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Basic Tenets of Osteopathy

Structural Cranial Osteopathic Technique . The body is a unit, and the person represents a combination of body, mind and spirit. Lisa A DeStefano, DO . The body is capable of self‐regulation, self‐healing, and health maintenance. Professor and Chairperson Department of Osteopathic Manipulative Medicine . Structure and function are reciprocally interrelated. College of Osteopathic Medicine . Rational treatment is based on an understanding of these Michigan State University principles: body unity, self‐regulation, and the interrelationship of structure and function.

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The Primary Respiratory Mechanism is a model William G. Sutherland, D.O. proposed by Dr. Sutherland to describe the interdependent functions among five components as follows: . Credited for extending the osteopathic . The inherent motility of the brain and spinal cord concept and . Fluctuation of the cerebrospinal fluid osteopathic manipulative treatment . Mobility of the intracranial and intraspinal above the membranes craniocervical junction. . Articular mobility of the cranial bones . The involuntary mobility of the sacrum between the ilia (pelvic bones)

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William G. Sutherland, D.O. The cranium is adapted for motion.

. Sutures functioned as . Sutures remain patient between the bones of the throughout life. and were intricately fashioned for the . Within the sutures maintenance of motion resides tissues whose . The skull would have normal role is passive transfer mobility during health and show restriction in response of force. to trauma or systemic disease

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Primary Respiratory Mechanism –first three Amplified Brain Motion components

. There is inherent motility of the brain and spinal cord and fluctuation of the cerebrospinal fluid and mobility of the intracranial and intra‐spinal membranes . We define this motion as the Cranial Rhythmic Impulse (CRI) • Cyclic waveform transferred onto the osseous cranium which is palpable with the human hand. • Rate is measured in cycles per minute – 1 Hz is defined as one cycle per second – 10 Hz is 10 cycles per second – .1 Hz is one cycle every 10 seconds or 6 cycles per minute

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Vasomotion Vasomotion

. First three of Sutherlands components are evidenced . Critical for maintaining many homeostatic functions. in the physiology of vasomotion. . Vasomotor tone is regulated by many factors . Vasomotion is the spontaneous oscillation in tone of blood . Hormonal control vessels, independent of heart beat, innervation or • Aldosterone, Angiotensin II, Antidiuretic hormone, Atrial respiration. natriuretic peptide, Epinephrine, Norepinephrine • Vasomotion has also been shown to exist in lymphatic vessels. . Neural control . Vasomotor tone is the amount of tension in the smooth • Baroreflex, Chemoreflex, Medullary ischemic reflex muscle inside the walls of blood vessels, particularly in . Local control arteries. • Vasodilation in response to local ischemia and accumulation of waste products or Angiogenesis in response to chronic ischemia.

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Wave forms of Vasomotion Inherent Motion

. Traube‐Hering‐Mayer (THM) waves were the first . Low‐frequency fluctuations (LFF) oscillations isolated during arterial blood pressure . frequencies similar to the 0.1 Hz Traube‐Hering waves monitoring by as early as the 19th century. . have been described in the brain using inter‐cranial . Measured at a rate of 0.1 Hz or 6 cycles per minute, it is pressure measurements, Doppler, and MRI. tension oscillation derived by the sympathetic nervous . Measured in CSF flow, venous blood flow, arterial blood system. flow and brain parenchyma . Low Frequency Fluctuations . Very Low Frequency Fluctuations

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Inherent Motion Function of the Primary Respiratory Mechanism

. CSF in interventricular and subarachnoid space of the . Sutherland believed inherent motion was necessary spinal cord has also been shown to have low‐ frequency for tissue cellular respiration, metabolic function, fluctuations. and well‐being. . Contrary to the low‐frequency arterial pulsations of the . In fact, low‐frequency fluctuations and vasomotion brain, motion of CSF is greatly enhanced by respiration have been linked to tissue oxygenation and neuronal . expiration encourages downward motion function . inspiration encourages upward motion . The literature supports altered states of vasomotion in persons with known disease states such as hypertension and diabetes.

