nicholas ch18 osteopathy in the cranial field

18 Osteopathy in the Cranial FieldTechnique PrinciplesOsteopathy in the c ran ia l f ie ld (OCF) as def ined by the Educat iona l Counci l on Os teopath ic Pr inc ip les (ECOP) is a ldquosys tem of d iagnos is and t rea tment by an os teopath ic prac t i t i oner us ing the pr imary resp i ra tory mechan ism and ba lanced membranous tens ion f i rs t descr ibed by Wi l l iam Garner Suther land DO and is the t i t l e o f the re ference work by Haro ld Magoun Sr rdquo ( 1 ) Suther land a s tudent o f A T S t i l l began a l i fe long s tudy o f the c ran ium and i t s anatomy and b iomechan ics as they re la ted to hea l th and d isease H is in te res t i n the cran ium began a f te r he v iewed a d isar t icu la ted sku l l when s tudy ing in K i rksv i l le MO (Amer ican Schoo l o f Osteopathy) A l though Suther land i s the name most o f ten assoc ia ted w i th th is fo rm o f techn ique many o thers took up h is work and cont inued the s tudy research and teach ing ( 2 3 ) ECOP has def ined the pr imary resp i ra tory mechan ism as ldquoa mode l p roposed by Wi l l i am Garner Suther land DO to descr ibe the in terdependent func t ions among f ive body components as fo l lowsrdquo ( 1 )

The inherent mot i l i t y o f the bra in and sp ina l cord Fluc tuat ion o f the cerebrosp ina l f lu id Mobi l i ty o f the in t racran ia l and in t rasp ina l membranes Art icu la r mob i l i t y o f the c ran ia l bones The invo lun tary mobi l i t y o f the sacrum between the i l ia (pe lv ic bones)

OCF has a lso been ca l led c ran ia l os teopathy (CO) ( 1 ) c ran iosacra l techn ique ( 4 ) and s imply cran ia l techn ique I t i s impor tan t tha t OCF be used wi th the a forement ioned pr inc ip les Other osteopath ic techn iques can be used on the c ran ium but a re used wi th the i r spec i f i c p r inc ip les fo r t rea tment e f fec t on somat ic dysfunc t ion For example counters t ra in so f t t i ssue myofasc ia l re lease and lymphat ic techn iques can a l l be used in th is reg ion but a re not c lass i f ied as OCF CO or cran iosacra l techn iqueMany phys ic ians were re luc tant to be l ieve tha t the cran ia l bones were capab le o f movement or tha t the phys ic ian cou ld pa lpa te movement A number o f s tud ies have shown ev idence o f such mot ion and sugges t tha t the c ran ia l su tures may not comple te ly oss i fy ( 1 ) A s imple example to i l lus t ra te tha t the su tures a l low c ran ia l bone mobi l i t y is to have one s tudent f i x a par tner s f ron tozygomat i c su tures b i la te ra l l y Th is is done by p lac ing one thumb over one f ron tozygomat ic su ture and the pad o f the index f inger o f same hand on the oppos i te f ron tozygomat ic su ture The s tudent gent ly rocks the zygomat ic por t ion f rom s ide to s ide wh i le the o ther hand is c rad l ing the head An aud ib le ar t icu la r c l ick may occur The opera tor the pat ien t o r bo th may fee l th i s mot ion We have not seen any adverse e f fec ts f rom th i s maneuver and so have conf idence in a pos i t ive educat iona l ou tcomeThe reason pat ien ts reac t pos i t ive ly to OCF is no t comple te l y unders tood and the under l y ing cause and e f fec t may be a combinat ion o f the s ta ted pr inc ip les Some o ther reasons may inc lude re f lex phenomena f rom connec t i ve t issue mechanoreceptors andor noc iceptors or mic roscop ic and macroscop ic f lu id exchange e i ther per iphera l ly (T raube-Her ing-Mayer osc i l la t ions) ( 5 ) o r in the cent ra l nervous sys tem Suther land a f te r pa lpa t ing many pat ien ts fe l t spec i f ic t ypes o f mot ions and he cou ld not account fo r these mot ions based on musc le ac t iv i ty upon rev iewing c ran ia l anatomy There fore he began pos tu la t ing an inherent invo lun tary mechan ism and eventua l ly came to the te rm pr imary resp i ra tory mechan ism (6 ) Pr imary resp i ra tory mechan ism i s fu r ther de f ined thus

Pr imary re fers to i n te rna l t i ssue resp i ra tory process Resp i ra tory re fers to the process o f in te rna l resp i ra t ion ( i e the exchange o f resp i ra tory

gases between t issue ce l ls and the i r in te rna l env i ronment cons is t ing o f the f lu ids bath ing the ce l ls )

Mechan ism re fers to the in terdependent movement o f t i ssue and f lu id w i th a spec i f ic purpose

