+ Nicette Sergueff lectures throughout Europe on manual principles,
+ diagnosis, and treatment, and maintains a private practice in Corbas,
+ France. She is an assistant professor.
+
+
+ Kenneth E. Nelson is a professor, and Thomas Glonek is a
+ research professor in the Department of Osteopathic Manipulative
+ Medicine, Chicago College of Osteopathic Medicine, Midwestern
+ University, Downers Grove, Illinois.
+
+
Context
+
+ A correlation has been established between the Traube-Hering-Mayer
+ oscillation in blood-flow velocity, measured by laser-Dopper-flowmetry,
+ and the cranial rhythmic impulse.
+
+
Objective
+
+ To determine the effect of cranial manipulation on the
+ Traube-Hering-Mayer oscillation.
+
+
Design
+
+ Of 23 participants, 13 received a sham treatment and 10 received cranial
+ manipulation.
+
+
Setting
+
+ Osteopathic Manipulative Medicine Department, Midwestern University,
+ Downers Grove, Illinois.
+
+
Participants
+
Healthy adult subjects of both sexes participated (N=23).
+
Intervention
+
+ A laser-Doppler flowmetry probe was place on the left earlobe of each
+ subject to obtain a 5-min baseline blood flow velocity record. Cranial
+ manipulation, consisting of equilibration of the global cranial motion
+ patter and the craniocervical junction, was then applied for 10 to 20
+ minutes; the sham treatment was manipulation only.
+
+
Main Outcome Measure
+
+ Immediately following the procedures, a 5-min postreatment laser-Doppler
+ recording was acquired. For each cranial treatment subject, the 4 major
+ components of the blood-flow velocity record, the thermal (Mayer)
+ signal, the baro (Traube-Hering) signal, the respiratory signal, and the
+ cardiac signal, were analyzed, and the pretreatment and posttreatment
+ data were compared.
+
+
Results
+
+ The 10 participants who received cranial treatment showed a thermal
+ signal power decrease from 47.79 dB to 38.490 dB (P < .001) and the
+ baro signal increased from 47.40 dB to 51.30 dB (P < .021), while the
+ respiratory and cardiac signals did not change significantly (P > .05
+ for both).
+
+
Conclusion
+
+ Cranial manipulation affects the blood-flow velocity oscillation in its
+ low-frequency Traube-Hering-Mayer components. Because these
+ low-frequency oscillations are mediated through parasympathetic and
+ sympathetic activity, it is concluded that cranial manipulation affects
+ the autonomic nervous system.
+
+
Introduction
+
+ Cranial manipulation is a form of broadly practiced alternative, manual
+ medicine. A fundamental component of cranial manipulation is the primary
+ respiratory mechanism (PRM).1 It is described as an
+ oscillation that is palpable; the cranial rhythmic impulse (CRI)2 has an
+ agreed-upon frequency of 10-14 cycles per minute (cpm).2,3{" "}
+ The PRM/CRI is a subtle phenomenon that is readily palpable only by
+ experienced individuals, making its very existence subject to debate.{" "}
+ 4,5
+
+
+ The Traube-Hering-Mayer (THM) wave is a complex oscillation in blood
+ pressure and blood-flow velocity. The Traube-Hering (TH) component of
+ this oscillation has a frequency of 6 to 10 cpm. Analysis of the TH was
+ first described in 1865, when Ludwig Traube reported the measurement of
+ a fluctuation in pulse pressure that occurred with a particular
+ frequency of respiration but persisted after respiration had been
+ arrested.6 Fourier-transform analysis applied to blood
+ physiologic parameters shows that this fluctuation consists of 3
+ principal spectral peaks: the thermal or Mayer (M) wave (1.2-5.4 cmp),
+ the baro or TH wave (6.0-10.0 cpm), and the respiratory wave, which
+ shifts in frequency with changes in the respiratory rate.7 Multiple
+ authors have commeted on the similarity between the TH wave and the CRI.
+ 8-11
+
+
+ By comparing cranial manipulation with laser-Doppler flowmetery, we have
+ demonstrated that the PRM/CRI is congruous with the TH component of the
+ THM oscillation in blood flow velocity.12 A question,
+ therefore, logically arises: can cranial manipulation affect the THM
+ oscillation?
+
+
Method
+
+ Healthy adult subjects (both sexes, N=23, institutional review
+ board-approved informed consent obtained) were divided randomly into
+ cranial palpation (n=13) and cranial manipulation groups (n=10). A
+ laser-Doppler probe (BLF 21 Perfusion Monitor, Transonic Systems, Inc.
+ Ithaca, NY) was placed on the left earlobe of each subject. After the
+ subject was allowed to lie quietly on the examination table for 3
+ minutes of equilibration, a 5-minute baseline blood-flow velocity record
+ was obtained. Cranial manipulation or manipulation, with the physician
+ blinded to the flowmetry recording, was then performed for 10 to 20
+ minutes. Following palpation or treatment, a 5-minute postcontact
+ laser-Doppler recording was acquired. During this entire procedure, the
+ subject remained on the examination table, and the laser-Doppler probe
+ was not disturbed.
+
+
+ Cranial palpation (simply counting the CRI but without intervention) and
+ manipulation (therapeutic intervention) were performed while the
+ subjects were supine. The individual performing the procedure was seated
+ at the end of the examination table with hi or her forearms resting upon
+ it. The examiner’s palms conformed to the curvature of the subject’s
+ head, contacting the lateral aspect of the great wings of the sphenoid
+ bone and the temporal, occipital and parietal bones bilaterally. For
+ this study, similar contact pressure, firm, but light enough not to
+ ablate the sensation of the CRI, was employed for both palpation and
+ manipulation. Manipulation was directed at modulation of the rate,
+ rhythm, and amplitude of the CRI and perceived functional asymmetry
+ through equilibration of the craniocervical junction and global
+ anerioposterior cranial motion. Specific interventions were dictated by
+ the physical findings of the individual’s cranial pattern.
+
+
Results
+
+ For each subject, 4 component parts of the blood flow velocity record
+ were analyzed: the thermal (M) signal, the baro (TH) signal and the
+ respiratory signal of the THM, and the cardiac signal. The mean
+ precontact and postcontact data for each group were compared using the
+ paired-samples 2 tailed t statistic (see Table). After palpation only,
+ the thermal signal power decreased 3 dB (42.93 to 39.58 Db, P <
+ .054), while the baro (39.83 to 40.10 dB, P < .805), respiratory
+ (27.54 to 27.20 dB, P < .715) and cardiac (37.92 to 37.14 dB, P <
+ .511) signals did not change.
+
+
+ After cranial manipulation, the thermal signal power decreased 9 dB
+ (47.40 to 51.30 dB, P < .021), while the respiratory (29.72 to 30.02
+ dB, P < .747) and cardiac (41.11 to 40.70 dB, P < .788) signals
+ did not change.
+
+
+ The 2 examples illustrated (see Figure), though visually exceptional,
+ illustrate the effects that can be obtained to varying degrees with any
+ subjecd, provided the treating physician possesses the requisite skill.
+
+
Comments
+
+ From the above data, we have drawn 3 conclusions. First, cranial
+ manipulation has an effect on low-frequency oscillations observed in
+ blood-flow velocity. It decreases the amplitude of the M wave and
+ increases the amplitude of the TH wave. Second, we conclude that cranial
+ manipulation affects the autonomic nervous system because it has been
+ demonstrated that the M an TH waves are mediated through parasympathetic
+ and sympathetic activity.7 Third, because palpation alone did not
+ greatly affect blood-flow velocity oscillations, we conclude that there
+ is a quantifiable difference between palpation and cranial treatment.
+ This conclusion suggests that palpation alone may be used as a sham
+ treatment in future research in the field of cranial manipulation.
+
+
+
+
+
+
+ Traube-Hering-Mayer signal power comparison before and after
+ palpation only and cranial manipulation
+
+
+
+
+
+
+ Palpation only n=13
+
+
+ Cranial manipulation n=10
+
+
+
+
+ Signal
+
+
+ Doppler record segment
+
+
+
+ Mean signal
+
+ power (dB)
+
+
+
+
+ Paired difference
+
+ before-after +/- SD
+
+
+
+ P
+
+
+
+ Mean signal
+
+ power (dB)
+
+
+
+
+ Paired difference
+
+ before-after +/- SD
+
+
+
+ P
+
+
+
+
+ Thermal (M)
+
+
+ Before After
+
+
+ 42.93
+
+ 39.58
+
+
3.36+/-5.69
+
.054
+
+ 47.79
+
+ 38.49
+
+
9.30+/-5.65
+
.001
+
+
+
+ Baro (TH)
+
+
+ Before After
+
+
+ 39.83
+
+ 40.10
+
+
-.27 +/-3.85
+
.805
+
+ 47.40
+
+ 51.30
+
+
-3.90+/-4.40
+
.021
+
+
+
+ Resp.
+
+
+ Before After
+
+
+ 27.54
+
+ 27.20
+
+
.34+/-3.23
+
.715
+
+ 29.72
+
+ 30.02
+
+
-.30+/-2.89
+
.747
+
+
+
+ Cardiac
+
+
+ Before After
+
+
+ 37.92
+
+ 37.14
+
+
.78+/-4.15
+
.511
+
+ 41.11
+
+ 40.70
+
+
.41+/-4.67
+
.788
+
+
+
+
References
+
+ 1. Sutherland WG. The Cranial Bowl. Indianapolis, Ind: American Academy
+ of Osteopathy, 1986. (Original work published 1939).
+
+
+ 2. Woods JM. Woods RH. A physical finding relating to psychiatric
+ disorders. J Am Osteopath Assoc. 1961;60:988-993.
+
+
+ 3. Lay E. Cranial Feild. In: Ward RC, ed. Foundations for Osteopathic
+ Medicine. Baltimore, MD: Williams and Wilkins; 1997:901-913
+
+
+ 4. Ferre JC. Barbin JY. The osteopathic cranical concept: fact or
+ fiction? Surg Radial Anat, 1991:13-65-179
+
+
5. Norton JM. Dig on [Letter to the editor]. AAOJ. 2000;10(2):16:17
+
+ 6. Traube L. Uber periodische Thatigkeits-Aeusserungen des
+ vasomotorishen un Hemmungs-Nervenzentrums. Centralblatt fur die
+ medicinischen Wissenschaften 1865:56:881-885
+
+
+ 7. Akselrod S. Gordon D. Madwed JB, Snidman NC, Shannon DC, Cohen RJ.
+ Hemodynamic regulation: investigation by spectral analysis. Am J
+ Physiol. 1985:249-H867-H875
+
+
+ 8. Frymann VA. A study of the rhythmic motions of the living cranium. J
+ Am Ossteopath Assoc. 1971:70-928-945
+
+ 10. Geiger AJ. Letter to the editor. J Am Osteopath Assoc.
+ 1992:92-1088-1093
+
+
+ 11. McPartland JM, Mein EA. Entrainment and the cranial rhythmic
+ impulse. Altern Ther Health Med. 1997:3(1):40-45
+
+
+ 12. Nelson KE, Sergueef N, Lipinski CL, Chapman A, Glonek T. The cranial
+ rhythmic impulse related to the Traube-Hering-Mayer oscillation:
+ comparing laser-Doppler flowmetry and palpation. J Am Osteopath Assoc.
+ 2001:101(3):163-173
+
+ There are a great number of conditions and a variety of states of
+ illness that result in the symptom of “back/neck pain.” Back and neck
+ pain can be related to conditions ranging from muscle strains, somatic
+ dysfunction to nerve compression and anatomic anomalies.