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Primary Respiratory Mechanism –fourth component ‐Articular mobility of the cranial Sutural Motion evidenced in the literature bones. . Heisey SR, Adams, T. Role of cranial . Reflections of multiple physiological sources of low‐ bone mobility in cranial compliance. frequency oscillations passively distributed Neurosurgery 1993 Nov;33(5):869‐ 76; discussion 876‐7 throughout the body’s fascia's are indeed palpable not only on the cranium but throughout the body. . Adams T, Heisey RS, Smith MC, Briner BJ. Parietal bone mobility in • Kenneth Nelson, D.O., and Nicette Sergueef, D.O.,31,32 (France) the anesthetized cat. Am Osteopath simultaneously recorded palpable CRI and the 0.10 to 0.15 Hz Assoc 1992 May;92(5):599‐600, 603‐ Traube‐Hering‐Mayer (THM) oscillation (6 to 9 cycles per minute) 10, 615‐22 using laser‐Doppler flowmetry in humans. • Moskalenko and Kravchenko, using cranial and lumbosacral bio‐ impedance plethysmography, recorded changes in blood/CSF volume which was synchronous with the THM oscillations at a rate of 6 to 10 cycles per minute.

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Bones of the skull are divided into those that are Articular mobility of the cranial bones paired and unpaired.

. Inherent motion of the brain and is associated . Paired . Unpaired structures is reflected onto the osseous cranium, . Parietals . Occiput where it is palpable. . Temporals . Sphenoid . This influence is very predictable . Maxillae . Ethmoid . Paired bones rotated internally and externally . Zygoma . Vomer . . Single bones flex and extend Palatines . Nasals . Although the quality and amplitude of motion is . Frontal variable one should have motion.

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Motion Sphenobasilar Flexion

. The sphenobasilar synchondrosis . The sphenoid rotates anteriorly . Basisphenoid and basiocciput articulation . the basisphenoid is elevated . Fuses after the late teens . the pterygoid processes moves inferiorly . Residual plasticity throughout life . The occiput rotates posteriorly . Flexion and extension . the basiocciput is elevated . The squamous portion and condylar parts move inferiorly . Sphenoid and occiput rotate in opposite directions around a transverse (L/R) axis . A component of the cranial rhythmic impulse (more to . Extension is the opposite come).

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Sphenobasilar Motion Sphenobasilar Motion

. Flexion . The combination of . Paired bones move into external rotation flexion‐extension of the . Unpaired bones move into flexion midline unpaired bones . Extension and the internal‐ . Paired bones move into internal rotation external rotation of the . Unpaired bones move into extension paired bones is palpable.

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Sphenobasilar Motion Meninges

. Flexion . Pia, arachnoid, dura . Transverse diameter of the skull increases . The external layer of the dura is continuous with the . The anteroposterior (AP) diameter decreases periosteum of the cranium . The vertex flattens . The internal layer of the dura has several . Extension duplications that separate segments of the brain and . Transverse diameter decreases encircle the venous sinuses. . AP diameter increases . Vertex becomes more prominent

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Dura Dura

. Dural attachments . Falx Cerebri . Foramen magnum . Tentorium cerebelli . Upper two or three cervical segments . Falx cerebelli . Upper segment of the sacrum in the spinal canal (posterior to the center of rotation) . Sphenobasilar flexion • Foramen magnum elevates • Upward tension of the dura causes the base of the sacrum to move posteriorly

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Falx Cerebri (Vertical System)

. Attachments . Crista galli of the ethmoid . Fronital bone . Parietals . Occipital Squama . Encloses the superior sagittal sinus and the inferior sagittal sinus . Separates the two cerebral hemispheres

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Tentorium cerebelli (Horizontal System)

