Beryl Arbuckle`s Cranial - American Academy of Osteopathy

Beryl Arbuckle’s
Cranial
“Controversy
Controversy in
Thought”
By
Kenneth Lossing D.O.
1
W.G. Sutherland D.O.
• One morning in 1899,
while still a student in
Kirksville, on his way to
class the idea for
class,
cranial mobility came
from viewing Dr
Dr. Still’s
Still s
Beauchene
disarticulated skull in the
North Hall.
With Thinking Fingers, A.
Sutherland
2
The First Thought
• “As I stood looking and thinking in the channel
of Dr. Still’s philosophy, my attention was
called to the beveled articular surfaces of the
sphenoid bone. Suddenly there came a
thought; I call it a guiding thought-beveled
thought beveled like
the gills of a fish, indicating articular mobility
for a respiratory mechanism” W.G. Sutherland
With Thinking Fingers, A.
Sutherland
3
Mobility
y
• “Mobility
Mobility is the state of being in motion.
• In physics, motion is a change in position of an
object
j
with respect
p
to time.
• Motion is typically described in terms of
velocity,
y, acceleration,, displacement,
p
, time and
speed”.
• Mobility, for some reason, is not defined in our
Osteopathic Glossary.
From Wikipedia, the free encyclopedia
4
Motility
• “Motility is a biological term which refers to
the ability to move spontaneously and actively
actively,
consuming energy in the process”.
• Again,
Again this term is absent from our Osteopathic
glossary
• So,
So the brain and fluids move with motility
motility, and
the container, the skull, needs to be able to
accommodate to this, and thoracic respiration.
p
From Wikipedia, the free
encyclopedia
5
Articular Mobility
• “A
“Articular
ti l mobility
bilit occurs iin th
the b
basilar
il
area, and that of the facial bones; such
basilar mobility being accommodated
through
g compensatory
p
y expansile
p
and
contractile service at the vault sutures”
• So,
So the question is: Is the mobility
responsive to primary respiration, or
th
thoracic
i respiration,
i ti
or b
both?
th? It’
It’s a
question of distance and distensabilty.
The Cranial Bowl, 1939, W.G.
Sutherland
6
Mental Picture
• “The formation of a “mental picture”
of the articular surfaces of the
cranial and facial bones, is the first
necessity for recognizing the fact of
cranial articular mobility”.
y
• “The picture should be like that of a
watchmaker
watchmaker”
• So, we need to know the whole
thing!
The Cranial Bowl, 1939, W.G.
Sutherland
7
So, what is “normal”
normal mobility?
• In his first book, “the Cranial Bowl”, published
i 1939
in
1939, S
Sutherland
th l d used
d ““position”
iti ” and
d
“motion testing” to diagnose the bones and
sutures of the skull
skull.
• The treatment techniques he describes are
nearly all “direct
direct techniques”
techniques .
• So he spent nearly 40 years doing direct !
• He also speaks about sutures that are
“locked”, in that they do not move when
motion tested.
The Cranial Bowl, W.G.
Sutherland
8
Why is this important ?
• We know babies skulls are like a water
b ll
balloon,
easy tto d
deform,
f
and
d th
they spring
i b
back.
k
• Most of our patient’s skulls are somewhere
b t
between
ab
basketball,
k tb ll and
dab
bowling
li b
ball.
ll
• Could he have possibly meant that an adult
skull could be nearly as freely moveable as an
infant skull?
9
The current biomechanical
terminolog : Visco
terminology
Visco-elasticity
elasticit of
Sutures
• S
Stiffness:
iff
tensile
il fforce/change
/ h
iin llength
h
• Ultimate stress: tensile force at suture
rupture/cross sectional area
• “Sutures demonstrate classical viscoelastic
behavior. During the elastic phase, they
elongated approx 1 um for every 1g of force
104 N/m. The ultimate tensile stress was approx
4 MN/m2. The estimated mean elastic
modulus
d l was 10 megapixels”.
i l ”
• “The Load-Displacement Characteristics of
Neonatal Rat Sutures
Sutures” The Cleft PalatePalate
Craniofacial Journal. Vol.37, McLaughlin
10
Stress Strain Graph
Strain
Stress
loading
unloading
E
•
•
E= elastic modulus
The angle of the curve
reflects the stiffness of the
tissue. A tissue that is stiff
will have a line to the left,
and a tissue that is less stiff
will have a line to the right.
