1) Define PRM. Primary Respiratory Mechanism. Underlies all processes, Cellular respiration, Mechanism of cellular resp. of body.

2) Identify the 5 components of PRM.

(1) Cranial membranes-dura/meninges; (2) cranial bones; (3) CSF; (4) CNS inherent motion; (5) Sacrum
3) What are the midline bones? (List them) sphenoid, ethmoid, occipital, vomer (all motions are flexion/Extension)
4) What is their physiologic cranial motion? (What is the axis?) Midline bones move in flexion/extension
5) Demonstrate the transverse axes that go through the occiput and the sphenoid. Describe where they are found.
Inherent flexion/extension motion @ level of jugular foramen through transverse axis.
Inherent flexion/extension motion @ level of sphenoid body through transverse axis.
6) Where is the transverse axis of the sacrum ? S2.
7) List the paired bones. Frontal. maxillary, zygomae, lacrimal, palatines, temporal, parietal, nasal, inferior conchae
8) What is their physiologic cranial motion? Internal and external rotation = motion of paired bones.
9) What are the axes of the frontals, zygomae, maxillae, and temporals?
Frontal Bone axis: Vertical (around metopic suture)
Zygomae axis: Oblique (hinges on joint w/ maxilla)
Maxillae axis: Vertical
Temporal axis: Oblique (hinges on PETROUS RIDGE, near petrosphenoidal ligament)
*Vomer axis: Transverse (moves in same direction as ethmoid)
10) During inhalation phase of the PRM what occurs at t he SBS, midline and paired bones, and sacral base? Exhalation phase?
INHALATION:
EXHALATION:
SBS Flexion
SBS Extention
Midline bones go into flexion.
Midline bones go into extension
Paired bones go into External Rotation.
Paired bones go into Internal Rotation
Sacrum goes into counternutation
Sacrum goes into Nutation
11) What are the points of dural attachment?
Foramen Magnum, Posterior portion of body on C3, Dens (C2), S2, posterior coccyx (filum)
Crista galli & cribiform plate, Anterior and posterior clinoid processes, petrosal ridge, occiput, all along venous sinuses.
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.
Normal
Axis
Rotation
direction
Bone
motion
Clinical

Lateral Strain

S-transverse 2 Vertical
O-transverse -sphenoid body
T-oblique
-foramen magnum
Same
S-vert
O-vert
TResult of
"Plagiocephaly" in
babies

Torsion

SBR

AP (nasion to opisthion)

2 Vertical (SB)
1 AP (rot)

Opposite
S-A/P
O-A/P
T-moves w/ occiput
CN II Optic N pathway
commonly disturbed

Vert-opposite
AP-same (inf)
S
O
T*Named by side of
convexity (feel a
"lateral fullness")

Vertical Strain
(inf or sup)
2 TransVerse
-thru S-S pivot
-jugular processes

Same
S-transv
O-transv
T-moves w/ occiput
CN VI entrapment beneath
petrosphenoidal lig, or in
Cavernous sinus.

14) Identify the common mechanisms of trauma that would induce each of the above strain patterns.
SBR= Lateral trauma at level of SBS.
Torsions=(think in quandrants)
-Uppercut in anterior LEFT quadrant = LEFT torsion
-Top of head anterior LEFT quadrant (@ left frontal bone) = RIGHT torsion
Lateral strains=(think of axis)
-LEFT lateral hit @ level of sphenoid ANTERIOR to the Axis = LEFT Lateral Strain
-LEFT lateral hit @ level of sphenoid POSTERIOR to Axis (on occiput) = RIGHT lateral Strain