. Attachments . Anterior Clinoid Process of the Sphenoid . Occipital squama . Both parietals . Both temporals (petrous ridge) . Encloses the transverse sinus at the sigmoid decent . Separates the cerebrum and cerebellum

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Reciprocal Tension Membrane

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Primary Respiratory Mechanism –fifth Sutherland fulcrum component‐ The involuntary mobility of the sacrum between the ilia (pelvic bones) . At the junction of the falx cerebri and . During flexion, the the tentorium cerebelli resultant pull on the falx cerebri reduces the AP . Location of the straight sinus diameter of the cranium . The paired bones move into external rotation. Thus, with the pull on the petrous portions of the , these bones externally rotate.

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Primary Respiratory Mechanism –fifth component‐ The involuntary mobility of the Respiration & the Three Diaphragms sacrum between the ilia (pelvic bones) . The SBS is drawn upward into . Inhalation enhances sphenobasilar flexion, and flexion with the anterior end of exhalation enhances sphenobasilar extension the moving in a downward nose‐dive. . The Tentorium is viewed as a diaphragm . The resultant pull on the dura lifts . Descends and flattens during inhalation similar to the the spinal cord upward and due to thoracoabdominal and pelvic diaphragm the dural attachment at the posterior S2 level results in an . In health the three diaphragms should function in upward and posterior movement synchronous fashion of the sacrum between the ilia. . During extension, the reverse occurs.

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Cranial Rhythmic Impulse Primary Respiratory Mechanism

. The motion perceived in the osseous cranium is . Inherent mobility of the brain and spinal cord termed the “Cranial Rhythmic Impulse” . Fluctuation of the cerebrospinal fluid . Widening and narrowing . Motility of the intracranial and intraspinal meninges . Normal rate 6‐10 cycles per minute . Articular mobility of the cranial bones . Result of the five components of the primary . The involuntary mobility of the sacrum between the respiratory mechanism ilia

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Primary Respiratory Mechanism

. Considered to include the innate motility of the CNS, which coordinates with the observable fluctuation of the CSF fluctuation, under the guidance and restraint of the reciprocal tension membranes, to produce motion in the linked craniosacral mechanism, and the two‐phase rhythmic cycle throughout the body….This cycle manifests as the cranial rhythmic impulse and represents a dynamic metabolic interchange in every cell, with each phase of action.

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Cranial Dysfunction Cranial Osteopathy

. Headaches . Anatomic studies . Neck pain . Sutures stay patent well into the 8th decade of life . Vertigo . Biomechanical studies . Temporomandibular Dysfunction . Vault bone energy absorption positively correlated with increased sutural interdigitation . Manifestations of Concussion/Traumatic Brain Injury . Mobility studies, radiographic studies, palpatory studies . The cranium motion is present and palpable with good reliability.

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Clinical Applications Clinical Application

. The sphenoid and . Posterior quadrant the apex of the . Occipitomastoid suture temporal bone • Suboccipital muscles . Trigeminal ganglion – C1‐ C2 referral . Cavernous sinus . Parietomastoid suture • CN 3, 4, 6 . Petrojugular suture • Profound facial and • Jugular foramina orbital pain – CN 9, 10, 11 – Inferior petrosal sinus – Transverse sinus

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Clinical Application Jugular Foramina & Petro‐Jugular Suture

. Temporal bone . . Auditory and vestibular portions of CN 8 . Facial nerve • Bells palsy

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Trigeminal Nerve Trigemino‐Cervical Reflex (TCR)

. Reflex interaction between nociceptive trigeminal afferents and both upper and lower cervical spinal cord motoneurons. . Considered a withdrawal reflex, the TCR is often triggered after trauma, such as whiplash.