I t i s be l ieved tha t a spec i f i c pa t te rn o f mot ion ex is ts and is read i ly apparent and pa lpab le in each person Th is mot ion pat te rn is de termined by a var ie ty o f fac tors bu t is thought to be re la ted to the beve l ing o f the su tures and the a t tachments o f the dura There fore to d iagnose and t rea t us ing OCF the phys ic ian mus t know cran ia l anatomy (e g a t the p ter ion the bones over lap as fo l lows f ron ta l par ie ta l spheno id and tempora l in a lphabet ica l o rder f rom inner to ou ter tab le) The in terna l dura l re f lec t ions o f the fa lx cerebr i the fa lx cerebe l l i and the ten tor ium cerebe l l i a re co l lec t ive ly known as the rec ip roca l tens ion membrane D is tor t ion in the pos i t ion or mot ion o f any cran ia l bone may be t ransmi t ted to the base and vau l t th rough th i s rec ip roca l tens ion membrane There fore rest r i c t ion o f c ran ia l bone mot ion wi th d is to r t i on o f i t s symmet r i c mot ion pat te rn is te rmed cran ia l somat ic dys func t ion The b iphas ic f luc tua t ion o f mot ion tha t is pa lpa ted in the cran ia l bones has been re fer red to as the cran ia l rhy thmic impu lse (CRI ) The emphasis in OCF is p laced on the synchronous movement o f the cran ium wi th the sacrum (c ran iosacra l mechan ism) The mot ion between the cran ium and sacrum is be l ieved to be assoc ia ted wi th the a t tachments o f the dura l tube a t the fo ramen magnum and the

second sacra l segment a t the resp i ra tory ax is Th is is somet imes ca l led the core l ink I t fo l lows a rhythmic cadence a t 8 to 14 cyc les per minute ( 1 4 ) Th is impu lse may be pa lpa ted anywhere in the body and i t i s used not on ly in os teopathy in the cran ia l f i e ld bu t a lso in ba lanced l i gamentous tens ion o r l igamentous ar t i cu la r s t ra in (BLTLAS) techn iques I ts ra te and ampl i tude may vary in cer ta in d isease processes (e g fever ) Cran ia l nomencla ture is genera l ly re ferenced to mot ion occur r ing a t the sphenobas i la r symphys is o r synchondros is (SBS) I t i s s l i gh t l y convex on the super io r s ide and th is convex i ty is increased dur ing f lex ion Th is can a lso be thought o f as the in fer io r por t i on o f the SBS creat ing an ang le so tha t th is i n fe r io r -s ided ang le becomes smal le r o r more acute wi th f l ex ion o f the SBSIn sphenobasi la r f l ex ion the bas iocc ipu t and bas ispheno id move cepha lad wh i le the occ ip i ta l squama and the w ings o f the spheno id move more cauda l ly These f lex ion and ex tens ion mot ions are ro ta t iona l about t ransverse axes one a t the leve l o f the fo ramen magnum and the o ther th rough the body o f the spheno id ( 6 ) A l l mid l ine unpa i red c ran ia l bones are descr ibed as mov ing in f l ex ion and extens ion

Flexion and Extension of the Sphenobasilar SynchondrosisDur ing f lex ion o f the cran ia l base ( F ig 18 1 ) the pet rous por t ions o f the tempora l bones move

cepha lad w i th the SBS Th is produces a f la r ing outward o f the tempora l squama ca l led externa l

ro ta t ion o f the tempora l bones Al l pa i red bones move in to ex terna l ro ta t ion synchronous wi th

sphenobas i la r f lex ion In terna l ro ta t ion o f the pa i red bones is synchronous wi th sphenobas i la r

extens ion There fore i t can be sa id tha t in f l ex ion the sku l l shor tens in the anteroposter io r d iameter

and widens la tera l ly In ex tens ion ( F ig 18 2 ) the sku l l lengthens in the anteroposter io r d iameter and

nar rows la tera l ly

Because o f the l ink be tween the c ran ium and the sacrum the sacrum wi l l move wi th the cran ium In

SBS f lex ion the sacra l base moves pos terosuper io r ly ( 1 ) and in SBS ex tens ion the sacrum moves

antero in fer io r l y Th is more recent cran iosacra l mechan ism termino logy has caused some confus ion

because o f i t s d i f fe rence f rom the prev ious ly used nomenc la ture fo r g ross sacra l mot ion In gross

sacra l b iomechan ics a sacra l base anter io r movement was descr ibed as f lex ion o f the sacrum

However f lex ion in cran iosacra l mechan ism termino logy is de f ined as the sacra l base moving

poster io r ly Some have dec ided to descr ibe sacra l base movements as nodd ing mot ions Thus

fo rward movement o f the sacra l base is ca l led nuta t ion and backward movement o f the sacra l base

is ca l led counternuta t ion No mat ter wh ich te rms one chooses ( f l ex ion and extens ion or nu ta t ion and

counternuta t ion) the sacra l base goes fo rward in gross f lex ion and in c ran iosacra l ex tens ion The

sacra l base moves backward in gross ex tens ion and cran iosacra l f lex ion

P 477

Figure 181 Flexion of the sphenobasilar synchondrosis O occipital axis of rotation S sphenoidal axis of rotation

Figure 182 Extension of the sphenobasilar synchondrosis O occipital axis of rotation S sphenoidal axis of rotation

