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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 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

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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 2 E E F Zygomatic bone G Glabella Lacrimal H Nasal I 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 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 8 Spheno-temporal suture of temporal bone 9 Spheno-

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

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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 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 . 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

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Exercise 6 Global suture palpation—continued

A Maxilla B Incisive fossa C Zygomatic bone Hard palate (maxilla) D Greater wing of sphenoid bone E Vomer, posterior border F Temporal bone Posterior nasal spine Hard palate G 1 Occipital bone A (palatine bone)

Posterior nasal aperture 2 Inferior orbital fissure B C C Pyramidal process of palatine bone 3 Pterygoid hamulus

D D Foramen ovale E Pterygoid plate

Groove for auditory tube F F Mandibular fossa Tympanic part of temporal bone Styloid process

Stylomastoid foramen F Mastoid process 4

F Mastoid notch

Carotid canal Mastoid foramen G Jugular foramen Parietal bone

1 Intermaxillary suture Lambdoidal suture 2 Palatomaxillary suture Hypoglossal canal 3 Interpalatine nasal suture 4 Occipito-temporal suture Foramen magnum

C Occipital crest Occipital condyle Exercise Figure 1 C Inferior view of cranium and its major landmarks and sutures.

5. As you come to the end of the coronal suture higher or lower on the head? Is there any you will feel a bony prominence and then a sense of one side being more ‘rigid’ than the depression, the pterion, the junction of the other or more prominent? sphenoid, frontal, parietal and temporal 7. The between the great bones. Compare one side with the other, wing of the sphenoid and the lower, outer carefully, using a feather-light touch. aspect of the frontal bone is relatively easy 6. From the pterion move onto the great wing to palpate as the great wing is flat, while of the sphenoid and palpate its contours and the lateral aspect of frontal bone bulges sutures. This is a very important landmark laterally. in cranial methodology. Are the two sides of the sphenoid symmetrical; is one side Exercise continues Exercises.qxd 24/03/05 2:05 PM Page 56

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Exercise 6 Global suture palpation—continued

Sagittal suture Lambda Frontal Lambdoidal Parietal bone Bregma bone suture

Coronal suture

Parietal Parietal bone bone

Parietal eminence Occipital bone Mastoid process Sagittal suture

External occipital Nuchal lines protuberance Lambdoidal suture Occipital bone D E Lambda Exercise Figure 1 D Posterior view of cranium and its Exercise Figure 1 E Superior view of cranium and its major landmarks and sutures. major landmarks and sutures.

8. The superior aspect of the great wing meets 11. At the end of this suture is the asterion, the parietal bone at the sphenoparietal which is the junction of the temporal, suture. parietal and occipital bones. Again compare one side with the other in the ways 9. The junction of the posterior aspect of the suggested above. Is there symmetry? great wing with the temporal bone is at the Unusual rigidity? Is there any irregularity sphenosquamous suture, where a slight of feel? ridge-like prominence is a normal feature of this intersection. 12. Just anterior to the asterion it is possible to palpate a small amount of the suture 10. From the great wings return to the pterion between the parietal bone and the mastoid and follow the squamoparietal (or parieto- process (parietomastoid suture). Compare temporal) suture between the temporal these for symmetry and irregularities and squama and the parietal bone on each side. also for differences in the attachments of the This travels backwards and curves over sternomastoid muscles that apply such force the ear. Use a light fingerpad contact at their attachment sites. on each side which gently, repetitively and thoughtfully travels superiorly and 13. Moving back to the asterion, feel for the inferiorly to cross and recross this border. meeting place of the mastoid and the Feel carefully (this is not an easy suture to inferior edge of the occiput, the occipito- locate) for the sense of greater fullness as the mastoid suture. This feels like a depression fingers move superiorly, where the parietal or furrow, running along the posteromedial bone overlaps the temporal bone. Sense for border of the mastoid. Allow your fingers to irregularities on one side compared with the follow the until it is other, of a sense of rigidity or of soft tissue lost under the soft tissues inserting onto the ‘congestion’, tension or fibrosis in the cranium. Assess these soft tissues bilaterally musculature. for evenness of feel. Exercises.qxd 24/03/05 2:05 PM Page 57