+
+
+
+ The focus of this article is to discuss herniation of intervertebral
+ discs as a cause of pain. We will examine the pathophysiology and
+ biomechanics of disc degeneration and herniation as well as aspects of
+ the epidemiologic data. Lastly, it is important to mention the role that
+ manual/manipulative medicine plays with regard to this issue. While the
+ general principles of herniated discs may be applied to any level of the
+ spine, we will discuss each spinal level from cervical, thoracic, to
+ lumbar.
+
+
+
Anatomic Review
+
+ An intervertebral disc is formed of two elements: the nucleus pulposis
+ and the anulus fibrosis. The anulus fibrosis is composed of sequential
+ layers of fibrocartilage that envelope the nucleus pulposis. The nucleus
+ pulposis itself is formed of a proteoglycan and a water/gel substance
+ that is held loosely in place by a network of collagen and elastin
+ fibers. Together they form the intervertebral disc and serve to
+ distribute weight and force equally throughout the spine, even during
+ motions such as flexion and extension1. Blood vessels course along the
+ outer edge of the anulus fibrosis and thereby force the disc to obtain
+ its nutrient supply via osmosis. When the discs age, they are subject to
+ gradual degeneration as the water content decreases and the ability to
+ absorb impact diminishes. Degeneration begins on a microscopic level
+ around the age of skeletal maturation, or fifteen years of age. At this
+ time, cell densities begin to diminish, resulting in microstructural
+ tears and clefts (2).
+
+
+
Pathophysiology
+
+ The microstructural defects accumulate over time as a person ages and
+ the pulposis protrudes deeper into the anulus. These defects can result
+ in frank tears of the anulus. There are three main tears that have been
+ distinguished, these include:
+
+
+
circumferential tears or delaminations
+
peripheral rim tears
+
radial fissures
+
+
+ The circumferential tears represent shearing forces acting on the
+ interlaminar layers of the anulus fibrosis. The characteristic disc for
+ this type of tear is an older disc that has an advanced amount of
+ dessication and degeneration, retaining a limited ability to absorb
+ these stressors (3). The second type of tear, the peripheral rim tears,
+ are most frequently seen in the anterior portion of the disc and are
+ associated with bony outgrowths. Histologic data suggest that the actual
+ tears are a result of repeated microtrauma (4). Lastly, radial fissures
+ represent a grouping of tears that typically occur in a posterior or
+ posterolateral direction and are associated with degeneration of the
+ nucleus pulposis. These tears have been simulated in cadavers with
+ repeated cycles of sidebending and compression (5).
+
+
+ These variations of degeneration, dessication, and microstructural
+ defects seem to be common among studies reported in the current base of
+ literature. These tears, however, have not been shown to have a
+ correlation with the actual prolapse, or herniation, of the disc. The
+ tears and disc degeneration have been shown to be correlated only with
+ repetitive mechanical loading and cigarette smoking6 (as this inhibits
+ the body’s regulatory healing mechanisms in a vast number of ways). The
+ prolapse of the disc has been shown to correlate with heavy lifting.
+ That is to say, the degeneration of discs, and not the herniation,
+ appears to be a normal process of aging (1).
+
+
+
Epidemiology
+
+ For the discussion of rates of occurrence and particular mechanisms
+ associated with disc herniation, we will begin at the cervical level and
+ progress inferiorly to the thoracic and finish at the lumbar vertebrae.
+
+
Cervical Disc Herniation
+
+ Cervical radiculopathy, or pain in a pattern of the nerve root that is
+ compressed, is estimated to occur in 85 per 100,000 people in the
+ population. Most commonly affected regions include the seventh cervical
+ vertebra, C7, and the sixth cervical vertebra, C6, at rates of 60% and
+ 25%, respectively (7). These radiculopathies in the cervical region are
+ commonly present in specific demographic groups. For instance, sudden
+ weight load on the neck while in either flexion or extension can be the
+ culprit. Also, in the elderly population, osteophyte formation can play
+ a role as previously mentioned. Sport-related injury can be more
+ insidious in nature, and can be attributed repetitive extension/rotation
+ while actively using postural muscles, as in swimming (7).
+
+
Thoracic Disc Herniation
+
+ Thoracic disc herniations appear to be less common than lumbar and
+ cervical herniations for a number of reasons. While they peak at the
+ third to fifth decade of life, similar to other herniations, estimates
+ place thoracic disc herniations only between 0.25% to 1% of all disc
+ herniations (10,11). One reason for decreased incidence, it is thought,
+ is the lesser degree of mobility in the thoracic spine due to the
+ presence of the rib cage. The articulation of the rib head with the
+ vertebral body naturally limits the amount of flexion, extension, and
+ sidebending. The majority of thoracic herniations occur below the level
+ of T7. Rib pairs 8-10 maintain a cartilaginous attachment to the
+ sternum, thus allowing more motion than vertebrae at higher levels. Rib
+ pairs 11 and 12 are known as “floating ribs” and do not maintain any
+ attachment to the sternum. This supports the theory that part of the
+ pathophysiology of herniated thoracic discs is directly related to the
+ ability of the segment to maintain a certain degree of flexability (12).
+
+
Lumbar Disc Hernation
+
+ Herniation of the nucleus pulposis of the lumbar disc is present more
+ commonly than the former two types. It is estimated that 95% of
+ herniated lumbar discs occur at the L4-L5 or L5-S1 level (13). Typical
+ presentation includes radicular pain that patients often describe as
+ shooting or stabbing pain that courses down the leg. There may also be
+ paresthesias present in the same distribution pattern. Often, the pain
+ is exacerbated by coughing, sneezing, straining, or standing for long
+ periods of time (14), as this increases the pressure on the disc and
+ therefore on the impinged nerve root. Pain is usually relieved by rest
+ and taking weight off of the prolapsed disc.
+
+
+
Manual/Manipulative Medicine and Cervical Disc Herniation
+
+ Considering the implications of nerve root impingement (including pain,
+ paresthesia, and decreased motor function) secondary to a herniated
+ disc, there is a natural concern regarding the safety of manual
+ manipulation of such an anomalous disc.
+
+
+ With regard to manipulation, a 2006 study was done to evaluate the
+ efficacy and safety of cervical manipulation in patients with spinal
+ cord compression and radiculopathy. The study incorporated a variety of
+ chiropractic techniques, including high-velocity, low-amplitude methods.
+ The conclusions drawn by the authors states, “The finding of cervical
+ spinal cord encroachment on magnetic resonance imaging, in and of
+ itself, should not necessarily be considered an absolute
+ contraindication to manipulation.” (8) The authors are specific in
+ mentioning exclusion criteria such as acute myelopathy or changes
+ indicating myelomalacia and make clear the message that special care and
+ astute clinical judgement need be exercised in cases of cervical
+ radiculopathy and pathologic segments.
+
+
+ A separate study suggests othewise, stating, “Cervical spinal
+ manipulation therapy may worsen preexisting cervical disc herniation or
+ cause disc herniation resulting in radiculopathy, myelopathy, or
+ vertebral artery compression.” (9) This study describes 22 case studies
+ and states in its conclusion a list of absolute contraindications
+ including patients with rheumatoid arthritis, acute fractures and
+ dislocations, os odontoideum, infection of bone, osseous malignancies,
+ or cervical myelopathy. These case studies included reports from
+ patients previously treated by chiropractors as well as osteopathic
+ physicians. The article puts forth the modality of surgical intervention
+ as the best treatment for certain cases of disc herniation and
+ radiculopathy.
+
+
+ With regard to the necessity of surgical intervention, let us consider a
+ 2007 article from the Massachusetts Medical Society (15). The study
+ examines the outcomes of two groups of patients with herniated lumbar
+ discs who were randomly assigned to either a surgical intervention or
+ observation and symptom management. The study was inconclusive
+ statistically due to the high rate of crossover. That is, 40% of
+ patients assigned to the surgical intervention declined surgery because
+ their symptoms improved before any intervention could take place (with
+ observation alone). Conversely, 45% of patients referred to the
+ observation therapy, opted for surgical intervention due to worsening of
+ symptoms (15). Even though the study is scholastically inconclusive and
+ statistically insignificant, it does highlight the need for
+ individualized care.
+
+
+
Conclusion
+
+ As with any topic at the forefront of medicine, especially issues which
+ can be treated via different modalities and by different specialists,
+ there will be controversy, bias, and ever-emerging new evidence to
+ consider. This article demonstrates the basic science behind disc
+ degeneration leading to pathologic herniation. It also shows two sides
+ of a clinical debate to which there is no defined rule for treatment.
+ Patients, therefore, need to be evaluated and treated appropriately on
+ clinical grounds of their individual situation by a physician
+ well-versed in neuromusculoskeletal medicine to determine which specific
+ modality best suits the individual.
+
+
References:
+
+
+ Michael A. Adams, PhD; Peter J. Roughley, PhD What is Intervertebral
+ Disc Degeneration, and What Causes It? Spine. 2006;31(18):2151-2161
+
+
+ Boos N, Weissbach S, Rohrbach H, et al. Classification of age-related
+ changes in lumbar intervertebral discs: 2002 Volvo Award in basic
+ science. Spine 2002;27:2631-44.
+
+
+ Goel VK, Monroe BT, Gilbertson LG, et al. Interlaminar shear stresses
+ and laminae separation in a disc. Finite element analysis of the L3-L4
+ motion segment subjected to axial compressive loads. Spine
+ 1995;20:689-98.
+
+
+ Hilton RC, Ball J. Vertebral rim lesions in the dorsolumbar spine. Ann
+ Rheum Dis 1984;43:302-7
+
+
+ Adams MA, Bogduk N, Burton K, et al. The Biomechanics of Back Pain.
+ Edinburgh, UK: Churchill Livingstone; 2002
+
+
+ Battie MC, Videman T, Gill K, et al. 1991 Volvo Award in clinical
+ sciences. Smoking and lumbar intervertebral disc degeneration: An MRI
+ study of identical twins. Spine 1991;16:1015-21
+
+
+ Malanga, Gerard A MD Cervical Radiculopathy. Spine 2006 accessed via
+ emedicine
+ http://www.emedicine.com/sports/TOPIC21.HTM#section~AuthorsandEditors
+
+
+ Murphy, DR; Hurwitz, EL; Gregory AA. Manipulation in the presence of
+ cervical spinal cord compression: a case series. J Manipulative
+ Physiol Ther. 2006 Mar-Apr;29(3):236-44
+
+ The goal of this article is to provide the clinician with information
+ and knowledge of known biological mechanisms involved in somatic
+ dysfunction.
+
+
The reader will have the ability to describe:
+
+
+ The neural endocrine-immune network and its relationship to somatic
+ dysfunction
+
+
How somatic dysfunction is endocrine-controlled and maintained
+
+ Some of the known mechanisms of how somatic dysfunction is altered
+ biomechanically, biochemically, and bioenergetically
+
+
+
+ The human body is a complex interdependent relationship of structure,
+ function, and mind. The body possesses complex homeostatic mechanisms
+ that maintain equilibrium for self-regulation and self-healing. These
+ homeostatic mechanisms represent an integrated network of messenger
+ molecules produced by cells in neural, endocrine, and immune systems.
+ Their signal coding and messenger molecules communicate through receptor
+ complexes located on cell membranes. The critical role of the nervous
+ system, especially the lymphatic, forebrain, and hypothalamus,
+ influences the output of the endocrine and immune systems.