Craniosacral MechanismDysfunct iona l pa t te rns o f c ran ia l mot ion have been descr ibed as e i ther phys io log ic or no t Examples

o f phys io log ic dysfunc t ions inc lude to rs ion s ide bend ing and ro ta t ion and f ixed ( f l ex ion and

extens ion) Compress ion ver t ica l s t ra ins (shear ) and la tera l s t ra ins are examples o f nonphys io log ic

dys funct ions They may be secondary to head t rauma b i r th t rauma denta l p rocedures in fe r io r

muscu loske le ta l s t ress and dysfunct ion and postura l abnormal i t ies

Tors ion invo lves ro ta t ion o f the SBS around an anteroposter io r ax is The spheno id and occ ipu t ro ta te

in oppos i te d i rec t ions Pa lpat ion o f a r igh t to rs ion fee ls as i f the greater w ing o f the spheno id on the

r igh t e levates and ro ta tes to the le f t wh i le the occ ip i ta l squama on the r igh t d rops in to the hands and

ro ta tes to the r igh t (F ig 18 3 )

Side bend ing ro ta t ion i s s ide bend ing and ro ta t ion tha t occur s imul taneous ly a t the SBS S ide

bend ing occurs by ro ta t ion around two ver t ica l axes one th rough the center o f the body o f the

spheno id and one a t the fo ramen magnum The spheno id and the occ ipu t ro ta te in oppos i te

d i rec t ions about these axes The ro ta t ion component o f the dys funct ion occurs around an

anteroposter io r ax is bu t the spheno id and the occ ipu t ro ta te in same d i rect ion Rota t ion occurs

toward the s ide o f convex i ty ( the in fer io r s ide) Whi le pa lpa t ing a le f t s ide bend ing ro ta t ion one

notes tha t the le f t hand fee ls a fu l lness as compared to the r igh t hand (s ide bend ing) and one a lso

fee ls tha t the le f t hand is d rawn cauda l l y bo th a t the spheno id and occ ipu t ( ro ta t ion) ( F ig 18 4 )

SBS compress ion e i ther fee ls rock hard l i ke a bowl ing ba l l (vo id o f any mot ion) o r the phys ic ian

beg ins to fee l a l l o f the dys funct iona l s t ra in pa t te rns together ( F ig 18 5 )

Super io r in fe r io r ver t ica l s t ra ins invo lve e i ther f l ex ion a t the spheno id and ex tens ion a t the occ ipu t

(super io r ) o r extens ion a t the spheno id and f lex ion a t the occ ipu t ( i n fe r io r ) The dys func t ion is

named by the pos i t ion o f the bas ispheno id Dur ing pa lpa t ion a super io r ver t ica l shear fee ls as i f the

greater w ings o f the spheno id are drawn too fa r cauda l ly In an in fer io r ver t ica l shear the spheno id

moves min imal ly caudad (F ig 18 6 )

Latera l s t ra in invo lves ro ta t ion around two ver t ica l axes bu t the ro ta t ion occurs in the same

d i rec t ion Th is causes a la tera l shear ing fo rce a t the SBS The dysfunct ion is named for the pos i t ion

o f the bas ispheno id Dur ing pa lpa t ion the la tera l s t ra ins fee l as i f the hands are on a para l le logram

(F ig 18 7 )

Figure 183 Right SBS torsion Figure 184 Left SBS side bendingrotation

P478

Technique ClassificationDirect TechniqueIn d i rect c ran ia l os teopathy the dysfunct ion is moved toward the rest r ic t ive bar r ie r (b ind tens ion)

The phys ic ian shou ld gent ly approach the bar r ie r and main ta in a l igh t fo rce unt i l a re lease occurs I f

the dysfunc t ion appears to be mos t l y a r t icu la r a d i rect techn ique is appropr ia te Th is techn ique i s

commonly used on in fan ts and ch i ld ren before fu l l deve lopment o f the cran ia l su tures and in very

spec i f ic dysfunc t ions in adu l ts ( 4 )

Indirect TechniqueIn i nd i rect c ran ia l os teopathy the dysfunc t ion i s moved away f rom the res t r ic t ive bar r ie r o r toward

the ease ( f reedom loose) The phys ic ian a t tempts to move the dys func t ion in the d i rect ion o f

f reedom unt i l a ba lance o f tens ion occurs (ba lanced membranous tens ion) ( 4 6 ) be tween the ease

and b ind The CRI i s mon i to red and the inherent fo rces eventua l ly cause a s l igh t increase toward

the ease and then movement back to the or ig ina l ba lance pos i t ion wh ich is a s ign o f the re lease

Th is techn ique is most appropr ia te i f the key dys func t ion is 2 n d a r y to a membranous rest r ic t ion( 4 )

ExaggerationExaggeration method is performed with the physician moving the dysfunction toward

the ease similar to indirect but when meeting the ease barrier an activating force is

added

Figure 185 SBS compression

Figure 186 SBS inferior vertical strain O occipital axis of rotation S sphenoidal axis of rotation

