Principles of CRI/PRM Flashcards
Definition of Cranial Manipulative Medicine
A system of diagnosis and treatment by DO using the primary respiratory mechanism and balanced membranous tension
Who “discovered” cranial?
William Garner Sutherland D.O.
Graduated from Kirksville in 1900
Sutherland’s Publishing Pathway
1931 - Published series of articles explaining concept of cranial = Pen name - Blunt Bone Bill
1939 - Published Cranial Bowl - Explaining treatments and mobility of cranium
1943 - Presented at Eastern Osteopathic Association Convention
1944 - Published in JAOA
When was the Sutherland Cranial Teaching Foundation established?
1953
What is the Primary Respiratory Mechanism?
“Fundamental life process”, “Breath of life”
Ebb and flow like breath with the movement of tissue and fluid for a purpose
Five Components of PRM
- Inherent mobility of the brain and spinal cord
- Fluctuation of CSF
- Mobility of the intracranial and intraspinal membrane
- Articulatory mobility of the cranial bones
- Involuntary mobility of the sacum between the ilia
What is thought to be responsible for PRM?
The contractile ability of elements within the brain
Traube-Hering Waves = Blood flow velocity changes
Glial cells = contribute to neurovascular coupling and regulates blood flow in the brain
Inherent Mobility and Amplified MRI Research
Methods: Compare aMRI of Chiari patients to aMRI of healthy individuals
Results: Abnormal biomechanics were seen on FFD maps of the Chiari I malformation patients
Conclusion: Phase-based a MRI could be used in the future to quantitatively analyze minute changes in brain motion. Preliminary data shows a potential phase-based aMRI to qualitatively assess abnormal biomechanic of Chiari I malformation - so basically nothing
What is Cranial Rhythmic Impulse (CRI)?
Rhythmic impulses on the human skull exhibits an average of 10-14 cycles/minute in normal adults
Key Concepts in Palpating the CRI
Physician must be relaxed with contant of the hands being very light
CRI is not visible motion
CRI is seperate from respiratory &/or circulatory physiology mechanisms, but they may influence each other
Motion Characteristics of CRIS
R-RADS
Rate - 10/14 bpm
Rhythm - palpated as regular
Amplitude - Significant SD diminishes movement
Direction - Healthy individuals have symmetrical movement
Strength - Significant SD and overally vitality of patient impacts strength
What is the Sutherland Fulcrum
The functional name given to the striaght sinus at the origin of the 3 sickle-shaped agents of the falx cerebri and tentorium cerebelli
What is Reciprocal Tension Membrane (RTM)?
The meninges and the cord constitute a link between the cranium and the sarcum
What is the “core link”?
The importance in connecting the articular mechanism of the cranium with the sacrum to coordinate action
Changes in meninges with spinal flexion and extension
Extension - relaxes meninges and allows increased blood flow through the spinal column and the nerve roots are more relaxed and horizontal
Flexion - meninges are tight which decreases blood flow to the cord and causes tension on the spinal nerve roots which orients them more verticle/oblique
What is the composition of the intracranial membranes/dura folds?
What creates the Reciprocal Tension Membrane?
Tentorium
Falx Cerebri
Falx Cerebellum
What is the function fo the RTM?
Attaches to bones of the vault and base and holds them under contant tension
Allows for change of shape of vault while maintaining relatively constant volume
Anterior/Superior Attachment of the RTM
Crstia galli
Anterior/Inferior Pole Attachment of RTM
Clinoid processes of the sphenoid
Lateral Pole Attachment of the RTM
Mastoid angles of parietals bones
Petrous ridges of the temporal bones
Posterior Pole Attachment of the RTM
Internal occipital protuberance
Transverse ridges of the occiput
5 components of Primary Respiratory Mechanism (PRM)
- Inherent mobility of the brain and spinal cord
- Fluctuation of CSF
- Fascial mobility and continuity significantly impacts the PRM
Articulatory mobility of the cranial bones
Involuntary mobility of the sacrum between the ilia
What is a fulcrum?
A point of rest around which motion occurs
Movement of Sutherlands fulcrum (3)?
Suspended - moves but remains in the RTM
Automatic - moves with the motion of the CRI
Shifting - the straight sinus moves up and down
What is the SBS?
The synchondrosis between the base of the sphenoid and the base of the occiput
Connected by a layer of cartilage
Where is the Bregma suture?
Between the frontal and parietal bones
Used to be old anterior fontanelle
Where is the lambda suture?
Between the occiput and the parietal bones
Where’s the Sagittal suture?
Between the two parietal bones
What does the head look like of someone with their cranium in extension?
Face in elongated and cheekbones are prominent
Head looks like Bert
Position of craium when people die
What do peoples heads look like when their cranium is in flexion?
Head is wider and shorter
Describe the inherent motion between the cranium and the sacrum?
Flexion of the occiput causes the sacrum sacrum to go into counternutation
Extension of the cranium causes the sacrum to go into nutation
What are the transverse axis of motion of the sacrum and where are the located?
Superior Transverse Axis - Passes through the Posterior aspect of articular process of S2
Middle Transverse Axis - Passes through the anterior aspect of S2
Inferior Transverse Axis - Passes through the inferior auricular surface of S3
What causes movement through the Superior Transverse Axis of the Sacrum?
Respiratory cycle and inherently due to PRM
What causes movement through the Middle Transverse Axis of the Sacrum?
Axis around which nutation and counternutation occurs from standing
Known as postural axis
What causes movement through the Inferior Transverse Axis of the Sacrum?
Axis of movement of the ilia on the sacrum
What is sacral nutation?
Base of sacrum moves anteroinferior
Associated with exhalation/cranial extension
Nutation towards nuts
What is sacral counternutation?
Base of the sacrum moves posterosuperior
Associated with inhalation/cranial flexion
Parietal Bone Motion Research
Adams, Heisey, Smith and Briner (1992)
Studied cranial motion in cats
Results - Spontaneous motion objectively observed at patietal bones. Parietal bones moved with compressive force applied on temporal bones and sagittal sutures. Moved 30-70 microns laterally and 250 microns rotationally at parietal bones
FIndings of External Pressure on Temporal Bones
Adams, Heisey, Smith and Briner (1992)
Pressure caused observed changes in respiration, blood pressure, and CSF pressure
Measured changes at parietal bones that reflected motion in multiple planes - lateral and rotational
FIndings of External Pressure on Sagittal Suture
Adams, Heisey, Smith and Briner (1992)
No change observed in respiration or blood pressure
Caused lateral and rotational movement at the parietal bones
JAOA Published Results of Finger sensation vs machines
Machines measure 2x as many impulses are fingers
Moskalenko Research In Hemodynamics and CSF Circulation
In healthy people found continous changes in cranial dimesnions with biphasic characteristics
Intracranial origin of bioimpedence related to blood supply and oxygen consumption of the cerebral tissue
What is the Asterion?
The point on the skull that corresponds with the end of the parietomastoid suture
What is the pterion?
The region where the sphenoid, frontal, parietal, and temporal bones come together
