Craniofacial Pain Neuromusculoskeletal Assessment Treatment and Management

The neurocranium: assessment and treatment techniques 385 right hand grasps that bone which is a part of Starting position and method the region to be examined. For example: With the patient lying supine with the head ● The temporal bone (Pe/T): Hold the thumb rotated about 30° to the left, the therapist stands of the right hand in front of the external on the left-hand side with the pelvis leaning acoustic meatus; the other fingers contact against the plinth. The therapist holds the pet- the rest of the temporal bone. rosal bone with the thumb and index finger of the left hand, keeping the left forearm perpen- ● The parietal bone (Pe/P): Hold the parietal dicular, and resting the right elbow on the bone slightly distal to the parietopetrosal right side of the plinth. joint with the right middle and ring fingers. ● For the right parietal bone, the whole surface of the parietal bone is taken in the right ● The occipital bone (Pe/O): Cup the occipi- hand. From here it is possible to do longitu- tal bone with the right hand in pronation. dinal posterior movements and cranial rota- tions around the sagittal, frontal and ● The sphenoid bone (Pe/S): Take the lateral longitudinal axes, as well as medial trans- border of the greater wing of the sphenoid verse movements. between the right index finger and thumb, as described as above. ● For movement of the temporal bone against the petrosal region, the right hand should The therapist holds the ventral side of the be positioned as for moving the temporal mastoid process with the flexed left index bone. Thus, the right ring finger would move finger, on the dorsal side to maintain a com- dorsal to the external auditory canal, the fortable grasp, keeping the left forearm per- right middle finger would be in the external pendicular to the petrosal bone. The movement auditory canal and the right index finger is produced by the thrust of the body. During would be on the zygomatic process of the examination and treatment the therapist temporal bone, as would the right thumb. should not increase the pressure between the index finger and thumb in order to keep the ● For the occipital bone movement the right patient’s head steady. forearm is on the plinth perpendicular to the occipital bone and cups around the Any accessory movement is possible in this occipital bone. Transverse movements and position. The lateral transverse movement is rotations around all axes of the occipital relatively difficult, and for the medial trans- bone are possible. verse movement the forearm must be posi- tioned at a perpendicular angle to the lateral THE PETROSAL BONE AND side of the right mastoid process. The thumb PLAGIOCEPHALY technique as described above for the parietal– parietal region can be used in the same way. Symptoms may not be so clearly recognizable where patients with minor plagiocephaly have Movement of the neighbouring bones associated abnormal forces happening in the against the petrosal bone asterion region, causing a deeper and more complex bone matrix. The area of involvement To complete the examination it is sometimes includes, distally, mainly the lambdoid suture necessary to move the region further once but also the parietopetrosal, occipitopetrosal some dysfunctional aspect has been recog- and proximal squamosal sutures (Jimenez et al nized. For the petrosal bone region the follow- 1994). In a study of this phenomenon most ing combinations are possible: patients showed that there was progressive involvement of the skull base, anterior shifts of ● Temporopetrosal region (T/Pe) – this region the ear on the ipsilateral side and compensatory is also discussed in the section on the tem- molar protrusion (Matson & Crigler 1969). poral bone ● Parietopetrosal region (P/Pe) ● Occipitopetrosal region (O/Pe).

386 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Petrosal bone movement is one of the most ● Frontomaxillary region (F/M) important areas to examine and treat in the ● Frontozygomatic region (F/Z). skull for the above reasons (Enlow 1982, Oudhof 2001). Minor neurodynamic changes Techniques for the frontal bone against three in the cranial nerves can be caused by petrosal neighbouring bones are discussed. The F/S, bone movements, along with changes in neigh- the F/N and the F/P will be covered in this bouring structures such as temporal bone section, while the other two, F/M and F/Z, are blood vessel changes (Enlow 1982, Patten 1995). covered in Chapter 16. Cranial nerves that might be affected could include the facial nerve (VII), the vagus nerve Frontosphenoid region (F/S) (X), the accessory nerve (XI) and the hypoglos- sal nerve (XII) (Leonetti et al 1993). Special Starting position and method facial nerve neuropathies and palsies can be complications of petrosal traumas, especially The patient lies in a relaxed supine position fractures (Kawamoto & Ikeda 2002, Lee & with glasses etc. removed. The therapist sits Halcrow 2002). Symptoms such as local pain, behind the patient’s head with the left hand dysphagia, voice changes, hearing loss, tinni- cupped to envelop the surface of the frontal tus, otorrhoea, trismus, and unilateral head- bone. To enable optimum emphasis on the aches might indicate the need for further frontosphenoid region, the therapist places examination of this region. As a therapist you the tip of the right thumb or middle finger on need to be convinced that there is no serious the greater wing of the sphenoid. It is impor- pathology in the region before you treat it with tant to avoid squeezing when holding the these techniques. It is possible, for instance, frontal bone in the left hand, and to flex the left that you may be looking at a case of parotid elbow and fix it against the trunk. neoplasm, a tumour that produces similar signs and symptoms as individual cranial The therapist moves the whole body slightly neuropathies (Hoyt 1989). towards the side to be examined without changing the position of the elbow. This posi- Finally, many structures have connections tion is particularly advantageous for sustained to the petrosal bone, such as petrosal nerves techniques and allows any accessory move- and the superior and anterior margins of the ments required (Fig. 14.23). internal fissure of the auditory canal for the endolymph area (Khosla et al 1994, Zielinski & Frontonasal region (F/N) Sloniewski 2001, Schulknecht & Graetz 2005). The frontonasal region is a functional connec- THE FRONTAL BONE tion of the calvarium to the facial skeleton. Although it does not directly belong to the The frontal bone is one of the largest skull orbit, the frontonasal region plays an impor- bones, the others being the parietal bones. It is tant embryological part in the history of the connected to the maxilla, as well as the nasal, facial bones of the orbital region (Hoyt 1989). zygomatic, sphenoid and parietal bones. The Treatment of this region often has the effect of general compression and distraction technique reducing orbital pain and hence plays a pivotal for the fronto-occipital region of the cranium is described earlier in this chapter. Parietal Frontal Nasal (F/P L)(F/P R) (F/N L)(F/N R) Signs and symptoms in the frontal region can be examined at the following regions: Zygomatic Sphenoid (F/S) (F/Z L)(F/Z R) ● Frontosphenoid region (F/S) Maxilla ● Frontonasal region (F/N) (F/Ma L)(F/Ma R) ● Frontoparietal region (F/P) Fig. 14.23 Functional interactions of the sphenoid region.

The neurocranium: assessment and treatment techniques 387 role in the treatment of the orbital and sinus skull base caused by nasopharyngeal carci- regions. noma and chronic sinusitis (Cheung et al 1994, Enepekides & Donald 2005). This type of path- The patient can use this technique advanta- ological change may also indicate involvement geously at home as a reassessment tool together of cranial nerves III and VI (Sham et al 1991). with automobilization techniques. If the clinical features do not fit and as a thera- pist you are not convinced about the cause of Starting position and method the problem, the patient should be referred to a specialist for further diagnosis. CT scanning The patient lies comfortably in supine. The and x-ray are better suited for providing a therapist sits to the patient’s right with the more complete diagnosis. underarm parallel to the patient’s sternum. The therapist controls the frontal bone with the Patients with a minor frontonasal dysplasia left hand so that the index finger and thumb or a palate disorder are not usually seen by a hold the frontonasal region. The right index neuro-ophthalmologist because of the relative finger and thumb are able to move the nasal moderate severity of their symptoms which bone in different accessory positions from this might include sinusitis, ocular defects or other point (Fig. 14.24). dysfunctional symptoms such as strabismus and diplopia. However, these patients should Movements such as longitudinal caudal and first be assessed by a neuro-ophthalmologist cranial rotation around the sagittal, longitudi- (Roarty et al 1994, Marcharc et al 2002). Hyper- nal and transverse axes to perform distraction telorism (an abnormal distance between two and compression techniques and transverse paired organs) with a minor midline facial lateral movements are all possible from this defect such as is seen in broad nasal root and position. The pressure needs to build up slowly nasal bifidity can lead to nasal airflow changes without causing any local pain of the contact and oral dysfunction because of the abnormal points. The patient’s head should be held craniofacial morphology. Affected individuals steady with the left hand. often complain of typical craniofacial pain, sinusitis and tiredness (Okeson 1996, 2005). ANATOMICAL PROBLEMS OF THE Experience shows that passive movements can FRONTONASAL REGION contribute to change in airflow and possibly to related symptoms in the head and neck region Movement of the frontonasal region may with this patient group. produce general local pain. This will often be the case where there is minor erosion of the Signs of rapid growth of the temporonasal and nasal regions can provide helpful clues during assessment and reassessment. These may take the form of enlargement of the frontal sinus or the patient may just have a subjective feeling of stenosis. Normal airflow should make a full low sound while sharp, high breathing suggests a stenosis (Björk 1955). Fig. 14.24 Accessory movements of the frontal Frontoparietal (coronal) region (F/P) bone. The nasal region is fixed by the index finger and thumb. The coronal suture is a large suture in the frontoparietal region created by the parietal bones and the frontal bone. This suture is the main focus for techniques in this area. The general techniques will be covered first, followed by some local thumb techniques.

388 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Starting position and method craniosynostosis of the coronal suture or scar tissue following trauma or surgery. The patient lies in a comfortable supine posi- tion with the head rotated about 30° to the left. Starting position and method For the convenience of the patient and the therapist, the patient can support the head by With the patient lying in a comfortable supine putting the left hand under the head. The ther- position, the therapist sits at the patient’s head apist sits on the side to be examined with the and holds the frontal bone with two-thirds of plinth adjusted to the optimum height. the volar side of the left hand, resting the left thumb pad on the frontal bone adjacent to the With the left hand in pronation, the thera- coronal suture. The fingers of the right hand pist cups the whole parietal bone from the and the right thumb contact the right parietal lateral side. The left little finger and hypothe- bone near the coronal suture. nar eminence should be parallel to the coronal suture. The therapist grasps the frontal bone During the manoeuvre the cranium is held with the right hand from the lateral side. As with the last four fingers of the right hand can be seen from Figure 14.25, the right thumb and a slight counter-pressure is added in the is parallel to the coronal suture without touch- cephalic region as both thumbs perform the ing the fingers of the other hand. longitudinal movement. Finger movement should be avoided and the patient advised to Any accessory movement for the parietal indicate if the pressure feels uncomfortable or bone can be made from this point with a move- increases too quickly. ment from the body. The thrust of the trunk is transmitted through the arms and hands so ANTERIOR–POSTERIOR AND POSTERIOR– that the left hand does not move at all. ANTERIOR THUMB TECHNIQUES LONGITUDINAL THUMB TECHNIQUE These are relative compression and distraction MOVING IN A DOWNWARD DIRECTION techniques for the coronal suture. The advan- tage of these techniques is that the therapist Thumb techniques such as this, and the one can emphasize pressure on the parietal or the described for the temporoparietal region, are frontal bone, or on both, using the same start- particularly useful for longitudinal movements ing position. downwards, anterior–posterior and posterior– anterior movements and transverse move- Starting position and method ments medial to the frontal bone. These techniques can be used to treat persistent local The patient lies in a comfortable supine posi- symptoms, for example contusion patients tion with the head rotated about 40° to the left who continue to suffer from headaches in this and a rolled-up towel supporting the head. area and whose symptoms may be due to Sitting at the end of the plinth, the therapist places the left thumb on the parietal bone and Fig. 14.25 Accessory movement of the frontal the right thumb on the frontal bone in a cross- bone with the parietal region fixed. grip, perpendicular to the coronal suture. The interphalangeal joints are slightly flexed and the other fingers are spread over the top of the calvarium to keep the thumbs stable. Only the thumbs are active during the movement, the fingers simply hold the patient’s head steady. By flexing and extending the interphalangeal joints of both thumbs, ante- rior–posterior and posterior–anterior move- ments can be performed, as long as the thumbs do not lose contact with the parietal bone. Movement can also proceed with both thumbs

