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Complete H&P I and II

Cranial I and II

1. History
a. William Sutherland
i. Student of AT Still
ii. Worked from structure of bone to its function
iii. Practiced it for many years, little acceptance until 1940
b. Charlotte Weaver
2. Cranial Concept
a. Primary Respiratory Mechanism
i. CNS + CSF + dural membranes + cranial bones + sacrum function as a unit to control and regulate
pulmonary respiration, circulation, digestion and elimination
b. 5 anatomical-physiological elements:
i. Inherent motility of brain and spinal cord
1. Subtle inherent, slow pulse-wavelike motion
2. Brain/spinal cord:
a. Lengthen/thin during exhalation
b. Shorten/thicken during inhalation
ii. Fluctuation of CSF
1. Produced by choroid plexus
2. Support/buffer for the CNS
3. 500cc produced daily
4. Cranial Rhythm Impulse
a. 10-14 cycles per minute
b. Decrease
i. Stress, depression, chronic fatigue, infections
c. Increase
i. Exercise, systemic fever, OMT to craniosacral mechanism
iii. Mobility of intracranial/intraspinal membranes
1. Meninges surround, support and protect the CNS
2. Dura Mater
a. Continuous with periosteum
b. Thick, inelastic
c. Forms falx cerebri and tentorium cerebelli
i. Falx Cerebri:
1. attaches to the occiput, parietal, frontal, crista galli
ii. Tentorium cerebelli
1. 2 halves arise at straight sinus and attach to the occiput, temporals
and sphenoid
d. DURAL ATTACHMENTS
i. FORAMEN MAGNUM, C2, C3 AND S2
e. Dura is inelastic and attached to the cranial bones so any movement of the dura
influences the cranial bones
i. Reciprocal Tension Membrane
1. Automatic, shifting fulcum
2. 5 points of attachment of dural membrane
a. Anterior-superior pole
i. The falx attaches to the cristi galli of the ethmoid and
to the frontal crest
b. Anterior-inferior pole
i. The tentorium attaches to the anterior and posterior
clinoid processes of the sella turcica
c. Lateral poles
i. The tentorium attaches to the petrous ridge of the
temporal bone and the transverse ridge of the
occiput
d. Posterior pole
i. The internal occipital protuberance
e. Sacral pole
i. The dura exits the foramen magnum attaches to C2
and then hangs loosely until it attaches to the S2
sacral segment
3. Arachnoid mater
4. Pia mater
iv. Articular mobility of cranial bones
1. Mobility responds to PRM, bevel changes located along suture lines
2. Restrictions can result from:
a. Prenantal intrauterine forces, L&D, any trauma
v. Involuntary motion of sacrum between ilia
1. Any motion of the RTM causes the sacrum to move
2. Slight rocking motion of the sacrum occurs about a transverse axis that runs through the
superior transverse axis of the sacrum
3. Firm attachment of dura to S2
4. Motion occurs around a superior transverse axis: respiratory axis, located at S2
5. Middle Transverse Axis- the functional axis of sacral nutation and counternutation in the standing
position.
6. Inferior Transverse axis-the functional axis of motion at the inferior auricular surface of SI joint
and is the axis of motion of the ilia on the sacrum
TMJ
1. TMJ Anatomy
a. Synovial joint
b. Head of the mandible, articular tubercle of the temporal bone, mandibular fossa of the temporal bone
c. Covered w/ fibrocartilage
d. Divided into 2 separate compartments by articular disc or meniscus
e. Capsule
i. This division by the disc means that there are actually two joints on each side:
ii. One between the ramus of the mandible and the articular disc
iii. Another between the disc and the temporal bone fossa
iv. During low-load opening activities (talking, gentle chewing) the motion is confined to the first
v. During high opening activities (Eating/Yawning) the motion involves the second joint this is usually
when/where dysfunction occurs
f. Ligaments
i. Lateral ligament
1. Attaches the mandible to the zygomatic arch on the lateral aspect of the TMJ
2. Helps strengthen the joint capsule
ii. Sphenomandibular ligament
1. Attaches the medial aspect of the mandible (lingula) to the spine of the sphenoid on the medial
aspect of the TMJ
2. Helps strengthen the joint capsule
iii. Stylomandibular ligament
1. Attaches the angle of the mandible to the styloid process of the temporal bone on the medial
aspect of the TMJ
