Download Potential Cranial Test questions: Lecture 1: Cranial I Know the 4

Potential Cranial Test questions:
Lecture 1: Cranial I
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Know the 4 principles of osteopathy:
o Body is a functional unit
o Structure and function are reciprocally interrelated
o Body heals itself
o Treatment depends on these precepts
Craniosacral mechanism augments cellular respiration
CNS + CSF + Dural Membranes + Cranial bones + Sacrum =
Primary Respiratory Mechanism = PRM
o Two phases – Flexion and extension
o Primary: 1st in importance, pulmonary secondary to this
o Respiratory: exchange of gases and other metabolites at a cellular level.
o Mechanism: “machine”  each part in working relationship to every other part.
Lack of Motion is the first sign of disease
Five components of the PRM (KNOW THIS):
o 1. Motility of CNS
o 2. Fluctuation of CSF
o 3. Mobility of intracranial/intraspinal membranes(reciprocal tension)
o 4. Articular mobility of cranial bones
o 5. Involuntary motion of sacrum between ilia
Things you should know about the Five components of the PRM:
o 1. Motility of CNS
 The entire CNS shortens and thickens during one phase (Flexion) and lengthens
and thins during the other (Extension)
 Subtle, slow, pulse-wavelike movement between the brain and spinal cord
o 2. Fluctuation of CSF
 Know CSF is produced by the choroid plexus, contained in the 4 ventricles of the
brain and surrounds the spinal cord, and bathes, protects and nourishes the
CNS, inside and outside of it. 500cc produced daily
 Pressure could rise because of rhythmic arterial input of blood into the cranial
cavity
 Fluctuates: wavelike motion of fluid within the cavity of that portion of the body
which encases the CNS & spinal cord.
 Biphasic rhythmic motion changes slightly the shape of the ventricles &
the fluid moves or “fluctuates.”
o 3. Mobility of intracranial/intraspinal membranes(reciprocal tension)
 The meninges (which consists of pia, arachnoid, and dura mater) envelop the
CNS, and the external layer of the dura is continuous with the periosteum of the
skull, so there is ability for motion, when moved by an outside force
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When motion occurs, that translates into the internal layers of the dura, which
has several folds which enclose the venous sinuses and separate the major
divisions of the brain
 KNOW THIS 5 poles of attachment - make up the reciprocal tension membrane:
 Guiding and limiting mechanism for the cranial and sacral bones as they are
involved in the PRM.
 falx cerebri
o Arises from: straight sinus
o Attaches to: occiput, parietals, frontal, and crista galli bones
 tentorium cerebelli
o Arises from: straight sinus
o Attaches to: occiput, temporals, and sphenoid bones
 falx cerebelli
 diaphrgma selle
 spinal dura
 Also KNOW the Dura mater has a firm attachment to: Foramen magnum, C2, C3,
and S2 = Craniosacral = Reciprocal Tension Membrane (RTM)
 This is why the movement of the cranium effects the sacrum…through
these attachments of the dura mater
 KNOW Reciprocal Tension Membrane functional anatomic unit
 dura within the cranium & spinal cord “core link” potential to transmit
biomechanical forces from the cranium to the sacrum.
4. Articular mobility of cranial bones
 Suture lines play a big role here  responds to PRM
 Nerves, blood vessels, and tissue are found IN sutures
 Allow for a minimal amount of motion
 KNOW SBS = spenobasilar symphysis  syncondrosis of hyaline cartilage
 Remains functional throughout life and is a A key area to evaluate in
order to arrive at a diagnosis (the central focus of PMR  Basi-sphenoid
& Basi-occiput)
 Know the driving force for SBS is:
o Fluctuation of the CSF
o Transferred to sphenoid through the dural membrane system
(“Reciprocal Tension Membrane”)
 Restrictions of motion from: prenatal intrauterine forces, process of labor and
delivery , and subsequent trauma at any age (could be as minor as dental work).
