Study Guide

Question 1

Define PRM.

Answer 1

Primary –underlying all other processes
Respiratory –cellular respiration
Mechanism – all of the component parts work together as a unit of function

Question 2

Identify the 5 components of the PRM.

Answer 2

1. Cranial Articular Mobility
2. Reciprocal Tension Membrane
3. Sacral Respiratory Motion
4. CNS Motility
5. CSF Fluctuation

Question 3

What are the midline bones (5)? (List them )

Answer 3

occiput, sphenoid, perpendicular plate of ethmoid, vomer, sacrum

Question 4

Midline Bones: What is their physiologic cranial motion? (What is the axis?)

Answer 4

Flexion and Extention

Question 5

Demonstrate the transverse axes that go through the occiput and the sphenoid. Describe where they are found.

Answer 5

Two transverse axes:
1) Through the body of the sphenoid; immediately anterior to and on level with the floor of the sella turcica. (The axis extends out approximately through the sphenosquamous pivots and out to the middle of the zygomatic arches.)
2) Just above jugular processes of occiput (at the level of the SBS)
(The bases rotate in opposite directions around their respective transverse axes.)

Question 6

Where is the transverse axis of the sacrum ?

Answer 6

Through S2

Question 7

List the paired bones (10).

Answer 7

parietals, temporals, frontals, zygomae, maxillae, palatines, lacrimals, nasals, inferior conchae, lateral masses of ethmoid

Question 8

Paired bones: What is their physiologic cranial motion?

Answer 8

External rotation and internal rotation.

Question 9

What are the axes of the frontals, zygomae, maxillae, and temporals?

Answer 9

Frontals: axis=center of each orbital plate through each frontal eminence (parallels long axis of whole body)
Zygomae: oblique axis (similar to temporal bones)
Maxillae: vertical axis
Temporals: axis=petrous ridge (axes of the 2 temporal bones converge anteriorly). “temporal bones follow the occiput”

Question 10

During the inhalation phase of the PRM, what occurs at the SBS, midline and paired bones, and the sacral base? Exhalation phase?

Answer 10

Inhalation Phase: SBS rises, midline bones go into flexion, paired bones go into external rotation “I FLEXTERNAL ROTATION”
Exhalation Phase: SBS descends, midline bones go into extension, paired bones go into internal rotation

Question 11

***What are the points of dural attachment?

Answer 11

Dural attachments (5) = foramen magnum, C2, C3, S2 and posterior portion of coccyx via filum terminale

b. Falx cerebri
i. Anterior superior pole – crista galli of ethmoid
ii. Posterior pole – superior surface of tenorium cerebelli @ area of straight sinus & internal occipital protuberance
iii. Superiorly – surface of skull, metopic & sagittal sutures
c. Tentorium cerebelli
i. Outer (convex) border –
1. Occiput – transverse ridge of sulcus of transverse sinus of occiput
2. Parietal – postero-inferior angle of parietal
3. Temporal – mastoid portion & petrous ridge
4. Sphenoid – posterior clinoid process
ii. Inner concave border – forms tentorial notch
1. Anterior clinoid processes, crossing over outer border of tentorium, which is attached to posterior clinoid processes (petro-sphenoid ligament)
d. Falx cerebelli
i. Superiorly – inferior surface of tentorium cerebelli @ area of straight sinus
ii. Inferiorly – to vertical crest on inner surface of occipital bone
e. Diaphragma sellae – around lip of hypophyseal fossa of sella turcica (sphenoid)

Question 12

12) Identify the axes of rotation and the motions of the sphenoid, occiput and temporals in the following patterns; normal physiologic flexion/ extension, torsion strain pattern, sidebending rotation pattern, lateral strain pattern, vertical strain patterns and SBS compression.

Answer 12

a

Question 13

13) Demonstrate what each of the above would look like on a phantom head.

Answer 13

a

Question 14

14) Identify the common mechanisms of trauma that would induce each of the above strain patterns.

Answer 14

a

Question 15

15) Discuss the venous sinus technique, the importance of each step and demonstrate each step on a skull.