DisengagementIn d i sengagement the phys ic ian a t tempts to open or separa te the ar t icu la t ion Depend ing on how the

ar t icu la t ion i s fe l t to be rest r i c ted t rac t ion or a compress ive fo rce may be added

Technique StylesInherent Force

Use o f the body s inherent fo rce th rough the pr imary resp i ra tory mechan ism is the major method o f

OCF Us ing the f luc tua t ion o f the cerebrosp ina l f lu id the phys ic ian can a l te r the pressure in one

area or another and cause th is f lu id to change the var ious bar r ie rs Th is is most ev ident in the V -

spread techn ique ( 4 )

P 479

Figure 187 SBS lateral strain

Respiratory AssistanceAs in o ther techn iques the use o f pu lmonary resp i ra t ion can

fac i l i ta te os teopath ic techn ique Th is re lease-enhanc ing

mechan ism wi l l inc rease movements assoc ia ted wi th

inha la t ion and exha la t ion For example i t i s be l ieved tha t

dur ing inha la t ion the SBS tends to move toward f l ex ion w i th

the pa i red bones moving more toward ex terna l ro ta t ion In

exha la t ion the unpa i red bones move pre ferent ia l ly toward

extens ion and the pa i red bones in to in te rna l ro ta t ion The

phys ic ian can have the pat ien t b reathe in the d i rect ion

pre fer red fo r i ts re la ted cran ia l e f fec t and te l l the pat ien t to

ho ld the breath a t fu l l i nha la t ion or exha la t ion Th is w i l l

enhance a re lease

Distal ActivationIn cer ta in cond i t ions the phys ic ian may pre fer to t rea t the pat ien t s p rob lem f rom the sacra l reg ion

or ext remi t i es By app ly ing tens ion on the sacrum the phys ic ian can gu ide the mechan ism f rom

be low and e f fec t the movement o f the SBS In add i t ion the phys ic ian may have the pat ien t ac t ive ly

a t tempt p lan tar f lex ion or dors i f lex ion to ga in a par t icu la r e f fec t on the SBS Dors i f lex ion enhances

SBS f lex ion wh i le p lan tar f lex ion enhances ex tens ion ( 4 )

Still PointIn th is method the phys ic ian a t tempts to res is t the pr imary resp i ra tory mechan ism tha t is be ing

moni to red th rough the CRI Th is is mos t commonly ca l l ed compress ion o f the four th vent r ic le (CV4)

Success o f the CV4 techn ique re l ies on inherent fo rces In th is techn ique the phys ic ian moni to rs

severa l cyc les o f CRI and then permi ts exha la t ion mot ion a t the bone be ing pa lpa ted (usua l ly the

occ ip i ta l squama) Then the phys ic ian gent l y res is ts f lex ion unt i l a cessat ion o f the cerebra l sp ina l

f lu id f luc tua t ion is pa lpa ted Th is is ca l led a st i l l po in t Th is pos i t ion is he ld fo r 15 seconds to a few

minutes un t i l the phys ic ian apprec ia tes a re turn o f the CRI Th is can be app l ied to the sacrum when

contac t ing the head is cont ra ind ica ted (e g acute head t rauma) ( 4 6 )

Indications Headaches

Mi ld to severe wh ip lash s t ra in and spra in in ju r ies

Ver t igo and t inn i tus

Oti t i s med ia wi th e f fus ion and serous o t i t i s med ia

Temporomandibu lar jo in t dysfunct ion

Sinus i t i s

Contraindications Acute in t racran ia l b leed ing and hemorrhage

Increased in t racran ia l p ressure

Acute sku l l f rac ture

Cer ta in se izure s ta tes ( re la t ive)

P480

General Considerations and RulesOCF may he lp a number o f cond i t ions I t s adverse reac t ions are few bu t the phys ic ian shou ld be on

a le r t as headache ver t igo t inn i tus nausea and vomi t ing can occur as can some autonomic re la ted

e f fec ts (e g b radycard ia) These are most ly seen when s tudents are f i rs t learn ing the techn ique and

do not rea l i ze the pressure be ing impar ted in to the i r pa t ien t s c ran ium Th is i s common w i th

improper ho ld ing techn ique ( loca t ion and incor rec t p ressure) seen a t t imes a t the occ ip i tomas to id

su ture Headaches nausea and vomi t ing wh i le no t common are seen occas iona l ly

There fore the phys ic ian mus t take care to contac t the pat ien t p roper ly and app ly enough but no t too

much pressure fo r the appropr ia te amount o f t ime The phys ic ian shou ld a lso make sure tha t the

pr imary resp i ra tory mechan ism i s p resent when dec id ing to end the t rea tment

