Cranial osteopathy

Summary

The craniosacral technique was established by Dr. William G. Sutherland in the 1940s. He reasoned that the cranial sutures in relation to the skull have their own mobility. After years of study, research, and manipulation, he concluded that the cranial bones, sacrum, dural membranes, and cerebrospinal fluid function as an interrelated unit. He termed this unit the primary respiratory mechanism. Osteopathic treatment in this region aims to restore the cranial rhythmic impulse to a normal rate.

Overview

Anatomy

  • See the learning card on the skull.

Primary respiratory mechanism (PRM)

  • The cranial rhythmic impulse (CRI) refers to the palpatory sensation of the widening and narrowing of the skull.
    • Normal rate: 8–14 times per minute
    • A result of the PRM
  • The PRM is composed of five elements
    1. Inherent mobility of the brain and spinal cord
      • Brain and spinal cord have an inherent wave-like motion.
      • Described as coiling and uncoiling of the CNS
    2. Fluctuations of the cerebrospinal fluid: volume of CSF changes in relation to the CRI
    3. Motility of the intracranial and intraspinal membranes
    4. Articular mobility of cranial bones
      • Although cranial sutures fuse shortly after birth, they contain small motions that cannot be felt individually.
      • An amalgamation of the cranial bones and multiple sutures allow for palpable motion.
    5. Involuntary mobility of the sacrum between the ilia
      • The dural connection between the cranium and S2 of the vertebral column causes sacral movement.
      • This dural connection is termed the reciprocal tension membrane (RTM).
      • The bones move in rhythm with the motion of the shifting tensions of the RTM.
  • The primary physiologic motion is between the articulation of the sphenoid and the occiput called the sphenobasilar synchondrosis.

Motion

  • Physiologic patterns
    • Flexion and extension
    • Torsion
    • Side bending and rotation
  • Nonphysiologic patterns
    • Vertical shears
    • Lateral shears

Diagnostic methods

Overview

  • Assessment of the sphenobasilar synchondrosis is primarily achieved by palpating the cranium using the vault hold.
  • Although there are several variations of the vault hold, the classic technique should be used by students.
  • Supplementary techniques allow for palpation of other cranial motions.

Vault hold

  • Function: allows for general palpation of the cranial bones
  • Position: supine
  • Procedure
    1. Place hands on either side of the cranium.
      • Index fingers: greater wing of the sphenoid over the pterion
      • Middle fingers: temporal bone, anterior to the ear
      • Ring fingers: temporal bone (mastoid region), posterior to the ear
      • Little fingers: occiput
      • Thumbs: gently resting over the superior-parietal aspect of the cranium
    2. Palpate the cranial motion through the respiratory cycle.

Frontal-occipital hold

  • Function: allows for palpation of the anterior-posterior movement of the cranial bones
  • Position: supine
  • Procedure
    1. Wrap the bottom hand posteriorly along the inion and nuchal line.
    2. Rest the top hand over the frontal bone, middle finger on glabella, 4th or 5th finger over greater wing of sphenoid.
    3. Palpate anterior-posterior movement of the cranial motion.

Posterior-occipital hold (Becker hold)

  • Function: allows for palpation of the posterior cervical spine and its interaction with the occiput
  • Position: supine
  • Procedure
    1. Cup the occiput with the palms.
    2. Rest thumbs on the mastoid processes.
    3. Place remaining fingers along the posterior aspect of the neck.
    4. Palpate interaction of the occiput with the cervical spine.

Strain patterns

Physiologic patterns

Flexion and extension

  • Axis: 2 parallel transverse axes
  • Sphenoid and occiput rotate in opposite directions around the two separate transverse axes

Flexion (inhalation)

  • Sphenoid rotates anteriorly and occiput rotates posteriorly
  • Basisphenoid and basiocciput move cephalad as greater wings move slightly lateral and caudad
  • Vault hold: index and little fingers spread (as paired lateral bones externally rotate) and move caudad

Extension (exhalation)

  • Sphenoid rotates posteriorly and occiput rotates anteriorly
  • Basisphenoid and basiocciput move caudad as greater wings move slightly medial and cephalad
  • Vault hold: index and little fingers narrow (as paired lateral bones internally rotate) and move cephalad

Torsion

  • Axis: 1 anterior-posterior axis (nasion to opisthion)
  • Named after the higher greater wing of the sphenoid
  • Sphenoid and occiput rotate in opposite directions

Left torsion

  • Sphenoid rotates to the right and occiput rotates to the left
  • Vault hold: left index finger feels more anterosuperior and right index finger feels posteroinferiorly rotated

Right torsion

  • Sphenoid rotates to the left and occiput rotates to the right
  • Vault hold: left index finger feels more posteroinferior and the right index finger feels anterosuperiorly rotated

Side bending and rotation

  • Axis: 2 parallel vertical and 1 anterior-posterior axis
  • Sphenoid and occiput rotate in the same direction on anterior-posterior axis and in opposite directions on the vertical axes
  • Side bending occurs through the vertical axes creating a convexity (on the side where the sphenoid and occiput spread apart)

Right side bending and rotation

  • Sphenoid and occiput are closer on the left
  • Vault hold: right fingers spread (convex) and move caudad, left fingers narrow and move cephalad

Left side bending and rotation

  • Sphenoid and occiput are closer on the right
  • Vault hold: left fingers spread (convex) and move caudad, right fingers narrow and moves cephalad

Non-physiologic patterns

  • Typically occur as a result of trauma or disease (e.g., birth trauma, falls, sports injuries, motor vehicle collisions, among others)

Vertical shears

  • Axis: 2 parallel transverse axes (similar to flexion and extension)
  • Named for the position of the basisphenoid in relation to the sphenobasilar synchondrosis
  • Sphenoid and occiput rotate in the same direction

Superior shear

Inferior shear

Lateral shears

  • Axis: 1 vertical axis
  • Named for the direction of the basisphenoid
  • Sphenoid and occiput rotate in the same direction but translate in opposite directions due to shearing forces.