1
Strain
Fundamentals of
Biomechanics,Ozkaya
Modern science says
• That the “mobility” or “viscoelasticity” of the
sutures
t
is
i specific,
ifi nott arbitrary.
bit
• A specific amount of force will create a
specific
ifi amountt off distensability
di t
bilit and
d
movement, in a normally functioning suture.
• In a suture that is malfunctioning
malfunctioning, stuck
stuck, or
locked, the normal amount of distensability is
reduced or lost.
12
Fronto-Occipital
Fronto
Occipital HoldHold Motion Test
• This is how Sutherland
taught up through at least
1946, according to Robert
Fulford.
• Thumbs on:
• mastoid process and
zygomatic process of frontal.
• Hands and fingers to
opposite side
• Actively “motion test” the
following strain patterns:
Atlas of manipulative Techniques for the Cranium and Face, Alain
Gehin
13
SBS
•
•
•
•
•
•
•
Flexion
Extension
Torsion
Side-bending
Vertical
Lateral
Compression
p
Osteopathy in the Cranial Field, Magoun
14
Beryl Arbuckle D.O.
• She started studying with
S th l d iin 1942
Sutherland
1942.
• She assisted Sutherland
i th
in
the early
l courses,
including the first course
at a school
school, Des Moines
Moines,
in 1944, where the
Becker’s were students.
• Remained on his teaching
staff for some years.
The Selected Writings of Beryl Arbuckle
Life in Motion, Rollin Becker
15
Beryl Arbuckle
• Since she wanted objective evidence of what
she palpated while treating patients, she
attended nearly every autopsy ( estimated at
about 200) on cranial pathology at a hospital in
Philadelphia over a many year time span
span.
• Observed fiber strands in specific directions,
which she called stress bands.
• Used positional and motion testing diagnosis.
• As she treated mostly children, she used direct
technique, with respiratory assistance when
possible ( step breathing or holding of breath as
long as possible)
possible).
The Selected Writings of Beryl Arbuckle
16
Beryl Arbuckle
• Presented her finding of stress fibers to the
study
t d group off the
th teachers
t
h
around
d
Sutherland.
• Sutherland
S th l d h
had
d no problem
bl
with
ith thi
this, or with
ith
Arbuckle.
• Shortly afterward,
afterward she started teaching on her
own, with the assistance of Paul Kimberly had
been on Sutherland’s
Sutherland s teaching staff, who also
did direct cranial.
Related by Ruby Day to James
Jealous
17
Dr. Robert Fulford
• Early student of Sutherland
(1944 or 45) and Arbuckle
(1953). Sutherland’s courses
were 2 weeks long
g at the
time.
• Stated many times that
patients referred to him by
other DO’s, because the
patient
ti t had
h d nott gotten
tt better,
b tt
that had years of cranial, had
heads that were balanced
balanced, but
Dr.“locked
Fulford’s Touchup”.
of Life
18
Robert Fulford
• Observed that Arbuckle came the closest to
reproducing the clinical results that Sutherland
did, so he went to study with her.
• “We
We tried to absorb his teaching (Sutherland),
(Sutherland)
but it didn’t take well. I left the Cranial academy,
went to Philadelphia, studied with Dr. Arbuckle,
and got a degree of understanding of stress
bands of the dura mater and really understood
th cranial
the
i l concept.”
t”
• Then, after years of practice, it started to work.
Robert Fulford,D.O. and the Philosopher Physician,
Zachary Comeaux
19
Unlocking technique
• Facing the patient, place a hand on each side
of the head
head. Do layer palpation into the dural
layer.
Fuford-paraphrased:
paraphrased: ”II place my hands on
• Dr. Fuford
the head, I feel the membranes wind up, until
they bust themselves loose. Sometimes it is
so strong
t
it knocks
k
k my hands
h d clean
l
off
ff the
th
head. Afterwards, you can do what you want
with the head.”