5. Involuntary motion of sacrum between ilia
 Firm attachment to cranium through dura (S2 attachment)  responds to PRM
 Allows sacrum to respond to:
o Inherent mobility of CNS
o Fluctuation of CSF
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o Pull of intracranial & intraspinal membranes
 Axes of motion are – superior, middle, and inferior transverse axes
 KNOW most motion occurs around a superior transverse axis because
this is the respiratory axis located at S2
Cranial Rythmic Impulse – CRI
o Each time the PRM goes through a cycle of expansion and contraction it produces a
palpable change at the Cranial level  How many times per minute the Phase occurs =
CRI
o Normal rate of CRI = 10- 14 per/min
 However, know Dr. William’s slides say 6 – 12, and Dr. Myles said it could be 8 –
14 several times during her lectures
o Amplitude: Full and unrestricted
o Things that decrease CRI:
 Stress (emotional, physical, mental)
 Depression, or other psych or debilitating conditions
 Chronic fatigue, infections, or poisonings
o Things that increase CRI:
 Vigorous physical exercise
 Systemic fever
 OMT for craniosacral
Lecture 2: Cranial II
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KNOW osteology of the skull and know which bones are paired and not paired (29 in total):
Cranial group - 8
o Midline (single) bones
 Occiput
 Sphenoid
 Ethmoid  not palpable
o Paired bones
 Frontal
 2 Temporals
 2 Parietals
Facial group - 14
o Midline (single bones)
 Vomer
 Mandible
o Paired bones
 2 Maxillae
 2 Palatines
 2 Zygoma
 2 Lacrimals
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 2 Nasals
 2 Inferior conchae  not palpable
Miscellaneous group – 7  not directly considered part of the cranial concept
o 6 ossicles (3 on each side)
 ears
o Hyoid
Know pterion is made up of the following bones:
o Frontal - anterosuperiorly
o Parietal – posterosuperiorly
o Sphenoid –lateral surface of great wing, anteroinferiorly
o Temporal - centrally
Know your coronal, sagittal, and lambdoid sutures, and where the Bregma, vertex, and Lambda
is:
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BREGMA: junction of coronal and sagittal sutures
VERTEX: highest point of the skull
LAMBDA: junction of lambdoidal and sagittal sutures
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Asterion: where 3 sutures come together posteriorly – occipitomastoid, lambdoidal,
parietomastoid.
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Know the following nerves out of holes in the head:
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Foramen Rotundum-CN5(V2)
Foramen Ovale-CN5(V3)/meningeal artery branches, emmisary vein
Foramen spinosum-Meningeal branches of CNV (V3) and middle meningeal artery
Foramen lacerum-Greater petrosal nerve
Carotid canal – internal carotid a.
Cavernous Sinus-CN3/CN4/CN6
Jugular foramen-CN9/CN10/CN11/meningeal vessels/
Hypoglossal canal-CN12/posterior meningeal artery
Foramen magnum – brainstem, CN10, CN11
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o Superior Orbital Fissure-CN3/CN4/CN5(V1)
o Internal Acoustic Meatus –CN7/CN8
o Stylomastoid-CN7
KNOW the temporal bone is the “trouble maker” of the head because it contains 9 out of 12
cranial nerves (CN 3 – 11)
Cranial nerves do not just poke through bone, but come through in a sheath and the problem
with neural entrapment is more with this sheath/dura rather than passing through a bony
entrance or exit through the foramina
Remember that parasympathetics are involved with the following CN – III, VII, IX, X
Things to know for particular CN:
o CN1 – Olfactory
 Watch out for a history for a blow to the heat  can cause anosmia or altered
sense of smell
 It is responsible for the ability to smell, moves with frontal bone, sphenoid,
ethmoid, and vomer bone motion
o CNV – Trigeminal
 Function
 Sensory to the Face, Motor to the muscles of mastication
 Structure
 V1=SOF, V2=Foramen rotundum, V3=Foramen ovale  KNOW
Meckel’s cave, petrosphenoid ligaments, Cervical spine
 Dysfunction
 Anesthesia, Trigeminal neuralgia (“Tic douleroux”)
o CN7 – Facial
 Function
 Motor to facial muscles
 Parasympathetic to glands
 Special sense to tongue
 Structure
 Stylomastoid foramen internal acoustic meatus
 Dysfunction
 Facial Paralysis (1/2 face….peripheral lesion), weakness, no or poor
taste sense
o Bell’s Palsy
o CN8 – Vestibulocochlear
 Function
 Sensory - hearing and balance
 Structure
 Internal acoustic meatus
 Dysfunction
 Hearing deficit, tinnitus, vertigo, otitis media and interna
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CNIX – Glossppharyngeal
 Function
 Motor to muscle
 Parasympathetic to glands
 Sensory to palate
 Structure
 Jugular foramen
 Dysfunction
 Difficulties swallowing, excessive gag reflex
o CNX – Vagus
 Function
 Motor to striated muscle
