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339 Chapter 13 Neuromusculoskeletal plasticity of the craniomandibular region: basic principles and recommendations for optimal rehabilitation Renata Horst CHAPTER CONTENTS INTRODUCTION Introduction 339 This chapter proposes an integrative neuro- Neurobiological mechanisms: a basis for orthopaedic concept encompassing biomech- anics and neurophysiology to approach the modern rehabilitation 340 way the central nervous system (CNS) organ- Basic principles for treatment and further izes individual movements. management 348 The chapter consist of three parts: the first Case studies 350 part discusses the neurobiological background, the second part explains the basic fundamen- tals of the approach and the last part describes treatment procedures in detail using two case studies. The paradigm of the 1980s and early 1990s of physiotherapy was that passive mobilization of joint structures was sufficient to restore normal function. However, restoring function is more than just mobilizing joint structures; there is evidence that a goal is needed during activation of muscles to accomplish function. Function may be defined as the complex activity of the entire organism with the aim of accomplishing a specific task. Optimal func- tion entails behavioural strategies that are needed to reach a task-oriented goal within a relevant environmental context (Shumway- Cook & Woollacott 2001).
340 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Muscle activation and joint mobilization Bernstein (1967) referred to the ‘degrees of should take place during a meaningful freedom’ of joints, questioning how these are exercise in an environmental situation that organized by the CNS. Today synergies are is relevant to the patient. Performing struc- considered to be variable and are thought to be tural treatment during a functional and goal- organized subconsciously according to task oriented activity promotes movement learning. and environmental demands. Shumway-Cook The effect on articular, muscular and neural and Woollacott (2001) define synergy as a func- structures while the patient is carrying out tional coupling of groups of muscles which act functional activities can open up completely together as a unit (synonym: coordinative new treatment modalities for the therapist. structure). NEUROBIOLOGICAL MECHANISMS: A muscle that is needed within a synergy to A BASIS FOR MODERN enable the performance of a specific activity REHABILITATION may also take part in a different synergy to carry out a different function. Basic principles and mechanisms which are fundamental for neuromusculoskeletal plas- Grasping a glass which stands upright on a ticity as a treatment concept in rehabilitation table will require the activation of a different are summarized as follows: synergy than if the glass is upside down. If the glass were standing upright and a person were ● Plasticity: to use the same synergy as when it is upside ❍ Neural down, one would say that the movement is ❍ Muscular abnormal. However, it may be very normal for that person if weakness or pain creates the ● Skeletal necessity to reach the goal in this manner. ● Protective mechanisms Here again, the need for change will cause ● Inhibition and habituation adaptation. ● Reciprocal innervation ● Subcortical and cortical organization of An example of a synergy can be seen on opening the mouth to eat, when the depressors movement. and protractors of the mandible are usually activated and the neck extensors stabilize the PLASTICITY head, eccentrically (Clark et al 1993). The neck extensors work concentrically to move the Plasticity is the ability to adapt to functional maxilla away from the mandible, thereby demands. opening the mouth (Zuniga et al 1995). When tasks vary or environmental condi- This is in fact the movement strategy tions change, then variability in patterns of employed throughout evolution prior to homi- interconnections within the sensory and motor nids becoming upright. If you fix the mandible system, as well as changes in the effectiveness with both hands at the chin and then attempt of neural connection, are required for learning to open the mouth you will notice that this is (Kandel et al 2000). Plasticity can be divided in only possible through extending the head (see neural, muscular and arthrogenic. Chapter 5). Neural plasticity Specific areas of the brain control different parts of the body. It has been shown that Broca’s There are many collateral connections within area and the surrounding areas on both sides the brain allowing variability according to of the sulcus lateralis control not only speech, behavioural needs (Edelman 1987). but also the mouth and face region, as well as mimicry of facial expressions (Calvin & Muscle synergies needed to perform a func- Ojemann 1994). This makes sense, since many tional task are referred to as volitional or func- functional activities of daily living involve the tional synergies (Umphred 2001). interconnection of hand–mouth coordination,
Neuromusculoskeletal plasticity of the craniomandibular region: optimal rehabilitation 341 such as eating, speaking and writing. One just Leroi-Gourhan (1995) explains that the needs to look at the homunculus to see how development of speech and hand function close together the representations of mouth, occurred at the same time during evolution. face and hand regions lie (Dudel et al 1996) He hypothesizes that since the hands were no (Fig. 13.1). longer needed for quadruped locomotion, they were able to be used for other manipulative Hand Trunk functions. As quadrupeds we were dependent on the mouth for grasping, as are many Feet animals. With the development of the hand for manipulative functions the mouth gained the Jaw opportunity to develop a new function – speech. Larynx Medial Pharynx According to use, receptors demonstrate plasticity, causing synaptic transmission to Lateral become stronger or weaker. If certain body parts are not used – due to weakness, pain or Fig. 13.1 Somatotopic representation of the motor even fear of movement – then the cortical map representations will also change. cortex (reproduced with permission from Dudel et al Merzenich et al (1984) showed in experi- 1996). ments with monkeys that, in this case, neigh- bouring areas take over these sites (Fig. 13.2). Ramachandran and Blakesee (2001) showed that hand amputees feel their individual fingers on the face. Area 3b 3 4 2 Area 1 Body Face 1 1 2 52 D5 D4 1 3 Hand 3 4 D3 4 5 D2 5 D1 d Post stimulation a b Before stimulation c Fig. 13.2 Reorganization of the somatosensory receptive cortical fields in response to training. The representation of the fingers which were used more increased in contrast to those which were used less (reproduced with permission from Merzenich et al 1984). a Somatosensory zones 1 and 3b for the left brain in oblique view (receptive fields for the fingers of the right hand, D1–D5). b Receptive fields before training. c Right hand and skin surface as represented in the relevant cortical zones. The fingers marked with a circle were used for training. d Receptive fields after training.
342 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Phantom pain can be explained by this, It was long believed that it was not possible since the afferent information is misinter- to change slow twitch fibres into fast twitch preted. Ramachandran developed a box into fibres with training. Unexpectedly, however, which amputees put their intact hand. The box some evidence was found in sprinters to contained a mirror so that when the amputee suggest that this is possible (Andersen et al placed the amputated limb alongside it looked 2000). During their resistance training period as if they had two hands. In this way the the amount of slow twitch fibres diminished. amputee was able to minimize phantom pain Two months after resistance training, they (Ramachandran & Blakeslee 2001). attained the same amount of phasic fibres as they had had prior to starting training. The Visualizing body parts obviously enhances astonishing thing was that they acquired cortical representation. Even imagining muscle double the amount of fast twitch fibres 3 contractions can result in an increase in months later (Andersen et al 2000). maximal voluntary contraction (see also Chapter 1). Muscles must be able to change their length according to the demands of the activity and Yue and Cole (1992) performed a study in the environment. For eccentric control, which which subjects imagined muscle contractions is required for postural adjustments, it is nec- over a 4-week period. They showed more essary that they have the structural elasticity maximal voluntary contraction than those needed for this. who did no training, although less than those who had actually trained physically. Immobility leads to stiffness, which appears The same central structures that are to be caused by changes in tendon and connec- activated during the performance of motor tive tissues such as water loss and collagen actions are activated during mental training deposition (Van den Berg 2000). Animal studies (Pascual-Leone et al 1995). Even the use of have shown that immobilization in shortened visual imagery to plan a movement invokes positions causes loss of sarcomeres, which the same patterns of activity in the premotor results in shortening and increased stiffness and posterior cortical areas as those that (Tabary et al 1972, Williams & Goldspink 1978, occur during performance of the movement Witzmann et al 1982). (Krakauer et al 2000). Muscle stiffness is defined by the force Passive mobilization of the temporoman- required to change the length of a resting dibular joint may be more effective if the client muscle (Dietz & Berger 1983). envisions opening the mouth to bite into an apple while being mobilized. Since the neces- Coordinated, skilful movements not only sary postural adjustments for this task can require that task-related muscles be activated, only be organized with the trunk in an upright but also require appropriate agonist recruit- position it may be best to choose this as a start- ment. However, if the cortical representation ing position for treatment. has changed, this cohesive process may be impaired. Excessive contraction may result as Muscular plasticity an adaptive strategy in the attempt to gain more control, which, in turn, promotes loss of In addition to neural changes, muscles and other motor control and causes stiffness. soft tissues adapt according to functional demands and use. If muscles are not used, in Bone adaptation most cases, they will become atrophic. Training will, of course, cause them to grow in size again. Changes in bone mass occur according to changes in the pressure put upon it. Astro- The fibre type may also change. With nauts who have been in space for a long period increasing age, the ratio of fibre types becomes lose bone mass (Netter 1987). If too much pres- more phasic at the expense of tonic fibres. sure is put on joints osteophytes develop. The Some diseases also cause change in the types same principle applies to the growth of of muscle fibre.
Neuromusculoskeletal plasticity of the craniomandibular region: optimal rehabilitation 343 the skull (Oudhof 2001). More pressure on the grow and remodel in response to external skull causes more growth and asymmetry forces exerted by the soft tissue (Rocabado & (Proffit 1993). Iglash 1991). This is why it is important for the therapist to know what activities the client Even the shape of our skull has changed needs to perform in daily life. during the course of evolution. The jaw has become smaller and Broca’s area – where The patient’s occupational demands must manipulation of the tongue, face and hand also be considered. It makes a difference if the muscles is coordinated – has become much strategies needed are mainly in sitting or larger (Leroi-Gourhan 1995) (Fig. 13.3). Here during heavy weight-bearing activities. Thus again functional demands have led to adapta- the choice of rehabilitation should be in a func- tion over time. tional position that provides optimal input for the somatosensory cortex which in turn Structures can only take over the function influences the motor system as needed for for which they have been trained. Bones can function. only take on loads that they are used to. They i 10° B i B a b 40° 20° i i BB cd 70° 60° i B Bi ef Fig. 13.3 The skull changed its form during evolution and development of the brain. The surface of the cortex in the frontoparietal region became larger as time went on (reproduced with permission from Leroi- Gourhan 1995).
344 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT PROTECTIVE MECHANISMS injury but which are no longer needed after healing. When danger threatens an organism, the limbic system is alerted. A number of reactions INHIBITION AND HABITUATION occur automatically when the autonomous nervous system is triggered by a subcortical Habituation is defined as a decrease in respon- nucleus (amygdala) with the aim of protecting siveness that occurs as a result of repeated the organism (Le Doux 1996). exposure to a non-painful stimulus (Shumway- Cook & Woollacott 2001). As already discussed, muscles will alter their activity according to changing demands. Repeated application of stimuli that are not If protection of a body part is necessary for harmful or do not cause fear of pain lead to healing to occur, then the muscles will try to biochemical changes in synapses in different ‘freeze’ the painful and damaged body parts. parts of the nervous system which can promote The tongue, lips and teeth constantly feedback reorganization (Butler 2000). The organism information which enables central pattern gen- adapts to these inputs over time and habitua- erators to choose the best chewing stroke. As tion occurs (Kandel et al 2000). The CNS soon as an efficient chewing pattern that mini- becomes desensitized. mizes damage to any structure is found, it is repeated and learned (Okeson 1996). Desensitization based on the same system is used to treat allergy patients, using homeo- Why are protective mechanisms pathic doses of the allergen that causes the learned? immune system to overreact. These small doses give the organism a chance to get used Biochemical changes also occur with the aim to these stimuli and adapt. Experience has of protecting painful body parts against exces- shown that if movements which were painful sive movement. The concentration of hyaluronic are performed in a manner that the patient can acid decreases, leading to less joint play. Matrix cope with without fear, then these movements production also decreases, leading to less cap- can be repeated. sular mobility. In addition, connective tissue becomes less mobile due to activation of myo- RECIPROCAL INNERVATION fibroblasts (Van den Berg 2000). Reciprocal innervation is task specific (Pearson Even within the blood, changes occur. It has & Gordon 2000). a lower concentration of oxygen and more carbon dioxide. It also becomes more acidic During fast goal-oriented voluntary move- (Van den Berg 2000). This leads to less nutri- ments the CNS activates a triphasic muscle tion for the nerves and causes pain mecha- activation pattern (Beradelli et al 1996, Ghez & nisms to continue. Pain mediators such as Krakauer 2000) (Fig. 13.4). First the agonists of bradykinin, prostaglandin and serotonin are the target movement are activated (accelera- produced and transported within the nervous tion phase). Shortly before reaching the target, system (Le Doux 1996, Squire & Kandel 1999). the antagonists contract to decelerate, after which the antagonists fire a second time to Repeated harmful stimuli or even fear of stabilize the end position. these will keep these changes going and temporal summation may facilitate hypersen- Executing a voluntary movement in a given sitivity within the entire nervous system direction using concentric agonist activity (Butler 2000). Serotonin is a necessary requires that the antagonists ‘know’ what to neurotransmitter for long-term memory (Le do at each moment. Depending on the task, the Doux 1996, Squire & Kandel 1999). This antagonists may have to relax or may have to explains why it is so difficult to abandon the maintain co-contraction. Gravity determines changes brought about by the protective whether the antagonists have to control the mechanism which were sensible at the time of movement eccentrically.
Neuromusculoskeletal plasticity of the craniomandibular region: optimal rehabilitation 345 Feedforward Feedback a α β Feedforward Feedback Ball falls Elbow angle Ball hits Wrist angle h=0.8 m Biceps Triceps Radial flexor carpi muscle Radial extensor carpi muscle 0 200 400 600 800 b Zeit (ms) Fig. 13.4 Feedforward and feedback mechanisms are required when catching a ball. Co-contraction is needed before the ball reaches the hand and afterwards (reproduced with permission from Ghez & Krakauer 2000). a Starting position for the ball experiment. The therapist drops the ball from a height of 80 cm. b Average responses of a person catching the ball. The upper part of this graphic shows the angle at the elbow and wrist. The lower part shows EMG activity of relevant muscles.
