Cranial Lab 1/7/16

Question 1

Set up for Frontal Bone Assessment

Answer 1

• Pt is supine
• Sit at the head of the table
• hand position for the frontooccipital hold = (1) One hand supports (is placed beneath) the occiput. (2) The other hand gently cradles the frontal bone.

Question 2

Flexion phase (felt in the frontooccipital hold)

Answer 2

the frontal bone behaves as both a single midline bone (moves into flexion) and as a paired bone by externally rotating (metopic suture gets deeper). The A-P diameter of the head decreases

Question 3

Extension phase (felt in the frontooccipital hold)

Answer 3

the frontal bone moves into extension and internally rotates (metopic suture becomes shallower). The A-P diameter of the head increases

Question 4

Set up for Parietal bone assessment

Answer 4

• patient supine.
• Sit at head of table.
• Spread your index, middle, ring and little fingers over the inferolateral aspects of the parietal bones.
• Avoid the temporal bones!
• Cross your thumbs over the sagittal suture (only if comfortable)

Question 5

Parietal bone assessment - flexion and extension

Answer 5

• During flexion the inferior portions of the parietal bones moves laterally. The sagittal suture moves inferiorly.
• The reverse occurs during extension

Question 6

Approximately 90% of the venous drainage from the head occurs through the ______, which courses through the ______.

Answer 6

internal jugular vein……jugular foramen

Question 7

The jugular foramen is located between the ______ bones along the occipitomastoid suture

Answer 7

temporal and occipital

Question 8

Compression of the occipitomastoid suture can _____ and ________

Answer 8

reduce drainage from the head…..affect cranial nerves 9, 10 and 11 (which also transverse through the jugular foramen)

Question 9

Compression of the occipitomastoid suture will affect the motion of the ______ and make it more difficult to treat when using _______.

Answer 9

temporal bone…..indirect technique.

Question 10

Occipitomastoid suture: Palpation of tissue texture changes

Answer 10

cradle the patient’s head in your hands. Very gently palpate along the occipitomastoid sutures with your fingertips. You don’t want to introduce compression and dysfunction into this area!

Question 11

What does a restricted Occipitomastoid suture feel like?

Answer 11

Firm to palpation and/or resistant to motion

Question 12

Occipitomastoid suture: Motion assessment

Answer 12

hook the distal aspect of your middle fingers around the mastoid processes of the temporal bones. Apply gentle superiorly-directed traction to each temporal bone, one side at a time. Test one side and then the other. Look for a sensation of firmness or a resistance to motion. Treat the side that is the most restricted. Treat both sides if bilaterally restricted.

Question 13

Standard Vault Hold

Answer 13

• Keep hands with contact similar to a silk scarf on the head
• Hands on either side of the head with thumbs touching each other along the sagittal suture
• Index fingers on the greater wing of the sphenoid
• Middle finger in front of the ear
• Fourth finger on mastoid process behind the ear
• Little finger on occiput
• Finger pads (not tips) contact the skull
• Entire finger and palm should contact the skull

Question 14

Venous Sinus Release Technique: Occipital Sinus

Answer 14

• Release the occipital sinus and confluence of sinuses by resting the head at the external occipital protuberance on the fingertips of the middle fingers.
• Hold this position until you perceive a “melting” of the tissues or “softening” of the bone.
• Maintain same hand position, move fingers a fingerbreadth down the midline of the occiput.
• Continue this method until the entire occiput has been released moving toward the foramen magnum.

Question 15

Venous Sinus Release Technique: Jugular Sinus

Answer 15

• Decompress the occiput from the atlas by placing your fingertips along the condylar aspect of the occiput. The weight of the head on your fingertips is sufficient force to accomplish the decompression.
• This “opens” the jugular foramen and allows the drainage of venous blood.
• Hold this position until you perceive a “melting” of the tissues.

Question 16

Venous Sinus Release Technique: Transverse Sinus

Answer 16

• Release the transverse sinuses by resting the occipital ridge on your fingertips.
• Hold this position until you perceive a “melting” of the tissues.
• The weight of the patient’s head is sufficient pressure.

