lossing berylarbucklescranial

Beryl Arbuckle’s CranialCranial

“Controversy inControversy in Thought”

BByKenneth Lossing D.O.

1

W.G. Sutherland D.O.W.G. Sutherland D.O.

• One morning in 1899, while still a student in Kirksville, on his way to class the idea forclass, the idea for cranial mobility came from viewing Dr Still’sfrom viewing Dr. Still s Beauchenedisarticulated skull in the North Hall.

With Thinking Fingers, A. Sutherland

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The First ThoughtThe 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 thecalled to the beveled articular surfaces of the sphenoid bone. Suddenly there came a thought; I call it a guiding thought-beveled likethought; I call it a guiding thought beveled like the gills of a fish, indicating articular mobility for a respiratory mechanism” W.G. Sutherland

With Thinking Fingers, A. Sutherland

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Mobilityy

• “Mobility is the state of being in motion.Mobility is the state of being in motion.• In physics, motion is a change in position of an

object with respect to time. j p• Motion is typically described in terms of

velocity, acceleration, displacement, time and y, , p ,speed”.

• Mobility, for some reason, is not defined in our Osteopathic Glossary.

From Wikipedia, the free encyclopedia 4

MotilityMotility

• “Motility is a biological term which refers to the ability to move spontaneously and activelythe ability to move spontaneously and actively, consuming energy in the process”.

• Again this term is absent from our Osteopathic• Again, this term is absent from our Osteopathic glossary

• So the brain and fluids move with motility andSo, the brain and fluids move with motility, and the container, the skull, needs to be able to accommodate to this, and thoracic respiration.p

From Wikipedia, the free encyclopedia

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Articular Mobility“A ti l bilit i th b il• “Articular mobility occurs in the basilar area, and that of the facial bones; such basilar mobility being accommodated through compensatory expansile and g p y pcontractile service at the vault sutures”

• So the question is: Is the mobility• So, the question is: Is the mobility responsive to primary respiration, or th i i ti b th? It’thoracic respiration, or both? It’s a question of distance and distensabilty.

The Cranial Bowl, 1939, W.G. Sutherland

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Mental PictureMental Picture• “The formation of a “mental picture”

of the articular surfaces of theof 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

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So, what is “normal” mobility?So, what is normal mobility?

• In his first book, “the Cranial Bowl”, published i 1939 S th l d d “ iti ” din 1939, Sutherland used “position” and “motion testing” to diagnose the bones and sutures of the skullsutures of the skull.

• The treatment techniques he describes are nearly all “direct techniques”nearly all direct techniques .

• So he spent nearly 40 years doing direct !• He also speaks about sutures that are• He also speaks about sutures that are

“locked”, in that they do not move when motion tested.

The Cranial Bowl, W.G. Sutherland

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Why is this important ?Why is this important ?

• We know babies skulls are like a water b ll t d f d th i b kballoon, easy to deform, and they spring back.

• Most of our patient’s skulls are somewhere b t b k tb ll d b li b llbetween a basketball, and a bowling ball.

• Could he have possibly meant that an adult skull could be nearly as freely moveable as anskull could be nearly as freely moveable as an infant skull?

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The current biomechanical terminolog Visco elasticit ofterminology : Visco-elasticity of SuturesS iff il f / h i l h• Stiffness: tensile force/change in length

• Ultimate stress: tensile force at suture rupture/cross sectional arearupture/cross sectional area

• “Sutures demonstrate classical viscoelastic behavior. During the elastic phase, they elongated approx 1 um for every 1g of forceelongated approx 1 um for every 1g of force 104 N/m. The ultimate tensile stress was approx 4 MN/m2. The estimated mean elastic

d l 10 i l ”modulus was 10 megapixels”.• “The Load-Displacement Characteristics of

Neonatal Rat Sutures” The Cleft Palate-Neonatal Rat Sutures The Cleft PalateCraniofacial Journal. Vol.37, McLaughlin

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Stress Strain GraphStress Strain Graph

• E= elastic modulus• The angle of the curve

StressStrain

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

loadingunloading

and a tissue that is less stiff will have a line to the right.

E

1

Fundamentals of Biomechanics,Ozkaya

Strain

Modern science saysModern science says

• That the “mobility” or “viscoelasticity” of the t i ifi t bitsutures is specific, not arbitrary.

• A specific amount of force will create a ifi t f di t bilit dspecific amount of distensability and

movement, in a normally functioning suture. • In a suture that is malfunctioning stuck or• In a suture that is malfunctioning, stuck, or

locked, the normal amount of distensability is reduced or lost.reduced or lost.