 Parasympathetic to smooth muscle and glands
 Sensory from viscera
 Structure
 Jugular foramen, foramen magnum
 Dysfunction
 Everything! (jk…)
 Numerous Somatovisceral; Posterior Headaches; More
o CNXI – Accessory
 Function
 Motor to SCM and trapezius
 Structure
 Cervicals, foramen magnum, jugular foramen
 Dysfunction
 Weakness/paralysis, torticollis
 Recurrent Trigger Points in SCM & Trapezius
o CNXII – hypoglossal
 Function
 Motor to tongue
 Structure
 Hypoglossal canal
 Dysfunction
 Dysphagia, tongue function
Sacrum stuff:
o Epiphyseal plates separate adjacent sacral segments
 These fuse sequentially beginning with the lowest segments working their way
up
 The upper 2 segments fuse about age 7-8 as do the sphenoid and occiput
 Completion of bony fusion by age 25 (Synchronous with the SBS)
Lecture 4 – Cranial III and IV
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Axes of normal motion for cranial bones (KNOW)
o There is NO axis of motion around sutures of cranial bones, they are just a point of
contact
o Single bones have horizontal/transverse axis
 Midline (single) bones  Occiput, Sphenoid, Ethmoid, Vomer, Mandible
o Paired bones have variations of a sagittal axis
 Paired bones  Frontal, 2 Temporals, 2 Parietals, 2 Maxillae, 2 Palatines, 2
Zygoma, 2 Lacrimals, 2 Nasals, 2 Inferior conchae,
Cranial and sacral bone motion (KNOW)
o Each individual bone in the cranium has a predictable motion based on bevel changes
o During Flexion Phase
 SBS rises
 all midline bones Flex around a transverse axis
 all paired bones externally rotate about an AP axis
 Sacrum moves posterior, cephlad
 Counternutation (on superior transverse axis)
 Bi-parietal diameter increases (skull widens laterally)
 AP diameter decreases (shortens)
 Respiratory (cellular) phase in inhalation
o During Extension Phase
 SBS falls
 all midline bones Extend around a transverse axis
 all paired bones Internally rotate about an AP axis
 sacrum moves anterior, caudad
 nutation (on superior transverse axis)
 Bi-parietal diameter decreases (skull narrows laterally)
 AP diameter increases
 Respiratory (cellular) phase is in exhalation
o KNOW motion is determined around the Spehnobasilar synnchondrosis = SBS
Know the 5 axes of motion for the sphenoid (midline) and occiput (midline)
o AP Axis ( 1 axis)
 From Nasion through SBS to Opisthion
o Vertical Axes (2 axes)
 Through Foramen Magnum of the Occiput
 Through Body of the Sphenoid
o Transverse Axes ( 2 axes)
 Through Body of the Sphenoid
 just above the Jugular Process on a level with the SBS
SBS motion – ethmoid and vomer (both midline bones)
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The basiocciput will move vertically in SBS flexion, causing a rotation of the ethmoid
bone
o The ethmoid will move in the same direction as the occiput
o The vomer will move in the same direction as the sphenoid
SBS motion – palantines (paired bones)
o During SBS flexion:
 The palatines will move in external rotation primarily
 Interpalatine suture will move inferiorly with vomer and maxillae
Remember that The temporal bone is the “trouble-maker” of the head (9 of 12 cranial nerves
affected)
Test questions she mentioned:
o Normal rate of CRI = 10- 14 per/min
o Midline cranial bones are in flexion and paired cranial bones are externally rotating =
while flexion
o While extension = midline cranial bones extend and the paired cranial bones internally
rotate
o Pterion
 Know four bones that connect to this and how they relate to each other
(Superior, inferior, etc…)
o The key to the motions like today
 Ex the SBS is in flexion
 Ethmoid bone moves in the same direction as the occiput
 Volmar bones moves in the same direction as the sphenoid
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Know temporal bone is trouble maker bc 9 out of the 12 cranial n are involved in it
Be comfortable to know everything labeled a diagram as a reference point
 Know the anatomy
Lecture 6 – Cranial V and VI
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Physiological strain patterns of the SBS
o Flexion/ Extension
 Can feel “endpoints” of the phases when measuring someone’s CRI
 Will have decreased flow in the opposite phase (e.g., flexion dysfunctions will
have diminished extension pattern)
 Will have opposite rotation about transverse axes – sagittal plane (Through
Body of the Sphenoid and just above the Jugular Process on a level with the SBS)
– Williams said Test Q
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Sphenobasilar Torsion (left and right)
 Torsion of the sphenoid about an anteroposterior (AP) axis extending from the
nasion through the symphysis to opisthion
 So basically, you have one axis  Antero-superior to Infero-posterior
 The sphenoid & anterior skull components are in one direction, the occiput &
posterior components in the other.