The neurocranium: assessment and treatment techniques 389 on the frontal or parietal bones to provide further information. ASSESSMENT OF THE FRONTAL REGION Fig. 14.26 A 36-year-old patient after a mandibular fracture with localized reddening and It is often noticed that assessment of the frontal sweating in the right craniocervical and region is the most relevant for patients who craniomandibular regions. The symptoms appeared present with the following: several minutes after the use of general frontoparietal techniques. ● A relatively wide cranium which is anteriorly proportionately shorter than posteriorly. ● A growth dysfunction, particularly seen in children who have a relatively flat occiput and prominent frontal bone in the sagittal plane (Marchac et al 2002). ● In cases of diffuse frontal head symptoms, local pain in the nasal region, pseudo- sinusitis and autonomic reactions in the face such as sweating, blushing or a feeling of eye pressure (Fig. 14.26). THE PARIETAL REGION Occiput (P/O) Parietal Together the parietal bones form the largest Frontal (P/F) expanse of the neurocranium and are con- nected to the temporal, frontal, occipital and Sphenoid Temporal sphenoid bones. As the only structure in the (P/S L)(P/S R) (P/T L) (P/T R) calvarium they are coupled bones which form a joint, the parietal–parietal or P/P region. In Fig. 14.27 Functional interactions of the temporal anatomy textbooks this connection is known region. as the ‘sagittal suture’ and has the ability to adapt to pressure changes into old age (Fehlow techniques are possible. There are general et al 1992, Oudhof 2001). techniques which influence the whole joint as well as localized thumb techniques, emphasiz- The regions and their neighbouring bones ing one part of the joint as appropriate. are: A GENERAL LONGITUDINAL TECHNIQUE ● Parietoparietal region (P/P) TOWARDS CAUDAL ● Parietotemporal region (P/T) Starting position and method ● Parietofrontal region (P/F) ● Parieto-occipital region (P/O) With the patient lying in a comfortable supine ● Parietosphenoid region (P/S). position, the therapist sits at the end of the plinth with the elbows flexed at a 90° angle and We will now discuss the parietoparietal region, the forearms level with the patient’s head. The focusing on its unique construction and clini- therapist rests the medial side of the right cal value, and cross-referencing the connec- elbow against the trunk and orientates by pal- tions to neighbouring bones (Fig. 14.27). pating the sagittal suture. The therapist then grasps the left parietal bone with the whole Parietoparietal region (P/P) hand and supinates the left forearm so that the thumb points to the front. The same procedure Because this joint has a particularly long applies to the right-hand side. The radial sides suture, averaging 12–15 cm in adults, many

390 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT of both thumbs and thenar eminences should therapist moves by slowly flexing the torso. be touching each other and, at that precise Excessive local pressure can be avoided point, lying over the sagittal suture. by slightly flexing the interphalangeal joints in the thumbs. The advantage of this thumb The torso should be rotated slightly to the technique is that it makes it possible to feel left so that the therapist can move backwards along the sagittal suture to localize the ab- and forwards with the right parietal bone. normal sites in this region and reproduce Without moving the hands at all it is possible symptoms. to move the trunk to transmit the movement through the right hand and arm. Only a slight ROTATION OF THE RIGHT PARIETAL movement is needed, since the range of move- REGION AROUND THE TRANSVERSE AXIS ment is small and a larger thrust will produce cervical torsion (Fig. 14.28). This technique may be applied for a number of reasons: A VARIATION USING LOCALIZED LONGITUDINAL CAUDAL ● It is easily performed THUMB MOVEMENT ● There is a large surface area to work with Starting position and method ● Patients often say that it relaxes them. The patient lies supine on the plinth. Using Starting position and method both hands, the therapist grasps both parietal bones as described in the last technique and With the patient lying comfortably supine on spreads the fingers of both hands around the the plinth, the therapist takes the parietal lateral sides of the parietal bones. The left and bones in both hands so that the fingers are right thumbs should be touching each other spread over the lateral sides of both bones as close to the sagittal suture, the left thumb on in the longitudinal thumb movement described the left parietal bone and the right thumb on above. The thumbs should be next to the sagit- the right parietal bone. tal suture. The procedure is the same as for the more The rotation is initiated by slightly moving general technique (see above) only now the the trunk towards the patient’s head, ensuring that the pressure at the points of contact remains constant. Anchoring the elbow against the trunk will help to avoid extraneous forearm movement. If an anterior rotation is to be per- formed it is easiest to pronate the right hand, hold it against the lower end of the parietal bone, just above the temporoparietal suture. The fingers of the right hand should be pointed in the direction of the trunk and covering the whole right parietal bone. Follow these principles for movement and rotation around the sagittal and longitudinal axes. Fig. 14.28 General longitudinal movement of the A LOCALIZED COMPRESSION AND right parietal region with a small body movement to DISTRACTION TECHNIQUE FOR THE the left. PARIETOPARIETAL REGION This technique can be used where the patient has localized symptoms such as regio- nal headaches or local stiffness after a skull operation.

The neurocranium: assessment and treatment techniques 391 Starting position and method If the patient complains of local dorsal head symptoms, or there are indications of dorsal With the patient lying comfortably supine on trauma or (sub)occipital surgery, a local post- the plinth, and sitting behind the patient, the erior–anterior technique can be useful either therapist takes the parietal bones in both hands as an examination or a treatment technique. with the fingers spread, crossing the thumbs and placing them perpendicular to the part A LOCALIZED of the sagittal suture region that is to be POSTERIOR–ANTERIOR TECHNIQUE examined. Starting position and method The therapist squeezes the sagittal suture The patient should be lying in a comfortable region with the thumbs, activating the inter- supine position for this technique. Sitting at phalangeal joints of both thumbs and ensuring the patient’s head, the therapist holds both that the pressure is evenly distributed and sides of the parietal bone in the spread fingers remains constant. of both hands, crossing the thumbs and holding them perpendicular to the part of the sagittal This technique is also used for distraction suture to be examined (lambda region). The in the parietoparietal region when the opposite thumbs are moved without increasing the of compression is desired. pressure of the fingers or moving the patient’s head. A GENERAL POSTERIOR–ANTERIOR TECHNIQUE FOR THE GROWTH PATTERNS OF THE PARIETOPARIETAL REGION PARIETAL REGION When symptoms are localized more in the The lambdoid suture is a paired structure that dorsal region of the head or when pressure on connects the sagittal suture superiorly to the the cranium in daily life such as lying supine parietomastoid and occipitomastoid sutures provokes symptoms, the movement/stress on along the cranial base. This suture facilitates the cranium needs to be in a posterior–anterior posterior skull growth via the growth of the direction. occipital bone. In particular the posterior part of the parietal bone, and hence the other skull Starting position and method bones, receive a growth impulse (Enlow 1982, Oudhof 2001, Aalami et al 2005). The patient lies comfortable and supine towards the right-hand side of the plinth with Abnormality or synostosis of the lambdoid the head rotated approximately 60° to the left. suture results in localized flattening of the The therapist supports the left side of the dorsal side of the skull due to abnormal cranial patient's head with the left hand, elbows point- forces (van der Kolk & Carson 1994). Lamb- ing behind. Pronating the right forearm, the doid synostosis was rare until recently when therapist holds the patient’s right parietal bone minor occipital and parietal deformities have in the right hand. become more common, perhaps influenced by dysfunction in early development. In most The trunk is rotated to the left to initiate cases surgery is indicated (Albright et al 1999, the technique; however, if the patient Christophis et al 2001, Anderson & David complains of neck pain due to excessive 2005). rotation in the cervical spine, the rotation is slackened to take it out of pain. The right A patient presenting with flattening to one forearm should be kept perpendicular to the side of the head and abnormal signs on exami- dorsal side of the patient’s head. This is possi- nation, particularly any suggestion of physical ble because the patient is placed on the dysfunction of the parietal bone region, would right side of the plinth, providing sufficient be a candidate for treatment in this area (Case room to move. study 2). Premature closure of the suture

392 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Case study 2 between the parietal bones or the sagittal suture restricts mediolateral growth of the An 8-year-old boy has been complaining of cranial vault which then presents longer and headaches and difficulty concentrating at more ovoid in shape than normal (Kohn et al school for 2 years. The school doctor and the 1994). Known as scaphocephaly, this is the child physiotherapist reported that his height most common form of craniosynostosis, seen and motor development were significantly more often in men than in women (Cohen retarded. The neurologist could not find a 1986). Although abnormal stress on the bones real pathology and diagnosed the boy as influences facial morphology (Kreiborg & having ‘migraine’. When he was 6 years old Pruzansky 1981), the literature is less clear he received medication (sumatriptan) which about how it affects development at the reduced his headache some of the time, but skull base (Babler & Persing 1985, Babler not always. In the last year the headache was 1989). A patient may show signs and symp- progressive (more easily exacerbated with toms originating in the parietal region as more background headache often present) well as in the facial and cranial bones. In and motor development was static. During this case it is wise to examine these regions manual physical examination of the also. It should be noted that intelligence defi- craniocervical and craniofacial region a ciencies are not always present (Hwang et al minor scaphocephaly with facial asymmetry 2002). (right facial region smaller than left, see Fig. 14.29a–c) was noted, and the sagittal Neurological complications and suture was hard, stiff and painful during craniosynostosis palpation. A right C0–C2 craniocervical dysfunction, which was painful during With craniosynostosis, neurological differ- examination, was noted. Furthermore, ences may present loud and clear, or they may possibly relevant functional impairments be much less obvious in their presentation. were also noted. Clear complications of premature cranio- Mainly craniofacial hands-on therapy, synostosis might be: especially of the parietal bones and their connections, and mobilization of the cervical ● Neuraesthenic disorders, especially head- dysfunction once a week for the first month aches and vertigo and once every 2 weeks for the next 2 months, together with continuing sensomotor ● Slight mental retardation training by the child physiotherapist, ● Schizophrenic and depressive psychoses eliminated the headache and increased ● Early changes in cerebrovascular diseases concentration. The child’s mother says that ● Disorders of the cranial nerves he plays more outside with his friends and ● Epileptic seizures (Magge et al 2002). laughs more than before. He no longer needs medication. The sagittal and coronal sutures have been particularly well investigated (Schmid 1969, During inspection after 3 months it was Fehlow et al 1992). Both reported that impair- clear to see that the craniofacial asymmetry ment of the frontal lobe, possibly caused by and the cervical dysfunction were reduced some of the symptoms listed above, resulted in and the general tone of his muscles was also shortening of the anterior cranial fossa and reduced (Fig. 14.29d–f). Retrospectively it is thus led to craniosynostosis. fair to conclude that the craniofacial and craniocervical dysfunction was relevant for Pertschuk and Whitaker (1985) studied 43 his problem and that treatment by passive children between the ages of 6 and 13 years movements in this area clearly changed his with various craniofacial anomalies caused signs and symptoms. by craniosynostosis compared with a control group. As might be expected, the symptomatic

The neurocranium: assessment and treatment techniques 393 b a c d ef Fig. 14.29 a 8-year-old boy with headache and concentration disturbances. b Slight sagittal synostosis with facial asymmetry. d–f Craniofacial asymmetry, cervical dysfunction and general tone of the neck musculature reduced on treatment.

394 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT children tended to have poorer self-image, performed over a longer duration (minutes) greater anxiety during examination and were and using minimal pressure. more generally introverted. Their parents reported that the children had more frequent SUMMARY negative social encounters and displayed more hyperactive behaviour at home. Teachers also ᭿ In this chapter the main accessory reported more disruptive classroom behav- movements in the region of the iour. In Italy, Giuffre et al (1978) also found neurocranium are discussed. The word behaviour disorders among children with 'regions' and not 'sutures' or 'joints' is craniosynostosis. Barrit et al (1981) found that used deliberately because it is believed teasing at school often led to a refusal to attend that during application of passive school in South Australian children with movements in the craniofacial region, scaphocephaly. Hence it is important for more than just sutures or joints are therapists to be aware of the physical, mental influenced. Literature and research data and social implications both during and after support this premise. treatment for these problems. The assessment of mental dysfunction can be very helpful. ᭿ With this starting point of Such tests might include learning, behaviour multistructural influences related to the and concentration indices alongside cranio- different shifts in pain mechanisms it is facial tests (Virtanen et al 1999, Speltz et al realistic to assert what exactly happens 2004). during the application of different techniques on the neurocranium. When it is possible to ameliorate symptoms Therefore at the end of each technique in the craniocervical region with parieto- section main contraindications and occipital techniques, passive movements different clinical patterns based on with a large amplitude (grades II and III) clinical experience and literature are often prove to be more successful than sus- discussed. tained pressure. Sustained pressure can some- times provoke a latent reaction such as neck ᭿ This chapter should give the reader the stiffness or dorsal headache, even if the patient impression that these (in the author's has not complained of pain at the time of opinion oft neglected) categories of treatment. patients also have a good chance of being influenced by the use of these The lambda region and fusion techniques. The lambda region is enormously flexible even ᭿ Clinical patterns and positive changes into middle age, and appears to ossify in dif- during and after the treatment have to ferent ways (Matsumara et al 1993). At around be observed. If not, the therapist has to 40–45 years of age it starts to fuse with neigh- stop and refer the patient to another bouring bones, leaving irregular sutures specialist for further diagnosis. between them. This might explain why large passive movements may work better than pres- ᭿ Good evidence-based knowledge in sure techniques in patients under 50. In the manual therapy in the craniofacial region author’s experience general techniques on the is still lacking. Standardization of tests parietal region are most useful in treatment for and techniques, which we try to start sympathetic dominant symptoms such as with in this chapter, as well as the dull, deep, undefined dizziness, cap headache, gathering of clinical data, open doors for vertigo and/or bilateral arm symptoms. This is further basic research. particularly prevalent with bilateral techniques

