Manual Therapy for the Cranial Nerves, 1e

271 Pages·2008·4.46 MB·English

by  Jean-Pierre Barral DO (UK) MRO F)

© 2009, English translation — The Upledger Enterprises. Published by Elsevier
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© 2006, French edition — Elsevier Masson SAS, Paris
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First published 2009
ISBN-13: 978 0 7020 3100 7
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Introduction
For more than 60 years, following the work their nervous system. Manipulations of the
of William Garner Sutherland, the cranium cranial nerves add to, and prolong, the impact
has fascinated the osteopathic world. Being of our techniques for the cranial contents.
the mechanics that we are, we continue to be This book is dedicated to the most pre-
captivated by its 22 bones, articulated by cious and mysterious part of the human
sutures and linked through membranes. The being: the brain. The brain has the consis-
fascination that this structure holds for us is tency of an egg custard and, although pro-
perhaps one of the reasons why most cranial tected by the cerebrospinal fl uid, is very
techniques address the skull — the container sensitive to all variations in pressure. In
— rather than its contents — the brain. this book you will fi nd ways of modifying
In our book, Manual Therapy for the Periph- intracranial pressure.
eral Nerves, we underlined the importance of The brain is shot through with arteries and
soliciting the body’s proprioceptive responses veins. Intracranial pressure changes have vas-
through manual therapy. This is because all cular and cerebral consequences. To function
tissues are endowed with a system of mechano- at its best, the brain requires malleability and
receptors connected to the cerebellum and plasticity. By manually modifying intracra-
the thalamus, and it is through their agency nial pressure, we produce promising effects
that we obtain both local and general on the hydromechanics of the brain.
results. The central focus of this book is on the
Cranial nerves supply sensitivity to the practical applications of cranial nerve manip-
bone, periosteum, sutures and meninges. ulations. With its wealth of illustrations, it is
Thus, central to obtaining an effect on the also an excellent guide with which we can
dura mater, the falx of the brain and the ten- visualize the cranial nerves and come to
torium of the cerebellum, is the treatment of understand their many functions.
xix
Acknowledgments
What a treasure Jean-Pierre Barral and Alain dous work. Annabel Mackenzie RST tackled
Croibier have brought to the health-care fi eld the translation of the textbook into English.
of Manual Therapy! In addition to being Susan Railer DO, RMT also assisted with the
excellent therapists, inquisitive scientists and translation process. Annabel Mackenzie RST,
creative developers, they are also very prolifi c Dawn Langnes and Emmanuel Frantzis, DC,
in their writing skills. This additional talent, DO edited the manuscript into the form you
too often lacking in creative therapists, allows see in your hands.
them to share their discoveries, ideas and The authors would like to thank the Barral
theories with the rest of the world. Manual Institute team for all their efforts in helping
Therapy for the Cranial Nerves is the follow-up to bring awareness of their work to you: Gail
to their highly acclaimed and successful Wetzler RPT, CVMI (Director of Curriculum
Manual Therapy for the Peripheral Nerves. Both and Program Development); Rene Assink
texts are having a positive infl uence on hun- DO, PT; Mark Bloemberg PT; Roberto
dreds of thousands of lives. Bonanzinga DO; Gabriela Cinerova PT;
It is truly an honor for me to have had the Florinda Czeija PT; AJ de Koning DO; Dee
privilege of helping translate their most recent Dettmann Ahern RPT; Lisa Brady Grant DC;
work into English. As with most projects I’ve Kenneth I Frey PT; Frank Hiltensberger; Alex
been involved with, this translation required Jozefyk, III; Benjamin Katz CMT, MFA;
a mix of administrative, technical and sup- Dawn Langnes; Barbara LeVan PT; Annabel
portive efforts. Administratively, I would like Mackenzie RST; Ron Mariotti ND; JR Olson;
to thank Dawn Langnes, whose tireless efforts Jorg Petersen; Lisa Polec DC; Christoph
helped make this whole project happen. Sommer Rolfer; Donna Upledger, John
I would also like to thank Elsevier, our Matthew Upledger; Bernhard Voss PT; Vicki
publisher, for their continued commitment Wengatz-McCabe, Kathleen Woll and Jean
to sharing this work with therapists through- Anne Zollars MA, PT.
out the world.
