ORIGINAL CONTRIBUTION A retrospective study of cranial strain patterns in patients with idiopathic Parkinson’s disease SONIA RIVERA-MARTINEZ, DO; MICHAEL R. WELLS, PHD; JOHN D. CAPOBIANCO, DO While providing osteopathic manipulative treatment to projections to the caudate and putamen of the basal ganglia. patients with Parkinson’s disease at the clinic of the New The loss of dopaminergic projections to the caudate and York College of Osteopathic Medicine of New York Insti- putamen produces serious disruption of the neurophysiologic tute of Technology, physicians noted that these patients activity in neuroanatomic pathways that influence muscle may exhibit particular cranial findings as a result of the dis- tone. The hallmark symptoms are a resting tremor, bradyki- ease. The purpose of this study was to compare the nesia or akinesia, and rigidity. recorded observations of cranial strain patterns of patients Patients may present with a rigid posture, characterized with Parkinson’s disease for the detection of common cra- as “simian” or “crouched”; a constant “pill rolling” trem- nial findings. Records of cranial strain patterns from physi- bling of the hands, which is more marked at rest; fixed mask- cian-recorded observations of 30 patients with idiopathic like expression; a typical stiff, shuffling, unbalanced gait; and Parkinson’s disease and 20 age-matched normal controls difficulty initiating movements. Intellect is usually unaffected were compiled. This information was used to determine until late in the disease’s progression, at which time about one whether different physicians observed particular strain third of these patients have signs of dementia. Speech may patterns in greater frequency between Parkinson’s patients become slow and reduced in volume. Without treatment, and controls. Patients with Parkinson’s disease had a sig- the disease progresses over 10 to 15 years to severe weakness nificantly higher frequency of bilateral occipitoatlantal and incapacity.1,2 Although there is no known cure for compression (87% vs. 50%; P Ͻ .02) and bilateral occipit- Parkinson’s disease, patients with this disease can obtain omastoid compression (40% vs. 10%; P Ͻ .05) compared considerable relief from the illness as well as improved quality with normal controls. Over subsequent visits and treat- of life by drug treatment and improvement of mobility ments, the frequency of both strain patterns were reduced through exercise and osteopathic manipulative treatment significantly (occipitoatlantal compression, P Ͻ .01; occip- (OMT).3-5 itomastoid compression, P Ͻ .05) to levels found in the con- The usually uneven muscular rigidity and weakness in trol group. patients with Parkinson’s disease produces numerous mus- (Key words: cranial strain patterns, Parkinson’s dis- culoskeletal findings throughout the body. Of these, structural ease, osteopathic manipulative treatment, OMT, osteopathy findings relevant to osteopathic diagnosis of the cranium are in the cranial field, OCF) thought to be primarily associated with the postural mus- culature related to the cervical and proximal body regions. The arkinson’s disease is the second most common neu- parkinsonian posture is described as “stooped” or “simian,” Prodegenerative disorder occurring primarily in older flexing not only the ankles, knees, and hips, but also the adults. The disease is associated with the loss of dopaminergic trunk and the head on the neck. In the usual progression of neurons in the substantia nigra, which provides dopaminergic the disease, one side of the body is affected more severely, and sidebending away of the trunk from the side of the tremor may be observed.6 The severity and chronicity of these pos- From the New York College of Osteopathic Medicine of New York Institute tural abnormalities and associated compensatory mecha- of Technology, Old Westbury, New York. Dr Rivera-Martinez, a medical stu- nisms may be expected to directly or indirectly contribute to dent at the time of this study, is at Long Beach Medical Center, Long Beach, observable cranial dysfunction. NY, for the traditional osteopathic rotating internship. Dr Wells is chairman of the Department of Biomechanics and Bioengineering. Dr Capobianco is a The mechanisms through alterations in the tone of mus- clinical associate professor in the Department of Osteopathic Manipulative cles between the craniocervical regions and upper torso, Medicine. which could contribute to cranial dysfunction in patients Research supported by the New York College of Osteopathic Medicine of New York Institute of Technology. with Parkinson’s disease, are complex. Magoun7 cites approx- Address correspondence to Sonia Rivera-Martinez, DO, Department of imately 36 muscles attaching from the body to the