A var ia t ion o f th i s techn ique is us ing a mul t ip le -hand approach Whi le one opera tor i s pa lpa t ing the

cran ium another can be on the sacrum or another a rea o f the pat ien t s body Th is can potent ia te the

e f fec t o f a t rea tment

P481Crania l Vaul t Ho ld

ObjectivesThe objective is to assess the primary respiratory mechanism as it manifests itself in the cranium and the degree of participation of each bone in the general motion of the craniumTechnique 1 The patient lies supine and the

physician is seated at the head of the table

2 The physician establishes a fulcrum by resting both forearms on the table

3 The physicians hands cradle the patients head making full palmar contact on both sides

4 The physicians index fingers rest on the greater wings of the patients sphenoid (A Fig 188)

5 The physicians middle fingers rest on the zygomatic processes of the patients temporal bones (B Fig 188)

6 The physicians ring fingers rest on the mastoid processes of the patients temporal bones (C Fig 188)

7 The physicians little fingers rest on the squamous portion of the patients occiput (D Fig 188)

8 The physicians thumbs touch or cross each other without touching the patients cranium (Figs 189 and 1810)

9 The physician palpates the CRI a Extensioninternal rotation coronal

diameter narrows anteroposterior diameter increases height increases

b Flexionexternal rotation coronal diameter widens anteroposterior diameter decreases height decreases

10 The physician notes the amplitude rate and regularity of the CRI

11 The physician notes which bones if any have an altered amplitude rate and regularity

Figure 188 Lateral view of skull with dots for finger placement (7)

Figure 189 Steps 1 to 8


The physician may instruct the patient to stop breathing to further distinguish the rhythmic sensations that occur in the CRI The physician can also have the patient inhale and exhale fully to increase the amplitude of the CRI which can make it easier to feel

P482 Fronto-occip i ta l Ho ld

ObjectivesThe objectives are to assess the primary respiratory mechanism as it manifests itself in the cranium to assess the freedom of motion of the cranial base especially at the SBS and to assess the frontal bone as it relates to the rest of the CRITechnique 1 The patient lies supine and the

physician is seated at the side of the head of the table

2 The physician places the caudad hand under the patients occipital squama with the forearm resting on the table establishing a fulcrum

3 The physicians cephalad hand bridges across the patients frontal bone with the elbow resting on the table establishing a fulcrum

4 The thumb and middle finger of the physicians cephalad hand rest on the greater wings of the patients sphenoid (if the hand spread is too short approximate the greater wings)

5 The physician makes full palmar contact with both hands (Figs 1811 1812 and 1813)






9 The physician pays particular attention to the SBS determining whether there is any preferred motion of the sphenoid and the occiput




The physician may instruct the patient to stop breathing to further distinguish the rhythmic sensations that occurs in the CRI The physician can also have the patient inhale and exhale fully to increase the amplitude of the CRI which can make it easier to feel

P483 Sacral Hold

ObjectiveThe objective is to create free and symmetric motion of the sacrum by palpation of the CRITechnique 1 The patient lies supine and the

physician is seated at the side of the table caudad to the sacrum

2 The patient is instructed to bend the far knee and roll toward the physician

3 The physician slides the caudad hand between the patients legs and under the sacrum and the patient drops his or her weight is on this hand

4 The physician allows the hand to mold to the shape of the sacrum with the median sacral crest lying between the third and fourth fingers the fingertips approximating the base and the palm cradling the apex (Figs 1814 and 1815)

5 The physician presses the elbow down into the table establishing a fulcrum

6 The physician palpates the craniosacral mechanism Sphenobasilar flexion is synchronous with sacral counternutation (sacral base moves posterior) Sphenobasilar extension is synchronous with sacral nutation (sacral base moves anterior)

7 The physicians hand follows these motions encouraging symmetric and full range of sacral motion

8 The physician continues to follow and encourage sacral motion until palpation of a release which is usually accompanied by a sensation of softening and warming of the sacral tissues

9 The physician retests the quantity and quality of sacral motion to assess the effectiveness of the technique



Figure 1816 Lumbar and sacral contact

The physician can also use the cephalad hand either sliding it under the patients lumbar area (Fig 1816) laying the forearm across both anterior superior iliac spines (ASIS) The additional hand placement gives the physician more information about how the sacrum relates to the respective areas

P484 Decompression of the Occip i ta l Condyles

ObjectivesThe objective is to balance the reciprocal tension membrane at the hypoglossal canal permitting normalized function of cranial nerve XIITechnique

1 The patient lies supine and the physician is seated at the head of the table with both forearms resting on the table establishing a fulcrum

2 The patients head rests on the physicians palms and the physicians index and middle fingers (or the middle and ring fingers) approximate the patients condylar processes (as far caudad on the occiput as the soft tissue and C1 will allow) (Figs 1817 1818 and 1819)

3 The fingers of both hands initiate a gentle cephalad and lateral force at the base of the occiput

4 The force is maintained until a release is felt

5 The rate and amplitude of the CRI as it manifests in the basioccipital region are retested to assess the effectiveness of the technique

Figure 1817 Steps 1 and 2



P485 Occip itoat lanta l Decompression (8 )

ObjectivesTo treat occipitoatlantal somatic dysfunction that results from rotation of the occiput on its anteroposterior axis resulting in misalignment of the condyles in the facets of the atlas In general this technique should be performed after decompression of the occipital condylesTechnique 1 The patient lies supine and the

physician is seated at the head of the table with both forearms resting on the table establishing a fulcrum