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Fronto-Occipital Hold- Motion TestFronto Occipital Hold Motion Test

• This is how Sutherland taught up through at leasttaught up through at least 1946, according to Robert Fulford.

• Thumbs on:• mastoid process and

zygomatic process of frontal.• Hands and fingers to

opposite sideopposite side• Actively “motion test” the

following strain patterns:following strain patterns:Atlas of manipulative Techniques for the Cranium and Face, Alain

Gehin13

SBSSBS

• Flexion• Extension• Torsion• Torsion• Side-bending• Vertical• Lateral• Lateral• CompressionpOsteopathy in the Cranial Field, Magoun 14

Beryl Arbuckle D.O.Beryl Arbuckle D.O.

• She started studying with S th l d i 1942Sutherland in 1942.

• She assisted Sutherland i th lin the early courses, including the first course at a school Des Moinesat a school, Des Moines, in 1944, where the Becker’s were students.

• Remained on his teaching staff for some years.

The Selected Writings of Beryl ArbuckleLife in Motion, Rollin Becker 15

Beryl ArbuckleBeryl 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 spanPhiladelphia over a many year time 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)long as possible).

The Selected Writings of Beryl Arbuckle 16

Beryl ArbuckleBeryl Arbuckle

• Presented her finding of stress fibers to the t d f th t h dstudy group of the teachers around

Sutherland.S th l d h d bl ith thi ith• Sutherland had no problem with this, or with Arbuckle.

• Shortly afterward she started teaching on her• Shortly afterward, she started teaching on her own, with the assistance of Paul Kimberly had been on Sutherland’s teaching staff, who alsobeen on Sutherland s teaching staff, who also did direct cranial.

Related by Ruby Day to James Jealous

17

Dr. Robert FulfordDr. Robert Fulford• Early student of Sutherland

(1944 or 45) and Arbuckle(1944 or 45) and Arbuckle (1953). Sutherland’s courses were 2 weeks long at the gtime.

• Stated many times that patients referred to him by other DO’s, because the

ti t h d t tt b ttpatient had not gotten better, that had years of cranial, had heads that were balanced butheads that were balanced, but “locked up”.Dr. Fulford’s Touch of Life 18

Robert FulfordRobert Fulford• Observed that Arbuckle came the closest to

reproducing the clinical results that Sutherlandreproducing the clinical results that Sutherland did, so he went to study with her.

• “We tried to absorb his teaching (Sutherland)We tried to absorb his teaching (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 i l t ”the cranial concept.”

• Then, after years of practice, it started to work.

Robert Fulford,D.O. and the Philosopher Physician, Zachary Comeaux

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Unlocking techniqueUnlocking technique

• Facing the patient, place a hand on each side of the head Do layer palpation into the duralof the head. Do layer palpation into the dural layer.

• Dr. Fuford-paraphrased: ”I place my hands onDr. Fuford paraphrased: I place my hands on the head, I feel the membranes wind up, until they bust themselves loose. Sometimes it is

t it k k h d l ff thso strong it knocks my hands clean off the head. Afterwards, you can do what you want with the head.”

Lecture at Cranial Academy, about 1995

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VariationsVariations

• Pt supine, their hands connected to your arms.

• Pt seated.• Pt seated, you stand or sit behind, make

contact with posterior cranium.

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Fulford’s Face testFulford s Face test

• A) With your left handA) With your left hand stabilize the frontal bilaterally.

• With your right hand translate laterally the:

A

1

• 1) Upper nose/maxilla-tests ethmoid!

23

• 2) Zygomas• 3) Lower maxillas

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Posterior Skull TestPosterior Skull Test

• With the patient psupine, use your right hand on the sagittal suture compresssuture, compress enough to catch the head, and lift it until ,the occiput is unweighted. Use your left hand to translateleft hand to translate the occiput left and right.

23

Early Sutherland Diagnostic y gSequence

• “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 skulland proceed as follows: the base of the skull, the back and sides ( all formed in cartilage), then vault and face”then vault and face .

The Selected Writings of Beryl Arbuckle

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Illustration of above sequenceIllustration of above sequence

• Head anterior and to the left on atlas

• Flexion of Occipital hingeleft on atlas

• Flexion of the sphenobasilar with

hinge• Occipital squama

flattened and rotated leftpsidebending rotation to the left

• Posterior divergence of

• Bilateral posterior and superior mastoid buckling• Posterior divergence of

condylar parts• A P crowding of the

buckling• Overriding of coronal

and lambdoid suturesgcondylar parts • Parietals over both

occipital and frontals• Depressed nasion


The question is: How can we get the cranial mechanism optimalthe cranial mechanism optimal function?