 So know the Spenoid and occiput rotate in opposite directions
 This strain is named for the side of the high wing of the sphenoid, right torsion
(RT) or left torsion (LT)
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So the strain will be named for the superior great wing of sphenoid
Side Bending Rotation (left and right)
 Two different axes
 Occurs around an AP axis (extending from the nasion through the
symphysis to opisthion) & around 2 parallel vertical axes (one through
the body of the sphenoid & one through the foramen magnum)
perpendicular to the physiologic transverse axes & the A-P axis
o A-P, Bilateral vertical axes – 3 axes in total
 As the SBS sidebends, it also rotates inferiorly to the convex sidebending side
(coupled motion)
 So know the Occiput and Sphenoid rotate same direction on AP axis;
side-bend away from each other on parallel vertical axes.
 It is named for the convexity (convex side of Sidebending)
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Non-physiological strain patterns of the SBS
o Lateral Strain (left strain and right strain)
 Aka ”parallelogram head”
 Sphenoid and occiput have the same rotation about the vertical axes (one
through the body of the sphenoid & one through the foramen magnum),
resulting in a lateral strain pattern
 Bilateral vertical axes
 Can happen with a one-sided impact from the front or back of head (off-center
impact)
 Named for the position of the base of the sphenoid, relative to the occiput at
the SBSS
 Named for position of basisphenoid
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Vertical strains (superior strain and inferior strain)
 Sphenoid and occiput have the same rotation about the transverse axes
(Through Body of the Sphenoid and just above the Jugular Process on a level
with the SBS), resulting in a vertical strain pattern
 Sphenoid and Occiput rotate same direction on parallel horizontal axes
 Named for the position of the base of the sphenoid, relative to the occiput at
the SBS
 So Named for position (superior/inferior) of base of Sphenoid
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Compression
 Aka, ‘bowling ball head’
 This is where the SBS has been compressed (think of a ‘jammed’ finger), causing
a near total lack of motion at the SBS in any particular direction
 Most commonly seen in frontal impact trauma, difficult births, and
circumferential loads to the skull, but can also be seen in severe psychiatric &
emotional states
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Remember your cranial and facial bone motions:
o Occiput, sphenoid, ethmoid, vomer
 Rotate about a transverse axis
 Physiologic flexion on the inhalation phase
o Paired bones of the periphery
 Frontals, temporals, parietals, maxilla, palatines, zygomae
 Rotate externally during cranial flexion
 Rotate internally during cranial extension
From this point on, I understand nothing…….
