3.

to the constancy of the cranial rhythm were detected in some para­ plegic cases. These were also the only at the lower extremities, cases values which exceeded the normal level of by almost 100% were meas­ It should be pointed out that these were later released from the to function and to move around. cranial 4. ological component to i ts prim­ arily as an amplifica tion circuit, at both ends of input and output it is a mechan­ As such i t is also i cal amenable to sensitive and non-invasive mechanical measure ments. They, un­ doubtedly, will throw more light on the subject when more data is accumulated. ACKNOWLEDGEMENT

Copyrighted Material

Tills research has been

i n part

281

APPENDIX B

by the JuHus Silver Institute of Biomedical Sciences and Grant 130-077.

of the nervous system. Edinburgh, 1783. a Kellie: Trans, Med. Chir. Soc. Edinburgh, 1824. <) Weed, LR: The cerebrospinal fluid, Phys. Rev. 2,

REFERENCES

1922, 171-203.

! Karni, Z, and Upledger, ]. E.: Early steps of cranial

10

therapy in Israel. Julius Silver Institute of Biomedical

ing through the skulL CSIR Symposium on Biotel­

Technology, Haifa, Israel. Research Report 79-1979. and Karni, Z.: Strain plethysmography

emetry, Pretoria, 1971. II

rhythm, Proe. XII Inter. ConL on Med,

volume of air On the compressibility of a stimulated

cranial cavity. Med. & BioI. Eng.

Part IV, 69.5. LiVingston, R.B., Woodbury, D.M, and Patterson, j.L., Jr.: Fluid compartment of the brain; cerebral

2 1 Haar, F.L. and

Physiology and Biophysics, 19th ed. W.B. Saunders, Philadelphia, 1965,93 5-958,

G.c.: Fluid flow-a special case. In: Brown,

].RV . , Engineering, F,A, Davis Co., Philadelphia, 1971,6981. Marmarau, A., Shulman, K. and

Comoutflow resis-

tance of the cerebrospinal fluid system.J. Neurosurg.

43, 1975,523-534,

14. 1976, 18-320,

Mmer, CA.: Hydrocephalus resulting

from superior vena cava thrombosis in an infant. J

circulation. In: Ruch, T.e. and Patton, RD, (eds.):

partmental analysis of compliance

Bunt,E.A., Pastall, G., Smoliniec,]. and Lewer Alien, K.: A measurement of the effect of an enclosed

and BioI. Eng.Jerusalem,Israel, August 19-24, 1979,

4 Agarwal,

Lewer A.Ilen, of the cerebrospinal fluid in man by remote monitor­

Engineering Sciences, Technion-Israel Institute of

Neurosurgery 42, 1975, 597, 13

T,W.: Increased intracranial pressure. Clin' Neurosurgery, Chap, XXI, Congress of Neurol­ Surgeons, Vol. 16, Williams and Wilkens, 1968.

1 4 Frymann. V,M.: A study o f the

the living cranium. Jour. Arner,

motions of Assoc. 70,

1971,928-945. I) Sutherland, W.G.: The Cranial Bowl. Free Press Co.,

Monkato, Minn"

1939, 140 pp.

16 Woods, ]'M. and R.H.: A physical finding related to

6 Lewer Mien, K. and Bunt, E.A.:

fluid mechanical craniospinal systems as

psychiatric disorders. Jour. Amer. Osteo. Assoc. 60,

stress/strain diagrams. Proe. Int. Conf. on Bioengin­

1961,988-993,

eering, Cape Town, South Africa, April 1977, 132151. 7 Monro: Observations on the structure and functions

17 Moskalenko,

V.Y.

and Naumenko, Y.: Cerebral

pulsation in the dosed cranial cavity. izv, Akad. Nauk SSSR (Bio!.) 4, 1961, 620-629.

Copyrighted Material

Jacobs,

Appendix C

Mechano-Electric Patterns During Craniosacral O steopathic Diagnosis and Treatment JOHN

UPLEDGER, DO.. FAAO, East Lansing, Michigan and ZVI KARNI. Ph.D., D.Se., Haifa Israel'

mampulative diagnosis and Cranial treatment is associated with palpatory sensations perceived by the cranially oriented osr,90p,(lUJ1C various locations on nature of these pa/patory sensations ranges from regular, and rhythmic to quick, jerky irregular motion. A of mechanf}electric measurements performed on patients in an inactive state of the body shows that distinct strain gauge, electrocardiography, electromyography, and integrated-electromyography patterns correspond with each one of the pa/patory Jensations. ThiJ correlation far exceeds random hrr�hnhtlifv

Motions that are detectab le by of individual cranial bones and/or en tire cranial vault are associated with simi­ lar motions at other locations on the body."} However, the cranium and the be­ sacrum were used in this cause the mo tion is most apparent in these two areas. The nature of the physician­ perceived sensations is variable. It ranges motion which fro m a ebbs and flows and occasionally ceases jerky or vibratory to a motion which may be quite The motions can be represented mechanically by a single, narrow band-width amplitude (Fig. la), by multipl e amplitudes with vary­ ing (Fig. 1 b), or by a form of a

In function) two instances, the baseline remains in the case of step a is indicated in the baseline for a (T O> which is attained (Fig. or gradually either (Fig. l d). The purpose of this research was to determine whether there were correlations between selected mechano-electric param e ters ( monitored at various of the of and the physician's the changes in craniosacral motion chanics) craniosacral diagnosis and treatment. The results indicate that almost every in craniosacral mo­ tion (mechanics) reported "blind"'" by the has its counterpart in the

"The experimental facility w a s physically arranged so that the physician (Dr. Upledger) was unable the recordings as

made in a timely on the graph by the scientinc observedDr. Karni) as the physician's impressions were verbally communicated. The scientific observer did not offer any verbal cues to the physician. U sually, the mechano-electric pattern changes preceded the verbal communic ations by approxi mately a second. This se' quence of events rules out any obscure possibility that the patients could have responded "bioelectrically" to verbal cues

OJleopa/hic AJJociatifJ",

212 E.

Ohio

SI.,

Chicago,

by the physician as his impressions

were

Reprintedfrom The Journal ojlhe American Osteopathic Association, Vol. 78, JlIly

•

visualize

were made. All notations were

JL 60611.

282

Copyrighted Material

1979, pp. 782·91,

by permission oj the Amuican

283

APPENDIX C

Voltage

(a)

Fig. 1

(c )

(b)

(d)

Modes of motion amplitudes: (a) single, (b) multiple, (c) step function, and (d) gradual step function.

mechano-electric changes in patterns re­ corded from other locations on the patient's body. The character of the recorded mechano­ electric patterns was not dependent on vo­ luntary muscle activity of the patient, nor was it attributable to changes in the contact sites on the patient's body by the physician's hands. Unless otherwise indicated, all record­ ings were made with the patient in a relaxed state. However, when voluntary muscle action did occur, it was indicated on the tracings. MA TERIALS

AND METHODS

The mechano-electric patterns in Figure 1 were extracted from the recorded moni­ toring of the time variations of mechanical strain and of electric potentials of the skin at different loci on the patient's body dur­ ing the cranial diagnosis and treatment. In the preliminary experiments, six- and eight­ channel tracings were recorded. Later, how­ ever, as the multi-channel record became correlated with the perceived palpatory sensation, the recording was reduced to fQur channels, which was easier for the observer to handle and interpret. The four channels included at least one strain gauge, a unipolar ECG rhythm strip, and at least one I-EMG measurement. The standard arrangement was as follows: (1) a

single strain gauge placed over the palpable pulse immediately below the inferior costal margin which monitored the patient's res­ piratory activity and the arterial pulsations; (2) a unipolar ECG rhythm strip; and (3) two EMG electrodes placed bilaterally and symmetrically on the anterior thighs. When our attention was focused upon respiratory activity, the following arrangement was used: (1) two strain gauges placed sym­ metrically and bilaterally just below the inferior costal margins; (2) a unipolar ECG rhythm strip; and (3) a single anterior thigh EMG. Sometimes both arrangements were applied to the same patient during a single treatment. The change from one arrange­ ment to the other required only a few seconds. The strain measurements were taken using Peekel electrical-resistance, high­ extension rubber strain gauges type 20S. 4 These gauges possess a maximum exten­ sibility of 20 percent and a maximum compressibility of 15 percent. Gauge speci­ fications are as follows: overall dimensions, 46 x 17 mm. (1.80 x 0.69 inches); active length, 13 mm. (0.51 inches); electrical resistance, 119.5 ohm ± 0.2 percent; gauge factor-static extension, -0.0136 ± 2 per­ cent; gauge factor-static compression, +0.0182 ± 2 percent. There is a negative gauge factor because of its construction; the resistance wire undergoes a compres-

Copyrighted Material

284

APPENDIX C

sion when a positive strain (extension) is applied. The adhesive recommended by the manu­ facturer for the gauge was a Peekel quick­ drying adhesive type L35 which requires skin cleansing with Benzene solution. After numerous tests, it was decided that clear surgical tape was an effective adhesive for proper skin fixation. This method was used for reasons of convenience. The strain gauges were connected to a portable Wheatstone bridge (constructed by N. St. Pierre of the Biomechanics Depart­ ment). Each bridge accommodated two strain gauges and was operated either by a battery power source contained in the bridge or by drawing a 12-volt output power from the polygraph. For the more sensitive ex­ periments, and to avoid polygraph noise, the battery source was employed. The electromyography was recorded using silver-silver chloride electrodes (of a unity gain), preamplification units, and an "audio-oscilloscope" t Hewlett Packard EMG Unit Mark 1510B. The EMG output then was passed into an integrater (also constructed by Mr. N. St. Pierre) which converted the AC signals into their DC time-integral values. The integrater com­ pu ted the area (definite integral) per unit of time between the original EMG-voltage ordinates and the time as an abscissa. The integrater also functioned as a rectifier and cut out small amplitudes below a specific threshold. Consequently, the spread of the EMG pattern was more pronounced because dominant Signals were magnified and se­ condary redundant signals were eliminated. This is illustrated in Figure 2, which com­ pares an ordinary one-lead ECG with its corresponding "integrated" ECG (I-ECG) recorded Simultaneously over the same point on the subject's body by means of chrome plated snap electrodes. It is appa­ rent that primarily the R-wave contributes to the time integral, and the influences of the other waves are small. Thus, in the inactive state of skeletal muscular activity, integrated electromyography (I-EMG) elit In our

experiments, the audio channels were complete·

ly shut off {not used at all}.

STRAIN

"II.

roV

1.0

mV

!-ECG/Vz

Fig. 2 Single lead ECG and I-ECG recorded simultaneously.

minated noise and was preferable for this research. The strain gauge, the ECG, and the I­ EMG pick-ups were all connected to a multi-channel Grass Polygraph. The high­ est sensitivity gain calibration was set on 0.01 mv./cm. The frequency gain settings during the experiments were 3 for the strain gauge measurements, 15 for the I-EMG, and 75 for the ECG. RESULTS Some typical four-channel recordings conducted during cranio-sacral manipula­ tive procedures are shown in the following figures. Although each patient showed uniquely personalized patterns, there were repetitive features in all the tracings which allowed us to consider at least four different patterns which all patients had in common. Using the classification suggested in Appli­ cation Note 700 of Hewlett Packard, 1969, we labeled these patterns as follows: (1) Rapid oscil/ations. In the strainography (SG) over the left hypochondrium, these oscilla­ tions had a relatively small amplitude of

Copyrighted Material

APPENDIX

28 5

C

0.02�0.1 percent strain t and measured fre­ of 5 2-96 cycles per minute (cpm). They were present throughout and, when correlated with the corresponded in a In fashion with aortic rare cases, the s train gauges also what may have been the echo cardiac valve closures. In the I� EMG the rapid oscillations with amplitudes of 0.1 0.2 mv. and measured cpm resulted cardiac e1ectroactivity which from the was picked up on the thighs. (2) Transient waveforms. These waveforms in the SG which an amplitude of up to 3 percent strain and a from 6 to 30 cpm were in one-to� with the respiratory rate (RR) (thoracic The average RR in the state ranged b e tween 14 and 18 per minute in the of cases. In our s tudy, trained athletes (karate ex­ perts) were able to voluntarily lower the RR to 6 per minute or less for 15 minutes or longer. (3) Rapt'd waveforms, or spikes. Apart from in the R-waveform in the and the spikes were seen in amplitudes varied from the I-EMG. 0.4 to 2.0 mv. The of occurrence seemed dependent upon the neuromusculoskeletal pain syn� and drome. The appearance amplitude) of spikes decreased with favor� able response to the treatment and became a landmark of correlation be tween the phy� sician's and sensations and the mechano-electric patterns. (4) Baseline changes. These "'''�Hf;'''', marily seen in I�EMG IJ"'�"""W�' 141""""'11 or abrupt. Baseline lasted fo r many seconds and then abrup tly the of a step func� tion. seemed to be correlated to ....rl
This is a smooth (1) Normal rhythm regular pulsatile cranial in a rhythm of 8-12 per minute. rhyth mic is in accord with the concep t of a Rhythmic Impulse as put forth Sutherland.l.3 The sensation of the normal rhythm as the is that of a uniform deformation of cranial vault shape, as its dimensions reciprocally and This rhythmic effect rhythmically can be sensed on the body. The cause tion is at present a subject for it seems related to the the dural compartment represents a semi� closed hydraulic system as it extends from canal to the the the cranium saC rum. This normal rhythm was not seen on our I-EMG recordings taken during the There is, however, some strain­ gauge pickup of the NR if the gauge is placed sufficiently close to the skulL (The fu rther work investigators strain which will attempt to demonstrate presence of a fluid wave (2) Still point (SP). 1.3 A still stops when the normal This cessation of motion might occur gradually as the rhythmic motion a mpli� tude decreases. it can tak e sud­ denly when the zero point of the pulsatory and the motion stops waveform is abruptly. On the I�EMG record over a an SP concurs with a short of 1.3 mv. (Fig. and with a to the baseline level jf an absolute s top occurs (Fig. (3) End of still point (ESP). Following a n the system, both skull and body, seems This expand a more even and sym me tric motion. The ESP corre lates on the I�EMG record with the delayed appearance of a 0.4 mv. the of the order of 1 second pr,,,,,r,u· and in contrast to the tak es an elevatd I-EMG following the ESP (4) Release (Re). This sensation is of a of the volumetric con� " plastic" tai ner in

Copyrighted Material

STRAIN

'Yo

5P._.

__

��U\ Figs. 3a and 3b.

:�OOZ'fiiiiltt --�·-�1� f -0 ..j

': •

"

..•..

,.0\0

\

Mechano-electric pattern for a still point (SP) as (a) spike, and (b) absolute stop.

. II I I I ' \ I • .' ' )

,

I

'

,I

!

! !

!

� -�'� -�� � �����·���·���

.

E!.P

Figs. 4a and 4b Mechan�electric pattern for end of still point (ESP) as (a) delayed spike, and (b) bejorean elevated I-EMG activity. or obstruction to fluidity have been over­ come. This relaxation of resistance is ac­ companied by a sharp I-EMG spike which, in magnitude, surpasses any of the previous­ ly described spike patterns. The release

Signals can be symmetric (Fig. 5a) or unila­ teral (Fig. 5b). They play a paramount role in the osteopathic treatment as landmarks for improved functional activities. (5) ShIfting. The impression of a tidal fluid

Copyrighted Material

287

APPENDlX C

•

f

� .

. I

.

•

2... 1 8 � O_ ! _

mV

---

�

IL·TH!GH mV

--

+-I I---;-;::d-:::-==+-

-- ---0_-_000 - ---

,o 0-i\"_

__

,

!

-

--j---+---t/I r ___ +--

-----\I

° °

-0.5 -I,D

Figs. 5a and 5 b on one tNgh.

Mechano--electric pattern Jor release (Re): (a) symmetrical on both thighs, (b) umlateral

motion and change of direction of flow is sensed by the physician. For example, the feeling or perception could be that of an uneven lateral expansion of the skull se­ condary to a volumetric fluid shift. When the direction of the fluid wave changes, a mechanical change takes place in concert with i t. The pattern of the mechano-electric changes in shifting is unique and unmistak­ able. The I-EM G shows a clear and distinct change of the baseline in the fo rm of a step function. This usually takes place during the peak of respiratory inhalation while the pulmonary volume is maximal. This is clear­ ly indicated by the strain gauge records (Figs. 6a and 6b). Our correlation between the sensation of shifti ng and the step-function patterns was 100 percent. (6) Pulsating. This is a rapid oscillatory motion of low-ampll tude and high-frequency (50-80 per minu te) which is most common­ ly perceived i n a localized area of the craniu m. Generally, i t precedes an ESP, a release, or a shifting. It is interpreted as an i�dica tion that some important mechanical change is abou t to occur. Pu lsating usually occurs during the resting phase of the respiratory cycle (Fig. 7). (7) Wobbling. This term was used to des-

cribe a low-mode (20-40 cpm), fluctuatory type of motion with amplitudes larger than those of " pulsating." Furthermore, the ef­ fect is not localized and can be felt over the body. Wobbling usually precedes a major release or shifting. The subjective impres­ sion of the physician is that of a braking mechanism whi ch interferes wi th the flui d motion. The typical electromechanical pat­ tern associated with wobbling is shown i n Figure 8. This event takes place during the respiratory hold phase following inhalation. (8) Torsion. ** In torsion, the impression is that of a rotational periodic motion abou t a longi tudinal axis through the patient's body where all sections of the body are not movi ng in synchrony. It is an asymmetric, distorti onal (not volumetric) type of a mo­ tion which is manifested as asymmetric 1EM G pickups on the lower extremities. Torsion is observed in Figu re 9 as a series of spikes with modest amplitudes (0.7-1.0 mv.). It does not show i n the respiratory activity recordings. A common denominator of the above physician-reported sensations is that they "Torsion a s used in this research is not to be confused with "torsion" as an abnormal relationship between the

sphenoid and occipital bones. U

Copyrighted Material

APPENDIX

288

Figs. 6a and 6b

C

Mechano-electric pattern for shl/ting: (a) long duration, (b) short duration.

are all passive or inherent to the patient's body; they all occur when the patient is in a relaxed and inactive state and when no gross manipulative treatment is being ap­ plied. They are most easily perceived or sensed when the patient is very quiet.

ments can only be increased at the expense of the others.

••

The dura mater has been described as a tough

inelastic membrane which forms the endosteum of the cranial vault. It attaches firmly about the entire circum­ ference of the occipital foramen magnum. It then passes

DISCUSSION

through the entire length of the spinal canal; its most

It tacitly has been assumed throughout this presentation that the mechanical model underlying the impressions reported by the physician involved a fluid container com­ posed of several physiologic compartments, each of which possessed uniquely different material properties. This container may allow for very slight changes in its volume capacity. In effect, and in accordance with the long accepted Monroe-Kellie doctrine,� the relatively inelastic dura mater faithfully encloses the brain and spinal cord as a continuous and connected material region, ** it may represent such a container. It is postulated that the contents of the dural container (brain, spinal cord, nerves, cerebrospinal fluid, blood, and other fluids) are very nearly incompressible. 6 As a result, the combined volume of the contents of the dural container must be very nearly constant; and the volume of any one of its compart-

firm attachments within the canal are only to the posterior aspects of the bodies of the second and third cervical vertebrae and within the sacral canal at the level of the second segment. It is separated from the spinal canal by the epidural space which ends at the second sacral segment (S-2). Below the level of S-2, the dura closely invests the filum terminale, passes through the sacral hiatus, and descends to the coccyx where it blends with the periosteum of that bone. The dura mater is connected to the dentate ligaments within the spinal canal, to the posterior longitudinal ligament, and to its nerve root sleeves wh.ich exit from the spinal- canal with the spinal nerves. The restrictions to dural motion afforded by the latter three described attachments are much less than the restrictions imposed by those attach­ mentS within tbe cranial vault, at the foramen magnum at C-2 and C- 3, within the sacral canal, and at the coccyx.

The size of volume capacity of the dural container is much greater than is required to accommodate only the neural structures and, therefore, is quite able to re­ spond somewhat independently to the stresses and pressures to which it is subjected. When considered as the material border of a fluid container with the previous­ ly described firm attachments to bone, the influence of these bony structures upon the mechanical forces within the container becomes quite apparent.

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2 89

APPENDIX C

Fig. 7

Mechano-electric pattern for pulsating.

The craniosacral osteopathic doctrine considers the major skull bones to be inter­ connected by viscoelastic sutu res/ acting as hinges about which a kinematic change in configu ration can take place. Furthermore, because the dura mater is memb ranous, it is susceptible to dynamic boundary changes which correlate to the p hysician's impres­ sion of the rhythmic and pulsatory motions of the cranial bones. The overall pictu re is, therefore, that of a less than rigid mechani­ cal model with a fluid content, the motion of which, although small, is still within the range of sensory percep tion for trained craniosacral osteopathic physicians. The nature of the mechanical cranio­ sacral effect on the neu romusculoskeletal system is, unquestionably, obscure. How­ ever, the fact that the craniosacral system does have a measu rable effect on other parts of the body has been demonstra ted on an input-output basis by this experiment. CONCLUSIONS Subjective imp ressions of various changes in the craniosacral mechanics which are re po rted by a trained craniosacral osteo­ pathic physician are documentable by in­ strumental means. This documentation consists ofchanges in the bioelectric activity recorded by I- E M G from the lower extremi-

Fig. 8 Mechano-electric pattern for wobbling.

Fig.

9

Mechano-electric pattern for torsion.

ties, ECG, and strain-gauge recordings of respiratory activity. Specific patterns of the monitored mechano-electric parameters correlate di­ rectly with subjective impressions of like­ wise sp ecific changes in craniosacral me­ chanics as reported by the p hysician. The range of the recorded integrated electromyographic signals is below the level of signals originating from any voluntary type of muscular activity, yet is by fa r larger than instrumental noise levels.

Copyrighted Material

This research has been partly supported by the COM/MSU. Department Appreciation is expressed to Drs. E. Retzlaff and R. Roppel for valuable Juggestions and the use technical of to Mr. N. St. assistance, and to Mr. J. Schulz from the Instruc­ tional Media Center, MSU, for the preparation of

Printing Co., Kirksville, Missouri,

1966.

4 Kami, Z. and Pollshuk, W.Z.: Multi-strain measure· ment of uterine activity. Proceedings of the

24th

Annual Conference in Engineering in Medicine and' Biology,

101,

Nov.

71.

Li\,inl>st,n". R.B., Woodbury, D.M., and Patterson,J.L. Jr.: Fluid compartments of the brain. Cerebral cireu­ ration. In Rueh, T.C., and Patton, RD., Eds. Physi­ ology and biophysics, W.R Saunders Co., Philadel­ phia,

.:mm."lano. W.A.: The cranial bowL Free Press Com­ pany, Mankato, Mi nnesota,

1939.

1965.

6 Agarwal, G.c.: Fluid flow. A spedal case. In Brown,

JH. U.,

Jacobs, j.E., and Stark,

A.L.: The work of William Garner Sutherland. JAOA 71:788-93, May

H.L:

Eds.: Biomedical

Engineering, F.A. Davis Co., Philadelphia,

72.

1971.

E., et al.: Sutural collagenous b undles and their innervation in Salmlr; sciureus. Anat Rec 187:692,

Osteopathy in the cranial field. Journal

Apr.

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77.

Appendix D

Management of Autogenic Headache JOHN UPLEDGER, D.O. AND JON D. VREDEVOOGD*

The functional anatomy of the head and neck supports the thesis that a number of headache problems are Tissue contracture is a

INTRACRANIAL FLUID CONGESTION of fluids within the cranial vault may be secondary to an obstruction to outflow at the cranial foramina that causes

lion of pain when it is no Various mechanisms and U)lfrcl./Jt:�;H� related to headache are

increases in back pressure. The most common areas for tissue contractures that increase back pressure are probably at the

Hypertonus, or contracture of the cranial or cervical soft tissue, is almost invariably a

foramina. These foramina are

located just lateral to the

1).

is not grossly

",,,,.,,,nro

A somatic

in the

relationship will very

concomitant feature of headache. When it

in tissue contracture, which will in­

discrete and tion will almost localized areas of abnormal tissue tonus.

crease the back pressure to cranial-vault venous outflow via these (jugular) foramina.

Often these soft-tissue tonus abnormalities persist between exacerbations of head Functionally, these loci may be considered

"The term "soft tissue," as used herein, refers to all

areas.

connective tissue except bone. Frequently, "soft· tissue

residual

The

soft-tissue

change may represent either a primary or a secondary feature of the headache syn­

contracture" and "hypertonus" cribe muscle conditions.

used only to desdemonstrated histo-

logically that collagen fibers are

drome. In either case, soft-tissue hyper­

elastic fibers. The microarchitecture of

inter-

tonus or contracture does contribute to

related fibers strongly suggests that

tissue

pOI;se!:ses contractile ability. The same

has shown

and recurrence.** This may occur

a

of mechanisms. Among them

are increased intracranial fluid congestion, occipital due to soft-tissue change in or the triangle, spinal dural stress or tension, and cranial-suture immobility and compression. Each of these will be discussed separately.

-Reprinted from Osteoptlthic Annals, Vol.

7.

of neurostructures also intimately related collagen-elastic-fiber complex. The presence of these nerve receptors and fibers in relationship to the collagen-elastic-fiber unit further

a ref1exly

controlled contractile function for

tissue. Col-

lagen (connective) tissue may, therefore, respond to local stimuli (such as stress and tension) and to messages from higher control centers, probably triggered by pain awareneSS or emotional stress.

