1. 1. CRANIAL MANIPULATION BASICS OSSEOUS & SOFT TISSUE APPROACHES Dr. KANNABIRAN BHOJAN .PhD, P.T CERTIFIED IN BASIC & ADVANCED OSTEOPATHY TECHNIQUES -OHWI-ONTARIO ,CANADA DIPLOMA IN FASCIAL MANIPULATION FM1-LUIGI STECCO METHOD ,ITALY CERTIFIED VISCERAL MANIPULATION VM1 BARRAL INSTITUTE ,USA TRIGGER POINT DRY NEEDLING DN1 MYOPAIN SEMINARS,USA PROFFESSOR RVS COLLEGE OF PHYSIOTHERAPY CONSULTANT ORTHOPEDIC MANIPULATIVE SPORTS PHYSIOTHERAPIST FAST GROWING AREA OF MANUAL THERAPY PRACTICE
2. 2. HISTORY With its modern roots in cranial osteopathy, as developed by Sutherland (Sutherland 1939) in the early years of the 20th century, Craniosacral manipulation was first introduced into the osteopathic profession in the 1930s. Instruction in the field began in the 1940s. The pioneering work of William Garner Sutherland (described in Upledger & Vredevoogd 1983)
3. 3. Sutherland 1939
4. 4. The Cranio Sacral skeleton The Cranio Sacral skeleton is the axial skeleton. It consists of the skull, vertebral column, sacrum, and coccyx.
5. 5. The Skull face and the calvarium. There are 28 moveable bones in the craniofacial skull, including the six ossicles of the inner ears within the temporal bones. Additionally, and also within the temporal bones, are the osseous labyrinths. The hyoid bone is considered by some to be cranial.
6. 6. There are eight cranial bones: 1. occiput 2. sphenoid 3. ethmoid 4. frontal 5. two temporals 6. two parietals
7. 7. There are fourteen facial bones: 1. mandible 2. vomer 3. two maxillae 4. two zygomatic 5. two palatines 6. two nasals 7. two lacrimals 8. two inferior conchae
8. 8. Skull & clavarium
9. 9. cranial mechanisms and number of overlapping processes About Mechanical bony restrictions or ligamentous or fascial structural and functional anomalies.
10. 10. cranial mechanisms and number of overlapping processes Dysfunctional situations where interference with normal pulsatile activities or soft tissue properties seems to have occurred and which have no easy, 'gross', structural or orthopedic consequence.
11. 11. cranial mechanisms and number of overlapping processes Bio-electromagnetic energy factors permeate all mechanical, functional and dysfunctional processes and that in some instances there seems to be no way of making sense of cranio sacral treatment without hypothesizing energetic involvement.
12. 12. cranial mechanisms and number of overlapping processes The unconvinced perspective-placebo effect
13. 13. cranial mechanisms and number of overlapping processes Gross mechanical, subtle pulsatile or energy imbalances
14. 14. FIVE KEY ELEMENTS PROPOSED BY SUTHERLAND INHERENT MOTILITY OF BRAIN AND SPINAL CORD FLUCTUATING CSF MOTILITY OF INTRACRANIAL AND SPINAL MEMBRANES MOBILITY OF BONES OF SKULL INVOLUNTARY SACRAL MOTION BETWEEN THE ILLIA
15. 15. INHERENT MOTILITY OF BRAIN AND SPINAL CORD
16. 16. CSF circulation
17. 17. FLUCTUATING CSF
18. 18. MOTILITY OF INTRACRANIAL AND SPINAL MEMBRANES A Modification in length of spinal canal in cervical region during flexion and extension. B Modification in length of spinal canal in lumbar region during flexion and extension
19. 19. MOBILITY OF BONES OF SKULL posterior & superior view
20. 20. MOBILITY OF BONES OF SKULL
21. 21. Cranioscaral movement
22. 22. INVOLUNTARY SACRAL MOTION BETWEEN THE ILLIA through this mechanism it is believed that the sacrum will be pulled up and the base will rotate forward during inhalation and then will lower slightly and the base will rotate backward during exhalation. It is the dural attachments that link the head to the sacrum and allows them to move in a coordinated rhythm.
23. 23. Concepts validity Is there palpable mobility at the cranial sutures and articulations and if so, what is the significance of such mobility in health terms? What are the reciprocal tension membranes and is there a linking mechanism between cranial and sacral motion? Does a cranial rhythmic impulse (CRI) exist and if so, what is it and, especially, what is its relationship with cerebrospinal fluid fluctuations and flow? What are the forces moving cranial structures and so producing the CRI? Most importantly, are these forces primary or is movement the result of a combination of normal physiological functions such as respiration and cardiovascular rhythms?