346 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Example 1 The movement target will determine the form of reciprocal innervation, i.e. whether the Different types of movement require different antagonist which inhibits the target move- information. Feedforward plays a major role ment-performing musculature is inhibited or in quick movements, which can be understood coactivated. as a neural process based entirely on the brain’s knowledge and calculations regarding The same can be observed in the cranio- the planned movement (Berry et al 1995). The mandibular region: when opening the mouth, movement is too quick for feedback to play mouth-closing muscles such as the masseter, an important part. temporal, suprahyoid and lateral pterygoid are also activated through reciprocal innervation. Sensory feedback is necessary, however, to create the brain’s model of the movement in Changing environmental conditions may the first place and this process contributes also influence reciprocal innervation. If the to the acquisition of new motor skills goal is to stabilize the arm on a table when (Rosenbaum 1991). perturbation occurs on the other arm, then the triceps brachii will contract. If the goal is to Feedback is also needed for making stabilize the arm in the air when holding a cup corrections, especially if unpredictable during perturbations on the other arm, then changes occur during the execution of a the triceps brachii will not contract (Pearson & movement. When moving the hand to the Gordon 2000). mouth to eat something, the biceps brachii must contract concentrically and the triceps One could hypothesize that, during a goal- brachii must allow the motion to occur oriented voluntary movement when antago- (reciprocal innervation). nists should normally relax, they may instead coactivate in order to avoid movements that Example 2 have been painful or still are. In this way, the need for protection could be fulfilled. When catching a ball, both the biceps and triceps must co-contract, and do so before If opening the mouth to eat or speak has the ball is caught as well as afterwards, even been a painful experience, this experience has though it is the biceps that gets stretched a powerful influence on the elevators of the due to the weight of the ball (Ghez & mandible, which are suddenly inhibited. This Krakauer 2000). This coactivation of biceps kind of memory behaviour can have enormous and triceps, before the ball is actually consequences for activities needed for function caught, is dependent on visual information within the orofacial region. (feedforward). The impact of the ball provides proprioceptive information so that the biceps SUBCORTICAL AND CORTICAL ASPECTS can react (feedback). Anticipation of the OF MOTOR CONTROL destabilization also causes the triceps to contract. The central nervous system controls move- ments both voluntarily and involuntarily (Ghez Information required by the antagonists of a & Krakauer 2000) (Fig. 13.5). Distal muscles are particular movement is supplied through the controlled cortically, i.e. distal body parts move interneurone connections within the spinal in a goal-oriented fashion and require cogni- cord and these receive their input from tive, visual and acoustic information. The paths corticospinal and other descending path- for these run laterally within the anterior horn ways (Pearson & Gordon 2000). of the spinal cord and often have very few synaptic connections. To some finger muscles there may only be one synaptic connection. This is why we can move our fingers so quickly and skilfully. On the contrary, proximal muscles are controlled subcortically. These
Neuromusculoskeletal plasticity of the craniomandibular region: optimal rehabilitation 347 Perturbation Perturbation Neuromuscular control of joint stability is also dependent on proprioceptive information. a Support at the table Holding a mug If tension in joint capsules and ligaments Perturbation increases, then receptors within these struc- Average triceps EMC activity tures will transfer information to the spinal Support at cord, activating an automatic spinal reflex to the table activate joint stabilizing muscles (Pollack 2000). Holding a mug The ligaments and muscles function syner- –50 0 50 100 150 200 gistically in stabilizing, for example, the shoul- der. Experiments have shown that the axillary b Time nerve takes up afferent information from the joint capsule of the shoulder and causes activa- Fig. 13.5 Reciprocal innervation is task specific. tion of the rotator cuff. If this nerve is cut then the rotator cuff remains inactive upon stimula- The triceps is active when the hand is placed on a tion (Guanche et al 1995). table; however, it remains silent when holding a cup, In order to activate stabilizing muscles of the neck and head as needed for functional although all other conditions remain the same activities it is important that the upper and lower cervical spine are aligned and the trunk (reproduced with permission from Ghez & Krakauer and head are in an upright position. Head and trunk stability is required for mobility of the 2000). temporomandibular joint as needed for eating and speaking. paths run more medially in the anterior horn of the spinal cord and have many synaptic con- What does this mean for the nections. This is why muscles of the head and craniomandibular region? neck region can interact with muscles of the pelvic and sacral region for quick postural In summary, the following basic principles of adjustments. rehabilitation can be formulated: Since proximal muscles as well as eccentric ● Postural control is organized subcortically control needed for postural adjustments are and needs to be automated for optimal controlled subcortically, they require proprio- function. ceptive information. Proximal muscles are activated proactively during goal-directed ● Active manual techniques for the temporo- movements. For example, the trunk must be mandibular and craniofacial region, or stable before the arm moves towards an object, intraoral techniques (e.g. for the tongue), just as the head must be stable before tongue may have a beneficial effect on other body and mouth motions for speech and swallow- regions, especially the cervical spine and ing can occur. If the mandible is hypomobile trunk. then these functions cannot be executed. The temporomandibular joint then becomes the ● If this stability cannot be organized auto- fixed point of the movement which leads to matically, then more proprioceptive infor- stiffness and pain within this region. mation may be needed during the execution of these functions. ● Using proprioceptive feedback, such as having the patient try to activate muscles against a tactile resistance applied by the therapist, will not enable the organization of postural control as needed for functional activities.
348 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT ● For this, proprioceptive information must Example 3 be applied during the simultaneous execu- tion of voluntary functional mouth and If a thyroid tumour has been growing for tongue activities. some time, the neck muscles (e.g. sternocleidomastoid) may be stiff on the BASIC PRINCIPLES FOR opposite side to allow more room for the TREATMENT AND tumour. Rather than just passively stretching FURTHER MANAGEMENT the muscle while lying in supine, it may be more effective to activate the contralateral The use of appropriate treatment techniques sternocleidomastoid by asking the patient to during the execution of functional activities look upward towards the stiff side. This leads can support correct acquisition of such activi- to reciprocal innervation. At the same time, ties. Concurrent active pain management is manual lengthening of the stiff structure instigated if the patient is pain-free during applies tactile information so that the these activities. The therapist’s main goal, sternocleidomastoid ‘knows’ what to do therefore, is to influence structures so that during this activity. Having the patient look in functional activities can be performed without a specific direction gives them the necessary the patient feeling pain. visual information and doing so while seated will provide them with the necessary INFLUENCES OF PERIPHERAL AND proprioceptive information so that the CENTRAL MECHANISMS required muscle synergies needed for postural control may be activated. The Since immobilization causes so many undesired sternocleidomastoid muscle is believed to be changes, it is essential that it be no longer the prime muscular source of proprioceptive than necessary for healing to occur. Preventing input relative to orientation of the head in stiffness and contracture (peripheral events) space (Zuniga et al 1995). and encouraging cortical representation (central mechanisms) are the main therapeutic Facilitation of face muscles by simple verbal goals at this time. When structural healing instructions, such as asking the patient to con- occurs the patient has to be encouraged to learn sciously lift the eyebrows or to lift the corners that the protective mechanisms are no longer of the mouth to smile, may be less effective needed. than causing a situation in which the patient may feel surprised or happy, or combining Facilitation of meaningful activities these muscle expressions with sounds, such as: ‘oh’, ‘ah’ or ‘wow’. Facilitating the facial muscles As protective mechanisms can be considered while the patient is lying supine does not result as physiological adaptive strategies needed for in the same gravitational forces acting on the protection of the injured structures, the thera- face as usually experienced when performing peutic goal is to facilitate meaningful activities functional activities for real. during which necessary proprioceptive and/ or cognitive information may be applied, rather Avoidance of predominantly cognitive/ than merely inhibiting these compensatory affective influences activities at a structural level. Fear of pain may have an even more detrimen- tal influence on the course of therapy than pain itself (Butler 2000). The patient needs to learn to cope with pain and consider it as a normal
Neuromusculoskeletal plasticity of the craniomandibular region: optimal rehabilitation 349 reaction to the healing process during the for an object. However, as this control is not (sub)acute phase of injury. Systematic, repeated, required in side-lying, a different motor strategy pain-free movements reduce fear of movement, is employed than the one needed in ‘real life’. in particular with centralized pain patterns. Knowledge of functional anatomy and biome- Hands-on versus hands-off chanics, wound healing processes, pain mech- anisms and good communication skills are A further debate concerns hands-on versus essential for optimal patient management. hands-off approaches. In fact, the question may be easily answered by reviewing the As representations in the sensory and motor neuroanatomical aspects and considering how cortices appear to change in response to pain the CNS organizes voluntary motions. it is a very important treatment goal to facilitate the representation of these body parts. The During the execution of voluntary move- brain must be familiar with the movements, i.e. ments or the attempt to move towards a goal, they must make sense. Performing movements distal body parts should be facilitated with without a context will probably lead to fear and visual and/or acoustic information, whereas further activation of protective mechanisms. proximal body parts should obtain adequate proprioceptive information. For example, good Active versus passive movement qualitative mouth opening without give (e.g. mid-cervical extension) can be promoted by Since different areas of the brain are activated functional movements, such as bringing the if movements are executed passively or actively, hand to the mouth as if eating, for which the it may be preferable when learning to perform eyes follow the movement of the hand. actions actively to at least imagine them being performed actively during passive execution. Proprioceptive information may be supplied by using tactile stimuli such as facilitation, Passive movements activate the contralateral mobilization or the use of appliances, for primary and secondary somatosensory cortex example the use of a spatula against the teeth whereas active movements activate other areas during testing or treatment (see Chapter 8). needed for planning and coordination of func- Orofacial activities such as yawning, chewing, tional synergies such the basal ganglia, cerebel- talking, singing and kissing may need to be lum and the premotor cortex (Taub et al 1993). facilitated in patients with new splints to enable the brain to form an optimal response to this Reciprocal innervation, as mentioned above, new information. is task specific. It would therefore make sense to have a goal in mind when moving rather The isolated application of tactile stimuli than just being moved passively. The starting without conscious and goal-orientated move- position is also a controversial issue; for ment on the part of the patient does not support example, grasping a glass while lying on the this learning process. side is not very realistic, since swallowing isn’t easy in this position either. Tactile stimuli may also have a psychologi- cal effect. Touching an adapted area can One might argue that gravity exerts a demonstrably reduce the production of stress different effect in side-lying, so that elevating hormoneswhichpromotedegenerative changes the arm should be easier since elevation in of the hippocampus (Meaney et al 1995). The this position does not require force against hippocampus is an important structure of the gravity. Notwithstanding the fact that no limbic system which is concerned with storage movement against gravity is required, the of memories among other functions (Le Doux overall picture still seems more difficult as 1996). Combining daily movements with touch postural control is different in side-lying from (facilitation) so that these are felt to be positive that in standing. can also promote learning processes. The posi- tive psychological effect of touch should there- As already discussed, the entire head and fore not be undervalued. trunk control is activated in a feedforward manner, even by the mere thought of grasping
350 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT SUMMARY Fig. 13.6 A 52-year-old patient with facial and shoulder pain. The patient has problems chewing and Joint movements can be neuromuscularly a class III mesial bite. controlled through mobilization or stabilization of joint complexes during a normal movement. Either mobility or stability, or in some cases both, may be required for a particular movement. Movement components that are unconsciously organized should be facilitated proprioceptively, whereas movement components that are consciously organized should be facilitated through visual stimulation or mental visualization of the movement. Facilitation through sensory input depends on the individual’s sensory deficiencies and biomechanical and neuromuscular conditions that are relevant for the functional movement. CASE STUDIES Physical dysfunctions Details of the investigation and treatment of Overhead activities with the right arm are the two following case studies are only given not possible. She can carry plates, but not in brief, and are therefore incomplete. The without pain. During palpation, the muscles main aim is to demonstrate the application of of the craniomandibular region are painful, the principles described above. especially the masseter and lateral pterygoid on the right side. The same was found in the Case study 1 digastric and omohyoid muscles on the same side. A 52-year-old female presented with facial and shoulder pain. Past history shows that Treatment she was provided with a dental prosthesis for Reciprocal innervation for the her lower teeth 5 years ago. After 1 year it sternocleidomastoid (Fig. 13.7) had to be renewed. The patient has problems Starting position and method chewing and still has a mesial bite (Angle class III) (Fig. 13.6). She is a waitress and The patient is seated and is asked to look must carry plates in external rotation. Six upwards towards her right eyebrow. This months ago she started experiencing shoulder causes lateral flexion of the cervical spine to pain and a gradual decrease in range of the left and rotation to the right. The movement. Six weeks ago, she had a therapist stands on the left side of the synovectomy and mobilization under general patient and stabilizes the right clavicle and anaesthesia. sternum caudally with the left hand, while the right hand applies proprioceptive information for lengthening of the muscle
Neuromusculoskeletal plasticity of the craniomandibular region: optimal rehabilitation 351 Fig. 13.7 Reciprocal innervation of the sternocleidomastoid muscle. Fig. 13.8 Reciprocal innervation of the digastricus venter posterior muscle. belly. The therapist should monitor the Fig. 13.9 Eccentric activation of the masseter patient’s chin, so that not too much muscle. extension between C0 and C1 occurs. Eccentric activation of the lateral While still seated, the patient is again pterygoid muscle (Fig. 13.10) asked to look upwards toward her right Starting position and method eyebrow while fixating her hyoid bone with While sitting, the patient stabilizes her head her left hand and mastoid process with her with her left hand while actively mobilizing right hand (Fig. 13.8). This causes lateral her tongue to the right. This mobilizes the flexion of the cervical spine to the left and mandible to the right. This activity may also rotation to the right, during which be executed while the therapist applies lengthening of the right digastric muscle pressure towards the muscle belly with the occurs. The patient’s fingers give proprioceptive information during lengthening of the muscle belly. Eccentric activation of the masseter muscle (Fig. 13.9) Starting position and method With the patient seated, the therapist stands on the patient’s left side and fixes the zygomatic bone with the right hand. The patient is asked to open her mouth, during which traction is applied by the therapist’s left hand which is placed on the chin. This activity can be accompanied by having the patient depress her tongue, pushing it against the lower teeth. Care must be taken that the patient’s head is not pulled towards the therapist, as this would cause lateral flexion.