Question 17

Venous Sinus Release Technique: Straight Sinus

Answer 17

• Release the straight sinus by placing your fingertips on the occipital ridge and crossing thumbs over each other . Rest thumbs gently on the sagittal suture over the vertex of the skull.
• Focus on directing CSF between your thumbs and fingertips.
• This is done by directing your attention to create a wave of fluid between your thumbs and fingertips. This is a thought, not an action.
• Hold this position until you perceive a “melting” of the tissues.

Question 18

Venous Sinus Release Technique: Sagittal Sinus

Answer 18

• Start by flexing the patient’s head forward so that you can place your thumbs at the external occipital protuberance.
• Release the superior sagittal sinus by applying gentle pressure with your thumbs crossed on either side of the sinus starting an inch above the external occipital protuberance. Alternately, you can place your index and middle fingers on either side of the sagittal sinus an inch above the external occipital protuberance with minimal flexion of the head and neck, apply gentle pressure distracting laterally away from the sinus.
• When “softening” is noted, move another inch upward.
• Continue moving upward an inch at a time and hold each position until you perceive a “melting” of the tissues.
• Work your way anterior along the suture towards bregma.
• Release the anterior portion of the superior sagittal sinus by resting your fingertips of both hands on either side of the metopic suture of the frontal bone.
• Hold this position until you perceive a “melting” of the tissues.

Question 19

One Full Primary Respiratory Mechanism (PRM) cycle equals?

Answer 19

one extension phase and one flexion phase

Question 20

Evaluation of a healthy vs unhealthy PRM includes assessing? (3)

Answer 20

• number of cycles
• quality
• amplitude

Question 21

PRM can be increased by? (3)

Answer 21

• exercise
• fever
• OCF treatment

Question 22

A decreased PRM rate or changes in amplitude or quality may be due to? (6)

Answer 22

• SD
• stress
• fatigue
• chronic infection
• Psych disorders
• chronic poisoning

Question 23

Inherenent motion of the cranium or PRM refers to flexion and extension around the ______.

Answer 23

Sphenobasilar symphysis/synchondrosis (SBS)

Question 24

Sphenobasilar symphysis/synchondrosis (SBS) joint is made up of ______.

Answer 24

the basisphenoid and basiocciput (proximal portions of the sphenoid and occiput respectively)

Question 25

Flexion and extension motions occur around _______ axes, one through _______ and one passing _______at the level of the _____.

Answer 25

two parallel, transverse axes……the body of the sphenoid……over the foramen magnum…….tentorium cerebelli.

Question 26

Flexion at the SBS means the _________ move cephalad while __________ move caudally.

Answer 26

basisphenoid and basiocciput……the wings of the sphenoid and the squamous portion of the occiput……

(ie - the sphenoid rotates anteriorly around the transverse axis through the body of the sphenoid while the occiput rotates posteriorly around the transverse axis above the foramen magnum)

Question 27

Movement of the sacrum during SBS flexion?

Answer 27

counternutation (sacral extension)

Question 28

In a vault hold, cranial flexion is felt as a …..

Answer 28

soft “filling” sensation in the palms; 2nd and 5th phalanges may be drawn inferiorly

Question 29

when the head moves into flexion, __________can be palpated as the paired cranial bones (ie temporal, parietal, and frontal bones) move into _____.

Answer 29

a transverse widening of the cranium……external rotation

Question 30

Extension at the SBS means the _________ move caudally while __________ move cephalad.

Answer 30

basisphenoid and basiocciput……the wings of the sphenoid and the squamous portion of the occiput……

(ie - the sphenoid rotates posteriorly around the transverse axis through the body of the sphenoid while the occiput rotates anteriorly around the transverse axis above the foramen magnum)

Question 31

Movement of the Sacrum during SBS extension?

Answer 31

nutation (sacral flexion)

Question 32

When the head moves into extension, _______can be palpated as the paired cranial bones move into ______.

Answer 32

a transverse narrowing ……internal rotation

Question 33

In the vault hold, cranial extension is felt as…..