+
+
Traditionally, the Immune and Nervous Systems
+
+ Traditionally, the immune and nervous systems were considered separate
+ and independent, each with its own cell types, cell functions, and
+ intercellular regulators. Altered function in each system was related to
+ the disease considered specific to that system. We now recognize not
+ only the interdependence and interlocking molecular organization but
+ also their extensive integration with the endocrine system. The
+ conceptual separations between the neural endocrine immune system
+ concerning structure, function, and communication have been discarded.
+ In their stead is a combination of multiple dimensional network
+ contributing to the functional unity of the body.
+
+
+ Today, we recognize this multifactorial nature is a result of the
+ following interactions of genetic, endocrine, nervous, immune, and
+ behavioral-emotional systems. This complex bi-directional interaction
+ occurs within the neural-endocrine-immune network. This network forms
+ the prime defense against disease and is responsible for the resistance
+ of infectious disease as well as cancer. The sensory information from
+ external and internal sources is tightly integrated with cognitive and
+ emotional processes which influence their neural endocrine immune
+ network through the hypothalamic-pituitary-adrenal axis.
+
+
Messengers
+
+ The basis for communication in the neural-endocrine-immune system is the
+ numerous messenger molecules that are released in the extracellular
+ fluid. These signal codes are small peptides, glycoproteins, amines, and
+ steroids. They express their activity through autocrine
+ (self-stimulating), paracrine (stimulates local tissue), synaptic, and
+ hormonal activity.
+
+
The Endocrine System
+
+ The endocrine system is described as using blood-borne messengers
+ operating over long distances by humoral transport. The neural system is
+ described as using chemical transmitters released into the neural
+ synaptic cleft, separating the pre and post-synaptic specialized nerve
+ cells. These common cellular mechanisms are bi-directional in
+ communication. Their similar molecular structure of many of the
+ messengers and the receptors are combined to transcend the traditional
+ borders that separate the neural, endocrine, and immune systems over the
+ years.
+
+
+ Monitoring the concentration of many of these extracellular messengers.
+ The central nervous system, particularly the limbic system and
+ hypothalamus, directly modulates the activity of the autonomic nervous
+ system and the endocrine systems. See The Network. Both of these systems
+ have extensive communication with the immune systems, thereby regulating
+ it under neural modulation as well. This combined action is
+ multi-dimensional and creates a compensatory reserve that enables the
+ body to mount an adaptive response to stressful conditions regardless of
+ their origin whether somatic, visceral, or psychogenic.
+
+
Stimuli-Somatic
+
+ Somatic, visceral, and emotional stimuli act as drivers capable of
+ influencing the activity via the hypothalamus, the spinal cord,
+ pituitary, to the autonomic nervous system, endocrine system, and immune
+ system, causing the general adaptive response. Noxious somatic stimuli
+ initiate protective reflexes providing the central nervous system with
+ warning signs. They influence the release of extracellular messengers
+ from the endocrine immune access system just described.
+
+
+ When activated by noxious stimuli such as rises from somatic
+ dysfunction, small capillary primary afferent fibers called alpha-gam
+ lambda and C-fibers, a-C-fibers or collectively referred to as (B
+ afferent system) from peripheral nociceptor endings, release neural
+ peptides such as substance P into the surrounding tissue thereby
+ initiating neurogenic inflammation.
+
+
+ The B afferent fibers systems represent a small subset of small
+ capillary primary afferent fibers with high threshold for activation
+ that are present in both somatic and visceral tissue. Central processes
+ of these fibers stimulate cells in the dorsal horn of the spinal cord.
+ Within the dorsal horn, the cells responding to the nociceptive input
+ initiate signals carried to the motor nuclei of the ventral horn to
+ alter the tonal muscles innervated by that particular spinal segment and
+ through the anterior lateral tract of the spinal cord which communicates
+ with the brain stem and the hypothalamus.
+
+
+ A significant result of the nociceptive input is increased activity in
+ the hypothalamic-pituitary-adrenal axis culminating in increased output
+ of norepinephrine from the sympathetic nervous system. This reflex can
+ be blocked by selectively eliminating the small capillary primary
+ afferent fibers. Capsaicin reduces the level of substance P in the
+ peripheral nervous system by destroying the small caliber primary
+ afferent fibers. This diminishes the hypothalamic response and reduces
+ the pituitary adrenal and autonomic responses to somatic stressors. The
+ neural-endocrine-immune network is affected by the output of the signals
+ from somatic dysfunction by initiating a compensatory shift in
+ extracellular messengers that then alters the function of the immune
+ system.
+
+
+ Collins and Strauss found that modulation of the sympathetic nervous
+ system plays an integral part in somatic pain and is a principal
+ mechanism of acupuncture’s action. The control of somatic sympathetic
+ vasomotor activity before and after the placement of acupuncture needles
+ resulted in pain relief by reducing sympathetic vasomotor activity.
+
+
+ Nakamura, et al. found that afferent pathways of diskogenic low back
+ pain are transmitted mainly by sympathetic afferent fibers in the L2
+ nerve root and after needle injection, pain dissipated.
+
+
Stimuli-Visceral
+
+ The visceral factors in the cervical, thoracic, abdominal, and pelvic
+ areas, as well as peripheral blood vessels, communicate with the brain
+ stem and spinal cord through an extensive complement of afferent fibers
+ also considered part of the B afferent system. The visceral afferent
+ fibers reach their target organs by coursing in the same nerves as the
+ efferent autonomic fibers. They follow the routes of the vascular
+ system. The visceral sensory fibers, typically small caliber and having
+ little or no myelin, have cell bodies located in the thoraco-lumbar
+ dorsal root ganglia and in ganglia of several cranial nerves. These
+ central processes, neurons, terminate in the superficial and deep
+ regions of the dorsal horn of the spinal cord.
+
+
+ Spinal trigeminal nucleus and solitary nucleus of the vagus. The
+ thoraco-abdominal and pelvic organs have extensive sensory innervations.
+ These afferent fibers travel to the central nervous system with efferent
+ autonomic fibers. These sensory fibers traveling in the parasympathetic
+ nerves such as the vagus carry non-noxious information for reflex
+ control of the organ. Those traveling with the sympathetic nerves such
+ as the greater splanchnic carry noxious information packets.
+
+
+ The neurons of the deeper portions of the dorsal horn receive extensive
+ convergence of information from the small caliber sensory axons arising
+ in both visceral and somatic sources.
+
+
+ A similar convergence of somatic and visceral input is seen in the
+ solitary nucleus of the vagus. Neurons responsive to both visceral and
+ somatic nociceptive stimuli are located in the spinal cord, brain stem,
+ hypothalamus, and thalamus. These dual response neurons provide an
+ explanation for the phenomenon of referred pain between visceral and
+ somatic sources.
+
+
Stimuli-Emotional
+
+ The emotional factors of the human effecting the neural endocrine immune
+ network arise largely from the limbic forebrain system and hypothalamus.
+ The major components of the limbic forebrain include large portions of
+ associated neocortex, which include the prefrontal area, the cingulate
+ cortex, the insular cortex, and the inferior medial aspect of the
+ temporal lobe. Hippocampal formation and the amygdala receive extensive
+ connections from the frontal parietal and cingulate associational areas
+ of the neocortex and in turn project to the hypothalamus from the fornix
+ and striaterminalis, influencing the hypophyseotropic and hypothalamic
+ nuclei.
+
+
+ This limbic forebrain areas exert considerable influence over the
+ pituitary gland as well as the autonomic nervous system affecting growth
+ hormone, ACTH, prolactin, and somatostatin. The limbic system also
+ increases the sympathetic output from the spinal cord. These alterations
+ in the neural-endocrine activity affect the metabolic processes of the
+ body, shifting peripheral tissue to a catabolic form of metabolism,
+ leading to marked changes in the function of the immune system,
+ including stress-induced suppression of immune function. These
+ conditions characterize the general adaptive response in life.
+
+
+ Highly stressful circumstances in life significantly alter the status of
+ the immune system. This can include the death of a loved one, caring for
+ a family member with chronic progressive disease, summer vacation,
+ change in lifestyle, divorce, new job, etc.
+
+
+ The regulation of the neural-endocrine-immune network increases
+ susceptibility to various disease states. Overproduction or
+ underproduction of extracellular messages in response to either external
+ or internal stimuli or as a secondary response to other
+ disease-dysfunctional processes result in dysfunction of many aspects of
+ the network. The aging process also alters the regulation of the network
+ and is associated with various disease-dysfunctional states.
+
+
+ Lundberg showed that psychosocial factors significantly associated with
+ back pain and shoulder problems were related to psychophysiological
+ stress levels, i.e., high psychophysiological stress levels and low work
+ satisfaction.
+
+
+ He also found that mental and physical stress was found to increase
+ physiological stress levels and muscular tension and that mental stress
+ is of importance for the development of musculoskeletal symptoms and
+ pain. In addition, mental stress is not only induced by high demands but
+ also by demands that are too low which happens in many repetitive and
+ monotonous work situations. Interestingly enough, women are more prone
+ than men to have somatic complaints with repetition and monotonous work.
+
+ T-Cells: Lymphoid cells that mature in the thymus & express the T-cell
+ receptor (TCR)
+
+
+ Helper T-Cells: Lymphoid cells responding to cell surface antigens by
+ secreting cytokines
+
+
+ Cytotoxic T-Cells: Lymphoid cells responding to the cell surface
+ antigens by lysing cell producing the antigen
+
+
+ B-Cells: Lymphoid cells that, when activated, are capable of producing
+ immunoglobulins
+
+
+ Natural Killer Cells: Lymphoid cells capable of killing tumor cells
+ and virus/infected cells
+
+
+ Neutrophils: Major Lymphoid cell of the acute inflammatory response
+ and effector cells of humoral immunity
+
+
+ Basophils: Effector cells of IgE-mediated immunity that secrete
+ histamine granules in response to IgE activation
+
+
+ Eosinophils: Lymphoid cells containing lysosomal granules that can
+ destroy parasites
+
+
+
NON-LYMPHOID CELL TYPES
+
+
+ Fibroblast: Connective tissue cell capable of secreting and
+ maintaining the collagenous fiber matrix
+
+
+ Endothelial Cell: Squamous cell lining of the inner aspect of the
+ vascular system
+
+
+ Mesangial Cells: Specialized mesenchymal cells found in the renal
+ glomerulus
+
+
+ Chromaffin Cell: Neural peptides secreting cell found in the adrenal
+ medulla
+
+
+ Enterochromaffin Cell: Neural peptides secreting cell found in the
+ lining of the gastrointestinal system
+
+
+ Hepatocyte Liver Cell: Liver cell capable of secreting the acute phase
+ proteins
+
+
+ Endometrial Cell: Epithelial cell lining the inner surface of the
+ uterus
+
+
+ Astrocyte: Neuroglial cell found in the central nervous system
+ involved in forming the blood-brain barrier
+
+
+ Oligodendrocyte: Neuroglial cell forming myelin sheath around axons in
+ the central nervous system
+
+
+ Osteoblast: Specialized mesenchymal cells capable of secreting the
+ osteomatrix for the formation of bones
+
+
+ Osteophyte: Connective tissue cell found in bone representing a mature
+ form of osteoblast
+
+
+ Reticular Cell: Endodermal cell creating a three-dimensional network
+ for lymphocytes in the thymus, spleen, and lymph nodes
+
+
+
IMMUNOREGULATORS
+
+
Interleukins 1-7
+
Interferons alpha, beta, and gamma
+
Tumor necrosis factor, beta
+
Colony-stimulating factors:
+
+
Granulocyte-stimulating factor
+
Macrophage-stimulating factor
+
Granulocyte macrophage-stimulating factor
+
Interleukin III
+
Leukemia inhibiting factor or neuroleukin
+
+
Transforming factor, beta
+
+
+ ENDOCRINE SUBSTANCES KNOWN TO INTERACT WITH THE NEURAL AND IMMUNE
+ SYSTEMS
+
+
+
Pituitary
+
+
Adrenal Corticotrophin-ACTH
+
Thyrotrophin-TSH
+
Growth hormone releasing factor-GRH
+
Somatostatin-SS-SS
+
Prolactin
+
+
Adrenal Medullary Hormones
+
+
Epinephrine
+
Norepinephrine
+
+
Adrenal Cortical Hormones
+
+
Cortisol
+
Corticosterone
+
Aldosterone
+
+
Thyroid Hormones
+
+
Thyroxine
+
Triiodothyronine
+
+
Growth Hormones
+
+
Somatotropin
+
Somatomammotropin
+
Somatomedin
+
+
Thymus
+
+
Thymulin
+
Thymosin
+
Thymopoietin
+
Thalmic factor X
+
+
Others
+
+
Estrogen
+
Testosterone
+
Insulin
+
+
+
References
+
+
+ Beal, Myron, D.O., FAAO, 1995-96 Yearbook, Osteopathic Vision,
+ American Academy of Osteopathy, 1996.