Lecture at Cranial Academy, about
1995
20
Variations
• Pt supine, their hands connected to your
arms.
• Pt seated.
• Pt seated, you stand or sit behind, make
contact with posterior cranium.
21
Fulford’s
Fulford
s Face test
A
1
2
3
• A) With your left hand
stabilize the frontal
bilaterally.
• With your right hand
translate laterally the:
• 1) Upper nose/maxillatests ethmoid!
• 2) Zygomas
• 3) Lower maxillas
22
Posterior Skull Test
• With the patient
p
supine, use your right
hand on the sagittal
suture compress
suture,
enough to catch the
head,, and lift it until
the occiput is
unweighted. Use your
left hand to translate
the occiput left and
right.
23
Earlyy Sutherland Diagnostic
g
Sequence
• “There is a definite orderly sequence of
cranial diagnosis as first taught by Sutherland,
which for clear understanding cannot be
improved upon. Start with the sphenobasilar
and proceed as follows: the base of the skull
skull,
the back and sides ( all formed in cartilage),
then vault and face”
face .
The Selected Writings of Beryl
Arbuckle
24
Illustration of above sequence
• Head anterior and to the
left on atlas
• Flexion of the
sphenobasilar
p
with
sidebending rotation to
the left
• Posterior divergence of
condylar parts
• A P crowding
g of the
condylar parts
• Flexion of Occipital
hinge
• Occipital squama
flattened and rotated left
• Bilateral posterior and
superior mastoid
buckling
• Overriding of coronal
and lambdoid sutures
• Parietals over both
occipital and frontals
• Depressed nasion
The Selected Writings of Beryl Arbuckle
25
The question is: How can we get
the cranial mechanism optimal
function?
• Answer: Get the container
moving well, so the contents can
express themselves.
• Mobilize the sacrum, upper
cervical spine, then unlock the
bones/sutures then unlock the
bones/sutures,
membranes.
q
locked
• The most frequent
sutures are: Left occipitalpetrosal, right pterygo-palatine,
left fronto-ethmoid
fronto ethmoid . KL
Osteopathy in The Cranial Field,
Magoun
26
Occipitopetrosal Manipulation
• Contacts: posterior to
mastoid tip on the fixed
side-W/R-anterolaterally
• Anterior to the mastoid
tip on the unaffected
side-W1/4Rposterlaterally
• Note: you can also use
your 4th and 5th finger
pads on the occiput to
lift a low side
side. Arbuckle
Cranial Sutures, Marc Pick
27
Force, Pressure Codes
• S=surface level= initial contact
• W=working level= ½ way between surface
and rejection level=pliable counter-resistance
• R=Rejection level=major tissue resistance (
tissue hardens), pt discomfort.
• So,
S W1/3R means ttake
k th
the ti
tissue tto working
ki
level force, then go 1/3 more of the way to
rejection level
level.
28
Cranial Sutures, Marc Pick
Sphenopalatine Manipulation
• Contacts:
• Bilateral maxilla’s,
inside of mouth near
last molars
molars-W-medial
W medial
• Pterygoid process,
anterior tip-W1/4Rtip W1/4R
posteromedial.
• Note: the most
common side is the
right, but I treat both.
KL
Cranial Sutures, Marc Pick
29
Frontoethmoid Manipulation
• To release lateral surfaces
and close the anterior
surfaces• Frontal’s metopic suture,
e tending laterall
extending
laterally over
o er
supercilliary arches and
maxilla’s-W1/3R-posterior
• Occiput-W/R anterior
Note: you are done when
the ethmoid is rocking
well, and the “upper face
translation test” is
normal.
Cranial Sutures, Marc Pick
30
The SacrumSacrum from Arbuckle
• The upper limb of the
L shaped sacroiliac
articulation is
convergent anteriorly.
The Selected Writings of Beryl Arbuckle
31
Sacrum, Arbuckle
• The lower limbs of the
L shaped sacroiliac
articulation is
divergent anteriorly.
• The upper and lower
limbs meet at S2, the
axis of rotation is
here Below this the
here.
lateral articulations
converge inferiorly
inferiorly.