• Answer: Get the containerAnswer: Get the container moving well, so the contents can express themselves.

• Mobilize the sacrum, upper cervical spine, then unlock the bones/sutures then unlock thebones/sutures, then unlock the membranes.

• The most frequent locked qsutures are: Left occipital-petrosal, right pterygo-palatine, left fronto ethmoid KLleft fronto-ethmoid . KL

Osteopathy in The Cranial Field, Magoun

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Occipitopetrosal ManipulationOccipitopetrosal Manipulation• Contacts: posterior to

mastoid tip on the fixedmastoid tip on the fixed side-W/R-anterolaterally

• Anterior to the mastoidAnterior to the mastoid tip on the unaffected side-W1/4R-posterlaterally

• Note: you can also use your 4th and 5th finger pads on the occiput to lift a low side Arbucklelift a low side. Arbuckle

Cranial Sutures, Marc Pick 27

Force, Pressure CodesForce, 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.S W1/3R t k th ti t ki• So, W1/3R means take the tissue to working level force, then go 1/3 more of the way to rejection levelrejection level.

Cranial Sutures, Marc Pick28

Sphenopalatine ManipulationSphenopalatine Manipulation

• Contacts:• Bilateral maxilla’s,

inside of mouth near last molars W mediallast molars-W-medial

• Pterygoid process, anterior tip-W1/4R-anterior tip W1/4Rposteromedial.

• Note: the most common side is the right, but I treat both. KLKL


Frontoethmoid ManipulationFrontoethmoid Manipulation• To release lateral surfaces

and close the anterior surfaces-

• Frontal’s metopic suture, e tending laterall o erextending laterally over supercilliary arches and maxilla’s-W1/3R-posterior

• Occiput-W/R anteriorNote: you are done when the ethmoid is rockingthe ethmoid is rocking well, and the “upper face translation test” is normal.


The Sacrum- from ArbuckleThe Sacrum from Arbuckle

• The upper limb of theThe upper limb of the L shaped sacroiliac articulation is convergent anteriorly.


Sacrum, ArbuckleSacrum, Arbuckle

• The lower limbs of theThe 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 thehere. Below this the lateral articulations converge inferiorlyconverge inferiorly.


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Sacrum, ArbuckleSacrum, Arbuckle• Use thumb on base and

apex of the same side. C b t d thCompress base toward the greater trochanter, then apex toward the ASIS, compare distensabiltycompare distensabilty.

• Then check other side the same way.

• On the most moveable• On the most moveable quadrant, placed a thumb, other thumb behind for reinforcement Exaggeratereinforcement. Exaggerate the strain. Have Pt take deep breath and hold. Sacrum should release with a jerk.


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Stress FibersStress Fibers

• “There are white fibrous strands, known as stress fibers throughout the otherwise yellowstress fibers, throughout the otherwise yellow elastic tissue.”

• “Theses stress fibers which follow a veryTheses stress fibers which follow a very definitely consistent pattern, are arranged in horizontal, vertical, transverse, circular, and

i l ”spinal groups.”• “There is no definite break in these fibers but

an intermingling or continuation of one groupan intermingling or continuation of one group with another so that forces may be directed and controlled throughout this mechanism.”


Stress fibersStress fibers

• “For descriptive purposes origin and termination of the various groups of fibers is given but itof the various groups of fibers is given but it must be remembered that these fibers are continuous and their firm boney attachmentscontinuous 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 f i th d i d di ti ”the necessary forces in the desired directions.”


Intracranial DuraIntracranial Dura

• “The torcular mass is quite an extensive dense fibrousan extensive dense fibrous mass about the confluence of sinuses. From this mass diverge four horizontal groups of fibers, namely:-

• Inferior horizontal fibers of falxInferior horizontal fibers of falx cerebri

• Horizontal fibers of the falx cerebelli

• Horizontal group in the under layer of each side of the tent ”layer of each side of the tent.


Primal Pictures 37

Horizontal Falx Cerebri Superiorp

• The superior phorizontal fibers of the falx in either side of the falx cerebrithe falx cerebri diverge somewhat from the metopic area pto the lambda, and margins of the superior part of thesuperior part of the sagittal sulcus of the occiput.


