This action might not be possible to undo. Are you sure you want to continue?
By Kenneth Lossing D.O.
W.G. Sutherland D.O.
• One morning in 1899, while still a student in Kirksville, on his way to class, class the idea for cranial mobility came from viewing Dr Still’s Dr. Still s Beauchene disarticulated skull in the North Hall.
With Thinking Fingers, A. Sutherland
The First Thought
• “As I stood looking and thinking in the channel of Dr. Still’s philosophy, my attention was called to the beveled articular surfaces of the sphenoid bone. Suddenly there came a thought; I call it a guiding thought-beveled like thought beveled the gills of a fish, indicating articular mobility for a respiratory mechanism” W.G. Sutherland
With Thinking Fingers, A. Sutherland
j p • Motion is typically described in terms of velocity. acceleration. Mobility • In physics. the free encyclopedia 4 . for some reason. time and y. From Wikipedia. speed”. is not defined in our Osteopathic Glossary. • Mobility. displacement. p . motion is a change in position of an object with respect to time. .Mobility y • “Mobility is the state of being in motion.
Motility • “Motility is a biological term which refers to the ability to move spontaneously and actively actively. the free encyclopedia 5 . glossary • So the brain and fluids move with motility and So. needs to be able to accommodate to this. the container. p From Wikipedia. • Again this term is absent from our Osteopathic Again. motility. and thoracic respiration. consuming energy in the process”. the skull.
or b th? It’ a th i i ti both? It’s question of distance and distensabilty. W. or thoracic respiration.Articular Mobility • “A ti l mobility occurs i th b il “Articular bilit in the basilar area. 1939. responsive to primary respiration. such basilar mobility being accommodated through compensatory expansile and g p y p contractile service at the vault sutures” • So the question is: Is the mobility So. Sutherland 6 . and that of the facial bones.G. The Cranial Bowl.
• “The formation of a “mental picture” of the articular surfaces of the cranial and facial bones, is the first necessity for recognizing the fact of cranial articular mobility”. y • “The picture should be like that of a watchmaker watchmaker” • So, we need to know the whole thing!
The Cranial Bowl, 1939, W.G. Sutherland 7
So, what is “normal” mobility? normal
• In his first book, “the Cranial Bowl”, published in 1939, Sutherland i 1939 S th l d used “ d “position” and iti ” d “motion testing” to diagnose the bones and sutures of the skull skull. • The treatment techniques he describes are nearly all “direct techniques”. direct techniques • So he spent nearly 40 years doing direct ! • He also speaks about sutures that are “locked”, in that they do not move when motion tested.
The Cranial Bowl, W.G. Sutherland 8
Why is this important ?
• We know babies skulls are like a water balloon, easy t d f b ll to deform, and th spring b k d they i back. • Most of our patient’s skulls are somewhere between a b k tb ll and a b li b ll b t basketball, d bowling ball. • Could he have possibly meant that an adult skull could be nearly as freely moveable as an infant skull?
The ultimate tensile stress was approx 4 MN/m2. d l i l ” • “The Load-Displacement Characteristics of Neonatal Rat Sutures” The Cleft PalateSutures Palate Craniofacial Journal. The estimated mean elastic modulus was 10 megapixels”. McLaughlin 10 .The current biomechanical terminology Visco-elasticity terminolog : Visco elasticit of Sutures • S iff Stiffness: tensile f il force/change i l / h in length h • Ultimate stress: tensile force at suture rupture/cross sectional area • “Sutures demonstrate classical viscoelastic behavior. they elongated approx 1 um for every 1g of force 104 N/m. Vol.37. During the elastic phase.
and a tissue that is less stiff will have a line to the right.Stress Strain Graph Stress loading Strain • • unloading E 1 E= elastic modulus The angle of the curve reflects the stiffness of the tissue. A tissue that is stiff will have a line to the left.Ozkaya . Strain Fundamentals of Biomechanics.
stuck. the normal amount of distensability is reduced or lost. • In a suture that is malfunctioning stuck or malfunctioning. 12 . locked. in a normally functioning suture. t i ifi t bit • A specific amount of force will create a specific amount of distensability and ifi t f di t bilit d movement. not arbitrary.Modern science says • That the “mobility” or “viscoelasticity” of the sutures is specific.
Alain Gehin 13 .Fronto Occipital Hold Fronto-Occipital Hold. • Thumbs on: • mastoid process and zygomatic process of frontal.Motion Test • This is how Sutherland taught up through at least 1946. • Hands and fingers to opposite side • Actively “motion test” the following strain patterns: Atlas of manipulative Techniques for the Cranium and Face. according to Robert Fulford.