+
+
+ A.A. Buerger, Ph.D., Philip E. Greenman, D.O., Empirical Approaches to
+ the Validation of Spinal Manipulation, 1985, published by Charles C.
+ Thomas.
+
+
+ D. Thomas Collins, S. Strauss, “Somatic Sympathetic Vasomotor Changes
+ Documented by Medical Thermographic Imaging During Acupuncture
+ Analgesia“, Clinical Rheumatology, 1992, 55-59.
+
+
+ Richard G. Gillette, Ronald C. Kramis, William J. Roberts, ”
+ Sympathetic activation of cat spinal neurons responsive to noxious
+ stimulation of deep tissues in the low back“, Pain , 1994, 56, 31-42.
+
+
+ Ulf Lundberg, ” Methods and application of stress research“,
+ Technology and Health Care, 1995, 3-9.
+
+
+ Shin-Ichiro Nakamura, Kazuhisa Takahasi, Yuzuru Takahashi, Masatsune
+ Yamagata, Hideshige Moriya, ” The Afferent Pathways of Discogenic Low
+ Back Pain“, Bone and Joint Surgery, 1996, July; 78/B, 606-612.
+
+
+ Robert C. Ward, Foundations for Osteopathic Medicine, American
+ Osteopathic Association, 1997; Williams & Wilkins
+
Reprinted with permission of the American Osteopathic Association.
+
+
+ Pain has been defined in many ways, as the sensation “resulting from the
+ stimulation of specialized nerve endings,”‘ or, more poetically, as a
+ punishment or penalty, as for crime. Other definitions include acute
+ discomfort of body or mind, bodily or mental suffering or distress; a
+ distressing sensation, as in a particular part of the body, and trouble
+ experienced in doing something. (2) One’s concept of pain may be colored
+ by diverse circumstances or, in scientific language, feedback. Head pain
+ is usually interpreted by the clinician from the therapeutic point of
+ view, that is, in terms of measures that may stop in, rather than in
+ pathophysiologic terms.
+
+
+
+ When analyzing head pain, the physician often prefers to look at it as a
+ phenomenon or as the result of stimulation of specialized nerve endings.
+ In reality, pain may be an interpretation of bodily or mental distress.
+ Boshes and Arieff (3) stated:
+
+
+
+ Certain aspects of pain are predicated exclusively on a neural
+ substrate. Here the basis is an event or an alteration in the nervous
+ system per se, as contrasted to pain caused by malignant disease,
+ infected tissue, fractures or the like. Various divisions of the nervous
+ system may be implicated and a description of the disability or the
+ manner of posture and movement is often sufficient to enable the trained
+ observer to gain an impression as to whether the pain is genuine or
+ functional. Such involvement may be at the receptive, the conductive,
+ the perceptive or the apperceptive level, or combinations thereof.
+
+
+
+ This would appear to be a generally accepted concept, and yet head pain
+ often is described and interpreted on the basis of a symptom complex
+ rather than in terms of the anatomic and physiologic organization of the
+ central nervous system. It is the purpose of this paper to attempt to
+ describe some of the mechanisms involved in head pain and to provide
+ these mechanisms with an osteopathic orientation.
+
+
+
Neural Pathways
+
+
+ Most of the sensory nerve distribution to the head and face occurs
+ through the trigeminal nerve (Cr V) and fibers of cervical nerves C1,
+ C2, and C3 (Fig. 1.). Smith (4) stated:
+
+
+
+ The trigeminal fibers subserving pain have their neurons in the
+ trigeminal or semilunar ganglion which lies in a cave of the aura mater
+ in the middle cranial fossa just anterior to the apex of the petrous
+ temporal bone. The peripheral branches of the trigeminal nerve, . . .
+ the ophthalmic, maxillary, and mandibular nerves . . . supply a fairly
+ well defined cutaneous area and broadly speaking, the deep structures
+ underlying it. There is little overlap with the adjoining cutaneous
+ fields of the cervical nerves….
+
+
+
+ The glossopharyugeal nerve supplies common sensibility to the posterior
+ third of the tongue, the pharynx, soft palate, tonsils and fauces, the
+ auditory tube, the tympanic cavity and mastoid air cells, and the inner
+ lining of the eardrum. The vagus nerve . . . supplies the general
+ somatic afferent fibers to the posterior portion of the external
+ auditory canal, part of the eardrum, and the skin of the cranial surface
+ of the auricle adjoining the scalp.
+
+
+
+ The pain and temperature fibers of the glossopharyngeal and vagus nerves
+ relay to the nucleus of the descending trigeminal tract.
+
+
+
+ The cutaneous distribution of C I is not consistent. Larsell (5) said:
+
+
+
+ Occasionally it gives a cutaneous branch to the skin of the upper part
+ of the back of the neck and the lower part of the scalp.
+
+
+
+ The second cervical nerve chiefly supplies the area of the head and neck
+ adjoining the trigeminal territory, to which the third cervical nerve
+ contributes fibers. (4)
+
+
+
Kimmel (5) stated:
+
+
+ The nerve fibers supplying the cranial aura mater are derived from the
+ trigeminal nerve, the upper three cervical nerves, and the sympathetic
+ trunk. Nerve branches from the upper three cervical nerves and the
+ superior cervical ganglion supply the aura mater of the posterior
+ cranial fossa. The aural nerves derived from the three divisions of the
+ trigeminal nerve and from the sympathetic plexuses on the internal
+ carotid and middle meningeal arteries supply the remainder of the
+ cranial aura mater.
+
+
+
+ The first division of the trigeminal nerve supplies the aura mater in
+ the anterior cranial fossa, the diaphragm sellae, nearly all of the
+ cerebral falx, the tentorium cerebelli, part of the superior sagittal
+ sinus, the straight sinus, the superior wall of the transverse sinus,
+ and the terminal parts of the cerebral veins entering these sinuses.
+
+
+
+ The maxillary division of the trigeminal nerve supplies the aura mater,
+ covering the anterior part of the middle cranial fossa. Branches of the
+ third, or mandibular, division of the trigeminal nerve supply the aura
+ mater in the posterior and lateral parts of the middle cranial fossa and
+ the aura mater lining most of the calvaria. (6)
+
+
+
+ Perhaps the more important aspect of pain is that it is not a single
+ identifiable entity. It may be represented by vastly complicated and
+ intricate processes or by the mere experiencing of the touch of a sharp
+ object. The integration of actual pain reception and perception
+ represents an area of widely diverse opinion. On the basis of the
+ observation that successive surgical interruptions of peripheral nerves,
+ posterior roots, spinal cord, and thalamus, and ablations of portions of
+ the cerebral hemispheres, may all fail to give permanent relief from
+ pain, Gooddy (7) concluded that “any nervous pathways are potential
+ ‘pain pathways.’ ”
+
+
+
+ Pain stimuli (or at least somatesthetic stimuli interpreted as pain)
+ arising from the spinal cord (C1, C2, and C3) pass principally to the
+ cuneate nucleus (homolateral), synapse, cross at this level, and ascend
+ to the ventrolateral nucleus of the thalamus.(8)
+
+
+
Finneson (9) stated:
+
+
+ The function of the thalamus is to pass impulses on to the
+ cerebralcortex, and it is presumed that these impulses are integrated by
+ the association nuclei in the thalamus before being relayed. The portion
+ of the thalamus that projects impulses to a specific cortical area
+ receives in return corticothalamic projection fibers from that area,
+ forming a circuit between thalamus and cortex.
+
+
+
+ Smith (4) said that pain fibers of the great auricular nerve synapse in
+ the substantia gelatinosa Rolandi, from which second order neurons
+ ascend in the lateral spinothalamic tract to the posteroventral nucleus
+ of the thalamus. He added:
+
+
+
+ Pain fibers from the trigeminal nerve have their cell bodies in the
+ semilunar ganglion…. Their central processes descend, as the spinal
+ tract of the trigeminal nerve, in the lateral brain stem from the upper
+ pons to the C-2 level of the cord or even somewhat lower, to terminate
+ in the associated spinal trigeminal nucleus which lies adjacent and deep
+ to the tract. The spinal tract and the spinal nucleus correspond to and
+ are continuous with the dorsolateral fasciculus of the cord and the
+ substantia gelatinosa respectively.
+
+
+
+ Pain afferents from the face, arriving via the trigeminal,
+ glossopharyngeal, and vagal routes, relay to the portion of the spinal
+ nucleus lying below the inferior limit of the fourth ventricle….
+
+
+
+ Second order neurons from the spinal trigeminal nucleus cross the
+ midline . . . at the ventral secondary tract to ascend on the medial
+ aspect of the lateral spinothalamic tract to gain the thalamus. There is
+ doubt as to the thalamic termination of these fibers. The classic view
+ is that the trigeminal lemniscus (combining the ventral and dorsal
+ secondary trigeminal tracts) projects to the medial portion (arcuate
+ nucleus) of the posteroventral nucleus of the thalamus…. From the
+ posteroventral nucleus of the thalamus, third order neurons pass in the
+ sensory radiation via the posterior limb of the internal capsule to the
+ somatic sensory area of the cortex in the lowest portion of the
+ postcentral areas (Brodmann’s areas 3. 1. 2) just above the fissure of
+ Sylvius. There is evidence of the face being represented bilaterally in
+ the thalamus and cortex…. It is likely that the thalamus is responsible
+ for the recognition of pain but that the perception of pain as a mental
+ event requires cortical participation-probably diffuse and generalized
+ cortical participation….
+
+
+
+ There is also evidence that pain pathways from both cord and medulla
+ relay bilaterally in the reticular formation of the brain stem and
+ ascend by slow, multisynaptic routes to the medial thalamic nuclei and
+ become part of the diffuse thalamic system. The latter system, which is
+ thought to control the general level and direction of attention. May
+ also be responsible for the affective coloring of pain.
+
+
+
Vascular Elements
+
+
+ The sensitiveness of the vascular elements has been discussed by Wolff
+ (11). His investigation showed consistent sensitiveness to compression,
+ stretching, and faradic stimulation in the arterial system. The great
+ venous sinuses were less sensitive than the arteries to these stimuli,
+ and the lesser sinuses and veins lost sensitiveness in proportion to
+ their distance from the greater sinuses.