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Exercise 6 Global suture palpation—continued

14. From the asterion move medially and from the other)? Are they symmetrical in superiorly along the serrated lambdoidal feel and do they have the same sense of ease suture. Bilaterally, using the same sutural when you lightly (half ounce maximum) evaluation method of crossing from side to ease them posteromedially or is one side side of the suture, evaluate for irregularities more resistant? and asymmetries. It normally feels wide and 17. Now move your hands to the face. Starting open. at the upper outer margin of the orbit, 15. Your fingers will meet when you reach the palpate laterally and inferiorly until you feel L-shaped lambda, commonly sensed as a the frontozygomatic suture, sensing for depression, lying on the midline, where the irregularities. occipital bone meets the sagittal suture. 18. Follow the lateral aspect of the orbit until Carefully evaluate the feel of this vital you find the zygomaticomaxillary suture. junction for evidence of crowding, distortion or asymmetry. This is close to where you 19. Palpate medially along the inferior orbit and began the palpation exercise. up the medial wall to feel the nasomaxillary junction and the frontomaxillary junction. 16. Palpate back down, along the lambdoidal Seek evidence of asymmetry and/or suture, to the asterion on each side and take unusual tissue feel. your searching fingerpads onto the mastoid process. Palpate the mastoids for symmetry. 20. Repeat these palpation moves until you are Do they seem to lie at the same angle on familiar with the contours, landmarks and each side? Are there signs of soft tissue feel of the skull in people of all ages and imbalance (sternomastoid attachments here in as many different states of health as can produce marked differences of one side possible.

Exercises 7a–7e Static (passive and kinetic) cranial suture palpation exercises – supine, seated and sidelying

Time suggested 20-25 minutes cranium is more readily available, without distorting pressures. There are suggestions that palpating the cranial sutures with the patient supine, as in the Exercise 7a Assessing gravity effect when previous exercise, creates pressures that distort palpating the accuracy of the findings, as well as making Time suggested 2–3 minutes Before performing access to the posterior aspects of the cranium seated cranial palpation (Exercise 7b), Pick (lambdoidal suture, for example) more difficult. suggests that the supine position be adopted in (Pick 1999). Pick notes: ‘Gravity could conceivably order to appreciate the effect of weight/gravity initiate a compressive strain on the sutures on supine palpation. touching the table … and consequently cause a global articular fixation throughout the cranial 1. The hands should be cupped to hold the supine vault’. patient’s head. Does one side feel heavier than The sheer weight of the head, resting on the the other? occipital bone, is seen as preventing normal 2. Rotate the head to face the side that feels sutural compliance during the palpation process. lighter and sense the change in weight With the person seated and the practitioner perceived by the supporting hands. standing at the front, back or side, access to the Exercise continues Exercises.qxd 24/03/05 2:05 PM Page 58

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Exercises 7a–7e Static (passive and kinetic) cranial suture palpation exercises – supine, seated and sidelying—continued

3. Return the head to the upright position and tone/tissue feel (hard/edematous, etc.). As with again note the change in perceived weight in Exercise 6, the more people’s heads that are the hands. palpated, of different ages, genders and states of 4. Gently elevate the head so that it is supported health, the sooner awareness will be achieved as on your extended fingertips and note the to what ‘normal’ feels like. This awareness degree of stress this causes over a short becomes a foundational marker to be used for period as the effect of gravity acts on the mass recognizing what feels abnormal, asymmetrical, of the cranium. unusual, questionable or frankly dysfunctional.