352 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Fig. 13.10 Eccentric activation of the lateral Fig. 13.11 Eccentric activation of the omohyoid pterygoid muscle. muscle. right index finger. The therapist’s left hand digastric muscle is under constant tension, stabilizes the patient’s upper jaw. placing the hyoid bone into a more cranial position. With this, more tension is placed on Eccentric activation of the omohyoid the omohyoid muscle. This, in turn, causes muscle (Fig. 13.11) protraction of the shoulder, so that Starting position and method subacromion compression occurs, especially The patient lies on her left side with the head on elevation of the arm and external and neck in partial lateroflexion to the left. rotation, which the patient needs for her job. The patient is asked to push the tip of her The majority of proprioceptive information tongue into her left cheek for which the originates from the craniocervical and therapist gives tactile information with the craniomandibular regions and enters the CNS left index finger. This stabilizes the hyoid (Schupp 2000). Because of the changes in bone. During active depression of the length and elasticity of these muscles, other shoulder the therapist facilitates caudal proprioceptive information relating to the movement of the superior angle of the position of the scapula is also transmitted. scapula with the right hand, giving proprioceptive information for lengthening of Conclusion and further procedures the muscle belly. It may be worth considering whether these Assessment before and after results can be maintained if the situation treatment (after six sessions) with the dental prosthesis is not dealt with. As long as malocclusion remains, inadequate The occlusion judged by the patient and the proprioceptive information will be a dentist remained unchanged. External predisposing factor for impaired function of rotation of the shoulder for grasping over and the craniofacial region. behind the head, as well as for carrying plates was improved. Palpation of the Further thought should be given to craniomandibular muscles was less painful. shoulder mobilization under anaesthesia. Since experiencing painless movements is so Hypothesis and a retrospective essential for motor learning to take place, it analysis Malocclusion causes changes in neuromuscular activity. For example, the
Neuromusculoskeletal plasticity of the craniomandibular region: optimal rehabilitation 353 may be worth considering having the patient passive flexion was severely restricted in this awake and aware of what is happening patient. The tongue is mobilized towards the during mobilization. If she sees the results, right with a gauze pad (Fig. 13.12). In this this visual experience could help her to plan position of the head, the left hypoglossal her movements better and to organize nerve is under less tension (for more functional synergies as needed for various information on the hypoglossal nerve, see tasks. Another possibility could be to record Chapter 18). the operation on video. Knowledge of results Inhibition of facial pain is one of the main criteria for motor learning, Starting position and method as is knowledge of performance (Schmidt & The patient is seated with her hand placed Lee 1999). Using the visual system aids comfortably on a table. The therapist planning and organization of goal-oriented mobilizes the scar tissue of the patient’s movements and helps the patient gain thumb without pain (Fig. 13.13). knowledge of performance and of results. Distraction of the temporomandibular Giving appropriate proprioceptive information joint (Fig. 13.14) while doing these goal-oriented movements Starting position and method also facilitates this learning process. With the patient seated, two mouth spatulas are placed between her left molars. She Case study 2 presses her chin upwards with her right hand while stabilizing her head with her left arm A 59-year-old female patient has a 20-year with the intention to press her front teeth history of migraine headaches accompanied together. This causes distraction at the by facial pain on the left side. Eight years temporomandibular joint. ago she had root canal treatment. Eight teeth were extracted, after which her migraine Fig. 13.12 Neurodynamic mobilization of the left headaches became rarer. She now has a hypoglossal nerve in a 59-year-old patient with diagnosis of soft tissue rheumatism and has a chronic migraine and left-sided facial pain. swollen temporomandibular joint about two or three times a year. She wears a dental prosthesis which does not fit when the joint is swollen. Physical dysfunction The patient’s main problem is that she still has frequent facial pain. Rotation of her head and neck towards the left is limited as is her mouth opening. Treatment Neurodynamic mobilization of the hypoglossal nerve Starting position and method The patient is seated. The therapist stands on her right side and stabilizes the head so that the craniocervical region is in lateroflexion of the cervical spine to the right. Active and
354 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Fig. 13.13 Repression of facial pain. The therapist Fig. 13.15 Reciprocal innervation of the scaleni performs a painless mobilization of the nerve tissue and infrahyoid musculature and mobilization of the at the thumb. hypoglossal nerve. Fig. 13.14 Distraction of the temporomandibular presses the tip of her tongue into her right joint. cheek to provide a fixed point for her hyoid bone. The therapist gives her tactile Reciprocal innervation of the scaleni information for the direction of the tongue and infrahyoid muscles and mobilization with the right index finger. During exhalation, of the hypoglossal nerve (Fig. 13.15) the therapist mobilizes the first and second Starting position and method rib as well as the sternum with the left hand The patient is in supine and asked to activate caudally. During inspiration, the therapist lateral flexion to the right to provide a fixed continues to apply pressure in a caudal point for the head and neck. In addition, she direction. The auxiliary breathing muscles are activated in their maximal lengthened position. Assessment before and after treatment Prior to treatment, the neurodynamic test for the hypoglossal nerve reproduced typical facial pain over the left eyebrow. After treating the scar on the thumb this pain disappeared immediately, and left rotation of the cervical spine improved from 45° prior to treatment to 80° afterwards. Retrospective analysis and hypothesis Since cortical representation of painful body parts diminishes and neighbouring areas overlap, it may be that the representation area of the face has been replaced by the hand. Treatment of the thumb led to a reduction in facial pain.
Neuromusculoskeletal plasticity of the craniomandibular region: optimal rehabilitation 355 Reciprocal innervation of the scaleni and SUMMARY—cont’d sternocleidomastoid as well as the infrahyoid muscles leads to increased cervical rotation. than it being a choice of techniques it Due to their activation in lengthened should be a choice of input systems, position, actin and myosin connections have which, in turn, depends on the patient’s changed, thus reducing stiffness and leading individual potentials and needs, as well to more optimal neurodynamics of the as the therapist’s neurophysiological hypoglossal nerve. knowledge as to how movements are planned and organized. SUMMARY Biomechanical and biomedical knowledge It is sensible to consider several as to how compensation strategies treatment options for craniomandibular evolve and are learned helps the dysfunction. Neural and muscular therapist choose alternative ways to interrelationships as well as functional facilitate functional activities. issues enable the therapist to consider several options for dealing with the Management of quality of life at a patient’s problem. functional level should be the dominant therapy goal, rather than merely The neural and muscular connections as influencing the quality of movement at a well as the functional relationships allow structural level. the therapist to choose different ways to attend to the patient’s deficits. Rather Interdisciplinary work with professionals from different fields is necessary to provide optimal management of patients with craniomandibular and related functional problems. References Dietz V, Berger W 1983 Normal and impaired regulation of muscle stiffness in gait: a new Andersen J L, Schjerling P, Saltin B 2000 Muscle, hypothesis about muscle hypertonia. genes and athletic performance. Scientific Experimental Neurology 79:680 American 283(3):48 Dudel J, Menzel R, Schmidt R 1996 Beradelli A M, Hallett J C, Rothwell R et al 1996 Neurowissenschaft. Vom Molekül zur Kognition. Single-joint rapid arm movements in normal Springer, Heidelberg subjects and in patients with motor disorders. Brain 119:661 Edelman G M 1987 Neuronal Darwinism: the theory of neuronal group selection. Basic Books, New Bernstein N 1967 The coordination and regulation of York movement. Pergamon, London Ghez C, Krakauer J 2000 The organisation of Berry M M, Standring S M, Bannister L H 1995 movement. In: Kandel E R, Schwartz J H, Jessell T Nervous system. In: Bannister L H, Berry M M, M (eds) Principles of neural science, 4th edn. Collins P, Dyson M, Dussek J E, Ferguson M W J McGraw Hill, New York (eds) Gray’s anatomy, 38th edn. Churchill Livingstone, Edinburgh Guanche C, Knatt Th, Solomonow M, Lu Y, Baratta R 1995 The synergistic action of the capsule and the Butler D 2000 The sensitive nervous system. shoulder muscles. American Journal of Sports Noigroup Publications, Adelaide Medicine 23:301 Calvin W H, Ojemann G A 1994 Conversations with Kandel E R, Schwartz J H, Jessell T M 2000 Principles Neil’s brain: the neural nature of thought and of neural science, 4th edn. McGraw Hill, New language. Addison-Wesley, Reading, MA York Clark G T, Browne P A, Nakano M, Yang Q 1993 Co- Krakauer J W, Pine Z M, Ghilardi M F, Ghez C 2000 activation of sternocleidomastoid muscles during Learning of visuomotor transformations for maximum clenching. Journal of Dental Research 72:1499
356 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT vectorial planning of reaching trajectories. Rocabado M, Iglash A 1991 Maxillofacial pain, Neuroscience 20(23):8916 musculoskeletal approach. J B Lippincott, Le Doux J 2000 The emotional brain. Touchstone, Philadelphia New York Leroi-Gourhan A 1995 Hand und Wort. Suhrkamp, Rosenbaum D A 1991 Human motor control. Frankfurt Academic Press, San Diego, CA Meaney M J, O’Donnell D, Rowe W et al 1995 Individual differences in hypothalamic-pituitary- Schmidt R A, Lee T D 1999 Motor control and adrenal activity in later life and hippocampal learning: a behavioral emphasis. Human Kinetics, aging. Experimental Gerontology 30(3–4):229 Champaign, IL Merzenich M M, Nelson R J, Stryker M P, Shoppmann A, Zook J M 1984 Somatosensory Schupp W 2000 Schmerz und Kieferorthopädie Eine cortical map changes following digital amputation interdisziplinäre Betrachtung kybernetischer in adult monkey. Journal of Comparative Zusammenhänge. Manuelle Medizin Neurology 224:591 Kieferorthopädie 38:322 Netter F H 1987 The Ciba collection of medical illustrations, Vol. 8, Musculoskeletal system. Part Shumway-Cook A, Woollacott M 2001 Motor controls. 1: Anatomy, physiology and metabolic disorders. Williams and Wilkins, London CIBA-Geigy Collection, Summit NJ Okeson J P 1996 Orofacial pain: guidelines for Squire L R, Kandel E R 1999 Gedächtnis Die Natur assessment, classification, and management. des Erinnerns. Spektrum Akademischer Verlag, Quintessence, Chicago Heidelberg Oudhof H A J 2001 Schädelwachstum und Einfluss von mechanischer Stimulation. In: von Piekartz H Tabary J C, Tabary C, Tardieu G et al 1972 J M (ed.) Kraniofaziale Dysfunktionen und Physiological and structural changes in the cat Schmerzen. Thieme, Stuttgart, p 1 soleus muscle due to immobilisation at different Pascual-Leone A, Dang N, Chen L G et al 1995 lengths by plaster casts. Journal of Physiology Modulation of muscle responses evoked by 224:231 transcranial magnetic stimulation during the acquisition of new fine motor skills. Journal of Taub E, Miller N E, Novack T A et al 1993 Technique Neurophysiology 74:1037 to improve chronic motor deficit after stroke. Pearson K, Gordon J 2000 Spinal reflexes. In: Kandel Archives of Physical Medicine and Rehabilitation E R, Schwartz J H, Jessell T M (eds) Principles 74:347 of neural science, 4th edn. McGraw Hill, New York Umphred D A 1995 Neurological rehabilitation. Pollack R G 2000 Role of shoulder stabilization Mosby, St Louis relative to restoration of neuromuscular control and joint kinematics. In: Lephart S M, Fu F H Van den Berg F 2000 Angewandte Physiologie für (eds) Proprioception and neuromuscular Physiotherapeuten, Bd. 1. Thieme, Stuttgart control in joint stability. Human Kinetics, Champaign, IL Williams P E, Goldspink G 1978 Changes in Proffit W R 1993 Contemporary orthodontics. The sarcomere length and physiological properties in development of orthodontic problems. Mosby Year immobilized muscle. Journal of Anatomy 127:459 Book, St Louis, p 139 Ramachandran V S, Blakeslee S 2001 Die blinde Frau, Witzmann F A, Kim D H, Fitts R H 1982 Hindlimb die sehen kann. Rowohlt, Reinbek immobilization: length-tension and contractile properties of skeletal muscle. Journal of Applied Physiology 53:335 Yue G, Cole K J J 1992 Strength increases from the motor program: comparison of training with maximum voluntary and imagined muscle contractions. Journal of Neurophysiology 67:1114–1123 Zuniga C, Miralles R, Mena B et al 1995 Influence of variation in jaw posture on sternocleidomastoid and trapezius electromyographic activity. Cranio 13(3):157–162
357 Chapter 14 The neurocranium: assessment and treatment techniques Harry von Piekartz CHAPTER CONTENTS INTRODUCTION Introduction 357 This chapter will discuss how the therapist can examine the patient with craniofacial dysfunc- Definitions and guidelines for passive tion through the use of passive movements. movements 357 It is described in an open thinking model and is divided into three parts, which will be General techniques for the discussed in the following order: neurocranium 362 ● Introduction to the nature of passive move- Specific techniques of the ments which can be applied in the cranio- neurocranium 367 facial region ● A general introduction to techniques and the reasoning behind them ● More detailed techniques from each neuro- cranial bone region. DEFINITIONS AND GUIDELINES FOR PASSIVE MOVEMENTS Passive movements (movements which are performed actively by the therapist) as manual skills play a large part in the assessment and treatment of the craniomandibular and cranio- facial regions. Aspects of these passive movements, which are the basis of these guidelines, are: ● Types of passive movement ● Dose ● Normal response. For documentation, specific abbreviations will be presented and advice for the interpretation
358 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT of pain responses during investigation will be tissues and biological mechanism, nothing given. more’ (Grieve 1995). Grieve’s statement can be interpreted as showing that passive move- TYPES OF PASSIVE MOVEMENT ments are not only restricted to physical changes of body tissue but that they also influ- Passive movements can be divided into two ence the whole person. This would mean that basic types: the value of placebo may not only be unilateral. This could be used by therapists in a positive ● Physiological movement: Movement that way in patient management. Accessory move- could otherwise be performed actively by ments of craniofacial bone tissue could be the patient. expected to have a similar effect. Therefore we have to define the accessory movements as ● Accessory movement: Movement that follows: cannot be performed actively by the patient, but which can be performed by another ● In which direction is the accessory move- person. Accessory movements are necessary ment applied by the therapist? for normal physiological joint movements. For example, lateral transverse movement of ● Which grade of movement is to be used? the mandible cannot be actively performed ● What changes are possible in response to the but is a movement which is necessary in order to be able to open the mouth. technique (in terms of signs and symp- toms)? This should be achieved through a ! Both physiological and accessory constant process of (re)assessment of clini- cal evidence (Yen & Suga 1982, Reynolds movements are possible in the 1987). craniomandibular region, but only accessory movements in the cranium. Definition of the direction of the accessory movements Definition of cranial accessory movements The direction of movement in which the thera- pist applies pressure is simple to understand It is important to define the terminology used and to describe, without having to use difficult to describe movement. In the literature many analyses of movement direction around the descriptions are given. For example, biome- artificial axes of biomechanical models (van chanical systems define movement in relation der Bijl 1986). You are free to use this model to to three imaginary axes through the body assist in the interpretation of clinical patterns, which are labelled X, Y and Z (Boyling et al but it is not obligatory. For example, osteopaths 1994). The anatomical system defines move- use a biomechanical model to describe ments in three planes, namely sagittal, coronal the classic sphenobasilar dysfunction, which and horizontal. All movements can be defined occurs when the sphenobasilar (spheno- as translation and/or rotation in any of these occipital) joint is fixed in a flexion position three planes. Clinically it is not known pre- (Cottam 1984, Margulies et al 1990). In the cisely what happens biologically or mechani- author’s opinion such biomechanical hypothe- cally when accessory movements are applied ses provide one basis from which to make a to the cranial bones. Grieve stated: ‘We do not clinical diagnosis (Yen & Suga 1982). There are know what the application of passive move- other hypotheses to explain the changes that ments does on the living human body. The therapists see in the clinic. only thing we can say is that it influences Reassessment using active, flexible and non-dogmatic thought processes allows the therapist to assess which examination tech- niques are most relevant for each individual patient (Yen & Suga 1982, Reynolds 1987). It is
The neurocranium: assessment and treatment techniques 359 clinically useful to use the biomechanical axes GRADES OF PASSIVE MOVEMENTS to determine the direction of the accessory movements. Some advantages of this are (Fig. The grades of passive movements described by 14.1): Magarey (1988), Maitland (1986), Jones et al (1994) and Maitland et al (2001) can be applied ● Biomechanical and anatomical knowledge to the cranium (Christensen 1967, Reynolds is of secondary importance compared to an 1987). Passive movements of a joint may be analysis of the response to the techniques. considered to begin at a defined point (A) and end at a defined point (B) with normal resist- ● Artificial axes on the cranium are simple to ance to movement occurring between the two, visualize. i.e. through range. The grades of movement can be defined as: ● Angulations and modification of the acces- sory movement can be described more Grade I: A small amplitude movement in easily. the resistance-free range The possible axis co-ordinates are: Grade II: A large amplitude movement within the resistance-free range ● The Y-axis is a longitudinal axis with longi- (R1 = first resistance) tudinal movements to cranial and caudal and rotation to left and right. Grade III: A large amplitude movement into resistance ● The Z-axis is a sagittal axis with anterior– posterior movement and posterior–anterior Grade IV: A small amplitude movement into movement; rotations are to the left and the resistance. right. Grade III and IV movements are of the same ● The X-axis is a transverse axis. Transverse strength but of different amplitude (Fig. 14.3). movement to medial and lateral and rota- tions to anterior and posterior are possible For more detailed information the reader is (Fig. 14.2). referred to the work of the above-mentioned authors. All movement analyses of passive Accessory movements of the craniomandibular region These are discussed in detail in Chapter 8. 1. Transverse laterally lat. 2. Transverse medially med Y 3. Longitudinal caudal caud X 4. Longitudinal cranial cran Z 5. Anterior–posterior Fig. 14.2 The three virtual rotation axes of the head: longitudinal (Y), sagittal (Z), and transverse 6. Posterior–anterior (X). 7. Rotation about X-axis transv, transv or (transverse axis) (x), (x) 8. Rotation about y-axis long., long. or (longitudinal axis) (y), (y) 9. Rotation about z-axis sag., sag. or (sagittal axis) (z), (z) Variation by angulation of these movements is possible Fig. 14.1 General accessory movements and their abbreviations.