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401 Chapter 15 The viscerocranium: examination and treatment guidelines Harry von Piekartz CHAPTER CONTENTS INTRODUCTION Introduction 401 The terminology and classification of the skull Specific techniques for the orbit, zygomatic was discussed in Chapters 1 and 2. In general, the face can be divided into three functional and maxillary regions 405 regions for the purposes of clinical investigation: ● The orbital region ● The zygomatic region ● The maxillary region. Why consider these divisions of the facial skeleton? Two arguments support making these distinctions: ● From the phylogenetic and ontogenetic point of view the viscerocranium develops later than the calvaria (Oudhof 2001). ● Clinical experience shows that sensory responses to passive movements differ between these different regions: the neuro- cranium responds mainly with diffuse, deep responses; the viscerocranium responds with local, sharp and largely superficial responses. The neurocranium is also fre- quently responsible for reactions and symp- toms elsewhere in the body which are more associated with increased output tendencies such as vegetative reactions and/or regulation (or dysregulation) of tone. The

402 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT viscerocranium generally reacts with clear Regions – Orbit symptoms that are well localized in the – Maxilla face. – Zygoma It is therefore practical to divide the face into Zygoma Orbit three regions when starting a therapeutic – Frontal – Frontal investigation using passive techniques. An – Maxillary – Maxillary impression of which region is most responsible – Sphenoid bone – Zygoma for the symptoms can thus be formed rapidly. – Temporal bone – Lacrimal When comparing the responses of the Maxilla neurocranium and viscerocranium to passive – Nasal movements, it will be observed that, in the case – Lacrimal of the neurocranium: – Frontal – Zygomatic ● Deep, diffuse pain with an extrasegmental – Palatine character is observed. Fig. 15.1 Functional interrelationships of the ● Large amplitude passive movements (grade viscerocranium (facial skeleton). II or III) provoke the responses in most cases. 1. Roof: orbital part of the frontal bone; lesser wing of sphenoid bone ● The responses during passive movements are cumulative or only appear after a latency 2. Lateral border: zygomatic and frontal period of seconds to minutes. bones ● Autonomic and motor responses are fre- 3. Medial border: ethmoid bone; lacrimal quently provoked. bone; sphenoid bone By comparison, in the case of the 4. Base: greater wing of sphenoid, palatine viscerocranium: and ethmoid bones. ● Local, sharp and superficial pain is often Foramina – including the optic canal (optic observed. nerve II) and anterior and posterior ethmoid foramen (ethmoid nerves) – are formed by the ● Passive movements of small amplitude in orbital region. resistance (grade IV) usually provoke responses. The regions we can influence directly with passive movements are: ● The responses can be provoked more fre- quently during passive movements. ● Zygomatic maxillary region (Z/M) ● Frontomaxillary region (F/M) ● The responses are most usually manifested ● Lacrimal maxillary and lacrimal frontal in the craniofacial region. region (La/M, La/F) The next part of the chapter is divided into two ● Sphenopalatine region (S/Pa) parts. The first part will describe the general ● Frontozygomatic region (F/Z) (Fig. 15.2). techniques of the three regions. The second part discusses in detail the most important General techniques for the orbit specific techniques of every region (Fig. 15.1). General techniques principally change the THE ORBITAL REGION stress-transducer system around the orbit and Relevant anatomy A SHORT REVIEW OF THE ANATOMY The orbital region is like a pyramid with four sides. The orbit is formed superficially by the following bones:

The viscerocranium: examination and treatment guidelines 403 Orbital surface of the frontal bone Orbital surface of Optic canal the lesser wing of the sphenoid bone Lacrimal bone Orbital surface of the lesser wing of the sphenoid bone Lacrimal saccate fossa Orbital surface of the zygomatic bone Fig. 15.2 The right orbit: overview of the facial bones forming the right orbit and their connections. therefore compression and distraction tech- Fig. 15.3 General bilateral compression of the orbit. niques are the ones to use initially. widening of the orbit without an uncomforta- General compression ble increase in pressure. STARTING POSITION AND METHOD THE ZYGOMATIC BONE The patient lies supine and is comfortable and Introduction relaxed. The therapist sits at the patient’s head facing the cranial side. The thumbs and index The zygomatic bone has a functional relation- fingers of both hands are placed around the ship with the maxilla, temporal and frontal bones orbital margin, with the right thumb on the (see Fig. 15.2). They influence each other directly right orbit and the left thumb on the left orbit, through stress and movement (Schwenzer as shown in Figure 15.3. The other fingers are & Ehrenfeld 2002). An impression of the zygoma spread out on the cranium and control the and its connections can be gathered using the facial bones. The index finger is on the maxilla following two general techniques medial to the maxillary foramen and the middle finger is on the inferior border of the General extraoral bilateral technique zygoma. Both thumbs and index fingers are moved towards the centre of the orbit. The STARTING POSITION AND METHOD therapist’s forearms are parallel and do not really move. The patient lies supine and is comfortable and relaxed. The therapist sits at the patient’s head The technique is based on a fine action which requires precise coordination of all the fingers as much as possible. The patient should not experience any uncomfortable local pres- sure of the fingers. General distraction For the general distraction technique the same hand position as above is used, but the thumbs and index fingers are very carefully hooked just inside the inner rim of the orbit. During the movement the fingers are moved from the centre of the orbit laterally to allow a general

404 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT and rests both forearms on the plinth which Unilateral technique (anterior– has been adjusted to a convenient height. posterior) movement The thumb, index and middle fingers of both hands touch and lightly pinch respec- STARTING POSITION AND METHOD tively the lateral border of the orbit, and the superior and inferior part of the zygoma bilat- The patient lies supine and is comfortable and erally (Fig. 15.4). In this position all accessory relaxed. The therapist sits at the patient’s head movements of the zygoma are possible, and and rests the left hand on the occipital region left/right comparisons are easy to assess. The of the head. The right hand is in pronation and movement is a small smooth movement from the part of the hand between the thenar and the wrist without movement of the forearm. hypothenar eminences contacts the highest The distance between the three fingers always point of the zygomatic bone. If convenient, the stays the same and care is taken that no volar side of the right fingers can make contact extra pressure is added when performing this with the dorsal side of the left hand to provide movement. better control while performing the manoeu- vre (Fig. 15.5). The general extraoral technique gains in- formation about signs and symptoms arising The therapist’s right elbow is slightly flexed from the zygomatic region. It also gives an and the sternum is perpendicular to the right indication about the difference in mobility of zygomatic bone. In this position a slow oscil- the left and right sides. Together with observa- latory movement can be initiated from the tion of the viscerocranium it gives a good body. During the movement you should be impression of the position, prominence and aware that there is a small natural neck move- shape of the zygomatic bone. It also helps to ment as a result of the anterior–posterior move- ascertain information about the general mobil- ment on the zygomatic bone. Therefore, do not ity of the cranium, perhaps because of the fix the cervical spine or the patient may feel too prominent role of the zygomatic bone during much local pressure. facial growth (Bentley et al 2002a). When this technique suggests symptoms arising from the This clinically valuable technique is often zygomatic region then unilateral techniques used during examination and treatment of are the next step in the examination. patients with severe irritable symptoms or long-term persistent stable midface complaints after facial trauma and long-term sinusitis. Fig. 15.4 General bilateral zygoma technique Fig. 15.5 General unilateral technique for the (rotation around the sagittal axis). zygomatic bone (anterior–posterior movement).

The viscerocranium: examination and treatment guidelines 405 Many patients in this category experience this pain as a ‘pleasant’ pain. In addition, it has shown clinical efficacy in patients with respi- ratory problems with nasal obstruction and associated difficulties. THE MAXILLA Fig. 15.6 General bilateral intraoral technique of the maxilla. Introduction elbow against the trunk, enabling a leaning The maxilla is connected to the frontal, zygo- position over the patient. During the move- matic, lacrimal and sphenoid bones. The ment the therapist makes a slow trunk move- maxilla is a coupled bone and forms a suture ment in the direction of the mobilization, between left and right (the intermaxillary preventing a forearm–hand movement. suture) which is partly intra- and partly extraoral. Intraorally, the maxilla also forms The distance between the right thumb and part of the hard palate – the palatine bone. index finger stays the same without increasing local pressure on the bones. When the maxilla All standard accessory movements are pos- is too small on the lateral side, the longitudinal sible. The general techniques can be divided movement to caudal can be better accom- into general bilateral and unilateral intraoral plished using a unilateral technique. techniques. Stiffness, pain and reproduction of symp- General bilateral intraoral technique toms are often noted during and after performing the general maxillary technique. General intraoral techniques of the maxilla These responses are often interpreted as mal- can best be accomplished by movements such occlusions, craniomandibular dysfunctions, as rotation (longitudinal and sagittal axes), neuropathic pain from the maxillary nerve longitudinal movements and transverse and maxillary sinusitis. movements. SPECIFIC TECHNIQUES FOR The aim is to establish whether the signs THE ORBIT, ZYGOMATIC AND and symptoms are more dominantly provoked MAXILLARY REGIONS from the maxillary region or from the orbit or zygomatic region. THE ORBIT STARTING POSITION AND METHOD The orbit is formed by the following main regions: The patient lies supine, comfortable and relaxed. The plinth is at the height of the thera- ● Zygomaticomaxillary region (Z/M) pist’s iliac crest. A small towel against the ● Frontomaxillary region (F/M) contralateral side of the patient’s head can be ● Lacrimal region: useful, especially during rotation and trans- verse movements. The web space of the left thumb and index finger spans the frontal bone and fixes the right lateral border of the frontal bone or fixes both sides of the greater wing of the sphenoid. This depends on which region is to be examined: the maxillofrontal or maxillo- sphenoid. The left thumb and index finger are placed left and right intrabuccally on the maxilla above the teeth (Fig. 15.6). The thera- pist leans gently against the plinth with the trunk and fixes the medial side of the right

406 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT ❍ Lacrimal frontal region (La/F) ing, post-traumatic conditions following ❍ Lacrimal maxillary region (La/M) surgery (e.g. septum reconstruction) and with ● Sphenopalatine region (S/Pa) no other underlying pathology may be indi- ● Frontozygomatic region (F/Z). cated for passive movements of this region (Younis et al 2002). Both bone partners can be moved separately or together and will be discussed in the follow- Lacrimal frontal and lacrimal maxillary ing text. region (La/F, La/M) Zygomaticomaxillary region STARTING POSITION AND METHOD (Z/M) (extraoral) Both these regions are dealt with here because STARTING POSITION AND METHOD they have nearly the same hand position – only the localization of palpation differs. The patient The patient lies supine, and is comfortable and lies in a comfortable and relaxed position. The relaxed. The therapist palpates the right zygo- therapist sits beside the plinth on the left-hand maticomaxillary suture with the right index side facing the patient’s head. For the lacrimal finger, and then fixes the zygomatic bone with frontal region the medial side of the pad of the the right thumb, index and middle fingers. The right index finger contacts the lacrimal bone; left hand palpates the maxilla with the thumb the left thumb and index finger hold the frontal and index finger, either extra- or intraorally. bone (Fig. 15.7). For the lacrimal maxillary The most commonly used and clinically rele- region the right index finger contacts the lac- vant movements are: rimal bone and the left index finger contacts the maxillary bone. The fingertips are pointed ● Longitudinal caudal, cranium in the opposite direction and lie adjacent to ● Rotation around the sagittal and transverse each other. For the lacrimal bone, slight longi- tudinal, anterior–posterior and rotational axes movements around the longitudinal axis are ● Transverse movement in medial and lateral performed. The longitudinal movement of the lacrimal bone is a flexion/extension movement direction. of the therapist’s interphalangeal joints. Rota- tion around the longitudinal axis is a rotation Frontomaxillary region (F/M) of the index finger around its own axis. The same standard movements can be performed STARTING POSITION AND METHOD for the maxillary and frontal bone with the lacrimal bone fixed and stabilized, ensuring The patient lies supine and relaxed with a that there is no increase in pressure on the small towel under the occipital protuberance regions that are fixed. (inion) to prevent shifting of the head. The head is rotated 30° towards the therapist. The It is possible that during examination of this therapist is seated at the patient’s head on region the nasolacrimal canal (Fig. 15.8), which the opposite side, with the plinth adjusted to a transports waste products from the eye to the convenient height. The left thumb and index nose and mouth, is influenced, and that patients finger contact the frontal bone; the right thumb with longstanding pressure in the medial and middle finger contact the frontal process orbital region or eye divergence problems of the maxillary bone lateral to the nose. The without clear pathology can be improved by right index finger palpates the region during this technique. Mechanical and neurological the movement. reflex stimuli can influence the production of tears by the lacrimal system. Objective and The most common movements for perform- subjective orbital pressure can be reduced ing this position are compression, distraction (Wagner & Lang 2000). in a longitudinal direction, transverse move- ments to one side and rotations around the sagittal, frontal and transverse axes. Patients with signs and symptoms includ- ing ventral nose pain, symptoms of chronic sinusitis (e.g. abnormal airflow), nose bleed-