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Referral Pain –Trigger Points Referral Pain –Trigger Points

. Sternocleidomastoid . Medial and Lateral Muscle Pterygoid Muscles . Head . Ear . Neck . Cheek . Orbit face . Teeth . Occiput

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Temporal Mandibular Joint with Deceleration Sensing the CRI Injury

. Vault Hold . Vault Hold Deconstructed . Six‐quadrant Diagnosis • Posterior • Temporal • Anterior

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Treatment Details and Sequence OCCIPITOMASTOID SUTURE

. Type II dysfunctions in the upper thoracic spine . The most common articular restrictor in the . Upper rib cage motion restrictions posterior quadrant. . Cranial motion restrictions . A vertical and horizontal limb with a bevel change at . Posterior (OM, PM, OA) the junction. . Temporal bone (SS pivot, PJ) . Frequently related to occipital condylar compression . Anterior (Palatine, Zygoma) and atlantooccipital joint dysfunction. . Monitor for any compressions and paradox’s . Treat remaining cervical segmental dysfunctions

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Occiptomastoid Suture Occipitomastoid Suture

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PARIETOMASTOID ARTICULATION (Parietal Parietal Notch notch)

. Usually associated with occipito‐mastoid dysfunction. . Diagnosis by bilateral medial compression on parietal, sensing for give and resiliency. . Goal of treatment is to LIFT the parietal from the horizontal portion of the mastoid process.

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Parietomastoid Articulation

TEMPORAL BONE

“A walk around the temporal bone.” “The trouble maker”

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TEMPORAL BONE AND CRANIAL NERVES TEMPORAL BONE

. The temporal bone has direct relationship to nine cranial nerves: . III, IV, V, VI, VII, VIII, IX, X, and XI

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TEMPORAL BONE TEMPORAL BONE

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MOTION PALPATION MOTION TESTING

. With five finger hold sense for inherent internal and . 5 Finger hold. external rotation. . Asymmetrical motion suggests SS Pivot restriction . Paradoxical motion makes diagnosis of petrojugular subluxation. . With five finger hold lift both temporals toward vertex. . With five finger hold with one hand and the other holding occiput, look for paradoxical motion and bilateral petrojugular restrictions.

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PETROJUGULAR SUBLUXATION Petrojugular Suture

. Rare! Occurs with trauma particularly dental extraction. . Diagnosis made by paradoxical temporal motion relative to the ipsilateral occiput. . Goal of treatment is to restore temporal bone motion relative to the occiput.

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Petrojugular Subluxation PETROBASILAR ARTICULATION

. During exhalation . In line with petro‐sphenoid ligamentous articulation. . Internally rotate temporal (Get two for one). . Extend the occiput . Diagnosis by assessing antero‐medial and postero‐ . Hold to balance lateral joint play. . During forced inhalation . Goal of treatment is to restore symmetry to postero‐ . Externally rotate temporal lateral glide. . Flex the occiput

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Petrobasilar Articulation SPHENOSQUAMOUS ARTICULATION

. An L‐shaped suture with a vertical and horizontal limb with a bevel change at the junction. . The most common dysfunction of the temporals. . Diagnosis assessed by restriction of temporal external rotation inherently. . Goal of treatment is to externally rotate temporal and lift sphenoid anteriorly and into flexion.

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SS Pivot Spheno‐Squamous Articulation

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PALATINES PALATINES

. Paired bones that internally and externally rotate. . With maxillae form the roof of mouth. . Serve as speed reducers between pterygoid processes of sphenoid and maxillae. . Articulates with sphenoid, maxillae, ethmoid, vomer, and inferior conchae.

. Most common restrictor in the front quadrant.

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Palatines PALATINES

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ZYGOMA ZYGOMA

. . . Zygomaticosphenoid suture. . Zygomaticomaxillary suture. . Zygomaticotemporal suture.

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ZYGOMA Compressions

. SBS Compressions . Sphenoid and occiput moving paradoxically . Lessor Wing . Frontosphenoid . Bilateral Petrojugular Compressions . Sphenoid Ethmoid Vomer Paradox

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