360 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT I II III IV clear, a decision can be made about dosage A R1 B (grade and movement) of the accessory movement that will be used to progress treatment. A NORMAL RESPONSES DURING B ASSESSMENT OF THE CRANIUM BY ACCESSORY MOVEMENTS Fig. 14.3 Grades of movement that can be applied to the cranium. The natural compliance of The range of motion of cranial facial bone craniofacial tissue allows early resistance (R1) and a tissue examined by accessory movements is small range of motion (AB line) during general very small and different qualities can be passive movements. In this model the AB range is recognized. In the following paragraphs the 3 mm. A: dotted line: start of passive movement. possible qualities are briefly described, seen in B: dashed line: end of passive movement. a person without symptoms: movements on different joints have their own ● Range of movement qualities. For example, posterior–anterior ● Onset of resistance movement of the shoulder differs in range, ● Local pain: onset and progression of resistance (R) and end-feel to that of the posterior–anterior move- ❍ No local pain at end of range ment of the thoracic spine. Likewise the ❍ Strong accumulating or increasing pain cranium has its own particular qualities. ❍ Local pain at the onset of resistance. POTENTIAL CHANGES IN SIGNS Range of movement AND SYMPTOMS FOLLOWING ACCESSORY MOVEMENTS From the literature it is known that cranial bones have only a small range of movement (a Because you never know for each individual few millimetres) and that this will vary in rela- patient exactly what the effects of cranial tissue tion to the location of the movement and age mobilization will be, it is useful to describe the of the subject (Retzlaff et al 1975, Enlow 1982, movement directions, starting positions and Oudhof 1982). Clinical observation is that grades. Whether the technique chosen for an the range of motion varies from 0–1 mm individual patient is valuable depends on reas- (e.g. occipital–parietal region) to 0–5 mm sessment of the signs and symptoms. This is (e.g. occipital–sphenoidal region). then the clinical evidence for this technique on this patient (Yen & Suga 1982, Reynolds 1987). Onset of resistance Once the patient’s reaction to the technique is The resistance to passive movement in every direction on the cranium usually starts early. Therefore a grade II accessory movement is difficult to perform and examination and treat- ment of these joints is mostly with grade III or IV (see Fig. 14.3). Local pain The experience of many therapists on individ- uals without symptoms in the head region follows four general patterns that are princi- pally input-based mechanisms (nociceptive and peripheral neurogenic):
The neurocranium: assessment and treatment techniques 361 ● No pain at end range: Often seen in the ● Confirmation of the dominant classification most mobile articulations such as occiput– of pain from which the patient is suffering sphenoid, nasofrontal and frontal– zygomatic regions. ● Explaining sensitivity and secondary hyper- algesia to the patient in order to reduce the ● Strong accumulating pain during the patient’s fear or hypochondriac thoughts manoeuvre and a decrease directly after (this strategy can be very helpful for further the manoeuvre: Seen in regions with a small management strategies, i.e. processing) range and a strong accumulative resistance during the manoeuvre. Some examples are ● Helping the patient to understand that not the occiput–parietal, petrosal–temporal and every stimulus on the head has to increase zygomatic–maxillary regions. the symptoms. ● Pain at the onset of first resistance (R1), For a more philosophical background, see which increases together with increasing Chapter 1. resistance: This can be more of an iatro- genic cause. Perhaps the contact of your ABBREVIATIONS FOR RECORDING hands is uncomfortable or the technique is performed too quickly and results in pain Because most of the 14 craniofacial bones (see and spasm with a strong accumulating Chapter 2) are easily palpable with many character during increased range. You have possible passive movement directions, is it to assess firstly the rhythm and secondly the important to make frequent short recordings starting position of the applied accessory of findings. movement. A slower rhythm of examination (one manoeuvre longer than 2 seconds) can In addition, adequate recording gives you change the pain behaviour. If it is still the the opportunity of ‘learning by doing’ and same you should change points of contact, thus recognizing clinical patterns retrospec- for example thumb techniques during move- tively (Christensen 1967, Schon 1983, Reynolds ment of the parietal–parietal and temporal– 1987). Therefore, simple additional abbrevia- parietal regions. tions for the cranial bones are required. Clini- cally the skull bones can be defined into two CRANIOFACIAL INVESTIGATION AND groups: the coupled bones and the uncoupled PAIN CLASSIFICATION bones. Recommended abbreviations are shown in Table 14.1. Therapists need to consider that the pain they are evoking does not necessarily arise from the The uncoupled bones form the skull base tissue under the hands. Input-based mecha- and the coupled bones are situated to the left nisms (e.g. nociceptive and peripheral neuro- and right of the base. For the uncoupled bones genic mechanisms) have the tendency to have the side which is examined can be described a local, on/off pain pattern accompanied by as left (L) or right (R). You can draw a line clear dysfunctions (Gifford 1998). The other under the bone which is examined or treated side of the spectrum are those patients without for convenience. The next step is recording the clear dysfunctions and a diagnosis such as sto- signs and the symptoms and, lastly, the grades. matodynia (pain in the mouth), atypical odon- Some general examples of recording are talgia, or atypical facial or idiopathic orofacial given: pain. These can be categorized as mainly processing and/or output mechanisms (Okeson ● Physical examination (P/E) 1996, Gifford 1998, Butler 2000, Woda 2000). Therefore passive craniofacial techniques are a • lat O/S 1/2 restrict. P↑↑ IV valuable instrument for: Transverse movement to lateral of the occip- ital bone while holding the sphenoid bone is approximately half as stiff in comparison with the other side, and reproduces symptoms at grade IV of passive accessory movement.
362 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Table 14.1 Functional classification and comments on the different bones the reader is notation: recommended abbreviations for the referred to the specific techniques in Chapter central (I) and paired (II) bones 15. For the purposes of this text, the starting position of all general techniques is that the Abbreviation patient lies supine on the plinth and the thera- pist stands or sits on the right side of the plinth. I P Any glasses, non-fixed dental prostheses and Parietal bone T pocket contents are removed before starting Temporal bone Pe the techniques. Petrosal bone Z Zygomatic bone M WHAT IS MEANT BY GENERAL Maxillary bone N TECHNIQUES AND WHAT ARE THE Nasal bone Pa INDICATIONS FOR THEM? Palatine bone La Lacrimal bone General techniques mean: II O ● First 'screening tests' by manual application Occipital bone S which gives an idea about which region of Sphenoid bone E the cranium may be relevant for the patient’s Ethmoid bone F problem. The parameters that can be meas- Frontal bone V ured are stiffness and response of the Vomer patient. PR/FV P↑ IV ● The techniques are based on subtle changes in the compliance and stress of cranial tissue On rotation of the right parietal bone to the as further described in this chapter under right about the transverse axis relative to the specific techniques. Therefore these tests frontal bone, resistance to grade IV move- are applied to different regions in different ment is no different from that on the oppo- directions. They are the techniques with site side. However, the beginning of symptom which you start and have the following onset is observed with a grade IV functions: movement. ❍ To obtain a general impression about ● Therapy (Rx) conditions such as severity, irritability and pain Rx • caud P/P II 2″ ❍ To supply information about which region has (relevant) dysfunction related A longitudinal caudal movement for 2 to the patient's symptoms and to provide minutes at grade II is applied to the right a platform with which to examine that parietal bone while stabilizing the left region with more specific techniques parietal bone. ❍ To allow the patient to get used to cranial techniques in general. For more information on abbreviation and recording, see Butler (2000) and Maitland et al In most cases five general techniques are nec- (2001). essary to get an impression of the condition of the neurocranium (Fig. 14.4): GENERAL TECHNIQUES FOR THE NEUROCRANIUM ● Compression techniques for the occipito- frontal region In this part of the chapter the main general cranial bone techniques are discussed. For ● Compression technique for the occipital general topographical details and clinical region ● Compression and distraction of the frontal region
The neurocranium: assessment and treatment techniques 363 Cranium Neurocranium • General techniques • Craniomandibular • Specific techniques • Craniocervical • Nervous system Viscerocranium • Others • General techniques • Specific techniques • Compression techniques for the occipitofrontal Fig. 14.5 General compression technique in the region occipital–frontal region. • Compression technique for the occipital region then makes a posterior movement with the • Compression and distraction of the frontal right hand. region If the therapist has gained insufficient infor- • Rotation and compression techniques for the mation, but still has the feeling that this general technique might be relevant, variations in the temporal region direction of movement might be chosen: • Compression and distraction of the parietal region ● Diagonal movements of the frontal and Fig. 14.4 General techniques of the neurocranium. occipital bones ● Rotation and compression techniques for ● Transverse movements of the occipital or the temporal region frontal bone ● Compression and distraction of the parietal ● Rotations around the sagittal, longitudinal region. and transverse axes. Compression techniques for the ANGULATION (DIAGONALS) occipitofrontal region Changes of the axis and the position on the Starting position and method two bones during these occipital–frontal tech- niques may also change stress levels through- The patient lies supine and the therapist is out the cranium and cause other responses. seated to the right of the patient with the right In the clinic, the following two diagonals are hand resting on the plinth. The therapist holds used most frequently: the patient’s occipital bone with the tips of the fingers on the left side. The therapist’s left hand ● With one hand on the left lateral side of the is placed on the frontal bone, keeping both occipital bone, the other hand grasps the elbows flexed, thus maintaining contact with right part of the frontal bone. the trunk. The therapist applies increasing pressure with the left hand posteriorly while ● With one hand on the right lateral side of the at the same time moving the right hand ante- occipital bone, the other hand grasps the left riorly in the opposite direction, thus increasing part of the frontal bones (Enlow 1982). pressure on the cranium. The therapist grasps with the whole volar side of both hands so that This diagonal technique is frequently the pressure is evenly distributed (Fig. 14.5). an appropriate and harmless technique in the examination and treatment of babies The same starting position can be used for and young children with (secondary) the traction technique. The therapist starts with the hands in the same position, makes an anterior movement with the left hand (avoid- ing squeezing the thumb and fingers together),
364 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT plagiocephaly. Differences noticed with the ROTATION ABOUT A LONGITUDINAL AXIS hands, resistance and sometimes (non-verbal) Starting position and method responses are easy to observe. It is often used as one of the first treatment techniques. With the patient lying supine, comfortable and relaxed, with the head resting on the plinth, TRANSVERSE MOVEMENT FROM RIGHT the therapist holds the frontal bone with the TO LEFT, WITH EMPHASIS ON THE volar side of the left hand, cradling the occipi- OCCIPITAL REGION tal bone in the right hand. By shifting the body Starting position and method weight to the left, rotation to the left is per- formed. There should be no increase in pres- Once the patient is lying comfortably in a sure through the thumbs or index fingers. supine position with the head resting on the plinth, the therapist takes the occipital bone in ! The same technique can be used the right hand as for the compression tech- nique. This time the forearm needs to be per- for rotating the occiput to the right. pendicular to the lateral side of the occipital Alternatively, it is possible to combine bone. The therapist first increases the pressure movements to move the occipital bone to from the right hand by holding the right hand the right while simultaneously moving the steady and moving the body, followed by the frontal bone to the left. To rotate in the right arm and right hand in the transverse opposite direction it is easier to start with direction. reversed hand positions. TRANSVERSE MOVEMENT TO RIGHT WITH ROTATION ABOUT A TRANSVERSE AXIS EMPHASIS ON THE FRONTAL REGION Starting position and method Starting position and method For this approach it is necessary to rotate the In the same starting position, the therapist frontal bones around an imaginary axis which places the left hand touching the patient’s runs through both temporal bones. The thera- frontal bone with the left forearm perpendicu- pist’s trunk is slightly flexed and the right lar. Without increasing the tension in the shoulder is slightly elevated and protracted. forearm, the therapist rotates the trunk from Control is maintained by anchoring the elbow left to right so that the grip tightens in both to the trunk and keeping a firm hold with the hands. right forearm on the patient’s occipital bone. These principles should be maintained for post- ROTATION ABOUT A SAGITTAL AXIS erior rotation. The therapist should hold the Starting position and method trunk in slight extension with the shoulder slightly depressed. From this position it is With the patient in supine position and the possible to perform occipital bone movements hands still holding the occipital and frontal with or without frontal bone movements, bones, the therapist applies a rotary force rotating to the left or right. around the sagittal axis with the thenar and hypothenar eminencies of the left hand on the COMBINATION OF TECHNIQUES USING lateral sides of the frontal bone. The therapist ROTATION ABOUT AN AXIS moves the fingers of the right hand down- Starting position and method wards, rotating to the right. For rotation to the left, the movement is reversed. A combination of techniques with rotation around axes is also possible. For example, These rotation techniques can be combined. rotation to the right around the transverse axis For example, the occiput can be rotated to the of the frontal and occipital bone or rotation right while the frontal bone is rotated to the left, or both can be rotated simultaneously to the same side.