Exercise 7b Seated global suture palpation Exercise 7c Kinetic sutural palpation, left side Time suggested 5-7 minutes (coronal and other sutures) 1. Patient is seated and practitioner stands (or Time suggested 4–5 minutes Patient is sidelying sits on a high stool) in front (slightly to one on the right or supine, head on a cushion, with side) – see Exercise Figure 2A. head turned to the right to examine the left side. 2. Palpation should start at the bregma and The practitioner is on the patient’s right, at head more or less follows the sequence described level. in Exercise 6, despite starting in a different The practitioner’s cephalad (left) hand holds place (i.e. at the bregma rather than the the head to support and stabilize it, with the lambda). fingerpads (usually index and/or middle) placed strategically to palpate whichever suture 3. The sutural palpation sequence should be: is being examined (see Exercise Fig. 2C). start at the bregma (see Exercise Fig. 2B) – For the coronal suture the left (palpation) palpate along the coronal suture to the hand rests so that the index and/or middle pterion – then move onto the great wing of fingers lie on the left side of the coronal suture sphenoid and palpate its sutures with the (see Exercise Fig. 2D), the thumb rests on the frontal and parietal bones, as well as the frontal bone. sphenosquamous (aka sphenotemporal) The gloved right hand is placed so that the suture – from the pterion palpate over the ear index and middle fingers (spread apart) are in toward the asterion (finger movement should contact with the crown surfaces of the posterior be superior-inferior-superior), following the molars, allowing these contacts to be used to squamoparietal suture (aka parietotemporal) introduce rocking movements, from side to side – and from the asterion, move inferiorly to or forward and backward, as motion at the the parietomastoid and occipitomastoid suture is evaluated. sutures, then back to the asterion and up the This is then compared with findings on the lambdoidal sutures to the lambda – then right side coronal (or other) suture being palpate along the parietal suture to return to palpated, with all hand and patient positions the start, at the bregma. (For more detail of reversed. what to look for and what to expect, reread This same basic position can be used to Exercise 6.) palpate motion at the sphenofrontal, spheno- The light to-and-fro, zig-zag motions of the parietal, sphenosquamous, squamoparietal and palpating fingers or thumbs over the sutures and even the parietomastoid sutures, by altering the junctional unilateral (lambda, bregma) and palpating left hand contacts to rest on the bilateral landmarks (asterion, pterion, mastoids, appropriate suture, as the same rocking motion etc.) should be constantly focused on key is introduced via the action of the right hand features such as asymmetry and altered sense of contacts on the maxillae. Exercises.qxd 24/03/05 2:05 PM Page 59

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Exercises 7a–7e Static (passive and kinetic) cranial suture palpation exercises – supine, seated and sidelying—continued

Exercise 7d Occipitomastoid suture Exercise 7e Sagittal suture Time suggested 4–5 minutes Patient is sidelying Time suggested 4–5 minutes The patient is on the right or supine, head on a cushion, with supine, head on a cushion. The practitioner is on head turned to the right to examine the left the patient’s right, at shoulder level. occipitomastoid suture. The practitioner’s cephalad (left) hand holds The practitioner is on the patient’s right, at the head, thenar eminence resting on the patient’s head level. The practitioner’s cephalad (left) right temporal bone, with the index, middle and hand holds the occiput to support and stabilize ring fingerpads placed strategically to palpate it, with thumb placed strategically to palpate the anterior or posterior aspects of the sagittal the left occipitomastoid suture (see Exercise suture (see Exercise Fig. 2F). Fig. 2E). The gloved right hand is placed so that the The gloved right hand is placed so that the index and middle fingers (spread apart) are in index and middle fingers (spread apart) are in contact with the crown surfaces of the posterior contact with the crown surfaces of the posterior molars, allowing these contacts to be used to molars, allowing these contacts to be used to introduce rocking movements, from side to side introduce rocking movements, from side to side or forward and backward, as motion at the or forward and backward, as motion at the suture is evaluated. suture is evaluated. The anterior and posterior half, or any local The right suture is assessed with all patient feature, of the suture should be evaluated for and practitioner positions, as described above, a sense of motion as the maxillary contacts reversed. introduce rocking motions.