On the technical side, several people John Matthew Upledger
should be acknowledged for their tremen-
xxi
PART ONE
THEORETICAL PRINCIPLES
1
Some preliminary
thoughts
Every nerve must be free to act and do its part.
Andrew Taylor Still
Before attempting to manipulate the cranial cells, to which they are attached, provide each
nerves, the reader is advised to study the nerve with additional reinforcement. The
properties of nerves by consulting our book, endoneurial tube is a distensible elastic struc-
Manual Therapy for the Peripheral Nerves. ture composed of a dense matrix of collagen
For readers who have no previous experi- tissue, which has a nutritive and protective
ence with peripheral nerves, we would like to function. Endoneurium plays an important
summarize briefl y some essential tenets. role in fl uid pressure. By maintaining a light
positive pressure in the endoneurial space, it
guarantees a constant environment for the
1.1 FUNCTIONAL ANATOMY
nerve.
OF NERVES
Perineurium
Nerve fi bers are grouped into functional his-
tological units taking the form of fascicles
Perineurium is the connective tissue sheath
surrounded by layers of connective tissue.
that surrounds several primary fascicles.
Connective tissue comprises 50–90% of the
When grouped together, clusters of primary
total mass of a peripheral nerve.
fascicles form secondary fascicles. The peri-
neurium comprises 7 or 8 layers that are
1.1.1 Connective tissue of nerves dense with fi broblast cells. The perineurium
The connective tissue component of periph- serves to:
eral nerve trunks divides into endoneurium, • protect its contents: the endoneurial
perineurium and epineurium, according to tubes
their topography. • provide a diffusion barrier to guard
against foreign substances
Endoneurium • provide resistance to external forces.
Endoneurium is the intrafascicular connec- The perineurium is the last connective
tive tissue. It is composed of several nerve tissue layer to break when a nerve is subjected
fi bers making up a primary fascicle. Glial to extreme traction. 1
Theoretical principles
Epineurium lized. Our neural manipulations have an
immediate vascular effect.
Epineurium is the interfascicular connective
tissue layer. It lies between and around the
1.1.3 Innervation of nerves
secondary fascicles and forms a sheath encir-
cling all peripheral nerve trunks. The epin- (nervi nervorum)
eurium is a continuation of the dura mater
The connective tissue of the peripheral nerves,
that extends to the ends of the peripheral
the nerve roots and the autonomic nervous
nerves. Functionally, the epineurium has a
system possess their own nerve supply. This
double role:
innervation is provided by the nervi nervo-
• The internal epineurium keeps the rum, which derive from local axon branches.
fascicles apart. These are the “nerves of the nerves” and
• The external epineurium forms a ensure intrinsic sensitivity. At the mechanical,
well-defi ned sheath around the metabolic and trophic levels, the state of the
fascicles. nerve is under continuous supervision and
control. The nervi nervorum are vital ele-
The epineurium is a vessel carrier, contain-
ments in the transmission of information at
ing the vasa nervorum which constitute the
the level of the medulla and the central
microvascularization of the nerve. The epi-
nervous system.
neurium is also a nerve carrier, containing the
The nervi nervorum are made up of an
nervi nervorum. These nerve fi bers extend
afferent track, which participates in the intrin-
from the nerves themselves and from the
sic sensitivity of the nerve and is often impli-
perivascular plexus. They are destined for
cated in any pathological process affecting
the epineurium, the perineurium and the
peripheral nerves. In response to diverse
endoneurium.
stimuli (chemical, electrical and mechanical),
The epineurium is a structure devised
the nervi nervorum behave like primary
for motion. It facilitates gliding between
nociceptors. They release into their environ-
fascicles.
ment, prostaglandins and neuropeptides
which are involved in the infl ammatory
process.
When a tissue suffers damage, the nocicep-
tor response is initiated. The damage may not
1.1.2 Vascularization of nerves
be severe enough to cause identifi able pain,
(vasa nervorum)
but is nevertheless suffi cient to disturb the
Within the epineurium the vascular network regional biomechanics and to create a protec-
is very well developed. The majority of arteri- tive response ensuring that the damaged
oles and venules are arranged longitudinally nervous area does not become overloaded.
and are widely anastomosed. Note: Nociceptive nerve endings are more
Within the perineurium exists a vast plexus responsive to stretching than they are to
of capillaries as well as an important network compression.
of arterioles and venules. The whole art of neural manipulation lies in
Within the endoneurium the capillary applying an effective amount of traction without
vessels are similarly organized in plexuses. an excess of compression.