The viscerocranium: examination and treatment guidelines 407 ab Fig. 15.7 Rotation around the longitudinal axis of the lacrimal bone while holding the maxilla with index finger and thumb. Lacrimal gland – orbital part (a) Superior lacrimal point Superior lacrimal canaliculus Fornix of lacrimal sac Lacrimal sac (b) Conjunctive semilunar plica Nasolacrimal duct Inferior nasal concha Inferior lacrimal point Fig. 15.8 Course of the lacrimal system. Lacrimal gland (a) and lacrimal sac (b) will be mechanically and neuroreflexively stimulated by, among others, medial orbit techniques. This technique is suitable for patients with Sphenopalatine region (S/Pa) facial paresis and dry eyes. The motor activi- ties responsible for secretion of tears from the The palate is directly connected with the sphe- lacrimal glands are less controlled. Lacrimal noid bone. The most dorsal part (soft palate) facilitation can be a positive contribution to the has a direct connection with part of the sphe- recovery of the normal water balance of the noid which is also the insertion point of the orbital region (Wagner & Lang 2000). superior head of the lateral pterygoid muscle

408 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT and the inferior head of the medial pterygoid such as a ‘pressure’ in the head, bilateral muscle (William et al 1989). The palatine burning pain in the eyes, tinnitus, dizziness process and the sphenoid bone together form and changes of skin colour (‘red spots’) without the caudal dorsolateral part of the orbital clear pathology are the commonest clinical fossa. signs that may require prompt treatment with these techniques. STARTING POSITION AND METHOD The above are extremely effective tech- The patient lies supine and is comfortable and niques for patients with bruxism or general relaxed. The therapist sits or stands beside the sympathetic type symptoms in the head region plinth on the right side, facing the patient. The and frontal symptoms in the nasofrontal therapist holds the patient’s sphenoid with region. the index finger and thumb of the left hand. The right index finger or right little finger is Muscular function may change (increase intraoral on the dorsolateral side of the hard of tone), for example because of parafunctions palate. such as bruxism or bracing, together with pulsing pain in the temporal and orbital The therapist presses slowly with the right regions of the same side. This reacts well to index or little finger on the palate, trying not passive movements of this region. The result is to increase local pain. The hard palate and the a reduction in muscle tone which clearly soft palate can be influenced. The soft palate is indicates a parafunctional clinical pattern. normally locally sore. The therapist must take care that, during the manoeuvre on the maxilla, Precautions the pressure on the sphenoid does not increase. Accessory movements towards longitudinal The clinician has to be aware that changes of cranial, transverse lateral, rotation around the symptoms (e.g. tinnitus, retro-orbital head- longitudinal axis and combinations of these ache) by passive movements can be a sign of are possible. arteriovenous malformation (AVM) of the anterior cranial fossa (Friedmann et al 2001, As the spheno-occipital region has a direct Shin et al 2002). Such signs often lead to spon- connection to the sphenopalatine region, taneous infracerebral haemorrhage (Stewart & assessment of the spheno-occipital region Soparkar 2005). This pathology has been during and after passive movements of the reported sporadically since the first report by palate is sensible and useful (see Chapter 14). Lepoire et al (1963); however, since the advent This technique may influence the spheno- of new radiology techniques the pathology palatine ganglion which influences cerebral and clinical presentation have been more fre- circulation (Hardebo & Elner 1987). quently described (Gerschman et al 1979). Further precautions are required in the event The sphenopalatine ganglion is an impor- of an extreme increase of symptoms and to tant structure for the function of the autonomic latency reactions with a long duration. Referral nervous system of the face; it is also believed to a specialist for further diagnosis is, in the to be important in atypical facial pain (Klein author’s opinion, the best clinical decision. et al 2001). Ganglion blockade is therefore often used with moderate success (Brown 1997), as Frontal plagiocephaly well as for other body regions (Quevedo et al 2005). Neurosurgical research has shown the impor- tance of the transducer system, the forces of Anatomically, direct influences of the the sphenofrontal suture (in the orbital region) foramen rotundum (mandibular nerve), and of the frontal plagiocephaly syndrome (an foramen ovale (maxillary nerve), foramen asymmetrical skull deformity due to prema- palatum (palatum major), canal caroticus, ture synostosis of a coronal hemisuture). Much caroticus, plexus sympaticus, carotid artery, of the stress in the region of the lateral orbital and the medial and lateral pterygoid muscles are possible. Bilateral signs and symptoms

The viscerocranium: examination and treatment guidelines 409 pillar and the pterion gives rise to a set of facial monkeys. However, it is known that the same and cranial deformities which vary according tendency of asymmetrical growth of the orbit to the predisposition and topography of the is observed in other cranial regions as seen in synostosis (Bentley et al 2002b). The most young children with an underdeveloped eye extreme frontal plagiocephalies may need a (Limborgh & Tonneyck-Müller 1976, Bentley bilateral orbitofrontal nasal osteotomy to give et al 2002a). In the author’s opinion, a young a better chance of normalization (Reinhart patient with a small orbit and associated symp- et al 1998). How the abnormal pressure during toms and signs of eye problems has the poten- face asymmetry in the orbital region relates to tial to change the symptomatic response symptoms in minor clinical presentation is at following passive movements in the orbital present unknown. region. Orbital changes caused by passive movement might also prevent changes in It is not uncommon for smooth passive neurodynamics of the optic nerve. In this movements in the frontonasal and fronto- group of patients, children as well as adults, sphenoidal region to invoke strong sympto- eye movements are in a different direction and matic reactions in some patients. In the clinical are not balanced. Treatment by passive move- setting it is often noticed that smooth passive ments together with active eye movement as a movements in the frontonasal and fronto- reassessment tool and/or target tissue activity sphenoidal regions provoke extreme symp- is often needed and useful. toms with a short duration. In most cases the patient has a history of craniofacial symptoms Anatomical variation of the orbit but these are decreased or gone completely. Some examples are facial pain after an old frac- Not only morphological but also anatomical ture together with headache, long-term chronic variations can influence eye function; this has conjunctivitis with facial pain, sinusitis with been seen with craniofacial malformation due general headache (poorly localized) and uni- to trigonocephaly – premature closure of the lateral burning eye pain after concussion. The orbit followed by oculomotor imbalance (Denis reaction to the first examination or treatment et al 1994, Schneider et al 2000). Each oculomo- is often more severe than the following tor muscle is covered by a sheath at the origin treatments. of the ligaments. The ligaments insert at the edge of the orbit. The shortest ligament belongs The major influence on facial growth to the lateral rectus muscle. It is inserted on the comes from the orbital region external orbital edge and wall in the region of the frontozygomatic bones (Proffit 1993). In growth studies it is seen that particular For example, minor strabismus symptoms with bones (frontal, zygomatic and maxillary bones) an abnormal shape of the orbit can be an undergo a direct displacement in relation to indication for orbital assessment, especially each other, especially during adolescence. This the frontozygomatic region (Fig. 15.9), and is regulated by the sutures of the orbit (Enlow neurodynamic testing of cranial nerves III, IV & Hunter 1996, Bentley et al 2002a). Ophthal- and VI. mological studies show the correlation between the growing eye and its exertion of a mechani- Three-dimensional computed tomography cal influence on the morphogenesis of the orbit. studies of apes and humans show large skull It is hypothesized that the extent to which the deformations (particularly in the zygomatic development of the eye influences the skull bone) during different phases of the chewing depends on the relationship between the inten- process. This is particularly noticeable at the sive growth rates of the orbit, the optic nerve zygomatic/maxillary suture (displacement of and the eye (Coulombre & Grelm 1958, Wohlrab maxilla and zygoma) which reacts strongly to et al 2002). These relationships have already orthodontic splints. These skull deformations been shown in studies on chickens and arise from normal forces during chewing and

410 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Fig. 15.9 A 25-year-old patient with unilateral plates in the frontozygomatic region, for headache, strabismus caused by a congenital example, result in a large frontal sinus (Reher dominant right eye dysfunction. Note the small right & Duarte 1994, Gasparini et al 2002). Clinically orbita, the flat right zygoma region and the this region is relevant if frontal sinus changes assymmetry of the lower face (left mandibula part is are indicated. 1.6 cm smaller than the right one). Orbital floor fractures together with orbital occlusion. Abnormal unilateral biting or abnor- floor fissures in the zygomatic–maxillary and mal mouth habits can change the stress trans- naso-ethmoidal suture lines are most com- ducer component in the face, particularly in monly seen after a midfacial trauma (Peter et the orbital region, and can predispose to signs al 1994, Lauer et al 1996, Sargent & Rogers 1999, and symptoms in later life (Fuchs & Scott 1973, Haug et al 2002). Entrapment of the infra- Schneider et al 2000, Azimi et al 2003). The orbital nerve is often seen as a complication therapist may often notice that patients with and is often decompressed by plastic surgery orofacial pain with dominant craniomandibu- in extreme ‘blow-in’ fractures (Gruss & lar symptoms have a wide orbit and a more Mackinnon 1986, Antomyshyn & Gruss 1989, prominent zygomatic bone. This is a possible Read & Sires 1998, Sakavicius et al 2002). sign to be considered alongside the patient’s Trauma in the midface with or without frac- symptoms. tures and fissures seems to have an enormous impact on the orbital bones (Fig. 15.10). This Fractures in the region of the orbit could be a broad explanation for the large number of patients with post-traumatic head That the orbital region is important for the injuries that complain about long-term facial function of the sinuses is seen retrospectively pain. Subjective thickness of the eye region, after surgery for maxillofacial trauma. Mini- numbness or burning eye pain, dry or wet eyes (often together with craniomandibular or upper cervical symptoms) are often found. From a clinical point of view it is felt that many of these post-traumatic symptoms are nocicep- tive, peripheral neurogenic and can be changed by smooth movement and pressure changes of the orbital region, together with neurodynamic assessment and treatment. It is known that the infraorbital nerve is often involved in orbital trauma (Read & Sires 1998, Benoliel et al 2001). In these cases care is required with techniques with longstanding effects as reactions may only appear after a latent period. This latency could be due to peripheral neuropathic reactions of the infra- orbital nerve. Palate techniques in such cases often give a release of the symptoms and are prognostically better when release of symp- toms takes place during the palate treatment. The superior orbital fissure and cranial nervous connective tissue The superior orbital fissure is a canal that lies between the greater and lesser wings of the

The viscerocranium: examination and treatment guidelines 411 sphenoid bone lateral to the optic canal. It con- tains the third, fourth and sixth cranial nerves and the branches of the ophthalmic division of the fifth cranial nerve. Most of the venous drainage from the orbit passes through this fissure within the superior ophthalmic vein (Morard et al 1994, Haug et al 1999, Fukai et al 2001). The nerves and supraorbital veins have tight adhesions with structures such as the dura mater and the orbital connective tissue (Housepain et al 1982, Austermann 2002). These anatomical facts may explain the clinical pattern seen in, for example, a patient with deep eye pressure or pain change on upper cervical flexion or extension which can change the cranial neurodynamics. The same effect is often seen during frontal, zygomatic and or a sphenoid bone movements. In addition, diver- gence of the eye and diplopia can, in the author’s experience, be changed quickly by orbital treatment techniques, especially on patients with a history of head and neck trauma. b SPECIFIC TECHNIQUES OF THE ZYGOMA REGION Fig. 15.10 a A patient 7 days after fracture of the left The main regions discussed are the: zygomatic bone and left orbit. Clinical pattern of ● Zygomatic–maxillary region (Z/M) endophthalmitis, lowered position of the left ● Zygomatic–temporal region (Z/T) eyeball, diplopia and functional deficit of the ● Zygomatic–frontal region (Z/F). rectus inferior muscle. b The same patient several months after surgical Intraoral unilateral techniques of repositioning of the zygomatic bone, orbitoplasty the zygomatic maxillary, temporal and correction of the position of the left eye. and frontal regions Facial symmetry and eye function have been restored. This patient may still have postoperative The advantage of intraoral techniques is that orbital pain and visual problems (reproduced with they have a local effect and, like the maxillary permission from Schwenzer & Ehrenfeld 2002). sinus, teeth, mouth and the orbit, can cause local pain during passive movements. The main accessory movements (e.g. longi- tudinal, transverse lateral and rotational) can be very effective. STARTING POSITION AND METHOD The patient lies supine, and is comfortable and relaxed. The therapist sits or stands at the patient’s head, on the left side. The right hand grasps the right zygomatic bone by placing the