cranium Osteopathic Manipulative Medicine, New York College of Osteopathic including the occiput and temporal bones. Notable among Medicine of New York Institute of Technology, PO Box 8000, Old Westbury, NY 11568-8000. these, which attach to the occiput and temporal bones and E-mail: [email protected] could produce a flexed position, are longus capitis and rectus Rivera-Martinez et al • Original contribution JAOA • Vol 102 • No 8 • August 2002 • 417 ORIGINAL CONTRIBUTION capitis anterior, and the sternomastoid, a lateral flexor and rotator of the head. A restriction in the latter muscles has Table 1 been reported by Bernhardi8 to be associated with somatic Demographic Features of Patients with dysfunction at the occipitoatlantal joint. Unilateral contraction Diagnosed Cranial Dysfunctions of the sternomastoid rotates the head to the opposite side. Concomitantly, it draws the occipital condyle anteriorly. Feature Parkinson’s Normal control Spasm of the sternomastoid, therefore, may lead to occipi- group group 9 toatlantal dysfunction. Fiske has substantiated this result Ⅵ Sex clinically, noting that a habitually flexed face directed down- Female 10 11 ward would result in dysfunction of the occipitoatlantal joint. Male 20 9 Cervical flexion would position the occiput posteriorly, and Ⅵ the attempt to compensate by looking horizontally would Age, y Mean 71.2 71.5 bring the atlas forward, resulting in occipitoatlantal dys- Median 73.5 69 function. The positioning of the head with an abnormally Range 47-83 52-88 retracted chin has also been described by Clark10 as being diagnostic of a lesion at the occipitoatlantal joint. These exam- ples suggest that the postural misalignment, muscular spasm, sphenoid bones near the dorsum sellae. Because of the inti- and contracture commonly seen in patients with Parkinson’s mate anatomic relation of this vital blood supply to the sphe- disease could result in dysfunction of the articulations of the noid and occipital bones, the ventral midbrain, including the occipital bone with the temporal bone, first cervical vertebra, substantia nigra, could potentially be affected by changes and the occiput itself (the condyles comprising two of the from the relationship between the positions of these cranial four parts of the occiput). bones. This may provide a mechanism through which cranial In addition to the somatic dysfunctions produced by bone movement dysfunction could contribute to a degener- abnormal muscle tone in the cervical spine and cranium, ative neurologic disease such as Parkinson’s disease. mechanisms have been proposed through which cranial dys- In clinical application, osteopathy in the cranial field function may contribute to the etiology and/or progression (OCF) may help to reduce cranial strains and correct restric- of neurologic diseases such as Parkinson’s disease.11,12 Move- tions that affect the normal mobility of the sphenobasilar ment of the cranial bones has been suggested to affect vascular symphysis and related structures. Obtaining greater mobility circulation in the brain.13 Of the cranial bone articulations, of the sphenobasilar symphysis would have the effect of those related to the sphenobasilar symphysis seem particu- improving the fluctuation of cerebrospinal fluid and blood larly important. Dysfunction of the occiput as the result of flow, thus increasing the delivery of nutrients and transport altered posture can cause distortion of the sphenobasilar syn- of wastes. The overall effect could be increased vitality and chondrosis (SBS), which is considered to be the major artic- health of the patient. For these reasons, an understanding of ulation of the cranium.14 Magoun15(pp117-121) describes the which cranial dysfunctions can be commonly and reliably association of the sphenobasilar symphysis with vascular observed in a neurologic disease such as Parkinson’s dis- supply to vital areas of the central nervous system. Dys- ease may be important. functions of sphenoid movement, especially torsion or sidebending rotation, may result in disturbances of the middle Methods cerebral artery and of the normal movement of the cere- The clinical records of 30 patients with Parkinson’s disease brospinal fluid in the subarachnoid space. The middle cere- and 20 age-matched normal controls were examined to collect bral artery after the loop of the carotid siphon proceeds lat- notations of cranial dysfunction. Subjects were randomly erally into the lateral fissure at which point it runs closely selected from the records of the examining physicians. All along the lesser wing of the sphenoid. This artery supplies the data collection was performed in compliance with established primary motor, premotor cortex, and primary somatosen- guidelines of patient confidentiality