Exercises: Refining Cranial Palpation Skills

Exercises.qxd 24/03/05 2:05 PM Page 51 51 Exercises: refining cranial palpation skills Exercise 1 To enhance awareness of CHAPTER CONTENTS palpated inherent tissue sensation Exercise 1 To enhance awareness of palpated inherent tissue sensation 51 Time suggested 10 minutes Exercise 2 To enhance bilateral perception of Frymann (1963) suggests that you sit at a table palpated tissue sensation 52 opposite a partner, one of whose arms rests on the table, flexor surface upwards. This arm Exercise 3 To enhance perception of subtle should be totally relaxed. Place a hand onto sensations in neurally connected areas 52 that forearm with attention focused on what the Exercise 4 To discriminate between palpated palmar surfaces of the fingers are feeling. The sensations deriving from indirectly related other hand should lie on the firm table surface areas 52 in order to provide a contrast reference as the living tissue is palpated, distinguishing a Exercise 5 To discriminate between various region in motion from one without motion. sensations deriving from a palpated Your elbows should rest on the table so that no pulsation 52 stress builds up in the arm or shoulders. Exercise 6 Global suture palpation 53 With eyes closed, concentration should then be projected into what the fingers are feeling, Exercises 7a–7e Static (passive and kinetic) attuning to the arm surface. Gradually, focus cranial suture palpation exercises – supine, should be brought to the deeper tissues under seated and sidelying 57 the skin as well, and finally to the underlying Exercise 8 Cranial vault palpation for cranial bone. motion 61 When structure has been well noted, the function of the tissues should be considered. Exercise 9 Cranial rhythmic impulse (CRI) Feel for pulsations and rhythms, periodically palpation 62 varying the pressure of the hand. At this stage Exercise 10 CRI palpation 64 Frymann urges you to: ‘Pay no attention to the structure of skin or muscle or bone. Wait until References 65 you become aware of motion: observe and describe that motion, its nature, its direction, its Exercise continues Exercises.qxd 24/03/05 2:05 PM Page 52 52 EXERCISES: REFINING CRANIAL PALPATION SKILLS Exercise 1 To enhance awareness of palpated Exercise 4 To discriminate between inherent tissue sensation—continued palpated sensations deriving from indirectly related areas rhythm and amplitude, its consistency or its variation’. Time suggested 5–10 minutes This entire palpatory exercise should take not less than 5 minutes, ideally 10 minutes and Frymann (1963) suggests that on another should be repeated with the other hand to occasion (or at the same session) you palpate ensure that palpation skills are not one-sided. one limb with one hand (say the upper arm) and another limb (a thigh, for example) with the other and that you ‘rest in stillness until you perceive the respective motions within’. Ask yourself whether the rhythms you are Exercise 2 To enhance bilateral perception feeling are synchronous and moving in the of palpated tissue sensation same direction. Are they consistent or do they undergo cyclical changes, periodically returning Time suggested 5–10 minutes to the starting rhythmic pattern? When you have palpated an arm (or any other You may actually sense, she says, that the part of the body) to the point where you are force being felt seems to carry your hands to a clearly picking up sensations of motion and point beyond the confines of the body, pulling rhythmic pulsation, place your other hand on in one direction more than another, with little the other side of the same limb. or no tendency to return to a balanced neutral Is this hand picking up the same motions? position. This may represent a pattern established Are the sensations noted in each hand as a result of trauma which is still manifest in moving in the same direction, with the same the tissues. Careful questioning might confirm rhythm and is there the same degree of the nature and direction of a blow or injury in amplitude to the motion? the past. In health they will be the same. When there is a difference it may represent the residual effects of trauma or some other form of Exercise 5 To discriminate between various dysfunction. sensations deriving from a palpated pulsation Time suggested 5–7 minutes with each hand Exercise 3 To enhance perception of subtle sensations in neurally connected areas Upledger (Upledger & Vredevoogd 1983) suggests that palpation and assessment of Time suggested 5 minutes obvious pulsating rhythms should be practiced, for example involving the cardiovascular pulses. Place one hand gently but fully on a spinal He describes the first stages of this learning segment from which derives the neurological process thus: supply to an area which is simultaneously being palpated