412 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT right thumb and index finger on the cheek Movement of neighbouring bones outside the mouth and the left index finger against the zygomatic bone intrabuccally to allow examination of the zygo- matic–temporal region. For the frontozygomatic Another possibility for treatment of the zygo- region, the right thumb and index finger are on matic region is moving the neighbouring bones the frontal bone. For the zygomatic–maxillary against the zygomatic bone. The starting posi- region the left index finger and right thumb are tion is the same as described above. The thera- on the maxilla intraorally (Fig. 15.11). pist needs to decide on an intra- or extraoral technique and fixes the zygomatic bone while For all movements it is important that the mobilizing the frontal, temporal or maxillary distance between the right index finger and bones. the right thumb remains the same. The thera- pist’s right elbow is directed laterally for all Growth pattern of the zygomatic bone, accessory movements. During the manoeuvre, maxilla and the maxillary sinus the therapist should ensure that there is no movement of the head. If the right index finger The different growth rates of the facial ecto- is uncomfortably large for the patient, then use and endocranial regions which form the the right middle or little finger. sinuses at different ages depend on genetics and stress-transducing forces on the facial Extraoral unilateral techniques for bones (Bear & Harris 1969). The zygomatic and the zygomatic bone maxillary bones play an important role in this development during adolescence (Ngan 2002). The starting position and method are the same Although expansion of the maxillary sinus in as described above, the sole exception being normal subjects results in a significant change that the therapist grasps the zygomatic bone in cranial vault length, the maxillary and extraorally with the right index finger and zygomatic bones predominantly change the thumb. These techniques are useful when shape of the face (Babler & Persing 1982, intraoral procedures are unacceptable because Persing et al 1994, Tsai 2002). Orthodontic of pain, during intraoral infection or spasm experiments show that orthopaedic interven- like trismus. A disadvantage can be that facial tions (splints) change the histology of the soft tissue changes can hinder these extraoral maxilla and shape of the sutures and contours techniques and further intraoral examination of the face (Enlow & Hunter 1966). Observa- is necessary. tions from animal experiments and human studies indicate that there is a close Fig. 15.11 Mobilization of the zygomatic bone correlation between the growth of the maxilla with an intraorally fixed maxillary bone. and the mandible (Lux et al 2002). Artificial synostoses of the orbital (frontonasal and frontopremaxillary) sutures in animal experi- ments imply that the growth in length of the mandible follows that of the maxilla (Xenakis et al 1995, Arens et al 2002, Dargaud et al 2002). In the clinical setting, head–neck facial pain patients are often seen with the following patterns: ● Differences in length of the mandibular ramus ● Shortened maxilla on one side ● Nasal airflow changes

The viscerocranium: examination and treatment guidelines 413 ● Subjective sinusitis symptoms this treatment method (Macfarlane et al 2002). ● Craniomandibular symptoms, e.g. shift Most of these individuals are diagnosed with headache of unknown origin, chronic tension during mouth opening, popping, clicking headache, craniomandibular dysfunction, with or without pain (pseudo)sinusitis, facial pain or symptoms of ● Past orthodontic treatment (Fig. 15.12). concussion syndromes (Harley 2001). Maxillary assessment can often change signs Youngsters who have had to wear orthodon- and symptoms in that region, and shows a tic stabilizing splints for several years belong good prognosis, especially when during a to another category (Needleman et al 2000, maxillary technique symptoms such as unilat- Bergius et al 2002). It is not unusual for this eral air stenosis or pain change after a few (in category of patients to have a highly sensitive average less than five) sessions. maxilla during passive movements. Undiagnosed facial pain in children That the maxilla is an important region for facial growth which responds strongly to the Children (adolescents) who have already been stress transducer system and can cause facial seen by different specialists (neurologists, dysfunction is described in the literature. For ophthalmologists, ENT surgeons, dentists, example, Nakamo (1993) proved, using dogs, orthodontists, etc.) but without being given a that a vertical sustained traction of the teeth clear diagnosis are particularly indicated for induces a vertical deformation of the maxilla, ab Fig. 15.12 Craniofacial growth model of 25-year-old monozygotic twins. The difference in form and size of their faces is particularly interesting. a Hans has persistent and inconsistent headache in the frontotemporal area of the ear, which started at age 7, the onset coinciding with a middle ear inflammation and occasional maxillary sinusitis, dominantly on the left-hand side. From that time until he was 15 there were recurrent episodes of inflammation, particularly on the left. Head and ear pain persist to this day. b Ron, his elder by 20 minutes, had no inflammation or related problems in infancy. Examination of the brothers showed that Hans had a clear craniofacial dysfunction but Ron did not. Hans’ right orbit is smaller, the zygomatic bone is less prominent and the right mandibular ramus is approximately 1.2 cm shorter than the left. The right ear is higher. Manual therapy of the zygomatic and maxillary bones reproduces his symptoms. Both regions play an important role in this case.

414 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT the neighbouring bones and the mid-palate ! Once again, it is important that it is suture. Baumrind et al (1983) showed in humans that maxillofacial deformity is the the body and not the hands that create the result of abnormal force on the maxilla. Cur- movement. Apart from anchoring the rently, there is little relevant literature about forearm against the trunk, concentrating on the behaviour of pain or other symptoms the thumb, index and middle fingers will related to orthodontic treatment. For this help with this. The therapist should ensure reason the therapist must be aware of atypical that the distance between the two fingers facial symptoms in this group of patients and on each hand remains the same, avoiding can use the maxilla and neighbouring bones any increase in tone in the hand. for examination and treatment. Further maxil- lary techniques should be used after zygo- Unilateral maxilla technique matic–maxillary fractures, during neuropathic pain of the maxillary nerve, phantom pain When unilateral dysfunctions and symptoms after tooth extraction, and pain after orthodon- are suspected, the therapist can focus tech- tic treatment, face surgery or trauma. niques on that side of the maxilla. THE MAXILLA STARTING POSITION AND METHOD Intra- or extraoral investigation of the follow- The patient lies supine, comfortable and ing areas is possible: relaxed. The plinth is at the height of the thera- pist’s iliac crest. A small towel against the ● Maxillofrontal region (M/F) contralateral side of the patient’s head can be ● Maxillozygomatic region (M/Z) useful, especially during rotation and trans- ● Maxillosphenoid region (M/S) verse movements. Flexing the trunk to facili- ● Palatine region (Pa) tate bending over the patient, the therapist ● Intermaxillary region (M/M) grasps the medial border of the lateral wall of ● Palatomaxillary region (P/M). the maxilla with the right thumb intraorally. The right index finger contacts the lateral part Techniques for the maxillofrontal and zygo- of the maxilla and the upper teeth. The right matic regions are discussed in the section on lower arm is in slight pronation, parallel with orbital techniques; techniques for the maxillo- the patient’s sternum. The position of the left sphenoid and palatine regions are detailed hand depends on which region is to be here. examined: Maxillosphenoid region (M/S) ● The maxillofrontal region: The left index and middle fingers contact the frontal bone STARTING POSITION AND METHOD on the medial border of the orbit. The patient lies supine and is comfortable and ● The maxillosphenoid region: The left index relaxed. The therapist sits or stands at the right finger and thumb contact the greater wings side of the patient. The therapist’s left index of the sphenoid as described in the standard finger and thumb grasp both greater wings technique. of the sphenoid bone, as well as grasping the maxillary bone intraorally with the right ● The maxillozygomatic region: The left index finger and thumb, just as in the general thumb, index and middle fingers are placed technique for the maxilla. The right elbow is perpendicular on the zygomatic bone. perpendicular to the patient’s face to prevent extraneous movement such as rotation of the Movements such as longitudinal to cranial and maxilla around all three axes, longitudinal caudal, transverse to lateral and medial, and and transverse movements (see Fig. 15.6). rotations on all three axes can easily be per-

The viscerocranium: examination and treatment guidelines 415 formed. During the movement a slow trunk Intermaxillary region movement in the direction of the mobilization prevents a right forearm–hand movement. The STARTING POSITION AND METHOD distance between the right thumb and right index finger stays the same without increasing The patient lies supine, and is comfortable and tension. relaxed with a small rolled towel in the neck (occipitoparietal region) to stabilize cervical THE PALATINE REGION extension when the mouth is open. Facing the patient, the therapist’s left thumb and index Introduction finger cups the frontal bone. For performing the technique with the right hand, the thera- The palatine is formed by two bones – the pist can choose between a one finger, two maxilla and the palatine – and is connected by finger or two thumb technique, depending three sutures: the intermaxillary, interpalatine upon the size of the patient’s oral cavity, the and palatomaxillary sutures. Together they are size of the therapist’s fingers and the spread of called the ‘crucifix suture’ (William et al 1989) symptoms (unilateral/bilateral). because of the crucifix form of these sutures (Fig. 15.13). In addition, it is richly innervated One finger technique by branches of the maxillary nerve which runs through six foramina (incisive fossa, two The pad of the right index finger touches the greater and two smaller palatine foramina). In palate on one side. The forearm and hand are this chapter we shall discuss the intermaxil- in supination and the middle finger leans or lary, interpalatine and palatomaxillary regions supports the right index finger. Movements (Fig. 15.13). such as longitudinal with or without angula- tion and transverse to lateral with little resist- ance are indicated. Fossa incisiva Sutura palatina mediana Processus Sulci palatinus palatini maxillae Sutura palatina transversa Lamina Foramen horizontalis palatinum ossis palatini majus Tuber maxillae Foramina palatina minora Processus pyramidalis Fig. 15.13 Overview of the palate region. Note the ‘cross’ which is formed between the intermaxillary, interpalatine and palatomaxillary sutures.

416 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT Two finger technique one part of the palate, for example with the middle finger, the index finger tries to fix the This technique can be performed in two ways: other side of the palate. The forearm stays in intraorally (Fig. 15.14) and intrabucally (lateral supination without extra movement. A more from teeth and medial from cheeks). For the intensive movement is produced when both intraoral technique the forearm and hand are fingers move in opposite directions, such as in supination and the right middle and index with the transverse movement. During this fingers make contact with the right and left technique the left hand tries to hold the frontal sides of the palate, respectively. For the intra- region to prevent movement of the head. The buccal technique two-thirds of the surface of pressure of the right middle and index fingers the right index finger and thumb are placed on increases slowly, trying not to change the both lateral sides of the maxilla. General com- contact points (the pads), otherwise the stress pression (bilateral transverse to medial) and within the palate complex changes. The rotation around the different axes are ideal intrabuccal position provides the option to techniques for this grip. perform a bilateral transverse movement to medial (recompression of the intermaxillary Two thumb technique region). During this technique the patient can emphasize the movement by strongly increased A stronger distraction technique (bilateral pressure of their upper lip muscles. transverse movement laterally) can be accom- plished by placing the two thumbs intraorally The interpalatine region (Fig. 15.15). The pads of the thumbs contact the ipsilateral sides of the hard palate and the fore- STARTING POSITION AND METHOD arms are in the midline so that the interphalan- geal joints of the thumbs are flexed. The middle The starting position and method is the same and index fingers of both hands are able to as for the intermaxillary region except that the palpate other regions during the movement fingers or thumbs contact the palatine region. (e.g. the nasofrontal region). Be aware that pressure on the soft palate can provoke a swallowing reflex (Wilson-Pauwels The best available intraoral movements are et al 2002). An alternative is to use both little transverse laterally and medially, longitudinal fingers instead of the middle and index to cranial, anterior–posterior and posterior– fingers. anterior. When the therapist wants to move Fig. 15.14 Two finger technique in the Fig. 15.15 Bilateral intraoral thumb technique for intermaxillary region. the palate region.