The Selected Writings of Beryl
Arbuckle
32
Sacrum, Arbuckle
• Use thumb on base and
apex of the same side.
C
Compress
b
base ttoward
d th
the
greater trochanter, then
apex toward the ASIS,
compare distensabilty.
distensabilty
• Then check other side the
same way.
• On the most moveable
quadrant, placed a thumb,
other thumb behind for
reinforcement Exaggerate
reinforcement.
the strain. Have Pt take
deep breath and hold.
Sacrum should release
with a jerk.
The Selected Writings of Beryl
Arbuckle
33
Stress Fibers
• “There are white fibrous strands, known as
stress fibers
fibers, throughout the otherwise yellow
elastic tissue.”
Theses stress fibers which follow a very
• “Theses
definitely consistent pattern, are arranged in
horizontal, vertical, transverse, circular, and
spinal
i l groups.””
• “There is no definite break in these fibers but
an intermingling or continuation of one group
with another so that forces may be directed
and controlled throughout this mechanism.”
The Selected Writings of Beryl Arbuckle
34
Stress fibers
• “For descriptive purposes origin and termination
of the various groups of fibers is given but it
must be remembered that these fibers are
continuous and their firm boney attachments
must be thoroughly understood with all possible
movements thereof in order to change the
planes and tensities of these various diverging
fans of fibers throughout the dura to achieve
th necessary forces
the
f
in
i the
th desired
d i d di
directions.”
ti
”
The Selected Writings of Beryl Arbuckle
35
Intracranial Dura
• “The torcular mass is quite
an extensive dense fibrous
mass about the confluence of
sinuses. From this mass
diverge four horizontal groups
of fibers, namely:• Inferior horizontal fibers of falx
cerebri
• Horizontal fibers of the falx
cerebelli
• Horizontal group in the under
layer of each side of the tent
tent.”
The Selected Writings of Beryl Arbuckle
36
Primal Pictures
37
Horizontal Falx Cerebri Superior
p
• The superior
p
horizontal fibers of the
falx in either side of
the falx cerebri
diverge somewhat
from the metopic
p area
to the lambda, and
margins of the
superior part of the
sagittal sulcus of the
occiput.
The Selected Writings of Beryl Arbuckle
38
Half a world away, Dr. Erich Blecshmidt’s
dissections show : Dural Girdles
• These are areas where the dura
is thickened, thought to be due
to a reaction to the brain
growing, a restraining function.
f
• 1-retromesencephalic dural
girdle
i dl
• 6-premesencephalic dural girdle
• 12- falx ( Arbuckle called this
the falx ceribri anterior vertical
fibers)
The Stages of Human Development before Birth,
1960, Erich Blechschmidt
39
Dural girdles-thickened
girdles thickened dura
• 3,8, right
g frontal
dural girdle, anlagen
of coronal and
sagital sutures
sutures, and
part of falx.
4-right
right parietal dural
• 4
girdle
• 6,11- occipital dural
girdle, connective
tissue analgen of
lambdoidal suture
The Stages of Human Development before Birth,
1960, Erich Blechschmidt
40
• The dura
forms a
“restraining
f
function”
ti ” to
t the
th
more rapid
growth of the
brain.
• Symposium on
the
Development
p
of the
Basicranium
The Biokinetics of the
Basicranium, Blechschmidt
41
FIBROUS TISSUE FORMATION
(STRETCHED MESENCHYME)
Retension Field: the
sick figures pull apart
on a tough material.
The rapid growth of the
brain stretches the
precursor of the dura,
forming a horizontally
directed thickening in
the falx.
Biokinetics and Biodynamics of Human
Differentiation
42
Has anyone
y
else thought
g about
this?
• “Quantification
Quantification of the
Collagen fiber
architecture of human
cranial
i l dura
d
mater”.
t ”
• Done at tissue mechanics
lab, dept. of biomedical
engineering, U of Miami.