The neurocranium: assessment and treatment techniques 365 around the longitudinal axis may both repro- duce the patient’s symptoms. A combination of these two movements may be applied to provoke symptoms where it is considered appropriate. ROTATION OF THE TEMPORAL REGION Fig. 14.6 General technique: rotation about a Starting position and method transverse axis in the temporal region. With the patient lying supine and comfortable increased pressure on the neck muscles. The on the plinth, the therapist rests the forearms therapist slightly adducts both upper arms, on the plinth and holds the dorsolateral side of keeping the trunk in slight flexion to avoid the patient’s temporal bone directly behind the creating increased tension. ear canal with the right hand. The therapist places the little or ring finger of the right hand If the responses are minimal, rotating in the external auditory canal and the thumb around the transverse and sagittal axes may of the same hand on the temporal part of the provide more information (Fig. 14.7). pars squamosa. The middle and index fingers of this hand should rest on the upper and ! Anatomically speaking, these types of lower sides, respectively, of the zygomatic process of the temporal bone. The same pro- technique can be used to influence the cedure takes place with the left hand and the hypoglossal canal and the foramen magnum. left temporal bone. In the clinic, patients have often reported that this technique is beneficial for dorsal It is now possible to initiate rotation around and frontal headaches, saying that it gives the transverse axis towards posterior and ante- them a ‘relaxed feeling’. Osteopaths have rior, comparing stiffness and responses. The advocated direct manoeuvres for the therapist must be careful that the movements occipital bone as a key relaxation technique. come from the trunk and that the lower arms The techniques may also influence changes stay perpendicular on the lateral side of the in the behaviour of mandibular depression head. When the pressure is spread over all movements, particularly during fingers the patient does not feel a local pres- craniomandibular dysfunction or pain. After sure of the fingers. In this starting position sustained pressure the patient will often other movement directions are possible, such show latent autonomic reactions such as as longitudinal caudal or cranial, anterior– sweating, a warm feeling, dizziness or posterior or posterior–anterior (Fig. 14.6). changes in breathing patterns. This is seen particularly after craniocervical and General compression technique for the craniofacial traumas such as post-whiplash, occipital region or pain following fractures in the neurocranium. Starting position and method With the patient lying supine, comfortable and relaxed, the therapist sits at the patient’s head, elbows resting on the plinth. The therapist positions their cupped hands so that the patient’s head is resting in them and then con- tacts the occipital bone, taking care not to contact the petrosal bone. Slight pressure is applied simultaneously via both thenar emi- nences, avoiding extraneous movement and
366 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Fig. 14.7 General compression technique in the compression (anterior–posterior) and rotations occipital region. around the sagittal and transverse axes. Fig. 14.8 General distraction technique in the ! The experience of patients is that this frontal region. technique relieves dull headaches, and Distraction of the frontal region causes a general relaxed feeling in frontal Starting position and method sinus pain, often independent of the diagnosis. Therefore the frontal traction The patient lies supine, comfortable and technique and its variations can often be relaxed with the head resting on the couch. used as a first treatment to reduce pain and The therapist is seated behind the patient, with to allow the patient to get used to this type the trunk making slight contact against the of treatment (Fig. 14.8). patient’s head. Both elbows are flexed and are resting on the plinth. The thenar and hypoth- Compression and distraction of the enar eminences of both hands contact the parietal region frontal bone. To ensure a good grip, a slight pronation of both hands is made to take up the Starting position and method ‘slack’ of the skin. In this position the therapist tries to initiate a movement in the posterior– The therapist sits behind the patient, who is anterior direction whereby the elbows lying comfortably in supine on the plinth. The move a little over the table towards the patient’s therapist slightly flexes the trunk so that the head. Variations of these movements are sternum faces the highest point of the sagittal suture. With both forearms in pronation, per- pendicular to the lateral sides of the cranium, the therapist takes the parietal bones in both hands. The therapist then moves the hands slowly towards the middle of the patient’s body, ensuring that the pressure is evenly dis- tributed between both hands. For traction, the therapist slowly moves the trunk toward anterior while at the same time trying to move both hands laterally. Both hands keep contact with the parietal bones during the manoeuvre. During compression, the trunk is moved approximately 10° dorsally so that a bilateral movement medially can be initiated with both hands. Rotation around a transverse axis is a good alternative if nothing relevant is found. ! It is known that general movements in the parietal regions can produce latent autonomic reactions. Responses such as dizziness, sweating, quick temperature changes or feelings of relaxation for several seconds or even minutes are not uncommon (Fig. 14.9).
The neurocranium: assessment and treatment techniques 367 Specific techniques ‘Specific’ here means ‘more detailed’ and ‘local’ means passive movements of a specific cranial bone structure where clear (relevant) dysfunc- tion and symptoms are suspected to originate. In general: Fig. 14.9 General techniques: distraction and ● One cranial bone will be held, usually in the compression in the parietal region. starting position, as described during the general techniques. FURTHER STEPS TO FOLLOW AFTER THE GENERAL TECHNIQUES ● Different movement directions of different adjacent cranial bones will then be How much dysfunction is present and the examined. degree of symptoms, as well as the mental and physical capacity of the patient, are important For example, during assessment using factors which help the therapist to decide general techniques, a patient with headache which pilot treatment or specific techniques to following a skull floor fracture has asymmetri- choose. cal stiffness and pain responses from the occipital region. As there is enough time, the Pilot treatment history is stable and an irritable situation is not present, the therapist decides to examine A pilot treatment can be viewed as a test treat- the patient further using specific accessory ment to see if the craniofacial dysfunction and movements of the parietal, temporal and symptoms can be influenced by one or more sphenoid region stabilizing the occipital bone. general techniques. Reassessment after more The therapist plans to make a pilot than 24 hours usually provides the answer as treatment of one or more movement directions to the relevance of the chosen techniques to provoke the most dysfunctions and/or (Maitland et al 2001). symptoms. Age, irritability of the problem and time It is important to emphasize here that the pressure are factors influencing the choice for therapist had already undertaken the general a pilot treatment. For example, during the first techniques before performing these ‘specific’ examination of a restless young child a specific techniques and has a good understanding of examination has no use. A 58-year-old female the pain state of the patient’s problem. Some patient with a fear of dizziness gets a mild of the more common specific techniques are increase of her symptoms during the first discussed in the following section. examination. In this case it is wise to leave the specific techniques alone and choose a stand- SPECIFIC TECHNIQUES OF THE ard craniofacial technique to try to reduce the NEUROCRANIUM dizziness. Some further points need to be emphasized regarding the special neurocranial treatment techniques already discussed in Chapter 13. The starting position for the majority of techniques is with the patient lying supine and the therapist sitting or standing on the right- hand side of the plinth. Glasses, non- permanent dental prostheses and pocket
368 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT contents should be removed. Six cranial bones The occipital, sphenoid, temporal, petrosal, and their anatomical relation to neighbouring frontal and parietal regions of the neuro- bones will be pointed out. The connections are cranium can be considered for the specific not described as ‘sutures’, ‘junctions’ or ‘joints’ techniques and will be described. The main but as ‘regions’ because the manual techniques accessory movements for these bones will be influence different cranial tissue, not just the covered below and, where necessary, sutures (for more information on this subject, cross-referenced. see Chapter 1). THE OCCIPITAL REGION Before the starting position and the method, the clinical relationship is exposed in a topo- In many ways this is one of the most important graphical map (Fig. 14.10). This means that the bones in the skull. From embryological studies lines which are connected with the cranial it is known that the shape and growth of the bone being discussed are correlated with the cranial bones are directly and indirectly topographical position of the connected bone. dependent on that of the occipital bone (Oudhof Thick lines refer to clear or relevant connec- 2001). This bone is connected to other bones tions which are often used in practice for such as the sphenoid, temporal and parietal examination or treatment. Thin lines do not bones in the neurocranium. The occipital bone indicate that this technique is not important, forms the base of the skull and, together with but rather that these techniques are ones that the other bones, in particular the sphenoid, may be important to the individual patient. it becomes the source of the main foramina, Therefore, clinical reasoning and clinical evi- namely the lacerated and the jugular dence will indicate whether or not the tech- foramina. nique is appropriate. The main techniques are also summarized in Figure 14.11. The foramen magnum and the hypoglossal canal are formed exclusively by the occipital Not all techniques are described but only bone. In addition, the internal layers of the those which are most used in daily practice. dura mater insert into the inner surface of the When you understand the basic principals, occipital bone, leaving only the cranial bone you can invent new techniques yourself, thus with a direct connection via the synovial joint opening a door for the recognition of new clin- to the cervical spine via the occipital condyles ical patterns. These patterns can be a basis for further management of the patient. Parietal (O/P L,R) Parietal (P) Sphenoid (S) Frontal (F) Occiput (O) Occiput Sphenoid (O/S) Temporal (O/T L,R) Petrosal (Pe) Temporal (T) Atlas (C1) Petrosal (O/Pe L,R) The thicker the lines between the regions the more often you will find relevant dysfunctions and symptoms Fig. 14.10 Topographical map of the occipital bone during examination by passive movements (O). During specific techniques the occipital bone is in the centre. Ventral–cranial is connected with the Clinically important regions to examine parietal bone (P), in the middle with the sphenoid Clinically moderately important regions to examine (S), and ventral with the temporal bone (T) and the Clinically less relevant regions to examine petrosal bone (Pe). Fig. 14.11 Functional connections and their relevance during neurocranial assessment.
The neurocranium: assessment and treatment techniques 369 (see Chapter 2). It is because of these direct The manoeuvre is initiated from the thrust of connections to the atlas that many ventral and the body which is transferred through the left dorsal neck muscles insert into the occipital hand without moving the fingers. bone (Williams et al 1989). For further information, see Chapters 5 and 12. CRANIOFACIAL MORPHOLOGY, HEAD POSTURE AND THE FIRST CERVICAL Examination of occipital bone junctions can VERTEBRA occur at the following regions: The craniocervical area in humans and other ● Occipital–cervical region (O–C1) animals is a marvellous example of function ● Occipital–sphenoid region (O/S) following form and form following function ● Occipital–temporal region (O/T) (Proffit 1993). For example, the relationship ● Occipital–petrosal region (O/Pe) between craniofacial morphology and head ● Occipital–parietal region (O/P). posture has been demonstrated by Solow and Tallgren (1976) and Huggare (1987). One such Occipital–atlas region (O–C1): occipital example is that of greater upper cervical head movements against C1 extension. Experimental studies on animals have reported a significant correlation between STRUCTURAL DIFFERENTIATION head posture and anomalies of the first verte- bra which were craniocaudally wider (Huggare Some of these smooth, passive accessory 1987, Kylämarkula 1988). The same pattern is movements can provide very useful tools for seen in children with tonsils who have a greater structural differentiation between cranium head extension due to different respiratory and cervical spine, particularly when there is behaviour and therefore atypical craniofacial a dominant input mechanism (nociceptive or growth (Linder-Aronson & Woodside 2000, peripheral neurogenic). Fig. 14.12). Starting position and method Grades of neck extension Induced mouth Normal breathing 4 breathing For this technique it is essential for the patient 3 to lie in a comfortable supine or prone position. If the prone position is adopted, the patient 2 will need to rest the forehead on overlapping palms of their hands to avoid rotation in the 1 neck. The spine should be in a neutral mid- flexion/extension position. Discussion of the 13 5 10 15 20 30 min. prone position is included here because the cervical spine is so often examined in this Fig. 14.12 Correlation between induced mouth position in the clinic. breathing and changed head posture in 12 healthy The therapist sits or stands cranially to the probands. The graph shows that EMG activity of the patient’s head. With the index finger and thumb of the right hand, the therapist holds the trans- suprahyoid muscles and head extension is increased verse processes of the patient’s atlas. With the left hand, the therapist grasps the whole occip- by an average of two to three grades with induced ital bone without touching the cervical spine. The forearms should be in supination and both mouth breathing. The process is reversible if normal forearms held parallel. breathing (without nasal obstruction) is restored In this position the therapist can perform any accessory movements for the occipital after 30 minutes. This supports the hypothesis that bone. During the manoeuvre the fingers of the left hand on the atlas must remain motionless prolonged extension of the head influences the face, to avoid movement of the occipital–atlas joint. the mandible and craniocervical growth (reproduced with permission from Linder-Aronson & Woodside 2000).
