Cranial Rhythmic Impulse (CRI)

Question 1

ECOP definition of OCMM

Answer 1

• System of diagnosis and treatment by an osteopathic physician using the primary respiratory mechanism (PRM) and balanced membranous tension
• first described by William Garner Sutherland, DO.

Question 2

Mechanisms of OCMM technique:

The interdependent functions among five body components as follows….

1. The _____ _____ of the brain and spinal cord

Answer 2

Mechanisms of OCMM technique:

The interdependent functions among five body components as follows:

1. The inherent motility of the brain and spinal cord

Question 3

Mechanisms of OCMM technique:

The interdependent functions among five body components as follows….

2. _____ of the cerebrospinal fluid

Answer 3

Mechanisms of OCMM technique:

The interdependent functions among five body components as follows:

2. Fluctuation of the cerebrospinal fluid

Question 4

Mechanisms of OCMM technique:

The interdependent functions among five body components as follows….

3. _____ of the intracranial and intra-spinal membrane

Answer 4

Mechanisms of OCMM technique:

The interdependent functions among five body components as follows:

3. Mobility of the intracranial and intra-spinal membrane

Question 5

Mechanisms of OCMM technique:

The interdependent functions among five body components as follows….

4. _____ _____ of the cranial bones

Answer 5

Mechanisms of OCMM technique:

The interdependent functions among five body components as follows:

4. Articular mobility of the cranial bones

Question 6

Mechanisms of OCMM technique:

The interdependent functions among five body components as follows….

5. The _____ _____ of the sacrum between the ilia (pelvic bones)

Answer 6

Mechanisms of OCMM technique:

The interdependent functions among five body components as follows:

5. The involuntary mobility of the sacrum between the ilia (pelvic bones)

Question 7

Primary Respiratory Mechanism

(CNS + CSF + Dural Membranes + Cranial Bones + Sacrum)

Primary because ?

Answer 7

Primary because its directly related to the internal tissue respiration of the CNS

Question 8

Primary Respiratory Mechanism

(CNS + CSF + Dural Membranes + Cranial Bones + Sacrum)

Respiratory because ?

Answer 8

Respiratory because it involves the exchange of fluids necessary for normal metabolism & biochemistry in all cells of the body

Question 9

Primary Respiratory Mechanism

(CNS + CSF + Dural Membranes + Cranial Bones + Sacrum)

Mechanism because ?

Answer 9

Mechanism because all parts work together as a unit

Question 10

Cranial rhythmic impulse (CRI)

CRI is?

Answer 10

CRI is the fluctuation of motion felt on the cranial bones

Question 11

Cranial rhythmic impulse (CRI)

Indications

Answer 11

• Headaches secondary to non-life-threatening biomechanical somatic dysfunction
• Mild to severe whiplash strain and sprain injuries
• Vertigo
• Tinnitus
• Otitis media with effusion and serous otitis media
• TMJ dysfunction
• Sinusitis

Question 12

Cranial rhythmic impulse (CRI)

Relative Contraindications

Answer 12

• Coagulopathies
• Space-occupying lesion in the cranium

Question 13

Cranial rhythmic impulse (CRI)

Absolute Contraindications

Answer 13

• Acute intracranial bleeding and hemorrhage
• Increased intracranial pressure
• Acute skull fracture
• Certain seizure states

Question 14

Classic Cranial Vault Hold

Purpose ?

*** dont forget to HIP FLOP ***

Answer 14

• To address the strains at the SBS
• Can use a direct or indirect method of treatment
  
  • Most common: indirect method
    
    • use to balance membranous tension

Question 15

Classic Cranial Vault Hold

Finger placement ?

*** dont forget to HIP FLOP ***

Answer 15

• Thumbs should not touch the skull
• Index: greater wing of the sphenoid
• Middle: temporal bone in front of the ear
• Ring: mastoid region of temporal bone
• Pinky: squamous portion of the occiput (medial to OCM suture)

Question 16

Classic Cranial Vault Hold

Why hip flop ?