• Endocranial dura
• Most regular arrangement
of fibers is in temporal
region
Hamann, Sacks, Malinin, J of Anat
Jan 1998
43
Study info
• 20 fresh cadavers,, no
pathology
• 0-92 years old
• Less than 24 hours
postmortum
• Superior
S
i sagittal
itt l sinus
i
and calvarial section
of ttissue
o
ssue
• Placed in saline and
frozen.
Hamann, Sacks, Malinin, J of Anat
Jan 1998
44
Study Information
• Tissue looked at
using small angle
light scattering HeNe
lazer, has optics
between optical
miscroscopy
i
and
d
gross visual analysis.
Hamann, Sacks, Malinin, J of Anat
Jan 1998
45
Dura
• The top picture is
viewed with the
eye, the bottom
picture shows
SALS applied to
the same area
th
with the direction
of the collagen
fibers more
apparent.
pp
Hamann, Sacks, Malinin, J of Anat
Jan 1998
46
Is the Collagen oriented along
vessels?
l ?
• Not found to be
oriented along
large vessels, but
along smaller
vessels
Hamann, Sacks, Malinin, J of Anat
Jan 1998
47
Near Coronal Suture
• The collagen fibers are
aligned in an
anterior/posterior
direction just behind
the coronal suture, in
th area off the
the
th remnantt
of an anterior dural
girdle.
girdle
• Thought to be the
result of growth stress.
stress
Hamann, Sacks, Malinin, J of Anat
Jan 1998
48
Treatment of horizontal fibers of
f l and
falx,
d opening
i middle
iddl b
buttress
• Lay the patient on their left
side,
id a pillow
ill
under
d th
their
i h
head.
d
• Place your left index finger
along the anterior falx, right
index finger along the posterior
falx.
• Follow
F ll
the
h PRM iinto
extension, don’t allow if to go
into flexion. After some time,,
maybe 5 minutes, the system
will become quiet, then go into
flexion and everything will
flexion,
soften.
Described by Dr Fulford
49
Buttresses
• “In the boney structure also
p areas of
there are developed
greater density known as
buttresses. Although this stage
of development is not reached in
infancy, the buttresses will be
described here since
understanding
d t di th
their
i normall or
expected positions, slight
deviations in the infant skull
which may result in gross
abnormalities are more easily
recognized
recognized”
The Selected Writings of Beryl Arbuckle
50
Butresses
• Anterior: across glabella
g
laterally, over superciliary
ridges to zygomatic process
of frontal.
frontal
• Posterior: inion, most
superior nuchal lines, mastoid
process
• Inferior: inion to opisthion,
foramen magnum,
magnum basion,
basion to
posterior wall of sphenoidal
sinus
The Selected Writings of Beryl
Arbuckle
51
Buttresses
• Superior: Inion, sagital
suture,
t
frontal
f t l crest,
t
glabella, crista galli
• Lateral Oval: mastoid
process, EAM,
EAM th
then 2
ridges. Outer: zygomatic
bone to zygomatic
process of frontal
frontal. Inner:
pteryoid process and
lesser wing
• Oblique basilar: Petrous
ridges of temporals, point
towards sphenoid sinus,
the roof of which forms
the floor of the sella
turcica.
The Selected Writings of Beryl Arbuckle
52
Buttresses
• “The various buttresses may be pictured as
radiating
di ti ffrom about
b t th
the sella
ll turcica
t i and
d iin a
manner similar to the stress bands of the
reciprocal tension membranes
membranes.”
• “1. Straightening or flattening the anterior
buttress will widen or cause the margins of the
ethmoidal notch of the frontal to increase their
posterior divergence
p
g
thus allowing
g for a
widening of the upper part of the lateral
masses”.
The Selected Writings of Beryl Arbuckle
53
Using the Buttress to mobilize the lateral
ethmoid’s
th id’ articulation
ti l ti
• To release lateral
surfaces and close the
anterior surfaces• Frontal’s metopic
suture, extending
laterally over
supercilliary arches and
maxilla s W1/3R
maxilla’s-W1/3Rposterior
p
anterior
• Occiput-W/R
Cranial Sutures-Marc Pick
The Selected Writings of Beryl Arbuckle
54
Median Buttresses
“Increasing or decreasing the arc of the
median buttress will allow the crista gali to fall
or elevate depending upon the type of head.