B

C A Exercise Figure 2 A Position for palpation of cranium with patient seated, practitioner standing. B Position of hand to help locate the bregma. C Examiner’s position relative to patient for sidelying passive kinetic palpatory examination of the cranial vault. (Redrawn with permission from Pick M 1999 Cranial sutures: analysis, morphology and manipulative strategies. Eastland Press, Seattle.) Exercise continues Exercises.qxd 24/03/05 2:05 PM Page 60

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Exercises 7a–7e Static (passive and kinetic) cranial suture palpation exercises – supine, seated and sidelying—continued

F

E D Exercise Figure 2 D Hand positions for passive kinetic palpatory examination of the coronal suture. E Hand positions for passive kinetic palpatory examination of the occipitomastoid suture. F Passive kinetic palpation of sagittal suture. (Redrawn with permission from Pick M 1999 Cranial sutures: analysis, morphology and manipulative strategies. Eastland Press, Seattle.)

Notes on cranial motion and palpatory accuracy CSF and other pulsations/motions? Or is it a more direct response to muscular or circulatory/fluid In classic craniosacral theory, motion of the cranial influences? The discussions in Chapter 2 will have bones is described as involving a flexion and an offered thoughts on what may or may not be extension phase of the cranial cycle at the happening and on the many different opinions sphenobasilar synchondrosis. and theories relating to cranial motion. The concept of any flexion potential at all at this In palpating the bones of the skull it is junction in the adult remains questionable. There suggested that the slight degree of motion that is is, however, an undoubted – if minute – degree of available be felt for, with no preconceptions as to pliability at the sutural junctions of the cranium degree or rate or, for that matter, what motive and a powerful pivot point between the occiput force might be involved. and the temporal bone, which allows the Based on research evidence, it is possible to temporals to ‘externally rotate’ (moving into what accept that sutural motion is a fact. However, is termed cranial flexion) when mobility is normal. since a sense of movement seems to be palpable In palpating the occiput the motion noted, of where osseous motion is unlikely (e.g. at the this bone, is seemingly one of easing anteriorly on synchondrosis) we need to reflect that manual inhalation and returning to its start position on assessment skills remain poorly tested by exhalation. Some believe this to be driven by researchers. When such skills are subjected to respiratory influences, although a definite sense of scrutiny both inter- and intraexaminer results are motion is palpable even during a held breath. Is anything but encouraging. this due to the influence of the reciprocal tension For example, McPartland & Goodridge (1997) membrane responding to intrinsic brain, glial cell, report that less than 30 interexaminer studies have Exercises.qxd 24/03/05 2:05 PM Page 61

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been published involving palpatory diagnosis. accepting any sense of movement at all in Most of these studies evaluate ‘traditional’ structures where movement is measured in palpatory tests (assessments performed at a single microns? articulation as used by clinicians to deter- What is undeniable, based on the research mine the need for joint manipulation) using up to discussed in Chapter 2, is that there is a degree of four criteria: joint tenderness; symmetry of cranial motion available at the sutures. This falls position; range of motion (ROM); and tissue into a range that is palpable. What significance texture change. In examination of range of motion sutural mobility has on health, when absent, is as at C1–C2 segments, only a slight degree of yet unproven, despite the impressive results agreement was noted amongst senior chiropractic achieved by cranial practitioners and therapists students. Osteopathic students and professors fare for over half a century. no better in similar studies. Where palpation of CRI (see below) is con- Where cranial palpation is concerned, Hartman cerned, it is as well to recall the suggestion (see & Norton (2002) report an almost non-existent Ch. 2) that what is being palpated relates to an degree of interexaminer agreement. interaction between yourself and the patient, If it is possible to achieve only modest agree- making interrater reliability unlikely. It is ment amongst highly skilled practitioners (or suggested that this does not discredit, nor should even none) in assessing range of motion changes it preclude, such palpation. in mobile structures, should we not pause before

