Cranial osteopathy

Last updated: March 22, 2022

Summary

The craniosacral technique was established by Dr. William G. Sutherland in the 1940s. He reasoned that 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 article on the skull.

Skull (frontal view) Cranial bones (frontal view) Skull (lateral view) Bones of the skull (lateral view) Skull (posterior view) Cranial bones (posterior view) Calvaria (cranial view) Inside of calvaria

The skull: interactive 3D model Bones of the skull: interactive 3D tour

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 motility 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. Mobility of the intracranial and intraspinal membranes
  - The meninges surround the CNS and are made up of the dura, arachnoid, and pia mater.
  - A continuous connection is present from the foramen magnum to the cervical vertebrae and second sacral segment.
  - These membranes move due to the inherent motility of the brain and spinal cord and fluctuations of the CSF.
  - Motion of these membranes causes the cranial bones and sacrum to move in relation to one another.
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.
- Moves in a biphasic cycle (flexion and extension) in response to the pull of the reciprocal tension membrane and fluctuations of the CSF

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.

Vault hold

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, 4^th or 5^th finger over greater wing of sphenoid.
3. Palpate anterior-posterior movement of the cranial motion.

Frontal-occipital hold

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.
  - Alternative placement: rest thumbs on the sphenoid bone (anterior to the ear)
3. Place remaining fingers along the posterior aspect of the neck.
4. Palpate interaction of the occiput with the cervical spine.

Posterior occipital (Becker) hold

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 and extension at the sphenobasilar junction

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

Torsion at the sphenobasilar junction

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 axes
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)

Side bending and rotation at the sphenobasilar junction

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

Vertical shears at the sphenobasilar junction

Superior shear

Sphenoid and occiput rotate anteriorly
Basisphenoid is higher at sphenobasilar synchondrosis compared to basiocciput
Vault hold: index fingers feel like they point caudad

Inferior shear

Sphenoid and occiput rotate posteriorly
Basisphenoid is lower at sphenobasilar synchondrosis compared to basiocciput
Vault hold: index fingers feel like they point cephalad

Lateral shears

Axis: 2 parallel vertical axes
Named for the direction of the basisphenoid
Sphenoid and occiput rotate in the same direction but translate in opposite directions due to shearing forces.

Lateral shears at the sphenobasilar junction

Right lateral strain (greater wing to the left)

Basisphenoid shears right, greater wing of sphenoid goes to the left, basiocciput goes to the left
Vault 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
Vault 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.

Compression at the sphenobasilar junction

Articulatory techniques

Condylar decompression

Function
- Decompresses occipital condyles
- Balances the reciprocal tension at the hypoglossal canal
- Normalizes the function of cranial nerve XII
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.

Sacral Rocking

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.

References

Seffinger M. Foundations of Osteopathic Medicine. LWW ; 2018
Destefano L. Greenman's Principles of Manual Medicine. Wolters Kluwer Law & Business ; 2015
Nicholas A. Atlas of Osteopathic Techniques. LWW ; 2015

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