2. Purpose of this ligament is unknown
g. Muscles
i. Lateral pterygoid
1. Depresses the mandible, also helps with protrusion and lateral movements
2. Upper head originates on the greater wing of the sphenoid
3. Upper head attaches to disc
4. Lower head of lateral pterygoid originates on the lateral pterygoid plate
5. Lower head attaches to mandible
ii. Medial pterygoid
1. elevates the mandible & helps with lateral & protrusive movements
iii. Masseter
1. Elevates the mandible, also protracts, retracts and helps with lateral movements
2. 3 points of attachment:
a. Superficial part from zygomatic process of the maxilla & from the anterior 2/3 of lower
border of the zygomatic arch
b. Middle part from the deep surface of the anterior 2/3 of the zygomatic arch & from the
lower border of the posterior one-third of the arch
c. Deep part arises from the deep surface of the zygomatic arch
iv. Temporalis
1. Anterior fibers elevate
2. Posterior fibers retract
v. Digastric
1. Depresses the mandible
vi. Mylohyoid
1. Depresses the mandible when hyoid is flexed
h. Motion
i. Depression (opening of the mouth from rest)
1. Suprahyoid and infrahyoid muscles contract, moving the head of the mandible and the articular
disc anteriorly
ii. Elevation (closing of the mouth to rest)
1. Temporalis (vertical fibers), masseter and medial pterygoid muscles contract, pulling the head of
the mandible and the articular disc posteriorly; very powerful movement
iii. Protrusion (carrying the mandible forward from rest)
1. Masseter, lateral pterygoid and medial pterygoids contract, causing the head of the mandible to
glide anteriorly but the articular disc to slide posteriorly
iv. Retraction (carrying the mandible back to rest)
1. Temporalis (horizontal fibers) and masseter contract to pull the head of the mandible posteriorly
and slide the articular disc anteriorly
v. Small amount of lateral movement (side-to-side movement from the rest position)
vi. Smooth, normal motion is a blending:
1. Muscular contraction on mandible
2. Ligamentous tension
3. Contraction, or lack thereof, by lateral pterygoid
4. Gravitational and structural forces acting on cranium and mandible
i. ROM
i. Jaw Opening - 40-50 mm
ii. Side to Side (lateral motion) - 8 mm
iii. Protrusion - 6-8 mm
iv. Retrusion- 3 mm
j. Vascular, Lymphatic, Neural
2. Dysfunction
a. Pain & clicking with mandibular motion
b. Tenderness to palpation over TM joint
c. Lateral pterygoid draws disc and mandible anteriorly with opening
i. when tight, prevents posterior motion of both
d. Anteriorly displaced mandible closing
e. Posteriorly displaced mandible opening
3. Dislocation
a. Most commonly due to the head of the mandible sliding anteriorly past the articular tubercle, either due to yawning
or taking a large bite, also can be traumatic.
b. Causes the mandible to be locked in a protruded position.
c. Treatment is reducing it by applying a gentle caudal force on the mandibular row of teeth.
4. History
a. High pillow, muscle spasm after dentist, bruxism, dental malocclusion, jaw clenching, gum chewing, trauma, Lyme,
JRA
b. Otalgia in kids
i. If >3-4d, unilateral, normal ear exam
5. Diagnosis
a. Anteriorly displaced mandible cant close well (more common).
b. Posteriorly displaced mandible cant open well.
i. Common TMJ problem: anterior gliding motion of mandible is restricted
ii. Ex. L TMJ dysfunction, but R side works normally, causes deviation of chin to the L (dysfunctional side)
c. Monitor pts TMJ with flats of fingers over TMJ just anterior to the tragus while patient opens & closes jaw.
d. Observe the mental area of the mandible for deviation while you simultaneously palpate the TMJs.
e. Similar in concept to open/closed facets.
6. Treatment
a. May need imaging, OMT, meds
b. Direct or Indirect
i. Muscle Energy
ii. Jones Strain-Counterstrain
iii. Balanced ligamentous tension
iv. Cranial techniques
c. Muscle energy
i. Diagnose side of dysfunction by putting fingers in front of EAC and having patient open jaw
ii. Side to which the jaw deviates is the dysfunction
d. BLT
e. Cranial
i. Unilateral Temporal hold
ii. External rotation of the temporal bone mandible deviates toward
iii. Internal rotation of the temporal bone mandible deviates away
iv.
Admit Orders