+
+
+
Crosby and associates (11) stated:
+
+
+ The blood vessels of the head receive their preganglionic sympathetic
+ innervation from T-1 to T-2, but C-8 and T-3 and even T-4 may also
+ contribute. The axons pass out into the sympathetic chain and ascend to
+ synapse in the stellate and the superior cervical sympathetic ganglia.
+ The postganglionic fibers distribute from the superior cervical
+ sympathetic ganglion with the external and internal carotid arteries to
+ the head. The intracranial postganglionics follow along the internal
+ carotid artery to the circle of Willis and along branches of the
+ external carotid and distribute to the adventitia and the smooth muscle
+ of intracranial vessels, including arterioles of the pie mater, but not
+ to the blood vessels in the brain substance. Postganglionic fibers also
+ distribute to the middle meningeal artery. The plexuses along the common
+ carotid and the internal carotid are not continuous with those on the
+ external carotid, so that stripping the plexuses from the common and
+ internal carotids will not destroy the sympathetic supply to the blood
+ vessels of the face and the head. Postganglionic fibers from the
+ stellate ganglion ascend along the vertebral arteries and the basilar
+ artery….
+
+
+
+ A parasympathetic innervation to some of the blood vessels of the head
+ likewise has been demonstrated. Preganglionic parasympathetic fibers of
+ the facial nerve turn off in the region of the geniculate ganglion to
+ run in the great superficial petrosal nerve to the plexus on the
+ internal carotid artery. Postganglionic fibers from small clusters of
+ ganglion cells on the blood vessels distribute as vasodilators of the
+ vessels.
+
+
+
+ The vascular tone (sympathetic-parasympathetic influence) appears to be
+ mediated through the forebrain with connections in the hypothalamic
+ nuclei. Crosby and associates (11) wrote:
+
+
+
+ The pathways by which these impulses are discharged to hypothalamic and
+ midbrain segmental areas . . . constitute the various
+ cortico-hypo-thalamic . . . systems and the cortico-thalamo-hypothalamic
+ tracts by way of the dorsomedial thalarnic nucleus.
+
+
+
+ It seems probable, as others have suggested, that the cortical paths are
+ regulatory over the hypothalamic systems…. The pathways in general
+ provide for emotional accompaniments to cortically initiated motor
+ responses carried over pyramidal and extrapyramidal systems. . . .
+ Evidence has been forthcoming that pyramidal as well as extrapyramidal
+ systems carry corticofugal fibers for autonomic centers of the spinal
+ cord.
+
+
+
+ Before proceeding to a discussion of the types of stimuli that may be
+ interpreted as pain, the character of nerve endings present in the
+ meninges and associated structures of the head and neck should be
+ considered in order to clarify the types of stimuli that may give rise
+ to pain. Crosby and associates (11) wrote:
+
+
+
+ The sensory terminations in the aura have been studied by various
+ observers…. The nerve endings at the base of the skull are less numerous
+ than on the convexity. They are in the form of end-branches knob- or
+ club-shaped terminations, or are like balls of twine.
+
+
+
+ They reported that Meissner corpuscles are associated with the finest
+ tactile sensation. The Golgi-Mazzoni receptor is said to be a pressure
+ receptor, of similar function to the Pacini corpuscle. The Krause
+ corpuscle has been associated with discrimination of low temperatures.
+ It has been suggested (11) that it may function to distinguish cool
+ rather than cold. Ruffini end organs appear to serve in more than one
+ type of receptor. The larger Ruffini endings serve as pressure endings,
+ while smaller endings of this type are present in the subcutaneous
+ connective tissue and are regarded as receptors of warmth. (11) Golgi,
+ Meissner, and Pacini corpuscles have been described as receptors of
+ discrimination in joint motion. They are credited with reporting motion
+ characteristics in regard to rate of position change, direction of
+ motion, and force required to produce position change. (12)
+
+
+
Characteristics
+
+
+ Now that the involved circuitry has been described, pain itself may be
+ considered. Pain may result directly from factors originating outside
+ the body (a sharp object or excessive heat), from pathophysiologic
+ changes within the body (sustained muscle tension or a tumor) or from
+ abnormally mediated psychologic factor~ through autonomic response. Pain
+ may result from mechanical or psychologic stimulation or a combination
+ of these. It may be described, then, as a response to stimuli that
+ threaten tissue integrity or organizational integrity of the body unit.
+
+
+
+ Various authors have classified pain according to the particular portion
+ of the nervous system immediate!! Responsible for the transmission of
+ the stimulus to the central nervous system. As Boshes and Arieff (3)
+ said pain may be classified as being at the receptive, the conductive,
+ the perceptive, or the apperceptive level, at a combination of these.
+
+
+
+ Pain must be discerned as a local, projected, or referred phenomenon.
+ Localized pain is restricted to the immediate area of reception, as in
+ pain in a toot from an apical abscess. Projected pain in the head may be
+ exemplified by trigeminal neuralgia, which Magoun (13) stated is . . .
+
+
+
+ apparently due to restriction in the aural investiture of the root as
+ passes over the petrous ridge, in Meckel’s cave housing the ganglia or
+ in the sleeves around the three branches as they exist from the skull.
+
+
+
+ ain is projected at times over the entire hemiface served by the nerve.
+ Referred pain may be exemplified by reference to the face of thrombosis
+ of the posterior inferior cerebellar artery. (4)
+
+
+
+ Although these classifications of pain overlap to some degree, the use
+ of a combination of classification helps to explain various phenomena of
+ pain production. The Patient waiting for the attention of the dentist or
+ surgeon may suppress pain mentally and say, “It doesn’t hurt as it did
+ yesterday,” until the approach of the time for local anesthetic
+ preparation. Then a touch by any object may produce a unique response in
+ the area of attention. The apperceptive mechanisms, mediated through the
+ nuclei of the thalamus and modified through the cortifugal control
+ systems of the cerebellum, (14-17) plus the pituitary-adrenal
+ hyperfunction due to fear, cause pain uniquely individualized by the
+ patient’s level of apprehension. The cortifugal controls exerted through
+ the cerebellum modify the intensity of activity occurring both on a
+ motor level and through the thalamic nuclei. It appears that damage to
+ or suppression of the control system may be responsible for the
+ rigidity, hyperactivity, dysmetria, ataxia, and epileptiform activity
+ exhibited by patients with brain damage or trauma.(15)
+
+
+
+ Sutherland (18) described his observations and conclusions in reference
+ to stress mechanisms involving the aura mater and cranial sutures. The
+ observations of the various types of nerve endings in the leptomeninges
+ make the information supplied by stress on the aura mater and pie mater
+ available to the centers of perception, apperception, and motor
+ activity. It has been demonstrated (19) that the recurrent meningeal
+ nerves in the spinal area (especially the branches that enter through
+ the foremen magnum along with the internal carotid artery) are derived
+ from the sympathetic trunk and supply the aura mater lining the
+ posterior cranial fossa. This distribution makes available to this area
+ information from the outer layers of the cranial aura mater, which forms
+ the periosteum of the cranium, and the inner layer, which forms the
+ investing aura of the brain (the tentorium cerebelli, falx cerebri, and
+ falx cerebelli), and from the spinal cord meninges and supporting
+ ligaments.
+
+
+
+ Ray and Wolff (20) in 1940 studied the probable causes of headache or
+ head pain in relation to the aura mater from observations made on 30
+ patients during surgical procedures on the head; they concluded that the
+ pains result primarily from inflammation, traction, displacement, and
+ distention of pain-sensitive structures, of which cranial vascular
+ structures are most frequent and widely distributed. Unfortunately, they
+ failed to mention until Wolff’s later work (10) that the actual pain
+ sensitive nerve endings are located in the aura mater, the arachnoid,
+ and the pie mater supporting the vascular structures. These factors cast
+ new light on the observations of Sutherland, especially since the aura
+ mater on the internal surface of the cranium is continuous with the
+ periosteum of the head.
+
+
+
+ No studies have been published to support the possibility of a strain
+ gauge type of reporting across the sutures, but the observation of the
+ sensory distribution to the internal and external surfaces of the
+ cranial vault would appear to make such an arrangement feasible. (4, 6)
+
+
+
+ The information available indicates that essentially the same types of
+ stimuli elicit painful reactions whether they arise inside or outside
+ the cranium. Psychologic modification, through mechanisms mentioned, is
+ most likely to affect those areas of reception most easily observed
+ through the special senses, such as sight and hearing.
+
+
+
+ Since involvement of the special senses introduces the possibility of
+ modification of afferent stimuli by the limbic system, Aird (21) stated:
+
+
+
+ Neurophysiologic evidence has suggested that this portion of the nervous
+ system is concerned with smell, taste, and other special senses, the
+ gastrointestinal system and other autonomic functions, and behavioral
+ reactions.
+
+
+
+ This brings pain into the area of psychoneurophysiologic processes of
+ reception, conduction, and perception to the stage of apperception or
+ total integration of the process of interpreting pain, and a possible
+ introduction of the subject of pain threshold (which is beyond the scope
+ of this paper).
+
+
+
+ It should be mentioned that there are definite interrelations between
+ the cortifugal system, mentioned earlier, and the limbic system, which
+ as yet are not clearly defined.
+
+
+
Osteopathic Approach
+
+
+ The foregoing discussion has described the circuitry necessary for the
+ identification and response to head pain. Feedback mechanisms necessary
+ to establish a cybernetic model have been outlined. On the basis of this
+ description it should not be difficult for the knowledgeable physician
+ to apply therapeutic measures. The knowledgeable osteopathic physician
+ possesses the palpatory skills to intervene directly in the
+ pathophysiologic process. Pain in the head, through the mechanism
+ described, produces palpable reflex area or tissue response, in the
+ superficial tissues such as the skin, the muscle, and deep connective
+ tissues. By discriminatory palpation he can determine the relative
+ duration or stage of chronicity of the condition and apply therapy.
+
+
+
+ Hoover (22-25) has written extensively and descriptively in regard to
+ application of technique to the various ages or stages of the process
+ involved in stress. He described a functional technique as opposed to
+ structural technique. By this technique the physician may affect the
+ established cybernetic system by entering the system as an aid in
+ diminishing the stress system established. In this mode of treatment
+ enough force is exerted, through the various planes of motion of
+ accommodation of the tissue or articulation, to bring the structures
+ involved to a point of what Hoover called “dynamic reciprocal balance.”
+ (25) In this way the physician establishes a servocybernetic system
+ which allows the tissue or articulation to establish a new state of
+ equilibrium within the limits of its ability to accommodate
+ physiologically. Hoover (24) stated:
+
+
+
+ Treatment by functional technic depends upon and is directed by the
+ reaction of a part of the patient to demands for activity made upon that
+ part.
+
+
+
+ By the recruitment of the demonstrable changes in tissue and its
+ activity, it is possible for the palpating hand to discern the
+ cybernetic mechanisms involved in the origin of head pain.
+
+
+
Harvey (25) stated:
+
+
+ A basic cybernetic mechanism is “feedback.” This is the process of
+ transferring energy or information from the output of a circuit to its
+ input and is a generally accepted control mechanism in all types of
+ self-regulating systems that use closed-loop, negative feedback
+ networks.