370 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Muscle imbalance in the head region also Symptoms of this syndrome could be seems to encourage compensation in the plagiocephaly (without synostosis), torticollis, morphology of the upper cervical vertebrae ‘bat ear’, scoliosis and limited hip abduction and cranium (Avis 1959, Kylämarkula 1988). with or without defective foot position. Indeed, it has been found that craniofacial dys- function influences the growth patterns in pre- Plagiocephaly caused by deformity with the pubertal children. Such imbalance is a possible same symptoms described above is often predictor for some growth characteristics increased because babies are placed in their and can lead to a predisposition for other cots lying on their backs, in preference to side dysfunctions. lying or prone postures, as a safeguard against cot death (de Jonge & Engelberts 1987, Ratliff- Some key points from this are: Schaub et al 2001, Ozawa & Takashima 2002). ● Morphological compensation may occur in Buchmann et al (1992) indicated in an epi- this area in relation to normal and/or abnor- demiologic study that one-third of newborns mal functioning. in a random population have an asymmetrical range of movement in the atlantocranial ● Morphological changes in the vertebrae may and atlantoaxial joints. Often their shape produce abnormal signs and symptoms is also abnormal. The asymmetry may during manual examination, not only of the remain or increase, but in most cases it is upper cervical spine region but also of the self-correcting. neurocranium (Maitland 1986, Gonzalez de Dios et al 1998). If the asymmetry remains, this can influ- ence the function of the cervical spine or the Morphological abnormalities can also be an hips, and also motor development. Buchmann expression of early abnormal stress-transducer et al (1992) and Biedermann (2001) established forces (Wagemans et al 1988, Oudhof 2001). the KISS syndrome, a craniocervical functional This may be due to external forces or stressors impairment, as a kinematic imbalance caused such as splints and/or sustained pressure, by suboccipital loading. Biedermann identified such as the wearing of a helmet. Passive move- some characteristic clinical patterns from the ments can influence these abnormal stress evaluation of typical radiological findings and transducer forces. In fact, passive accessory questionnaires in a group of 100 babies. Cranio- and intervertebral movements of the upper vertebral functional impairments were often cervical spine as well as accessory movement accompanied by symptoms such as torticollis, of the cranium can be useful in detecting cranial scoliosis, flat dorsal head with unilat- relevant dysfunction and pain. This in turn eral swelling of the facial soft tissue, acute sen- might also highlight the need for further sitivity of the neck, opisthotonos and C-shaped management. scoliosis of the spine (Neufeld & Birkett 2000). ABNORMAL CRANIOCERVICAL AREAS IN THE NEWBORN AND FURTHER Risk factors appear to be: CONSEQUENCES FOR DEVELOPMENT ● Trauma to the upper cervical spine during A complex of symptoms in newborn babies is birth, which may be caused by assisted often described in the literature under differ- delivery ent diagnoses, such as newborn scoliosis (Mau & Gabe 1981, Slate et al 1993), ‘moulded’ baby ● Prolonged expulsion phase syndrome (Good & Walker 1984), habitual ● Injuries occurring in early childhood unilateral supine position (Palmèn 1984), squint baby syndrome (Ruige et al 1993) and TAC syn- (Biedermann 1995, Krous et al 2001). drome (turned head, adducted hip, truncal curvature; Hamanishi & Tanaka 1994). In the eighteenth century Nicolas Andry, a very important figure in general orthopaedics, was already using gross craniofacial manoeu- vres for young children with torticollis (Andry 1741). General manual therapy and osteopathic
The neurocranium: assessment and treatment techniques 371 literature from the last three decades has Where this clinical pattern is recognized, described the relevance of manual treatment and the atlantocranial differentiation and for this region to reduce dysfunction and movement of the occiput are extremely painful, symptoms as described above. For example, a further examination and diagnosis is indicated clear link has been found in newborn and (Capobianco et al 2002). A final diagnosis of young children between atlantocranial and a possible avulsion fracture of the occipital atlantoaxial joints and asymmetry in the condyle can only be made with high resolution cranium due to a type of scoliosis (Meissner CT (Miltner et al 1990, Stroobants et al 1994). 1992). Manual therapy of the upper cervical Passive movements are not indicated in such a spine was said to influence the pathogenesis of case. torticollis and scoliosis. Biedermann’s inter- views with patients (Biedermann 1996) and NON-INVASIVE AND POSTOPERATIVE long-term radiological studies (Meissner 1992) TREATMENT OF AN ATLAS FRACTURE were used as a gold standard. A fracture of the atlas is a serious injury with Frymann (1983) undertook a classic study important diagnostic traps. The type of frac- showing different types of morphological ture indicates whether an operative or non- change in the neurocranium during the first 24 invasive treatment is needed (Grob & Magerl hours after birth in asymptomatic newborn 1987). Cranial nerve paralyses are exception- babies. Frymann found that during manual ally rare with atlas fractures, but have been examination, different types of stress were described in the literature (Henche et al 1994). observed on the occipital, temporal and pari- The glossopharyngeal (IX), vagus (X) and etal bones when craniocervical dysfunction accessory (XI) nerves, and especially the was present. Frymann suggested that this hypoglossal (XII) nerve, appear to be suscepti- abnormal stress-transducer in the cranium can ble to damage from atlas fractures at the lead to 80% of the body being predisposed to base of the skull (Zielinski et al 1982, Aebi & further symptoms which children will often Nazarian 1987, Capobianco et al 2002, Kaushik go on to develop. As therapists, however, we et al 2002, Muthukamar 2002). need to be aware that not all asymmetry in the neurocranium and atlantocranium leads to Some clinical studies show a significant symptoms. Buchmann et al (1992) advocate correlation between atypical craniofacial pain reassessment after short- and long-term treat- and other diagnosed symptoms following atlas ment of each patient to provide clues as to the fractures. Trauma to the neck and cranial relevance of the dysfunction. region varies in impact and direction. Post- traumatic symptoms can also differ. Common OCCIPITAL CONDYLE FRACTURE AND symptoms in post-whiplash patients such as CRANIOFACIAL PAIN minor neck pain and headaches, burning eye pain, pressure on the throat, dysphasia, etc. Standard x-rays of the skull and cervical spine without clear CT or MRI findings lead one to after head injury with an occipital fracture suspect that a minor neuropathy in one of the usually show soft tissue injuries (Alker et al cranial nerves described could be producing 1978, Hanson et al 2002). After removing the the symptoms. In this situation it will be neces- cervical collar, palpation of the occipitocervical sary to examine the craniocervical and cranio- region, active flexion, extension and touching facial areas, together with the neurodynamics the lateral area of the head can be painful. of the cranial nerves, to clarify the diagnosis. Rotations are generally pain-free (Stroobants et al 1994, Kaushik et al 2002). Such an indi- INFANTILE CEREBRAL PALSY AND THE vidual, who on first impression is a reasonably CRANIOCERVICAL REGION straightforward post-traumatic patient, will often visit a therapist specializing in the neuro- Many practitioners from a variety of fields musculoskeletal system for treatment. agree that the current definition for cerebral palsy (CP) – ‘an irreversible sensory–motor
372 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT dysfunction caused by early brain damage’ palsy in this region is a new area to consider. (Cano et al 2001) – needs to be made more These cranial techniques as described above specific (Flehming 1979, Biedermann 1995). can be good non- invasive, painless techniques Of all children seen in the clinic with output for this purpose, in conjunction with other mechanism changes such as behaviour treatment strategies. For more detailed infor- changes, asymmetrical muscle tone or motor mation about children, cranial techniques and retardation, 20% are diagnosed as having CP. motor problems, see Chapters 19 and 20. Modern ultrasound and MRI techniques now used as the gold standard show that only 1% Occipital–sphenoid region (O/S) of these cases have any real cerebral damage (Largo 1986, Biedermann 1996). Dysfunc- Starting position and method tional atlantocranial and atlantoaxial joints (Buchmann et al 1992, Lohse-Busch & Kraemer With the patient lying in a comfortable supine 1994), as well as abnormal stress and strain on position, the therapist sits or stands at the the neurocranium, is found to be significantly patient’s head. The therapist cups the occipital higher in these children (Frymann 1983). bone in the right hand, the elbow resting on the plinth. The therapist holds the greater Two main features are: wings of the sphenoid bone between the tips of the thumb and index finger of the left hand, ● Cerebral afferent input is the most impor- steadying the left forearm against the trunk tant requirement for cerebral development during movement of the occipital bone to in newborn babies (Flehming 1979, prevent extraneous movement. Buchmann & Bülow 1989). In this position it is possible to perform any ● The most measurable afferent propriocep- of the accessory movements. Transverse move- tive signal originates from the craniocervi- ments and rotations around the sagittal and cal region: head stabilization is a complex longitudinal axes are simple to perform and process involving the interaction of verte- very valuable clinically. In order to move in the bral, visual and proprioceptive reflexes anterior–posterior direction, the therapist will (Schor et al 1988). need to rotate the patient’s head at a 30–40° angle with the right hand and hold the occipi- One possible hypothesis is that abnormal affer- tal bone perpendicular. When applying longi- ent stimulation from the craniocervical region tudinal cranial movements, this position (which stimulates abnormal effects in the sometimes provides a comfortable alternative brain) exaggerates abnormal output mecha- (Fig. 14.13). nisms, creating aberrant movements and forces. This leads to irregular learning behav- SPECIFIC TECHNIQUES iour which in turn has consequences for later neuromotor development (Lohse-Busch & The occipital–sphenoid region is often one of Kraemer 1994, Biedermann 1995). Passive the first regions that should be examined using movements such as mobilization and manipu- specific techniques. Some reasons for this lation of the upper cervical junction can nor- might be: malize the control mechanisms from motor and vegetative systems (Buchmann et al 1992, ● The relatively long duration of suture mobil- Lohse-Busch & Kraemer 1994). Cranial tech- ity which can be a source of dysfunction and niques may reduce stress in the caudal tissue, pain. Researchers have varying opinions encouraging normal cranial nervous tissue about the age at which union of the sutures movement and influencing fluctuations in the occurs. cervical fluid and altering hyperactivity in the nervous system (Frymann 1983). ● The sphenoid bone and its foramina are responsible for the majority of skull growth, The key message here is that adequate which can predispose to changes in cranio- hands-on management of infantile cerebral neurodynamics (Chapters 2, 17 and 18).