No.6, J/ll1e 1979. pp. 232-41, by permission of tbe tI/ltbors. 291

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APPENDIX D

r1 )b-v

0

0

/"r\;)

\Ui

1 Interior aspect of skul/. foramen. 2: Occipital condyles.) foramina also afford passage The 1 0 th, and 1 1 th nerves. Disturto the bances of these nerves may resul t in clinical symptoms related to cardiac tion, bowel function, swallowing, etc. spinal accessory portions of the 1 1 th cranial nerve arise from the upper five or six They pass cervical through foramen magnum into the cranial vault. They exit from the vault via foramina and provide motor the fibers to the sternocleidomastoid and trap­ ezius muscles. On the basis of these anatomic relationit can be seen that tissue in o f the occipital condyles and jugular foramina may resul t in varied pain and autonomic syndromes. An effective therapeu tic approach must deal with all the soft-tissue disorders that may cause ob­ struction to fluid outflow from the cranial vault. THERAPEUTIC APPROACH The cranial vault may be considered a

semiclosed fluid container. The various of entry and exit foramina represent The fluid volume for this is maintained at a constant volume homeostatic mechanin fluid volume and isms. Subtle in head pain and auto­ nomic These sub tle "".Ull�"'" may be due to increased back pressure, as or to a change in the fluid described retention of the cranial vault contents. Medications may result in toxic arachnoiditis or cerebral they should be used in cases of or recurrent head pain and with full awareness that the clinical syn­ drome may be iatrogenically perpetuated and perhaps worsened. The intracranial fluid volume may also be increased by function of arterial tonus, which causes more inflow than can be accommodated by the outflow. The resultant head pain causes of soft tissue, a neu rogenic which in turn reduces the ou tflow capabili ty. In any of these cases, effective therapy must enhance outflow capability so that intracranial fluid is reduced. Nonspecific "Thrust" Technique for the Cervicothoracic Region

This technique should b e applied bilater­ somatic ally. It is not directed at prohibits proper dysfunction unless (It is preferable positioning of the to make specific corrections after the generalized tissue tonus has been reduced.) is the enhance­ The goal of the ment of flu id motion from the cranial vault into the thoracic cage. with the The patient should be cephalad. The physician's right is placed so that the palm is supportFirm contact the lower cervical is established between the radial side of the physician's righ t palm and the cervicoThe thoracic region of the dan's left palm is then used to support the releft upper cervical and IH ''''I I-'''I{W UCllUl:U
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29 3

APPENDIX D

forces stretch the soft tissues on the left side. The patient is then asked to hold a deep inhalation as long as possible while side bending is fu rther increased. This causes more tissue relaxation. The b reath­ ing assistance procedure is repeated until no further side bending can be introduced at the end of the held inhalation. Frequent­ ly, the physician will notice that first-rib articulations occur spontaneously during this procedure. While side bending is maintained at i ts extreme, left rotation is introduced. Lock­ ing should not be attempted. The rotational motion affects C7 through T3 ()r T4. A " thrust" is then carried through ( I t t: b.n n e r to further mobilize the tissues of the cer­ vicothoracic region. The procedure is then repeated in the opposite direction (Figure 2). First-Rib Restrictions Remaining restrictions of the first rib are then easily corrected by bend ing to the side of the restriction so that maximal tissue

Figure 2

relaxation is obtained. With the thumb and index finger grasping the tissues in the region of the first-rib head, mobilization can usually be accomplished by the use of direct gentle pressure. If fu rther mobiliza­ tion is required, respiratory assistance (as above) may be quite helpful. Release of Upper Cervical and SuboccIpital Tissues The patient and physician remain in the same position except fo r the physician's hands. These hands are approximated palms up, with the fingers flexed so that the distal phalanges are oriented at approximately 90 d egrees to the longitudinal plane of the patient's cervical spine (Figure 3). The fin­ gertips apply deep pressure in the subocci­ pital region bilaterally. The physician's fin­ gertips are also used to support the patient so that the occipital region is ini tially sus­ pended above the physician's palms. Finger­ pad contact should be maintained with the inferior aspect of the patient's occiput. As

Nonspecific thrust for the cervicothoracic region.

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294

APPENDIX D

motion testing,

using the fingertips to

move the articular pillar regions as the occiput is supported in the upturned palms. Testing for translatory, side bending, and anterior motion usually suffices to identify remaining specific somatic dysfunctions. Those found can be gently corrected by either direct or indirect techniques with respiratory assistance. The techniques described above are all aimed at alleviating obstruction to the out­ flow of fluid from the cranial vault and,

3 Hand position for release of sub­ occipital tissue. Figure

therefore, favorably influencing the inflow­ outflow pressure diffe rential. This approach, in sequence, will usually effectively inter­ rupt the autogenic nature of head pain due

the suboccipital tissues relax, the occiput

to intracranial fluid congestion by facilita­

will gently settle into the physician's up­ turned palms. The firmness of bone (the

etal lift) is aimed at directly alleviating intra­

atlas) will be apparent at the fingertips on

cranial fluid congestion.

completion of this technique. This is a passive and waiting technique on the part of

tion of outflow. The next technique (pari­

Parietal Lift

the physician. Respiratory assistance (as above) by the patient may be employed to facilitate tissue relaxation. As the tissues relax, a discrete area of tissue contracture may be discovered. This

The physician should be seated above the patient's head. The physician's finger­ tips are placed

gently

in contact with the

lateral aspects of the patient's parietal bones bilaterally. The fifth-finger pads are

may be a key trigger to the pain syndrome. It should be specifically treated with further

in contact with asterion, anterior to the

deep pressure until it is perceived to relax.

roparie tal sutures. The other three fingers

This technique is aimed at releasing all tissue hypertonus that may influence out­ flow from the jugular foramina.

lambdoid sutures and just above the tempo­ of each hand are placed about

1 cm. apart

and must be above the patient's temporo­ parietal sutures (Figure

4). The physician's

thumbs are now crossed upon each other

Mobtlization of Occipitoatlantal and Atlantoaxial Joints

above the patient's head. (They do not

Once the relaxation of the suboccipital tissues has been obtained as outlined above, the freedom of motion of the atlas and axis should be tested by fingertip pressure as the occiput is ge ntly supported in the physi­ cian's upturned palms. Any restriction of motion can usually be corrected with gentle direct or indirect technique in conjunction with respiratory assistance by the patient. Be gentle; do not cause tissues to reflexly contract against your palpatory intrusion.

touch the patient's scalp.) Next, after finger placement is rechecked,

pressure is

the parie tal bones medially (Figure 5 ). 1£ the temporal bones are pressured, the tech­ nique will not work and may, in fact, worsen the clinical symptoms. The amount of pres­ sure exerted on the parietal bones is on the order of

5-1 0

gm. The thumbs, in contact

with each other, are used to steady the phy­ sician's hands. This gentle pressure on only the parietal bones is held constant for several minutes.

Mobilization of the Remainder of the Cervical Spine

gentle

exerted to compress the lateral aspects of

(Usually three to five

minutes will suffice.) As the temporopari­ etal sutures disengage, it will feel to the

The entire cervical spine (segment by

physician as though the parietal bones are

segment) can now b e palpated by gentle

moving superiorly and spreading very slight-

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2 95

APPENDIX D

Figure 4 Suture landmarks for parietal lift. {I : Coronal suture. 2: Temporal parietal suture. 3: Asterion. 4: Lambdoid suture') Iy. Do not release your parietal pressure suddenly. Do it gradually; otherwise you may worsen the symptoms. Usually when this release is felt, the patient will remark that "pressure" within the head has been relieved. * Peripheral Stimulation Therapy Directed at the Alleviation of Intracranial PluM Congestio,r Peripheral stimulation therapy is aimed at the activation of specific loci within the musculoskeletal system and often produces predictable therapeutic results. The activ­ ating stimulus may be a needle puncture, deep pressure, circular massage, ultrasound, or any other of a number of techniques. The important factor is that the stimulus be applied to a specific anatomic location. Only the anatomic locations that have proved useful for the achievement of the desired results are described here. The choice of the technique should be made using precautions dictated by the medical expertise of each physician. Peripheral stimulation therapy loci, which are often effective in the reduction of tonus of the cervical musculature, are lo­ cated on many areas of the body. Those given below have been the most effective in

my practice. 1 . On the midline of the body - at the juncture of the sagittal and lambdoid su­ hues on the scalp, between the occiput and the atlas, between C2 and C3 (spinous processes), and between C7 and T1 (spinous processes). 2. At the juncture of the metacarpal bones of the thumb and index finger on the distal aspect of that joint capsule, about midway between its palmar and dorsal sur­ faces (Hoku). This locus is very reactive to needling and deep pressure (Figure 6). 3. At the midpoint of the popliteal crease bilaterally (B54). The best effect is obtained by needling ( Figure 7). 4 . Immediately inferior to and directly over the mastoid tips bilaterally. The best effect is obtained by transcutaneous need­ ling or by gentle pressure and circular massage. Do not use even moderate pres­ sure on this area, or you may induce a variety of autonomic responses. If your pressure worsens the head pain, it is too firm. 5 . At the inferior aspect of the occiput on the lateral aspect of the trapezius, bilater­ ally. These loci are very effectively treated

'The author realizes that the presentation of this cranial technique may be controversial. However, i f it is carried out with caution and sensitivity to the delicacy of the structures it affects, it can provide dramatic relief to a 2 large number of suffering patients

Figure 5

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Hand position for parietol lift.

296

APPENDIX 0

Figure 6 Hoku peripheral stimulation point.

\

Figure 7 Pertpheral stimulation point for re­ laxation of cervical muscle tension.

by needling or deep pressure. 6. About 1 inch inferior to the superior border of the trapezius, midway between the deltoid origin on top of the shoulder and the vertebral articulation of the first rib. These areas are well known to many patients as effective for the use of relaxing massage. They are very effective loci for needling to achieve cervical relaxation and to reduce intracranial fluid back pressure.4 (Look for discrete areas of acute tenderness.) 7. The medial aspects of the scapular spines (b ilaterally) frequently present ef­ fective peripheral stimulation loci, as do the medial borders of the scapulae superior to their spines. Peripheral stimulation therapy loci, which are very useful in the reduction of in tracranial fluid pressure,) are known in acupuncture as Kl , GV24 . 5 , and GV26. Kl is located bilaterally on the soles of the feet just proximal to the prominence of the metatarsophalangeal joints between the second and third metatarsals. These loci are very responsive to needling or deep pressure (Figure 8). The other two loci (GV24.5 and GV26) are found, respectively, on the mid­ line between the medial aspects of the eye­ brows (over the glabella) and above the mucocu taneous junction of the upper lip a third of the way towards the base of the nose. These loci are very responsive to

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297

APPENDIX 0

OCCIPITAL NEURALGIA, OCCIPITOFRONTAL CEPHALGIA, AND THE SUBO CCIPITAL TRIANGLE

to somatic dysfunction of the tissues of the suboccipital triangle is exactly the same as that described above for release of sub­ occipital tissues and upper cervical vertebrae. The peripheral stimulation therapy loci are exactly the same as those described above for the relaxation of the cervical soft tissues. All vertebral restrictions to motion should be treated to re-establish mob ility.

The upper three cervical nerves contri­ bute to the occipital nerves. Cl is primarily motor to the muscles of the suboccipital triangle but has some sensory fibers. C2 is the largest contributor to the greater occi­ pital nerve, which supplies sensory fibers to the obliquus capitis inferior and to the splenius and longissimus capitis muscles. C3, the lesser or third occipital nerve, sup­ plies sensory innervation to small portions of the oCcipital and mastoid scalp and to the posterior neck. It supplies motor innerva­ tion to the semispinalis capitis (Figure 9). This brief look at the pertinent anatomy serves to illustrate the autogenic nature of head pain as tissue tension causes nerve stimulation that in turn increases tissue tension. The therapeutic approach to occipital neuralgia and oCcipitofrontal neuralgia due

Figure 9 SuboCCIpital triangle. (1: Rectus capitis posterior major. 2: Obliquus capitis inferior. 3: Obliquus capitis superior. 4: Ompital nerve.)

needling or to the application of locally applied heat by contact with a warm me tal­ lic object. All four of these areas should be stimu­ lated within a few minutes of each other in order to achieve maximum benefit.

SPINAL DURAL STRESS

Figure 8 Peripheral stimulation point lor re­ duction 0/ intracranial fluid congestion.

The dural tube is a relatively inelastic and tough membrane. It attaches firmly at the foramen magnum to the posterior bodies of C2 and C3 but not again within the spinal canal until it reaches the level of S2 . It be­ comes the filum terminale externus, passes out the sacral hiatus, and attaches to the coccyx as its periosteum.6 Considering the anatomic relations of the dura below the foramen magnum and the fact that it forms the endosteum of the cranial-vault bones, it becomes apparent that any continuing stress on the dura mater is capable of producing head pain. A common situation, often ignored, is the anterior flexion of the coccyx due to trauma. The patient seldom perceives the relationship between a fall on the " poster­ ior" and the subsequent onset of persistent

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298

APPENDIX D

head Consideration of the d ural os­ seous attachments readily illuminates a mechanism of dural stress transmission from the flexed coccyx to the of the occiput. This stress, of low grade, is continuous and may cause recurrent oCcipitoatiantal .. ... which in turn causes obstruction at the foramina and intracranial fluid >" UHJ',"'" The cervical musculature becomes tonic in response to irritation of the motor nerves. Visceral autonomic fre­ quently oCClir. These syndromes resemble each other and become au togenA l l the desicall y may be instituted; cribed permanent res ults will not be obtained until the coccyx is mobilized. .... U·

JH.

Direct Tel:-;)niq�(e

comfo rtably flexed i n With the the lateral recumbent position, the dan's index finger is the anus. The coccyx is (in the the index Anterior flexion and posthumb terior extension motion is gently carried o u t. Very often the will comment that anterior flexion increases or and causes head extension motion relieves it somewhat. These obser­ the patient confirm your diag­ correction is achieved the of gentle direct technique against the pathologic motion barrier with assistance until a relaxation is treatment is very effective. It has solved some very severe and persis­ ten t headache problems. CRANIAL SUTURAL PAIN often head pain is localized along the course of a given suture of the cranial vault. This condition an aftermath of the treatment due to intracranial fluid Retzlaff et aF have illustrated histol­ -0------, that the microanatomic stru c tu res for pain are p resent within the cranial suture. Dysfu nction of the s u tu re may therefo re result in localized pain as

well as in more generalized symptoms. Once localized su tural pain has been identified, it may be treated quite and e ffec tive two needle stimulation and the S utherland tech­ nique of "direction of fluid." Local Needle Stimulation

A small-diameter (27-gauge o r , sterile needle is inserted transand threaded in the subcutan­ eous tissues of the scalp immediately super­ to the affected sutural ficial and needle should not invade the suture, nor should it disrupt the of the cranial bones (Figure 10). O nce in place, the needle hub should be until the pain is relieved. Pain relief usually occurs in less than three minutes. it appears that this p rocedure mobilizes the sutural restriction stimulating nerve receptors are to but influence intrasutura l connective tissues), _ _ _" _ _ _ _ _

Sutherland's Technique urI" '"",,, Fluid"

This makes use of a mechanism that is not yet Scientifically understood but predictably favorable clinical It is not necessary to be an experiin order to sucenced cranial this very effective thera­ approach. Place the pads of one or two fingers on the scalp directly over the painful suture area. Now, imagine a line or vector from the painful area through the center of the skull (using a globe as the ideational and out the other side of the patient's head so that an diameter has been formed ( Figure 1 With the other very gently for a pulsation of the at the region where the vector (diameter) would emerge fro m the patient's skulL The exact location can easily be determined in a few seconds with an exlight touch. has been 10Once the area o f pads to the two or three of the opposite hand the painful suture) are

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2 99

APPENDIX D

gently laid upon the scalp so that the length of two of these fingers parallel the painful suture about 0.5- 1 .0 cm. on either side of it (Figure 1 2). The painful suture will seem to begin pulsating. This pulsating will con­ tinue for a matter of minutes. As the pulsa­ tion gradually subsides, so will the pain. A very gentle spreading action by the fingers paralleling the painful suture will speed the therapeutic effect, but it is not mandatory. Remember that gentleness is absolutely necessary for the success of this technique.

Figure 1 0 Needle position for subcutaneous scalp stimulation.

Figure 1 2 direction.

Treatment ofpainful suture byfluId

BIBLIOGRAPHY

1. Retzlaff, E.W. Personal communication. 2. Magoun, H.I., Sr. Osteopathy inthe C"milll Field, Second Edition. Kirksville, Mo.: Journal Printing Company,

3.

1966, p. 1 79. Upledger,].E. Integration of acupuncture and mani­ pulation. Osteopathic Medkine 2:7 ( 1 977), 1 8 .

4 . Academy o fTraditional Chinese Medicine. A n Outline of Chinese Acupuncture. San FranCisco: China Books & Periodicals, 1 9 7 5 , p. 1 75 . 5 . Frost, E. Personal communication. 6. Warwick, R., and Williams, P.L. (eds.). Gray'sAnotomy. 35th Edition, Philadelphia: W.B. Saunders Company,

1 9 7 3 , pp. 806-809. 7. Retzlaff, E. W., MitcheU, F.L.,Jr., UpJedger,].E., and

Figure 1 1

Techniquefor locatingflulddirection.

Biggert, T. Nerve fibers and endings in cranial su tures.

JA.O.A.

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77

( 1 978), 474.

E

Spontaneous R elease by Positioning LAWR Et\CE H UG H JONES, D.O., Ontario, Ore.'

of what appears to be a new of lesion production has resulted easy method of correction use of force. many osteopathic physi­ cians have observed occasional cases of spontaneous lesion correction. Probably most o f them have and wished be corrected so easily­ that all lesions b u t that it is a one-in-a-thousand non and not worth thinking abou t, j us t a fortunate combination of influences. Most physicians can remember some case that was seemingly i mpos­ a case that resisted all their skill, and continued to and their best and again until them from admitwere Each vis! t became a that after l'''JU ';HJJJ� frustration. disorder one day spontaneously and easily before corrected their eyes. This of frustration is inc luded b ecause it furnished the necessary for 10 years of experimentation. The ease and effectiveness of this techand the tails are very difficult to as who have use of a certain amount of H"'Y\\lPr"

force to attain a correction on hundreds of thousands of lesions in their prac­ tices. Yet, demonstrations in seminars in the western states have shown most of the that the osteopathic physicians technique is practical for them on their first or second attempt. They are convinced only after feeling it happen under their own fingers or on their own lesions. BACKGROUND In the original case a fortunate combina­ tion of accidents made the correction pos­ sible. A man had had a very severe and ful second l umbar lesion with psoasitis for a long period, and I had b een unable to cor­ rect it despite maximal efforts. He had com­ plained of being awakened every few min­ u tes during the night by his pain. I was de­ voting an entire treatment period to 'W'�""5' if possible, a position of relative comfort which h e might use to secure rest without heavy sedation. We fmally found a position which achieved a high degree of comfo rt, b u t it was aston­ ishingly extreme. It was unbelievable that such a rigid patient could tolerate, let alone enjoy, such a position. He was nearly rolled into a ball, with the pelvis rotated abou t 45 and laterally flexed about 3 0

'Reprinted/rom The D. O.,ja(/. 1 964, pp. 109·116, by permissiOfi o/the America" Osteopathic A S5(1(iaiion, 2 1 2 E. Ohio St. • Chicago. 60611.

300 Copyrighted Material

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301

APPENDIX E

The patient was so well relieved that he was propped up and left in the position while I treated another patient. When I returned and restored him to a normal posi­ tion, he remained comfortable! Examina­ tion revealed an excellen t correction of the lesion, with marked improvement in free mobility and two-thirds reduction in pain and tenderness. To accomplish a correc­ tion so easily in a case so desperately "im­ possible" was hardly believable. It was too impressive to be ignored. Expe rimentation was begun on other second lumbar lesions. Many were corrected in positions similar to the one that had been effective for the first man. Most of the others responded to minor modifications of the original position. Experimentation seemed relatively safe, because no force was necessary and a position which b rought i m­ mediate comfort could hardly be construed as an injury. Gradually the time of support in the position of release was reduced from 20 minutes to 1 0 and then to 5 . Success continued down to a period of 90 seconds. Below this time, success was irregular, even though we achieved an excellent position for relief of pain and tenderness in the lesioned jOint. It still appears to be the mini­ mum, though probably some skilled tech­ nicians will be able to reduce it fu rther. Success with second lumbar lesions en­ couraged attempts on other lesions. Some results were gratifying, others disappoint­ ing, but little by little it became clear to me that all osteopathic lesions will correct spontaneously in a position of release, and that a large proportion of lesions of a given joint will follow a pattern of position com­ mon to other lesions of that joint. Du ring this time the pOSition of release and comfort was found in a high percen­ tage of the cases to be simply an exagger­ ation of the abnormal bony relationship found u pon examination. This has occurred so conSistently that I have accepted it as proof of diagnosis. On the occasions where th� two do not agree, I distrust my diag­ nosis and rely on the pOSition of release as both diagnosis and treatment. SOME APPARENT PRINCIPLES Most lesions can be corrected in exagger-

ation o f the diagnosed abno rmal bony rela­ tionship. OccaSionally diagnoses are not clear. We are saved from testing aimlessly by the fact that most lesions of any given joint are likely to follow a pattern. Through the years I have been able to accumulate a list of the more common l esions. In three fourths of the lesions in which the diagnosis was not clear, disorders were found to respond to positioning according to the directions on the list, with minor variations. This list, which will be presented later, is offered not to be blindly imitated, b u t as means of saving the busy physician the time-consuming experimentation needed to develop it. He must never lose sight of the principle. The techniques are success­ ful only if they achieve the position of relief of tenderness and pain. If unsure of his diag­ nosis, he tries the basic positions first. Then, if necessary, he abandons them and learns the effective pOSition by trial and error, secure in the knowledge that there is such a position for each lesioned joint. After a few weeks of practice he will not need to delay long on any lesion. Can this simple, easy method of correc­ tion be possible? How can it be, and yet have escaped the notice of thousands of osteopathic physicians all these years? Yet the first published reference I could find to anv similar work done is a statement by Dr. Ir; c. Ru mney of Kirksville College of Osteopathy, in January 1 9 6 3 . ' In a sum­ mary of forces which can be used to re­ establish normal spinal moti on, he lists: "Inherent corrective forces of the body-if the patient is properly positioned, his own natural forces may restore no rmal motion to an area." The phenomena demonstrated i n this work indicate that the lesion formation occurred in a position much more extreme than the pOSition in which we found the lesioned vertebrae u pon examination. The patient had no pain in this extreme pOSition. He reported, "It hurt when I started to straighten up." It hurt more as he continued to straighten. Muscles which were relatively relaxed in the extreme position tensed i n an effort to splint this lesioned joint from fur ther strain.

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Is the muscular tension arranged so as to splint this joint, to prevent i t from moving back into its eccentric position? No! The muscular tension resists any motion away from the extremeposition in which the lesioning occurred Even the severest lesions will readily tolerate being retu rned to the position in which lesion formation originally occurred, and only to this position. When the joint is returned to this position, the muscles promptly and gratefully relax. These joints do not cause distress because they are crooked; they are paining because they are being fo rced to be too straight. This is the mechanism of strain. This protec tive muscle splinting is the "bind." The three schematic drawings of joints in Figu res 1 , 2 and 3 illustrate a normal joint in normal position, a normal joint in extreme position in which lesion fo rmation occurs but not strain, and the joint as found by the physician in lesion and in strain. Muscular tension is not the result of muscle stre tch­ ing or a reflex splinting to prevent return of the joint to the extreme position. It is the opposite. It is the reflex muscle splinting which preventsfurther movements awayfrom the extreme position where lesion fo rmation occu rred. In Figure 3, muscle "A" is splinted in chronic contraction. Muscle "B," though stretched, is not splinted or contracted. The effect is that the joint may easily move back to the extreme position which brings relief. Any movement away from the extreme position increases the strain and is resisted by increased splinting of muscle " A. " To initiate a spontaneous correction, a relaxed patient is positioned so as to return the joint to the extreme position, hold it for 90 seconds, and return the still-relaxed patient to normal. DISCUSSION In the light of this knowledge, what happens to some of our concepts of the osteopathic lesion? Could exaggeration of a deformity bring immediate relief to a lesion if the main fac tor of that lesioning were strain of ligaments or other periarticular tissues or compression of the emerging nerve? It appears likely that exaggeration of

Fig. 1

Fig. 2

Fig.

3

the deformity would aggravate the pain in either case because of fu rther overstretch­ ing of ligaments or comp ression of nerves. Local edema begins to resorb immediately upon achieving the position of release, but it requires some time. What " released," so that it could start to resorb? I still have no sa tisfactory ex plana tion. Yet this new knowledge does upset many of the accepted concepts of the mechanism of producing and maintaining factors of the osteopathic lesion. It would be a tremendous task to check each muscle and ligament involved in an osteopathic lesion to prove this theory.