Half a world away, Dr. Erich Blecshmidt’s dissections show : Dural Girdles

• These are areas where the durais thickened, thought to be due to a reaction to the brain

fgrowing, a restraining function.• 1-retromesencephalic dural

i dlgirdle• 6-premesencephalic dural girdle• 12- falx ( Arbuckle called this

the falx ceribri anterior vertical fibers)fibers)

The Stages of Human Development before Birth, 1960, Erich Blechschmidt

39

Dural girdles-thickened duraDural girdles thickened dura

• 3,8- right frontal , gdural girdle, anlagen of coronal and sagital sutures andsagital sutures, and part of falx.

• 4-right parietal dural4 right parietal dural girdle

• 6,11- occipital dural girdle, connective tissue analgen of lambdoidal suturelambdoidal suture

The Stages of Human Development before Birth, 1960, Erich Blechschmidt

40

• The duraforms a “restraining f ti ” t thfunction” to the more rapid growth of thegrowth of the brain.

• Symposium on• Symposium on the Development pof the Basicranium

41The Biokinetics of the Basicranium, Blechschmidt

FIBROUS TISSUE FORMATION (STRETCHED MESENCHYME)(STRETCHED MESENCHYME)

Retension Field: theRetension 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 indirected thickening in the falx.

Biokinetics and Biodynamics of Human Differentiation

42

Has anyone else thought about y gthis?

• “Quantification of theQuantification of the Collagen fiber architecture of human

i l d t ”cranial dura mater”.• Done at tissue mechanics

lab, dept. of biomedicallab, dept. of biomedical engineering, U of Miami.

• Endocranial dura• Most regular arrangement

of fibers is in temporal regionregion

Hamann, Sacks, Malinin, J of Anat Jan 1998

43

Study infoStudy info

• 20 fresh cadavers, no ,pathology

• 0-92 years old• Less than 24 hours

postmortumS i itt l i• Superior sagittal sinus and calvarial section of tissueo t ssue

• Placed in saline and frozen.


44

Study InformationStudy Information

• Tissue looked atTissue looked at using small angle light scattering HeNelazer, has optics between optical

i dmiscroscopy and gross visual analysis.


45

DuraDura

• The top picture isThe top picture is viewed with the eye, the bottom picture shows SALS applied to ththe same area with the direction of the collagenof the collagen fibers more apparent.pp


46

Is the Collagen oriented along l ?vessels?

• Not found to beNot found to be oriented along large vessels, but along smaller vessels


47

Near Coronal SutureNear Coronal Suture

• The collagen fibers areThe collagen fibers are aligned in an anterior/posterior direction just behind the coronal suture, in th f th tthe area of the remnant of an anterior duralgirdlegirdle.

• Thought to be the result of growth stressresult of growth stress.


48

Treatment of horizontal fibers of f l d i iddl bfalx, and opening middle buttress

• Lay the patient on their left id ill d th i h dside, a pillow under their head.

• Place your left index finger along the anterior falx, rightalong the anterior falx, right index finger along the posterior falx.F ll h PRM i• Follow the PRM into 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 willflexion, and everything will soften.

Described by Dr Fulford 49

ButtressesButtresses• “In the boney structure also

there are developed areas of pgreater density known as buttresses. Although this stage of development is not reached inof development is not reached in infancy, the buttresses will be described here since

d t di th i lunderstanding their normal or expected positions, slight deviations in the infant skull which may result in gross abnormalities are more easily recognized”recognized


ButressesButresses

• Anterior: across glabellaglaterally, over superciliaryridges to zygomatic process of frontalof frontal.

• Posterior: inion, most superior nuchal lines, mastoid process

• Inferior: inion to opisthion, foramen magnum basion toforamen magnum, basion, to posterior wall of sphenoidalsinus


51

ButtressesButtresses

• Superior: Inion, sagitalt f t l tsuture, frontal crest,

glabella, crista galli• Lateral Oval: mastoid

EAM th 2process, EAM, then 2 ridges. Outer: zygomaticbone to zygomaticprocess of frontal Inner:process of frontal. Inner:pteryoid process and lesser wing

• Oblique basilar: PetrousOblique basilar: Petrousridges of temporals, point towards sphenoid sinus, the roof of which forms the floor of the sellaturcica. The Selected Writings of Beryl Arbuckle 52


• “The various buttresses may be pictured as di ti f b t th ll t i d iradiating from about the sella turcica and in a

manner similar to the stress bands of the reciprocal tension membranes ”reciprocal tension membranes.