Right lateral strain (greater wing to the left)

  • Basisphenoid shears right, greater wing of sphenoid goes to the left, basiocciput goes to the left
  • Volt hold: parallelogram with the index finger shifting to the left and the little finger shifting to the right

Left lateral strain (greater wing to the right)

  • Basisphenoid shears left, greater wing of sphenoid goes to the right, basiocciput goes to the right
  • Volt hold: parallelogram with the index finger shifting to the right and the little finger shifting to the left

Compression

  • Sphenoid and occiput movement is restricted.
  • Compensatory patterns may be present.
    • Increased internal and external rotation of the paired lateral bones
  • Lateral compression can occur with unilateral impaction and temporal bone restriction to that side.

Articulatory techniques

Condylar decompression

  • Function
  • Position: supine with examiner seated at the head of the table and both forearms resting on the table (establishing a fulcrum)
  • Procedure
    1. Have the patient's head rest on your palms with the index and middle fingers contacting the condylar processes (as far caudad on the occiput as the soft tissue and C1 allow) on both sides.
    2. Apply a gentle cephalad and lateral traction at the base of the occiput.
    3. Achieve a balanced tension.
    4. Maintain traction until a release is felt.
    5. Reassess.

Base spread

  • Function: diagnoses and treats tension at the craniocervical junction
  • Position: supine with examiner seated at the head of the table
  • Procedure
    1. Have the patient's head rest on your palms with the index fingers on the mastoid process (of the temporal bone), middle and ring fingers on either side of the occipitomastoid suture, and little fingers on the occiput and the head slightly flexed.
    2. Apply gentle superior-lateral traction.
      • Index fingers tract more laterally to match the angle of the petrous portion (∼ 45° from midline)
      • Middle and ring fingers tract along the occipital condyles (∼ 30° from midline)
    3. Assess for restriction.
      • Increased resistance along index finger → temporal bone restriction
      • Increased resistance along middle finger → occipital restriction
      • Increased resistance along middle and ring fingers → occipitomastoid restriction
    4. Maintain traction until a balance is achieved along all fingers.
    5. Reassess.

Occipitomastoid suture release

  • Function: releases tension on the vagus nerve by releasing restriction at the occipitomastoid suture
  • Position: supine with examiner seated at the head of the table
  • Procedure
    1. Cup the occiput with the contralateral palm with the fingertips just medial to the occipitomastoid suture.
    2. Grasp the mastoid process with the thumb and index fingers of the ipsilateral hand just lateral to the occipitomastoid suture.
    3. Evaluate motion of the suture by gently separating the left and right fingers without sliding over the skin.
    4. Move fingers in opposite directions until a release is felt.
    5. Reassess.

Venous sinus technique

  • Function: decrease venous congestion and improve circulation and drainage of the head through the jugular foramen
  • Position: supine with examiner seated at the head of the table
  • Procedure
    1. Perform thoracic inlet release and treat any cervical restrictions.
    2. Use finger pads to treat each sinus by spreading the overlying sutures.
      • Occipital sinus: finger pads rest just below the inion (occipital sinus)
      • Transverse sinuses: little fingers rest on the inion (medially) and index fingers rest along nuchal line (laterally)
      • Superior sagittal sinus: starting at lambda, thumbs travel along the sagittal suture until the bregma is reached
    3. Reassess.

CV4: bulb decompression

  • Function: restores normal craniosacral mechanism and increases amplitude of the cranial rhythmic impulse
  • Position: supine with examiner seated at the head of the table
  • Procedure
    1. Place thenar eminences just below the nuchal line, medial to the mastoid processes.
    2. Apply gentle superomedial traction.
      • Exaggerate traction during the exhalation phase.
    3. Hold until a still point is reached.
    4. Reassess.

V spread

  • Function: reduces restriction along any cranial suture
  • Position: supine with examiner seated at the head of the table
  • Procedure
    1. Place two fingers on each side of the restricted suture.
    2. Turn the patient's head to shift weight onto your fingers.
    3. Apply gentle pressure with the opposite hand directly opposite to the affected suture.
    4. Apply a distracting and separating traction with your fingers.
    5. Hold until a release is felt.
    6. Reassess.

Sacral rocking

  • Function: improves movement of the sacrum in relation to the primary respiratory mechanism
  • Position: prone
  • Procedure
    1. Place one palm on the apex and the other on the base and interlock your fingers.
    2. Ask the patient to take deep breaths.
    3. Exaggerate motion of the sacrum through inhalation (counternutation) and exhalation (nutation).
    4. Continue for 4–5 cycles or until motion is improved.
    5. Reassess sacral motion.

Temporal rocking

  • Function: restore synchronous motion of the temporal bone
  • Position: supine with examiner seated at the head of the table
  • Procedure
    1. Support skull in the palms and place thumbs just anterior to the mastoid processes.
    2. Apply posteromedial traction on the inferior aspect of the mastoid processes (introduces external rotation).
    3. Apply a posteromedial compression on the superior aspect of the mastoid process (introduces internal rotation).
    4. Continue rocking motion until motion on each side synchronizes.
    5. Reassess temporal bone motion.
last updated 08/05/2019
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