SBS • • • • • • • Flexion Extension Torsion Side-bending Vertical Lateral Compression p 14 Osteopathy in the Cranial Field. Magoun .
in 1944. S th l d i 1942 • She assisted Sutherland in the i th early courses. Moines. • She started studying with Sutherland in 1942.Beryl Arbuckle D. Rollin Becker 15 . • Remained on his teaching staff for some years. The Selected Writings of Beryl Arbuckle Life in Motion.O. where the Becker’s were students. l including the first course at a school Des Moines school.
with respiratory assistance when possible ( step breathing or holding of breath as long as possible) possible). The Selected Writings of Beryl Arbuckle 16 . which she called stress bands. • As she treated mostly children. • Observed fiber strands in specific directions. she attended nearly every autopsy ( estimated at about 200) on cranial pathology at a hospital in Philadelphia over a many year time span span. she used direct technique. • Used positional and motion testing diagnosis.Beryl Arbuckle • Since she wanted objective evidence of what she palpated while treating patients.
ith Arbuckle.Beryl Arbuckle • Presented her finding of stress fibers to the study group of the teachers around t d f th t h d Sutherland. • Shortly afterward. who also Sutherland s did direct cranial. • S th l d h d no problem with thi or with Sutherland had bl ith this. Related by Ruby Day to James Jealous 17 . with the assistance of Paul Kimberly had been on Sutherland’s teaching staff. she started teaching on her afterward own.
ti t h d t tt b tt that had years of cranial.Dr. had heads that were balanced but balanced. “locked up”. because the patient had not gotten better. • Stated many times that patients referred to him by other DO’s. Sutherland’s courses were 2 weeks long at the g time. Fulford’s Touch of Life 18 . Dr. Robert Fulford • Early student of Sutherland (1944 or 45) and Arbuckle (1953).
I left the Cranial academy. • “We tried to absorb his teaching (Sutherland) We (Sutherland).Robert Fulford • Observed that Arbuckle came the closest to reproducing the clinical results that Sutherland did. so he went to study with her. Arbuckle. but it didn’t take well. studied with Dr. went to Philadelphia. and got a degree of understanding of stress bands of the dura mater and really understood the th cranial concept. Robert Fulford.O. it started to work.D.” i l t” • Then. after years of practice. Zachary Comeaux 19 . and the Philosopher Physician.
Fuford paraphrased: I • Dr. about 1995 20 . Sometimes it is so strong it knocks my hands clean off the t k k h d l ff th head. until they bust themselves loose.Unlocking technique • Facing the patient. I feel the membranes wind up.” Lecture at Cranial Academy. layer. Fuford-paraphrased: ”I place my hands on the head. place a hand on each side of the head Do layer palpation into the dural head. Afterwards. you can do what you want with the head.
• Pt seated. you stand or sit behind. their hands connected to your arms.Variations • Pt supine. • Pt seated. make contact with posterior cranium. 21 .
Fulford s Fulford’s Face test • A) With your left hand stabilize the frontal bilaterally. • With your right hand translate laterally the: • 1) Upper nose/maxillatests ethmoid! • 2) Zygomas • 3) Lower maxillas 22 A 1 2 3 .
and lift it until . Use your left hand to translate the occiput left and right. 23 .Posterior Skull Test • With the patient p supine. use your right hand on the sagittal suture. the occiput is unweighted. suture compress enough to catch the head.
then vault and face”. the back and sides ( all formed in cartilage). Start with the sphenobasilar and proceed as follows: the base of the skull skull.Early Sutherland Diagnostic y g Sequence • “There is a definite orderly sequence of cranial diagnosis as first taught by Sutherland. which for clear understanding cannot be improved upon. face The Selected Writings of Beryl Arbuckle 24 .
Illustration of above sequence • Head anterior and to the left on atlas • Flexion of the sphenobasilar with p sidebending rotation to the left • Posterior divergence of condylar parts • A P crowding of the g condylar parts • Flexion of Occipital hinge • Occipital squama flattened and rotated left • Bilateral posterior and superior mastoid buckling • Overriding of coronal and lambdoid sutures • Parietals over both occipital and frontals • Depressed nasion 25 The Selected Writings of Beryl Arbuckle .
then unlock the bones/sutures. bones/sutures then unlock the membranes. Magoun 26 . q • The most frequent locked sutures are: Left occipitalpetrosal. upper cervical spine. right pterygo-palatine. so the contents can express themselves. KL fronto ethmoid Osteopathy in The Cranial Field. • Mobilize the sacrum. left fronto-ethmoid .The question is: How can we get the cranial mechanism optimal function? • Answer: Get the container moving well.