2 The physician places the pads of both middle fingers on the posterior aspect of the cranium and slides these fingers down the occiput until the fingers are against the posterior arches of the atlas (Figs 1820 1821 and 1822)

3 The physician applies caudad pressure with both middle fingers to separate the facets from the condylar parts

4 While the physician maintains this caudad pressure the patient tucks the chin into the chest making sure NOT to flex the neck (this is the nodding movement that occurs at the occipitoatlantal joint)

5 This motion carries the occipital condyles posteriorly tenses the ligaments in the region and stretches the contracted muscles in the occipital triangle

6 The physician maintains this position while the patient holds one or more deep inspirations to their limit This will enhance articular release

7 The rate and amplitude of the CRI as it manifests in the basioccipital region are retested to assess the effectiveness of the technique Occipitoatlantal motion testing can also be assessed for normalization




P486 Compression of the Fourth Ventr ic le

ObjectivesTreatment often starts with compression of CV4 for ill patients The treatment augments the healing capabilities of the patient relaxes the patient and improves the motion of the CRITechnique 1 The patient lies supine and the


2 The physician crosses or interlaces the fingers of both hands cradling the patients occipital squama

3 The physician places the thenar eminences posteromedial to the patients occipitomastoid sutures If the thenar eminences are on the mastoid processes of the temporal bones the compression that follows will bilaterally externally rotate the temporal bones which may cause extreme untoward reactions (Figs 1823 1824 1825 and 1826)

4 The physician encourages extension of the patients occiput by following the occiput as it moves into extension

5 The physician resists flexion by holding the patients occiput in extension with bilateral medial forces Note The occiput is not forced into extension Rather it is prevented from moving into flexion It is as if the physician is taking up the slack created by extension and holding it there

6 This force is maintained until the amplitude of the CRI decreases a still point is reached andor a sense of release is felt (a sense of softening and warmth in the region of the occiput)


Figure 1825 Superior view of hand position


7 As the CRI resumes the physician slowly releases the force allowing the CRI to undergo newfound excursion

8 The rate and amplitude of the CRI are retested to assess the effectiveness of the technique


P488 Interpar ieta l Sutura l Opening (V-Spread)

ObjectiveTo restore freedom of movement to the sagittal suture increasing the drainage of the superior sagittal sinusTechnique 1 The patient lies supine and the

physician is seated at the head of the table with both forearms resting on table establishing a fulcrum

2 The physicians thumbs are crossed over the patients sagittal suture just anterior and superior to lambda

3 The remainder of the physicians fingers rest on the lateral surfaces of the patients parietal bones (Figs 1827 1828 and 1829)

4 The physicians crossed thumbs gently exert a force pushing the patients parietal bones apart at the sagittal suture The physicians other fingers encourage external rotation of the parietal bones decompressing the sagittal suture (this may be accompanied by a sensation of softening and warming or an increase in motion and a physical spreading)

5 The physician moves the thumbs anteriorly approximately 1 to 2 cm and the procedure is repeated The physician continues to move along the sagittal suture to the bregma (This technique may be carried even farther forward along the metopic suture)

6 The rate and amplitude of the CRI especially at the sagittal suture are retested to assess the effectiveness of the technique




P489 Sutural Spread (V-Spread D irect ion-of -F luid Technique)

ObjectiveThe objective is to release a restricted cranial suture (eg left occipitomastoid suture)Technique 1 The patient lies supine and the

physician is seated at the head of the table with both elbows resting on the table establishing a fulcrum

2 The physician places the index and middle fingers on the two sides of the patients restricted suture

3 The physician places one or two fingers of the other hand on the patients cranium at a point opposite the suture to be released (Figs 1830 1831 and 1832)

4 With the lightest force possible the physician directs an impulse toward the restricted suture with the hand opposite the suture initiating a fluid wave The object is not to physically push fluid through to the opposite side Instead the physician is using the fluctuation of the cerebrospinal fluid to release the restriction The physician uses intention to initiate this wave this method contracts the fewest muscle fibers and so applies the slightest force

5 This fluid wave may bounce off the restricted suture and return to the initiating hand which should receive and redirect the returned wave toward the restricted suture

6 This back-and-forth action may be repeated for several cycles before the physician feels the suture spread and the wave penetrating the suture does not return to the initiating hand

7 The rate and amplitude of the CRI at that suture are retested to assess the effectiveness of the technique




P490 Venous Sinus Drainage (6 )

ObjectivesThe objective is to increase intracranial venous drainage by affecting the dural membranes that comprise the sinuses Thoracic outlet cervical and occipitoatlantal joint somatic dysfunctions should be treated first to allow drainage from the venous sinusesTechnique 1 The patient lies supine and the physician

is seated at the head of the table with both elbows resting on the table establishing a fulcrum

2 For transverse sinus drainage the physician places the first and second finger pads of both hands across the superior nuchal line (blue line Fig 1833) (Fig 1834)

3 This position is maintained with minimal pressure (the weight of the patients head should suffice) until a release is felt (apparent softening under the fingers)