The viscerocranium: examination and treatment guidelines 417 The palatomaxillary region a normal palate b 60 – 80° STARTING POSITION AND METHOD c flat palate The starting position and method is the same as for the intermaxillary region. The two finger steep palate technique is an easy technique to perform and generally comfortable for the patient, with the therapist touching the palate with the right index finger and the maxilla with the right middle finger. The palpation between the hard (maxilla) and soft palate (palate) is not difficult to differentiate. The soft palate has less resist- ance and is locally more sensitive than the hard palate. Distraction (abduction of both fingers), compression (adduction of both fingers) and rotation techniques around a longitudinal axis of one of the two fingers are the most commonly performed movements in this area. Alternatively, for distraction and compres- sion, the left hand can be held around the maxilla, intra- or extraorally, and the distrac- tion and compression performed using the index, middle, ring or little finger. The choice depends on the shape and size of the patient’s oral cavity. The therapist should ensure that the right hand is in supination without extra contact with other intraoral tissue. This can be prevented by only moving the chosen finger by interphalangeal extension for distraction and interphalangeal flexion for compression. Palate and physical structure d asymmetric palate The facial skeleton, including the palate, can (steep/flat) take a number of different physical forms, reflecting (possibly abnormal) craniofacial e morphology (Subtelny 2000, Arens et al 2002). For example: Fig. 15.16 Palate shapes and their clinical patterns. ● The palate is round and symmetrical in a The therapist can judge the shape of the palate by normal, symmetrical craniofacial growth standing in front of the patient and looking into the (Fig. 15.16b). patient’s open mouth from below. ● A child who breathes mainly through the mouth develops a rather narrow midface and has a narrow, flat and symmetrical palate (Linder-Aronson & Woodside 2000) (Fig. 15.16c). ● Patients with retrognathia corresponding to Angle class I type 1 have a steep, small and

418 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT symmetrical palate which appears as if the flat left palate, which is often seen in patients tongue is projected forward (Fig. 15.16d). with chronic sinus conditions or in patients ● An asymmetric palate (flat or steep) is often following middle ear inflammation during a associated with an external factor causing growth phase. growth disturbances, such as prolonged catarrh or middle ear inflammation during Influences on the midface structures growth (Fig. 15.16d) (Harley 2001). Anatomically, palate techniques can directly These clinical patterns can assist the therapist influence the vomer and indirectly the perpen- in deciding whether it is important to examine dicular plate of the ethmoid bone (Breitsprecher and/or treat the palate. et al 1999). The interpalatine techniques par- ticularly influence the vomer–sphenoid con- Palate forms and their clinical patterns nection because of the large movement of vomer and the small distance between the soft palate These forms are generally recognizable if the and the sphenoid bones (Ortiz Monasterio et al therapist stands in front of the patient and 1996, Subaric & Mladina 2002). inspects the palate from below (Fig. 15.16a). Therefore symptoms due to airflow changes NORMAL PALATE (sinusitis), frontal headache, craniomandibu- lar dysfunction, malocclusion, neuropathies of The palatal arches are symmetrical, and the palate nerves and neurological patients with middle of the tongue has enough space to speech and swallowing problems can, in the stretch against the uppermost edge of the rim author’s opinion, be positively influenced by of the palatal arch. There is no need to exert an these techniques. anterior pressure of the tongue to make more space (Fig. 15.16b). Palate and forces FLAT PALATE Orthodontically, large orofacial splints which influence the face, particularly the maxilla and The lateral tongue angle diverges from the par- palate, can be used to direct the growth pattern. allel line. The angle of the lateral part of the Maintenance of extraoral lateral pressure on the palate is clearly smaller than 60/70° with the maxilla or crossbite corrections of the maxilla horizontal plane, and the side of the tongue no with splints is followed by palate plane altera- longer contacts the palate. This is often seen in tion and exerts different forces on other facial patients with a poorly developed midface or in regions (Ricketts 1960, Merrifield & Cross 1970, mouth breathers. This condition is also com- Van Harberson & Myers 1978, Bernhart et al monly seen in patients with marginal prog- 2000). nathia because the midface has not developed proportionately with age (Fig. 15.16c). A therapist who works with palate treat- ment can change forces or stress which is STEEP PALATE transformed throughout the whole face. In the study of Merrifield and Cross (1970) it was The distance between one side and the other is shown that the zygomatico- and frontomaxil- smaller and the upper surface of the palate is lary sutures were the most common areas too steep, so that the middle part of the tongue where forces are adapted during long palate cannot move aside. In the majority of cases, the stress (Booy et al 2000). tongue is protruded and there is retrognathia (Fig. 15.16d). In clinical experience some atypical facial pain, especially in the nose region, often ASYMMETRICAL PALATE changes during or after palate movements. Sometimes during subjective examination, Many combinations of palatal forms are pos- patients mention that extreme long pressure sible: steep/normal, flat/normal, steep/flat. against the palate reduces their symptoms Figure 15.16e shows a steep right palate with a (Fig. 15.17).

The viscerocranium: examination and treatment guidelines 419 Together with assessment and treatment with cranioneurodynamic techniques, optimal results can be achieved (see Chapters 18 and 19). a Palate and growth b Results from experiments on rhesus monkeys (Macaca mulatta) suggest that sutures of the Fig. 15.17 midface, in particular the transverse palatine a Woman with exostosis of the intermaxillary suture, may be important in the bony develop- ment of the palate during growth (Kremenak region which is responsible for her headache and et al 1967, Ross 1987, Lehman et al 1990). Mid- tinnitus. Compression of the maxilla provokes her facial prognathism, deformities such as maxil- headache, distraction reduces it. Longitudinal lary hypoplasia, and malocclusion (class III movements to cranial around the exostosis occlusal relationship) can be the result of palate produce a local sharp pain. anomalies (cleft palate) (King 1993, Rothstein b Profile of the same patient. Note reduced & Yoon-Tarlie 2001). Minor examples of these maxillofacial growth. craniofacial abnormalities and craniofacial symptoms may be changed by palate mobiliza- tion, especially using lateral and medial move- ment of the palate. The explanation for the change in symptoms and the craniofacial anomalies may be stress transducing forces (Oudhof 2001). Hearing loss in infants with craniofacial anomalies is often seen (Downs & Silver 1972, Feinmesser & Tell 1976, Jones 1988, Proffit 1993). Auditory brainstem responses (ABRs) show significantly different results in young children with cleft lip and/or palate abnor- malities or external ear anomalies (Jones 1988, Friede 1998). Previous investigations have reported that otitis media with effusion is commonly or virtually universally present in children with unrepaired cleft palate (Paradize & Bluestone 1974, Helias et al 1988, Friede 1998). This was investigated in young children (within the first year after birth). Most authors in this specialist field are convinced that young children with craniofacial anomalies represent an otologic and audiologic emergency (Coplan 1987, Fria et al 1987). In the clinic and from the literature it is known that minor craniofacial anomalies (e.g. minor palate abnormality) may be related to ear dysfunction and pain in older children. Generally two to four sessions are needed to change chronic eye and ear pain and/or sinusitis symptoms without clear

420 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT pathology. Palate assessment and treatment CNV can be very useful in patients with dysphagia CNVII and headache with no clear pathology (Jones 1988). Ganglion pterygo- Palate and the nervous system palatinum Minor neuropathies of the branches of the Ganglion maxillary division of the trigeminal nerve in cervicale the region of the greater palatine foramen are superius not uncommon (Shane 1975, Shankland 2001). Deep burning oral or cheek pain can be one of Sympathetic the major symptoms (Meechan et al 2000). The pathway published descriptions of the position of pala- Parasympathetic tine foramen in the adult human skull have not pathway been consistent (Ajmani 1994). Therefore, pal- pation with the tip of the little finger is useful Trigeminal to orientate where the nerve is running to pathway prevent compression of these nerves by passive movements in the posterolateral border of Ganglion the palate. Together with neurodynamics of stellatum the trigeminal nerve, signs and symptoms in the cheek region caused by a cranial neuro- Fig. 15.18 Sphenopalatine ganglion (SPG): pathy can be changed. topography and its neural connections (modified after Klein et al 2001). The sphenopalatine ganglion Afferent to the SPG: ● Sensory fibres of the maxillary nerve of the The sphenopalatine ganglion (SPG) is a mechanosensitive parasympathetic ganglion trigeminal nerve (CN V) that lies in the roof of the pterygopalatine fossa ● Parasympathetic fibres via the petrosal nerve of (Fig. 15.18) (Shankland 2000). It is intimately connected with the fifth and seventh cranial the facial nerve (CN VII) nerves and the sympathetic nervous system ● Sympathetic fibres via the internal carotid plexus (Hardebo & Elner 1987, Klein et al 2001). In the early part of the 20th century, Sluder reported and the deep fibres of the petrosal nerve. the potential importance of the SPG in the Efferent fibres of the SPG: mediation of headaches, facial neuralgia, ● Nerve fibres running to the nasal cavity, palate, earache and ‘lower-half’ headache (Sluder 1908). Ruskin (1946) and Scudds et al (1989, upper larynx and lacrimal gland. Other branches 1995) described the use of SPG blocks using of the maxillary nerve lie in close proximity. lidocaine in patients with chronic muscular pain syndromes in the face. Nowadays micro- muscle, abnormal saliva production and tin- surgery techniques are improved and SPG nitus are changes that are not uncommon. In blocks have moderate to good results in atypi- addition, neuropathic trigeminal pain without cal facial pain patients (Klein et al 2001). The secondary hyperalgesia or allodynia reacts literature and clinical studies describe sympa- well to palate treatments. To influence the thetic regions in the palate which often arise region of the SPG it is necessary to bring during SPG blocks. the finger in a posterolateral direction towards the posterior wall of the hard palate. When the Abnormal sweating in the head region, local pressure is too painful one has to position changes of muscle tone of the masticatory

The viscerocranium: examination and treatment guidelines 421 the fingers a little more medially. If this tech- equilibrium of forces is essential for optimal nique is performed too quickly, immediate maxillofacial growth and development (Kraus (para)sympathetic reactions may be produced, 1994, Ozbek et al 1998). Assessment and treat- such as watering of the eyes, a sudden feeling ment (using passive movements) of the palate of warmth throughout the head or dizziness in children with bad postures, abnormal and brief tinnitus. maxillofacial or craniofacial growth and bad habits could be a wise action. Together with AFFERENTS TO THE SPG treatment of the facial muscles and stimulation of the palate by passive movements, the ● Sensory fibres of the maxillary nerve from somatosensory cortex receives new informa- the trigeminal nerve (V). tion which may contribute to normal maxillo- facial development and posture (Morales 1991, ● Parasympathetic fibres of the facial nerve Ramachandran & Blakesee 2000). (VII) via the petrosal nerve. It can also been used for educational pur- ● Sympathetic fibres via the plexus of the poses. The patient can break bad orofacial internal carotid artery and the deep petro- habits and stimulate new functions of the oro- sal nerve. facial region. Together with attention paid to the rest of the body, posture can be positively EFFERENTS FROM THE SPG influenced. These include fibres which run to the nasal SUMMARY cavity, palate, upper larynx and the tear gland. Other branches of the maxillary nerve are ᭿ This chapter describes the main found in the vicinity (modified after Klein viscerocranial accessory movements. et al 2001). Relevant comments are based mostly on clinical features and literature. Palate and posture ᭿ The quality of sensory responses to Unfavourable forces on the palate result from passive movements in the facial region undesirable habits such as thumb sucking, pro- are different (more local and severe) in tracted dummy use, abnormal tongue pressure, comparison with the neurocranium. etc. These can disturb not only the develop- Accessory movements of the cranium are mental dynamics of teeth, joints and adjacent easy to integrate into daily practice and soft tissues but also influence the position of can be used for assessment, treatment, the head and the vertebral column (Duyzings to prove relevant dysfunction and for 1959). Several authors have reported the neces- further management. sity of the normal reposition of tongue against the palate (Rocabado 1992, Coste et al 1999, Ono et al 2000, Battagel et al 2002). Together with the position of the orbicularis oris muscles and the external masticatory muscles, this References Respiratory and Critical Care Medicine 165:117 Ajmani M 1994 Anatomical variation in position of Austermann K 2002 Frakturen des Gesichtsschädels the greater palatine foramen in the adult human (Mittelgesichtsfrakturen) In: Schwenzer N, skull. Journal of Anatomy 184:635 Ehrenfeld M (eds) Spezielle Chirurgie, Zahn-, Mund-, Kiefer-, Heilkunde, Bd. 2. Thieme, Antomyshyn O, Gruss J 1989 Blow-in fractures. Stuttgart, p 339 Plastic and Reconstructive Surgery 84:20 Azimi C, Kennedy S, Chitayat D et al 2003 Clinical and genetic aspects of trigonocephaly: a study of Arens R, McDonough J, Corbin A et al 2002 Linear dimensions of the upper airway structure during development: assessment by magnetic resonance imaging. American Journal of

