Competency 3

Question 1

3a. Perform evaluation of parietal bones for dysfunctional motion and demonstrate and describe parietal lift technique.

Answer 1

1. Demonstrate use of a modification of vault hold to contact parietal bones bilaterally while seated at head of table with patient supine
2. State that the parietal bones move into external rotation with cranial flexion and internal rotation with cranial extension
   A. External rotation during cranial flexion:
   I. Inferior border moves laterally while superior border moves medially & inferiorly (increase R/L diameter)
   Ii. Motion is similar to DeLorean car door or wings of eagle
   B. Internal rotation during cranial extension
   I. Inferior border moves medially while superior border moves laterally and superiorly (decrease R/L diameter)
   II. Motion is similar to DeLorean car door or wings of eagle
3. State that dysfunction of parietal bone is associated with headache, alteration of seizure threshold, and localized pain
4. State that the parietal bone rotates around an anterior/posterior axis in coronal plane
5. Describe and demonstrate parietal lift treatment technique
   A. Objective: to restore proper physiological motion to parietal bones when they are restricted in either internal or external rotation
   B. Position of pt: supine
   C. Position of doc: seated at pt’s head
   D. Points of contact: modified vault hold with fingers brought up to contact across inferior aspect of parietal bones, thumbs interlocked above sagittal suture
   E. Technique motions:
   I. Apply a slight force to parietals by pulling thumbs against each other as if to separate them. This will increase pressure on fingertips to start moving bones toward internal rotation. This will disengage inferior sutures from temporal bones
   II. Disengage parietals by gapping as above and then distracting sutures with a cephalad force
   III. Maintain forces until a change in quality/quantity of CRI motion is palpated, then gently release forces on cranium and release head. Reassess motion

Question 2

3b. Perform evaluation of frontal bones for dysfunctional motion and demonstrate and describe frontal lift technique

Answer 2

1. Demonstrate contacting frontal bones bilaterally while seated at head of table with patient supine. Note that the metopic suture’s functional presence is why this is named a paired bone.
2. State that the frontal bone rotates around two anterior/posterior axes in coronal plane
3. State that the frontal bones move into external rotation with cranial flexion and internal rotation with cranial extension.
   A. External rotation during cranial flexion:
   I. Inferior/lateral angles move laterally and anteriorly with glabella moving in posterior motion.
   II. Associated with finding of a low sloping forehead (Toboggan Slide Forehead)
   B. Internal rotation during cranial extension
   I. Inferior/lateral angles move medially and posteriorly with glabella moving in anterior motion
   II. Associated with finding of a high bulging/prominent forehead (Ski Jump Forehead)
4. State that the dysfunction of frontal bone is associated with
   A. Headache, visual, or smell disturbances (anosmia due to association with ethmoid)
   B. Restriction can limit falx and all attachments
   C. Frontal can get wedged from trauma
5. Describe and demonstrate frontal lift treatment technique:
   A. Objective: to allow frontal bone to perform its normal physiological motions and to free inferior aspects of coronal suture
   B. Position of pt: supine
   C. Position of doc: seated at pt’s head
   D. Points of contact:
   I. Interlace fingers above frontal bone
   II. Hypothenar eminences are then placed on corresponding lateral angles of frontal bone with heels of hand in front of coronal suture.
   E. Technique motions
   I. During extension/internal rotation, doc’s interlaced fingers exert a gentle, even, and constant pressure against each other
   II. This results in a medial pressure against frontal eminences via hypothenar eminences
   III. Doc raises frontal bone anteriorly either unilaterally or bilaterally as appropriate to diagnosis. Maintain concentration to motion that occurs, which is frontal bone moving toward external rotation. WHen release of tension occurs in frontal bone and motion toward external rotation is palplated, gently release cranium and reassess the motion.

Question 3

3c. Perform evaluation of temporal bones using 5-finger hold. Then demonstrate and describe temporal rocking technique.

Answer 3

1. Demonstrate contacting temporal bones bilaterally while seated at head of table with patient supine. Note that the 5-finger hold can be done unilaterally or bilaterally
2. Describe and demonstrate 5-finger temporal bone hold in following manner:
   A. Place middle finger gently in pt’s external auditory canal (posterior to tragus)
   B. Doc places pt’s zygomatic arch between index finger and thumb
   C. Place ring and little fingers anterior and posterior to mastoid process respectively
   D. If done unilaterally, opposite hand cradles occipital squama, medial to occipitomastoid suture
3. State that the temporal bones rotate around an oblique axis from jugular surface to petrous apex. While there is no exact plane, it is considered to be modified coronal plane motion.
4. State that the temporal bones move into external rotation with cranial flexion and internal rotation with cranial extension
   A. External rotation during cranial flexion
   I. Superior border of petrous portion moves anterolaterally
   II. Mastoid tip moves posteriorly and medially
   III. This gives a wobbly wheel type of motion
   B. Internal rotation during cranial extension
   I. Superior border of petrous portion moves posteromedially
   II. Mastoid tip moves anteriorly and laterally
5. States dysfunction of temporal bone has been associated with
   A. OM, mastoiditis, tinnitus, hearing loss, dizziness, migraines, Bell’s palsy, neuralgia
   B. Dysfunction can be due to trauma (birth, mandible), whiplash, chronic neck tension, dental extraction
   C. Internal rotation can close Eustachian tubes, producing a high pitched tinnitus
   D. External rotation is associated with a low roaring sound or tinnitus
6. State that the temporal bone has anatomical association with the following
   A. Middle ear, Eustachian tubes, carotid artery, internal jugular vein, cranial nerves III-XI, and cervical muscle attachments
7. Describe and demonstrate temporal rocking technique
   A. Objective: to release or relieve cranial nerve IX, X, XI entrapment/dysfunction, Eustachian tube compression, jugular vein compression, restricted temporal/occipital articulation, and/or tinnitus
   B. Position of pt and doc: Pt supine with doc seated at head of table using a bilateral 5-finger hold
   C. First encourage freedom of motion directions (indirect aspect of treatment)
   I. To encourage external rotation, ring, and little finger exert medial pressure on mastoid, and thumb and index direct zygomatic arch superiorly and laterally
   II. To encourage internal rotation, opposite motions are performed by thumb and index
   III. Therefore, simultaneous ER/IR motions are encouraged in a back-and-forth manner until bones are brought into asynchronous motion