4 The physician maintains this pressure until both sides release

5 For drainage at the confluences of sinuses the physician cradles the back of the patients head and places the middle finger of one hand on the inion (blue dot Fig 1835) (Fig 1836)

6 Step 4 is repeated until a softening is felt

Figure 1837 Occipital sinus

7 For occipital sinus drainage the physician cradles the back of the patients head and places the second to fourth fingers of both hands in opposition along the midline from the inion to the suboccipital tissues (blue

Figure 1833 Transverse sinus


Figure 1835 Confluence of sinuses

Figure 1836 Step 5

line Fig 1837) (Fig 1838) 8 Step 4 is repeated until a softening is felt 9 For drainage of the superior sagittal sinus

the physician places two crossed thumbs at lambda and exerts opposing forces with each thumb to disengage the suture

10Once local release is felt the physician moves anteriorly and superiorly along the superior sagittal suture with the crossed thumb forces noting releases at each location toward bregma (blue line Fig 1839) (Fig 1840)

11Once at bregma the physician places the second to fourth fingers of both hands in opposition along the midline on the frontal bone at the location of the metopic suture (blue line Fig 1841) (Fig 1842)

12The physician continues anteriorly on the frontal bone disengaging the suture by gently separating each finger on opposing hands

13The rate and amplitude of the CRI especially fluid fluctuations are retested to assess the effectiveness of the technique

Figure 1842 Step 11

Figure 1838 Step 7s

Figure 1839 Superior sagittal sinus


Figure 1841 Metopic suture

P492 Uni latera l Temporal Rocking Example Lef t Temporal Bone in External or Internal Rotat ion

ObjectiveThe objective is to treat a dysfunction in which the temporal bone is held in externalinternal rotationTechnique 1 The patient lies supine and the


2 The physicians left hand cradles the patients occiput

3 The physicians right thumb and index finger grasp the zygomatic portion of the patients right temporal bone thumb cephalad index finger caudad

4 The physicians right middle finger rests on the external acoustic meatus of the ear

5 The physicians right ring and little fingers rest on the inferior portion of the patients mastoid process (Figs 1843 1844 and 1845)

6 During the flexion phase of cranial motion the physicians ring and little fingers exert medial pressure This pressure is accompanied by cephalad lifting of the patients zygomatic arch with the physicians thumb and index fingers encouraging external rotation of the temporal bone

7 During the extension phase of cranial motion the physicians fingers resist motion of the patients temporal bone toward internal rotation

8 An alternative method encourages internal rotation and inhibits the external

Figure 1843 Steps 1 to 5 anatomic location of finger placement

Figure 1844 Steps 1 to 5 fingers on zygoma


rotation

9 The rate and amplitude of the primary respiratory mechanism especially at the temporal bone are retested to assess the effectiveness of the technique

P493 Fronta l L i f t (8 )

ObjectiveThe objective is to treat dysfunctions of the frontal bones in relation to their sutural or dural connections (ie frontoparietal compression frontonasal compression)Technique 1 Patient lies supine the physician is seated

with both forearms resting on the table establishing a fulcrum

2 Place both hypothenar eminences on the lateral angles of the frontal bones and the thenar eminences of both hands anterior to the lateral aspects of the coronal suture

3 The physician interlaces the fingers above the metopic suture (Fig 1846)

4 The physicians thenar and hypothenar eminences provide a gentle compressive force medially to disengage the frontals from the parietals (arrows Fig 1847) internally rotating the frontal bones

5 The physician while maintaining this medial compressive force applies a gentle anterior force either on one side or both as needed to disengage the sutural restrictions (arrows Fig 1848)

6 This position is held until the physician feels the lateral angles of the frontal bones move into external rotation (expansion under the hypothenar eminences)

7 The physician gently releases the head

8 The rate and amplitude of the primary respiratory mechanism especially at the frontal bones are retested to assess the effectiveness of the technique

Figure 1846 Steps 1-3 hand placement

Figure 1847 Step 4 compressive force

Figure 1848 Step 5 anterior guided force

P494 Parieta l L i f t (8 )

ObjectiveThe objective is to treat dysfunction of the parietal bones in relation to their sutural or dural connections (ie parietotemporal parietofrontal)Technique 1 The patient lies supine and the


2 The physician places the fingertips on both parietal bones just superior to the parietal-squamous sutures

3 The physician crosses the thumbs just above the sagittal suture (Fig 1849) Note The thumbs are NOT to touch the patient

4 The physician presses one thumb against the other (arrows Fig 1850) (one thumb presses upward while the other resists it)

5 Pressing one thumb against the other approximates the fingertips This induces internal rotation of the parietal bones at the parietal-squamous sutures

6 While maintaining pressure the physician lifts both hands cephalad until fullness is felt over the fingertips this fullness is external rotation of the parietal bones (arrows Fig 1851)




Figure 1850 Step 4

Figure 1851 Step 6 external rotation of parietals

P495

References1 Ward R (ed ) Foundat ions fo r Os teopath ic Medic ine 2nd ed Ph i lade lph ia L ipp incot t Wi l l iams amp