Answer 15

a. Confluence of Sinuses: The physician places his two middle fingers tip to tip with the pads of the fingers away from the surface of the table to provide a support, the only support for the patient’s head. The fingers support the head at the external occipital protuberance. This contact is maintained until the physician senses a “softening” of the bone on his/her fingers and the beginning of inherent motion.
b. Occipital Sinus: Maintaining a similar relative position, the fingers are moved about a finger’s width down the occipital sinus; i.e., down the midline of the occiput. Again, await the softening and the sensation of inherent motion.
c. Condylar Decompression: Next, move down the convexity of the occiput toward the foramen magnum. The physician’s fingers will now be inclined toward each other at about 45° to the vertical. With a very gentle impulse posteriorly as the pressure is maintained, (think of approximating the wrists), the occiput is decompressed from the atlas and the condylar parts of the occiput are also released. Wait until “softening” and inherent motion are palpated.
d. Transverse Sinus: Approximate the pads of the little fingers beneath the external occipital protuberance and let the pads of the other fingers support the head by contact along the superior nuchal line to the inferior lateral angle of the parietals.
e. Straight Sinus: The head rests on the fingers and the thumbs are placed one on top of another over the sagittal suture. Imagine a line from the thumbs into the center of the head and visualize its intersection with the anterior end of the straight sinus. Maintain these contacts until “softening” and motion are noted.
f. Superior Sagittal Sinus: Return to the external occipital protuberance as in the technique for the Occipital Sinus. Flex the patient’s head so as to enable you to place your thumb pads at the external occipital protuberance. Note that inherent motion is palpable. Now address an area about an inch superior to the protuberance. With the palms of the hands facing the surface of the head, place the pad of the left thumb just to the right of the midline, and the pad of the right thumb just to the left of the midline. The thumbs are crossed and apply a gentle distracting force, the right thumb directed towards the left, the left thumb directed towards the right. When “softening” and motion are palpated, move the thumbs about an inch forward and repeat the procedure. Continue step by step along the sagittal suture towards the bregma (the intersection of the sagittal and coronal sutures).
g. Metopic Suture: To complete the anterior portion of the superior sagittal sinus, place the finger pads on either side of the metopic suture (the midline) of the frontal bone; i.e., the index finger just anterior to the bregma, the little finger above the nasion, the other fingers between the two. The right fingers are on the right side of the suture, the left fingers are on the left side of the suture. Gentle pressure with slight separation is maintained until “softening” and physiologic motion is palpated.

Question 16

16) List the indications for the venous sinus technique.

Answer 16

a. hard rigid head w/ decreased resiliency
b. severe headache from venous congestion
c. free up cranial motion → seen in SBS Compression

Question 17

17) Describe how to perform a CV4 and list the endpoints that indicate that the technique is complete.

Answer 17

a. Place hands medial to the occipitomastoid condyles bc you don’t want to compress the sutures. Hold at the end of extension and lateral rotation. Resist flexion
b. Endpoints:
i. STILL POINT = a moment of intense activity
1. No flexion or extension phase of the PRM
2. Diaphragmatic respiration
3. Pulsation – heart beat
4. Warmth
5. Moisture
6. Softening
7. Rocking…like a boat on quiet water
8. Resumption of occipital flexion and extension
c. Decreased back conductivity, blood sugar, WBCs, pain from tension HA, sleep latency and sympathetic activity.
d. Help to induce labor
e. Entrainment = operator and subject get a still point

Question 18

18) List the indications for the CV4.

Answer 18

a. Any acute illness – normalize functions, ↓ temp
b. Allergies
c. Asthma
d. Acute low back pain, esp. if can’t touch area
e. If something needs to be expelled, e.g. fetus post-term gestation 38-42 weeks
f. Emotional reactions and states
g. Induces sleeping/calming

Question 19

19) Describe how to perform both the frontal and parietal lifts and perform on a skull.

Answer 19

Frontal:
a. Physician rests elbows on the table. Place the hypothenar eminences on the lateral angles of the patient’s frontal bone and interlace the fingers over, but not in contact with, the forehead.
b. Attempt to draw the fingers of one hand from the fingers of the other, yet at the same time gripping the fingers of the one hand with the other (action of the lumbrical muscles.) In this way, the hypothenar eminences exert an influence of internal rotation on the lateral angles of the frontal.
c. Coordinate this action with a lifting of the frontal anteriorly (toward the ceiling) until the lateral angles can be felt moving into external rotation.
d. Gently release the hands from the patient’s forehead.
Parietal lift:
a. The physician rests forearms on the table, and places the finger tips on the inferior border of each of the two parietals just superior to the squamous temporal suture.
b. Cross the thumbs above, but not in contact with the sagittal suture.
c. Firmly press one thumb against another;i.e., one thumb presses upward as the other resists this motion by pressing downward. Thus the fingers will approximate and induce internal rotation of the inferior border of the parietal bones.
d. At the same time, lift both hands in a cephalad direction (towards the physician) until the parietal bones move into external rotation.
e. Release the patient’s head gently.