+
+
+
+ I have not found active and passive joint motion palpation to be
+ sufficiently discriminating in the analysis of such cybernetic
+ mechanisms to allow me to enter into a servocybernetic relation with the
+ patient on a therapeutic level. After observation of several highly
+ skilled osteopathic physicians in their approaches to palpation and
+ treatment of a wide variety of pathophysiologic processes and syndromes,
+ a method of diagnostic palpation became apparent. As the newly found
+ method was used, its applications and uses began to reveal themselves,
+ and this continues. Articles (27, 28) have been published by two of the
+ highly skilled physicians whose work has been observed. The use of the
+ principles presented by these physicians allows one to determine the
+ area or areas of stress and the character of the assault involved and to
+ counteract their deleterious effects.
+
+
+
+ The previous discussion of mechanisms in the central nervous system
+ covered what is presently known of the circuitry involved in feedback
+ mechanisms of the human body in relation to head pain. After the
+ physician has determined the areas of stress and the character of the
+ assault, he bases his treatment on the counterbalancing of the stress
+ forces, that is, changing the characteristics of the input and feedback,
+ so as to create a servocybernetic system. Establishing controlled input
+ alters the level of control influence exerted by the negative feedback
+ network.
+
+
+
+ The completion of treatment for any particular time is signaled by
+ improved physiologic reaction of the tissues involved, that is, an
+ increase in activity in hyperactive tissue, and a synchronous motion
+ (internal or external rotation; flexion or extension) with the basal
+ respiratory cycle or primary respiratory mechanism, as defined by
+ Magoun. (13) This allows the patient to establish a new level of
+ homeostasis compatible with his or her ability at any particular time to
+ recover from the original assault.
+
+
+
+ Stress patterns of considerable duration complicated by numerous
+ overlying injuries have responded in a surprising manner to treatment
+ applied in this manner.
+
+
+
Case Report
+
+
+ A 44-year-old white woman was admitted to the hospital with a chief
+ complaint of severe headaches, which occurred in the left occipital area
+ and radiated to the left temporal bone and vertex of the skull. The
+ headaches were associated with nausea and vomiting. Their onset was
+ associated with an automobile accident that had occurred six years
+ before this admission. Following the accident hemianesthesia involving
+ the left arm, leg, and side of the face developed. At that time the
+ patient had been hospitalized for 22 days. Her condition improved with
+ bed rest, but she had not been freed of pain, and paresthesia of the
+ left arm, leg, and side of the face remained. She was unable to turn
+ from a supine position to a left lateral recumbent position. It was not
+ clear whether this was due to weakness, loss of proprioception, or loss
+ of motor control. The patient had spent a total of 66 days in the
+ hospital over the next two years for paresthesia of the left side of the
+ body and headache (hemicephalgia on the left). The patient said that she
+ had not been unconscious at the time of or after the accident. There was
+ no familial history of neurologic disease or headache.
+
+
+
+ During the six years after the accident the patient had received nearly
+ every know type of therapy for cephalgia and migraine, including
+ administration of narcotics and adrenocorticoids and trigger-point
+ injections.
+
+
+
+ The patient’s surgical history included appendectomy, cesarean section,
+ and total hysterectomy. Neurological examination did not demonstrate any
+ abnormality, and the cellular structure of the cerebrospinal fluid and
+ the chemical contents were not remarkable. The pressure of cerebrospinal
+ fluid was in the middle of the normal range, and the Queckenstedt test
+ did not show abnormality. Laboratory tests, including complete blood
+ count, measurement of fasting blood sugar an creatinine, urinalysis, and
+ the VDRL test for syphilis at the time of admission and discharge showed
+ no abnormality. X-ray examination at the time of admission showed what
+ appeared to be an articulation between the posterior tubercle of the
+ posterior arch of the atlas an the occiput, and a decrease of the normal
+ lordotic curvature of the cervical spine, that is, a reversal the normal
+ cervical curve.
+
+
+
+ After a week’s hospitalization, I was called in consultation, and my
+ examination elicited the following additional findings: decrease in
+ backward bending the cervical spine, decrease in mobility in all
+ direction through the occipito-atlanto-axial articulation flattening of
+ the cervical lordotic curvature, bilateral compression through the
+ sacroiliac articulation sphenobasilar compression of the cranial
+ mechanic, with vertical strain (spheroid high), side bending rotation,
+ with convexity to the left, and slight torsion on the right. The entire
+ paravertebral mass from occiput to sacrum was under extreme tension.
+
+
+
+ The findings were compatible with the following diagnosis: Spinal
+ ligamentous strain and sprat (spheroid high), left side bending
+ rotation, and right torsion of the cranial mechanism. Treatment was
+ directed at relieving the stress on the meninges an vascular channel
+ throughout the cranial sacral mechanism to reduce edema, muscle tensions
+ and spasm and to reduce the level of afferent CNS input to establish a
+ more physiologic level of function.
+
+
+
+ Both cranial treatment and fascial release technique were directed to
+ the sphenobasilar vertical strain suboccipital area, and sacrum because
+ of the hyperirritability of these tissues and their inability to react.
+ The patient was not treated again for 48 hours because of other demands
+ on the physician’s time. At the second treatment the tissue reaction was
+ much improved, an the patient could withstand deeper treatment to the
+ involved area without excessive pain or tissue reaction After this
+ treatment the patient’s cervical spine was reexamined
+ roentgenologically, and the films showed that the posterior arch of the
+ atlas was no longer in contact with the occiput and that there was
+ improvement in the cervical anteroposterior curvature. The patient’s
+ pain decreased over the next 24 hours, and she was released from the
+ hospital to be seen at my office within 48 hours. The patient was seen
+ twice a week for the next three weeks. At the end of this time the
+ patient had been free of pain for approximately 10 days, end that length
+ of time between treatments was extended to, a week.
+
+
+
+ As the patient’s tissue response improved, the interval between
+ treatments was lenghtened correspondingly, without recurrence of severe
+ headaches until her daughter, who had a congenital cardiac valvular
+ lesion, told her parents she was pregnant. Headaches recurred, but
+ responded well to treatment. They recurred frequently but were
+ terminated on the arrival for a normal healthy granddaughter. At the
+ time of this report the patient still was seen on occasion for
+ maintenance and preventive treatment
+
+
+
Treatment Discussion
+
+
+ The treatment of this patient was carried out according to the
+ principles already described.
+
+
+
+ After routine physical examination a thorough palpatory examination was
+ carried out. Palpation began at the sacral area. With the patient in the
+ supine position, her sacrum was cupped in the examiner’s left hand, with
+ the first finger extending over the right sacroiliac articulation to
+ make contact with the right iliolumbar ligament (lower portion). The
+ little finger was placed at the left sacroiliac articulation and the
+ second and third fingertips placed just lateral to the tip of the
+ spinous process of the fifth lumbar segment of the spine. Light
+ palpation demonstrated relatively little activity of the tissues. When
+ palpation was deepened it demonstrated a rigidity of the ligamentous
+ structures supporting the sacroiliac articulations both anteriorly and
+ posteriorly and extreme tension through the iliolumbar ligaments
+ bilaterally.
+
+
+
+ The examining procedure is as follows: Light palpation is carried out
+ with light contact with skin. The depth of palpation is increased by
+ establishing a fulcrum and gently increasing the tension or pressure
+ distal to the fulcrum so that the palpating hand may remain relaxed and
+ be used as a palpating instrument rather than attempting to constantly
+ monitor its own proprioceptive phenomena. The pressure is gently
+ increased until reaction is stimulated in the layer of tissue the
+ examiner wishes to palpate. The resulting tissue reaction will
+ demonstrate to the examiner the resultant force (the summation of the
+ various forces exerted at the time of injury) that elicited the
+ protective reaction of the tissues under examination.
+
+
+
+ The transition from examination to treatment is a matter of following
+ the resultant force to the point of dynamic reciprocal balance and
+ maintaining this balance until the tissues complete their accommodation.
+ This accommodation is accompanied with increased tissue relaxation, a
+ feeling of increased tissue vitality, and a longitudinal to-and-fro
+ motion corresponding to the primary respiratory cycle.
+
+
+
+ If continued force is applied to the injured tissues after the immediate
+ response, the ensuing fatigue may result in an adverse or excessive
+ reaction of the treated tissues, which appears to create a type of
+ kinesthetic shock (a dissociation of the proprioceptive motor feedback
+ mechanism resulting in a loss of coordinated, previously programmed or
+ learned motion patterns with an increase in sensitiveness and possibly
+ pain in the particular ligaments and connective tissues. This causes
+ gait or motion aberration that is not typical of the individual. This
+ usually occurs in a single member or limb or segment of such member or
+ limb.
+
+
+
+ Each area found to be involved in the total stress mechanism is treated
+ in a similar manner, the only differences being in the method of
+ application of the testing or treating forces to accommodate the
+ peculiarities of anatomic structure, of the region under study and
+ treatment. In the cervical area palpation is performed along the lateral
+ margin of the paravertebral mass that is located over the articular
+ pillar. This permits palpation of the paravertebral mass, the
+ periarticular ligaments, and the reaction of the musculature attached to
+ the anterior aspects of these vertebral segments. In palpation of the
+ cranium, the index finger approximates the lateral aspect of the great
+ wing of the spheroid; the second finger is placed posterior to the
+ sphenosquamal articulation; the third finger is placed at the
+ parietotemporo-occipital articulation (asterion), and the little finger
+ is placed on the occiput.
+
+
+
+ This contact is often altered to suit unusual injury patterns, but in
+ any case the application of treatment follows the same basic principles.
+ The fulcrum is usually established by crossing the thumbs. The flexor
+ pollicis longus muscle of each thumb is utilized to maintain good
+ contact and allow the hands to remain as relaxed as possible. Thus the
+ hands may be free to move within the demonstrated force mechanisms and
+ establish the dynamic reciprocal tension necessary to allow the tissues
+ to overcome injury force mechanisms. The mastering of this type of
+ therapeutic and diagnostic approach is not difficult but requires
+ studious concentration to avoid hindering the activity of the tissues,
+ so that they may reveal the stress patterns to which they have been
+ subjected. The physician must remain relaxed and observant so he may
+ participate in assisting the tissues to reach and maintain the point of
+ dynamic reciprocal tension.
+
+
+
Comments
+
+
+ The studies reviewed here demonstrated the possibility that pain may
+ arise from the neck and possibly lower levels. In many cases the
+ involvement of arthrodial articulations may require more stringent or
+ forceful modes of treatment than those described here. Hoover (22)
+ described the use of high velocity manipulation to accomplish a
+ “popping” of the joint so that the involved levels of discrimination
+ must rearrange their synaptic organization in response to shock produced
+ by the forceful articulatory motion. By this method a new level or at
+ least a different degree of function is established.
+
+
+
+ The little understood mechanisms of the central nervous system are
+ slowly revealing their intricacies through the devoted efforts of many
+ dedicated and curious researchers. These workers can divulge their
+ observations, but it becomes the responsibility of the physician to be
+ aware of their discoveries, analyze the information, and apply it
+ discreetly in clinical situations. The information presented here may
+ give the osteopathic physician a slightly different view and increase
+ the effectiveness of his application of osteopathic manipulative therapy
+ to his patient.
+
+
+
+ The neuroanatomy and physiology involved in head pain have been
+ discussed. Various types of input that may be characterized as pain have
+ been mentioned, and mechanisms involved in the apperception as pain have
+ been demonstrated. An attempt has been made to correlate the wide
+ varieties of osteopathic manipulative approach to the particular
+ situation in which pain is expressed in the head. A case history
+ exemplifying my approach to such problems has been presented and the
+ principles of treatment described.
+
+ 4. Larsell, O.: The nervous system. In Human anatomy. By H. Morris. Ed.