*** dont forget to HIP FLOP ***

Answer 16

Involuntary Mobility of the Sacrum between the Ilia

• Cranial dura is continuous with the C2/3 Vertebral Spinal Dura.
• The spinal dura extends through the Vertebral Canal into the Sacral Canal.
• It attaches to the posterior aspect of S-2.

Reciprocal Tension Membrane: Core Link

• The inferior attachment of the dural tube is to the posterior aspect of the body of S2
• The sacrum is suspended between the ilia by anterior, posterior, and intra-articular ligaments

Question 17

Classic Cranial Vault Hold

Craniosacral Motion overview ?

*** dont forget to HIP FLOP ***

Answer 17

• Cranial nomenclature is generally referenced to motion occurring at the sphenobasilar symphysis (SBS) or synchondrosis.
• The sphenoid articulates with the occiput just below the sella turcica (home to the pituitary gland) at the sphenobasilar synchondrosis.
• The occiput and the sphenoid rotate in opposite directions.

Question 18

Craniosacral Motion

Cranial Flexion movements ?

(SBS, midline bones, paired bones, PRM, Sacral base, AP diameter of cranium)

*** dont forget to HIP FLOP ***

Answer 18

• SBS: SBS Rises
• Midline Bones: Flexion
• Paired Bones: External Rotation + Superior
• PRM: Inhalation
• Sacral Base: Posterior base (Counternutation)
• AP Diameter of Cranium: Decreased

Question 19

Craniosacral Motion

Cranial Extension movements ?

(SBS, midline bones, paired bones, PRM, Sacral base, AP diameter of cranium)

*** dont forget to HIP FLOP ***

Answer 19

• SBS: SBS Falls
• Midline Bones: Extension
• Paired Bones: Internal Rotation + Inferior
• PRM: Exhalation
• Sacral Base: Anterior base (Nutation)
• AP Diameter of Cranium: Increased

Question 20

Craniosacral Motion

Cranial Flexion hand / finger movements ?

*** dont forget to HIP FLOP ***

Answer 20

Cranial Flexion:

the AP diameter of the skull shortens and widens laterally

• External rotation of temporal bones
• Sphenoid bone tilts forward & occiput tilts backward
  
  • Fingers should move forward and spread out
• Axis: 2 parallel transverse axis → rotate OPPOSITE
  
  • Sphenoid: through sphenoid body at S/S pivot
  • Occiput: cephalad to jugular process at level of SBS

Question 21

Craniosacral Motion

Cranial Extension hand / finger movements ?

*** dont forget to HIP FLOP ***

Answer 21

Cranial Extension:

the AP diameter of the skull lengthens & narrows laterally

• Internal rotation of temporal bones
• Sphenoid bone tilts backward & occiput tilts up
  
  • Fingers should move back and come together
• Axis: 2 parallel transverse axis → rotate OPPOSITE
  
  • Sphenoid: through sphenoid body at S/S pivot
  • Occiput: cephalad to jugular process at level of SBS

Question 22

Craniosacral Strain Patterns

Physiologic ?

Non-Physiologic ?

Answer 22

• Physiologic
  
  • Torsion
  • Sidebending Rotation
• Non-Physiologic
  
  • Lateral
  • Vertical (superior / inferior)
  • Compression

Question 23

Craniosacral Strain Patterns

Physiologic

Describe Torsion using hands and verbalize

Answer 23

Torsion

• Axis: 1 AP axis
  
  • Direction: sphenoid + occiput → rotate OPPOSITE
• Named: for the greater wing of the sphenoid that is more superior
  
  • Ex: right torsion feels as if the greater wing of the sphenoid on the right elevates and rotates to the left

Question 24

Craniosacral Strain Patterns

Physiologic

Describe Sidebending Rotation using hands and verbalize

Answer 24

Sidebending Rotation

• Axis + Direction: 3
• Rotation:
  
  • Egg analogy: Dump the egg
  • 1 AP axis: sphenoid + occiput → rotate SAME
• Sidebending:
  
  • Egg analogy: Crack the egg
  • 2 Parallel verticle axis: → rotate OPPOSITE
    
    • Base body of sphenoid
    • Foramen magnum
• Named: for the side of convexity
• What is the motion?
  