Vertical strains=(think MIDLINE

-midline uppercut thru the chin = Inferior Vertical Strain
-hit head midline on a shelf = Superior Vertical Strain
Directly Midline = SBS compression (head feels "hard")
15) Discuss the venous sinus technique, the importance of each step and demonstrate each step on a skull. C-O-C-T-S-S-M
(1) confluence of sinuses (at external occipital protuberance)
(2) occipital sinus (approximate wrists, brings fingers apart)
(3) condylar decompression (at occipital ridge)
(4) transverse (thumb over thumb, posterior to bregma)
(5) straight sinus
(6) superior sagittal sinus (start at lambda-external occipital protuberance & work upward along sagittal suture)
(7) metopic
*between each step, wait for a "softening" before moving on
16) List the indications for the venous sinus technique. poor drainage, headache, SBS compression, ANS dysfunction, hard rigid head
*17) Describe how to perform a CV4 and list the endpoints that indicate that the technique is complete.
Volleyball handhold. Initiated on EXTENSION, resist flexion. Hold UNTIL Still Point. Let go when body naturally returns to motion
(body usually moves into flexion).
Test Q: What happens after Still Point when physiologic motion returns. Respiration becomes slow and diaphragmatic and same as the
PRM (pg 146)
18) List the indications for the CV4.
ANS dysfunction, calms down the sympathetics. Other indications same as venous sinus drainage. Goal is to increase body's therapeautic
potential to overcome dysfunction, enhance fluid movement, cahnge diaphragm rhythm, restor normal F/E of crainum and restore
autonomics.
19) Describe how to perform both the frontal and parietal lifts and perform on a skull.
Frontal Lift- Hypothenar eminances @ lateral angle of frontals, puts it into internal rotation, lift. Look for balance/wobble point. End
point=full flexion/external rotation.
Parietal Lift- claw hands, thumbs crossed in air . Fingers on temporalis muscle ridge on parietal bone. Lift. Look for balance/wobble point.
End point = full flexion.
20 ) Identify common cranial nerve entrapment neuropathies that affect newborns and how they might present.
CN X (vomiting) and XII (suckling issues) usually caused by SUPERIOR Vertical Strain & SBS compression.
CN XI (spinal accessory) - can't hold head up (flaccidity) and torticollis (SCMs become hypertonic)
CN XII only - condylar compression is likely
21) Identify all of the cranial nerves. 22) Describe which foramina they traverse and their general functions.
I olfactory - thru crista galli (smell)
II optic- optic canal (vision)
III oculomotor- SOF (extraocular mm)
IV Trochlear - SOF (Superior Oblique mm)
V1-SOF (senory cornea, eye, nasal sinus, lacrimation parasympathetics)
V2-rotundum (sensory midface)
V3-ovale (sens low face, ant 2/3 tongue, mascication mm motor)
VI Abducens - SOF (lateral rectus mm)
VII Facial - internal acoustic & Stylomastoid Foramen (facial mm, taste anterior 2/3, middle ear)
VIII Vestibulocochlear - internal acoustic meatus (hearing & equilibrium)
IX Glossopharyngeal - Jugular Foramen (taste post 1/3 tongue, pharynx, otic gang to parotid, carotid sinus, soft palate)
X Vagus - Jugular Foramen (phaynx, larynx, esophagus, abdom and thoracic viscera)
XI Accessory- Jugular Foramen (trapezius and SCM)
XII Hypoglossal - Hypoglossal Canal (tongue mm, supra- and infrahyoid mm, proprioception of tongue)
23) Describe the sphenosquamous pivot and its clinical importance. Middle Meningeal Artery (may cause migraines)
24) List the bones that make up the orbit. (7) zygomatic, lacrimal, nasal, frontal, maxilla, ethmoid, sphenoid (NOT temp)
25) Define the following and identify their physiologic rate (if applicable); baroreflex wave ______________
cranial rhythm impulse (CRI) __________
Traube -Hering wave/oscillations _____________.
PRM usually 10-14 per minute.

26) Which CN is compromised by dysfunction of the petrosphenoid ligament? CN VI -- runs near petrosphenoid ligament
27) Identify problems that may occur with the TMJ. HA, jaw pain, tinnitus etc.
28) Describe treatments that may be beneficial to disorders associated with the TMJ.
Sphenomandibular Ligament Release: inferior pressure on mandible, induces sphenoid FLEXION
Stylomandibular Ligament Release: 5 finger grip at temporal (EAM, zyomatic process, mastoid and occiput), finger in mouth over last
molar, pull inferior-lateral-anterior until compliance felt.
Pterygoid Release (1 or 2 operators)- 2 thumbs in mouth, holding mandible, BLT.
NELSON research article: Oscillations created in interstitial spaces by your heartbeat, causing fluid waves in your interstitium. TraubeHering oscillations & Meyer oscillations are related. Research method was via using Laser Doppler Flowmetry. (NELSON T-H-M
LASER DOPPLER)
UENO Research article: Pulsed Phase Lock Loop. Using ultrasound as a noninvasive measure of intracranial pressure (ICP). There is a
correlation between diameter of cranium and intracranial pressure (both amplitude and frequency). (PULSE PHASE UENO)
CROW research article: Cranial Bone motion demonstrated on MRI. Compelling evidence for mobility of cranial bones. (CROW MRI)
Heisy Research: used cats, injected saline into dura. Increased CSF increases parietal bone movement. (HEISY CATS)
Moskalenko research : researched PRM. used human models to show intracellular respiration & water balance. (MOSK-rat WATER
PRM)
Injury Patterns:
TORSIONS
- upper cut to cheek
- parietal hit posterior to SBS
- frontal bone hit from inferior force
- occiput hit from superior force

INFERIOR VERTICAL STRAIN

- hit posterior to sphenoid axis, but anterior
to SBS
- forcible landing on heels
- uppercut to mandible

LATERAL STRAIN
- hit laterally in front of SBS but behind
the sphenoid axis.