by the other hand. With the subject lying comfortably supine, By patiently focusing for some minutes – palpate the radial pulses. Feel the obvious peak eyes closed – on what is being felt, Frymann of the pulsation. Tune in also to the rise and states, ‘a fluid wave will eventually be fall of the pressure gradient. established between the two hands’. How long is diastole? Can you feel this or anything which What is the quality of the rise of pulse approximates it? pressure after diastole? Exercises.qxd 24/03/05 2:05 PM Page 53 Exercises 53 Exercise 5 To discriminate between various sensations deriving from a palpated pulsation—continued Is it sharp, gradual, smooth? How broad is body. You should be able to mentally reproduce the pressure peak? your palpatory perception of the pulse after you Is the pressure descent rapid, gradual, have broken contact. smooth or stepped? Upledger then suggests you do the same thing with the carotid pulse and subsequently palpate Memorize the feel of the subject’s pulse so that both radial and carotid at the same time and you can reproduce it in your mind after you have compare them. broken actual physical contact with the subject’s Exercise 6 Global suture palpation Time suggested 10-15 minutes Greenman’s cranial palpation exercise (supine) (see Exercise Figs 1A–E) Bregma A Parietal bone B Occipital bone C Temporal bone Pterion D Vertex Sphenoid bone 2 E E Frontal bone F Zygomatic bone G Glabella Lacrimal H Nasal I Maxilla bone J A Nasion Mandible bone Ethmoid bone 9 3 H Lambda D G 6 C 8 Anterior nasal aperture Zygomaticofacial foramen Posterior pole 4 F Anterior nasal spine 1 5 Infra-orbital foramen I Asterion B 7 Inion 1 J Lambdoidal suture External acoustic meatus Mental protuberance 2 Coronal suture Mastoid process 3 Fronto-zygomatic suture Tympanic part Mental foramen 4 Tempero-zygomatic suture Styloid process 5 Zygomatico-maxillary suture Inferior border Condylar process 6 Parieto-temporal suture Coronoid process of mandible 7 Occipito-temporal suture Zygomatic arch Zygomatic process 8 Spheno-temporal suture of temporal bone 9 Spheno-frontal suture A Exercise Figure 1 A Lateral view of the cranium and its major landmarks and sutures. Exercise continues Exercises.qxd 24/03/05 2:05 PM Page 54 54 EXERCISES: REFINING CRANIAL PALPATION SKILLS Exercise 6 Global suture palpation—continued Metopic suture 1 Nasion Internasal suture 2 Zygomatico-maxillary Supraorbital foramen suture A 3 Intermaxillary suture Lesser wing of sphenoid Parietal bone Superior orbital fissure Greater wing of sphenoid Ethmoid bone 1 B C B Squamous part of temporal bone Inferior orbital fissure Lacrimal bone Zygomaticofacial foramen 2 Middle nasal concha D D Inferior nasal concha Infra-orbital foramen 3 E Anterior nasal spine of maxilla Perpendicular plate Mastoid process of ethmoid bone Styloid process A Frontal bone Vomer B Sphenoid bone C Nasal bone D Zygomatic bone Mental foramen Symphysis menti E Maxilla F (union of mandibular halves) F Mandible B Exercise Figure 1 B Frontal view of cranium and its major landmarks and sutures. 1. Sit at the head of the table with your partner suture to feel more ‘open’ than the lying face upwards, no pillow. anterior third. This is due to the size of the serrations rather than being an 2. Palpate the vertex of the skull with your abnormality. thumb or fingerpads. Moving them gently from side to side, feel the serrated contours 4. Starting from the bregma, lying in a slight of the sagittal suture. Locate the posterior depression, palpate bilaterally (both ways at aspect of the sagittal suture, the L-shaped the same time) sideways along the coronal lambda. suture. You are feeling the junction between the parietal and the frontal bones. Compare 3. Follow the sagittal suture from where it what one fingerpad feels with what the begins at the lambda, where the parietal and other is sensing, trying to determine any occipital bones meet. Try to note irregularities, indication of the frontal or the parietal asymmetries (for example, one side being bone being more prominent on one side raised compared with the other), areas of compared with the other, assessing for contrast in terms of hardness/softness, etc. irregularities, hard and soft areas, rigidity, Palpate with fingers or thumbs lightly criss- etc., seeking evidence of any asymmetry. crossing the suture, moving anteriorly in Pick (1999) describes the area between the this manner until you reach the bregma, bregma and the great wing as feeling ‘like a triangular depression, the junction of an open trench’, as though the suture has the sagittal and the coronal sutures. It is ‘spread apart’. normal for the posterior third of the Exercises.qxd 24/03/05 2:05 PM Page 55 Exercises 55 Exercise 6 Global suture palpation—continued

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