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APPENDIX E

resistance and pain is a opposite to that of the original For instance, a lesion of left lateroflexion resists most violently a bend lateroflexion. On the other hand, into most acute lesion will readily even movement in exaggera­ submit to tion of the diagnosed lesion, and in this palpates the tense Jesioned the patient into a ex:agj�eratl'0n. When he attains the there is an almost instan­ of tense tissues which is taneous so marked that it is palpable osteopathic physician with ordinary At the will same time the patient if report that "you took the p ressure off." Localized edema is felt to s tart to " melt" immediately, but it requires many seconds is for the effect to be complete. This the factor requiring the 90-second support of the joint in the position of release to effect a correction. The concept of tissue stasis in lesions seems to be borne out, but what was the instantaneous " catch" that s tarted it, and of dewhere? For a long time the of the nucleus pulposus seemed secure. Yet the princ iples described apply as well to all appendicular lesions as to spinal lesions. Where was the " catch" there? in or around What have we left? is "caught. " the I-> ""rtlu what it is, we do not occurs in a markedly eccentric goes into a strain pattern when away from that position. It will correct itself in the spontaneously if it is original eccentric and then is returned, s till to normal. Once the physician has attained the of re­ lease, no further effort is necessary. pily back out of the con tinuous strain it been suffering, the joint can in 90 seconds restore its own normal function again. SPECIFIC MYOFASCIAL TRIGGERS Many

of tenderness

remote from the vertebral area. Since m y been along the lines " -'-- , "- 0 has "f.""",,Hv lesion for a I have down an associa­ tion between a certain pain and/or area of acute with a lesion. But are so vague we find that many about the nature and distribution of their that from a practicing physician's the areas of acute sensitivity to be m uch more reliable. These are are a valuable aid to diag­ nosis for any osteopathic physician, and there are many successful tricks of by some physicians counterirritation in treatment. In this treatment by use of the of release they are of inestimable guesswork. value i n For instance, in lower lumbar lesions it is easy to mis take paravertebral tenderness of a fou rth for that of a fifth lumbar in many instances, tenderness close t o the may be so mild as to dissuade the operator from giving either much credence. O n the other hand, their points are inches apart and are so sensitive as to remove all doubt of which lesion is the offender. Whereas the vague tension and tenderness near the al jOint may give a relatively inconclusive manifestation of success in finding the tion of release, pain at the dissolves as if it has suffered a power The sudden definite release is so that the uninitiated patient will doubt that you are still probing the spot. The physician knows his treatment is correct, and the patient also k nows. all have Some of the triggers and been known for many years. Works and �"apHH'H , Travell, Judovich and Yoshio Nakatani are extensive. The gers offered here for easily found and are tations oj specific lesions. point is causative lesion in the in Though we use the the trigger as evidence of the correct not myowe are position fascial triggers but lesions. Tension

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APPENDIX E

and tenderness near the spinal lesion are relieved with relief of the SPECIFIC TRIGGERS AND ASSOCIATED L ESIONS Right sacroiliac; Diffe rent usually relieved by different The upper is 1 inch from of at 5 0' clock. The middle trigger is near the third sacral foramen, or about 2 Y, inches from posterior spine, at 7 o'clock. The lower is just lateral to sacral cornu (associated with and The trochanter is on the surface greater trochanter o f femur. The pubic trigger is on the of pubic b o ne 1 y, inches lateral to last two are used i n a Rightfifth lumbar: The upper trigger is on the medial of ilium near the posterior The lower the notch just caudad to the superior spine. Rigbtfourtb lumbar: This trigger is abou t y, to tensor fascia lata and 2 inch inches caudad to the rim of the ilium. Rigbt third lumbar: This is 1 to 1 Y, inches caudad to the anterior superior spine of the ilium or in tensor fascial lata. The posterior third l u mbar iliac inches lateral to the spine and l o/.l inches caudad to the iliac crest.

lesion: This is assoc­ with tenderness 2 or 3 inches below the xiphoid p rocess, and often with epi-

pain and ileitis. Paravertebral tenas to and here is often so be overlooked. Tbird thoracic: This inches caudad to the of the V�.'"u'a and 1 inch medial to the lateral border of the scapula. Second tboracic: This is a of the above the medial to acromial process. Secondcervical: This is b eneath the superior nuchal 1 y. inches lateral to the midline. is on the posFirst cervical: The terior border of the ramus of the mandible' Yo inch above the Humerus: Affectations here appear to be actual lesions of the humeral jOint, although different ones are often associated with upper thoracic lesions as indicated. Treatof release in ment is directed to a techthe humeral joint ( 1 ) The first is a the 1 y, inches below short head of the the coracoid the scapula (often associated first thoracic ond is a point abo u t 1 inch nAC".r"�. Another trigger above. middle of the deltoid, 1 the acromion (usually associated with a second thoracic lesion). (3) Another is on the pos­ �erior 1 y, of the deltoid Inches from the acromial p rocess of the (often associated with third thoracic lesions). (4) Another is in the of the fold of the shoulder near teres major (often associated with fou rth thoracic (5) The circumflex nerve is abou t 1 y. inches below the the scapula and 3 inches medial to the ac romion. Elbow lesion: Elbow tenderness is on the head of the radius or in the belly o f the brachioradialis m uscle on lateral epicondyle usually is a from first thoracic or first rib). Tenderness on medial from the epicondyle usually is a fou rth thoracic or the rib, o r a simple extension o f the ulno-humeral £1prn,"cc

BASIS OF SUGGESTED

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A large p roportion of spinal joint lesions

305

APPENDiX E

will be found to follow a pattern. The of lesions of each joint tend to be It::"'Ul" t:: U in a COmmon to that joint. there are many atypical lesions that do not conform, the busy physician may save much time by checking out probable !-'U""'Ul", first. If successful, he has verified diagnosis while making his correction. he will encounter enough a­ o r less common lesions that he will \,.Vl,Hll,lU"UY find it necessary to abandon the lesion and rely u pon his of the the of the lesion. ""'.'!<,HV.,',H!', it he will exaggerate the to the position of release. Occa­ the diagnosis will not be clear, and he will need to search by trial and error. This him when he becomes will not certain that every osteopathic spinal lesion has a position of release and that by finding it he can p roduce a correction. Contemplation of the thousands of pos­ may seem overwhelming sible until we reduce the consideration of the possible positions to their three basic ele­ ments. We need to consider only the direc­ tion of rotation and/or bend and how much. 1. Rotation can be only to the right (indicated by "R") or to the left (indicated by These are described according to the direction of rotation the body of the vertebra in relation to the body of inferior vertebra. 2. Bending (use of such words as flexion and extension is avoided because mean different things to different osteopathic can be toward any one of 3 60 but requirements for use here are that we bend in a direction within 3 0 {jpl>r,>p!,: of the ideal direction. Forward o r backward bending i s considered simultaneously with side as one because it is one bend and not two as we are used to thinking of it. Then, if we imagine our standing in the center of a o n the floor which has been placed face and standing so that he mark of 1 2 0'clock (Fig. 4), he b e considered to bend in the direction any hour on the for clock face. This will be accurate

M

K

11

A

I I

2

H

B

D

8

G

5

1

view

E

a mau staudt'ug

on a

effective use, though minor modi­ fications may increase the effectiveness. rather than to describe the a lesioned side and forward we can say 2 o'clock. for the p urpose o f To further we may substitute a letter record for each hour and record a bend toward 2 , 0' clock as . or a bend toward 6 0' clock as " and so forth. 3. The amount of bend needed is quite unjform and can easily b e learned with Now, since we have indicated rotation as "R" and rotation left as "L," we can indicate a fou rth lumbar lesion bent to the left side and backward and rotated to the left as "4L-HL" (Note that "M" is used at 1 2 o'clock rather than "L" to avoid of specific suggested tech­ niques will include these symbols to indi­ cate the influence brought to bear on the lesion under discussion. In most cases the pelvis is thought of as i f each side were swinging on t h e sacru m o n a tranSverse axis. This does not cover v u u ,", u"" bends. TECHNIQUES High right lIium:

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The

nOS'f-'no

306

APPENDTX E

spine of right is higher cephalad than the left. The patient is prone on the table. Find the trigger point (probably the middle or upper trigger; see section on trigger points). Raise the right thigh, extending the hip; start a little abduction of the thigh, for mid­ trigger relief (E). The upper trigger needs no abduction (F); the lower trigger requires a little adduction (G). Low right ilium: The posterior superior spine is lower on the right. Treat the patient in a supine position, using the trochanter or pubic trigger. The thigh is flexed about 1 3 5 degrees on the hip; usually about a 20degree abduction of the thigh is required, and slight medial turning in of the leg on the thigh. Right oblique, sacroiliac: The trigger here is on right side of posterior surface of sacrum. ( 1 ) Heavy pressure (40 pounds) is applied over the base of sacrum on the left side. (2) Heavy pressure is applied near the apex of the sacrum. (3) Apply pressure as in ( 1 ), but over the right side of the base. Rightfifth lumbar: ( 1 ) This technique is for the lower trigger. The patient is prone. Find the trigger under posterior superior spine. Hang the patient's right thigh vertically off the side of the table; the doctor holds the leg a few inches below the knee and abducts the leg on thigh moderately (B). (2) For the upper fifth lumbar trigger, the technique is the same except that the pull is on the other leg and side bending is in the opposite direction 0). (See Figure 5.) (3) This tech­ nique involves simple rotation, as in fourth lumbar, R or L. (4) This technique is used in lordotic spines. The patient is prone; the doctor stands at the left and places his right foot on the near edge of the table, reaches across, and lifts the patient's right leg onto the doctor's thigh just below patient's knee (GL). Right fourth lumbar: ( 1 ) This is similar to the fifth lumbar upper trigger technique. (2) The patient is prone; the doctor stands at the left side and reaches across to grasp the patient's anterior ilium. He rotates the patient's pelvis about 45 degrees, and leans back so that his body weight does the work (L) . (3) This technique is like (4) in fifth lumbar correction.

Fig. 5 A demonstration ofthe technique usedfor the tipper trigger of the fifth right Itlmbar vertebra

UJ.

Third lumbar: ( 1 ) This is opposite of(2) for fourth lumbar (R) correction. (2) This is like (4) for fifth lumbar correction. Third, fourth, or fifth Itlmbar with lordosis or definite spondylolisthesis: ( 1 ) The patient is in a prone position with the doctor at his left side. The doctor puts his right foot on the table and raises the patient's right leg up about 30 degrees and toward him, until the pelvis is rotated about 30 degrees (GL). For spondylolisthesis, repeat from the opposite side (ER). Right second lumbar: The patient is in a supine position. Find the trigger point in front of the right ilium near middle of inguinal ligament to the lower end. Bend thighs to a little above vertical, with knees bent. Rotate the pelvis toward the left side of the patient's body, and side bend toward the left to the point of trigger relief OR). Support the top ilium against excess ad­ duction of the flexed thigh by a forward pull on the top of the ilium. Right first Itlmbar, and elevellth and twelfth thoracic: The patient is supine, with a folded pillow beneath the lower lumbar area. In marked antexion, thighs are flexed to about a 45-degree angle with the body. Then the knees are brought slightly to the patient's right and feet slightly toward the patient's left (KL). A variation would be opposite rotation (KR) (Fig. 6). Right tenth and eleventh thoracic: ( 1 ) With the patient prone, the doctor, at the pa-

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APPENDIX E

tient's right, grasps the left anterior super­ ior spine by reaching over the right side. He rotates the pelvis to a point of trigger release (about 45 degrees) (R). The trigger here is paravertebral. (2) This technique is like that used for correction of the seventh, eighth, and ninth thoracic, right. Right seventh, eighth, and ninth thoracic: The patient is prone, arms hanging off the table, and the doctor is at the left side. He raises the patient's right arm up beside his head, holds the arm near the axilla, rotates the upper chest to the right, and side bends to left (RI). Eighth and ninth flexion lesions: The patient is prone, with a large pillow folded under the lower half of the sternum. The doctor lifts up on either shoulder and rotates (BR or JL) ( Fig. 7). Rightfifth and sixth thoracic: (1) This tech­ nique is as in seventh, eighth, and ninth thoracic correction. (2) The doctor is on the right side. He reaches across to left shoul­ der; the patient's right arm is up beside his head, or at least hanging more cephalad, and the left arm is hanging. He pulls the left shoulder back and around the caudad (JL). Rightfourth and second thoracic: The pa tien t is prone, arms hanging. The doctor's hand is placed on the patient's chin and cheek. He bends the neck backward, to the left, and rotates slightly to the right (GR). Variations

Fig. 6 A demonstration of a technique for right twelfth thoracic correction (KR).

include left rotation (GL), and right side bending (ER or EL). Right third thoracic: Raise the patient's right arm beside the head, rotate, and side bend the head and neck toward the left, letting the head hang partly off the table in flexion of the upper thoracic area. Elevate the right shoulder in posterior direction, with the doctor's arm under the patient's axilla (JL). Rightfirst thoracic: Extend, side bend, and rotate to the right (DR). This is irregular; it may be necessary to side bend left (HR).

Fig. 7 A demonstration offorward bending for right eighth and ninth thoracic correction UL). Right eighth cervical: The patient is in a supine position. Mild forward b ending, ro­ tation, and side b ending away from lesioned side are applied. (Palpate the transverse process in the side of the neck) (JL). Sixth and seventh cervical: The patient is in a supine position, head off the end of the table. Back bending, side b end away and rotate toward the side of lesion or as indi­ cated by the position of spinous process (GR). For seventh cervical lesions, rotate left (GL). FIfth cervical: This technique is similar to that for eighth cervical correction except that more forward b ending is used; it may be necessary to reverse sides (KL). Fourth cervical: ( 1 ) This area frequently is in either back bending or spondylolisthesis. Lesions are corrected in marked backward

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APPENDIX E

bending and slight side bending as indicated. Check progress by the tender transverse process (GR). (2) Use rotation and side bending to the same side without any back bending (IL). Try the opposite if the first attempt fails (CR). Third cervical: ( 1 ) Use side bending and rotation toward the side of the prominent tender spinous process of the second cervic­ al vertebra, with fairly marked forward bending (AL). (2) An alternative is the same except for opposite rotation (AR) . First and second cervicaL· ( 1 ) Correction usually is attained with the patient in marked backward bending and with slight side bending and mild rotation as indicated by diagnosis and comfort (ER or EL) (GR or GL) (Fig. 8). (2) An alternative is marked rotation as indicated, with no bending (L) or (R). Shoulder joint: Frozen shoulder may be eased beyond aid obtained by upper thor­ acic and lower cervical corrections by find­ ing an arm position which relieves the tender spot in the shoulder (see trigger points). Shoulder stiffness with triggers 2 , 3 , and 4 are relieved i n the prone position with the elbow behind the midline with abduction varying from 80 to 0 degrees (Fig. 9). Trigger 1 usually is relieved in a supine position with the upper arm vertical and the forearm halfway b etween cephalad position and across the shoulder girdle. Ten pounds of pressure are applied downward

through upper arm and shoulder. Both may be further improved by traction in a caudad direction, usually with 30-degree abduction, occasionally adducted, across chest follqw­ ing corrections above. Acromio-c/avicular: The upper arm is fully abducted and the forearm cephalad. Elbow, right radialhead: Usually supination is used; occasionally some abduction or adduction are necessary. (Tenderness of the lateral epicondyle indicates probably a first thoracic or first rib lesion.) Wrirt, thumb, and other fingers: All can be easily relieved by finding tender spots and locating the position of release. The thumb is usually bent backward and rotated. Ten­ derness is near the metacarpophalangeal joint or the carpometacarpal joint. Knee: The medial meniscus is nearly al­ ways relieved by internal rotation of the extended leg on the thigh, usually with slight flexion and adduction (Fig. 1 0). The lateral meniscus usually requires external rotation. Feet: ankle sprain: There is tenderness � inch below the malleolus, usually a little anteriorly. This usually is relieved by inver­ sion of the foot with external rotation, occasionally by eversion or dorsiflexion. An ankle sprain is an osteopathic lesion and can be treated in this manner, giving much relief. Calcaneus: There is tenderness beneath the proximal head; this usually is corrected

Fig. 8 A demonstration of technique for cor­ rection of a right first cervical lesion (EL).

Fig. 9 A demonstration of the second thoracic shoulder reflex. The upper arm is at 8 o'dock, in 60-degree abduction, and under slight traction.

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APPENDIX E

caudad on the right shoulder (BR). Fifth, sixth, seventh, and eighth rib.r: Use a folded pillow under left shoulder. GENERAL RULES 1 . Treat "hot" lesions first.

Fig. 1 0 A demonstration of correction of the right medial meniscus lesion. Internal rotation' adduction, and slight flexion are applied in eversion or outward rotation of heel on foot. Cuboid: There is tenderness b eneath it. There is eversion of the lateral side of the foot with moderate dorsiflexion. Navicular: Inversion and a little internal rotation of front of foot, with some dorsi­ flexion. Fibula, proximal head' ( 1 ) One method is similar to the treatment for ankle sprain. (2) It may be held forward by thumb pressure. Bunion: There is tenderness at lateral sesamoid, which is relieved by flexion, ab­ duction, and eversion of the great toe until sesamoid tenderness is relieved. Right ribs: ( 1 ) The patient sits with his back to the doctor. The doctor's left foot is on the table, with a pillow on the doctor's knee. The patient drapes his left arm over the pillow, tilts his pelvis to the left, puts his feet at the right side of his hips. The pOSition is marked right side bending, moderate forward bending, and right rota­ tion. It takes 1 to 2 minutes to achieve the necessary relaxation. The pOSition is (BR), or rarely, the opposite rotation (BL). (2) The patient lies on his left side, with his thighs flexed 90 degrees and his right arm hanging behind him. The doctor stands behind and holds the patient's head forward, side bent, and rotated right, and presses

2. Straighten the patient out slowly enough that he can remain relaxed. He will resist and tense if rushed. 3. Check for relief of pain after correc­ tion, if only to demonstrate its absence to the patient. 4. An especially "dry" lesion will some­ times be tender after correction. A minute's traction will ease it. 5 . Patients will try to help you. Don' t let them. SUMMARY Osteopathic spinal and appendicular le­ sions occur in pOSitions more eccentric than that found by the examining physician. They are in a state of strain because the natural position of the patient holds him away from the eccentric position. The strain is relieved by exaggerating the de­ formity found upon examination. The le­ sions will release and correct spontaneously if held relaxed in the exaggerated position for 1 Y, minutes. The correction itself is restful and comfortable. Grateful acknowledgment is given to many who have contributed techniques or Meas, in particular: Harry Davis, D. 0., deceased; G. B. Holt, D. O., Pendleton, Ore.; Hugh Barr, M.D., Penficton, R c.; Annabelfe F. Thorne, D. O., San Francisco, Calif; Margaret W Barnes, D. 0.; Carmel, Calif; Carl L Fagan, D. o., Monterey, Calif; james B. Spencer, D. o., Palo Alto, Calif; Melvin Hennig­ son, D.D. s., Hayward, Calif, Rolfin B. Becker, D. O., Daffas, Texas; Harold V. Hoover, D. o., Tacoma, Wash.; T.J. Ruddy, D. O., Los Angeles, Calif; Harold S. Saita, D. O. Vancouver, B. c.; and Paul K. Theobald, D. o., Oakland, Calif REFERENCE 1. Rumney, I.e.: Structural diagnosis and manipuJa­ 70:2 1 -3 3 , Jan. 1 963; D.O. 4: 1 3 5 - 142, Sept. 1 96 3 . tive therapy. J. Osteopathy

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Appendix F

Self-Induction of JAt\1ES NELSON RILEY,

R. I. Still Point

Tandem

Balls

Ph.D.'

b u t do so

THE DEVICE balls) are are touchone another. This can be done by the balls on a with heavy or l eather ties. Alternatively, the two balls can b e placed in the toe of a sock which is then knotted tightly. I n order to assure that the balls in contact with each the sock i nside another sock which is also tied Two tennis balls

INSTRUCTIONS Recline on your back, on the floor or upon a sofa or bed. Place the device u nder your head so that the entire weight head rests on the two balls. should b e with respect t o t h e midline. are placed about midway "up" the of the head in the following location: At the top of the occipita l bone (bu t b elow This is in a the lambdoidal depression in the just above the bony prominence, which is in turn just above the attachment of the main neck musc les. The level is above that of the ear Allow the of your head to rest upon the device for 1 5 minutes. Relax comfortably. You may shift in order to maintain sym metry and

and gradually.

Repeat daily.

THEORY The craniosacral (" CR.I.") is the of the craniosacral system. The structures of the craniosacral system �l".a,,,,,c"u around the meningeal mem­ and the craniosacral system is intima tely related to the function of the nervous system directly the brain and spinal the musculoskeletal system (most the cranium, and pelvis), related fascia, and other systems. in Induction of momentary "still the craniosacaral rhythmical is an the for effective craniosacral system' s inherent self-correct­ which in turn can have prothe fou nd beneficial e ffec ts body. INDICATIONS This is a good "shotgun" technique for tissue and fluid motion, especial­ ly relaxing connective tissues throughout the and for of autonomic nervous system response. It is beneficial for acu te and chronic musculo'-""""'- ''''1'',

'Reprinted ",jIb permission oJlhe author. 310

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APPEN DIX F

skeletal lesions, ar­ thritis. It can lower fever as much as 4° F. I t can reduce cerebral or pulmonary congesedema. It has b een used tion, or auto-immune disease, au tistic to behavior of children, and can benefit most individThis uals to some degree, and is harmful.

CONTRAINDICATIONS The only contrai ndications are in situa­ tions in which even a nd transient increases in intracranial pressure are to be avoided: cerebrovascular aneurism or in acute stage of stroke or cranial trauma.

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Appendix G

Treatment of

Diagnosis Biomechanics,

Head Professor, ER!\jEST

JOHN E. UPL E DGER, D.O., FAAO,

W. RETZLAFF, Ph. D . , Professor, Department of

o f Osteopathic Medicine and JON D. V R E D EVOOGD. F . F . iI. . , Assistant Professor, College of

Human Ecology. Michigan State U niversity, East Lansing, M ichigan'

R ecent evidence related to the microanatomy ofthe cranial suture of fers the baJisfor a newlypostulated mechanism for recurrent headpain andfor mild to moderate cerebral dysjuncHon, A nfJJ1COJW/h{tC
hrllbll?m.r is dprrr""pd

and treatment

MECHANISM AND FUNCTIONAL ANATOMY A

of the desof diagnosis and treat­ ment an appreciation of the re­ cently illuminated microarchitecture of the sutu re; a review of the gross anatomic features of the su ture muscle, its and of the and the bones to which it attaches. Traditionally, anatomists have that the sutural articulations of the adult human are fused and hence immovable. Recent work done by on adul t human sutural material would con­ tradict this view. The specimens studied adult skulls at the the in vivo circumstance. the use of modified to , the a u thors have been demonstrate the presence of viable ated and u nmyelinated nerve fibers, nerve

•

cranial suture, We have also demonstrated that these structures frequently penetrate the sutural bone margins and traverse from the diploe into the suture and vice versa. There is also evidence to suggest that some of the intrasutural vascular and neural structures may arise from the intracranial (Fig. The of these is simply that now the hu man cranial suture may be (and in fact must be) considered as a functional anatomical complex of dysfunction resultant to various stresses, and traumas. Since the suture is now known to possess the neural structures necessary for nerve sensory input into the ner­ rel1ex vous system, and motor activity, it becomes apparent that a distortion of the functional relationships between the sutural osseous boundaries may produce abnormal neuro­ genic as well as intrasutural is­ chemia. Either one or both of these con­ resul t in local as well as referred our conjecture is that al­ pain. though evidence is scant at present, the intracranial vascular delivery system may be influenced by neurogenic reflex mechan-

pp. 1 9-26, bypermissi0110/A rthlir Retlaw & Associrlles, Inc., Snite 570, 1000 Skokie ilnd. by permission 0/ the ulithors.

Reprinted/rom Orteopathic Medicil1e, j"ly 1 9 78,

Blvd.,

Wi/melle.

IL

60091,

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APPENDIX

313

G

Figure 1 Photomicrographs ofhllman cranial bone andsutllre showingpenetrating Sharkey 'sfibers. Phot(}­ graph on left demOflstrates how sensory nerve fibers accompany .the Sharkey's fibers. Photograph on right stained by protangol silver-gelative method Photomicrograph on left stained by Masson's acidfuscin-aniline blue COf111ective tisslle method isms that possess intrasutural stimulus receptors. In view of the aforesaid findings, it seems obvious that the restoration of sutural mo­ bility is desirable. Several mechanisms which underlie sutural dysfunction are possible. One-which has been almost completely overlooked-is hypertonus or contracture of the temporalis muscle. This muscle is frequently and chroni cally con­ tracted in si tuations of increased e motional stress, dental malocclusion, andlor tempo­ romandibular joint dysfunction, among other things. Consideration of the anatomy of the temporalis muscle shows tha t during its contracted state it is capable of producing compression of the temporoparietal su­ ture. The insertional attachments of the tem­ poralis muscle are from the ramus of the coronoid process and from the anterior border of the ramus of the mandible. The muscle arises from the floor of the temporal fossa and from the temporal fascia. I t can be seen in Figure 2 that the temporal fossa extends superior to the temporoparietal suture and, therefore, that contraction of the temporalis muscle does, in fact, cause

the parietal bone to move in an inferior direction thereby producing a compression of the temporoparietal suture contents. The potential results of this su tural com­ pression have been discussed earlier. The anatomy of this suture is such that temporalis muscle contraction wilJ produce a gliding motion of the parietal bones' sutural surface inferiorly after the superior motion of the mandible is effectively resisted by the approximatio n of the upper against the lower molar teeth or by the su rfaces of the mandibular ramus coming into opposi­ tion with the roof of the mandibular fossa of the temporal bone. The bony surfaces of the temporopari­ etal suture are beveled and grooved in such a way that a sutural shearing force is gener­ ated by temporalis muscle contracture (Fig.

3 ).

This shear may longitudinally stress the collagen (Sharkey's) fibers that appear to be innervated. It may also reduce the cross­ sutural physical dimensions and, therefore, produce intrasutural pressure ischemia, as well as disrupt normal neurogenic reflex activity resulting frorp pressure stimulation of receptors. It may interfere with normal nerve fiber conduction as well.

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Figure 2

Temporalis muscle attachment.

Figure 3 Coronal section: temporoparietal suture bevel.

ation table beside and superior to the pa­ tient's head. The physician then makes fi nger contact with the tissues immediately overlying the inferior posterior borders of the mandibular rami bilaterally. A bilateral­ ly equal, superiorly-directed force is then applied to the mandibular rami (Fig. 4) so that the expression of force carries through the temporomandibular joints causing the te mporal bones to move slightly in a superior d irection. This force stresses the temporoparietal sutures bilaterally. The fo rce is initiated gently and is slowly in­ creased until the patient reports either an increase in the present symptoms or the onset of their familiar symptom pattern. If this result occurs, we consider that the diagnosis is confirmed . Next, the physician must consider the causes of temporoparietal sutural dysfunc­ tion. A visual examination of the posterior molars will offe r evidence either fo r or against dental malocclusion. (Consultation with a dentist may be in order at this juncture.) The tonus of the temporalis muscles should be evaluated by palpation. A fib rous texture and extraordinary tissue firmness coupled with an apparent wearing down of the molar su rfaces is supportive of chronic temporalis muscle hypertonus most often resulting from emotional stress or repressed anger.

DIAGNOSIS AND TREATMENT The diagnosis of symptoms (head pain­ cereb ral dysfunction) resulting from dys­ function of the temporoparietal suture is usually straightforward. Sutural compression when exaggerated, will quickly i ncrease symptom severity if the examination is done du ring an exacer­ bation. If the patient's condition is quies­ cent du ring the examination, the symptom complex can often be produced in a matter of minutes. The examination technique is done with the patient co mfortably in the supine posi­ tion. The physician should be seated above the patient's head with the forearms and elbows co mfortably resting on the examin-

Figure 4 PhysiCian hand placement for tech­ nique to exacerbate symptom.

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APPENDIX G

Temporomandibular j oint dysfunction is best diagnosed by palpation and observa­ tion as the mandible is pu t through its range of motion. Primary treatment must be di­ rected toward the cause of the abnormal condition of the temporalis muscle be it emotional, dental, or temporomandibular joint. Often the primary cause is no longer in existence; however, the physiologic state of the temporoparietal suture has been so disrupted by previous events that it has become immobilized in an abnormal ana­ tomicophysiologic s tate of comp ressed immobility. In this circumstance, a simple mobilizing procedu re may only require a few repetitions. If there is a continu ing cause for the sutu ral dysfunction, tempor­ ary relief of symptoms can usually be ob­ tained by the use of one or all of the therapeutic techniques described below. O STEOPATHIC M ANIPULATIVE T ECHNIQUE TO R ELIEVE T EM POROPARIETAL S UTURE D YSFUNCTION

After the diagnostic temporoparietal suture comp ression technique the gentle pressure is continued until the tissues are perceived to relax or soften. This phe­ nomenon probably occurs because of neu­ rogenic fatigue with secondary reduction in tissue tonus. The palms of the hands can be used to determine when temporalis muscle relaxation occurs. After this change in tissue tonus, gentle traction is applied over the superficial sur­ faces of the mandibular rami bilaterally. This traction is extremely gentle and incor­ porates a balancing effort on the part of the physician. It is directed inferiorly following the direction of least resistance. The tech­ nique is aimed at decomp ressing the tem­ poromandibular joints, the temporoparietal sutures, and at stre tching the temporalis muscles by traction. Gentleness is the rule. If the physician perceives a contractile re­ sponse to his traction from the tissues the efforts are too vigorous and will be self­ defeating. There are limits of tractional force within which tissues can be gently stretched and which are below the contrac-

tile reflex threshold. I t is within this range that this treatment technique can be effec­ tively applied. The same technique will effectively assist in the treatment of temporomandibular joint dysfunction. T RANSCUTANEOUS N EEDLE S TIMULATION FOR TH E T REATMENT OF T EMPOROPARIETAL S UTURE DY SFUNCTION

Gentle palpation of the involved sutu re will usually reveal localized areas of tender­ ness along its course. The transcutaneous insertion of a disposable 2 7-gauge hypo­ dermic needle through the scalp i nto the subcutaneous tissues immediately over the tender area will almost invariably normalize the sutu ral dysfunction. The needle should be inserted at app roximately a 30° angle to the sca-lp surface along a line parallel to the direction of the suture. Because of the reciprocal innervation principles that seem effective in all parts of the body, these needles should always be inserted bilater­ ally. Aseptic techniques should, of course, be employed. If temporomandibu lar joint dysfunction is present, bilateral transcutaneous need­ ling immediately over the tender areas will prove to be a valuable adjunct. Needles should be left in place at least 5 minu tes or until pain is relieved. M AN DIBULAR F ULCRUM T ECHNIQUE FOR T EMPOROPARIETAL S UTURE DY SFUNCTION

A nother effective treatment technique makes use of two rolls of gauze or other suitable material. The rolls should be about � inch to % inch in diameter. They are placed between the u pper and lower teeth bilaterally at about the region of the second molar ( Fig. 5 ) . A gentle force is then applied manually in a superior di rection on the anterior inferior aspect of the mandible. The gauze rolls act as fulcrums and the mandibular rami as levers which apply de­ compressive tractional force to the tem­ poromandibular joints and to the temporo­ parietal sutures. The force applied is light

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APPENDIX G

so that a contraction response is not stimulated. Patients can be patient can method ofself-help. the amou nt of learn to force to b e � v vu'-"'. They can discern when own tissues are from relaxed to contracted states.