Exercise 8 Cranial vault palpation for cranial motion

Time suggested not less than 10 minutes A wave-like sensation is being looked for in The patient is supine and you are at the head of the cranial structures as these movements and the table, thumbs resting on the bregma, finger- functions produce their influences. If the falx pads on the parietals, superior to the suture and cerebelli is restricted and there is a depressed carefully avoiding the temporal articulation with cranial bowl, this wave-like motion will be less the parietals (see Exercise Fig. 3). easily achieved. The hands will palpate, stabilize and monitor Additional fascial maneuvers which amplify as well as allowing the thumbs to apply the effects can include clenching of fists on light pressure to the bregma, the triangular inhalation, tightening of abdominal muscles, depression which is the junction of the sagittal using one foot only or alternating foot involve- and coronal sutures. ment in the process and/or introducing The patient inhales very deeply and, at the sucking (thumb/pacifier, etc.) coincidental with same time, moves the feet into dorsiflexion, as inhalation. you apply palpatory pressure (grams only) to the The motion should be felt at both the bregma bregma (this is achieved by pressing the heels of and the occiput. As well as palpating at the your hands together, which lifts the parietals and bregma with your thumbs, you can alter your presses the thumbs gently against the bregma). hand position to cradle the occiput while the On exhalation the patient is asked to plantar- thumbs rest on the bregma. flex the feet, as your hand contacts monitor the What do you feel? motions resulting from the fascial tug caused How do you account for the movements you by inhalation and dorsiflexion, followed by sense other than as a result of fascial and/or exhalation and plantarflexion. muscular influences? Exercise continues Exercises.qxd 24/03/05 2:05 PM Page 62

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Exercise 8 Cranial vault palpation for cranial motion—continued

1

3

1

2

1

Exercise Figure 3 Fingers should be placed superior to the temporal suture with the parietals and the thumb either directly onto the bregma or, as a variation, crossed (as in the figure) and lying on the parietal bones close to the bregma.

Exercise 9 Cranial rhythmic impulse (CRI) palpation

Time suggested not less than 10 minutes vault hold 9 (see Exercise Fig. 4). This is achieved The ‘normal’ CRI rate remains a matter for with the palms centered on the posterior surface debate (see Ch. 2) and it is suggested that you try of the parietal bones. The fingers are usually to perform this exercise with no preconceptions placed so that the small finger rests on the as to what you might sense or feel. occipital bone, the ring and middle finger are To accomplish palpation of CRI you need to resting one behind and one in front of the ear, be relaxed, focused and centered. with the index finger on the great wings of the The amount of contact pressure required to sphenoid, thumbs crossed and supporting each accomplish CRI palpation is around 5 grams. other, but not in contact with the head. (Exercise CRI is said to best be felt at the parieto- Fig. 4 shows a variation on this hand position, temporal squama, using what is known as the thumbs resting on the great wing.) Exercises.qxd 24/03/05 2:05 PM Page 63

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Exercise 9 Cranial rhythmic impulse (CRI) palpation—continued

Exercise Figure 4 Hand placement for palpation of cranial rhythmic impulse. Note that the forearms are supported by the table to prevent undue fatigue.

It is important that your forearms are your focus to the proprioceptors in your wrists supported on the table, your feet flat on the floor, and lower arms. Sense what these, rather than eyes closed, with all tension in the shoulders, the neural receptors in your hands, are feeling. arms and hands eliminated. Magnify in this way the very small amount of Spend the first 2–3 minutes noting the various actual cranial motion available for palpation and pulsations and subtle motions under your hands, you might gradually begin to feel as though quite both cardiovascular and respiratory and possibly a considerable degree of motion is taking place, others. as though the entire head were expanding and After several minutes bring the focus of your contracting laterally to a very slow rhythm, un- attention to the motions of the head in relation to related to cardiovascular or respiratory function, respiration only. anything from 4 to 10 times per minute (or more?). Have your patient/partner breathe normally A faint, wave-like ‘pushing’ might be noted. as well as, at times, with increased emphasis on At this stage trust what you feel uncritically. inhalation and/or exhalation. Can you sense a rhythm? Compare what you feel as the breathing Can you describe what you feel in words? pattern alters. Is there a periodic ‘prickling’ or pressure Have the person hold the breath for sensation in the palms of the hand? 10–15 seconds and again see whether you notice Does it feel like a ‘tide’ coming in and then any difference in the motions under your hands. receding? Then for a minute or two screen out What words would you use to describe what respiratory motion and try to pick up subtle you feel? cardiovascular pulsations. Once you are sensing a rhythmic impulse start Now screen out and temporarily ignore both to time it by counting silently to yourself as each cardiovascular and respiratory motions and see impulse begins (‘one-hundred’, ‘two-hundred’, what else you can feel in the background. etc. counts roughly a second at a time). Imagine that your hands are totally molded to Remember what the count was as the the head, without more than a few grams of sensation appeared and as it receded and later, pressure and with this whole hand contact shift Exercise continues Exercises.qxd 24/03/05 2:05 PM Page 64