The number of venules is, as a rule, slightly There is also an extrinsic vasomotor inner-
greater than the number of arterioles. Empty vation for the vasa nervorum. It is provided
capillaries are frequently found inside the by the fi bers that penetrate the nerve at the
endoneurial space; their effect is to isolate level of the perivascular plexus. The blood
part of the vascular bed. vessels of the perineurium and epineurium
These excluded capillaries resume their are innervated by the sympathetic nervous
2 function as soon as the nerve is lightly mobi- system.
1
Some preliminary thoughts
1.2 MECHANICAL PROPERTIES Extrinsic intraneural pressure
OF NERVES
A nerve is subject to the pressure surrounding
tissues might impose on its various enve-
1.2.1 Mobility
lopes. If this exogenous pressure is sustained,
Nerve tissue is subjected to the numerous the extrinsic intraneural pressure rises.
demands imposed upon it by movements of
the body. According to the circumstances, it The tension/compression relationship
can adapt to the constraints in two ways:
Pressure imposed on a nerve increases its
• by gliding within its anatomical internal tension level. Inversely, longitudinal
environment
tension placed on an already constrained nerve
• by adapting its shape in such way as to can augment its internal pressure gradient.
diminish itself (by creasing, furrowing
or folding) or to allow itself to be
1.2.4 Permanent distal tension
stretched.
Over many years of practicing nerve palpa-
1.2.2 Visco-elasticity tion, we have observed the phenomenon of
permanent distal tension. This occurs as the
Visco-elastic materials, when subjected to a
distal part of a nerve seeks to elongate towards
strain force, respond by instantly deforming;
the periphery.
on returning to their original form, they retain
The anatomist Brachet (1921) studied the
a little of the deformed shape. This differs
development of nerves, in particular the
from elasticity, which is the ability of a mate-
embryological evolution of the vagus nerve.
rial to regain its original shape immediately
He stated the following, which confi rms our
after the force is removed.
theory:
A nerve is a visco-elastic structure. As such,
it permanently displays some internal con- The part of the vagus nerve that was originally
straint. The level of tension perpetually varies cervicocephalic extends to the viscera and second-
according to the external stress applied to it. arily moves towards the trunk. Extension into
When a nerve is subjected to forces of trac- lower regions has become a general tendency of
tion, visco-elasticity is its trump card, lending nerves.
it great adaptability and resistance to being
In the treatment of nerves the aim is
overstretched. On the other hand, a nerve is
always to stretch them as distally as possible
extremely vulnerable to all forces of compres-
in order to achieve an effect on their intrinsic
sion, even mild ones. In our work we use the
tension.
quality of visco-elasticity to further slow down
the nerve’s naturally delayed return to form.
1.3 FUNCTIONAL UNITY OF
1.2.3 Neural constraints THE NERVOUS SYSTEM
Intrinsic intraneural pressure It is important to emphasize that the nervous
system is an indivisible entity. No other struc-
Intrinsic intraneural pressure represents the
ture in the body possesses the same degree of
sum of all intracellular axon pressures, aug-
connectedness and complexity.
mented by the intravascular pressure within
This functional unity rests on the follow-
the vasa nervorum. It is further modulated by
ing parameters:
intrafascicular pressure. The visco-elastic
property of the nerve exposes it to longitudi- • Electrical. Neurons are interconnected.
nal, centrifugal and distal tension; any varia- Any impulse generated at one end of the
tion in its intensity alters the intrinsic system can, in a millisecond, reach the
intraneural pressure. other end. 3
Theoretical principles
• Mechanical. There is a continuity of formation of intrafascicular scarring. There-
tissue envelopes between the central fore, all phenomena of fi brosis or edema
nervous system and the peripheral affect the intrinsic adaptive mechanism of
nervous system. nerves.