REFERENCES 1 . Retzlaff, E., Mitchell, F., Upledger, J., Biggert, T: of c ranial sutures. Anol Rec 190:520, 1978. 2. E . . Mitchel!, F., Upledger, J.. Biggert, T., Vredevoogd, J.; Tempomlis Muscle Action in Parie­ totemporal Suture Co mpression. Presented at 22nd Annual Research C..onvention of American Osteo­

Fig u re 5 Fulcrum placement for decompression of temporoparietal suture and temporomandibular jOint.

p athic Association, Chicago, 1978. 3. Retzlaff. E., Fontaine, J.: Reciprocal inhibition as indicated by a differential staining reaction. Scif111ce 1 3 1 : 1 04·1 0 5 , 1 960.

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Appendix H

Roentgen Findings in

Craniosacral Mechanism

P H I L I P E. GR E E N MAN, D . O . , FAAO, Kenmore, New York'

Although the craniosacral mechanism has been of interest to a search reports of the the This x-ray appearance article describes identifying craniosacral mechanics and correlating the findings with clinical observations. between roentgenoGood correlation was graphic findings and observations made independently by a physician schooled in the cranial concept of osteopathy.

The craniosacral mechanism has been much contro­ the subject of much versy, and much interest on the part of the Since the first desosteopathic cription of of osteopathic theory and to the cranial field b y Sutherland/ there have been many devoted students and advocates as well as many However, throughskeptics and out the of the osteopathic sion a dedication to the p remise that body function is related to normal body structure has been axiomatic. The value of physical and in diagnosis an important part contribution o f Throughout i ts history, numerous x-ray techniques have to assist the clinician i n been

•

alterations o f structure and im­ ability to return the structure to normal. The osteopathic profession can acknowledge i ts development and x-ray examination of the in clinical My interest in the utilization of x-ray examination of the skull and lower part of the back as a diagnostic aid to the p1.'.... .l... 'l1l'} clinician of the science and art c ranial oste(>p�lthIV was first stimulated at the Buf­ falo Clinic in the middle 1 950s. Dr. Edith Dovesmith had under this type of care and requested that x-ray examinations be made of the skull and to lower part of the back of these obtain any information A review of the osteopathic and allopath­ ic literature yields few reports authors who have studied the x-ray appearance of al­ the altered structure of the it has been intimately and by those schooled and accomp­ lished in the cranial concept o f osteopathic theory. Weaver-4 contributed an extensive series of papers in the middle 1 9 30s and a basis for the contributions of on the other workers5-? in a in references to series of x-ray studies were no report of a made. There was,

Reprintedfrom ThejOlJrfla/ ofthe AmeriCtlfl OsteopathiC Association, Vol

OsteopathiC Association.

212 E.

Ohio St., Chicago,

[L 6061 1.

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APPENDIX H

series o f cases and no u ti l ized . White7 is requ ired these x-ray studies" and commented:

The lesion patterns to be considered are shown in 1 , 2, and 3.

In our second annual symposium planned to be

For the pu rpose of this x-ray films of the skull, lumbar spine, and pelvis, and, in most instances, of the upper cervical notably the atlas and axis, were used. The skull was examined in the antero­ posterior later.. aI, OCCipital (Towne), Waters, and sub men­ tovertical projections, the standard radio­ used a t a 3 6- inch graphic technique target-to-film distance. The l umbar and and lateral in the erect. These were supplemented ob lique projections and study of the sacroiliac joints_ As the it was found to b e the

given here next year at this time, we hope to have one paper devoted

to the

___

. .___ , __ _

of x-ray study of the plastic base.

Unfortunately, there has been no subse­ quen t report in the literature. Kimberl� did u ti l ize a basilar view (sub­ of the skull as a aid i n the treatment of the cranium i n newborn and older infants. Magoun9 raised the question of the practicability of x-ray study in confirming the position o f some o f the c ranial s tructures, particularly the tembone. years, I h ave done In the past additional work in cooperation with Dr. Dovesmith in an to a method of identification altered cranio­ sacral mechanics to substantiate the findof the clinician and to assist the clini­ cian in the treatment of patients afflicted with abnormalities in this mechanism. Since for this there are no documented type of study, it has b een necessary to devise some new and adapt some o ld techof the skulL in the roentgen TERMINOLOGY OF LESION PAITERNS The area to which maximum attention has been directed is that of the sphenoid and baSioccipital bones. The terminology to be used i s that by the p roponents of the c ranial concep t.9 to be The abnormalities described called are those of "''' ''''''JA1, "''''' '''''''' '' '1'0 rotation, s train (vertical or lateral), com­ IJL10""'U" , and interosseous lesion. From the o f this work, m os t of the atten.. toward four lesion pat­ those of flexion, exte nsion, terns, torsion, and Side-bending rotation. With in­ creased and s tudy, the conclu­ sion has been reached that an occasional \'H�'I'."'V0'" of lateral and/or vertical strain o f inte rosseous lesion may be made_

X-RAY

detail with regard to poses o f measurement without restraining device, b u t, for re-evaluation of the in skull patterns after treat­ ment, i t would be to have a device for exact repOSitioning of the patient. All studies included in this work demon­ strated normal vascular and sutural mark­ ings in normal diploe with no gross organiC abnormalities. The usual of the studies u tilized would be FILM MEASUREMENT

In the Angle bose ofthe skull (Fig. lateral p rOjection, an is drawn between the nasion 1 ), the tuberculum sellae turcicae (point 2), and the anterior of the foramen magnum (point The normal here has been it has been 1 30 b u t in my 2 degrees. Measurement of this angle is b ecause of the accurately the

1.

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319

APPENDIX H

BOOY Of THE SPHENOID

III

---- fORAMEN MAGNUM ----"::::-

1 . (I). Flexion. Viewedfrom the side, flexion of both sphenoId and convexity) results in elevation of the sphenobasilar symphysis towards the vertex. the reverse. neutral position is shown in the shaded areas. (II). Extension ofboth (III). Torsion. Viewedfrom above, left torsion ofthe sphenobasilar symphysis (greater wing and basisphenoid move cephalad on the while the basioCCtput and condylarpart move caudad on the same Hde). (IV). Right by Harold L torsion ofthe sphenobasilar symphysis isjust the opposite. 9

Executive Vice

Su therland Cranial Teaching

of the foramen mag num, anterior but i t does serve as an index of the flexion or extension of the When the measurement is with the over-all appearance of the skull in i ts and a sion pattern of the can be made (flexion more than normally acute sion by a more obtuse correlated with the

is defined as the percentage relation of the of the skull and can be breadth to the calculated by the CI BIL X 100 where CI is the cephalic and L, length. The skull is (normal) when the CI is between 75 80; brachycephalic (short) when it is more than 80; and dolichocephalic (long) when it is less than 7 5 . 2. A nteroposterior measurement (Fig. A mid­ line point of reference (line AB) is ob-

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APPENDIX H

2 . (1). Stdebending rotation above. In sidebending rotation to the angulates to the left and moves caudad on that side. opposite Occurs. The position of the bones in netltral is shaded 9 D . O . , Executive Vice Su therland Cranial VTTlfJF!IV'"

tained by drawing a line from the vertex o f the skull 1) t h e nasion (point 2) to midpoint between the condylar parts of the 3). This line usually carries the odon toid process of the axis through the of the cervical are not used as of reference. Horizontal lines are drawn across the fol­ lowing anatomic landmarks: the tuberculum sellae tu rcicae (line the horizontal base of the squama occipital­ is and the condyla r parts of the occiput (line (inferior These horizontal lines run dicular to the midline tor measurements of formed are made to determine i n fact, there is variation of the horizontal lines from the true and determ ina­ tion is thereby made of the declination of the structure measured. A "high" and a "low" side are recorded. Side of convexity. From the midline per­ pendicular, measurements to contralateral poi nts of the and bones

3.

the Sf)fJenooaS,lIar

Sr. ,

are made. The points found farthest from the midline are as being on the side of I t should be noted that the overall appearance of the skull many times shows an obvious pattern. Film measurement only substantiates the nosis in these instances, but in many in­ stances is necessary to establish the pattern 4. At/as rotation (Fig. 6). Because observa­ tions on the relation of the atlas to the occi­ pital condyles in varying patterns aroused interest, it was found valuable to utilize a of the rotation of the atlas . ! l Measurement is made of the relative width of each lateral mass of the atlas (A), to determine which is larger. to the the wider side is the one lying anterior to its fellow. Allowance must be made for asym­ metric development. In addition, the space between the medial of the lateral masses of the atlas and the odontoid process and the on each side (B) also is side in which the atlas is closer to the odon­ toid is considered to be the anterior lateral

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APPENDIX H

SPHENOBAsILAR SYMPHYSIS

SPHENOBASILAR SYMPHYSIS

.. SPHENOBASILAR SYMPHYSIS

Vertical strain. Viewedfrom the side the sphenobasilar symphysis has been with the moving cephalad and the basioccipu! or vice versa. &th bones rotate about parallel transverse axes in the same direction. The lesion is named from ofthe with the vertical strain etc. (IJ). Lateral strain. Viewed from above the with the basisphenoid moving to one side and the hmc<",·rtll"f axes in the same direction. The lesion is sphenoid to the right, etc.9 by Harold I.

Sutherland Cranial

Foundation.)

mass of the atlas. An attempt is made to coordinate these findings with the position of the atlas demonstrated in the Waters and sub mentovertical views of the skull. It has been my that in almost all cases the atlas assumes an anterior pOSition on the side in which the occiput of the skull is found to be low.

ROENTGEN DIAGNOSIS the previously described x-ray tech­ an effort was made to identify the lesions described in a For the determination of U""l\.JU. Ul�'�lJlU"l" is made on the composite 1111 � l ""­ sion of the angle of the base of the

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APPENDIX H

Fig. 6.

4. Measurement 0/ the angle 0/ the base 0/ skull

5 . Anteroposterior meaJurement. cephalic and the reduction of the anteroposterior diameter of the s kull. It is believed that this can be made of the the or less, the 8 1 , and the Le'Jll"'llL index is greater rnr'rp�"'r.n of the skull shows fore­ diameter.

Measurement 0/ atlas rotation.

For the diagnosis of an extension tern, the criteria are the opposite of for flexion. That if the of the base of the skull is 1 3 2 index is 74 or and the ratio of diameter of the skull diameter is de­ a diagnosis of extension is made. For a of sphenobasilar torsion, it is necessary to ascertain that one side of the bone is than the other and that one side of the oCciput is lower than the with a and a low occiput occurring on the same side. A diagnosis of sphenobasilar torsion is made on skull the side of the sphenoid being on line CD 5 ) and the low side of the occiput demonstrated on lines EF and GH. It is unusual to find a side o f when the skull is this particular pattern. pattern of the " IJ J" ",,,r The basilar j unction is seen when the low side of the is on the same side of the skull as the low side of the sphenoid bone. When these findings are noted on lines CD, EF, and and substantiated by film measure­ ment shOWing the side of convexity of the s kull to be on the same side, a of Side-bending of the sphenobasilar junction is made. It is m uch more difficult to demonstrate roentgenographically the criteria necessary for diagnosis o f lateral strain at the spheno­ basilar j unction than the other lesions afore­ mentioned. It appears, however, that this diagnosis is by clear visualization j unction on the subof the mentovertical film. The axis of the osseous

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APPENDIX

H

323

sphenobasilar junction is well demonstrated in this projection. observing the relation of the axis o f the bone and the axis of the sphenoid on sinus, it may be the film the the axes a re conti nu­ ous. If the axis o f the sphenoid bone is demonstrated to be to one side or the other of the axis o f the occiput and i f it is possible to demonstrate in the same view that the skull is the oflateral can b e strain at the sphenobasilar made. The of quadrilateral skull is demonstrated when the axis of the frontal to the left occipital bone is of different length than the axis fro m the left frontal to the occipital bone. This �" 5 " �V'V is It is believed, however, that these two will substantiate the criteria for lateral strain at the sphenobasilar vertical strain at the sphenoTo basilar j u nction is extremely because on conventional lateral grams there is considerable bones other than the and these are diffic ult it is strate in this projection. to demonstrate well both the and the basioccipital bone in the "I-""� and if the axes o f one pres!�n(;e of vertical strain. area is easier to demonstrate i n child­ ren prior to the development of the mastoid process. Tomography with a midline sagittal cut could be most helpful in identifying changes in this area. To date, no studies this line have been attempted. Combinations of the abnorma li ties just described also occur and a re diagnosed when the criteria for flexion or extension are present in a skull wherein the c riteria for or torsion also are present. I n practice, it appears that combination patlesions. terns are as common as Table 1 shows the lesion strated in 25 consecutive patients in whom the x-ray just described were carried out. In addition, the relation of the atlas to the was determined in each •.' � " _

the c riteria previously described following observations were

5 ).

10 Atlas anterior on side of low Atlas anterior o n side o f high occipu t 3 No atlas rotation 1 2 CLINICAL CO RRELATION For 1 0 of the 25 patients S lllUI o;;U . possible to o b tain an evaluation by a cranial "elF.,r, ,,,, relation between clinical and x-ray nosis in seven of these and in three. In two of these three the lesion was diagnosed as torsion by x-ray appearance and Side-bending by clinical appearance. In the third, x-ray was that of left side-bending, was that o f Owing t o t h e difficulty i n correlating clinical and roentgen observations in the first two cases mentioned, a review of the ray appearance of the pattern was made, and an discovery was made. In both cases, there was marked asymmetry in TABLE 1 . CRANIAL L ESIONS IN 25 PATIENTS 2

Flexion Extension Torsion Left

o 3 2

3 4 & flexion

7 4

0 4

& extension 0 1

Left Torsion & flexion Left ;)lCJe"Dt:W"llng & lateral strain lateral strain flexion None

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2

3

5

1

&

1

3 24

APPENDIX H

the region of the superior orbital fissure. Since the superior orbital fissure is formed by the lesser and greater wings of the sphen­ oid bone, asymmetry of the sphenoid must be present. From the clinical point of view, the diagnosis of sphenoid position is taken from the great wing, whereas the roentgen view of the sphenoid is taken across the tuberculum sellae turcicae ( line CD) basic­ ally through the root of the lesser wing. Therefore, when there is asymmetry at the sphenoid, lack of correlation of clinical and x- ray diagnosis is to be expected. Of further interest is the fact that in embryologic de­ velopment of the sphenoid, the body and lesser wings form in one part and the great wing and pterygoids develop in another part. 1 2 It might be hypothesized that the finding of asymmetric sphenoidal develop­ ment with asymmetric superior orbital pressure might be the result of an inter­ osseous lesion of the sphenoid prior to complete ossification. Obviously, the correlation of roentgen and clinical observations in a much larger series of cases would be necessary to sub­ stantiate the 70 per cent correlation ratio in the cases reported here. The findings to date, however, are most encouraging. In 2 3 of the 25 patients it was possible to attempt correlation of the relation of the sacral base to the cranial base as demon­ strated by the occiput. According to the cranial concept, the occiput should be found low on the same side as the low side of the sacrum. In this series, there were three patients in whom the occiput was level and three in whom the sacrum was level, leaving a total of 1 7 in whom this evaluation might be made. In 1 5 of these 1 7 , the occiput was found to be low on the same side as the sacrum. In only two was the occiput found to be high on the side on which the sacrum was low. This gave a correlation of 89 per cent. In addi tion, an attempt was made to correlate the angle of the sacral base with the findings of flexion or extension in the cranium. In this series it was not possible to find any correlation between the presence of flexion, extension, or normal base of the skull with any findings of increased, de-

creased, or normal angle of the sacral base. Continued study of this question should be made. ILLUSTRATIVE CASES CASE 1

A 4 3-year-old woman had had intermit­ tent right-sided headache from the occiput to the right retro-orbital area for several years. It was not associated with nausea or vomiting and apparently not related to physical activity or menstrual function. There had been no known injuries to the head or neck. Symptoms had been unre­ sponsive to therapy, although temporary relief had been ob tained with the usual analgesics. The system history and physical examination elicited no other abnormali­ ties. Structural evaluation revealed an S­ shaped spinal curvature convex to the right in the cervicodorsal area and left in the lower dorsal and lumbar area, with a pelvic tilt to the left, bilateral lumbar muscle spasm, restriction at the left sacroiliac re­ gion, and some occipital spasm bilaterally, the left occiput being low. Roentgen examination demonstrated the sacral base plane to decline to the left with a type 1 rotary scoliosis convex to the left in the lumbar area (Fig. 7). The lumbo­ sacral angle was 39 degrees, with normal appearance to the lumbar lordosis (Fig. 8). The left occipital bone was low, as was the left sphenoid bone (Fig. 9). The angle of the base of the skull was 1 2 8 degrees (Fig. 1 0). The convexity of the skull was to the left (Fig. 1 1 ), and the cephalic index was 77. There was evidence o f anterior rotation of the atlas on the left side. The craniosacral diagnosis was that of left side-bending pat­ tern of the skull and sacral base declination left, with left lumbar lordosis. CASE 2

A 5 1 -year-old woman had had recurrent retro-orbital and temporal headache assoc­ iated with occipital pain and occasional nausea and vomiting. Symptoms were never bilateral but could be on either side. This patient had received such analgesics as Darvon, mixed tranquilizers, estrogenic

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APPENDIX H

Fig. 7 . (left). Standing view ofthe APllumbar spine andpelvIs demonstrates shortening of311 6 " ofthe left lower extremity; sacral base declination of 718 " to the left; and rotary scolirJJts ofthe lumbar spine convex to the left. Fig. 8 . (right). Standing lateralprojection oflumbar spine demonstrates a lumbosacral angle of39° with normal lumbar lordosIs and intervertebral dIsk spaces.

substances, and Wigraine, all with no relief. Symptoms had been increasing fo r the pre­ ceding 2 years. Approximately 8 years pre­ viously she had had osteopathic manipulat­ ive therapy for pain in the lower part of the back, with a lift to the right shoe. This had controlled the symptom. During the period of present complaint, the patient had not been wearing the shoe lift. The remainder of the system history and physical examina­ tion showed no abnormality. Structural ex­ amination revealed an S-shaped spinal scol­ iosis, which was convex to the left in the cewicodorsal area and convex to the right in the lower thoracic and lumbar area. The pelvis showed tilting to the right side, and the right occipital bone was low. There was rather marked subOCcipi tal muscular spasm

bilaterally, with restrtctlOn of atlanto­ occipital motion. X-ray study showed short­ ening of the lower extremity by Ys inch, with sacral base declination to the right ofYa inch (Fig. 1 2). There was lumbar scoliosis convex to the right. The lumbosacral angle measured 39 degrees, and there was normal lumbar lordOSiS (Fig. 1 3). The skull x-rays revealed that the right OCCipital bone was low and the right sphenoid bone high (Fig. 14). The angle of the base of the sku\l was 1 24 degrees, with a fairly normal appear­ ance (Fig. 1 5 ), and the cephalic index was 8 1 (Fig. 16). The atlas showed anterior ro­ tation on the right. The craniosacral roent­ gen diagnosis was right torsion, with short right lower extremity and sacral base dec­ lination to the right.

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APPENDIX

Fig. 9 . A nteroposterior view of the skull shows the sphenoid to be low on the left side. The occipital squama and conylar parts are low 011 the left side. The SIde of convexity of the skull lJ to the left.

H

Fig. 1 1 . Occipital view of the skull shows the occiput to be low on the left and the Side ofconvexity to the left.

SUMMARY AND CONCLUSIONS

Fig. 1 0 . Lateral view of the skull shows the angle of the base to be 128°.

An attempt has been mad e to develop an x-ray examination procedure and diagnos­ tic criteria for abnormalities of cranial con­ tour and stru'ctural relation in keeping with abnormalities described on a clinical basis by proponents of cranial osteopathy. The technique of film measurement and inter­ pretation has been described. Two illustra­ tive cases have been presented. Observa­ tions in the fi rst 2 5 patients studied have been reported. At present it appears that it is possible to demonstrate roentgenographically side­ bending, torsion, flexion, and extension patterns of the skull. It appears also that occasionally la teral and vertical strain of the sphenobasilar junction can be demonstrated.

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APPENDIX

3 27

H

Fig. 1 2 . Anteroposterior standing view of the lumbar spine andpelvis demonstrates 3/8 " shorten­ ing of the right lower extremity with sacral base declination of 5/8 " to the right, and lumbar scoliosis convex to the right.

Correlation of clinical obs ervations with the finding of low occipu t on the side of the low sacrum is excellent, but that with the lumbosacral angle and the angle of the base of the skull is extremely poor. It appears that the atlas tends to rotate anteriorly on the side of the low occiput. The correlation of the roentgen findings and independent clinical evaluation in a short series appears to be good and mos t en­ couraging. It is hoped that this work will serve as the basis fo r additional studies by others interested in this field. Additional areas for study might well include the use of stereoscopic and tomographic x-ray tech­ niques. The encouraging results to date provide a stimulus to search for increased knowledge in this intriguing field.

Fig. 1 3 . Standing lateral view of the lumbar spine shows normal lumbar lordosis and interver­ tebral disk spaces. The lumbosacral angle is 39°.

Fig. 14. Anteroposterior view ofthe skull shows the right occiput to be low and the right sphenotd to be high.

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328

APPENDIX H

Fig. 1 5 . (above). A lateral film of the skull shows the angle of the base to be 124°. The anteroposterior diameter is normal. Fig. 1 6 . (right). An occIpital view of the sklill shows the right OCClPlit to be low with no particlilar side of convexity. author

1 . Sutherland, W . G . : The cranial bowl. Treatise relat­ i ng to cranial articular mobil ity, cranial articular lesions and cranial technic. W.G. Sutherland, Man­ kato, Minn., 1 9 39 2 . Weaver,

c.: c.:

c.:

W . B. Saunders Co., Philadelphia, 1 9 5 6

The cranial vertebrae. JAOA 3 5 : 328-

1 1 . Worrzman, G . , a n d Dewar, F . P . : Rotary fixation o f t h e atlantoaxial j o i n t. Rotational atlantoaxial sub­

The cranial vertebrae. Part I I . JAOA

3 5 : 3 74-9, Apr 36 4. Weaver,

]ournal Printing Co., Kirksville, Mo., 1 966 1 0 . Meschan, I: Roentgen signs i n c l i nical diagnosis.

36, M a r 36 3 . Weaver,

9 . Magoun, H . I . : Osteopathy i n the cranial field. Ed. 2.

The cranial vertebrae. Part

Ill. ]AOA

luxation. Radiology 90:479·87, Mar 68 1 2 . Gray. H.: Anatomy o f the human body. Ed. 2 8 .

3 5 :4 2 1 -4, May 3 6

5 . N a y l o r , C L . : Sympos i u m on t h e plastic basicrani­ u m . I. The basicranium. JAOA 3 7 :94-7, Nov 37 6 . Sanborn, E. E . : Symposium on the plastiC basic rani­ um.

n.

The intracra n i u m . JAOA 3 7 : 1 8 3-9, ]an 38

7 . White, E . C : Symposium on the plastic basic ran i u m .

Edited by C M . G o s s , L e a & Febiger, Philadelphia,

1 966 Shanks, S . C , and Kerley, P .. editors: A textbook of x-ray diagnosis. Vol. 1 , Head and neck. Ed. 4. W . B .

Saunders C o . , Philadelphia, 1 969

I I I. Lesionab i l i ty o f t h e basic rani u m . ] A O A 3 7 : 1 8 3-

Yound, B . R . : The skull, sinuses, and mastoids. A

9, Jan 38

handbook of roentgen diagnoses. Year Book Pub­

8 . Kimberly, P.E.: Personal c o m m u n ication to the

Copyrighted Material

I ishers,

I n c . , Chicago, 1 948

Appendix I

Findings In Grade School

R elationship of Craniosacral with Problems JOHN E. UPLEDGER, D.O., FAAO, East Lansing, Michigan'

A standardized craniosacral examinatiol1 was COl1-

ducted on a mixed sample 0/ 203 grade school children. The probabilities calculated supported the existence 0/ a positive relationship between elevatedtota/ craniosacral motion restriction scores and the classifications o/"not normal, " "behavioral problems, " and "learning dtsabled, " by school authorities, and 0/ motion coordination problemJ. There was also a positive relationship between an elevated total craniosacral motion restriction score and a obstetrically complicated deliv-ery. The quantitative craniosacral motion restriction score was most positively relatedto those children with multiple problems.

This research was undertaken to determine if there is a between of the craniosacral sys­ problems in grade particularly "exceptional " those who have learning dis­ abilities and emotional impairments. A standardized craniosacral examination UC"'�.IH:::: U and conducted on each of a of 203 school children A study of interexaminer agreement for the reliability of the examin­ was previously done by the ation author with three other examiners. ' The work and results described herein r epresent a part of a b roader research pro-

that is still under way. The ultimate goal of this research is an evaluation of the of craniosacral osteopathic manipas it applies to "exceptional ulative children." work is presently under way investigators in the areas of education and psychology to more and define the individual probchildren." lems of these The ulti mate to determine if exist between "I-"e,,"'''''" treatment program is in progress. The weaknesses of the p resent categori­ zation me thods fo r the children's p roblems These weaknesses are being are time. addressed at the of the examina Hons of the results i n had n o afflict-

TH E EXAMINAnON Table 1 is the standardized examination for each of the form which was children.