Question 20

20 ) Identify common cranial nerve entrapment neuropathies that affect newborns and how they might present.

Answer 20

a

Question 21

21) Identify all of the cranial nerves.

Answer 21

a

Question 22

22) Describe which foramina they traverse and their general functions.

Answer 22

a

Question 23

23) Describe the sphenosquamous pivot and its clinical importance.

Answer 23

a. Middle mengingeal artery is located underneath.

b. Assoc. w/ HAs

Question 24

24) List the bones that make up the orbit.

Answer 24

(PLSZ F ME).

a. Palatine
b. Lacrimal
c. Sphenoid
d. Zygomatic
e. Frontal
f. Ethmoid
g. Maxilla

Question 25

25) Define the following and identify their physiologic rate (if applicable); baroreflex wave, cranial rhythm impulse, Traube -Hering wave.

Answer 25

a. Baroreflex (aka Traube-Hering wave) = measurable waveform of about 0.1 hz frequency that corresponds to the motins felt on the cranium and throughout the body. It is altered by manipulations of the cranium.
b. Cranial rhythm impulse (CRI):
i. Palpable motion felt at cranial vault (parietal bones); now includes motion of PRM anywhere in the body
ii. Rate = 5-15 cycles/minute, flexion-extension cycle every 4-12 seconds

Question 26

26) Which CN is compromised by dysfunction of the petrosphenoid ligament?

Answer 26

CN VI (abducens)

Question 27

27) Identify problems that may occur with the TMJ.

Answer 27

a

Question 28

28) Describe treatments that may be beneficial to disorders associated with the TMJ.

Answer 28

a. Sphenomandibular Ligament Release:
i. Operator: Stand on the side of the table opposite to the side being treated. Operator may bring knee up to table to support patient’s head and prevent operator from using too much pressure during the technique.
ii. Position one hand over the forehead so that the greater wings of the sphenoid are being monitored by the thumb on one side and index or middle finger on the other side.
iii. Place a cotted thumb on the occlusal surface of the last lower molar on the side of the mouth being treated.
iv. Exert slight pressure on the mandible with the gloved thumb so as to move the mandible inferiorly. If there is restriction, or decreased resiliency, you will note the monitoring hand will feel the greater wing of the sphenoid move into a superior direction (i.e., toward extension).
v. If this is the case, use what was the monitoring hand to direct the sphenoid toward flexion while maintaining the inferior pressure on the mandible until the tissue tension is released and physiologic motion is restored.
b. Stylomandibular Ligament Release:
i. Operator: Initial set up is the same as for the sphenomandibular ligament release.
ii. Palpate over the temporal bone with one hand by placing the middle finger in the external auditory meatus, the little and ring fingers on the mastoid process, and the index finger and thumb grasping the zygomatic arch.
iii. Place a cotted thumb on the occlusal surface of the last lower molar on the side of the mouth being treated and wrap the rest of the fingers around the ramus of the mandible.
iv. Apply gentle traction on the mandible with the gloved thumb in an inferior, lateral, and anterior direction until the tissues become more compliant and physiologic motion is restored.
c. TMJ Decompression:
i. Operator: same initial set-up as sphenomandibular release
ii. Palpate over the temporal bone with one hand by placing the middle finger in the external auditory meatus, the little and ring fingers on the mastoid process, and the index finger and thumb grasping the zygomatic arch.
iii. Place a cotted thumb on the occlusal surface of the last lower molar on the side of the mouth being treated and wrap the rest of the fingers around the ramus of the mandible.
iv. Attempt to decompress the TMJ by placing slight anterior-inferior pressure on the mandible.
v. If it will not move easily, apply gentle compression of the head of the mandible into the glenoid fossa until spontaneous decompression occurs.
d. TMJ Balancing Technique:
i. Operator: Sit at the head of the table
ii. Hold the mandible with both hands by placing thumbs on the anterior aspects of the left and right mandibular rami and wrapping the index fingers around the posterior side of the rami.
iii. Motion test in anterior-posterior directions to determine which side moves more freely, and in which direction.
iv. Move the mandible as far into the direction of ease as possible without forcing it, hold.
v. Await a fascial “unwinding” and restoration of a gentle, symmetrical motion.