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Beryl Arbuckles Cranial Controversy in Controversy Thought

By Kenneth Lossing D.O.


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W.G. Sutherland D.O.


One morning in 1899, while still a student in Kirksville, on his way to class, class the idea for cranial mobility came from viewing Dr Stills Dr. Still s Beauchene disarticulated skull in the North Hall.

With Thinking Fingers, A. Sutherland

The First Thought


As I stood looking and thinking in the channel of Dr. Stills 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 like thought beveled the gills of a fish, indicating articular mobility for a respiratory mechanism W.G. Sutherland

With Thinking Fingers, A. Sutherland

Mobility y
Mobility is the state of being in motion. Mobility 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

Motility
Motility is a biological term which refers to the ability to move spontaneously and actively actively, consuming energy in the process. Again this term is absent from our Osteopathic Again, glossary So the brain and fluids move with motility and So, motility, the container, the skull, needs to be able to accommodate to this, and thoracic respiration. p

From Wikipedia, the free encyclopedia

Articular Mobility

A ti l mobility occurs i th b il Articular bilit in the basilar area, and that of the facial bones; such basilar mobility being accommodated through compensatory expansile and g p y p contractile service at the vault sutures So the question is: Is the mobility So, responsive to primary respiration, or thoracic respiration, or b th? It a th i i ti both? Its 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 mobility? normal


In his first book, the Cranial Bowl, published in 1939, Sutherland i 1939 S th l d used d position and iti d motion testing to diagnose the bones and sutures of the skull skull. The treatment techniques he describes are nearly all direct techniques. direct 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 balloon, easy t d f b ll to deform, and th spring b k d they i back. Most of our patients skulls are somewhere between a b k tb ll and a b li b ll b t basketball, d bowling ball. Could he have possibly meant that an adult skull could be nearly as freely moveable as an infant skull?

The current biomechanical terminology Visco-elasticity terminolog : Visco elasticit of Sutures


S iff Stiffness: tensile f il force/change i l / h in length 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 was 10 megapixels. d l i l The Load-Displacement Characteristics of Neonatal Rat Sutures The Cleft PalateSutures Palate Craniofacial Journal. Vol.37, McLaughlin
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Stress Strain Graph

Stress loading

Strain

unloading E 1

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.

Strain

Fundamentals of Biomechanics,Ozkaya

Modern science says


That the mobility or viscoelasticity of the sutures is specific, not arbitrary. t i ifi t bit A specific amount of force will create a specific amount of distensability and ifi t f di t bilit d movement, in a normally functioning suture. In a suture that is malfunctioning stuck or malfunctioning, stuck, locked, the normal amount of distensability is reduced or lost.

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Fronto Occipital Hold Fronto-Occipital Hold- 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


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Osteopathy in the Cranial Field, Magoun

Beryl Arbuckle D.O.


She started studying with Sutherland in 1942. S th l d i 1942 She assisted Sutherland in the i th early courses, l including the first course at a school Des Moines school, Moines, in 1944, where the Beckers 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 group of the teachers around t d f th t h d Sutherland. S th l d h d no problem with thi or with Sutherland had bl ith this, ith Arbuckle. Shortly afterward, she started teaching on her afterward own, with the assistance of Paul Kimberly had been on Sutherlands teaching staff, who also Sutherland s did direct cranial.

Related by Ruby Day to James Jealous

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Dr. Robert Fulford


Early student of Sutherland (1944 or 45) and Arbuckle (1953). Sutherlands courses were 2 weeks long at the g time. Stated many times that patients referred to him by other DOs, because the patient had not gotten better, ti t h d t tt b tt that had years of cranial, had heads that were balanced but balanced, locked up. Dr. Fulfords Touch 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 tried to absorb his teaching (Sutherland) We (Sutherland), but it didnt 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 the th cranial concept. i l 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 Do layer palpation into the dural head. layer. Fuford paraphrased: I Dr. Fuford-paraphrased: I place my hands on the head, I feel the membranes wind up, until they bust themselves loose. Sometimes it is so strong it knocks my hands clean off the t k k h d l ff th head. Afterwards, you can do what you want with the head.

Lecture at Cranial Academy, about 1995

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Variations
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 Fulfords Face test


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
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A 1 2 3

Posterior Skull Test


With the patient p supine, use your right hand on the sagittal suture, suture compress enough to catch the head, and lift it until , the occiput is unweighted. Use your left hand to translate the occiput left and right.
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Early Sutherland Diagnostic y 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

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Illustration of above sequence


Head anterior and to the left on atlas Flexion of the sphenobasilar with p sidebending rotation to the left Posterior divergence of condylar parts A P crowding of the g 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
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The Selected Writings of Beryl Arbuckle

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, bones/sutures then unlock the membranes. q The most frequent locked sutures are: Left occipitalpetrosal, right pterygo-palatine, left fronto-ethmoid . KL fronto ethmoid
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 Arbuckle side.
Cranial Sutures, Marc Pick 27

Force, Pressure Codes


S=surface level= initial contact W=working level= way between surface and rejection level=pliable counter-resistance R=Rejection level=major tissue resistance ( tissue hardens), pt discomfort. S W1/3R means t k th ti So, take the tissue t working to ki level force, then go 1/3 more of the way to rejection level level.