That is, in an extreme flexion head it would be
wiser to attempt to lift the crista galli by
increasing the arc of the anterior buttress thus
narrowing the lateral masses of the ethmoid. (
Horizontal falx technique).
technique) In an extreme
extension head we would rather allow the
crista galli to fall permitting widening of the
l t l masses off
lateral
ff the
th ethmoid”.
th id” (A/P
compression- face with inion)
The Selected Writing of Beryl
Arbuckle
55
Treatment of “Horizontal fibers of
Falx” and increase the arc of
Falx
“Anterior Buttress”
• Lay the patient on their left side, a pillow under
their head.
• Place your left index finger along the anterior falx,
right
g index finger
g along
g the p
posterior falx.
• Follow the PRM into extension, don’t allow if to go
into flexion. After some time, maybe
y 5 minutes, the
system will become quiet, then go into flexion, and
everything will soften.
Described by Robert Fulford
56
Buttresses
• Zygomatic pillar of the face-from the first
molar
l ttooth
th tto the
th zygomatic
ti angle
l off th
the
frontal
• By
B increasing
i
i or d
decreasing
i th
the iinferior
f i
convergence of the zygomatic pillars, change
in the posterior divergence of the margins of
the ethmoid notch of the frontal may be
obtained.
The Selected Writings of Beryl Arbuckle
57
Frontoethmoidal Manipulation
• To release anterior,
and close laterally• Bil contact superior
p
to
sphenofrontal sutureW1/3R-medially.
• Lateral aspect of hard
palate- W1/3Rl
laterally,
ll then
h pullll
anteriorly
The Cranial Sutured, March Pick
The Selected Writings of Beryl
Arbuckle
58
59
The Vault, Fontanelles, and
Sutures
•
•
•
•
•
•
•
•
From left to right:
g
14 weeks
20 weeks
24 weeks
30 weeks
34 weeks
Adult
In the fetal skull there
are 6 fontanelles
60
Anterior Fontanelle
• Anterior fontanelle becomes
bregma
g
after the fontanel
closes and the sutures form. It
is between the 2 halves of the
frontal bone ((metopic
p suture))
and the 2 parietals.
• The metopic suture is open at
birth separating the frontal into
birth,
2 halves, from nasion to
bregma. It ossifies during
growth but retains a natural
growth,
malleability, moving during
flexion-extension, aided by the
attachment of the falx
falx. “The
The
cranial puzzle”
61
Bregma Treatment Part 1
• Due to the overlapping of
the sutures
sutures, the medial ends
of the coronal suture need to
be treated first, then the
anterior
t i portion
ti off the
th
sagittal suture.
• The medial end of the
coronal suture is treated by
the fingers of one hand on
glabella, depressing
posteriorly, while the thumb
of the other hand is posterior
to bregma, depressing
The Selected Writings of Beryl Arbuckle
62
caudad.
Bregma Treatment part 2
• The sagittal suture is
treated with fingers on
parietals, thumbs
overlapped over the
anterior part of the
suture,
t
force
f
directed
di t d
posterior, inferior and
lateralward Arbuckle
lateralward.
The Selected Writings of Beryl
Arbuckle
63
Bregma
• Trauma at bregma. (trauma may be direct on
area or indirect from a fall on the feet or
buttock). The bone is pushed inferiorly at
bregma
g
and forced laterally
y at p
pterion. This
will restrict the great wing and the
sphenobasilar. The sagittal suture will be
depressed or one parietal lowered in relation
to the other. The occipital condlyes may be
moved back in the pits of the atlas (bilateral
posterior occiput). OCF
64
Beryl Arbuckle
• Preserved Sutherland’s earliest approaches to
mobility diagnosis ( position and motion testing) and
mobility,
treatment (direct).
• Refined the view of the reciprocal tension
membrane into 20 different directions of fibers, all of
which are helpful in diagnosis and treatment (both
by themselves and as handles for the bone).
• Described thickened areas of bone called
buttresses, that can be used in diagnosis and
treatment (by themselves and as handles to the
membranes).
membranes)
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• Was way ahead of her time.
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household word.
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