Occipitopetrosal Manipulation • Contacts: posterior to mastoid tip on the fixed side-W/R-anterolaterally • Anterior to the mastoid tip on the unaffected side-W1/4Rposterlaterally • Note: you can also use your 4th and 5th finger pads on the occiput to lift a low side Arbuckle side. Cranial Sutures. Marc Pick 27 .
then go 1/3 more of the way to rejection level level. • S W1/3R means t k th ti So. pt discomfort.Force. Marc Pick . Pressure Codes • S=surface level= initial contact • W=working level= ½ way between surface and rejection level=pliable counter-resistance • R=Rejection level=major tissue resistance ( tissue hardens). 28 Cranial Sutures. take the tissue t working to ki level force.
KL Cranial Sutures. anterior tip-W1/4Rtip W1/4R posteromedial.Sphenopalatine Manipulation • Contacts: • Bilateral maxilla’s. but I treat both. • Note: the most common side is the right. Marc Pick 29 . inside of mouth near last molars W medial molars-W-medial • Pterygoid process.
Marc Pick 30 . Cranial Sutures.Frontoethmoid Manipulation • To release lateral surfaces and close the anterior surfaces• Frontal’s metopic suture. and the “upper face translation test” is normal. extending laterally over e tending laterall o er supercilliary arches and maxilla’s-W1/3R-posterior • Occiput-W/R anterior Note: you are done when the ethmoid is rocking well.
from Arbuckle Sacrum • The upper limb of the L shaped sacroiliac articulation is convergent anteriorly.The Sacrum. The Selected Writings of Beryl Arbuckle 31 .
The Selected Writings of Beryl Arbuckle 32 . • The upper and lower limbs meet at S2.Sacrum. Arbuckle • The lower limbs of the L shaped sacroiliac articulation is divergent anteriorly. the axis of rotation is here. here Below this the lateral articulations converge inferiorly inferiorly.
placed a thumb.Sacrum. The Selected Writings of Beryl Arbuckle 33 . then apex toward the ASIS. • On the most moveable quadrant. other thumb behind for reinforcement. reinforcement Exaggerate the strain. distensabilty • Then check other side the same way. Sacrum should release with a jerk. Compress b C base t toward th d the greater trochanter. compare distensabilty. Have Pt take deep breath and hold. Arbuckle • Use thumb on base and apex of the same side.
Stress Fibers • “There are white fibrous strands.” i l ” • “There is no definite break in these fibers but an intermingling or continuation of one group with another so that forces may be directed and controlled throughout this mechanism. vertical. circular. elastic tissue. transverse. known as stress fibers throughout the otherwise yellow fibers.” Theses • “Theses stress fibers which follow a very definitely consistent pattern. are arranged in horizontal.” The Selected Writings of Beryl Arbuckle 34 . and spinal groups.
Stress fibers • “For descriptive purposes origin and termination of the various groups of fibers is given but it must be remembered that these fibers are continuous and their firm boney attachments must be thoroughly understood with all possible movements thereof in order to change the planes and tensities of these various diverging fans of fibers throughout the dura to achieve the th necessary forces in the desired di ti f i th d i d directions.” ” The Selected Writings of Beryl Arbuckle 35 .
namely:• Inferior horizontal fibers of falx cerebri • Horizontal fibers of the falx cerebelli • Horizontal group in the under layer of each side of the tent ” tent. The Selected Writings of Beryl Arbuckle 36 .Intracranial Dura • “The torcular mass is quite an extensive dense fibrous mass about the confluence of sinuses. From this mass diverge four horizontal groups of fibers.
Primal Pictures 37 .
The Selected Writings of Beryl Arbuckle 38 .Horizontal Falx Cerebri Superior p • The superior p horizontal fibers of the falx in either side of the falx cerebri diverge somewhat from the metopic area p to the lambda. and margins of the superior part of the sagittal sulcus of the occiput.
• 1-retromesencephalic dural girdle i dl • 6-premesencephalic dural girdle • 12. thought to be due to a reaction to the brain growing. Dr. Erich Blecshmidt’s dissections show : Dural Girdles • These are areas where the dura is thickened.falx ( Arbuckle called this the falx ceribri anterior vertical fibers) The Stages of Human Development before Birth. Erich Blechschmidt 39 .Half a world away. a restraining f function. 1960.