Thejournal o[ the Amerkan Osteopathic Association, Vol. 11. jlille 1 9 78,

UJf
Ohio St., Chicago,

IL 60611.

pp.

738·54, by permISSion of the Ammcafl

329 Copyrighted Material

T A B LE ) . - STANDARD EXA M I N ATION FORM Subjects name _______

Date Age

Hei�ht

______

C.ardiac pulse rate/ m in u te Respiratory rate/m i n u te

_______

Wei�ht

_ _ _ _ _ _ _ _ _ _ _ _

�

_ _ _ _ _ _ _ _ _ _ _

__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Cranial pulse rate/ m i n u te

_ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Craflium - obvious asymmetries ( face, orbits, ears, b rows, forehead, mandibular deviation - m o u t h open and closed)

SutllreJ

- tissue texture abnormali ties and overriding noted

Motion Ratin�

Variables

I - Occ i p u t - Right restriction of motion

2

Left restriction of motion

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

3 - Temporal bones - Ril(ht restriction of motion

4

Left restriction of motion

_ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _

5 - Cranial vault - Restriction toward Oexion (Extension lesion') .

6

8

9 10

Restriction toward e x tension (Flexion lesion') _______ _______

13 14

15

16

17

18

19

Side bending rotation. restriction toward right (Left side bendin� and restriction lesion') __ Side bending rotation. restriction toward left (Right side bendinl( and restriction lesion') __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Torsion. restriction toward right ( Left torsion lesion') __

_______

Torsion. restriction toward left (Right t o rsion lesion') Compression·dec o m p ression restriction

II

12

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_______

_______

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Lateral strain. restriction toward right (Left lateral strain lesion')

_ _ _ _ _ _ _ _ _ _ _

Lateral strain, restriction toward left (Right lateral strain lesion-)

_ _ _ _ _ _ _ _ _ _ _

Vertical strain, restrictjon toward superior motion ( I n ferior vertical strain lesion-)

_ _ _ _ _

Vertical s t ra i n , restriction toward inferior motion (Superior vertical strain lesion-)

_ __ _ _ _

- Sacrum - Restriction toward Oexion (Extension lesion')

__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

______

Restriction toward extension (Flexion lesion')

______

Restriction toward right torsion (Left torsion lesion')

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Restriction toward left torsion (Ril(ht torsion lesion')

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Exa m i n e r - Name __

Cardiac pulse rate/minute Respiratory rate/ m i n u te

__ _ _ _ _ _ _ _ _ _ _ _

_ __ _ _ _ _ _ _ _ _ _ _

A l l motion variables ratE'd:l

- No r�Striclion

1 .5 -

2

- Moderate and transitory

3

>'=

2.5 -

Se"er� restriction

'Traditional Cranial Academy term inolo�y for " n a m i nl( the lesion."

Precautions were taken to minimize the possible effect of other cues to the examin­ er on the conduct and reporting of the results of the craniosacral examination. A research assistant recorded the name, age, height, and weight of each child before summoning the examiner. The parents had no significant contact with the examiner prior to the examination. The initial con­ tact between the examiner and the subject was in the examination room. Every effort was made to have the child lying quietly in the supine position on the table when the examiner entered the room.

Prior to the craniosacral motion testing, the examiner's pulse and respiratory rates were taken and recorded by the research assistant, as were the pulse, respiratory, and cranial rhythmic impulse rate of the child. 2 Obvious asymmetries noted visually and by palpation were then orally reported to the research assistant. Next, each motion variable (Numbers 1 to 1 9 , Table 1 ) of the craniosacral system was carefully tested and rated on a scale of 1 to 3 . Motion variables were tested and reported in a specific sequence (Table 1) to eliminate differences which might result

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331

APPENDIX I

from the order of motion Each motion was tested and rated in terms of restriction of response to a force in a given d i rection. In the restriction or resistance to induced motion, scores were "'�"ll4l1C;'U. a score ofl no restriction; 2 transitory restricof severe restriction. 1 . 5 and 2 . 5 were allowed. The resistance to that motion was re­ por ted and rated rather than the "positional lesion." This liberty was taken the au thor in o rder to m inimize conceptual error and controversy related to the cause of the note that restriction. It is our the restriction was the types of motion, In movement the head in the desired lion was ini tiated by the examine r. The motion was then mon i tored u n til it reached a restricted end point. R ange-of-motion, and ease or restriction to bilateral moti o n, as initiated the were evaluated. each of The exact proced u re for the 19 parameters shown i n Table 1 was as fol lows. PARAMETERS 1 AND 2O CCIPUT, RI G HT A N D L EFT

comfortably and With the the examiner comfo rtably seated at the head o f the table, the examiner's hands were laid palms up on the table s o that the ulnar sides of the two hands approxima ted each other. The fi ngers were flexed beThe tween 60 and 90 were placed in contact with the in a (nearly) caudad to superior nuchal line. The examiner's fingertip con­ tact was allowed to remain u n til the soft tissues relaxed and the examiner could sense the firmness of the struc­ tures. Once this relaxation of soft tissue

moved in c ompliance with this traction, a directed force was added to traction by each of the examiner's hands. The resistances of the two sides of

the occiput to this examiner-induced m o ti o n were then rated i ndiVidually on the 1 to 3 scale. P ARAMETERS T EMPORAL

3

AND 4R IGHT AND L EFT

For testing of restriction to motion of the temporal bones, the examiner and the patient remai ned i n .the same relative posi­ tions as afo rementioned. was gently cradled The i n the examiner's i n terlaced palms up). The exa miner's were positioned so that were in contact with mastoid processes and tips. the a side-to-side m o tion was gently i nd uced s o that when one mastoid tip was pressed medially, the was al­ in a lateral di rection lowed to move and vice versa. The motions were tested in rhythm with the cranial (CRI).* Several excu rsions were monitored . resistance to a very minute circula r motion of the temporal bones was tested. The axis of this m o tion can be ized as running the aud­ itory canal and through the petrous portion of the bone. Resistance to these exa miner- i nduced motions was rated on each side in terms of i ts Before this tempo ral bone symmetry of motion was restored by the examiner.

5 THROUGH SPH ENOBASILAR JOINT

P ARAMETERS

1 5-

were all tested hold. " The positions of the subject and the examiner were of the examiner's except for the head. hands to the The " va u l t hold" is the for the method of application of the examiner's hands to the head. This applica-

• The c ra nial rhythmic impulse (CRI) is an involuntary. physiologic, rhythmic motion which been reported b y those s k illed in cranial osteopathy. It i s perceived by placed the examiner as his hands are gently and upon the subject's head. The perceived is reported ly not in synchrony with the cardiovascular and respira tory rhythms of either the subject or the examiner.

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332

APPENDIX I

tion was for the evaluation of the inte rosseo us motions which are to occ u r between the bones the cranial vault. The index of each hand were applied gently to the area the external surfaces of the great of the The fifth of each hand rested in contact with the approximately one-half inch to the occipito-mastoid suture above the superior nuchal line. Some differ­ ences in the placement of these resul t if examiners have small head is relatively i n size, but this does cues no t i nterfere with the that can be The third and fou rth process were not used in the during evaluation. The head thumbs did not contact the b u t did contact each other. provide the examiner with and kinesthetic cues abu t the equali ty of motion when movements i n one direction movements were compared with in the opposite direction. The types of cranial motion tested using the vau l t hold were: Parameters 5 and 6-Flexion-extension. and left side Parameters 7 and of rotation. with a and left Parameters 9 and torsion. Parameter 1 sion. and left Parameters 1 2 and 1 lateral strain. Parameters 14 and 1 strain i n superior and inferior directions. PARAMETERS 5 AND 6FLEXION. EXTENSION

Using the vaul t hold, the examiner exerted a force over the occipital of the sphenoid was directed by h is paired index caudad and was and fifth The thumbs were in contact with each other and furnished proprioand kinesthetic c ues so that the examiner's force was as symmetrically equal as After the cranium re-

sponded to the force (of approximately 5 . 0 grams or the examiner became passive and followed the cranial motion to i ts restricted end point. This was this the test for flexion. Restriction examiner-induced motion was then rated after and for extension, next. To test for extension, a similar bilaterally the examiner in a equal force was cephalad direction. The was then rea reliable peated u ntil the exami ner impression as to the relative ease/resriction of these motions. PARAMETERS 7 AND 8SIDE BENDING· ROTATION, RESTRICTION TOWAR D RIGHT AND LEFT, RESPECTIVELY

The vault hold was as aforementioned. In order to test for restriction toward the toward side the exami ner's left index and fifth finand megers were approximating each dialward other. Resistance (restriction) to this motion was examiner-induced with side bending-rotation mo­ tion toward the left. In order to test for restriction toward the pa tie nt' s left, the the same procedure examiner his hand. Restrictions were rated on the 3 point scale, each side indiPARAMETERS 9 AND 1 0 TORSION· RESTRICTION TOWARD T H E RIGHT AND LEFT, R ESP ECTIV ELY

the vau lt hold, the examiner apforce with the index of and the fifth finger of the other in a superior alad) direction. F irst, testing was LV1 U ;J1<:; for torsion on one side and, the motion to return to a neutrality, testing was completed on s ides. The forces were ex· FollOWing the i nitiation of motion the examiner, the motion was monitored to i ts restricted end point. The restriction was rated for the side on which

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333

APPENDIX I

wing of the sphenoid bone re­ superior motion; if the left great wing and the right squamous moved easi ly in a tion, but the moved with the restriction was rated as a 2 or right s ide in reference to the of the bone res ismotion. tance to the P ARAMETER 1 1 COMPRESSION-DECOMPRESSION R ESTRICTION

the vault the examiner exerted a force over the great of the This bone with his index was in a frontal d i rection away from the fifth immobilthe areas over the squama. It is essential that this force be applied as biThe examiner's equaUy as thumbs in contact with each other furnish valuable kinesthetic and this testing cues ing the i ni tiation of the motion, it was monitored to the res tricted end point and rated on the 3 point scale in response to the

gently held immovable b y the examiner's fifth (overlay­ his index ing the great wings of the sphenoid bone) exerted a gentle fo rce on a frontal plane first in a superior (or direction, and then in an inferior , _ ,. _.• , direction. As the vertical motion carries to that i t it can be its end possesses a n arcing compone n t which is direc ted posteriorly. Restrictions were rated as they limited the superior inferior response to motion testing in those directions. _ ..

P ARAMET E RS 1 6 , S ACRUM

1 7 , 1 8,

A N D 1 9-

All four of these parameters were tested with the patient upon the palm of the examiner's right hand. The of the sacrum rested in the space between the examiner's third and fou r th The sacral apex and coccyx rested in examiner's The of the examiner's third and fou rth processes of were lateral to the the fourth or fifth lumbar vertebra size). The distal aspects on the the examiner' s index and fifth fi ngers lateral were in contact with the aspects of the sacrum. PA R AMETER 1 6

The test for restriction toward sacral by using the examflexion was induce an anterior i ner's palm to motion of the sacral apex.

PARAMETERS 1 2 AND 1 3 LATERAL STRAIN- R ESTRICTION TOWARD TH E R IGHT AND

R ESPECTIVELY

Using the vau l t hold, the was gently held immovable by the examiner's fifth The i ndex were then used to induce motion and test restriction i n a direc­ to the s ubject's head. Restrictions toward this induced moti on were rated and recorded toward the right and toward the left o f the examiner. 1 4 AND 1 5 V ERTICAL STRAIN· RESTRICTION O F S UPERIOR MOTION AND IN F E R I O R

The test for restriction toward sacral ex­ an an­ tension was terior motion of the sacral base. Both of these mo tions were tested through several cycles of the CRI and the restrictions to examiner-i nduced motion toward both flexion and extension were rated on the 1 to 3 scale. P A RA M ETERS 1 8 AND 1 9 R ESTRICTION TO W A R D R IGHT AND R ESPECTIVEL Y L EFT

M OTION, R ESPECTIVELY

Using the vault hold, the

P A R A M ETER 1 7

was

The examiner maintained the same sacrum as manual contact with the

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3 34

APPENDIX I

was used for testing Parameters 1 6 and 1 7 . To test for restriction toward right torsion, pressure was applied in an anterior di rec­ tion on the left sacral base area. Pressure on the right side was applied similarly to test for restriction toward left torsion motion. Both parameters were then rated on the 1 to 3 scale for restriction toward induced pas­ sive motion. THE SAMPLE Two hundred and three subjects for this study were obtained by parental response to written notices taken home by children attending Ingham County G rade Schools and by children enrolled in the MSU Motor Coordination Clinic. These notices informed parents of the objectives and protocol of the research. Cooperation and signed con­ sent of interested parents was requested. There was also some direct communica­ tion between a limited number of interested special educators and school nu rses, and the parents of " exceptional children." Parents who expressed a desire to have their children participate in the research (by returning the signed consent form to the cooperating agency) were then contacted by the research assistant who arranged all appointments for examinations, reviewed pertinent records, and obtained develop­ mental and o ther historical data. There was no situation in which the examiner had significant contact with parent or subject prior to completion of the craniosacral examination. Significant data were then extracted from these records and histories by the re­ search assistant in cooperation with the statistical analysis consultan t (Eric Gordon, Ph. D.). Eigh t categories of significant p rob­ lems were then decided u pon by Dr. Gor­ don (Table 2). Categories 1 to 4 were con­ sidered the major problem areas. Categor­ ies 5 to 8 represent factors from the history that were considered as possibly clinically significant. The criteria for entry into one of the eight problem categories were as follows. CATEGORY 1 NORMAL·NoT NORMAL t

A child was considered "not normal" in

this category only if one of the following criteria were met: ( 1 ) A classroom teacher had first sus­ pected that the child manifested a problem which would label that child as "exception­ al." (The problem could have been in either the behavioral, motor coordination, and/or learning disability area.) (2) The classroom teacher felt strongly enough about that suspicion to seek and obtain evaluation by a specialist in either psychology, motor coordination, and/or remedial education. (3) That specialist did, in fact, concur with the classroom teacher's opinion and recommended appropriate specialized treatment or a training program for the child in question. Children classified as "Not normal" in category 1 were not so classified on the basis of a teacher's opinion alone, nor was this classification made solely on the basis of the parent's opinion. Confirmation by an ap­ p ropriate specialist was a required criterion. There were 1 64 children categorized as

TABLE 2. EIGHT PROBLEM CATEGORIES CONSIDERED SIGNIFICANT FOR DATA COLLECTION Category l-"Normal-Not normal" 2-Behavioral problems 3-Motor coordination and speech problems

Diagnosed by School authorities

School authorities School authorities Motor Coordination Clinic 4- Learning disabilities School au thori ties 5- Seizure history History obtained from parents 6- Head injury History obtained from parents 7- Obstetrical com plica· History obtained from tions parents 8- Ear problems (H istory History obtained from of with or withou t parents hearing loss)

t The author recognizes that the terms "normal" and "not normal" are not truly definable. Classroom teachers, however, d id use this terminology in describing the subjects examined in the project. Therefore, these descriptions have been used in reporting this research.

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APPENDIX I

335

"Normal" and 39 children classified as "Not normal" in this category. CATEGORY 2-

tained

BEHAVIOR PROBLEMS

evaluations

The in this category on

Children were

teria, which were included in the data. In these cases (Table 3), disability" who obwas noticed first by the

bases: the (1) when a specialist in the field of psych­

and the children were of " exceptional children." This category included

indicated on the school record.

dysgraphia,

(2) when the child had proven to be un-

and confirmed the positive Uuy uL5" in

in private

schools which specialized in remedial train-

(usually a school psychologist) had so

HU;"'1","'''LJ H;; to the parent so that professional evaluation (child or had been obtained privately

a psychologist.

suspicions were confirmed

anomia,

and

CATE G O R Y

5-

SEIZU R E HISTO R Y

3) wherein the

All children in this category had a history

parent and not the classroom teacher sought help for "behavioral "

of at least one episode of seizure or convul­ sion. Most of these histories were validated

psycholoIn all of these cases a gist had confirmed the problem, even though the children's school conduct was not con­ sidered

by the teacher. Therethese subjects were considered as

"normal" in category 1. All other children in this

category (2) were considered

by

medical histories furnished

by and

if a parent the incidence of seizure or

convulsion and the description of the event seemed accurate, the child was

The purpose of collecting these data was

" not normal" and to have "behavioral problems"

their teachers.

and craniosacral restrictions,

as well as to illuminate this problem category as a possible contributing factor for 1 to 4. findings in

MOTOR COORDINATION A N D SPEECH P ROBLEMS All children in this

category

were referred from the MSU Motor Coordination

relationships between seizure

CATEGO R Y 3-

area of

in

this category.

where a problem in this had been confirmed.

There were 1 9 subjects with

CATEGO R Y 6HEAD Children were placed in this category on the basis of information from parents and

motor coordination problems who were

from medical records when available. The

considered " normal" in category 1

research assistant attempted to eliminate

the

school teachers (Table 3). Therefore, were considered as "normal" in ,-a.l""" J�

from this category.

All other motor coordination the classroom teachers.

The nized;

minor

were noted

and " cuts" on the head of data obtained is only those children

history

CATEGOR Y 4-

fracture and/or included.

LEARNING DISABILITIES

" concussion," unconsciousness

were

dis-

The purpose for the inclusion of this

abled" if the classroom teacher noticed the

category was to search for areas which may,

problem, obtained confirmation from a

in fact, j ustify more

Children were considered

specialist, and had the child

in a

special education program. There were four exceptions to these cri-

of head factors to the children."

Copyrighted Material

investigation

336

APPENDIX I

Subject children numbers 1 through 4 1 no classifiable problems within Subjects 42 through 1 3 5

CATEGORY 7 O BSTETRlC C OMPLlCATIONS

";;>'C ili leu

of the following; ( 1 ) Cesarean section (2) High delivery ( 3) Induction lab or for reasons o ther than convenience (4) Fetal distress in u tero (5) B reech delivery labor (6) labor Toxemia of pregnancy (9) Severe trauma during pregnancy which resulted in pelvic fracture All information was obtained from the paren ts. Documen tation was available from medical records'' this was the Even though val idity of these data may b e the included the category in order to uncover tendencies toward correlation b etween obfacstetric tor to prob lems in 1 to 4, and a correlation between craniosacral restric­ tion patterns and obste tric complications. More in-depth study seems justified by these results.

2, 3, in subjects 1 3 6 through 1 64 in the aforementioned deal with those paragraphs The column on the extreme Table 3 indicates the quantitative total scores given each for the cranio­ sacral examination. The occ urrence of other problems in 8 for the children who 2 were c lassified as "not normal" by class­ room teachers and school authorities is lis ted in Table 4 . The total craniosacral examination score is the column on the extreme table. Comparison of Tables 3 and 4 an overview of the o f problem occurrence in 2 , 3 , and 4 when child ren were as "normal" or Hnot normal" in category 1 . (This comparison lends support to the validity of the class­ room teacher's of the of the child's STATISTICAL ANALYSIS

CATEGORY 8E A R PROBLEMS

Children placed in this tories o f or recurrent ear (at least 5 repeti­ tions) which had required treatment by a Oti tis externa was not included. This category was inc luded simply be­ cause of the frequency with which the prob­ lem occurred in the histories. The statistical further does not appear to in categorThe occu rrence of children ex8 for ies 2 amined who were classified as "normal" the classroom teachers and school a uthor­ ities are in Table 3. One hundred and thirty-five of these 1 64 children had no classifiable problems in 4 (behavioral, m'�'r'r_.o�,'�� disabili ties, respec tively).

involved three types This of statistical measures: ( l ) Su mmary descrip tive statistics were used to describe the '"''11 L' H;; . (2) Two tailed " t" tests were used to test the differences in mean scores between groups in the various calceb'on ( 3) Pearson Product- Moment correla­ tions were calculated in order to the relationships between (The readers should b e aware that no pre­ viously determined levels of Significance [al pha] are available.) RESULTS AND DISCUSSION Table 5 gives the mean scores, the stand­ ard deviations, and the standard errors de­ rived from the craniosacral examination and the that the differences in mean scores for each of the 8

Copyrighted Material

APPENDIX I

337

could have occurred by chance. in which the craniosacral examination score differences were considered to be sig­ nificant are as follows: 1 (Normal-Not Norma/)- The ability o f the differences in mean examina­ tion scores and with the opinion of the school authorities by chance is less than 1 in 1 000 « .001).

Problems)- The Category 2 correlation found be tween probability school authority opinions and c raniosacral examination scores occurring by chance is less than 1 in 1 000 « .00 1 ) . ,"u" e-P'Jf v 3 (Motor Coordination ,n'()1t7f1JI­ of the differences in mean cranial examination scores occurri ng and agreeing with the Motor Coordination Clinic

TABLE }, OCCURRENCE O F OTHER PROBLEMS FOR CHILDREN CLASSIFIED AS "NORMAL" IN CATEGORY 1 , Category

Total

cranio-

Subject

sacral exam

number

(I: V) score'

No positive findings i n categories

! through 8

I

22.5

2

2 } ,0

3

2 7 .0

4

2 l .5

5

2 2 ,0

6

28,0

7

2 2 .0

8

28,0

9

24,5

10

2 1 .0

II

} 1 .0

12

24,5

13

2 3,0

14

2 5 ,0

15

3 1 .0

16

2 3,0

17

24.0

18

34.0

19

}2,0

20

27,5

21

22,5

22

30,0

23

26.5 25 0

24 25

n.o

26

24,0

27

24,0

28

2 1 .5

29

2 3,0

30

26,)

31

2 2 ,0

32

23,)

33

2 ) ,0

34

28,5

35

2 2 ,0

36

24,)

37

27,)

38

2 3,0

39

20, 5

40

2 2 ,0

41

29,0

Copyrighted Material

338

APPENDIX I

TABLE

(continued)

Ca[e�()ry Subject number

r

2

.

3

4

6

5

Ch ildren with no pos i tive findings in categories

7

,

8

Toral craniosacral exam ( I: V) score'

1 through 4 , but with positive findings i n the 5 through

contributing categories

X

42 43

44

X X X

X

45

X X

X 47 48 49 50 51 52 53 54 55 56 57 59 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96

X X X

X X

X

X X X

X X X X X X

X X X X X X X X X

X X X X X X X

X X X

X

X X

X X

X X X

X X

X X

X X X X X X

X .X

X

X X X X

X

X

X X X X

X

X

X X

X

Copyrighted Material

X X X X X X X

X X

26.5 2 2.0 27.0 2R.5 22.0 2 7 .0 23.5 29.5 2 5 .0 26.0 26.5 3 1 .0 25.0 25.5 2 2 .0 24 . 5 23.5 25.5 26. 5 24 . 5 21.5 30.5 28.0 24.0 24.0 26.5 27.5 28.0 24.0 1 9.0 23.5 25.5 23.5 1 9.0 2U .� 4 . 5 22.5 24.0 26.0 2 5 .0 22.5 26.0 26. 5 3 5 .0 27.0 27.0 24.0 26.0 24.0 25.5 2 3.0 25.5 21 3 4 .0 2 7 .0

APPENDIX

TABLE

3

3 39

I

(conti nued) Category

Subject number

"

X

97

2 5 .0

X X

98 99

24.0

X

1 00

X X

101

X X X

1 02 103 1 04

X

1 08

X

1 09

X X

X

24 . 5 27.0 28.5 2 5 .0 26.0

X X

1 14

X

X X

23.5 2 1 .5 24 . 5

X

1 1 5

26.0

X

1 16

34.0

X X X X

1 17 1 18 1 19 1 20

28.0

X

25.0

X X X

1 22 1 23 1 24

X X

X

X

X X X X X X X

X

1 27 1 28 1 29

X

1 30 131

X X X X

X

X X

1 33 1 35 3. and Occurrence of positive findings in categories by teachers

X X X

1 36 1 37 1 38

144 145

23.0 2 3. 5 36.5 27.0 21

X X X X

22.0 23.5 28.0 2 7 .0 "

24.0

X X

X X X X

25.5

in children categorized as normal"

X

142

27.0

24 . 5

X X X

143

4

25.5

22.0

X

1 32 1 34

24.5 30.0

1 25 1 26

24 . 5 24.0

121

149

28.0

X X X

25.0

112 1 1 3

148

23.5

X

1 1 1

147

24 . 5

X

X

llO

146

24.0

27.5

1 07

141

27.5

X

1 06

1 40

X X

29.5

lOS

1 39

Total craniosacral exam (I: V) score'

X X X X

22.5 2 7 .0 2 7 .0 26.0

X

34.0

X X X

25.5 28.0 26.0

X

30.0

X X X

X

X

3 5 .0 20.0

X

Copyrighted Material

34. 5

340

APPENDIX I

TA B L E 3 . (continued)

Category Toral cranio: Subject number

,

2

A

3

4

1 '0

X

X

1,1

X

152

X

153

X

1 ,4

X

1'5

7

8

29. '

X

30.0

X

X

X

X

X

X

X X

X

1 59

X

1 60

X

29.0 39.' 2 1 .0

X

158

sacral exam ( I: V) score' 23.'

X

X

1 56 157

6

,

,

32.0

X

3l.5 29.5

X

22.'

X

161

X

162

X

163

X

1 64

X

X

32.5

X

37.0

X

28.'