24. 24. Cranial structures and their mobility Sutherland (described in Upledger & Vredevoogd 1983) observed mobile articulation between the cranial bones almost 100 years ago and researched the concept for the rest of his life. influence of the intracranial ligaments and fascia on cranial motion, which he suggested acted to balance motion within the skull. PRM 'primary respiratory mechanism' which was the motive force for cranial motion PUMPING CSF.
25. 25. RTM
26. 26. Inhalation and exhalation phases of primary respiratory mechanism
27. 27. RTM
28. 28. Tensegrity
29. 29. Before fusion
30. 30. Cranial structures
31. 31. Flax Cerebri &Tentorium Cerebelli
32. 32. Cranioscaral movement
33. 33. What drives the cranial rhythm? The perpetual outpouring of impulses from the brain to maintain postural equilibrium, chemical homeostasis, and so on, conceivably may multiply the activity of individual cells into a rhythmic pattern of the whole brain, small enough to be invisible to the naked eye, but large enough to move the cerebrospinal fluid which in turn moves the delicate articulated cranial mechanism.(Frymann 1971)
34. 34. WAS FRYMANN RIGHT ABOUT CRANIAL RHYTHM RESEARCH SUPPORT IT
35. 35. MODELS OF CRANIAL THERAPEUTICS CRANIAL OSTEOPATHY- WILLIAM GARNER SUTHERLAND 1939 CST- JOHN UPLEDGER 1995 SOMATIC CRANIAL WORK- SHEA 1997 SACROOCCIPITAL TECHNIQUE & APPLIED KINESIOLOGY DEJARNETTE 1975-78 ECLECTIC DENTAL AND CRANIOFASCIAL APPROACHES VERNON 2001 POLY VAGAL CONCEPT- SAHAR 2001 & PORGES 2001
36. 36. CONCLUSIONS THERE EXISTS A PURELY CRANIAL MODEL INCORPORATES KNOWINGLY OR UNKNOWINGLY PRINCIPLES OF TENSEGRITY INVOLVES FLUID/ELECTRIC ASPECTS CAN RANGE PARTLY MECHANISTIC TO ALMOST TOTALLY ENERGETIC/SPRITUAL
37. 37. What are the clinical implications of cranial dysfunction? Assuming being a direct connection between such Cranial motion and Sacral motion and, further, that this motion has a rhythmicity which is palpable. McPartland gives some indications Upledger & Vredevoogd (Upledger 1996) offer a long list.
38. 38. Some indications Acute sprains and strains using a variety of techniques. Chronic pain problems (using techniques such as CV-4 as well as balancing tissue tension and dural membrane balancing). Visceral dysfunction (peptic ulcers, ulcerative bowels, tachycardia, asthma, etc. treated by means of normalizing restriction patterns in the craniosacral system). Autonomic nervous system problems such as Raynaud's syndrome (treated by using CV-4 daily). Rheumatoid arthritis (CV-4, often applied by a family member, daily). Emotional disorders - especially anxiety (using specialized techniques). Scoliosis, which is often seen to be a direct result of craniosacral distortions.
39. 39. Hand placement for palpation of cranial rhythmic impulse. The forearms are supported by the table to prevent undue fatigue.
40. 40. cranial rhythmic impulse As you begin to explore these cranial palpation and assessment sensations, it is suggested that you keep a journal of your feelings and findings, as well as the answers to the queries posed in the exercise descriptions.
41. 41. What are the clinical implications of cranial dysfunction? Let us assume, hypothetically speaking, that it is possible to establish that mobility exists between cranial bones in normal situations, as well as there being a direct connection between such motion and sacral motion and, further, that this motion has a rhythmicity which is palpable.
42. 42. Non-cephalic medical presentations benefiting from manipulation Most orthopedic complaints routinely referred to physical therapy Extensor tendonitis Tennis elbow Biceps tendonitis Frozen shoulder Lumbar strain Plantar fasciitis*
43. 43. Non-cephalic medical presentations benefiting from manipulation Most orthopedic complaints routinely referred to physical therapy Peripheral neuropathies Carpal tunnel syndrome Brachial plexus compression/thoracic outlet syndrome* Sciatica Vertebral disk prolapse
44. 44. Contraindications Structurally or medically unstable conditions Stroke in evolution Suspicion of subarachnoid hemorrhage Suspicion of acute fracture, cranial or cervical Suspicion of cancer not yet diagnosed or staged Potential for metastasis when cure is still sought Acute encephalopathy or meningitis Vertebral disk prolapse Dizziness, loss of consciousness, blurred vision with cervical rotation/side bending
45. 45. Hand placement for palpation of cranial rhythmic impulse. The forearms are supported by the table to prevent undue fatigue.
46. 46. Vault hold for cranial palpation. Relative head and hand size may prevent precise replication of suggested sites for finger placement.
47. 47. Vault hold for cranial palpation
48. 48. Fronto-occipital hold for cranial palpation.
49. 49. sacral palpation and treatment.