+ 11, edited by J.P. Schaeffer. Blakiston Co., New York, 1953
+
+
+
+ 5. Kimmel, D.L.: The nerves of the cranial aura mater and their
+ significance in aural headache and referred pain. Chicago Med Sch Quart
+ 22:16-26, Fall 61
+
+
+
6. Gooddy, W.: On the nature of pain. Brain 80:11831, 1957
+ 8. Finneson, B.E.: Diagnosis and management of pain syndromes. Ed. 2.
+ W.B. Saunders Co., Philadelphia, 1969
+
+
+
+ 9. Wolff, H.G.: Headache and other headpain. Ed.2. Oxford University
+ Press, New York, 1963
+
+
+
+ 10. Crosby, E.C., Humphrey, T., and Lauer, E.W.: Correlative anatomy of
+ the nervous system. Macmillan Co., New York, 1962
+
+
+
+ 11. Korr, I.M., and Buzzell, K.A.: Personal communication to the author
+
+
+
+ 12. Magoun, H.I.: Osteopathy in the cranial field. Ed.2. Journal
+ Printing Co., Kirksville, Mo., 1966
+
+
+
+ 13. Steriade, M.: The cerebello-thalamo-cortical pathway. Ascending
+ (specific and unspecific) and corticofugal controls. Int J Neurol
+ 7:177-200,1970
+
+
+
+ 14. Gerstenbrand, F., et al.: Cerebellar symptoms as sequelae of
+ traumatic lesions of upper brain stem and cerebellum. Int J Neurol
+ 7:271-82, 1970
+
+
+
+ 15. Snider, R.S., Mitra, J., and Sudilovsky, A.: Cerebellar effects on
+ the cerebrum. A microelectrical analysis of somatosensory cortex. Int J
+ Neurol 7:141-51, 1970
+
+
+
+ 16. Ito, M.: Neurophysiological aspects of the cerebellar motor control
+ system. Int J Neurol 7:162-76, 1970
+
+ The newborn skull is designed to provide maximum accommodation to the
+ forces of labor and minimum trauma to the developing brain. However,
+ injury to the head during birth is more common than many people realize.
+
+
+ In a study of 1,250 newborns I conducted a few years ago, it could be
+ demonstrated that severe visible trauma was inflicted on the head–either
+ before or during labor–in 10 percent of the infants. Membranous
+ articular strains, which could be detected by the physician proficient
+ in the diagnostic techniques of osteopathy in the cranial field, were
+ present in another 78 percent. Thus, nearly nine of every 10 infants in
+ the study had been affected. (1)
+
+
+ How important are these membranous articular strains to the physician? I
+ have found that common problems of the neonatal period–such as
+ difficulty in sucking, vomiting, nervous tension, and irregular
+ respiration–are frequently overcome just as soon as these strains are
+ corrected. Similar strains are encountered in school children who have
+ learning and behavior problems.
+
+
+ In a study of 100 children between the ages of five and 14 who were
+ having learning or behavioral difficulties, it was found that 79 had
+ been born after a long or difficult labor and had one or more of the
+ common symptoms of the neonatal period. Also, it is my impression that
+ many cases of childhood allergy can be traced to musculoskeletal strains
+ originating at the time of birth. (2) And vertebral scoliosis occurring
+ in childhood and adolescence is, in many instances, the consequence of
+ cranial scoliosis originating during birth. (3 ) Thus, recognition and
+ treatment of dysfunction of the craniosacral mechanism in the immediate
+ postnatal period represent one of the most, if not the most, important
+ phases of preventive medicine in the practice of osteopathic medicine.
+
+
+ To gain a clearer understanding of the origin and nature of these
+ membranous articular strains, it will be helpful to review the anatomic
+ features of the newborn skull and to note how they are affected by the
+ forces of labor.
+
+
Labor
+
+ As was mentioned above, the newborn skull is designed to provide maximum
+ accommodation to the forces of labor, minimum trauma to the infant’s
+ brain, and complete restoration to free mobility of all its parts once
+ the stress of labor is over.
+
+
+ Just before birth, the infant in utero is positioned for delivery by
+ presenting the smallest diameter of his head to the largest diameter of
+ the mother’s pelvis; this is the position of full fetal flexion. As
+ contractions continue, the infant is conducted by the inclination of the
+ maternal pelvic floor into the midline for delivery around the pubic
+ symphysis by a process of extension of the head.
+
+
+ This descent in full flexion, progressing to birth by extension of the
+ head, is of profound significance to the initiation of pulmonary
+ respiration. The respiratory activity associated with the vigorous vocal
+ activity of the newborn serves to expand the cranial mechanism and
+ restore the bones and membranes to their anatomic relationships
+ (permitting their free physiologic motion). Healthy sequential
+ development of the central nervous system within can then continue.
+
+
+ These ideal circumstances, however, seldom occur in our modern,
+ civilized world. Owing to such factors as poor nutrition of the mother,
+ structural inadequacies before and during pregnancy, drug abuse,
+ inadequate preparations for labor, and, sometimes, the mechanical or
+ artificial acceleration of labor by an impatient obstetrician, only a
+ relatively few infants are born without undue skein or cranial trauma.
+
+
+ Instead, structural inadequacies of the maternal pelvis may cause the
+ fetus to assume a degree of extension (and lateral cervical flexion)
+ greater than the ideal; the result will be a presentation of a portion
+ of the head greater than the minimum occipitobregmatic diameter. This
+ can range from a moderate extension to posterior occiput, to transverse
+ arrest, to brow presentation, or even to a complete extension in which
+ the face itself presents-a position in which vaginal delivery is
+ impossible. In such a circumstance, cesarean section will be necessary
+ if the baby is to survive.
+
+
+ But the compressive forces will have already traumatized the head as the
+ uterine contractions force it progressively towards the birth canal.
+ Prominence of the base of an anterior maternal sacrum may obstruct
+ descent of the head on one side, and such asynclitism can distort the
+ cranial mechanism. The presence of large twins, both striving to present
+ the head at the same time, may cause cranial stress to one or both even
+ before active labor begins. These are only a few of the mechanical
+ insults that may occur before birth.
+
+
+ So much for the passage of the infant into the birth canal. Now let us
+ consider the structure of the infant skull itself at the time of birth.
+
+
Anatomy
+
+ The vault of the newborn skull is a membranous structure. Plates of bone
+ are enveloped in two layers of membrane, which are in apposition at the
+ anterior and posterior fontanelles and sometimes at the pterion and
+ asterion. These plates of membranous bone are designed to telescope into
+ each other as the skull passes through the birth canal-the parietals
+ overriding the frontal at the coronal suture, and the occiput at the
+ lambdoid suture. The degree of this overriding is controlled and limited
+ by the investing aural membranes.
+
+
+ The bones of the base develop from the cartilaginous chondrocranium. At
+ birth, development is still incomplete.(4) The occipital bone is in four
+ parts, united by intraosseous articular cartilage. The spheroid is in
+ three parts, the temporal in two, the maxilla in two, the frontal
+ frequently in two.
+
+
+ The cranial suture is designed for a very small but vital degree of
+ motion.(5) How much greater is the potential motion of the bones of the
+ developing newborn skull! At this time each part of each of these bones
+ functions virtually as a separate bone, moving in relation to its other
+ parts.
+
+
+ Let us consider the occiput. It is most commonly the presenting part,
+ and therefore the part that may take the brunt of the trauma of labor.
+ The four developmental parts surround the foremen magnum. The base
+ articulates anteriorly with the base of the spheroid. Posterolaterally,
+ it articulates with the lateral masses. The hypoglossal nerve, which
+ innervates the muscles of the tongue, passes out of the skull between
+ the base and the lateral mass, through the intraosseous cartilage in the
+ space that will become the condylar canal. The occipital condyle, which
+ articulates with the atlas, spans the intraosseous cartilage; its
+ anteromedial third is found on the base, the posterolateral two-thirds
+ on the lateral mass.
+
+
+ Immediately anterolateral to this condylar area is the jugular foremen,
+ a space between the condylar part of the occiput and the petrous portion
+ of the temporal. This foremen gives passage not only to the jugular vein
+ but also to cranial nerves IX, X, and XI (glossopharyngeus, vague, and
+ accessorius, respectively). The vagus nerve provides innervation to the
+ gastrointestinal and cardiorespiratory systems.
+
+
+ The supraocciput formed in cartilage fuses with the membranous
+ interparietal bone to form the occipital squama. Compression transmitted
+ through the squama to the condylar part on one side may disturb the
+ function of the vagus and/or hypoglossal nerve, causing vomiting,
+ irregular respiration, and difficulty in sucking. If this compression is
+ transmitted further to the base, the relationship of the base of the
+ occiput to the base of the spheroid may be distorted, causing a lateral
+ strain of the sphenobasilar articulation and a parallelogram deformity
+ of the cranium(5) (Figure 1).
+
+
+ Figure 1. Lateral strain of the sphenobasilar articulation. Viewed from
+ above, the sphenobasilar symphysis has been strained (displaced), with
+ the basisphenoid moving to one side and the basiocciput to the other.
+ Both bones side-bend about parallel vertical axes in the same direction.
+ The lesion is named from the position of the basisphenoid: lateral
+ strain with the spheroid to the right, etc. (From Magoun, H.{" "}
+ Osteopathy in the Cranial Field.)
+
+
+ Bilateral condylar compression may cause a buckling type of strain of
+ the cranial base, producing a vertical strain between the occiput and
+ the spheroid at the sphenobasilar articulation. This may be associated
+ not only with vagal dysfunction but also with symptoms of tension,
+ spasticity, opisthotonic spasms, sleeplessness, and excessive crying due
+ to the irritation of the pyramidal tracts on the anterior and lateral
+ aspects of the brain stem in the foremen magnum. This should be
+ considered as a precursor of the spastic type of cerebral palsy.
+
+
+ The spheroid bone is in three parts at birth; the central body bears the
+ lesser wings, with the greater wings (from which the pterygoid process
+ subtends) on either side. The greater wing-pterygoid unit articulates
+ with the body by an intraosseous cartilage. This is situated immediately
+ beneath the cavernous sinus, through which pass cranial nerves III, IV,
+ and VI, innervating the extraocular muscles, and the ophthalmic division
+ of V, which is sensory to the orbit, upper face and scalp. The body of
+ the spheroid articulates with the base of the occiput posteriorly and is
+ therefore distorted by the lateral or vertical strains resulting from
+ condylar compression. Anteriorly the body carries the lesser wings,
+ which enter into the formation of the orbit. The orbit is approximately
+ pyramidal in shape; the apex is at the optic foremen-that is, the root
+ of the lesser wing at the body. Its anatomic integrity is dependent on
+ the relationship of the greater wing to the lesser wing, which is in
+ fact the relationship of the greater wingpterygoid unit to the body.
+
+
+ In the event of a lateral strain at the base due to unilateral condylar
+ compression of the occiput, the orbit will be distorted by rotation of
+ the base of the spheroid carrying the lesser wing anterior on one side
+ and posterior on the other. In the parallelogram head due to lateral
+ compression, the greater wing is compressed medially and carried forward
+ on one side and posterior on the other. In either event, lateral muscle
+ imbalance of the eyes is commonly found in varying degrees ranging from
+ mild esophoria or exophoria to severe strabismus.