• “1. Straightening or flattening the anterior buttress will widen or cause the margins of thebuttress will widen or cause the margins of the ethmoidal notch of the frontal to increase their posterior divergence thus allowing for a p g gwidening of the upper part of the lateral masses”.


Using the Buttress to mobilize the lateral th id’ ti l tiethmoid’s articulation

• To release lateral surfaces and close the anterior surfaces-

• Frontal’s metopicsuture, extending laterally overlaterally over supercilliary arches and maxilla’s-W1/3R-maxilla s W1/3Rposterior

• Occiput-W/R anteriorp

Cranial Sutures-Marc PickThe Selected Writings of Beryl Arbuckle

54

Median ButtressesMedian Buttresses“Increasing or decreasing the arc of the median buttress will allow the crista gali to fallmedian 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 bywiser 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) In an extremeHorizontal falx technique). In an extreme extension head we would rather allow the crista galli to fall permitting widening of the l t l ff th th id” (A/Plateral masses off the ethmoid”. (A/P compression- face with inion)

The Selected Writing of Beryl Arbuckle

55

Treatment of “Horizontal fibers of Falx” and increase the arc ofFalx and increase the arc of “Anterior Buttress”

• Lay the patient on their left side, a pillow under their head.their head.

• Place your left index finger along the anterior falx, right index finger along the posterior falx.g g g p

• Follow the PRM into extension, don’t allow if to go into flexion. After some time, maybe 5 minutes, the ysystem will become quiet, then go into flexion, and everything will soften.

Described by Robert Fulford 56


• Zygomatic pillar of the face-from the first l t th t th ti l f thmolar tooth to the zygomatic angle of the

frontalB i i d i th i f i• By increasing or decreasing the inferior convergence of the zygomatic pillars, change in the posterior divergence of the margins ofin the posterior divergence of the margins of the ethmoid notch of the frontal may be obtained.


Frontoethmoidal ManipulationFrontoethmoidal Manipulation

• To release anterior,To release anterior, and close laterally-

• Bil contact superior to psphenofrontal suture-W1/3R-medially.

• Lateral aspect of hard palate- W1/3R-l ll h lllaterally, then pull anteriorly

The Cranial Sutured, March PickThe Selected Writings of Beryl

Arbuckle58

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 FontanelleAnterior Fontanelle• Anterior fontanelle becomes

bregma after the fontanel gcloses and the sutures form. It is between the 2 halves of the frontal bone (metopic suture) ( p )and the 2 parietals.

• The metopic suture is open at birth separating the frontal intobirth, separating the frontal into 2 halves, from nasion to bregma. It ossifies during growth but retains a naturalgrowth, but retains a natural malleability, moving during flexion-extension, aided by the attachment of the falx “Theattachment of the falx. The cranial puzzle”

61

Bregma Treatment Part 1Bregma Treatment Part 1• Due to the overlapping of

the sutures the medial endsthe sutures, the medial ends of the coronal suture need to be treated first, then the

t i ti f thanterior portion of the sagittal suture.

• The medial end of the• 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 posteriorof the other hand is posterior to bregma, depressing caudad.


Bregma Treatment part 2Bregma Treatment part 2

• The sagittal suture isThe sagittal suture is treated with fingers on parietals, thumbs overlapped over the anterior part of the

t f di t dsuture, force directed posterior, inferior and lateralward Arbucklelateralward. Arbuckle


63

BregmaBregma

• Trauma at bregma. (trauma may be direct on area or indirect from a fall on the feet orarea or indirect from a fall on the feet or buttock). The bone is pushed inferiorly at bregma and forced laterally at pterion. This g y pwill restrict the great wing and the sphenobasilar. The sagittal suture will be depressed or one parietal lowered in relationdepressed 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 ArbuckleBeryl Arbuckle• Preserved Sutherland’s earliest approaches to

mobility diagnosis ( position and motion testing) andmobility, diagnosis ( position and motion testing) and treatment (direct).

• Refined the view of the reciprocal tensionRefined 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).

• Was way ahead of her time. 65

FORCEFORCE• Force= Foundation for Osteopathic Research

and Continuous Educationand Continuous Education• Do you believe that Osteopathic Medicine

should be the standard of conservativeshould be the standard of conservative medical care in America ?

• Need for research-evidence based medicine-eed o esea c e de ce based ed c epayment for treatment.

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• Grateful patients can donate. • Help us help you- Making Osteopathy a

household word.66

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lossing berylarbucklescranial

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