Answer 33

a soft “emptying” sensation in the palms; the 2nd and 5th phalanges maybe drawn superiorly

Question 34

Techniques: Frontal lift

Answer 34

• Considerations: ensure the heels of your hands are completely on the frontal bones (not on any other cranial bones) so no sutures become compressed
• pt is supine; PCP at head of table

1. contact the lateral angles of the frontal bone with you hypothenar eminences and interlace your fingers above the metopic suture
2. rest your elbows on the table so proper leverage can be gained
3. during cranial extension apply a gentle medially - directed force with both hands
4. maintain the medial force, during cranial flexion, lift the frontal bone anteriorly
5. hold this position until you fell equal tension from side to side
6. release your forces slowly before removing your hands. return to neutral and reassess.

Question 35

Technique: Parietal Lift

Answer 35

• Considerations: make sure your fingers are completely on the parietal bones so avoid compression of sutures.
• Pt is supine with PCP at head of the table

1. place your 2nd - 5th digits bilaterally over the inferolateral aspects of the parietal bones
2. Cross your thumbs over the sagittal suture lightly, without pressing down on the cranium or lift the remaining digits away from the skull
3. To emphasis cranial extension apply a gentle, medially - directed force with your fingers.
4. maintain the force with your fingers and with the next cranial flexion phase lift the parietal bones superiorly
5. hold this position until you feel equal tension from side to side
6. release your forces slowly before removing your hands. return to neutral and reassess.

Question 36

Technique: V-Spread

Answer 36

• pt supine, PCP at the head of the table
• Ex Dx = compressed left Occipitomastoid (OM) suture

1. Place your left index and middle finger on either side of the left OM suture
2. place your right thumb, index and middle fingers over the right frontal bone
3. gently spread your left index and middle fingers apart to disengage the left OM suture using just enough force to meet the tension that is present
4. use your right hand to gently introduce a fluid wave to your left hand by very slightly introducing writs flexion.
5. ones the fluid wave reaches your left hand send it back to your right hand
6. continue this back and forth until you feel a melting or softening of the OM suture
7. Return pt to neutral and reassess

Question 37

Compression of the 4th Ventricle Considerations

Answer 37

Considerations: this technique helps reset the primary respiratory and circulatory centers in the medulla oblongata (found on the floor of the 4th ventricle) therefore helping improve motion and function of the entire system. Ensure your hands are medial to the occipitomastoid suture to not compress this region. The technique has also been linked to the ONSET OF LABOR, so USE WITH PRECAUTION IN PREGNANCY ESPECIALLY IN PRE-TERM.

Question 38

Technique: Compression of the 4th Ventricle

Answer 38

• Pt supine with PCP at the head of the bead

1. Approximate your hands with your fingers overlapping each other and make a flat surface with your thenar eminences for the occiput to rest on
2. Place your thenar eminences under the occiput just inferior to the external occiput protuberances.
3. During cranial extension apply a gentle superior force by leaning back with your body.
4. Maintain this force on the occiput and continue to encourage extension even when flexion begins
5. during the next cranial extension phase, pick up the slack
6. the rate of flexion and extension may slowly increase and the amplitude may decrease until you reach a “still point” when flexion and extension cease. You may feel a softening of the occiput and the pt my sigh and/or breath more deeply and slowly. Flexion and extension will then resume with improved amplitude and motion.
7. release your forces slowly before removing your hands. return to neutral and reassess.

Question 39

Technique: Suboccipital

Answer 39

• pt supine with PCP at head of table

1. monitor and support the occipital and upper cervical region with one hand
2. Place the other hand on the vertex of the pt’s skull and bring the cervical spine into a neutral position by gently flexing it (this takes away the normal lordotic curve)
3. position the pt’s head and cervical spine until maximal reduction of tissue and muscle tension is palpated (this is usually into extension, sidebending and rotation towards the tight mm)
4. apply a gentle axial compression from the hand that is on the vertex to the suboccipital mms to obtain maximal mm relaxation
5. slowly return to neutral, release your compression and reassess.