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Face affected most by Sphenoid, Temporals & Sacrum by Occiput
o Effect on Internal/External Rotation on Paired Bones of Face
 Easiest: Flexion or Extension Type
 Palate/Dental Arch:
o Extension = high & narrow
 Also note:
 Orbit narrows/ recedes
 Nasolabial crease
 Cheek prominent
 Ears- inflared
 Increased Frontal Eminence
 Receding Forehead
o Flexion = low & wide
 Also note:
 Orbit widens/ protrudes
 Nasolabial crease
 Flattened Cheek
 Ears – outflared
 Decreased Frontal Eminence
 Prominent forehead
“Quadrants” of Torsions and Sidebending Rotation’s can be identified as being in external
rotation by which greater wing is relatively higher and which occipital shelf is relatively lower
o Flexion
 Findings-all quadrants in external rotation
 Increased transverse diameter
 Forehead wide and sloping(brow prominent with forehead receding)
 AP diameter equal on both sides
 Sagittal suture flattened or depressed
 Sphenoid
 Superomedial-inferolateral diameter greater
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 Orbits wider
 Eyeballs protuberant
 Increased fronto-zygomatic angle
 Frontal processes of maxillae are nearly in coronal plane
 Maxillary palantine processes flattened
Occiput
 Protruding ears
 Mastoid tips posteromedial
Maxillae
 Nasolabial crease deeper
Extension
 Findings-all quadrants in internal rotation
 Long narrow head
 Decreased transverse diameter
 Forehead prominent with Brow receding
 Sphenoid
 Superomedial-inferolateral diameter decreased
 Decreased frontozygomatic angle
 Orbit narrowed
 Eyeballs retruded
 Frontal processes of the maxillae are nearly in sagittal plane
 Maxillary palantine processes arched
 Occiput
 Ears close to head
 Mastoid tips anterolateral
 Maxillae
 Nasolabial crease shallow
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Right Torsion
 Findings- asymmetric quadrants
 Sphenoid-1 quadrant in external rotation
o Higher greater wing side relative to the other
 Orbit wide
 Frontolateral angle anterior
 Zygomatic orbital rim everted
 Maxillary frontal processes in more coronal plane
 Maxillary palantine processes flattened
 Occiput-1 quadrant in external rotation
o Low occiput side relative to the other
 Protruding ears
 Mastoid tips posteromedial
Right SideBending Rotation
 Findings- 1 side of face full and convex with the opposite side flattened (side of
the lower greater wing of the sphenoid)
 Sphenoid Side of low greater wing in internal rotation
o Lateral fontal angle posterior
o Orbit narrower
o Eyeball retruded
o Frontozygomatic angle lessened
o Zygomatic tuberosity prominent
o Maxillary frontal process more sagittal
o Maxillary palantine process more arched
 Occiput
 Mastoid tip –posteromedial
 Ear protruding
Lecture 9 - Cranial review Dr. Williams
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Articular movement of the Sphenoid
o Transverse axis through the center of its body is in the area of the sella turcica
o The motion of the sphenoid occurs in the sagittal plane described as flexion and
extension
o Flexion:
 Posterior aspect of the body elevates. The sella turcica moves anterosuperiorly.
 Greater wings move forward and slightly laterally and inferiorly.
 The pterygoids move posteriorly and inferolaterally.
 The body expands a little as it carries the resistance of the facial bones.
o The Sphenoid primarily influences ethmoid, vomer and facial bones
Articular movement of the Occiput
o The occiput has physiologic motion of flexion & extension in the sagittal plane around a
transverse axis, lying just above the jugular processes.
o Flexion - the occipital base moves superiorly, the posterior aspect moves posteriorinferiorly & the occipital condyles move anteriorly.
o The occiput primarily influences the parietals & temporal bones.
Articular movement of the Temporal bone
o The motion of the occiput is directly responsible for the motion of the temporal bones.
o The axis of physiologic motion runs from the jugular surface to the petrous apex parallel
to the petrous ridge.
o In the flexion phase, the temporal bones externally rotate. The squama moves
anterolaterally and the mastoid portion moves medially and slightly posteriorly.
o In the extension phase, the reverse occurs
Articular movement of the Frontal bone
o Axis of rotation runs from the center of the orbital plate up through the center of the
orbital eminence near the change of bevel at the cranial border. Hinge-like action along
the metopic suture, remains a line of persisting flexibility (why this is a paired bone)
o In external rotation, the inferior lateral angles (zygomatic angles) of the frontal bone
move laterally, inferiorly and slightly forward. The opposite occurs in internal rotation.
o The glabella tends to recede slightly in external rotation due to the pull of the falx
cerebri.
Articular movement of the Parietal bone
o Axis runs parallel to the sagittal suture through the change of bevel at the anterior &
posterior borders of each parietal bone
o In external rotation, the inferior borders of the parietal bone moves laterally. A
“widening” occurs which is greatest at the posterior aspect of the bones. Internal
rotation the inferior borders move medially.
Know how to palpate the CRI – TEST Q
Vault Hold
o Thumbs-not touching or barely in contact with the sagittal suture.
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o Index- frontosphenoidal on Greater Wings of Sphenoid
o Middle- ant to ears on temporal (zygomatic process)
o Ring- post to ears on temporal (on or near mastoid process)
o Little- occipital bone (squamous portion)
Fronto-occipital hold
o Posterior hand-cups squama of occiput
o Anterior hand-greater wings of sphenoid