The neurocranium: assessment and treatment techniques 373 the cranial and ventral part of the temporal bone; the hand should remain perpendicular to the temporal bone and supinated. From this position any accessory move- ments described below are possible, always being careful to prevent shift or glide move- ments of the neck and head. Fig. 14.13 Accessory moments of the occiput Occipital–parietal region (O/P) while holding the sphenoid bone with the head in 30° of rotation. Starting position and method ● General signs and symptoms can be traced The patient should be lying in a comfortable to deformation or dysfunction in this region, supine position with the therapist sitting at the with consequences for neighbouring bones end of the plinth, cupping the patient’s occipi- and foramina. The jugular foramen which is tal bone with the supinated right hand. The formed by the temporal and occipital bone therapist holds the left parietal bone by posi- at the skull base is a case in point. The tioning the left lower arm in pronation, with jugular vein drains blood from the cranial the point of the elbow supported on the plinth, vault, while cranial nerves IX, X and XI pass steadying the proximal third of the right through the same foramina. Symptoms such forearm against the trunk. This is important to as problems with the gag reflex, abnormal avoid unnecessary tension in the hands. taste at the back of the tongue, problems speaking and swallowing, vagus symptoms From this position it is possible to produce such as cranial arrhythmia, digestive prob- any accessory movements by moving the body. lems and abnormal sternocleidomastoid There should be no increase in pressure from and trapezius tone may be closely related to the fingers in the left hand on the parietal obstructed flow of intracranial fluids (Patten bones during the manoeuvre. 1995, Zuniga et al 1995). The manual technique for the occipitosphenoid region AN ALTERNATIVE IN PRONE is therefore considered as the sixth screen- Starting position and method ing test for the cranium. For this technique, it is best if the patient lies Occipital–temporal region (O/T) prone with their hands under the forehead. If this is uncomfortable, have the patient lie Starting position and method prone, arms at the side, with a rolled-up towel under the forehead to reduce pressure from With the patient lying comfortably on their the plinth. The therapist stands at the patient’s back, the therapist sits or stands at the patient’s head with the hands pronated and forearms head with the left hand in supination. The perpendicular to each other. The therapist therapist cups the patient’s occipital bone in takes the parietal bones in the left hand with the palm of the left hand and rotates the the medial side of the left elbow resting on the patient’s head approximately 30° laterally. The plinth, then, with the right hand resting on the right index, middle and little fingers grasp plinth, the therapist cups the occipital bone without touching the other hand or the lamb- doid suture. This alternative position is easier for anterior–posterior or posterior–anterior movements and rotations. Any accessory (but particularly longitudi- nal and transverse) movements are easy to perform in this position. If the technique is uncomfortable for either therapist or patient, it
374 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT can be done standing at the side. The hand For a longitudinal movement in upwards contact points are the same, except the fore- direction with compression on the bone con- arms do not rest on the plinth as before. nections, the therapist flexes the interphalan- geal joints of the left hand. Simultaneous POSTERIOR–ANTERIOR MOVEMENTS movement of the opposite thumb will produce USING A LOCALIZED THUMB TECHNIQUE greater compression. Sometimes it is useful to examine or treat with An extension of this movement of the inter- localized techniques, for example in the pres- phalangeal joint of the right thumb will ence of extracranial scar tissue or craniosynos- produce longitudinal movement downwards tosis in a specific area. The author has also seen while the left thumb movement will add a patients following cerebral concussion where decompression. significant changes in signs and symptoms were observed after sharp local pain was These local techniques can be useful in pro- treated with localized techniques. Here post- ducing symptoms which help to compare the erior–anterior manoeuvres with angulations left and right sides of the skull in terms of local and longitudinal movements can usefully be symptoms. For example, ‘spot’ pain can be applied. compared in this way with traumatic neck and skull problems such as contusion syndromes, Starting position and method contusion in the cervical spine, whiplash and consolidated skull fractures. The patient lies in a prone position with the arms by the sides and a rolled-up towel under A NOTE ON PLAGIOCEPHALY AND the forehead. The therapist stands at the POSTURE patient’s head, the exact position depending on the area to be examined. Both thumbs should Symptoms such as deformity, torticollis, be touching the desired location on the occipi- adduction restrictions of the hip and scoliosis tal bone, adjacent to the lambdoid suture. The are suggestive of plagiocephaly and are therapist spreads the fingers over the lateral significantly more common in children with sides of the parietal and occipital bones, build- preferential posture, particularly babies up to ing up pressure slowly using an oscillatory the age of 6 months (de Jonge & Engelberts movement by moving the trunk rather than 1987, de Jonge 1992, Gonzalez de Dios et al adding flexion via the thumbs or fingers. Trunk 1998). Boere-Boonekamp and van der movements help to prevent localized pain. Linden-Kuiper (2001) conclude that the resting position of the child after the first week of Accessory movements are now possible by life, as well as the feeding method adopted, angling the body and holding the patient’s contributes significantly to risk factors in head steadily in position against the trunk. plagiocephaly. They concluded retrospectively The therapist can vary the emphasis by focus- that, of one-third (32%) of babies who ing on the occiput in order to change the were treated, more than 50% still had residual symptom response. movement restrictions and associated symptoms after 1 year, though consequences LONGITUDINAL MOVEMENTS in later years are unknown. Neufeld and Starting position and method Birkett (2000) suggest starting with posture reposition techniques (posture changes) For this technique the patient lies in a comfort- and physiotherapy at an early stage to reduce able supine position with the therapist sitting the dysfunction as soon as possible. Should or standing at the head end. The therapist this management prove ineffective, a helmet places the thumbs slightly flexed, longitudi- or band may be implemented (Neufeld & nally and crossed on the lambdoidal suture, Birkett 2000, Losee & Mason 2005). Symptoms with the other fingers resting on the occipital in schoolchildren such as frequent severe and parietal bones. migraine, torticollis, neck stiffness with
The neurocranium: assessment and treatment techniques 375 periodic adolescent scoliosis, concentration Spheno-occipital region (S/O) disturbances, motor retardation, cranioman- dibular malformations and face asymmetry Starting position and method may all be expressions of unrecognized dysfunction of the cranium or craniocervical Start as for the technique that moves the junctions early in the child’s life (von Piekartz occipitosphenoid region, except that this time 2001, Spermon Marijnen & Spermon 2001). the occiput is held and the sphenoid is moved. Such symptoms provide a valid reason for further examination and treatment of the The patient lies comfortably in supine and the cranium and craniocervical region. therapist sits or stands at the end of the plinth. The therapist cups the occipital bone in the right THE SPHENOID BONE hand, the elbow resting on the plinth. Holding the greater wings of the occipital bone between General qualities the tips of thumb and index finger of the left hand, the therapist steadies the left forearm The sphenoid bone is at the base of the against the trunk during movement of the sphe- skull, wedged between the frontotemporal noid bone to prevent extraneous movement. and occipital bones. It has a central body as well as greater and lesser wings. The lateral ! Once again, it is important that it is the side of the greater wing is easy to palpate, which makes it ideal for examination and/or body and not the hands that create the treatment. movement. Apart from anchoring the forearm against the trunk, concentrating on In the literature, opinions differ as to the age the thumb, index and middle fingers will at which sphenoid–occipital bones fuse. One help with this. Watch that the distance author states that they are completely fused by between the two fingers is always the same, the age of 25, whereas others describe cranial avoiding any increase in tone in the hand movement still occurring into old age (Enlow muscles. The patient should be asked to 1982, Proffit 1993). indicate if there is any increase in localized pressure from the fingers. The joint complexes and functional connec- tions of the sphenoid bone are as follows ALTERNATIVE PROPOSAL FOR (Fig. 14.14): ASSESSMENT OF A PATIENT WITH A BIG HEAD AND/OR A THERAPIST WITH ● Spheno-occipital region (S/O) SMALL HANDS ● Sphenofrontal region (S/F) ● Sphenotemporal region (S/T) The therapist’s hands might be too small to ● Sphenoparietal region (S/P). grasp both lateral sides of the greater wings of the sphenoid bone. In this case it is proposed Parietal that the patient’s head be rotated approxi- (S/P L)(S/P R) mately 40° away (in this case to the left) from the therapist with a supporting pillow on the Occiput (S/O) Sphenoid Frontal (S/F) left side of the patient's face. Temporal The therapist sits on the right side of the (S/T L) (S/T R) patient as during the standard technique and places the thumbs softly on the right lateral Fig. 14.14 Functional interactions of the sphenoid side of the sphenoid bone. The right hand sup- region. ports the left side of the occipital bone. In this position the therapist initiates the transverse movement of the sphenoid region towards the left.
376 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT BILATERAL THUMB TECHNIQUE anchors the left elbow against the body to prevent further movement of the head, while The second alternative technique that can be holding the greater wings of the sphenoid bone used in appropriate situations, for example if with the thumb and index finger of the right the patient cannot tolerate the head being hand with the forearm in pronation. touched, is the bilateral thumb technique. All accessory movements for the sphenoid Starting position and method bone can be performed from this position. The therapist should increase pressure slowly, The patient lies supine and the therapist sits on avoiding provocation of localized pain at the the short end of the plinth. Both of the lower contact points of the thumb and index finger. arms rest on the couch in supination. The ther- apist grasps the occipital bones as with the AN ALTERNATIVE METHOD FOR general occiput compression. The pads of both UNILATERAL LONGITUDINAL CRANIAL thumbs contact both greater wings of the sphe- MOVEMENT OF THE SPHENOID BONE noid. Rotation around all three axes is possible but also anterior–posterior and posterior– This is a clinically useful technique that can be anterior movement without too much pressure used for undefined (atypical) facial pain which from either thumb. The therapist should be has a relative local projection. The method is aware of increasing unilateral pressure during intraoral. performance of the movement. The patient should be asked to indicate any increasing Starting position and method local pressure under the thumbs. The patient should lie in a comfortable supine Sphenofrontal region (S/F) position, close to the edge of the plinth with Starting position and method their head turned to the left. The therapist sits at the side so that the trunk is touching the The patient should be lying comfortably in parietal and temporal bones on the right-hand supine with the therapist sitting or standing at side. The therapist takes the skull in the left the head end. The therapist holds the whole hand, with the fingers holding the temporal of the frontal bone in the pronated left hand, bone above the zygomatic bone. The proximal with the thumb adjacent to the sphenofrontal two-thirds of the left index finger should be suture and the index, middle and ring fingers holding onto the greater wing of the sphenoid on the other side (Fig. 14.15). The therapist so that the finger can be flexed at the inter- phalangeal joints. With the right hand supi- Fig. 14.15 Accessory movements of the sphenoid nated, the therapist puts the little finger inside bone while holding the frontal region. the patient’s mouth on the external surface of the pterygoid process, slightly extending the interphalangeal joint of the little finger while guiding the little finger upwards. The therapist should avoid applying extra pressure through the other fingers. This technique can be used as an alternative if the bilateral thumb technique produces too much local ‘pressure’ pain. It also gives an idea of the range of movement and is most useful in the presence of unilateral symptoms. It is also easier to hold the index, ring and little fingers on the frontal bone and to move the sphenoid with the middle finger when not totally satisfied about the outcome.
The neurocranium: assessment and treatment techniques 377 DEFORMATION OF THE FRONTAL REGION ● Compression techniques on the ipsilateral BY IMPACT AND SUSTAINED POSITIONS occipital bone and contralateral frontal bone of the flattened side Studies of frontal and occipital impacts con- clude that there is a relatively large stress/ ● Distraction techniques for the contralateral pressure factor and shear distribution on the occipital bone and the ipsilateral frontal cranium and hence, the brain (Sano et al 1969, bone of the flattened side. Chu et al 1994). This could explain why, during passive movements, symptoms are often repro- VERTICALIZATION OF THE MANDIBLE duced in the occipital and neck region. It might also explain why, after cerebral contusion, Longitudinal radiocephalometry in children patients will sometimes react with severe with mandibulofacial dysostosis (MFD) shows symptoms when treated with a minor passive that progressive cranial basilar kyphosis places application on the frontal and/or occipital abnormal stress on the sphenofrontal suture. bone. With this in mind it is important to This allows less opportunity for verticalization assess the treatment dose carefully. Extreme of the mandible and hence is followed by abnor- deformities such as frontal plagiocephaly mal growth of the mandible and associated where there is flattening on one or more sides dysfunction of the airway (Schlenkler et al of the cranium are often seen at birth. Minor 2000; see also Chapter 22). Such an extreme forms are usually neglected and can be seen in craniofacial growth pattern can exist in minor old age (Hansen & Mulliken 1994, Besson et al forms and apply the same extreme pressure to 2002). the sphenofrontal region (Cordasco et al 1999). Abnormalities such as unilateral growth of the Plagiocephaly and ocular torticollis occur mandible, airway dysfunction and long-term together in 1 in 300 births (Dunn 1974). Slate et sinusitis complaints might indicate the need al (1993) reported in their research that more for cranial mobilization. As always, it is prudent than 50% of these children have C1–C2 sub- to heed contraindications and respect the nec- luxations with no other neurological deficit. essary precautions. All patients in the group had positional skull moulding, with consistent flattening of the Frontal bone movement can also be benefi- contralateral occipital parietal region as well as cial in assessment and treatment of the follow- the ipsilateral fronto-orbital region, relative to ing clinical patterns: the side of the torticollis. The atlas was rotated forward on the side opposite to the torticollis. ● General dull headache symptoms with an Conservative non-surgical treatment produced autonomic output component favourable results, and if the child was under 1 year old positioning in helmet moulding was ● Facial dysfunction or pain after cranial also successful (Ripley et al 1993, Neufeld & trauma or operations in the area, e.g. cystec- Birkett 2002). tomy for chronic sinusitis, hypophysectomy or intracranial nasal operations There is as yet a scarcity of studies that have considered the relationship between minor ● Frontal sinusitis symptoms. Several factors plagiocephaly and the manifestation of head– influence the frontal sinus morphology: neck symptoms. These include craniofacial configuration and the width of the frontal bone in relation Craniofacial and craniocervical treatment to the intracranial pressure (Brown et al using passive movements might be helpful in 1984, Bracard et al 1987). changing the signs and symptoms in this patient group. The author proposes either or Sphenotemporal region (S/T) both of the following examination and treat- ment techniques, coupled with assessment of This technique has enormous clinical value. It the craniocervical region: can be an effective technique for treating sub- jective tinnitus, bruxism and non-infectious earache. It can also be applied in trying to
378 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT change the diameter of the unilateral skull and index finger on the sphenoid remains con- foramina which might result from neural con- stant and should try not to increase the tone of tainer dysfunction in the cranial nervous tissue the hand muscles. The patient should be asked (as described in Chapter 17). to indicate if the grip becomes uncomfortable at any stage of the process. Starting position and method THE TEMPORAL BONE The patient lies supine and comfortable on the plinth with the head rotated 20–30° to the left. The temporal bone forms the lateral side of the The therapist holds both greater wings of the neurocranium and is connected to the petro- sphenoid bone between the left index finger sal, parietal, sphenoid and occipital bones of and thumb, keeping the left forearm parallel to the cranium. The temporal fossa connects to the torso. The therapist pronates the right hand the head of the mandible to form the temporo- and places it on the temporal bone, with the mandibular joint (TMJ). right thumb resting on the dorsolateral side of the temporal bone, directly behind the external The way in which the TMJ interacts with the auditory canal. The little finger of the right temporal bone has great influence on the hand should be in the external auditory meatus growth and shape of the skull (Oudhof 2001; and the middle and ring fingers of this hand see Chapter 2). It is possible to see from the lie adjacent to the sphenoid–temporal region kind of sutures found in the temporal bone so that this region can be accentuated when how many different forces have an input necessary. towards its function (see Chapter 2). The temporoparietal and temporosphenoid con- From this position it is possible to perform nections are described in the literature as being any of the accessory movements for the still mobile in old age and can be palpated as sphenoid bone. The longitudinal movement is follows (Fig. 14.16): transmitted through the forearm via the little finger holding the pterygoid process. The index ● Temporoparietal region (T/P) finger of the left hand needs to be flexed during ● Temporozygomatic region (T/Z) the manoeuvre to support this action. ● Temporopetrosal region (T/Pe) ● Temporosphenoid region (T/S) Sphenoparietal region (S/P) ● Temporo-occipital region (T/O) This connection is relatively small and is con- Movement of the temporal bone nected to the sphenotemporal and fronto- against neighbouring bones sphenoid joints (see Chapter 2). Starting position and method Starting position and method With the patient lying supine and comfortable The patient lies supine and comfortable on the on the plinth, the therapist rests the forearms plinth. With the tip of the thumb and index on the plinth and holds the dorsolateral side of finger of the left hand, the therapist holds both parietal bones adjacent to the sphenoid– Parietal parietal region. The right index finger should (T/P L)(T/P R) be resting on the left part of the greater wing of the sphenoid, adjacent to the sphenoid– Occiput (T/O) Temporal Zygomatic parietal region; the right thumb should be (T/Z L) (T/Z R) resting on the greater wing of the sphenoid on the right hand side. Sphenoid (T/S L) (T/S R) From this position any accessory sphenoid movements are possible. The therapist should Petrosal ensure that the distance between the thumb (T/Pe L) (T/Pe R) Fig. 14.16 Functional interactions of the temporal region.