Strain Pattern:

Possible Cause:

Flexion/Extension

Physiologic, trauma can induce asymmetry

Torsion

Blow above or below on the anterior quadrant (frontal or

cheek), or posterior quadrant blow from above or below
(occiput or parietal)

SBR

Lateral blow at the SBS

Lateral Strain

Blow to side head, anterior or posterior to SBS

Vertical Strain

Superior: vertex blow behind SBS but anterior to occiput

axis, blow thru the mouth anterior to SBS but posterior to
sphenoid axis
Inferior: vertex blow anterior to SBS but posterior sphenoid
axis, heels or mandible blow posterior to SBS but anterior to
occiput axis

SBS Compression

Blow along the AP axis (nasion to opisthion)

Venous flow:

Superior Sagittal sinus Rt. Transverse sinus

Inferior Sagittal sinus Lt. Transverse sinus
Transverse sinus Sigmoid sinus Internal Jugular Vein which courses along with CN IX, X & XI and exit through
Jugular
Foramen which is between two bones, the occiput and temporal.
Great vein of Galen together with the Inferior Sagittal sinus Straight sinus Confluence of Sinus
Cavernous sinus empties into the Inferior and Superior Petrosal sinuses. Inferior Petrosal sinus Sigmoid sinus and the Superior
Petrosal sinus Transverse sinus.
The venous sinuses lie between the two layers of dura. These veins lack smooth muscle, elastic fibers
and valves. They are
dependant on the mobility of the dura for drainage
Beveling:
External bevel: Suture is on the external surface of the bone. If a bone is externally beveled it is overlapped by another bone.
Internal bevel: Suture is on the internal surface of the bone. If a bone is internally beveled then it overlaps another bone.

Example: At the occipitomastoid suture the Temporal has internal beveling and the Occiput has external beveling. In this
case the Temporal overlaps the Occiput.
Note: Above the SS pivot point the temporal overlaps the sphenoid and below this point the sphenoid overlaps the temporal.

1
2
3
4

The Three Articulations between the Temporal and Occipital Bones:

Condylosquamomastoid Pivot: Rocking motion
Jugular Process: occiput drives the temporal
Petrobasilar: Tongue and groove & Hinge/Glide motion
Combination of all three equals wobble
Sutherland's Fulcrum: Area of straight sinus (junction of three sickles of dura mater); automatic shifting suspension fulcrum point
of rest on which a lever moves and from which it gets its power..." (Magoun)
Sphenobasilar synchondrosis: Major joint in cranium, formed in cartilaginous tissue, becomes cancellous bone around the age of 25
and maintains pliability, flexibility thereafter.
Flow of CSF: Lateral ventricles Interventricular foramen of Monroe 3rd ventricle Aqueduct of Sylvius 4th ventricle through
Midline foramen of Magendie or lateral to foramen of Luschka subarachnoid space brain and spinal cord

What runs thru cavernous sinus? CN III, IV, V1, V2 (rarely), VI, Internal Carotid Artery and Sympathetics.
What all meets up at the Confluence of Sinuses? SSS, Straight and Occipital venous sinus. (all drain dura) into transverse sinus
Where does the Confluence drain into? Transverse sinus.
What bones make up the pterion? Frontal (most medial), Parietal, Sphenoid, Temporal
Tricky, which DO NOT articulate with the Temporal Bone? Maxilla and Frontal DON'T touch temporal.
Tricky, which DOES NOT articulate with the Sphenoid? Maxilla, lacrimals, mandible
MOTIONS OF FLEXION/"PRM" INHALATION:
- SBS RISES.
- Midline bones - Flexion (around a transverse axis)
Ethmoid, Vomer and Occiput - clockwise
Sphenoid - counterclockwise
- Paired bones- External Rotation
- Temporals overall - anterior along an oblique axis
Temporal mastoid portion -posteromedial
Temporal squamous portion-anteriolateral
- Frontals-flatten
- Palatines-flatten
- Zygomae-externally rotation at an Oblique axis (flatten)
- Sacrum- COUNTERNUTATION (aka posteral extension), Coccyx goes inward, while base goes outward.