X

26. '

X

X

X

28.5

'Perfect score (no restriction) = 1 9

diagnosis b y chance i s 2 i n 1 000 (.002). Category 4 (Learning Disability)-The prob­ ability of the differences in mean examina­ tion scores occurring and agreeing with the opinion of the school authorities by chance is less than 1 in 1 000 « .00 1 ). Category 7 (Obstetric Complications)- The probability of the agreement between the presence of a history of an obstetrically complicated delivery of the subject child and the elevation of the mean scores of the craniosacral examination in those children occurring by chance is less than 1 in 1 000 « .00 1 ). The craniosacral examination appears to be valid as a test for behavioral problems, learning disabilities, obstetrically compli­ cated deliveries, and to confirm the opinion of the child's teacher as to whether the child's progress in school is "normal" or " not normal." Table 6 gives the correlation coefficients (r) between each singular parameter studied during the craniosacral examination and the total score derived from the motion re­ striction rating of the 1 9 parameters tested. The (r) and (p) values were computed to determine which of the parameters would most reliably predict high total numerical scores derived from the 1 9 motion

-

parameters. There is no apparent significant relation­ ship between total motion restriction of the craniosacral system and the subject's age, height, weight, pulse rate, heart rate, or the rate of the cranial rhythmical impulse. All children were within normal ranges of height and weight. The most reliable predictors (of the in­ dividual motion parameters measured) for the highest total scores have the highest (r) values. Motion Parameter 1 1 (Compression­ Decompression) was the most reliable pre­ dictor of widespread restriction within the total craniosacral system as tested. All other parameters of motion were found reliable at probabilities of less than 1 chance in 1 000. The correlation coefficients (r) for all combinations of motion restriction vari­ ables (5 ) and Categories (C) of problems are presented individually and in summation in Table 7. All (r) values presented represent probability (p) values of less than .05 (5 chances in 1 00) of the correlation occur­ ring as a random happening. Correlation coefficients (r) which are equal to or greater than . 2 1 on the table represent probabilities of .001 (1 chance in 1 000) or less of the relationship between the examination

Copyrighted Material

APPENDIX I

TABLE4, OCCURR ENCE OFOTI-lER PROBLEMS FOR CHJLDREN CLASSIFIEDAS "NOTNORMAL" lN CATEGORY l, Category Subject number

X

167

X

168

X

2 7 ,0

X

X

37.5

X

X

X

29, 5

X

X

33,5

X

25,5

X X

score'

X

X

171

1: V)

29,5

X

X

1 70 172

sacral exam ( X

165 1 66

1 69

Total cranio-

r

20,0

X

173

X

174

X

X X

X

X

29.0

X

39.0

X

3 2 ,0

X

X

X

X

1 76

X

X

X

X

X

34,0

1 77

X

X

X

X

X

28,5

X

X

X

28,5

1 75

178 1 79

X

1 80

X

181

X

X

X X

X

1 84

X

1 85

X

X

186

X

X

187

X

X

1 88

X

X

X

X

X

X

X

40,0

X

X

X

X

34,0

X

4 5 .0

X

28,0

32.5 35,5 33.5

X

X X

28,0

X

3 5 .0

X

192

X

193

X

194

27.0

X

X

X

1 96

X

X

X

X

X

1 97

X

29,0

X X X

1 99

X

X

200

X

X

20] X X

47.5 '13 , 5 26,0

X

'Perfect score (no restriction)

X

X

1 98

203

X X

X

195

34 , 0

X

X

X

191

202

2 7 ,0 X

32,0

X

183

1 89

X

X X

182

1 90

X

34,5

X

X

X

X

X

X

33.5 X

30,0 26,0 X

2 1 .0 27,0

X

30,0 24,0

X

29.5

19

score and the presence o f a in that category having occurred b y chance. It can b e seen that the total numerical score of the 19 motion parameters tested is most Significantly correlated with the pres­ ence o f problems. T h e c ranio­ sacral examination would also appear to be reliable i n identifying those children whom the school authorities have as "not normal," and those children classified as having "behavioral and/or disabilities." The craniosacral

examination also method of as having motor coordination Study of restriction patterns as reflected the ( r) values the hypothesis problems may be rethat specific types lated to certain motion restrictions and/or restriction patterns of the craniosacral system. Further research of this hypothesis is under way by the author.

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34 2

APPENDIX I

TABLE 5 . PROBABILITY OF MEAN CRANIOSACRAL MOTION EXAMINATION SCORE DIFFERENCES FOR EACH OF THE EIGHT CATEGORIZED PROBLEM TYPES. Mean

Standard

Standard

CateRory

Frequency

SCOre

deviation

error

Probability

I - " N o rmal"

165 (82%)

26.05

3 . 704

0.288

.000

38 ( 1 8%)

3 1 . 24

5 . 7 36

0.93 1

"Not normal" 2 - B ehavioral No 3-Motor - Speech No 4- Learning disability No 5-Seizure history No 6 - H ead injury No 7-0bstetrical complications No 8- Ear and hearing problems No

3 2 ( 1 6%)

3 1 . 30

5 . 763

1 .0 1 9

1 7 1 (84%)

26. 2 2

3.891

0. 298

34 ( 1 7%) 1 69 (83%)

29. 1 9

5 . 585

0.958

26.59

4. 279

0. 329

25 (1 2%)

3 2 .40

5 .949

1 . 1 90

1 78 (88%)

26. 27

3.850

0.289

25 ( 1 2%)

2 7 . 70

5 .429

1 . 086

1 78 (88%)

26.93

4.495

0.337

9 2 (45%)

2 7 . 78

5 .086

0 . 5 30

I I I (5 5%)

26. 39

4.097

0. 389

67 (3 3%)

28.78

5.161

0.63 1

1 36 (67%)

26. 1 5

4. 064

0 . 34 3

55 (27%)

27. 19

5 . 592

0.754

148 (63%)

26.96

4.21 1

0 . 346

.000 .002 .000 .434 .032 .000 .752

TABLE 6. RELATIONSHIPS BETWEEN TOTAL SCORES AND TESTED SINGULAR VARIABLES. Singular

Correlation

Probability

variable

coefficient (r)

(p)

Age

.09

. 10 1

Height

.08

. 1 28

Weight

.03

.322

P u l s e rate

.01

.415

Resp. rate

.05

.233

CRI. rate

.04

. 305

Motion parameters I

.37

2

. 38

3

. 36

4

.40

5

.46

6

.45

7

.44

8

.42

9

. 39

10

.37

II

.53

12

. 39

13

.33

14

.24

15

.45

16

.47

17

. 36

18

. 30

19

.24

< <

<

<

<

< <

<

< <

<

<

<

<

<

< <

<

<

.001

Right occiput restricted

.00 1

Left occiput restricted

.001

Right temporal restricted

.00 1

Left temporal restricted

.00 1

Flexion, restricted toward

.00 1

Extension, restricted toward

.00 1

S. B . & R . , restricted toward right

.001

S. B.&R., restricted toward left

.001

Torsion, restricted toward right

.001

Torsion, restricted toward left

.001

Compression-decompression, restriction of

.00 1

Lateral strain, restricted toward right

.00 1

La leral strain, restricted towa rd left

.00 1

Ven. strain, restricted superior motion

.00 1

Vert. strain, restricted inferior motion

.001

Sacrum restricted toward flexion

.001

Sacrum restricted toward extension

.00 1

Sacrum restricted toward right torsion

.00 1

Sacrum restricted toward left torsion

Copyrighted Material

APPENDIX I

TABLE 7. RELATIONSHJPS BETWEEN MOTION PARAMETERS ( l · 19) AND PROBLEMS FOUND IN CATEGORlES ( 1 THROUGH 8)-CORRELATION COEFFIOENTS (r) (N-203) Motion restriction variAbles

Normal not GI

l3ehav. problems C-2

Motor­ speech C- 3

, 1 793

. 1485 . 1 2 26 .1710

,2752

. 2 3 38 , 3 1 07 .2 1 1 5 7,S.8. & R. toward .2801 tight 8-S,B, & R toward , 1 694 left ,2672 9- Tornion toward tight IO-Torsion towa rd ,2284 left ! I -Compression - ,26 3 1 decompression 1 2,Lat. strain toward tight . 1 676 I3-Lat. strain toward left . 1 708 I 4-Vert. strain

row.ud superior 1 5-Vert, strain toward inferior 1 6-Sacrum toward flexion 1 7-Sacrum toward extension 1 8-Sacrum toward righ t torsion 19-5acrum toward left torsion

L V Total Score

Learn disabilities C4

. 1 26 2

Head injury C-6

, 1 474 , 1 292 .3052 , 2 3 36 . 1 877

,2080 . 1683 1 696 .2497

, 1 745

,2 1 78

.1812

. 1634

,2 1 40

, 1 386

, 1 784

.2337

,2020

Obstetrical complications C-7

,2798 , 1 798 , 167> . 1 362 ,2005

, 1 327

, 1 399 , 1 349

. 1 864

Ear problems C-8

Multiple problems LC .2596 . 1 080 ,2290 . Q9 50 .3014 .1515 .2629 ,2571

, 1 798

, 35 1 3 . 2 1 35 ,2 1 24

. 1639 .1 161

. 1 6 39 .2225

Seizure history C-5

, 1 1 84

, 1 }2 3

. 1 1 63

, 1470

. 1 949

. 1 669

.1311

,24 30

. 1 392

.24 1 3 . 1 46 1 .0876

, 1 804

,2519

.4396

.40 1 9

. 1 5 38

.21 14

.4380

. 1 505

.2268

,2225

,2687

,50 1 4

, 2 1 probability i s less than ,00 1 values given represent probabilities of less than ,05,

CONCLUSIONS 1 . The use of a standarruzed "l.U,d.HlLlUd.UJit: craniosacral motion examination represents to the s tudy of rela· b etween craniosacral motion re&­ trictions and a variety of health problems which may or may not be related to central nervous function. 2 . I n general, the accuracy of school authorities' opinions which child­ ren as "normal" or " no t normal" are sup­ by these data (Tables 3 and 4). 3. The probabilities calculated (Tables 5 and 7) support the existence of a between elevated total cranio-

sacral motion restriction scores and classifi­ cations of "not n o rmal," "behavioral " and " learning disabled" by authorities, and of motor coordination problems, as diagnosed by the MSU Motor Coordination Clinic. be4. There is a tween an total craniosacral motion restriction of an ob­ s tetrically (Tables 5 and 7) . craniosacral 5 . The total motion restriction score ( L V) is most pos­ related to those children ( 1:: o n Table 7 . with multiple

Copyrighted Material

344

APPENDIX I

1. Upledger, ].E.: The reproducibility of craniosacral

pliance and resistance to absorption. ]AOA 74: 8 7 3-6, May 7 5 .

examination findings. JAOA 76:890-9, Aug 7 7 . 2 . Magoun, H.I., Sr.: Osteopathy i n the cranial field. Journal Printing Co., Kirksville, Mo., 1 966, pp. 3 1 323.

Michael, D.K., and Retzlaff, E . W . : A preliminary study of cranial bone movement in thesquirrel monkey.JAOA 74 : 866-9, May 7 5 . Miller, H.C.: Head pain. ]AOA 7 2 : 1 3 5-43, OCt 7 2 .

Baker, E.G.: Alteration i n w id t h o f maxHlllry arch and its

Morris, P.R., and Whiting, H.T.A.: Motor impairment

relation to sutural movement o f cranial bones. JAOA

and compensatory education. G. Belland Sons, London,

7 0 : 5 59-64, Feb 7 1 .

1971.

Beter, T.R., Cragin, W.D., and Drury, F.: The mentally

New York Academy o f Science. Minimal brain dysfunc­

retarded child and his motor behavior. Charles C.

tion. Annals of the New York Academy of Science, vol.

Thomas, Publisher, Springfield, III., 1 9 7 2 .

2 0 5 , February 28, 1 9 7 3 .

B rierley, ] . B . : Metabolism o f the nervous system. D.

Pritch ard, ] .J . , Scott, ] . H . , and Girgis, F.G.: The Struc­

Richter, Ed. Pergamon Press, New York, 1 95 1 , pp. 1 2 1 -

ture and development of cranial and facial sutures. ]

35.

Anat 90:70-86, Jan 5 6 .

Brooks,

c.,

Kao, F.F., and Lloyd, B . B . : Cerebrospinal

fluid and the regulation of ventilation. F.A. Davis

Co.,

Retzlaff, E . W . , e t a l . : T h e structures o f cranial bone sutureS. JAOA 75 :607-8, Feb 76.

Philadelphia, 1 96 5 .

Retzlaff, E. W., Michael, D.K., and Roppel, R.M.: Cranial

Davson, H . : PhYSiology o f t h e cerebrospinal fluid.

bone mobility. ]AOA 74:869- 7 3, May 7 5 .

Churchill, London, 1 96 7 .

Retzlaff, E .W . , Roppel, R . M . , a n d Michael, D.K.: Possi­

Dunbar, H . S . , Guthrie, T.e.,

ble functional s ignlficance of cranial bone sutures.

the cerebrospinal fluid pulse wave. Arch Neurol

Association of Anatomists, 88th Session, MSU-COM,

cago) 1 4 : 624-30, Jun 66.

24-27, Mar 1 9 7 5 .

Frymann, V.M.: Relation of disturbances of craniosacral

Sutherland, W . G . : T h e cranial bowl. Free Press Co.,

mechanisms to symptomatology of the newborn: Study

Mankato, Minn., 1 9 39.

of 1 ,2 5 0 infants. JAOA 6 5 : 10 5 9- 75 , Jun 66.

W ales, A . L . : The work of William Garner Sutherland,

Leusen, I.: Regulation of cere brospinal fluid composi­

]AOA 7 1 :788-93 , May 7 2 .

tion with reference to b reath ing. Physiol Rev 5 2 : 1 - 1 4,

Winchell, C.A.: The hyperkinetic child. Greenwood

Jan 7 2 .

Publishers, Westport, Conn., 1 9 7 5 . H.!., Sf.: The temporal bone. Troublemaker i n ]AOA 7 3 : 8 25 - 3 5 , l u n 74.

Woods, R . H . : Structural normalization i n infants and children with particular reference to disturbances o f the

Michael, D.K.: The cerebrospinal fluid. Values for com-

central nervous system. ]AOA 7 2 :903-8, May 73.

Copyrighted Material

Ap

J

The Reproducibility 0/Craniosacral Examination Findings: A Statistical Analysis JOHN E. UPLEDGER, D.O., FAAO, East Lansing, Michigan'

A statistical

of the data derivedfrom 50 craniosacral examinations on 25 preschool children

IS presented. These data would seem to support the reliability and reproducibility examination findings when the examinations are performed by skilled examiners. During aI/50 examinations, the rate of the cranial rhythmical impulse

examiner. (No inference is made from these as to whether the perceived CRI may o r may not be the resultant modulation of other rhythms, as has been hypotheSized by some and whether

was

countedand compared with thepulse and respiratory rates of both the subject and the examiner. The results this comparIson would tend to help eRl as on independent physiologic

rhythm. A Single-blindprotocol was employed. All reasonable precautions were token to control variables.

This is the first part of a clinical research p roject currently in progress, the broad objectives o f which are: in fact, there ( 1 ) To determine is a cranial rhythmical impulse (CRI) ..... ceptible by a craniosacral examiner) is different from the cardiovascular and rhythms of the and the " The cranial rhythmical impulse (CRl) is a n involuntary, ph)'siologic, rhythmic motion which has been reponed by

skilled in cranial osteopathy. It is perceived by

rhe exam iner as his hands are gently and upon the subject's head. The

placed is re-

with the cardiovascular and

portedly not in

of either the subjeCt or the examiner.

•

craniosacral dysfunctions, o n "minimal b rain damage/dysfunction" (MBD) syndromes o f school children (for hyperkine-��'-��"r--' dyslexia, and motor discoordina­ on the other. (3) To determine whether c raniosacral may osteopathic childmodify the to their 0;;;.11. 1"""15 ren when (remedial therapy, motor et cetera). (4) To photographic which may or may not support the cranio­ sacral examination findings. The aim of the first part of the research was completed to test the of the author's c raniosacral examina­ tion findings. The recorded results of 50 craniosacral examinations performed on 2 5 preschool

Repr/fl/edfrom Thejon",ol ofthe Am.ril/In Ostl!Opothk AnGeio/lon, Vol. OSleopothic Association, 212

E.

OhifJ

51.,

Chicogo,

lL 60611.

76, August 1977, /1/1. 890-99,

hy permission ofthe AmericlIN

345 Copyrighted Material

34 6

APPENDIX ]

children were subjected to statistical analy­ sis an unbiased statistician. Each child was examined b y the author and either Dr. year student at MSU­ Irvin Gastrnan COM, trained in craniosacral techniques b y the Dr. Fred 1. Mitchell, (De­ '-HaC"l'-", MSU-COM), or C. Ward (O ffice of Medical Research and MSU-COM). Nineteen parameters o f craniosacral motion", 6. 10 were rated on a scale: 1 easy or "normal" response to in­ duced passive motion; 2 moderate or motransient restriction to induced restriction tion; and 3 severe or to induced passive motion. Increments of 1 ). 0.5 were allowed The was single b lind examiner had knowledge of the other's findings). Ac, the examination p r o­ the results were verbally reported each examiner to a technician who recorded them. 5, 6 , I ! The was by the examiner at the beginning examination, as were the child's and tory rates. These findings were recorded on the child's examination sheet b y the tech­ nician, as were the examiner's own pulse rates. These physiologic and were recorded so that the CRI with other body rhy­ examiner and the subject.

TABLE 1 . PARAMETERS RATED BY EACH 4 68 EXAMINER , ,

OCCIput (restriction o f motion) (restriction of motion)

Temporal bones 3- Right (restriction of motion) 4- Left (restriction of motion)

Sphmobasi/a( joint 5 - Restriction toward flexion 6- Restriction toward extension

=

7-S1debending rotation, restriction toward

=

8-Sidebending rotation, restriction toward 9 -Torsion, restriction toward right 10-Torsion, restriction toward left l 1 -Compression-decompression restriction 1 2 - Lateral strain, restriction toward rigllt 1 3- Latenll strain, restriction toward left 14- Vertical strain,

restriction

toward superior

restriction

toward inferior

motion 1 5 -Vertkal strain, motion

Sacrum 1 6- Restriction toward flexion 1 7 -Restriction toward extension I S- Restriction toward right torsion 1 9 - Restriction toward left torsion The rating system employed is as follows: 1

=

easy or "normal" response to induced passive motion

2

�

moderate Or transient restriction t o induced passive motion

3 = severe or complete restriction to induced passive

METHOD The employed in this study is a straightforward, single-blind protocol. The examinations were done on the premcenter i n East L anises of a local Michigan. child ren were between the ages of 3 and 5 years. Each child was into the examination a rea by a teacher who remained with the child throughout the two examinations (performed the author and one of the three examiners named previously). Since each child was examined in a familiar setting with a fam iliar teacher and ap­ of present, prehension were Afte r the height, weight, and age were

motion Increments of 0.5 between 1 and 3 on the ratmgscale were allowed,

the child was on a in a treatment The first examiner was seated comfortably at the head o f the table. (The other examiner was away from the examination area while the first examiner reported his findings.) Prior to the commencement of the cran­ ial portion of the examination, the technician recorded the and ra tes of both the examiner and

Copyrighted Material

347

APPENDIX )

these data were taken as the child was allowed to lie quietly on the table. Next, the examiner verbally to the tech­ nician (for recording) the CRI rate of the child as counted for one minute. these initial steps, the exam­ iner was asked by the technician to ra te and the ease/restriction to ex­ alllllllt: l-lUUU'''CU passive motion for each of 19 parameters of craniosacral motion. were recorded on the examThese ination sheet by the technician as were rejJo:rreu. The technician to elicit of each of the from the examiner the parameters in the sequence below. Where examiners were hesitant or doubtthe technician forced a decision. the first the completion examination, the second examiner was summoned and the examination rp,n""Hf"
uU'�

� ••� ,

-----

--

RESULTS The results of the statistical analysis of examination data follows, in tabular form (Tables 19 are delineated Parameters 1 in Table 1 . This system of parameter identi­ fication is carried through all data tables. Appendix A presents the mean and stan­ dard deviation values. The raw data are preB. sented i n

DISCUSSION is the The primary of this determination of inter-rater reliability and percentage of agreement as relate to data derived from the craniosacral examin­ ation of p reschool children. the The examination data author were compared data rethree other examiners skilled i n craniosacral examination Each of 2 5 was examined the author and one of the other three examiners. The author was first examiner for 1 3 and second examiner for 1 2 A n examination protocol was devised to include the recording of the CRI rate per rate minute ;, 5, 6. 1 1 the pulse and and the per minute of both the examiner, and 1 9 parameters o f induced craniosacral motion. rating of restriction system relates to the toward each passively induced motion evaluated the examination It should be noted that the parameters refers to restriction toward the named motion rather than the of the " lesion" of the craniosacral mechan­ ism . 6 This modification in nomenclature was made to mini mize " lesion" ization as a source of error. was the A second objective of the mrlarlson of CRI rate per minute with of both the the examiner. Tables 2, 3 , and 4 g ive the coefficients and the percentage o f ment of the author's data as each of the other three examiners individ­ ually. Table 5 compares the author's data with all o ther examiners' data as an aggre­ gate. The appearance of a low reliability coefficient where of agreement is lack of variance from high is due T for normal of a restriction of the �"AAv"� as 1 (no restriction to rated flexion). Dr. Gastman gave 1 ratings to 1 0 of these children and 1 , 5 to 1 child. These data suggest that none of the 1 1 children

Copyrighted Material

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-. .

APPENDIX ]

TABLE

2.

Parameter

AUTHOR'S EXAMINATION RESULTS COMPARED W l TH DR. GASTMAN'S RESULTS (N

Reliability coefficient

."

Percentage of ."rt. Ratin!': variance allowed {

"

between examiners Total percentage of agreement achieved allowing up to 0.5 rating variance

1

Al

82

0

18

0

82

2

39

73

9

0

82

3

.57

64

18

18

18

0

82

4

.47

73

18

9

0

91

5

0

91

9

0

0

1 00

6

.67

91

9

0

0

1 00

7

.95

91

9

0

0

1 00

8

.73

73

18

9

0

91

9

.29

55

27

18

0

82

10

.75

73

27

0

0

1 00

II

92

73

0

0

100

12

.88

82

18

0

0

1 00

1 3

.66

36

55

9

0

91

14

.44

55

27

18

0

82

15

.87

27

1 8

0

82

16

0

18

0

0

1 00

82

1 1 ).

17

0

82

18

0

0

1 00

18

.77

64

36

0

0

1 00

19

. 36

64

18

18

0

82

' Rating scale o f restriction t o induced passive motion; I nO restriction; 1 . ' mild restriction; 2 . 0 moderate restriction; moderately severe restriction; 3 severe to absolute restriction, 2.5 =

TABLE

3.

Parameter

AUTHOR'S EXAMINATION RESULTS COMPARED WITH DR. WARD'S RESULTS (N

Reliability coefficient

Percentage of agreement between examiners Rating variance allowed (%)* Total percentage o f agreement achieved allowing up to 0 . 5 rating variance

'.

I

.71

75

2

25

0

75

2

.76

63

25

I}

0

88 75

3

.49

7'j

0

25

0

4

. 50

75

0

25

0

7'j

5

LOO

1 00

0

0

0

1 00

6

.96

88

1 2

0

0

1 00

7

.87

75

1 3

1 2

0

88

8

.98

88

12

0

0

1 00 1 00

9

1 . 00

1 00

0

0

0

10

.61

50

25

25

0

75

II

.9�

75

25

0

0

1 00

12

.98

75

25

0

0

1 00

I)

.71

88

12

0

0

100

14

. 54

n

1 3

12

0

88

15

0

88

12

0

0

1 00

16

. 24

1 3

n

62

0

38

17

0

12

0

0

1 00

18

.44

88 88

0

12

0

88

19

.60

7)

0

25

0

n

• Rating scale of restriction to induced passive motion: I 2.5

8).

no restriction; t . 5 m i ld restriction; 2 . 0 moderate restrlction� moderately severe restriction; 3 severe to absolute restriction, =

Copyrighted Material

349

APPENDIX ]

TABLE 4. AUTHOR'S EXAMINATION R ESULTS COMPARED WITH DR. MITCHELL'S RESULTS (N � 6). Percentage of agreement between examiners Rating variance allowed Reliability Para.meter

coefficient

I'±O

.

±0. 5

(%)'

Total percentage of agreement achieved

± 1 .0

, ± > 1 .0

allowing up to 0 . 5 rati ng . variance

I

.77

83

0

17

0

83

2

1 . 00

1 00

0

0

0

100

3

0

50

17

33

0

67

4

.82

50

33

17

0

83

5

. 70

67

0

33

0

67

6

.88

83

0

17

0

83

7

.53

67

0

17

16

67

8

.63

83

0

17

0

83

9

.70

50

17

33

0

67 67

10

0

67

0

33

0

I I

.61

50

33

17

0

83

12

1 .00

1 00

0

0

0

1 00

13

0

83

0

17

0

83

14

.53

83

17

0

0

1 00

15

.65

50

17

33

0

67

16

0

50

17

17

16

67

17

0

0

17

50

33

17

18

0

50

0

50

0

50

19

.63

67

0

17

16

67

· Ra t i nA scale o f restriction t o induced passive motion:

1 = no restriction� I. � = mild restriction; 2,0 .,. moderate restriction;

2.5 = moderately Severe restriction; 3 = Severe to absolute restriction.

TABLE 5. AUTHOR'S EXAMINATION RESULTS COMPARED WITH RESULTS O F ALL OTH ER EXAMINER'S R ESULTS A S A N A G G R EGATE (N - 2 5 ) .

Percentage o f agreement between examiners (total) Rating variance allowed Reliabi l i ty Parameter

coefficient

rxO

,

±0. 5

(%)'

±1.0

± > 1 . 0'

allowing up to 0 . 5 rating variance

I

.72

80

0

20

0

2

.77

76

12

0

88

3

. 56

64

12 12

24

0

76

4

.75

68

16

16

0

84

5

.88

88

4

8

0

92

6

.9 1

88

8

4

0

96

7

.70

80

8

8

4

88

8

.87

80

12

8

0

92 84

80

9

.78

68

16

16

0

10

.54

64

20

16

0

84

I I

.9 1

68

28

4

0

96

12

·97

84

16

0

0

1 00

I3

.85

64

28

8

0

92

14

.85

68

20

12

0

88

15

. 88

20

16

0

84

64

16

.38

52

20

24

4

74

17

.16

64

16

12

8

80

18

.67

68

20

12

0

88

19

.46

68

8

20

4

76

' Rating scale of restriction to induced passive motion: I =

Total percentage of agreement achieved

no restriction; 1 . 5 = mild restriction; 2 . 0 = moderate restriction;

2.5 = moderately severe restriction; 3 - severe to absolute restriction.