The neurocranium: assessment and treatment techniques 379 the temporal bone directly behind the auricle ● Temporo-occipital region: With your left with the right hand. The therapist places the hand in supination, hold the occipital bone in right little or ring finger in the external audi- the palm of this hand. Move the patient’s tory canal and the thumb of the same hand on head into slight extension in order to relax the the temporal planum of the pars squamosa. soft tissue of the upper cervical spine. Rest The middle and index fingers of this hand the right index and middle fingers on the should rest on the upper and lower sides, temporal bone ventromedially to the mastoid respectively, of the zygomatic process of the process on the side to be examined. temporal bone. The therapist holds the neigh- bouring bone whose connection is to be exam- ● Temporopetrosal region: With the patient’s ined in the left hand. head rotated 50° away from the side to be examined, sit to the patient’s left with the The following positions can be adopted by torso slightly flexed. The left arm should the therapist for the relevant region: be parallel with the patient’s body while holding the patient's mastoid process ● Temporoparietal region: With the left hand between the flexed left index finger and in pronation, hold the parietal bone with thumb. the whole palm of that hand, the thumb lying along the temporoparietal suture It is possible to make any of the accessory (Fig. 14.17a). movements for the temporal bone from these positions. The rotations around a transverse ● Temporosphenoid region: With the web- axis are produced by pronating or supinating space of the left hand parallel to the coronal the forearm; otherwise the movements are ini- suture, hold the greater wing of the sphe- tiated from the trunk. For a more efficient noid bone between the left thumb and left movement during the lateral transverse move- middle or ring finger, as described for the ment, it is necessary to hook the slightly flexed occipitosphenoid region. right ring finger in the external auditory canal while the middle and index fingers squeeze ● Temporozygomatic region: Rotate the the zygomatic process. Even pressure on the patient’s head 30° away from the side to be temporal bone is maintained by keeping the examined. Hold the zygomatic bone between fingers equidistant. the index finger and thumb of the left hand (Fig. 14.17b). ab Fig. 14.17 Movement of the temporal bone. a Movement of the temporal bone in the standard position as described during the general techniques and holding in this case the parietal bone. b Movement of the temporal bone with fixed zygomatic bone.
380 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Movement of neighbouring bones VARIATIONS FOR LONGITUDINAL against the temporal bone MOVEMENTS IN COMPRESSION AND DISTRACTION Starting position and method This technique uses six fingers, three from The starting positions for the techniques are as each hand, to perform the movements. described above, only this time the therapist’s right hand holds the temporal bone and the Starting position and method left changes according to the junction being examined. The patient lies comfortably in supine, with the therapist standing or sitting to the left of From that position the right hand stays on the patient’s head, which is rotated approxi- the temporal bone while the left initiates the mately 30° to the left. With the three middle movement towards the direction to be exam- fingers of the right hand, the therapist holds ined. Clinically this technique is more used the squamosa of the temporal bone just below than others, perhaps because it presents greater the parietotemporal region. The therapist clinical advantages, such as its large area and grasps the spaces between the fingers of the its relative flexibility into old age (Oudhof right hand with the middle fingers of the left 2001). An exception to this is the temporopari- hand to link hands and hold the suture on the etal region discussed in more detail below. parietal bone. The forearms should be parallel to each other. Temporoparietal region (T/P) The movement is produced by slightly There are a few main techniques that are often extending the distal and interphalangeal finger used in the clinic for this region. These are joints and slightly abducting the forearms, longitudinal movements up and down using ensuring that the patient’s head remains stable compression and distraction, rotations about and that the fingers do not dig in and feel the longitudinal, transverse and sagittal axes uncomfortable. and anterior–posterior or posterior–/anterior movements. A localized thumb technique can also be used to carry out the procedure. The principle Starting position and method is the same except that the thumbs are kept parallel to each other and extend and flex the The patient lies in a comfortable supine posi- interphalangeal thumb joints to produce dis- tion with the head rotated 30° to the left, the traction and compression of the parietotempo- therapist sitting to the right of the patient’s ral joint. head. The therapist rests the palm of the left hand on top of the skull with the middle and THE TEMPORAL BONE IN RELATION TO index fingers on the parietal bone distal to the THE HEAD OF THE MANDIBLE AND parietotemporal region. The hypothenar emi- SKULL GROWTH nence of the right hand should be over the pars squamosa with the fingers facing towards the The temporal bone and the mandibular condyle face. The therapist's right middle finger is are seen together as an important growth touching the zygomatic process while the little centre for the development of the facial skele- finger of that hand is touching the mandibular ton and the mandible. During normal oral angle (see Fig. 14.17a). function such as eating, talking, chewing, licking, lapping and sucking there is a constant The temporal movement must be initiated articular contact of mandibular condyle and from the trunk in the direction to be tested. temporal bone which influences the shape and Slight counter-pressure should be applied in strength of the skull by remodelling and the opposite direction to emphasize the squeeze reabsorption of bone tissue (Akahane et al action of the pars squamosa (the temporo- 2001). In Enlow’s (1982) words: ‘The growth of parietal region).
The neurocranium: assessment and treatment techniques 381 the mandible and its functional agents is a Case study 1 special product of all different regional func- tional agents of growth control acting on it to A 16-year-old female with deep earache and produce the topographical complex shape of burning eye pain on the right side presented the mandible and the face as a whole’. In other complaining about clicking in her left words, the mandible takes its form from the temporomandibular joint. She said she stress transducers in the cranium but the forces sometimes experienced local pain around her from the mandibular head on the temporal right auriculotemporal region. She had been bone also influence the shape and form of treated by an orthodontist who prescribed the cranium. Schellhas et al undertook an inter- splints which she said did not help her esting study in 1992 using radiography and symptoms. tomography to investigate temporomandibu- lar joint degeneration in 100 patients without Manual examination consisted of slight previous mandibular fractures. Results transverse compression medially on the revealed three factors: temporal bone as she opened her mouth. The deep earache changed, she had more ● The chin deviated more often to the side range of movement on the right, and the where more degeneration was apparent. temporomandibular joint clicking had gone. Treatment of the right temporal bone was an ● An unstable occlusion caused facial skeletal important factor in further treatment of her changes. cranium, relieving her symptoms considerably (Fig. 14.18). ● The mandibular condyle and the temporal bone tended to be smaller on the degener- ated side. This is also confirmed by other research Fig. 14.18 A 16-year-old female patient with a (Nerder et al 1999). Other abnormal forces on craniomandibular dysfunction and asymmetric the temporal region are seen due to minor inju- craniofacial growth. ries to the facial–oral region. Many injuries might result in possible development of mal- functioning in remote areas of the cranium. These include injury that occurs during birth such as from forceps delivery or long drawn- out births, or in childhood sporting and car accidents, or even after oral and dental surgery (Frymann 1983, Biedermann 1995). This is why it is so important to be aware of any historical injuries that might relate to the onset of symp- toms. This can be confirmed by checking to see if the patient has facial asymmetry with abnor- mal positioning and movement patterns of the head of the mandible in the glenoid fossa. In such cases there is usually subluxation with local pain. In addition, abnormal cranioman- dibular signs with aberrant signs on accessory movement of the temporal bone will often be found. In this case it is possible to change signs in the craniomandibular region after accessory movements to the temporal bone (Case study 1).
382 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Related structures and specific to a neurosurgeon or neurologist for further clinical patterns diagnosis. We know from functional anatomy that the Eagle’s syndrome dural membrane and all the cranial nerves except for the olfactory (I), optic (II) and acces- Eagle’s syndrome is a common name for a sory (XI) nerves touch the temporal bone series of clinical symptoms arising from an (Counter 1989, Lang 1995, Wilson-Pauwels et al elongated styloid process (Babler & Persing 2002). The dural membrane also contains all 1985, Jung et al 2001, Murtagh et al 2001). Fre- the organs of balance including the three semi- quent presentations occur after tonsillectomy, circular canals in each temporal bone (Patten with nerve irritation (particularly the hypo- 1995, Wilson-Pauwels et al 2002). Thus, mal- glossal nerve) and where there is impingement functioning of the temporal bone can result in on either external or internal arteries. Other changes in these tissues and might be expressed symptoms will often appear, for example some as symptoms in the absence of clear organic throat, glossodynia and craniofacial pain abnormalities. An example of this is seen in (Chien et al 1991, Prasad et al 2002, Renzi et al the literature where facial paralysis, hearing 2005), temporal headache with pain in the loss, vertigo, craniofacial pain and trismus craniomandibular region, ear soreness, voice after cranial trauma is often described changes, pain in the masseter muscle, restricted (Avrahami 1994, Hickham & Cote 1995). Bower mandibular openings or lock jaw, sinusitis, tin- and Cotton (1995) reported that children with nitus, excessive lacrimation and bloodshot eyes unexplained vertigo as well as middle ear pain (Ozawa et al 1995, Wong et al 1995). There is a and migraine symptoms often show abnormal dearth of literature available about the percent- pressure on the brain which appears related to age of relapse and patients who either fail to the temporal bone in CT scans. Also relevant improve or experience persistent postoperative anatomically is the fact that the facial canal is symptoms. a relatively long canal through which the facial nerve runs for several centimetres, giving it a For minor presentations of Eagle’s syndrome predisposition to development of facial neuro- as might be seen in patients who experience pathies (Lang 1995, Patten 1995). some postsurgical pain, a ‘hands-on’ approach using passive movement of the temporal bone In cases of diabetes, after radiotherapy in the and hyoid could be combined with an assess- region (Guida et al 1990) and where there are ment of neurodynamics of the hypoglossal temporal haemangiomas (Eby et al 1992) the nerve to relieve pain. facial nerve is often involved and hemifacial spasm and facial paresis can follow. Minor Zaki et al (1996) support conservative man- changes in pathodynamics can be attributed to agement of patients’ symptoms where the modest temporal dysfunction which can in styloid process is found to be elongated. A turn provoke physical dysfunction of the facial patient who experiences painful and limited nerve. Fundamental literature in this area jaw opening can become symptom-free. While appears to be sparse. We can conclude that this suggests that the styloid process is a symptoms such as oral and facial pain, cranio- painful dynamic structure it also indicates its mandibulardysfunction,non-infective earache, ability to adapt to passive movements, poten- dizziness, vertigo, tinnitus and minor cranial tially useful knowledge for us as therapists nerve symptoms can be related to the function- (Zaki et al 1996). For more information about ing of the temporal bones. Significant changes the neurodynamics of the hypoglossal nerve, in symptoms may be noticed after two to four see Chapter 17 (Fig. 14.19). treatments focusing on the temporal bones. If the symptoms remain the same or increase, Contraindications wise action dictates that the patient be referred The most common symptoms that present from dural defects in the temporal bone are
The neurocranium: assessment and treatment techniques 383 Normal 16 4 16 22 Slightly Bent Divided Very stretched stretched 2 6 6 2 1 1 1 1 1 4 2 1 2 2 1 1 7 12 3 25 mm Fig. 14.19 Variation of the shape of the styloid process. A summary of 1771 panoramic radiographs revealing various degrees of elongation of the styloid process (after Corell & Wescott 1982). Depending on the shape and form, an abnormal interface of the glossopharyngeal nerve may develop, which can cause a (minimal) neuropathy. unilateral ear ‘fullness’, pain in the temporal Parietal region and mild hearing loss which can be (Pe/P L)(Pe/P R) reproduced during manual examination. Some examples include: Occiput Petrosal Temporal (Pe/O L)(Pe/O R) (Pe/T L)(Pe/T R) ● Ruptures of the arachnoid membrane or penetration of the brain due to a defect in Fig. 14.20 Functional interactions of the petrosal the protective dura which manifests as region. cerebrospinal fluid leakage as in otorrhoea or otorhinorrhoea (Montgomery 1993). General qualities ● Tumours that mimic temporomandibular The petrosal bone is connected to the temporal joint disorders and temporal pain or bone at the temporopetrosal sutures, to the infratemporal space pathology. parietal bone at the parietopetrosal sutures, the occipital bone at the occipitopetrosal Keith and Glyman (1991) assert that patients sutures and with the sphenoid bone at the with these types of tumour are often treated sphenopetrosal sutures. It differs from the for temporomandibular dysfunction and are temporal bone in the following ways subsequently diagnosed as suffering some (Fig. 14.21): kind of pathology of the infratemporal space. A patient who presents with these symptoms ● It is part of the chondrocranium. Together and fails to improve after treatment using with the occipital, sphenoid and ethmoid passive movements should be referred for bones, the nasal bones and the pterygoid further diagnosis. process the petrosal bone is developed from cartilage (Enlow 1982; see also Chapter 2). THE PETROSAL BONE ● It may be responsible for signs and symp- Another area which can be examined is the toms other than those arising from the tem- petrosal bone region. This chapter describes poral bone. As a therapist it helps to bear in the petrosal region separately from the tempo- mind that during movements other bones ral bone region because of different patterns are also moving but to a lesser degree. that are seen clinically. In the anatomical litera- ture there is still debate as to whether or not the petrosal bone belongs to the temporal bone (Zielinski & Sloniewski 2001) (Fig. 14.20).
384 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Os parietale Os temporale Pars petrosa Os ethmoidale Os occipitale Sinus sphenoidalis Fig. 14.21 The petrosal region in relation to other structures. A general technique for movement of Fig. 14.22 General technique for influencing the the petrosal region left and right petrosal region. The aim of the general technique is to gain Movement of the petrosal bone against information about the mobility, type and neighbouring bones behaviour of symptoms provoked. This tech- Starting position and method nique makes it possible to gain a quick impres- sion of the relevance of the petrosal bone to the The patient lies comfortably in supine with the problem. If this is considered relevant, further head rotated approximately 30° to the left. The examination will be needed. therapist stands on the other side of the plinth with the left forearm parallel to the patient’s Starting position and method body and perpendicular to the caudal side of the mastoid process of the petrosal bone. The With the patient lying in a comfortable supine position, the therapist sits at the patient’s head, resting both forearms on the plinth perpen- dicular to the lateral side of the mastoid process. The therapist takes the dorsal part of the mastoid process between the flexed index fingers with the thumb resting ventrally to the mastoid process. In this position general movements (e.g. rotation, posterior–anterior and transverse movements) are possible and provide the required general information about the petro- sal bone. Avoid pressing with tips of fingers and especially tips of thumbs, as this can cause a small irritation of branches of the vagus and facial nerves (Fig. 14.22).
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