28 Cranial Sutures, Marc Pick

Sphenopalatine Manipulation
Contacts: Bilateral maxillas, inside of mouth near last molars W medial molars-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 Frontals metopic suture, extending laterally over e tending laterall o er supercilliary arches and maxillas-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 Sacrum- from Arbuckle Sacrum


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

The Selected Writings of Beryl Arbuckle

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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. here Below this the lateral articulations converge inferiorly inferiorly.
The Selected Writings of Beryl Arbuckle 32

Sacrum, Arbuckle
Use thumb on base and apex of the same side. Compress b C base t toward th d 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. reinforcement Exaggerate 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 throughout the otherwise yellow fibers, elastic tissue. Theses Theses stress fibers which follow a very definitely consistent pattern, are arranged in horizontal, vertical, transverse, circular, and spinal groups. i l 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 the th necessary forces in the desired di ti f i th d i d directions.

The Selected Writings of Beryl Arbuckle

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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

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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 area p 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 Blecshmidts 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 f function. 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 dura girdles thickened


3,8- right frontal , g dural girdle, anlagen of coronal and sagital sutures and sutures, part of falx. 4 right 4-right parietal dural 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 function to the f ti t th more rapid growth of the brain. Symposium on the Development p of the Basicranium
The Biokinetics of the Basicranium, Blechschmidt
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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 else thought about y g this?


Quantification of the Quantification Collagen fiber architecture of human cranial d i l dura 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 S Superior sagittal sinus i itt l i and calvarial section o tissue of t 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 and i d gross visual analysis.

Hamann, Sacks, Malinin, J of Anat Jan 1998

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Dura
The top picture is viewed with the eye, the bottom picture shows SALS applied to the th same area 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

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Near Coronal Suture


The collagen fibers are aligned in an anterior/posterior direction just behind the coronal suture, in the th area of the remnant f th t 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 falx, d f l and opening middle b i iddl buttress


Lay the patient on their left side, a pillow under th i h d id ill d their head. Place your left index finger along the anterior falx, right index finger along the posterior falx. F ll Follow the PRM i h into extension, dont allow if to go into flexion. After some time, , maybe 5 minutes, the system will become quiet, then go into flexion, flexion and everything will soften. Described by Dr Fulford 49

Buttresses
In the boney structure also p there are developed areas of greater density known as buttresses. Although this stage of development is not reached in infancy, the buttresses will be described here since understanding th i normal or d t di their l 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, basion to magnum basion, posterior wall of sphenoidal sinus
The Selected Writings of Beryl Arbuckle 51

Buttresses
Superior: Inion, sagital suture, frontal crest, t f t l t glabella, crista galli Lateral Oval: mastoid process, EAM th 2 EAM, then ridges. Outer: zygomatic bone to zygomatic process of frontal Inner: frontal. 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 f di ti from about th sella t i and i a b t the ll turcica d in 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 p posterior divergence thus allowing for a g g widening of the upper part of the lateral masses.
The Selected Writings of Beryl Arbuckle 53

Using the Buttress to mobilize the lateral ethmoids articulation th id ti l ti


To release lateral surfaces and close the anterior surfaces Frontals metopic suture, extending laterally over supercilliary arches and maxilla s W1/3R maxillas-W1/3Rposterior p Occiput-W/R anterior
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) In an extreme technique). extension head we would rather allow the crista galli to fall permitting widening of the lateral l t l masses off the ethmoid. (A/P ff th th id compression- face with inion)
The Selected Writing of Beryl Arbuckle 55

Treatment of Horizontal fibers of Falx Falx and increase the arc of Anterior Buttress
Lay the patient on their left side, a pillow under their head. Place your left index finger along the anterior falx, right index finger along the p g g g posterior falx. Follow the PRM into extension, dont allow if to go into flexion. After some time, maybe 5 minutes, the y 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 t th t the zygomatic angle of th l tooth to th ti l f the frontal B increasing or d By i i decreasing th i f i i the inferior 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

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Frontoethmoidal Manipulation
To release anterior, and close laterally Bil contact superior to p sphenofrontal sutureW1/3R-medially. Lateral aspect of hard palate- W1/3Rlaterally, then pull l ll h ll anteriorly
The Cranial Sutured, March Pick The Selected Writings of Beryl Arbuckle 58

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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
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Anterior Fontanelle
Anterior fontanelle becomes bregma after the fontanel g closes 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, birth separating the frontal into 2 halves, from nasion to bregma. It ossifies during growth, growth but retains a natural malleability, moving during flexion-extension, aided by the attachment of the falx The falx. The cranial puzzle
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Bregma Treatment Part 1


Due to the overlapping of the sutures the medial ends sutures, of the coronal suture need to be treated first, then the anterior portion of the t i ti f 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, force directed t f di t d posterior, inferior and lateralward. lateralward Arbuckle

The Selected Writings of Beryl Arbuckle

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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 and forced laterally at p g y 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

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Beryl Arbuckle
Preserved Sutherlands earliest approaches to mobility, mobility diagnosis ( position and motion testing) and 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) 65 Was way ahead of her time.

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