Copyrighted Material

APPE NDIX ]

350

TABLE 6, PERCENTAGE OF AGREEM ENT B ETWEEN TH E AUTHOR A N D OTHER EXAMIN ERS ON TOTAL EXAMINATION, allowed

Dr. Gastman (N I I )

Dr. Ward ( N 8)

Dr. Mitchel! ( N 6)

A�gregat1: (N 25)

0 ±O, 5

7 2% 92%

77% 88%

65% 74%

71% 86%

Rating variance

displayed even moderate restriction toward flexion. B o th examiners are in 1 00 percent this finding. Since the agreement agreement is so high, the probability that these particular children did not manifest restriction toward flexion is also very high. However, since the variance of fro m normal is practically zero, the c oefficient is zero. This appearance of Ull"l<:;dULlHi!'; , since both examiners conclusions . coefficients with high percentage of agreement may also occur when neither physician actually examines the parameter but and when the test is insenrates it as parameters o ffer testimony this possibility.) Similar situations to the wherever the reader one described observes a low reliability coefficient coupled with a high percentage o f agree­ ment on the same parameter. The fre­ quency o f this happening is related to the fac t that most of these somewhat randomly selected children may be thought "n'o rmal," and, of as that there was little o r motion. coefficient and the both high, this percentage indicates that an abnormal was reSimilarly both examiners. For in Table 2, parameter 7 , the coefficient is .95 and the percen­ tage of agreement is 1 00 percent if one allows ±O.S motion restriction rating vari­ ance (9 1 if one allows 0 rating parameter is a measure of restriction toward induced passive right motion:-6 The data reflect that there were indeed restrictions noted and that the of the abnormal restrictions was both highly reliable and

�

�

Another example of a highly reproduc­ ible and reliable rating is seen in Table 3, parameter 9 toward induced right torsion of the sphenobasilar jOint4.6). The author and Dr. Ward achieved a reliability coefficient of 1 .00 and 1 00 percent The range of for both ex· was 1 - 3 the mean aminers was 1 . 7 5 0. This indicates that both the author and D r. Ward found the same re­ striction unde r blind condi tions on the same every time. The variances from a 1 are such that a coefficient of reliab ility was achieved as well as a pe rcentage of agreement. Parameters that show a low reliability of agreecoefficient and a low restrictions ment indicate that were found b u t that agreement between ex­ of restriction was aminers as to the 1 7 of poor. Such is the case for Table 4 , with t h e author D r. Mitchell in rather marked 1 7 rates induced sacrum toward extension. this instance, the author rated all between 1 and 2, with a mean rating . D r. of rating was 1 - 3, with a Mitchell's mean of 1 .92. d isagreement indicates that the two examiners are either measurdifferent things, or that are interdiffe rently. their I t is interesting to note the data derived from the examination of the sacrum (para­ only the per­ meters centage of agreement, the author and Dr. Gastman achieved 1 00 percent agreement (allOWing ± on parameters 1 6, 1 7 , and 1 8 , and 82 percent on parameter 1 9 . Since Dr. Gastman was trained in craniosacral technique by the author, it would indicate similar meththat both examiners are

Copyrighted Material

35 1

APPENDIX ]

TABLE 7.

COMPARISON OF CRl RATE WITH PULSE A N D RESPIRATORY RATES O F EXAMINER AND

SUBJECT. Examiner

Patient Patient No.

/

\

.

Pulse/mi n u te

Resp./minute

CRl/minute

(

.

Pulse/minute

'l Resp.lminute

84

18

12

80

84

24

15

68

18

2

84

22

12

74

18

84

22

15

80

16

3

96

18

9

84

16

88

22

8

76

18

96

24

8

76

18

84

34

8

72

16

84

30

12

90

20

1 20

28

14

84

28

92

22

14

72

16

88

20

16

70

20

I

4 5 6 7 8

9 10 11

18

92

24

16

86

22

88

24

14

76

18

80

24

12

94

16

1 00

26

16

76

20

100

22

12

90

18

96

24

14

98

22

96

24

12

74

18

96

24

13

80

16

84

20

12

78

20

1 00

28

12

72

18

12

90

24

16

84

16

96

24

16

62

10

13

1 10

24

12

76

16

120

36

12

66

16

96

20

10

74

16

84

24

14

60

14

92

20

12

80

1 6.

82

36

1 3

60

12

92

20

10

80

14

82

20

12

72

16

96

24

1 3

82

16

14 15 16 17

96

24

12

72

14

18

90

24

10

78

16

96

36

1 3

66

14

19

1 20

24

12

82

40

12

64

16

92 88

28

I I

84

1 00

20

10

76

16

90

24

12

90

20

88

22

10

80

14

82

22

10

74

18

1 24

24

10

76

22

76

16

10

88

16

80

16

9

76

16

88

18

12

80

16

84

20

10

74

16

82

24

1 1

82

18

80

28

8

80

15

20 21 22 23 24 25

ods and techniques which then result in similar interpretations and ratings. Agreement achieved between the author and Dr. Ward indicate only 38 percent agreement in evaluation of sacral f1exion,4.6

14 18

but 1 00 percent agreement i n the evalua­ tion of sacral extension.4,6 The reverse is true of the resul ts of achieved percentage of agreement with Dr. Mitchell. The author and Dr. Mitchell reached 6 7 percent agree-

Copyrighted Material

APPENDIX A l

APPENDIX A2 MEAN TABLE.

Parameter

Minimum

Maximum

Standard

Parameter

Minimum

Maximum

number

value

value

Mean

deviation

number

value

value

Mean

deviation

1

1 .00

2 . 00

1.23

. 4 1 0 1 00

I

1 . 00

3.00

1 . 75

. 7 0 7 1 07

2

1 .00

2.00

I . 32

.4622 0 8

2

1 . 00

3 . 00

1 .94

.863444

3

1 .00

2.00

1.73

.467099

2 . 00

3.00

19

. 37 20 1 2

4

1 . 00

2 .00

1 18

.404 5 2 0

;.

4

1 .00

2.00

1 .50

. 5 34 5 2 2

;;

1 . 00

1 .0 0

1 .00

.000000

5

1 . 00

3 . 00

1 . 50

. 7 5 5 9 29

6

1 . 00

1 .50

1 .05

. 1 .5 0 1 5 6

6

1 .00

2.00

1 .) 0

. 5 34 5 2 2

7

1 .0 0

2 . 00

1 .4 1

.490825

7

1 .00

3.00

1 . 56

. 7 28869

8

1 .00

2.50

1 .2 7

. 5 1 7863

8

1 . 00

3 . 00

1 . 88

.83452 3

UpJedger

Standard

Upledger

9

1 .00

2.00

1 .27

.410 100

9

1 . 00

3.00

1 .75

. 70 7 1 07

10

1 .00

2 . 00

1.18

.404 5 20

10

1 . 00

3 . 00

1 . 44

. 728869

11

1 .00

3.00

1 .4 1

.6640 1 0

II

1 .0 0

3 . 00

2 . 00

. 7 5 5 929

12

1 . 00

2.00

1 .27

.4 1 0 1 00

12

1 .00

3 . 00

1 .69

, 7 98995

13

1 . 00

3 . 00

1 .9 5

.47 1 940

13

1 .0 0

3 . 00

1 .6 3

.744024

14

1 .0 0

2 . 00

1 .2 3

.343776

14

1 .00

3.00

1 . 38

744024

15

1 .0 0

3 . 00

1 .3 2

.64 3 1 46

15

1 .00

3.00

1 .44

. 728869 . 70 7 1 07

16

1 .00

1 .0 0

1 .00

.000000

16

1 .00

3 . 00

1 .50

17

1 .00

1.50

1 .0 5

. 150756

17

1 .00

2.50

1. 3 1

.5 9 3867

18

1 . 00

2.00

1 . 36

. 39 31 2 3

18

1 .00

3 . 00

1 .75

.707 1 0 7

19

1 . 00

2 . 00

1 .27

. 4 1 01 00

19

1 .00

2 . 00

1 . 38

. 5 1 7 5 49

I

1 .00

2.00

1.23

.4 1 0 1 00

1

1 . 00

3 . 00

1 . 75

. 7 0 7 1 07

2

1 .00

2.00

1.18

. 3 3 7 1 00

2

1 .0 0

3 . 00

1 .88

.640870

3

1 .0 0

3.00

1 . 59

.664 0 1 0

3

1 .00

3.00

2. j }

.640870

4

1 . 00

2 . 00

1.18

. 3 37 1 00

4

1 .00

2.00

1 .50

.5 34522

5

1 .00

1 .5 0

1 .0 5

. 150756

5

1 .00

3.00

1 . 50

. 7 5 5 9 29

6

1 .0 0

1 .50

1 .09

. 2 0 2 260

6

1 .00

2.50

1 .56

.6 2 3 2 1 2

Gastman

7

Ward

1 .0 0

2 . 00

1 .36

.452267

7

1 .00

3 . 00

1 . 38

,744024

8

1 .00

2.00

1 .36

.504 5 2 5

8

1 .0 0

3 . 00

1 .8 1

. 7 )2970

9

1 .0 0

2.00

1 . 32

.4622 0 2

9

1 .00

3.00

1 .75

. 707 1 07

10

1 . 00

2.00

1.23

. 34 37 7 6

10

1 .00

2,00

1 . 56

.495 5 1 6

11

1 . 00

2.50

1 . 36

. 5 5 1 85 6

11

1 .00

3.00

2. 1 3

.694365

12

1 . 00

2.00

1 .1 8

.404920

12

1 .00

2.50

1 . 56

. 6 2 32 1 2

13

1 .0 0

3 . 00

1 .77

.606780

13

1 .00

2.50

1 .5 6

.6232 1 2

14

1 .0 0

2 . 00

1 . 32

.462208

14

1 .0 0

2.50

1 .44

.62;'2 1 2

15

1 .00

3 .00

1 .59

.700649

15

1 .00

3.00

1 .50

.7 55929

16

1 .00

1 .50

1 .09

.202260

16

1 .00

2.00

1 . 75

.4629 1 0 .462 9 1 0

17

1 .00

1.50

1 .0 5

. 1 50 7 5 6

17

1 . 00

2.00

1 .25

18

1 . 00

2.00

1. 3 2

.404 ) 2 0

18

1 .00

3.00

1 .63

.744024

19

1 . 00

2 . 00

1 . 27

.467099

19

1 .00

2 .0 0

1 .6 3

.5 1 7549

ment on sacral but 17 percent agreement on sacral extension. Further, it may be noted that the percentage of agree­ ment achieved b etween the author and Dr. Mitchell on the c ranial of the examination is much than that achieved on the sacral motion testing. The reader should be aware that the auth o r and Drs. Ward and Mitchell did n o t discuss or pracwith each other tice c raniosacral upon this study. prior to author asked these two examiners

to fa miliarize themselves with the examina­ tion protocol and then to adhere to it as as possible. } Table 5 presents the data on all 2 5 for comparison of the author with the other three examiners as an aggregate. These data are more strictly a statistical evaluation of the reproducibility of the author's examination results. This analysis was carried out because this study is essen­ tially an attempt to determine the relia­ bility and reproducibility of the author's

Copyrighted Material

35 3

APPENDIX ]

APPENDIX A4. MEAN TABLE.

APPENDIX A3. MEAN TABLE. Parameter Minimum Maximum number value value

Mean

Standard deviation

Parameter Minimum Maximum number value value

Mean

Standard deviation

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

1 .00 1 . 00 2.00 1 . 00 1 .00 1 .00 1 .00 1 .00 1 . 00 1 . 00 2.00 1 .00 1 . 00 1 . 00 1 .00 1 .00 1 . 00 1 . 00 1 .00

2.00 2.00 2.00 3.00 3.00 3.00 3.00 2.00 3.00 2.00 3.00 3.00 3.00 3.00 3.00 2.00 2.00 2.00 2.00

1 . 83 1.17 2.00 2.00 1 .67 1 . 33 1 . 50 1.17 1 .92 1.17 2.25 2.33 1 . 67 2.08 1 . 75 1 . 50 1 . 50 1.17 1.17

.408248 .408248 .000000 .894427 . 8 1 6497 . 8 1 6497 . 836660 .408248 .80 1 04 1 .408248 .4 1 8 3 30 1 .032796 1 .032796 . 80 1 04 1 . 758288 .547723 .547723 .408248 .408248

Upledger 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

1 .00 1 .00 1 .00 1 . 00 1 . 00 1 .00 1 .00 1 .00 1 .00 1 .00 1 .00 1 .00 1 . 00 1 . 00 1 . 00 1 . 00 1 .00 1 .00 1 .00

3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 2.50 3.00 2.00

1 . 54 1 .48 1 . 94 1 .48 1 . 32 1 . 26 1 .48 1 . 44 l . 58 1 . 26 1 . 80 1 . 66 1 . 78 1 .48 1 .46 1 .28 1 .24 1 .44 1 . 28

. 5 75905 .668954 .416333 .65 3 1 97 .627 1 6 3 . 5 2 28 1 3 .637050 .66645 8 .656379 . 5 2 28 1 3 . 7 2 1 688 . 8 1 29 1 7 .708284 .684349 .69 1 0 1 4 . 5 220 1 5 .459 1 66 . 5 46 1 9 9 .4349 3 3

Mitche l l 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

1 . 00 1 .00 1 .00 1 . 00 1 . 00 1 . 00 1 . 00 1 .00 1 .00 1 .00 2.00 1 .00 1 .00 1 .00 1 .00 1 .00 1 .00 1 .00 1 .00

3.00 2.00 2.00 3.00 3.00 3.00 3.00 2.00 3.00 2.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 2.00 3.00

2.00 1.17 1 . 58 2.00 1 .67 1 . 50 2 . 00 1. 33 2.00 1.17 2.58 2.33 1 . 83 2.17 2.17 1 .92 1 . 92 1 . 33 1 . 67

.632456 .408248 .49 1 596 .948683 . 8 1 6497 .836660 .894427 . 5 1 6 398 .894427 .408248 .49 1 596 1 .032 796 .983 192 .752773 .752773 . 9 1 7424 . 9 1 7424 . 5 1 6398 1 . 032796

Aggregate 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

1 .00 1 .00 1 .00 1 . 00 1 . 00 1 . 00 1 . 00 1 . 00 1 . 00 1 .00 1 .00 1 .00 1 .00 1 . 00 1 .00 1 . 00 1 . 00 1 . 00 1 . 00

3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 2 . 00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00 3.00

1. 58 1 .40 1 . 76 1 .48 1 . 34 1 . 34 1 .52 1 . 50 1 . 62 1 . 32 1 .90 1 .58 1.72 1.56 1 . 70 1 . 50 1. 32 1 .42 1 .48

.64-0 3 1 2 . 5 5 90 1 7 .6474 3 1 .6 5 3 1 9 7 .624500 . 5 7 2 276 .699405 . 6 1 2 372 .6964 1 9 . 4 30 1 1 6 .763763 .786342 .6934 2 1 .6664 5 8 . 7 50"000 .629 1 5 3 .6 1 0 328 . 5 5 3022 .653197

Upledger I

craniosacral findings (thus lending more credibility to the balance of the research project). Perusal of Table 5 reveals that the reliability coefficients are below accept­ able levels (0.7) on parameters 3 and 10 in the cranial portion of the examination. This low reliability coupled with high percent of agreement is probably due to the scarcity of abnormal findings. Table 6 gives the overall percentage of agreement for the total examination be­ tween the author and the other examiners,

both individually and as an aggregate. In calculating the total percentage of agree­ ment, a weighting system was applied so that the number of examinations done by each examiner is proportionately repre­ sented. Allowing ± 0 . 5 variance on the motion restriction rating scale for all 1 9 parameters, the overall agreement was 86 percent. The author considers this level of agreement acceptable to validate the relia­ bility and reproducibility of the results of his craniosacral examinations.

Copyrighted Material

APPENDIX ;

APPENDIX B. E X A M I N ATION RES ULTS Subject No.

Physician

U

2

4

6

U G U G

2 1 .5

2

I

L5

2

I

U

L5

1 .5

2

2 2

2

II

G U G

2

1 .5

1 2

1.5

1.5

1 .5

3

2

1.5

I

1.5 l.5

2 1.25

2 2 2

2

1 . 25 1.5

1.5

L5 2

2

1.5

L5

2

l.5

1

2

2

1

1.5

2

2

l .5

2

2

2

1.5

L5

2

2

2

2

2

2

1

2

2

U

2.)

2

2

2.5

1.5

2

W

2

2

2.5

3

3 2. )

2

2.5

2

2

3 2 5

2.5

2 2 2

I

1.5 2

U

3

I 2

2

W

2

U

3 2

1

2

2

2

2

2. 5

1

2

U

2

2

2

2

2

2

2

U

2

2

2 2

U

2

M

2

2 L5

U

2

M

2

2

2

2

2 l.5

1 ,5

3 I

2

2

2

U M

2

2.5

2

3

2 L5

2

2

M M

2

2

2

2

I

1

2

2

2

2

3

2.5

2.5

3

3

Copyrighted Material

2

2

2

2

2

2

2 2

2

!

U

U

5

3

W 2

2 L5

U

1.5

2

U

L5

2

2. :; 2

2

2

1 .5 2

1

M

25

1.5

1

2

U

W

24

1 .5

1.5

W

23

I

1.5

2

2

2

l.5

U

W

22

1.5

U

1.5

W

21

2.5

2

2

2

20

2

2 1

19

1.5

U

2

18

2

2

U

17

1.5

2. :;

2

2

2 l .5

U

2

1.5

I

2

2

W

2

2

U

G

16

1 .5

2.5

U

10

15

I

1.5 L5

2

2

G

14

2

1 .5

8

13

2

2

3

G

12

1.5

1.5

2

I

L5

1 .5

I

U

G 7

U

1.5

G U G U G

2

2 2

1

355

APP ENDlX J

Table 7 presents the data derived fro m the measurement o f the CRI rate and the other body rhythms each of the .50 Perusal of examinations of the 2.5 this data reveals that in .5 0 measurements ( 1 0 rate within one another rhy­ thm of either examiner or subject. Theretime the CRI ra te was 90 different from the pulse and rates of the examiners and subjects. This finding evidence in favor of the CRI as an body rhythm. The au thor does not mean to imply that the CRI may not be the resultant modulation of other body rhythms, it was different that 90 percent of the time. CONCLUSIONS it is able degree percentage of agreement iners craniosacral examination methods and techniques. Second, this interexaminer reliability and percentage of agreement lends c o n­ siderable evidence to the existence of a real and perceptible craniosacral motion system. an craniosacral examination and well-trained examiner may be considered reliable and reproduc­ is reserved for ib le.

5.

Wales,

The work of William Garner Suther­ May 7 2 Magoun, H.I., Sr.: Os te opa thy i n t h e cranial field. J o urnal Printing Co., K i rksville, M issouri, 1 966 Magoun, R I . , The tem p o ral bone, Troublemaker i n the head. JAOA 7 3 : 8 2 5 - 3 5 , Jun 7 4 Woods, R.H.: Structural normalization in infants and c h i ldren with particular reference t o disturb­ ances o f the central nervOUs s yst em . ] AOA 7 2:903A.L.:

land. ]AOA 7 1 : 788-93,

6. 7, 8.

8, May 9.

1 0. II,

Michael, D.K., and Retzlaff, E.W.: A preliminary study of c ra n i a! bone movement in the squirrel monkey. JAOi\ 74:866-9, May 7 5 Retzlaff, E.W., Michael, D.K., a n d Roppel, R . M . : Cranial b o n e mo bi l i t y. )AOA 74:869- 7 3 , May 7 5 Dunbar, H.S., Guthrie, T.C, a n d Karspell, B , : A study of the cerebrospinal fluid pulse wave. Arch Neurol (Chicago), 1 4 : 6 24·30, Jun 66

Baker, E.G.: Alteration i n width of max illar y arch and its relation to sutural movement of cranial bones, 70: 5 5 9 -64, Feb 7 ! Brierley, J.B., and Field, EJ.: Connexions o f spinal sub­ arachnoid space with lymphatic syste m. J Anat 8 2 : 1 5 366 , Ju 1 4 8 Brierley, ). B.: Metabolis m of the nervous system. D. Richter, Ed. , Pergamon P ress, New Y o r k , 1 9 5 7 K ao , F . F . , and Ll o yd , B . B , : Cerebrospinal fluid and Ihe regulation o f ventilation. F.A. Davis Co. , Philadelphia, 1 96 5

Brooks. C ,

Brown, ].H.V., Ja co bs, ).E., and Stark, L.: Biomedical engineering. F.A. Davis Co., Philadelphia, 1 9 7 1 Dandy, E . : The brain. Harper & Row, New York,

1 969

Davson, H.: PhYSiology of the cerebrospinal fluid. C h u rchill, London, 1 9 6 7

Flexner,

L.B.: Some problems o f origin, circularion and

absorption of c erebrospi na l fluid.

Quart Rev BioI 8 : 397-

4 2 2 , Dec 3 3

Appreciation is expressed to the officials ofthe East schools and to Drs. john Haubenstricker and Vernon Seefeldt, the Motor Coordination Physical Clinic in the Departmmt of Education and Recreation of Michigan State Uni­ versity, who have been so generous with their time and efforts in this research.

I.

2.

3.

4.

Winchell, C A. : Theh ype rk i n e tic child. Greenwood Publishers. Westport, Conn" 1 9 7 5 W . E . , and Drury, F . : The menBe te r. T.R . , tally retarded and his motor behavior. Charles C. Thomas, Publisher, Springfield, Ill., 1 97 2 Mor ris, P.R., and W h iting, H.T.A.: Motor impair­ ment and c o m pe nsa t ory education. G. Bell and Sons, London, 1 9 7 1 Sutherland, W.G,: The cranial b owl . Free Press Co., Mankato, Minn., 1 9 39

Frymann, V.M.: Relation o fdisturbances o fc ra ni os ac ral mechanisms to sy mp t om at o l ogy o f the newborn, Study o f 1 ,2 5 0 infanls. J AOA 6 5 : 1 059-7 5 , Juo 66

G ray, R : Anatomy of Ihe h u ma n body. Ed. Goss, Ed. Le a & Febiger, P hi la d e l ph ia, 1 9 5 4

26. C M .

Hamil, H.F., B eall, A. C .,J r. , and DeBakey, M.E.: Hemo­ dynamic influences upon brain and cerebrospinal fluid pul sati on s and p r ess ures. J Trauma 5: 1 74-84, Mar 65 Leusen, L: Regulation o f cerebrospinal fluid composi­ tion with re fe ren c e 10 b reathing. Physiol Rev 5 2 : 1 -5 6 , Jan 72 Michael, D.K.: Th e c er e br ospi na l fluid. Values fo r c o m­ pl ia nce and resis ta nc e to ab sor ption. ) AOA 74:87 3-6, May 7 5

Miller, H .C : Head

pain, J AOA 7 2 : 1 3 5 -4 3 ,

Oct

72

Netter, F. H.: T h e nervous system. Ciba Pharmaceutical Products. Inc . . New York, 1 9 5 3 Pritchard, J.J., Scott, ) . R , and GirgiS, F.G.: The struc­ ture and development o f cranial and facial s uture s. J

Copyrighted Material

356

APPENDIX ]

Weed, L H. : Positional adjustments of the pressure o f

Anat 90:70-86, Jan 5 6 Retzlaff, E.W., Michael, D.K., F.L.: The structures o f

RM., and Mitchell, s u rures. ]AOA

cerebrospinal fluid. Physiol R e v 1 3:80- 1 02, J a n 3 3 Weed, L.S.: The cerebrospinal fluid. Physiol Rev 2 : 1 7 1 22

7 5 :607-8, Feb 76

Welch, K., Friedman, V.: The cerebrospinal fluid values.

Retzlaff, E.W., ble functional

bone Sutures.

American A ssociation of Anatomists, 88th Session, MSU-COM, March 24-27, 1 9 75

Brain 8 3:454-69, Sep 60 Wolstenholme, G . E . W . , and O'Connor, C.M.: aBA symposium on cerebrospinal fluid production, circula­

Rubin, R.C., e l al.: The production o f cerebrospinal

tion, and absorption. Churchill, London, 1 9 5 2

fluid in man and its modification b y acetozolamide. J Neurosurg 2 5:4 30-6, Oct 66 Schaltenbrand, G . : Normal and pathological physiology o f cerebrospinal fluid circulation. Lancet 1:805-8, 2 5

for publication in March 1977. as necessary, has b een done

Apr 5 3 Thomas, L M . , e t

Static deformation and volume

changes i n the human skull. Stapp Car Crash P roceed­ ings, 1 2 th Annual Conference, Detroit, October 22-2 3 , 1 968 Warwick, R . , and Williams, P.L.: Gray's Anatomy. Brit. Ed. 35. W. B. S a u nders Co., Philadelphia, 1 97 3

has been funded in part by N1H Biomedical Research Grant No. G RSP 1 8- 1 976 and by an institutional grant from the AOA Bureau of Research.

Copyrighted Material

Appendix K

Holism, Osteopathy and Biomechanics JOHN E. UPLEDGER, D.O., F . A . A . O . , Associate Professor, Michigan State University, College of Osteopathic M ed icine, Guest Editor'

Recently I have material in several "Holistic Pain Control" seminars, There seems to be considerable amount of activity in this area by medical als around the world, I have been Almost without imp ressed that "Holism" translates to mean "multidisciplinary," It does not appear to to mean me that "Holism" is that the "Holistic must search for and treat the primary cause of the approach means Pain Control" that Centers are being born which include such modalities as: Therapy Acupuncture Transcu taneous Electrical Nerve Stim­ ulation evaluation and Pastoral counseling Manual Medicine Physiotherapy Self Hypnosis (Positive imaging) Surgical procedures Environmental Nutritional Therapy Environmental Therapy, and the like

Each of these modalities will produce effect i n selected cases. some Taken in combination, the percentage o f effectiveness is increased. that the I am, very words " Holistic Pain Control" u nder which the philosophical many of these It does not mean elimination o f pain by and treating the cause, I t simply means the reduction of to tolerable levels by the use of newer and as well as by It

primary cause. It is, obvious that an awareness of the neuromusculoof the skeletal system and biomechanics is devel­ oping as this Holistic approach grows. gain inclined will begin to realize that in a number of cases this magnificent neuromus­ culoskeletal system contains the patient's £OTi'llHt:tt: s tudy medical history. And that by of this system, the dedicated physician i s usually able t o determine the cause of the the need for "Holistic thus Pain Control."

'Reprinted/rom Michigan OsteopathicJot/rna/' November J 977, p. 11, bypermission o/tbe Michigtlfl Associotion 0/Ostcopothie PhysicioflS ,md Surgeons, Inc.