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Exercise 9 Cranial rhythmic impulse (CRI) palpation—continued

after the exercise, count at the same rate and And are the feelings symmetrical or is there a check the number of seconds it takes from the difference felt by one hand or the other? start of one cranial impulse to the start of the Record all your findings in a journal or onto next. Work out the rate per minute. tape. See also what happens when your patient/ partner holds his/her breath as you continue to Variation It is possible to palpate the CRI on assess the CRI. your own head if you are seated, elbows on a Does it change? table and hands resting on the head, fingers As time goes by and you palpate more heads, interlaced or with a palm on each asterion. become aware of not just the rate of any The feeling you are seeking, in your own rhythmic pulsation you may sense but also the or anyone else’s head, is of a ‘fullness’ in amplitude of these pulsations. your palms, a warmth, a wave-like pushing, a Does the impulse feel sluggish and labored or sensation rather than an actual osseous energetic and brisk or something else? movement.

Exercise 10 Cranial motion and CRI palpation

Time suggested not less than 10 minutes Describe this in your journal or onto tape. Once you feel competent at sensing CRIs, of And can you, through your thumb contact, being able to count the rate and sense the sense what the parietal bones are doing during amplitude – whatever the origin of the rhythm the cycles of rhythmic activity which your palms you are sensing – try a different approach. This and (perhaps) other finger contacts are sensing? time perform palpation of the head using a Describe this as well. different hold. What can you sense when the subject is The tips of the ring and little fingers should be breathing lightly, as well as when they are placed on the occipital bone. The middle and deliberately breathing deeply and when they index fingers rest on the mastoid bone and the hold their breath? thumbs are resting gently on the parietal bones. What do these finger contacts sense when you Using your fingertip contacts to assess motion, ask the subject to periodically dorsiflex and ask yourself whether you sense a very slight plantarflex the feet, at the same time or only on dipping forward of the occiput at any stage one side? of the cranial rhythmic pulsation – as lateral Can you sense osseous motion in response to expansion occurs, producing a sense of increasing the fascial pulls that these movements exert at ‘fullness’ in the palms. any of the contacts or only at one or some? Does this ‘fullness’ slowly recede periodically, as the head ‘narrows’ again? Suggestion As you begin to explore these Can you, through the available contact of your cranial palpation and assessment sensations, it is middle and index fingers (resting on the mastoid suggested that you keep a journal of your bone and temporal bone respectively), sense feelings and findings, as well as the answers to what is happening to these during the various the queries posed in the exercise descriptions. By phases of the cranial cycle? referring back to the words you use to describe Do you have any sense of a change in the your first tentative explorations you will note the tissues under these very light but adherent progress you are making, as time passes and contacts? practice produces palpatory literacy. Exercises.qxd 24/03/05 2:05 PM Page 65

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REFERENCES

Frymann V 1963 Palpation – its study in the workshop. compared. Journal of Bodywork and Movement Academy of Applied Osteopathy Yearbook, Colorado Therapies 1(3): 173–178 Springs, CO, pp 16–30 Pick M 1999 Cranial sutures: analysis, morphology and Hartman S, Norton J 2002 Interexaminer reliability and manipulative strategies. Eastland Press, Seattle cranial osteopathy. Scientific Review of Alternative Upledger J, Vredevoogd J 1983 Craniosacral therapy. Medicine 6(1): 23–35 Eastland Press, Seattle McPartland J, Goodridge J 1997 Counterstrain and traditional osteopathic examination of the cervical spine Exercises.qxd 24/03/05 2:05 PM Page 66