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425 Chapter 16 The cranial nervous system: assessment and treatment basics Harry von Piekartz CHAPTER CONTENTS INTRODUCTION Introduction 425 In recent decades the interest of physiothera- The cranial nervous system as a part of the pists and manual therapists in the movement behaviour of the nervous system, including its peripheral nervous system 425 response to movement, has increased greatly and it has become difficult to imagine daily physiotherapy practice without it. This chapter will give an overview of the anatomical (patho)biology of the peripheral nervous system only. In combination with the results from current research this will form the basis for the development of cranioneuro- dynamic tests. THE CRANIAL NERVOUS SYSTEM AS A PART OF THE PERIPHERAL NERVOUS SYSTEM Clinicians often need to be reminded that the cranial nerves belong to the peripheral and not to the central nervous system. The following definition may clarify this: All afferent fibres and of the nervous system, that arrive from outside the dorsal horn or the brain stem nucleus, belong to the peripheral nervous system (Butler 2000, Hu 2001). This includes the peripheral nerves of the extremities and the trunk as well as the cranial

426 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT nerves and the dural tissue within the spine rium, the endoneurium and the perineurium. and the cranium. This becomes obvious when These are formed like a tube (Fig. 16.1) that the skull is opened and the spine is dissected provides mechanical protection and nourishes (von Hagen 1997). It will be noticed that the the nerve (Cornelius 2002). Sunderland (1978) nerve roots, the spinal and cranial ganglions estimates that the connective tissue forms as well as the spinal and cranial dura are 21–81% of the peripheral nervous system. This almost identical regarding their anatomical also allows for a movement of the peripheral constitution and a differentiation into cranial nerve by sliding the layers intraneurally and spinal nervous tissue is practically impos- against each other (Millesi 1986). This poten- sible (Murzin & Goriunov 1979). tial expansion provides the opportunity to adapt neurodynamically at places where there Anatomical and physical features is limited space such as within the facial canal, the cerebellopontine angle and the foramina at The features and anatomical similarities of the the base of the skull (Breig 1960, Lang 1995). spinal and the cranial nervous tissues may be summarized as follows. INNERVATION CONSTITUTION OF THE CONNECTIVE Nervous tissue is richly innervated and is TISSUE therefore sensitive to pain. The craniofacial meninges are dominantly innervated by the The cranial nerve consists of three layers, the trigeminal nerve. The posterocranial fossa (the same any other peripheral nerve: the epineu- dorsal part of the neurocranium) is innervated a External epineurium Interfascicular epineurium b Nerve Perineurium fascicle Endoneurium c Schwann cell e d Non-myelinated Myelinated fibre fibre Fig. 16.1 Overview of the nervous connective tissue (after Schwenzer & Ehrenfeld 2002). The microstructure (modified from Brandt & Mackinnon 1997) shows that the axons are surrounded by connective tissue. The cross-section shows various structure types: a Cross-section of a nerve with monofascicular structure. b Cross-section of a nerve with oligofascicular structure. c Cross-section of a nerve with grouped polyfascicular structure. d Cross-section of a nerve with non-grouped polyfascicular structure. e Components of a peripheral nerve.

The cranial nervous system: assessment and treatment basics 427 by the sinovertebral nerves that run through nutrients, resorbs carbon dioxide and other the foramen magnum of the upper three cervi- waste products and is then transported away cal segments (Bogduk 1988). The cranial dura by the veins (Westmoreland et al 1994). After shows a significantly greater innervation than cranial trauma and inflammatory processes in the spinal dura. This fact explains, for example, the meninges (e.g. encephalitis), an impaired the mechanisms of dural headaches and the flow of CSF is frequently observed. The conse- intensive pulling and pushing extrasegmental quences for the local trophic situation may (craniocervical) pain which occurs during include dural headaches (Davies 2003, Inoue active craniocervical flexion (von Piekartz 2001, et al 2003), cervical movement restrictions and Davies 2003). The connective tissue that sur- growth dysfunctions of the neurocranium and rounds the cranial nerves is innervated in the the viscerocranium (Murzin & Goriunov 1979, same manner as the connective tissue of other Wagemans et al 1988). Lumbar dural puncture peripheral nerves: causes craniodural traction with a decreased cerebellopontine angle and stress/pressure on ● Intrinsic innervation: This is provided by the blood vessels and cranial nerves (Patten local axonal branches that perforate and 1995). innervate the connective tissue (Hromada 1963, Thomas & Olsson 1984). These branches PLASMA are also called nervi nervorum and it is assumed that they play an important role in Plasma is a fluid that is five times more thixo- neurogenic inflammation (Sauer et al 1999). tropic (viscous) than water. The most impor- Neurogenic inflammation of the mandibu- tant function is communication with its target lar nerve following tooth implantation in tissue and supporting anabolic and catabolic older age is an increasingly common phe- metabolism of the target tissue (Delcomyn nomenon (Janssen 2000). A physiologically 1998, Medeiros & Moura 2003). A more exten- reduced jaw increases the chance of nerve sive overview is found in Butler (2000). branch irritation due to the implanted metal that leads to a neurotoxic reaction of the AXOPLASMATIC TRANSPORT inferior alveolar nerve and causes orofacial symptoms like orofacial dysfunctions and It is known that dysfunctional axoplasmatic movement restrictions (Janssen 2000). transport and a change in depolarization of the cranial nerves influences the constitution of ● Extrinsic (vasomotor) innervation: This is the connective tissue and the function of the provided by the autonomic nervous system target tissue (Lundborg 1988, Cornelius 2002). of the adjoining perivascular plexi (Thomas & Olsson 1984). Okeson (1996) indicates that Adhesions due to previous surgery or to patients with migraine-type headaches trauma may therefore predispose to impaired also show a higher prevalence of minimal axoplasmatic transport. For example, scarring cranial neuropathies that may become due to facial trauma or surgery may impair symptomatic. vascular and axoplasmatic microcirculation and thereby result in poor function of the FLUIDS target tissue (Schumann & Hyckel 2002) (Fig. 16.2). The nervous system contains large amounts of fluids such as cerebrospinal fluid (CSF) and The therapist should be aware that body the cytoplasm of peripheral nerves called axo- movements assist the dynamic function of the plasm. The CSF protects the nervous system CSF (Nicholas & Weller 1998). Axoplasmatic and the cranium against acceleration. This movements are also positively influenced by ‘pillow of water’ surrounding the nervous range-of-motion movements (ROM) which system in the cranium and the spinal cord also optimize the transport of proteins and nerve provides the nervous system with oxygen and growth factor (NGF) (Ochs & Jersild 1984, Dahlin & McLean 1986, Nicholas & Weller 1988, Elvey 2001). On this basis it is sensible, in

428 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT certain cases, to include passive and active with unusual forces such as compression cranial neurodynamic tests in rehabilitation and distortion (Gifford 1998). They supply programmes. the nervous tissue with oxygen and metabolic substances to support normal function. The BLOOD SUPPLY studies of Dommisse (1994) showed that the nervous system requires a large amount of Neurones are well supplied with blood vessels, oxygen: although the brain and spinal cord which run both within and outside the nerve account for only 2% of body weight, they (Lundborg 1988, Butler 2000). They are adapted absorb approximately 20% of oxygen from the for elongation and retraction and can cope circulation. Fig. 16.2 Patient with a suprahyoid scar and Intrinsic blood vessel structure consists of adhesions of branches of the hypoglossal nerve. After a longitudinal and a transverse system. The 15 minutes of speaking she suffers from dysphagia transverse system permeates the perineurium and dysarthria (Photograph by Paul Kubben). because it does not contain a barrier to diffu- sion and osmosis, and therefore provides optimal vascularization of the perineurium. The advantage of this arrangement is that normal macrolevel functional movements act as a vascular pumping mechanism as proposed for the spinal canal by Brieg (1978) (Fig. 16.3). The same arrangement is also found within the cranium. Furthermore, the cranial nerves within the cranium have a relatively long distance to travel to the transitional regions, are often bundled and frequently encounter Fig. 16.3 Macroscopic model showing the effect of normal deformation of the intra- and extraneural blood vessels on nerve movement. The transverse and longitudinal blood vessels close and open rhythmically during movement increasing the blood flow within the nerves (modified from Breig 1978).

The cranial nervous system: assessment and treatment basics 429 bottlenecks (von Piekartz 2001). This also In summary, the cranial nervous tissue is applies in a narrow sense to blood vessels. very similar anatomically and physiologically Poor vascularization due to (minimal) com- to the rest of the peripheral nervous system. pression and neurogenic inflammation in a critical intracranial area may have minor or Reaction to movement major consequences for cranial cerebral func- tion. The best-known critical area is the vascu- The anatomic construction of the peripheral lar compression at the cerebellopontine angle nervous system seems to be particularly and the sinus cavernosus (Fig. 16.4). adapted to movement (Breig 1978). The cranial nervous system shows three adaptation GANGLIA mechanisms: The cell bodies of the primary neurones POSITION OF THE MOVEMENT AND are generally positioned outside the central LOCALIZATION OF THE NERVOUS TISSUE nervous system in the sensory ganglia. The dorsal root ganglia of the spinal nervous The upper cervical flexion–extension axis is system show the same structure as the cranial ventral to the brainstem (Rossitti 1993, von ganglia but are generally smaller and are easily Piekartz 2001). Since most of the cranial nerves missed (von Piekartz 2001, Wilson-Pauwels originate at the dorsolateral side of the brain- et al 2002). They are very mechanosensitive stem – the V to XII – cranial nerves need to and may produce neurotransmitter substances adapt the most (Breig 1960, Rossitti 1993). after orthodrome and antidrome stimulation, which may cause or maintain neurogenic ADAPTATION BY SLIDING, ELONGATION inflammation (Sugawara et al 1996). This AND COMPRESSION usually occurs after long-term compression or abnormal pressure with movement. Examples Normally, sliding, elongation and compression of ganglia which may cause a neuropathic dis- occur in combination. One example is the order are the trigeminal ganglion, the vestibu- spinomedullary angle which increases by lar ganglion, the ganglion oticum and the between 1 and 32° (average 14°) on craniocervi- ganglion pterygopalatinatum (for anatomical cal flexion. Upper cervical flexion increases the background, see Chapter 2). spinomedullary angle by an average of 14° (6–32°). Doursounian et al (1989) showed in dynamic MRI that the medulla oblongata A. cerebelli N. trigeminus superior N. trigeminus A. cerebelli ab inferior Fig. 16.4 Pathophysiology of idiopathic trigeminal neuralgia according to Janetta. The trigeminal nerve is compressed within the cerebellopontine angle by (a) the arteria cerebelli superior and (b) the arteria cerebelli inferior (modified from Cornelius 2002).

430 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT moves upwards and that the dorsal part Cranioneurodynamics refers to neurody- becomes longer (elongation). Pericranially the namics occurring topographically in the face, lingual nerve (branch of the mandibular nerve) the neck and the head (von Piekartz 2001). It elongates on mouth opening by an average of includes all neural tissues of the craniofacial 8 mm (Schlessel et al 1993). and the craniocervical region down to the third cervical vertebra. Although it is difficult CONNECTION TO THE SURROUNDING to discriminate clinically, based on anatomical, TISSUES biomechanical and empirical assessments that form the basis for current neurodynamic tests, The human body does not show a uniform it seems logical to use C3 as a cut-off point. tissue adaptation to movement as, for example, As described above, anatomical and clinical does a rubber band. As the neuraxis and the studies confirm the tremendous neurodynamic peripheral nerves contain various amounts of adaptation capacities during upper cervical connective tissue and are of different widths flexion and extension (Janetta 1976, Breig 1978, as well as having various connections to Barba & Alksne 1984, Doursounian et al 1989). their surrounding tissues (Sunderland 1978, It is observed clinically that upper cervical Lundborg 1988), different mechanical forces flexion (occiput–C3) is an important cranio- occur. Where the nervous system cannot adapt neurodynamic testing manoeuvre. Therefore it to movement it will compensate by pressure or makes sense to define the topography of the pulling (Breig 1978, Shacklock 1995). Areas cranial nervous system from C3 upwards. where the nervous system is tightly connected to the surrounding tissue are predisposed as Neural pathodynamics and pain contributing areas to neuropathic changes mechanisms (Butler 2000). Chapter 1 describes how an injury to the The neuraxis of the craniocervical region peripheral nervous system causes an increased will serve as an example. The dura is con- nociceptive input. The type of nociceptive nected dominantly at the insides of the verte- afference depends on the localization and bral bodies of the second and third vertebrae, structure of the peripheral nerve. Two main but not as much to the atlas. Tight connections categories apply: are found at the intercranial part of the occiput and the foramen magnum (Lang 1995, Patten ● Sensory ends of the connective tissue of an 1995). One can imagine the pulling forces that unhealthy, injured peripheral nerve such as occur on flexion of the rather heavy (5–8 kg) an inflamed cranial dura or an irritation of head, especially given the 2–3 cm elongation of the perineurium of the lingual nerve after the craniocervical neuraxis from the occiput to an implantation (Cornelius 2002). C7 and the 1.5-fold decrease in craniocervical diameter from occiput to C6 (Breig 1960). ● Abnormal depolarization and spontaneous impulses of peripheral nerves. This phe- Other regions with tight connections that nomenon is known as abnormal impulse gen- may predispose to neuropathies are those erating sites (AIGS) or ectopic pacemakers and around the major occipital nerve within the will be described later in this chapter (Devor occipital fascia, around the auriculotemporal 1994). nerve within the temporal fascia (Lang 1995) and the superior laryngeal nerve (branches of Both categories may be involved in the devel- the vagus nerve) within the neck fascias opment of neuropathic pain and result in the (Gavilán et al 2002). typical clinical picture of peripheral neuro- pathy (Devor 1996). Pathophysiological changes Cranioneurodynamics of peripheral nerve tissue are the prerequisite for increased nociceptive inputs from the Shacklock (1995) introduced the term ‘neuro- peripheral nervous system. Some facts about dynamics’ to describe mechanical and biologi- cal mechanisms and their interactions.