Erich Blechschmidt 40 . connective tissue analgen of lambdoidal suture The Stages of Human Development before Birth. anlagen of coronal and sagital sutures and sutures.Dural girdles-thickened dura girdles thickened • 3.8. g dural girdle.occipital dural girdle. part of falx. 4 right • 4-right parietal dural girdle • 6.right frontal . 1960.11.
• Symposium on the Development p of the Basicranium The Biokinetics of the Basicranium. Blechschmidt 41 .• The dura forms a “restraining function” to the f ti ” t th more rapid growth of the brain.
The rapid growth of the brain stretches the precursor of the dura.FIBROUS TISSUE FORMATION (STRETCHED MESENCHYME) Retension Field: the sick figures pull apart on a tough material. forming a horizontally directed thickening in the falx. Biokinetics and Biodynamics of Human Differentiation 42 .
U of Miami. t ” • Done at tissue mechanics lab. dept. • Endocranial dura • Most regular arrangement of fibers is in temporal region Hamann. J of Anat Jan 1998 43 . Sacks.Has anyone else thought about y g this? • “Quantification of the Quantification Collagen fiber architecture of human cranial d i l dura mater”. of biomedical engineering. Malinin.
pathology • 0-92 years old • Less than 24 hours postmortum • S Superior sagittal sinus i itt l i and calvarial section o tissue of t ssue • Placed in saline and frozen. J of Anat Jan 1998 44 . no . Hamann. Sacks.Study info • 20 fresh cadavers. Malinin.
Malinin. Hamann.Study Information • Tissue looked at using small angle light scattering HeNe lazer. has optics between optical miscroscopy and i d gross visual analysis. Sacks. J of Anat Jan 1998 45 .
Sacks. J of Anat Jan 1998 46 . Malinin. pp Hamann.Dura • The top picture is viewed with the eye. the bottom picture shows SALS applied to the th same area with the direction of the collagen fibers more apparent.
Is the Collagen oriented along vessels? l ? • Not found to be oriented along large vessels. Sacks. J of Anat Jan 1998 47 . Malinin. but along smaller vessels Hamann.
Near Coronal Suture • The collagen fibers are aligned in an anterior/posterior direction just behind the coronal suture. Malinin. J of Anat Jan 1998 48 . in the th area of the remnant f th t of an anterior dural girdle. stress Hamann. Sacks. girdle • Thought to be the result of growth stress.
then go into flexion. Described by Dr Fulford 49 . don’t allow if to go into flexion.Treatment of horizontal fibers of falx. • F ll Follow the PRM i h into extension. a pillow under th i h d id ill d their head. • Place your left index finger along the anterior falx. flexion and everything will soften. right index finger along the posterior falx. maybe 5 minutes. d f l and opening middle b i iddl buttress • Lay the patient on their left side. . After some time. the system will become quiet.
the buttresses will be described here since understanding th i normal or d t di their l expected positions. Although this stage of development is not reached in infancy. slight deviations in the infant skull which may result in gross abnormalities are more easily recognized recognized” The Selected Writings of Beryl Arbuckle 50 .Buttresses • “In the boney structure also p there are developed areas of greater density known as buttresses.
basion to magnum basion. foramen magnum. mastoid process • Inferior: inion to opisthion. over superciliary ridges to zygomatic process of frontal. frontal • Posterior: inion. most superior nuchal lines. posterior wall of sphenoidal sinus The Selected Writings of Beryl Arbuckle 51 .Butresses • Anterior: across glabella g laterally.
sagital suture. crista galli • Lateral Oval: mastoid process. frontal crest. t f t l t glabella. The Selected Writings of Beryl Arbuckle 52 . Outer: zygomatic bone to zygomatic process of frontal Inner: frontal.Buttresses • Superior: Inion. EAM th 2 EAM. the roof of which forms the floor of the sella turcica. pteryoid process and lesser wing • Oblique basilar: Petrous ridges of temporals. then ridges. point towards sphenoid sinus.
Straightening or flattening the anterior buttress will widen or cause the margins of the ethmoidal notch of the frontal to increase their p posterior divergence thus allowing for a g g widening of the upper part of the lateral masses”. • “1. The Selected Writings of Beryl Arbuckle 53 .Buttresses • “The various buttresses may be pictured as radiating f di ti from about th sella t i and i a b t the ll turcica d in manner similar to the stress bands of the reciprocal tension membranes ” membranes.
extending laterally over supercilliary arches and maxilla s W1/3R maxilla’s-W1/3Rposterior p • Occiput-W/R anterior Cranial Sutures-Marc Pick The Selected Writings of Beryl Arbuckle 54 .Using the Buttress to mobilize the lateral ethmoid’s articulation th id’ ti l ti • To release lateral surfaces and close the anterior surfaces• Frontal’s metopic suture.