D. Example: Left temporal bone prefers external rotation, and right temporal prefers internal rotation
I. Left hand exaggerates left temporal in flexion (external rotation)
II. Right hand exaggerates right temporal in extension (internal rotation)
III. After getting two bones in equal and asynchronous motion, then this process is reversed by resisting temporal motions through several cycles until bones are to a balance point (still point) and followed by symmetrical return of external and internal rotation (balanced membranous tension technique)

E. State that it is important not to leave pt with asynchronous motion as vertigo may result

Question 4

3d. Perform evaluation of temporal bones using 5-finger hold, then demonstrate and describe V spread technique

Answer 4

1. Demonstrate contacting temporal bones bilaterally while seated at head of table with pt supine. Note that the 5-finger hold can be done unilaterally or bilaterally
2. Describe and demonstrate 5-finger temporal bone hold in following manner:
   A. Place middle finger gently in pt’s external auditory canal (posterior to tragus)
   B. Place pt’s zygomatic arch between index finger and thumb
   C. Place ring and little fingers anterior and posterior to mastoid process, respectivley
   D. If done unilaterally, opposite hand cradles occipital squama medial to occipitomastoid suture
3. State that the temporal bones rotate around an oblique axis form jugular surface to petrous apex. While there is no exact plane, it is considered to be a modified coronal plane motion
4. State that the temporal bones move into external rotation with cranial flexion and internal rotation with cranial extension
   A. External rotation during cranial flexion:
   I. Superior border of petrous portion moves anterolaterally
   II. Mastoid tip moves posteriorly and medially
   III. This gives a wobbly wheel type of motion
   B. Internal rotation during cranial extension
   I. Superior border of petrous portion moves posteromedially
   II. Mastoid tip moves anteriorly and laterally
5. States that dysfunction of temporal bone has been associated with
   A. OM, mastoiditis, tinnitus, hearing loss, dizziness, migraines, Bell’s palsy, neuralgia
   B. Dysfunction can be due to trauma (birth, mandible), whiplash, chronic neck tension, dental extraction
   C. Internal rotation can close Eustachian tubes, producing a high pitched tinnitus
   D. External rotation is associated with a low roaring sound or tinnitus
6. State that the temporal bone has anatomical association with the following:
   A. Middle ear, Eustachian tubes, carotid artery, internal jugular vein, cranial nerves III and XI, and cervical muscle attachments
7. Describe and demonstrate V spread technique for OM suture
   A. State that the objective is to release or relieve any peripheral suture tension or restriction
   B. Pt is supine with student seated at head of table. Place ipsilateral hand with second and third fingers on either side of suture to be released and contralateral hand 180 degrees opposite with palm or two fingers in contact with cranium
   C. Initially spread the 2nd and 3rd fingers apart to disengage suture
   D. Gently apply a force with opposing hand towards dysfunctional suture such that a fluid flow or tide is produced toward fingers making the V
   E. Maintain the hold until there is a response felt at suture in question
   F. Reassess motion of paired bones and at suture between them

Question 5

3e. Describe and demonstrate compression of fourth ventricle (CV4) technique

Answer 5

1. State that the objective is to stimulate body’s inherent capacity (autonomics) to deal with whatever dysfunction is present
2. Doc is seated at head of table with pt supine
3. Have one hand in palm of other so that the thenar eminences are parallel (essentially in volleyball bump position)
4. State that the palmer portion of hands contact lateral angles of occiput, medial to occipitomastoid sutures
5. State that the technique is done as follows:
   A. Note first the movement of occiput
   B. In this method, do attempts to resist primary respiratory mechanism that is being monitored through CRI. Gently encourage extension of occiput while discouraging flexion
   C. Success of CV4 technique relies on inherent forces. Continue encouraging extension while discouraging flexion until a cessation of cerebral spinal fluid fluctuation is palpated. This is called “still point”
   I. Motion ceases
   II. Doc may feel warmth in hands
   III. Pt may have perspiration bead on brow

D. This position is held for 15 seconds to a few minutes until physician appreciates a return of CRI. This can be applied to sacrum when contacting head is contraindicated (acute head trauma)

E. Carefully remove hands and let pt’s head rest on table once motions return