  • Right Sidebending/Rotation (picture)
    
    • Right hand: Fingers should move forward and spread out (feels full)
    • Left hand: Fingers should move back and come together and move superiorly

Question 25

**_Craniosacral Strain Patterns_** Physiologic Describe **Lateral strain** using hands and verbalize

Answer 25

**Lateral strain** * **Axis: 2 parallel vertical** axis → rotate **SAME** * Base **body of sphenoid** * Foramen **magnum** * **Named:** for the position of **basi-sphenoid** * Head appears "**parallelogram**"

Question 26

**_Craniosacral Strain Patterns_** Physiologic Describe **Vertical strain** using hands and verbalize

Answer 26

**Vertical strain** * **Axis: 2 parallel transverse** axis → rotate **SAME** * **Sphenoid:** through sphenoid **body** at **S/S pivot** * **Occiput:** **cephalad** to **jugular** process at level of **SBS** * **Named:** for the position of **basi-sphenoid** * **What is the motion?** “Jump Under/Over the Fence” * **Superior (OVER):** * FLEX @ sphenoid + EXTEND @ occiput * Index fingers move DOWN + pinky fingers more UP * **Inferior (UNDER):** * Extend @ sphenoid + FLEX @ occiput * Index fingers move UP + pinky fingers move DOWN

Question 27

**_Craniosacral Strain Patterns_** Physiologic Describe **Compression strain** using hands and verbalize

Answer 27

**Compression strain** * occurs when the **occiput and sphenoid** are **pressed together** * **preventing motion** (or void of any motion) * feels **rock hard** like a **bowling ball**, **jammed together** * **CRI** can be almost completely **gone**

Question 28

**_CV 4_** Objectives

Answer 28

Treatment often starts with **compression** of **CV4** for **ill patients**. * The treatment **augments** the **healing capabilities** of the patient * **relaxes** the patient * and **improves** the **motion** of the **CRI**

Question 29

**_CV 4_** Technique

Answer 29

* Pt supine, phys seated at head with both forearms resting on the table, establishing a fulcrum. 
 * **Interlaces** the **fingers**, **cradling** the pt’s **occipital squama**. 
 * **Thenar eminences postero- medial** to the pt’s **occipitomastoid sutures**. * If thenar eminences on the mastoid processes, compression that will bilaterally externally rotate temporal bones * may cause extreme untoward reactions * Phys **encourages extension** of the **occiput** by **following** the occiput as it moves **into extension**. 
 * Phys **_resists flexion_** by **_holding_ occiput** **_in extension_** with **_bilateral medial forces_**. * This force is **maintained until** the **amplitude** of the **CRI decreases**, a **_still point_ is reached IN _EXTENSION_**, and/or a **sense of release** is felt. * As the **CRI resumes**, the physician **slowly releases** the force, allowing the CRI to undergo newfound excursion **into flexion**. 
 * The **rate** and **amplitude** of the **CRI** are **retested** to assess the effectiveness of the technique. 
 * \*\*\*Video NOTE: Know the indications, know to **_stay midline_**, know what phase you are trying to accentuate. \*\*

Question 30

**_Venous Sinus Drainage_** Objectives \*\*\* REMEMBER RESPIRATORY ASSIST THROUGHOUT-may take 3-4 breath cycles to feel the softening \*\*\*

Answer 30

* The objective is to **increase intracranial venous drainage** by **affecting** the **dural membranes** that comprise the sinuses. * **Thoracic outlet**, **cervical**, and **occipitoatlantal joint** somatic dysfunctions should be **treated first** * to **allow drainage** **from** the **venous sinuses**.