The cranial nervous system: assessment and treatment basics 431 the cranial nervous tissue are described in the chewing which causes rhythmic stress to following. the trigeminal ganglion which is less than 1 cm from the temporomandibular Pathophysiology of the cranial nervous joint (von Piekartz 2001), or entrapment system of the glossopharyngeal nerve between the stylomandibular ligament and the Healthy movement behaviour of the cranio- mandible on swallowing (Shankland neural tissue shows mechanical features includ- 1995) ing elongation, sliding and compression in ❍ Long-term compression. Neurogenic combination with optimal physiology (vascu- dysfunction and pain due to compres- larization, axoplasmatic transport) (Shacklock sion caused by scar tissue after maxillo- 1995). This is not always the case. Abnormal facial surgery is an unpleasant side effect forces or physiological changes, for example that is often difficult to treat adequately diabetes mellitus or serious blood pressure (Schumann & Hyckel 2002, Schwenzer & abnormalities, may impair the balance. This will Ehrenfeld 2002). Small scars due to peri- lead to pathophysiological and pathomech- auricular acne may also lead to minimal anical changes in the nerve (Powell & Meyrs neuropathy of branches of the facial 1986, Dyck et al 1990). Shacklock introduced nerve and the vagus nerve later in life the term ‘neural pathodynamics’ that includes (Gavilán et al 2002). both mechanical and physiological changes (Shacklock 1995). Abnormal impulse generating sites (AIGS) Abnormal longstanding forces, by changing the pressure on the nerve, may lead to a lack The above-mentioned mechanical processes of circulation and cause degenerative changes may lead to degenerative changes of the nerve of the nerve. This is not necessarily associated such as sprouting, demyelinization, ephatic with neurogenic inflammation or pain transmission (abnormal cross-talk of two (Olmarker et al 1995). This process is enforced axons) and/or neuromas that may result in and symptoms are enhanced when more than spontaneous and long-term abnormal nerve one pressure change has taken, or is taking impulses. This type of impulse is called an place. If the circulation is impaired in multiple ectopic pacemaker or abnormal impulse gen- sites and axoplasmatic transport is dysfunc- erating site (Devor & Seltzer 1999, Mongini tional the nerve becomes unhealthy and will 1999). eventually degenerate or fibrose (Lundborg 1988, Patten 1995, Wilbourn & Gilliat 1997). The structures that are principally respon- Other criteria are: sible for AIGS are ion channels, which are pro- duced and transported by spinal and cranial ● The status of the nervous system before the ganglia. Ion channels are small protein mol- abnormal mechanical load occurred ecules that arise in proximity to neurogenic trauma sites and provoke a depolarization of ● The frequency, quality and intensity of the degenerative area (directed by the gan- forces acting on the craniofacial region, glion), potentially leading to further ectopic which may be subdivided as follows: impulses (Devor & Seltzer 1999, Waxman ❍ Direct acting forces, e.g. abnormal trac- 2000). The extent of depolarization is influ- tion and compression enced by temperature changes, cytokines, cat- ❍ Long-term pressure, e.g. of the lower part echolamines (e.g. adrenalin), inactivity and of the spectacles’ frame on the point of mechanical stress (Devor 1994, Bennet 1999, exit of the maxillary nerve from the Butler 2000). This explains how a spontaneous infraorbital foramen increase in symptoms may be caused by a ❍ Repetitive mechanical forces, e.g. sub- dominantly neurogenic source. luxation of the head of the mandible on mouth movements such as speaking and

432 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT AIGS that may cause peripheral neurogenic trigeminal ganglion). These activities are also pain have been identified in the cranial nervous called ignitions (Rappaport & Devor 1994) (Fig. tissue. Examples include the following: 16.5). A minor injury along the trigeminal nerve facilitates the AIGS in a local group of the As already mentioned, the cranial dural trigeminal ganglion. If the activities are sup- tissue is innervated more thoroughly by the N. ported by neighbouring neurones due to stimu- recurrens than the spinal dural tissue (Kumar lation of peripheral sensitized zones in the skin et al 1996). The severe, often spontaneous pain or muscle, spontaneous long-term impulses that occurs due to scarring of the cranial dural may occur leading to long-term and/or sponta- tissue and the high concentration of nerve neous neuralgic pain (Mongini 1999). Similar irritating substances lead to the assumption phenomena have been described for the glosso- that AIGS are very active in these structures pharyngeal nerve, the major occipital nerve (Schlessel et al 1993). and the maxillary nerve. This may explain diagnoses such as idiopathic glossopharyngeal Ephatic transmission has been shown to be neuralgia, occipital neuralgia and burning pain indicative for trigeminal neuralgias (Fromm & in the mouth (Mongini 1999). Sessle 1991). Abnormal cross-talks cause a low- ering of the stimulus threshold in the neigh- Pathobiological changes resulting in bouring axons (Fields & Rowbotham 1993). dysfunction and pain This will eventually lead to a sensitization of the dorsal horn where the secondary neurones, Figure 16.6 gives an overview of the topics in the wide dynamic range (WDR) cells, play an this section. Long-term (minimal) mechanical important role in the processing of sensory changes such as compression or distraction stimuli to the craniofacial region. A gentle lead to vascular changes and ischaemia. touch to the face will result in increased firing Neurogenic inflammation may also be part of of the WDR neurones. The nervous system will the morphological changes of the nerve. This perceive the information as a normally gener- will eventually influence the function of the ated noxious stimulation (Dubner et al 1987, nervous tissue, leading to the status of an Schlessel et al 1993). Classically this will occur ‘unhealthy neurone’. As such, pathodynamic during an idiopathic trigeminal neuralgia but changes in combination with the sensitization may also be caused by minor trauma such as of the nervous system will have consequences a tooth extraction or a minimal (sports) injury for the functioning of the target tissue (Hasue to the face (Zakrzewska 1995, Butler 2000). 1993, Gifford 1998). Other increased or spontaneous electrogenic activities are found in various ganglia (e.g. the Trigger point Compression site Ignition focus Fig. 16.5 The trigeminal ganglion: ignition hypothesis according to Rappaport and Devor (1994). Dark circles: ectopic excitation of a focal group of axons from the trigeminal ganglion following a minor trauma of a trigeminal branch. Light circles: neighbouring neurones that are excited by peripheral stimulation.

The cranial nervous system: assessment and treatment basics 433 Sustained increase in mechanical pressure Nerve Compression of compression the blood supply Ischaemia Loss of intraneural lymph Fibre Intraneural oedema conduction Increased Fibrosis, scarring of Inflammation intraneural connective tissue pressure Dysfunction of Physiological Changed Possible connective changes mechanisms symptoms tissue fibres Damage, dysfunction and death of nerve fibres lead to the development of atypical irritation – triggering areas (peripheral neurogenic pain mechanism) – input from different fibres in the neural connective tissues (nociceptive pain mechanism) Diseased neurone Effects on other areas, nerves, target tissue, CNS Fig. 16.6 Pathobiological effects of a (minimal, long-term) compression to a peripheral nerve (modified from Gifford 1998). Modern neurodynamics and (P1 = onset of sensory response) and the onset evidence-based practice (EBP) of resistance (R1) as parameters, while Hall et al (1998) studied the behaviour of the nervous The increasing importance of evidence-based tissue more effectively in an end of range situ- practice has led to a number of research projects ation using the parameter of muscular reflex about neurodynamic tests. These can be sum- activity (first spasm, S1). marized as follows. The reliability of normative neurodynamic Most studies are based on an anatomical test studies such as straight leg raising (SLR), and/or clinical model (Selvaratnam et al 1994). slump and upper limb neurodynamic test Kleinrensink et al (2000), for example, exam- (ULNT) is controversial. These studies com- ined cadavers to assess the movement behav- monly rely on intratester reliability which iour of nervous tissue in the upper extremities. is generally between medium and good Coppietersen (2001) used submaximal pain (Matheson 2000). Currently authors are using

434 CRANIOFACIAL PAIN: NEUROMUSCULOSKELETAL ASSESSMENT, TREATMENT AND MANAGEMENT various techniques to standardize the test Implications for clinical practice methods and to assess intratester reliability (Huck 2000, Matheson 2000). Practically this It is quite understandable that inveterate theo- implies that the therapist will need to stand- rists may regard neurodynamic tests as irrele- ardize the test each time and eliminate exter- vant and utterly useless due to their low nal variables such as temperature, equipment, reliability, the lack of accuracy and their un- verbal information, etc. demonstrated efficacy. A neurodynamic test is generally not a Does that mean that neurodynamic tests are useful diagnostic test (a test that minimalizes useless and without practical value? It has the probability of clinical signs in healthy been shown in clinical practice that neuro- individuals as well as in the pathological dynamic tests support the decision-making group). To put it simply, after one testing process when forming hypotheses about dys- procedure the therapist will not be able to functions, sources and pain mechanisms. Fur- determine whether or not the patient suffers thermore, it is not uncommon for a therapeutic from a neuropathy, and will certainly be unable method that follows the neurodynamic concept to describe the localization and extent of to be appropriate for the clinical situation. The the dysfunction. The original testing paradigm following explanations are found in the of neural tissue testing relied on the mobiliza- literature: tion of (mainly peripheral) nerves and dural tissue. Pathobiologically it was performed ● The therapist recognizes a clinical pattern to detect a neuropathy. Current knowledge from the results of the subjective and physi- of the central nervous system and its afferent cal examination (see Chapter 3). inputs has shown that the wide variety of responses to afferent inputs has a considerable ● The results of other neural tests such as con- influence on the organism’s reaction. This duction tests and palpation increase the is expressed as different types of pain (primary probability of a potential neuropathic and secondary hyperalgesia) and different problem (Gifford 1998, Butler 2000). output reactions such as motor excitations and inhibitions (Butler 2000, Sterling et al ● If the symptoms and/or other responses 2001). The challenge now is to put the know- (e.g. the conduction test results, palpation ledge of pain mechanisms and biopsychosocial and neurodynamic tests) to treatment of the theories together with the neurodynamic neural connective tissue (the structures sur- test results. This way of thinking requires a rounding the peripheral nerve) change, the new approach to test validation and is still likelihood increases that the health of a at a very early stage of development (Butler nerve plays a role in this particular patient 2000). (von Piekartz 2001). There are still insufficient effect studies that In his book, Butler (2000) presents the essential compare neurodynamic mobilization with, or features of a positive test and its relevance for integrate it with, other therapy methods. The the discussion. It is fundamental that the ther- assessed population is often very small (usually apist recognizes the following two values between 10 and 20 participants) and the meas- whenever it comes to clinical decisions: urements vary from R1 (onset of resistance), to P1 (onset of pain). Discussions about appropri- ● A positive tests that indicates a neurogenic ate assessment concepts and inclusion/exclu- source shows various features including the sion criteria are lively and exciting (Butler reproducibility of symptoms, differences 2000). between left and right, support of subjective and physical data and the potential for In summary, it is impossible at the present structural differentiation (Butler 2000). This time to make a definite statement on the effects does not imply that the test is also relevant of neural mobilization. for the particular syndrome. ● The relevance of a test is connected to func- tion and the improvement of function. The