+
+
+ The temporal bone is in two parts at the time of birth -the petromastoid
+ portion, developed in cartilage that projects obliquely between the
+ occiput and the greater wing of the spheroid to articulate at its apex
+ with the body of the spheroid, and the squamous portion, developed in
+ membrane the forms the greater part of the lower lateral wall of the
+ skull. The tympanic portion is not yet a bony canal but resembles a
+ horseshoe adherent to the inferior posterior aspect of the squama. These
+ two parts, the squamous and tympanic, unite just before birth. The
+ petromastoid portion contains the auditory and the vestibular apparatus.
+
+
+ The auditory apparatus consists of the bony eustachian tube emerging
+ between the petrous and squamous portions, from which the cartilaginous
+ tube extends to the fossa of Rosenmuller. The eustachian tube is
+ susceptible to distortion, which may impair hearing if lateral stress
+ compresses the squamous portion. Laterally the eustachian tube opens
+ into the middle ear, which, by the ossicular mechanism, transmits the
+ auditory vibrations received from the tympanic membrane to the internal
+ ear. The vestibular apparatus includes the semicircular canals,
+ precisely related to each other and geometrically balanced with those of
+ the opposite side. Distortion of the axis of the petrous portion may
+ disturb this delicate mechanism of equilibrium.
+
+
+ The maxilla develops in two parts-the premaxilla, which will give origin
+ to the incisor teeth, and the body, which carries the canine and all the
+ other upper teeth. Angulation between these two developmental parts of
+ the maxilla gives rise to malalignment and malocclusion in later years.
+
+
+ Thus far our consideration has been directed to certain structural
+ changes that may sometimes be visible and are always palpable following
+ various difficulties of labor. Radiologic techniques have been developed
+ to substantiate many of these palpatory observations and confirm their
+ persistence in childhood problems.(7)
+
+
Examination
+
+ The craniosacral mechanism of the newborn infant should be examined
+ within the first few days of life. There is probably no field of
+ osteopathic diagnosis where the injuction “if at first you don’t
+ succeed, try, try again” applies more than in the examination of the
+ newborn cranium. The mobility of the cranial mechanism is much greater
+ at this age than it is in the adult skull, although the range of motion
+ is of course much smaller. Dr. R. McFarlane Tilley used to speak of the
+ amplification mechanism within the human hand and brain, which permits
+ the perception of motion in the range of 0.0001 inch. It is this
+ perceptive mechanism that must be developed in order to make a
+ meaningful examination and to complete an adequate treatment program for
+ these infants.
+
+
+ Furthermore, one must learn to palpate motion within motion, for these
+ infants rarely lie absolutely still for an examination. One should first
+ consider the contours and articulations by passing the hands gently over
+ the surface. Look for asymmetry, bossing of the frontals or parietals,
+ grooves above the eyebrows, overlapping of one bone on the other at the
+ coronal or lambdoid suture, prominence and compression of the sagittal
+ or metopic suture, and depression of the pterion. Let the occiput rest
+ in the palm of the hand, and note unusual prominence of the
+ interparietal occiput or hard flattening of the supraocciput. Study the
+ relative size and position of the eyes and nostrils and the inclination
+ of the mouth. Examination for inherent motility will be facilitated if
+ the baby is nursing or sleeping. Here is a check list that may be
+ helpful:
+
+
+ 1. Place the hands gently on the vault, with the index fingers on the
+ greater wing of the spheroid and the little fingers on the lateral
+ angles of the occiput. The other fingers lie comfortably between them.
+ Is your first palpatory impression that your two hands are symmetrical?
+
+
+ 2. Are the index finger and the little finger of one hand cephalad or
+ superior to those of the other, as in a torsion strain. If so, the
+ spheroid and occiput will have rotated around an anteroposterior axis in
+ opposite directions, elevating the greater wing of the spheroid on one
+ side and the lateral angle of the occiput on the other (Figure 2).
+
+
+ Figure 2. Torsion strain. Torsion of the sphenobasilar symphysis occurs
+ about an axis running from the nasion (anterosuperior) to opisthion
+ (posteroinferior) at approximately right angles to the plane of the
+ sphenobasilar symphysis. In bottom view, a left torsion lesion is
+ diagrammed, with the greater wing and basisphenoid high on the left side
+ and the basiocciput and squama lower on that same side. (From Magoun, H.{" "}
+ Osteopathy in the Cranial Field, Second Edition. Kirksville,
+ Mo.: Journal Printing Company, 1966).
+
+
+ 3. Are the index finger and little finger of one hand caudad or inferior
+ to those of the other hand, with a sense of fullness in the palm of the
+ inferior hand, as in a side-bending rotation strain. In this instance,
+ the spheroid and occiput have side-bent in opposite directions around
+ parallel vertical axes and rotated inferiorly into the convexity thus
+ created.
+
+
+ 4. Is there a sensation that the index fingers on the greater wings are
+ directed towards one side, while the little fingers on the occiput are
+ carried to the other side? This is lateral strain (Figure 1). Owing to a
+ lateral force, the spheroid and the occiput have rotated in the same
+ direction around parallel vertical axes, causing a shearing strain at
+ the symphysis between them.
+
+
+ 5. Are the two index fingers on the greater wings forward and downward
+ (caudad) as compared with the little fingers on the lateral angles?
+ Conversely, the index fingers may be superior (cephalad). These are
+ vertical strains (Figure 3 ). Both superior and inferior strains are
+ shown in the diagrams (superior on the left). The spheroid and the
+ occiput have rotated in the same direction around parallel transverse
+ axes, producing a vertical shearing strain at the sphenobasilar
+ articulation.
+
+
+ Figure 3. Vertical strains of the sphenobasilar symphysis. Viewed from
+ the side, the sphenobasilar symphysis has been strained or displaced
+ before ossification, with the basisphenoid moving cephalad (flexion) and
+ the basiocciput moving caudad (extension), or vice versa. Both bones
+ rotate about parallel transverse axes in the same direction. (From
+ Magoun, H. Osteopathy in the Cranial Field Second Edition.
+ Kirksville, Mo.: Journal Printing Company, 1966.
+
+
+ 6. Is there a sense of hardness and tension under your hands, resembling
+ wood? This suggests a compression strain.
+
+
+ These palpatory observations of asymmetry are clues to the dysfunction
+ of this mechanism: But it is the nature of the inherent cranial rhythmic
+ impulse-its symmetry, rate, amplitude, and constancy of pattern- that is
+ important. If the inherent motion is distorted, impeded, limited, or
+ retarded, there are certainly membranous strains that need attention.
+
+
+ It is not possible to develop the necessary tactile skills in a few days
+ or during a brief course of instruction. But with assiduous application,
+ the sensitivity will be developed, and you will be able to make these
+ vital diagnoses at the age when they are most susceptible to correction.
+
+
+ 7. With your index finger on the greater wing of the spheroid and your
+ little finger on the lateral angle of the occiput, be still and permit
+ the mechanism to convey its movement through your fingers and hands. Is
+ there rhythmic, symmetric expansion and contraction of{" "}
+ external and internal rotation of the bilateral vault
+ bones that accommodates the flexion and extension of
+ the spheroid and occiput? (This is transmitted to the index fingers as a
+ rhythmic downward and forward and then upward and backward cyclic
+ motion, while the little fingers also move downward and backward, then
+ upward and forward. ) Is the direction of motion that of the torsion,
+ side-bending rotation, vertical or lateral strains?
+
+
+ 8. Cradle the occiput in the hands, and place the tip of the index
+ fingers on the mastoid process of the temporal bone bilaterally. (While
+ there is no bony mastoid process at birth, the attachment of the
+ sternomastoid muscle provides the palpatory landmark.) Is the sensation
+ that of symmetry, or does one fingertip seem posteromedial to the other?
+ If the tip of the mastoid is posteromedial (i.e., less prominent) the
+ temporal bone is externally rotated. If it is anterolateral (more
+ prominent), the temporal bone is internally rotated. This asymmetry of
+ the mastoid process is indicative of the position of the occiput, with
+ the internally rotated temporal bone or the prominent mastoid process
+ being associated with the elevated lateral angle of the occiput. Is one
+ temporal bone more anterior than the other without the medial or lateral
+ motion? This suggests a lateral strain of the sphenobasilar articulation
+ that has carried the head into a parallelogram distortion. Again, be
+ still, and observe the relative mobility of the two temporal bones.
+
+
+ 9. Steadying the head with the two fingers gently on the frontal bone,
+ slip the other hand down and around the curve of the prominence of the
+ occiput. Two fingers are usually adequate. Note the tension of the
+ suboccipital muscles, and compare the two sides of the midline. Does one
+ of the two palpating fingers come in contact with the arch of the atlas
+ before the other? If it does, this is probably the side of condylar
+ compression, for the occiput will have rotated anteriorly on this side.
+ Be still, and observe the motility. Impaired motion on one side or both
+ will suggest, respectively, unilateral or bilateral condylar
+ compression.
+
+
+ 10. By now the baby may have finished nursing and may even be asleep.
+ Now change your position, and sit at the infant’s right side, at the
+ level of his lower limbs. Steady the pelvis with the left hand while
+ placing two fingers of the right hand under the sacrum. Are the two
+ sides of the body symmetrical? Does the sacrum project into the hand at
+ the coccyx? Be still; observe the motion of the sacrum in relation to
+ the ilia. Is the motion symmetrical, around a transverse axis? Or do you
+ find a rotating motion superiorly on one side, around an anteroposterior
+ axis?
+
+
+ 11. Place the hands under the lumbar spine, and note the presence of
+ lateral flexion producing a concavity to one side. Relate this to
+ lateral motion of the pelvis.
+
+
+ The treatment of the craniosacral mechanism cannot be learned solely
+ from the written word. The palpatory skills must be developed and
+ evaluated with supervised experience. But the treatment, in summary,
+ consists of finding the point of balanced membranous tension of the
+ mechanism, holding it, and permitting the inherent therapeutic force
+ within to normalize the body.
+
+
+ “The osteopath reasons that order and health are inseparable,” said Dr.
+ Andrew Taylor Still, “and that when order in all parts is found, disease
+ cannot prevail.” And as Dr. W. G. Sutherland reminded his students, as
+ the twig is bent, so the tree is inclined.
+
+
+ Give attention to those little bent twigs, so that they may grow into
+ handsome, healthy, happy generations for the future.
+
+
References
+
+ 1. Frymann, V. M. Relation of disturbances of craniosacral mechanism to
+ symptomatology of the newborn: Study of 1,250 infants.{" "}
+ J.A.O.A. 65 (1966), 1059-1075.
+
+
+ 2. Frymann, V. M. The osteopathic approach to the allergic patient.{" "}
+ D.O. 10:7 (1970), 159-164.
+
+
+ 3. Cathie, A. Growth and nutrition of the body with special reference to
+ the head. Yearbook of the Academy of Applied Osteopathy,
+ 1962,pp.149-153.
+
+
+ 4. Crelin, E. S. Anatomy of the Newborn: An Atlas.
+ Philadelphia: Lea & Febiger, 1969.
+
+
+ 5. Pritchard, J. J., Scott, J. H., and Girgis, F. G. The structure and
+ development of cranial and facial sutures. J. Anat. 90
+ (1956), 73-86.
+
+
+ 6. Magoun, H. I. Osteopathy in the Cranial Field, Second
+ Edition. Kirksville, Mo.: Journal Printing Company, 1966, p. 133.
+
+
+ 7. Greenman, P. E. Roentgen findings in the craniosacral mechanism.{" "}
+ J.A. O.A. 70 (1970), 60-71.
+
+
+ 8. Still., A. T. Philosophy of Osteopathy. Ann Arbor, Mich.:
+ Edwards Brothers 1899
+