Wi lk ins 2003

2 Arbuck le B The Se lec ted Wr i t i ngs o f Bery l E Arbuck le Camp Hi l l PA Nat iona l Osteopath ic

Ins t i tu te and Cerebra l Pa lsy Foundat ion

3 Weaver C The Cran ia l Ver tebrae J Am Osteopath Assoc 193635328ndash336

4 Greenman P Pr inc ip les o f Manua l Med ic ine 3 rd ed Ph i lade lph ia L ipp incot t Wi l l iams amp Wi lk ins

2003

5 Ne lson K Serguef f N L ip insky C e t a l Cran ia l rhy thmic impu lse re la ted to the T raube-Her ing-

Mayer osc i l la t ion Compar ing laser Dopp ler f lowmetry and pa lpa t ion J Am Osteopath Assoc

2001101163ndash173

6 D iG iovanna E Sch iowi tz S An Os teopath ic Approach to D iagnos is and Treatment Ph i lade lph ia

L ipp incot t Wi l l iams amp Wi l k ins 2005

7 Mod i f ied wi th permiss ion f rom Agur AMR Da l ley AF Grant s A t las o f Anatomy 11 th ed Ba l t imore


8 Magoun H Os teopathy in the Cran ia l F ie ld 3 rd ed Bo ise Nor thwest Pr in t ing 1976

second sacra l segment a t the resp i ra tory ax is Th is is somet imes ca l led the core l ink I t fo l lows a rhythmic cadence a t 8 to 14 cyc les per minute ( 1 4 ) Th is impu lse may be pa lpa ted anywhere in the body and i t i s used not on ly in os teopathy in the cran ia l f i e ld bu t a lso in ba lanced l i gamentous tens ion o r l igamentous ar t i cu la r s t ra in (BLTLAS) techn iques I ts ra te and ampl i tude may vary in cer ta in d isease processes (e g fever ) Cran ia l nomencla ture is genera l ly re ferenced to mot ion occur r ing a t the sphenobas i la r symphys is o r synchondros is (SBS) I t i s s l i gh t l y convex on the super io r s ide and th is convex i ty is increased dur ing f lex ion Th is can a lso be thought o f as the in fer io r por t i on o f the SBS creat ing an ang le so tha t th is i n fe r io r -s ided ang le becomes smal le r o r more acute wi th f l ex ion o f the SBSIn sphenobasi la r f l ex ion the bas iocc ipu t and bas ispheno id move cepha lad wh i le the occ ip i ta l squama and the w ings o f the spheno id move more cauda l ly These f lex ion and ex tens ion mot ions are ro ta t iona l about t ransverse axes one a t the leve l o f the fo ramen magnum and the o ther th rough the body o f the spheno id ( 6 ) A l l mid l ine unpa i red c ran ia l bones are descr ibed as mov ing in f l ex ion and extens ion

Flexion and Extension of the Sphenobasilar SynchondrosisDur ing f lex ion o f the cran ia l base ( F ig 18 1 ) the pet rous por t ions o f the tempora l bones move

cepha lad w i th the SBS Th is produces a f la r ing outward o f the tempora l squama ca l led externa l

ro ta t ion o f the tempora l bones Al l pa i red bones move in to ex terna l ro ta t ion synchronous wi th

sphenobas i la r f lex ion In terna l ro ta t ion o f the pa i red bones is synchronous wi th sphenobas i la r

extens ion There fore i t can be sa id tha t in f l ex ion the sku l l shor tens in the anteroposter io r d iameter

and widens la tera l ly In ex tens ion ( F ig 18 2 ) the sku l l lengthens in the anteroposter io r d iameter and

nar rows la tera l ly

Because o f the l ink be tween the c ran ium and the sacrum the sacrum wi l l move wi th the cran ium In

SBS f lex ion the sacra l base moves pos terosuper io r ly ( 1 ) and in SBS ex tens ion the sacrum moves

antero in fer io r l y Th is more recent cran iosacra l mechan ism termino logy has caused some confus ion

because o f i t s d i f fe rence f rom the prev ious ly used nomenc la ture fo r g ross sacra l mot ion In gross

sacra l b iomechan ics a sacra l base anter io r movement was descr ibed as f lex ion o f the sacrum

However f lex ion in cran iosacra l mechan ism termino logy is de f ined as the sacra l base moving

poster io r ly Some have dec ided to descr ibe sacra l base movements as nodd ing mot ions Thus

fo rward movement o f the sacra l base is ca l led nuta t ion and backward movement o f the sacra l base

is ca l led counternuta t ion No mat ter wh ich te rms one chooses ( f l ex ion and extens ion or nu ta t ion and

counternuta t ion) the sacra l base goes fo rward in gross f lex ion and in c ran iosacra l ex tens ion The

sacra l base moves backward in gross ex tens ion and cran iosacra l f lex ion

P 477

Figure 181 Flexion of the sphenobasilar synchondrosis O occipital axis of rotation S sphenoidal axis of rotation

Figure 182 Extension of the sphenobasilar synchondrosis O occipital axis of rotation S sphenoidal axis of rotation




























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nicholas ch18 osteopathy in the cranial field

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