That is.face with inion) The Selected Writing of Beryl Arbuckle 55 . in an extreme flexion head it would be wiser to attempt to lift the crista galli by increasing the arc of the anterior buttress thus narrowing the lateral masses of the ethmoid. ( Horizontal falx technique) In an extreme technique).Median Buttresses “Increasing or decreasing the arc of the median buttress will allow the crista gali to fall or elevate depending upon the type of head. extension head we would rather allow the crista galli to fall permitting widening of the lateral l t l masses off the ethmoid”. (A/P ff th th id” compression.
don’t allow if to go into flexion. • Follow the PRM into extension. the y system will become quiet.Treatment of “Horizontal fibers of Falx Falx” and increase the arc of “Anterior Buttress” • Lay the patient on their left side. and everything will soften. Described by Robert Fulford 56 . then go into flexion. maybe 5 minutes. • Place your left index finger along the anterior falx. After some time. right index finger along the p g g g posterior falx. a pillow under their head.
change in the posterior divergence of the margins of the ethmoid notch of the frontal may be obtained.Buttresses • Zygomatic pillar of the face-from the first molar t th t the zygomatic angle of th l tooth to th ti l f the frontal • B increasing or d By i i decreasing th i f i i the inferior convergence of the zygomatic pillars. The Selected Writings of Beryl Arbuckle 57 .
• Lateral aspect of hard palate.Frontoethmoidal Manipulation • To release anterior. and close laterally• Bil contact superior to p sphenofrontal sutureW1/3R-medially. then pull l ll h ll anteriorly The Cranial Sutured.W1/3Rlaterally. March Pick The Selected Writings of Beryl Arbuckle 58 .
The Vault. and Sutures • • • • • • • • From left to right: g 14 weeks 20 weeks 24 weeks 30 weeks 34 weeks Adult In the fetal skull there are 6 fontanelles 60 . Fontanelles.
The cranial puzzle” 61 . aided by the attachment of the falx “The falx. birth separating the frontal into 2 halves. growth but retains a natural malleability. from nasion to bregma. It is between the 2 halves of the frontal bone (metopic suture) ( p ) and the 2 parietals.Anterior Fontanelle • Anterior fontanelle becomes bregma after the fontanel g closes and the sutures form. • The metopic suture is open at birth. It ossifies during growth. moving during flexion-extension.
while the thumb of the other hand is posterior to bregma. • The medial end of the coronal suture is treated by the fingers of one hand on glabella. then the anterior portion of the t i ti f th sagittal suture.Bregma Treatment Part 1 • Due to the overlapping of the sutures the medial ends sutures. depressing posteriorly. depressing The Selected Writings of Beryl Arbuckle 62 caudad. . of the coronal suture need to be treated first.
lateralward Arbuckle The Selected Writings of Beryl Arbuckle 63 . inferior and lateralward. thumbs overlapped over the anterior part of the suture.Bregma Treatment part 2 • The sagittal suture is treated with fingers on parietals. force directed t f di t d posterior.
Bregma • Trauma at bregma. This will restrict the great wing and the sphenobasilar. The occipital condlyes may be moved back in the pits of the atlas (bilateral posterior occiput). (trauma may be direct on area or indirect from a fall on the feet or buttock). The bone is pushed inferiorly at bregma and forced laterally at p g y pterion. OCF 64 . The sagittal suture will be depressed or one parietal lowered in relation to the other.
. that can be used in diagnosis and treatment (by themselves and as handles to the membranes).Beryl Arbuckle • Preserved Sutherland’s earliest approaches to mobility. mobility diagnosis ( position and motion testing) and treatment (direct). all of which are helpful in diagnosis and treatment (both by themselves and as handles for the bone). • Refined the view of the reciprocal tension membrane into 20 different directions of fibers. membranes) 65 • Was way ahead of her time. • Described thickened areas of bone called buttresses.
Making Osteopathy a 66 household word. • Help us help you. y • Do you believe that Patients need to know about the Osteopathic approach ? • Grateful patients can donate.FORCE • Force= Foundation for Osteopathic Research and Continuous Education • Do you believe that Osteopathic Medicine should be the standard of conservative medical care in America ? • Need for research-evidence based medicineeed o esea c e de ce ed c e payment for treatment. .
Join FORCE • Force is committed to by 100% of the BOT • Force is committed to by 100% of the BOV • We need your help! 67 .
This action might not be possible to undo. Are you sure you want to continue?
We've moved you to where you read on your other device.
Get the full title to continue reading from where you left off, or restart the preview.