357 Copyrighted Material

358

APPENDIX K

Perhaps this to identify and treat causes of symptoms and dysfu nctions, can be named Holistic and Treatment. hand, i t has already On the and Treatment and does not need further name IJ U ,- " L l V l l of the princi­ osteopathic profession

virtue of educational and philo­ than are other branches in of the healing arts. Osteopathy possess a l l of the tools to p ractice Holistic medicine or healing. Osteopathic their careers in the healing arts with this definite

flit. GtllUW. and attacks many our osteopathic physicians is i n­ deed an unfortunate circumstance which has caused a upon (if not ·an embarrassment related to) the r.�tpF' m . t h and treatment. use of the hands i n It is time that we physicians gained some pride in the use of our hands as the fine diagnostic and treatment tools they are. We understand very li ttle of the unpotential which the human organ­ ism possesses in terms and understand patient IJHJU" ,-",,,,, you this because I want to I am for make a begin to use the hands can when neuromusculoskeletal system in the search for the cause of the

Copyrighted Material

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Copyrighted Material

Index

A

Temporal, 1 5 9, 1 7 2 Vomer, 1 96 Zygoma, 1 98

Abscesses, 266 Acupuncture, 1 9 9 , 2 6 7 , 2 9 5 ·96

B

Adhesions, post operative, 240 A l lergies, 1 08 , 1 20 Anatomical directions, 24 Aneurysm, intracranial, 269 Anterior-posterior

see Compression of

of the cranial base

see

Arachnoid granulations, 1 2

Birth trauma, 1 1 5 , 1 24

Arcs, l oc alizing restrictions through, 244-4 5 , 249-50

Asterion, 24 Asthma, 2 6 7 A tlantooccipital compression

Restrictions

Biliary dyskineSia, 2 6 7

Arachnoid villae, 1 1 , 1 2 , 1 4 Arbuckle, Beryl E., 2 5 6 n

Articulatory technique, 1 40

alsD

Becker, Frederick, 1 3

Arachnoid membrane, 1 5 - 1 6, 2 3 8

Rheumatoid , 267-68

Elastic, 20 Rigid, 1 9

Anxiety, 2 1 3 , 268

Arthritis, 4 3

Barriers

see

restriction osseous

Bowel dysfunction, 260, 267 Brain, right a nd left, 2 6 - 2 7 Breathing assistance, 70, 1 09 Bregma, 2 4 , 1 88 Bunt, E . A . , 1 2

see Occipital condyles, Compression of

Atlas, 5 8 Atrial tachycardia, paroxysmal, 2 6 7

c

Autism, 2 3, 1 20 Craniosacral motion in, 8 Craniosacral related research, 1 2 2-24, 2 6 2 - 6 3 Lumbosacral co mpression a n d , 1 4 1

Carotid sheath, 2 3 9

Temporal compression and, 1 76

Cephalgia

Treatment, 4 5 , 26 3-64 Autonomic flexibility, 22, 43 Autonomic nervous system, 2 2 Dysfunction, 1 4 9 , 1 76 , 2 6 7 Axis of rotation

see

Headache

Cerebellar tent

see Tentorium

cerebelli

Cerebral ische mia, 2 1 2 Cerebral palsy, 1 1 6 , 2 6 1 -6 2

Ethmoid, 1 56

Cerebrospinal fluid, 1 4 , 2 0 , 6 1

Frontal, 1 5 8

Cerebrospinal fluid pressure, 8 9

Nasal, 1 99 OCCiput, 1 5 9 Sacrum, 6 Sphenoid, 1 5 5

Control mechanisms, 1 2 Cervjco-thoracic junction see Thoracic inlet

Cervicothoracic thrust, 54

361 Copyrighted Material

Choroid plexus, I I , 1 2 , 14 Cicatrix, 8, 2 39-40 Circu mferential treatment technique, J 79 Clinoid Jef clinoid process e N . III, 9 2 eN. I V , 9 2 eN. V, 9 2 eN, VI , 9 2 CN. VII, 9 5 eN. IX, 9 5 , 206 e N. X, 9 5 , 206 e N. XI, 9 3 , 95, 206 eN. XII, 9 5 , 1 69 Coccyx, anterior flexion, 1 49 · 5 0 Treatment of, 79, 1 50 , 2 9 8 Collagen fibers, 1 3 0, 2 3 6 Coma) craniosacral motion in� 6 ) 249 Com p ression-decompression of the cranial base, 74-76, 1 2 5-26 Compression of the cranial base Clinical significance, 1 20, 268 Definition, 1 0 1 - 1 02 , 1 22 Evaluation for, 1 2 5 Lateral, 1 2 7-28 Treatment, 1 2 5-26 Com p ression of the fourth ventricle ief CV-4 Condyles see Occipital condyles Connective tissue, mechanical properties of, 1 28- 30 Core l i n k , 1 6- 1 7 Jee a!so Dural tube Cranial base Ana tomy, 1 6 Compression, 1 2 0- 22 n-dec<)m'pressi':>n, 74-76, 1 25-26 Mobilization in np,,,, OMI1< 2 5 8 Osseous com ponentS of, 88 Release, 5 7 - 5 8 Cranial base dysfunction I a t rogenic, 1 9 7 Motion testing for, 1 0 1 - 1 0 5 , 1 1 1 - 1 3 , 1 1 8 Sutherland model of, 9 5 -96 Cranial base fossa(e) Anterior, 89-90 Middle, 90-92 Posterior, 92-95 Temporal, 92 Cranial rhythm see Craniosacral motion Cranial rhythmic i m p ulse (CRI) see Craniosacral motion Cranial sutures Classification, 1 5 2-5 3 M o ti o n a t , 1 2, 1 6 , 60, 1 5 2 Structure of, 2 7 3 iee also Sutures Cranial vault, 1 6 Cran iosacral (rhythm ic) motion, 2 7 5 - 7 7 Becker's m o d e l of, 1 3 Definition, 6 in Denervated tissue, 8 in Infants, 2 5 6

i n Inflamma tory conditions, 8 Pressurestat model of, 1 1 - 1 2 Quality of, 24 3 Rate of, 24 3 from Sacrum, 3 3,34 S u t h e rland model of, 1 1 - 1 2 Symmetry of, 24 3 Craniosacral system, 5 , 1 4- 1 5 Craniosacral treatment, contraindications, 265 CRr Craniosacral motion Cribiform plate, 90 Crista gal li, 90 CV-4 , 7 9 Contraindications, 4 2 restriction, 54 ImeClnon. 266 Occipital technique of, 4 1 -44 for Paravertebral somatic dysfunc tion, 1 3 8- 39 for Raynaud's phenomenon, 2 6 7 Results, 42-43 for Rheumatoid arthri tis, 267 Self-induced, 3 1 0- 1 1 see also S ti l l point

D Dashpot, 1 28 Decom pression of cranial base, 7 4-76 Denervated m uscles, 248-49 Dental trau rna and scoliosis, 268 Depression (of mood), 1 4 1 , 240 Compression of the cranial base and, 1 20, 268 Diaphragms, cross·restricting, 2 3 Pelvic, 49-5 2 Respira tory, 46-49 Direct technique, 2 1 , 1 14 , 1 1 8 Cautions regarding, 1 9 7 Facial problems and, 1 8 5 Newborns and, 2 5 8 Direction o f energy. 7 4 F a l x cerebr! released by, 7 4 , 1 6 3 for Local infection, 2 6 3 Paravertebral somatic dysfunctions released by, 1 39· 40 Subcoronal membranous restrictions released by, 74 Sutural restrictions trea ted by, 1 64-66 Direction of fluid see Direction of ene rgy Dorsum sellae, 9 2 Dura mater, 1 5 , 1 3 1 , 2 38 Spinal, 1 3 1 , 32 see IIfso Dural tube Dural continuity, 6 7 , 1 3 2 Dural drag. 240, 243-44 Dural membranes, 1 5 , 1 6 Abnormal tension. 60 Anatomy, 6 1 -67 Anterior-posterior. 6 7 . 69- 7 7 Fiber orientation, 60 Horizontal system, 69

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INDEX

Durnl m e m b ra ne s l�'JIll'W"<"" } Inflammation 8 Local izing restrictions, 244 Osseous attach me nts, 1 3 1 Superior- inferior, 69, 7 7-80 T rans ve rse system, 69 Vertical sy stem , 67, 7 7 Dural slee ve s, 1 3 1 Dural tube Evaluation of mobility, 7 7-78, 1 3 3-35 Localiza tio n of restrictions, 79, 245-47 Mobilization, 1 38-39, 2 5 9-60 fee alJ. Core link Dyslexia, 1 76, 2 1 1 , 2 6 1

E Ear proble m s, middle, 269 " Ea r pull" technique, 1 27-28, 1 79-82 Edema, 4 3 Elastic fibers, 2 36 "ElastocolJagenous complex," 2 36 Embryology of the skull, 1 68-69 Emotional disorders, 268 Endocrine disorders, 1 20 Ethmoid (bone), craniosacral motion of, 1 5 6-5 8

Fever, 6, 42-43 CV-4 treatment of, 266 Flexion Definition, 7 , 1 9, 3 1 , 1 0 2 , 3 1 9 Sutherland's definition, 1 0 3 Flexion lesion pattern (of c ranial b a se) Characteristics o f people with. 1 08 Clinical Significance, 1 05 - 1 0 8 Motion testing, 1 02 Treatment, 1 08- 1 09 Floppy baby, 260 Fora m en cecu m , 90 Foramen, 58, 9 5 , 1 70 , 205-206 92 Foramen Foramen magnum, 6 4 , 7 7 , 9 3-95 , 1 69 Foramen rotund urn, 9 2 Foramen spinosum, 9 2 18, 42 Fou rth Frontal bone, 2 1 9 Craniosacral motio n, 1 56-58 F r onta l 11ft (with t ractio D ) , 69-70, 1 6 3

Glabella, 296 Greenman, Phillp E., 1 0 3

E x tension

Definition, 7, 1 9, 3 1 , :H, 1 02 , 3 1 9 103 Extension lesion (of cranial ba s e) Charac teristicS peo ple with, 1 09 Cli n i c a l s ign ificance , 1 05 - 1 08 Motion testing, 1 02- 1 03 Treatment, 1 09- 1 1 0 External rotation, 7 , 1 0 8 Temporal bone, 1 72-73

H

Sutherland's definition,

see alsQ Flexion

Eye movements, abnormalities o f, 1 1 4 , 1 87

F Facial expression, abnormalities of, 1 8 7 Falx cerebelli, 1 5 , 6 1 , 7 7 , 88, 9 5 Falx cerebri, 1 5 , 6 1 , 64 , 7 7 , 88 Restrictions of, 244-45 Tre a t m e n t of, 69-70, 74 Ve rt i ca l strain lesions and, 1 1 9 Fascia(e), 9, 2 3 6- 3 9 Biochemical m a keu p, 2 36-37 Cervical, 5 3 5 3-54, 2 38-39 p
1 08, 1 48 , 1 7 1 , 240, 2 5 4 Migraine, 1 09 , 240 O c cip i tal, 2 9 7 see I1tJO P a i n , hea d

Headache,

249 i n tracranial, 269 Hydraulic syste m , 1 4 , 6 1 Hyoid (bone), 2 28 Hyperirritability of newborns, 2 60 Hyperkinesis. 6, 2 3 , 1 7 1 . 24 3 , 260-61 Hypothalamus, 1 20 Hypothenar e m i nence, 2 5 H e m i p l egia, craniosacral motion in,

H e mo r rhag e ,

I Indirect technique, 2 1 Infants Respiratory distress of, 1 7 1 Skull of, 60, 2 5 6 Infectio n Localized, 266 SystemiC, 266 Infe r i o r vertical strain

see Vertical s train, inferior Inion, 24, 1 99 I n terference waves, 249

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3 64

INDEX

Internal milieu, 2 3 Internal rotation, 7 Jet

01$0

M eningeal membranes

see Dural memb ranes

ExtenSion

Menstrual disorders, 240

Intracranial membrane restriction localization, 244-45

Motion Non-physiological, 1 9 Testing, 2 1 -2 2 Muscles A u riculus posterior, 2 1 5 Buccinator, 2 2 1 , 2 2 7 Coccygeus, 5 1 , 2 34

Karni, Zvi, 4 3 , 2 36

Constrictor pharyngeus superior, 2 1 0 , 2 1 7 , 22 7-28 Denervated, 8 , 3 8 Digastricus, 2 1 2- 1 3, 2 2 5 , 2 29

L

Frontalis, 220 Geniohyoideus, 2 2 8 - 2 9 G l uteus maximus, 1 4 8 , 2 3 3 Treatment, 1 4 8

Labor, regulation of, 4 3 Lambda, 24

I liacus, 1 47-48, 2 3 2

Lateral compression of the c ranial base, 1 2 7 Treatment, 1 27 - 2 8 , 1 80-82

Influence o n craniosacral system, 20 3-204 Infrahyoid, 5 3 Levator ani, 49-) 1 , 2 3 4

Lateral strain patterns (of cranial base) Axes of, 1 1 2 , 3 2 1

Longissimus capitis, 2 1 3

Clinical significance, 1 1 4 - 1 6

Longus capitis, 204

Definition, I l l , 3 2 1

Masseter, 1 7 5 , 2 1 4- 1 5 , 2 2 1 - 2 2 , 2 2 3- 24 , 2 2 7

EtiOlogy, 1 1 2

M u ltifidus, 1 48 , 2 3 3- 34

Motion testing, 1 1 1 - 1 3

Treatment, 1 4 8

Nomenclature (right or left). 1 1 2- 1 3

Mylohyoideus, 2 2 5 , 2 2 9

Treatment, 1 1 3- 1 4

Obliquus capitis inferior, 206-207

Learning disorders, 2 3

Obliquus capitis superior, 206

Craniosacral dysfunction and, 1 1 5 , 2 1 1 , 260

OCcipitalis, 2 1 0

Treatment, 260, 2 6 1

OmohYOideus, 2 30

Lesion(s), 2 3

Paravertebral, 3 8

Craniosacral, 1 0 1 , 1 0 3

Piriformis, 1 1 1 , 1 4 5-46, 2 3 1 - 32

CV-4 a n d , 4 3

Treatment, 1 46-47

Ulaj.(llU"1> of midline, 244-45

Rectus capitis anterior, 204-205 Rectus capitiS lateralis, 205-206

1 2 3 , 1 26

Osseous, 1 26

Rectus capitis posterior, 206

Osteopathic, lee Somatic dysfunction

Rectus

posterior major, 206

Lig. melliS, 2 3 4 - 36

capitis, 208

Ligamentum nuchae, 208

Splenius capitis, 2 1 4

Litlle, Robert M., 1 2 8

SternocleidomaslOideus, 5 3 , 209, 2 1 0-2 1 1

Loewenstein Neu rological Institute, 6, 2 4 8 , 2 7 5

Sternohyoideus, 2 1 5 , 2 2 9

Lower ex tremities, induction o f still point from, 3 9 - 4 1

Styloglossus, 2 1 5

Lu mbosacral junction Compression, 1 24 , 1 4 0-4 1 , 2 34 , 268 Decompression, 79-80, 1 40-44 by Positional technique, 1 4 3-44 Lymphatic pump, 2 5 , 4 2 , 266

StylohYOideus, 2 2 9 Stylothyroideus, 2 2 9 Temporalis, 1 74 - 75 , 2 1 1 - 1 2, 2 1 7 , 2 1 8- 1 9, 2 1 9-20, 2 2 7 Tensor veli palatini, 2 1 7 , 2 2 2- 2 3 Thyrohyoideus, 2 3 0 Trapezius, 5 3 , 208-209 Muscular hypolOnus i n infa n ts, 260

M N Mandible, 84-8 5 , 2 2 4 Mastoid process( es)

see Temporal bones, maStoid process(es)

Mastoid t i p technique, 1 7 7 Maxilla(e), 1 87 - 8 8 , 2 2 0 Treatment, 1 87 - 8 8 Medulla o b l a ngata, 9 3 _ 9 5 Herniation, 2 6 5 Memb ranes

Jee Dural memb ranes

Nasal bone(s), 1 99 Ne rve(s) Abducens, 9 2 Glossopharyngeal, 9 5 , 206 Great superficial petrosal, 9 2 Facial, 9 5 Hypoglossal, 9 5 , 1 69 Oculomotor, 9 2

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INDEX

Nerve(s) (continued)

from Sacrum, 3 3- 34

Spinal accessory, 9 3 , 9 5 , 206

of Denervated muscles, 248-49

Trigeminai, 92

Proprioceptors and, 2 0

Troch lear, 92

for Scars, 2 4 0

Vagus, 9 5 , 206

Self, 3 1 - 3 2

Neurologic disease, craniosacral motion in, 2 7 7 - 7 9 Neuromusculoskeletal system, 2 3 Neutral zone of movement, 7 , 1 9

Simu ltaneously at sacrum and occ i p u t, 3 6

Whole h a n d , 20

" Parallelogram" head

see Lateral strain o f cranial base

Newborns Common problems related to craniosacral system, 260

ParasympathetiC nervous system, 2 2

Craniosacral examination and treatment, 2 5 7-60

Parietal ( b ones), 2 1 7- 1 8 Craniosacral motion, 1 59-6 1

Nystagmus, 2 1 0, 269

Tentorium cerebelli balancing from, 1 59 - 6 1 Parietal l i ft ( w i t h traction), 7 7 , 1 6 1 -6 2

o

Pelvic diaphragms, 4 9- 5 1 Pelvis, balanCing o f i n i n fants, 260 Pe riphe ra l stimulation therapy, 2 9 5 -9 7 Personality disorders, 1 1 5 , 1 20

O-A compression

Petrous ridges see Temporal

see Occipital condyles, compression of O-A release

Pituitary gland, 1 20

Occipital condylar somatic dysfunction, 1 70-7 1

Position and hold technique, 5 9 , 305- 3 0 9

Occipital condyl es, 5 8

for Cervical lesions, 1 36

a t B irth, 1 68

for Lumbosacral compression, 1 4 3-44

Comp ression of, 1 70- 7 1

for M u ltifidus hypertonus, 1 48

Decompression of, 1 7 1 , 2 5 8- 5 9

Pressurestat model of craniosacral rhythmic motion, 1 1- 1 2

Hyperkinesis and, 260

Occiput,

bones, petrous ridges

Pia mater, 1 6, 2 3 8

Cranial base, release of

Pterion, 24

5 8 , 204

Pterygoid

Axis, 1 5 9

plates

Sphenoid, pterygoid plates

Craniosac ral motion of, 1 5 9

Pulmonary congestion, 4 3

Embryology of, 1 69-70 Synchrony with sacrum, 36 Temporal bones and, 1 59 Tentorium

cerebelli

R

balanc e d from, 8 5 -86

Occiput and sac rum Axes o f rOlation, 1 3 3 Connections

between,

1 3 3- 34

Horizontal dural membrane balancing from, 8 5 - 8 7

Raynaud's phenomenon, 2 6 7 tension membrane, 1 1 , 6 4 , 244

i n Newborns, 2 59-60 S i m u l taneous palpation, 36, 80 lesion

Dural

m e mbranes

Release, 1 9, 1 09 Methodology of, 2 1 , 5 6 - 5 7

dysfunction

clues to, 1 09 305- 309

by

Remolding t h e c r a n i u m i n newborns, 2 5 9

p

Research o n the craniosacral system, 6 0 , 1 28 , 1 ) 2 , 2 1 8 , 2 36- 3 7 , 262-63 diaphragm, 46-48

Pain, 1 8 7 , 2 2 7

48-49 Restriction(s), 1 9

Arm, 1 76 Chest, 2 5 4

Bony, 1 9, 1 26 , 2 6 3

Chronic,

Dural tube, 2 4 5 -4 7

267

Head, 1 1 5 , 1 20, 1 3 1 , 1 4 1 , 1 82-8 3 , 2 34 Low

back,

Elastic, 2 0 , 70, 1 2 3 , 1 26 , 2 6 3 Fascial, 2 4 7 -48

see a/so Headache 131

Intracranial, 244· 4 5

Neck, 1 3 1 , 2 5 4

Memb ranous, 2 0 , 70, 1 2 3 , 1 26 , 2 6 3

Shoulder, 1 76

Osseous, 1 9, 1 26 , 2 6 3 Surural, 70, 1 26

Palate, hard, 1 8 5 Palatine (bones), 1 9 3-95 , 2 2 2

Training method to localize, 2 4 7

Palpation, 2 0 - 2 1

Transverse, 4 6 , 5 8 - 5 9

RW.,

I

of Cardiovascular pulse, 2 7-28

Retzlaff,

of Craniosacral

Rheumatoid arthritis, 267-68

motion,

29-38

from Head, 2 9 - 3 1

R h i n i tis, 1 8 7

fro m Paravertebral musculature, 3 8

R i mland, Bernard, 1 2 3-24 , 2 6 2

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INDEX

s

Sacrococcygeal complex, 1 7- 1 8, 79, 1 3 5 , 2 30-3 1 .lee a/so Sacrum Sacroiliac impaction, 1 49 Sacrioliac restrictions, patient's aid in releasing, 80 Sacrum, 1 1 1 , 2 30 , 3 1 Axis, 6 Craniosacral motion, 3 4 OCCiput a n d , 36 Palpation of, 3 3- 36 Scoliosis and, 269 Still point induction through, 4 5 Sacrum and pelvis, balancing i n newborns, 260 Scars, 8 , 2 3 9-40 Schizophrenia, childhood, 262 SCia tica, 1 20 Scoliosis, 268-69 Sella turcica, 90-92, 1 5 5 Semi-closed hydraulic system, 1 4 , 6 1 Sidebending lesion (of cranial base) Cha racteristics people with, 1 1 1 Clinical Significance, 1 0 5 - 1 08 Defi n ition, 1 03 , 320 Motion testing, 1 0 3- 1 04 , 1 1 3 Treatment, I I I Sinus(es) see Venous sinus(es) Sinusitis, 1 08, 1 20 , 1 8 7 Skull Fetal, 2 5 6 Fracture, 2 6 5 Somatic dysfunctio,\, 8, 2 3 , 1 05 , 240-4 1 , 302 OCCipital condylar, 1 70 Paravertebral, 1 39-40 Somatoemotional recal l and release Rationale, 2 5 0-5 1 Technique, 2 5 1 - 5 4 Sphenobasilar joint see SphenobaSilar synchondrosis Sphenobasilar symphysis Sphenobasilar synchondrosis Sphenobasilar synchondroSiS Clinical import, 1 0 , 96 Compression of, see Comp ression of the cranial base Cont roversy concerning nature of, 1 0 Dysfu nction of, 9)-96, 1 0 1 - 1 05 , 1 1 1 - 1 1 3 , 1 1 8, 1 97 E mb ryology of, 1 0 , 1 67 Histology of, 1 0 Sphenoid (bone), 2 1 5 Axis, 1 ) 5 Clinoid process(es), 6 7 , 7 4 , 80, 90, 9 2 Craniosacral motion, 1 5 5 - 5 6 G reater wings, 7 4 as Keystone of crani0sacral system, 1 0 , 2 1 :5 "'''' cuor",'' plates of, 1 8 5 U rrlf'flar,O model of craniosacral motion, 1 0 Sphenomaxillary impaction, 1 9 2-93 Sphenomaxillary torsion, 1 8 8 -9 1 transverse shear, 1 9 1 -9 2 cord i njury, 8 , 249

Spinal dural tube see Du ral tll be Sprains, 267 Spring and dashpot model of tissue properties, 1 2 8-30 . Still point, 40-4 1 . Children and, 4 5 Contraindications to, 4 1 from Lower extremities, 39-4 1 from Sacrum, 4 5 Self-induction of, 3 1 0, 1 1 See also CV-4 Strabismus, 1 1 4 - 1 5 , 1 76 , 2 1 0 , 269 Strain patte rns see Cranial base dysfunction Strains (musculoskeletal), 267 SubOCCipital triangle, 207-208 Sutherland, William G., 64 Cranial base dysfunction model, 95-96, 1 0 1 Craniosacral motion model, 1 0- 1 1 , 2 7 6 CV-4 and, 4 2 Discovery of craniosacral system, 9 - 1 1 Lateral strain lesion pattern model, 1 1 2 Temporal bone motion observations, 1 72 - 7 3 Vau lt holds, 96-97 Suture(s) Coronal, restriction in cerebral palsy, 2 6 2 Cranial base, 1 26, 1 76 OCcipi tomastoid, 4 3 , 1 58 , 209, 2 1 1 , 2 1 4 , 2 6 1 Temporoparietal, 80-8 3, 2 1 1 - 1 2 , 1 83-84 fee (liso Cranial sutures Sympathetic nervous system, 2 2 Effect o f CV-4 o n , 4 2

T Tela, 5 2 Temporal (bones), 2 1 0 Anatomy, 1 7 2 Auditory problems and, 269 Axis, 1 5 9 , 1 7 2 Clinical significance, 1 76 Craniosacral motion, 1 5 8 , 1 72-74 Dyslexia and, 2 6 1 Mastoid process(es), 8 0 , 1 75 M e dial compression, 1 27 , 1 80 i n Newborns, 1 7 2 Petrous ridges, 6 7 , 80, 1 7 2 Rocking, 1 7 7 Styloid process(€;s), 2 3 4 Treatment, 1 7 7-82 Warning regarding treatment, 1 79 Zygomatic arch, Zygomatic process(es) Zygomatic process« ;s), 1 7 3 , 1 7 5 Temporal bone decompreSSion, 1 27-28, 1 80-82 Temporal mandibular joint 80, 1 8 3-84, 200-202

Evaluation, 1 99-200 Horizontal membrane release t hrough, 80-85 Tentorium cercbelli, 1 5 , 6 1 -62 , 8 8 , 1 1 4

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INDEX

Tentorium cerebelli (continued) AnatOmy. 67 An terior-posterior restrictions, 74·77, 1 26 BalanCing of, 80-86 Spheno-tempora! relations via, 80 Visual problems and, 2 1 0, 269 Thenar eminence, 2 5 Therapeutic pulse, 74 Thi rd venlricle, 1 2 . 1 8 Thoracic inlet, 5 2·5 7 Re lease of, 54-57 Thrust, cervicothoracic, 5 4 Tinni tus, 269 Tissue Memory, 2 5 1 Tension balancing, See POSition and hold technique Toothache, 1 87 Torsion lesion pat terns (of cranial base) Characteristics of people with, 1 1 1 Clinical Significance, 1 05- 1 08 Definition, 1 04- 1 0 5 , 3 1 9 Motion testing, 1 0 5 Sphenomaxillary, Sphenomaxillary torsion Treatment, 1 1 1 Vomer, see Vomer torsion Traction, use in localization of restrictions, 246-47 T ransverse restrictions, 46, 58-59 Traube-Herring phenomenon, 6 Trauma, 8 Birth, 1 1 5 · 1 24 as Etiology of craniosacral dysfunction, 1 24 , 1 8 5 Treatment principles, 2 1 Trigger points, 236

v V-spread- t",'h ,,, n"p see Direct[{)p energy Venous sin us(es), 60, 88 Inferior, 64 Occipital, 9 5 Sagittal, 1 , 64, 9 0 Straight, 1 2, 64, 67, 76, 7 7 , 204 Transverse, 67, 8 5 , 9 5 Ventricle Fourth, 1 8 , 4 2 Third , 1 2, 1 8 t h e brain, 1 8 (of c ranial base) ""fllllc.,nce. 1 1 8· 1 20 Definition, 1 1 6· 1 1 8 , 3 2 1 Etiology, 1 1 9 Inferior, 1 1 6 Mo tion testing, l i S S uperior, 1 1 6 Treatment, 1 1 8 Viscera, 2 2 5 Visual problems, 2 1 0 , 269 Vomer, 1 8 7 , 1 9 5-96 Shear. 1 97 Torsion, 1 96-97

y Yin/Yang a n d craniosacral motion, 2 4 3

u

z 267

.fee Soma toemotional recall and release Urogenital diaphragm see Pelvic d iaphragms

Zygomatk arch see Temporal bone, Zygomatic process(es) Zygo matiC bone(s), 1 97·99 , 2B-24 ZygomatiC process(es) see Temporal bone, Zygomatic p rocess(es)

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