Presenting a Case

Axial Skeleton

Pelvis

Cranial II
1. Cranial Bone Motion
a. Midline bones
i. Occiput, sphenoid, ethmoid, vomer, frontal
ii. Flex or extend around a transverse axis
b. Paired bones
i. Temporals, parietals, palantines, lacrimals, maxillae, nasals, frontals
ii. Internally or externally rotate
c. Flexion phase
i. All midline bones flex
ii. All paired bones externally rotate
2. Articular Mobility of Cranial Bones
a. Sphenoid
i. Initially: lesser wing and body, 2 greater wing-pterygoid units
ii. Adult sphenoid: body, greater and lesser wings, pterygoid process
iii. Articulates w/ 13 bones
iv. Movement
1. Transverse axis:
2. Motion
a. Posterior aspect of the body elevates. The sella turcica moves anterosuperiorly.
b. Greater wings move forward and slightly laterally and inferiorly.
c. The pterygoids move posteriorly and inferolaterally.
d. The body expands a little as it carries the resistance of the facial bones
v. Influences the ethmoid, vomer and facial bones
b. Occiput
i. Dural attachments form venous sinuses
ii. 4 parts: squamous, 2 condylar, basilar
iii. all parts are formed from cartilage except interparietal occiput
iv. Motion
1. The occiput has physiologic motion of flexion & extension in the sagittal plane around a
transverse axis, lying just above the jugular processes.
2. Flexion - the occipital base moves superiorly, the posterior aspect moves posterior-inferiorly & the
occipital condyles move anteriorly.
v. The occiput primarily influences the parietals & temporal bones
c. Temporals
i. 3 portions at birth: squamous, tympanic plate, petromastoid
ii. The occiput has physiologic motion of flexion & extension in the sagittal plane around a transverse axis,
lying just above the jugular processes.
iii. Flexion - the occipital base moves superiorly, the posterior aspect moves posterior-inferiorly & the occipital
condyles move anteriorly.
iv. The occiput primarily influences the parietals & temporal bones.
3. Cranial Cycle
a. 2 motions at the SBS: flexion and extension
b. Midline (Single) Bones
i. Sphenoid, Occiput, Ethmoid, Vomer, Sacrum,Frontal
c. Paired Bones
i. Parietals, Temporals, Zygoma, Palantines, Lacrimals,Parietals,Frontal
d. FLEXION
i. Midline bones of the cranium move through FLEXION phase
1. Sphenoid, occiput, ehtmoid, vomer
ii. Paired bones of the cranium move through EXTERNAL ROTATOIN phase
iii. Flexion of the SBS will cause the dura to be pulled cephalad, moving sacral base posterior through the
superior transverse axis of the sacrum
1. Counternutation
iv. Widens the head slightly, decreases AP diameter
v. Ernie
e. EXTENSION
i. Midline bones of the cranium (sphenoid, occiput, ethmoid, vomer) move through EXTENSION phase
ii. Paired bones of the cranium move through an INTERNAL ROTATION phase
iii. Extension at the SBS causes dura to move caudad ,moving sacral base anterior, through the superior
transverse axis of the sacrum
1. Nutation
iv. Extension narrows the head slightly and increases its AP diameter
v. Bert
4. Axes of Motion
a. AP Axis (1 axis)
b. From Nasion through SBS to Opisthion
c. Vertical Axes (2 axes)
d. Through Foramen Magnum of the Occiput
e. Through Body of the Sphenoid
f. Transverse Axes ( 2 axes)
g. Through Body of the Sphenoid
h. Just above the Jugular Process on a level with the SBS

Sacrum

Hip

Lower Extremity

Ribs

Upper Extremity

Viscerosomatic Reflex

Cranial Mechanics

Cranial IV

Cranial V

1) Normal Cranial Bone Motion


a.

Cranial VI

Chapmans Points
Special Tests

Cranial III
1. Cranial Bone Motion
a. Midline bones
i. Occiput, sphenoid, ethmoid, vomer, frontal
ii. Flex or extend around a transverse axis
b. Paired bones
i. Temporals, parietals, palantines, lacrimals, maxillae, nasals, frontals
ii. Internally or externally rotate
c. Flexion phase
i. All midline bones flex
ii. All paired bones externally rotate
2. Strains
a. Torsion
b. SB/Rotation
c. Vertical strain
d. Lateral strain
e. Compression
3. Treatment
a. Venous Sinus technique
b. CV4: Bulb decompression
c. Vault hold
d. V spread
e. Lift technique

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