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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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continues
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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are jammed
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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22
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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29
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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41
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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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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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
60 Copyrighted Material
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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98
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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112
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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124
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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129
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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132
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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133
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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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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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
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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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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
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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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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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Axes of external rotation
\J
I