Question 31

**_Venous Sinus Drainage_** Technique location overview \*\*\* REMEMBER RESPIRATORY ASSIST THROUGHOUT-may take 3-4 breath cycles to feel the softening \*\*\*

Answer 31

1. Pt supine, phys seated at head both elbows resting on table establishing a fulcrum. 2. **Inion (Confluence of Sinuses)** 1. PC1 Inion: Flex, Sara 3. **Occipital Sinus** 4. **Condylar Decompression** 5. **Transverse Sinus** 6. **Superior Sagittal Sinus** 7. **Metopic Suture** 8. **RATE AND AMPLITUDE of CRI are RETESTED to assess the effectiveness of the technique.**

Question 32

**_Venous Sinus Drainage_** Technique **Inion (Confluence of Sinuses)** \*\*\* REMEMBER RESPIRATORY ASSIST THROUGHOUT-may take 3-4 breath cycles to feel the softening \*\*\*

Answer 32

* Pt supine, phys seated at head both elbows resting on table establishing a fulcrum. * **Inion (Confluence of Sinuses):** * Physician cradles back of the patient’s head and places **middle finger on inion**. * Maintain pressure until softening is felt. * PC1 Inion: Flex, Sara

Question 33

**_Venous Sinus Drainage_** Technique **Occipital Sinus** \*\*\* REMEMBER RESPIRATORY ASSIST THROUGHOUT-may take 3-4 breath cycles to feel the softening \*\*\*

Answer 33

* Pt supine, phys seated at head both elbows resting on table establishing a fulcrum. * **Occipital Sinus:** * Physician cradles back of patient’s head and places the **second and fourth fingers** of both hands **in opposition along midline** **from inion to** the **suboccipital tissues**. * Maintain pressure until softening is felt.

Question 34

**_Venous Sinus Drainage_** Technique **Condylar Decompression** \*\*\* REMEMBER RESPIRATORY ASSIST THROUGHOUT-may take 3-4 breath cycles to feel the softening \*\*\*

Answer 34

* Pt supine, phys seated at head both elbows resting on table establishing a fulcrum. * **Condylar Decompression:** * Keep fingers in **suboccip region**. * **Bring elbows together**, **causing** the **fingers to spread** out laterally. * **Let the head do all the work** with the weight. * Have them **breathe in and out**.

Question 35

**_Venous Sinus Drainage_** Technique **Transverse Sinus** \*\*\* REMEMBER RESPIRATORY ASSIST THROUGHOUT-may take 3-4 breath cycles to feel the softening \*\*\*

Answer 35

* Pt supine, phys seated at head both elbows resting on table establishing a fulcrum. * **Transverse Sinus:** * Physician places the **first and second finger pads** of both hands across the **superior nuchal line.** * The position is maintained with minimal pressure (weight of the patient’s head should suffice) **until the release** is felt **bilaterally**. * This will feel like softening under the fingers.

Question 36

**_Venous Sinus Drainage_** Technique **Superior Sagittal Sinus** \*\*\* REMEMBER RESPIRATORY ASSIST THROUGHOUT-may take 3-4 breath cycles to feel the softening \*\*\*

Answer 36

* Pt supine, phys seated at head both elbows resting on table establishing a fulcrum. * **Superior Sagittal Sinus** (demonstrated with thumbs crossed and modified hand position): * **Placed 2 crossed thumbs** on either side **to disengage** the **suture**. The **head** will be **flexed**. * Once the **release is felt**, physician **moves anteriorly** and **superiorly** along the **superior sagittal suture** with **crossed thumb forces**, noting releases at each location **toward the bregma**.

Question 37

**_Venous Sinus Drainage_** Technique **Metopic Suture** \*\*\* REMEMBER RESPIRATORY ASSIST THROUGHOUT-may take 3-4 breath cycles to feel the softening \*\*\*

Answer 37

* Pt supine, phys seated at head both elbows resting on table establishing a fulcrum. * **Metopic Suture:** * Once **at the Bregma**, place the **second-fourth fingers** of both hands **in opposition along the midline** of the **frontal bone** at the location of the **metopic suture**. * **Continue anteriorly**, **disengaging the suture** by gently **separating each finger** on opposing hands.