• Biomechanical. The same
neurotransmitters are found in the central
1.4.2 Compression
and peripheral nervous systems. There is
The physiology of compression is complex.
centrifugal and centripetal axon–plasmic
The following succession of events may be
fl ux.
found with direct compression of nerve fi bers
• Electromagnetic. The perineural system
and ischemia, and can create a vicious circle:
is a carrier of continuous currents,
initiated by brain waves, which diffuse • compression
through the neural network to the • primary ischemia
interior of the body. These currents play • transudation
a key role in tissue repair following an • increase in intraneural pressure
injury. They are important in maintaining • limitation of lymph and venous
homeostasis and in the organization of drainage
the scarring process. • nerve edema
In addition, from the electrical or magnetic • increase in intraneural pressure
point of view, nerves are not completely iso- • blockage of arterial supply
lated. There are exchanges of information • secondary ischemia
with neighboring tissues, particularly with • nerve lesion.
the fascial system. In osteopathy, it has long been thought
that only extraneural forces were responsible
for compression phenomena. A great many
1.4 FUNCTIONAL PATHOLOGY techniques have been developed with the
OF NERVES aim of releasing the external forces exerting
themselves on a nerve. However, in reality,
1.4.1 Neural fi brosis compression appears to be more complex.
Intraneural movement occurs between neural Intrinsic pressures, fi brosis and edema of the
tissue and connective tissue components. The nerve itself must be addressed. These com-
nerve fi bers are able to crease and then unfold pressive elements have a direct effect on the
themselves in relation to the layer of endo- nerve and its perineural connective tissue,
neurium. At the interior of a nerve or nerve as well as on its microvascularization and
root, a fascicle has the ability to glide in rela- micro-innervation.
tion to another fascicle. Due to this fl exibility,
the various components are able to withstand
1.5 FROM SPECIFIC TO GLOBAL
external forces without threat of rupture. In a
similar manner, the brain can move in rela- We unreservedly and enthusiastically support
tion to the cranial dura mater that surrounds A.T. Still’s concept of globality (1899).
it, and the spinal cord moves in relation to All parts of the body play an indispensable
the spinal dura mater. role in ensuring homeostasis. The organism
When the nerve trunk is traumatized, it is a marvelous machine that requires all of
almost immediately produces an albumin its components to be in good working
exudate, which circulates at the site of injury. order. The individual is a whole that must
Endoneurial edema increases intravascular not be compartmentalized. To do so would
pressure, diminishing circulation in the risk manual therapists being perceived as
capillary blood stream. Long-standing specializing in a particular part of the
4 edema causes endoneurial fi brosis and the body.
1
Some preliminary thoughts
We fi rmly believe that manipulations The manipulation of the cranial nerves is
should be precise. In order to achieve this an exceptional tool for treating the brain and
precision, specifi c knowledge is necessary. the rest of the body. Manipulation of the
The acquiring of such education demands cranial nerves allows us to have an effect on
that the manual therapist be a generalist. the sutures, the meninges and the encepha-
For manual therapists to be good general lon. All local stimulation has as its goal the
mechanics of the body, they must have the generation of a whole-body response on the
same manual dexterity when working on part of the organism: in this case, one induced
a foot, an organ, the spinal column or the by the brain. It is in the spirit of A.T. Still that
cranium. we have written this book.
5
2
Characteristics of
cranial nerves
2.1 REVIEW emerge from the skull, are of medullary
origin and can therefore be considered
The core of the central nervous system is con-
spinal nerves.
nected with the peripheral organs (sensory or
• The vagus nerve (X) and the medullary
motor) by the cerebrospinal nerves, the entire
part of the accessory nerve (spinal or XI)
assembly making up the peripheral nervous
constitute one and the same nerve: the
system. Upon emerging, the peripheral nerves
vago-accessory.
are termed cranial if they arise from the
• The trigeminal (V) nerve in mammals
encephalon or the cerebral trunk. They are
results from the merging of two nerves,
termed spinal if they issue from the spinal
distinct in all other vertebrates: the deep
cord.
ophthalmic and the maxillo-mandibular
Like the nerves of the vertebral column,
nerves.
the cranial nerves are symmetrical, corre-
sponding to the cerebral spinal axis. Number- In this book we will endeavor to use the
ing 12 pairs, they cross the various meningeal new terminology. For those like us, who
layers to exit foramina at the cranial base, just learned the cranial nerves by their old desig-
as the spinal nerves emerge on the lateral side nation, we have included a table of corre-
of the vertebral column. sponding terms (Table 2.1). Some cranial
nerve branches and a few ganglions have also
had their designation changed (Table 2.2).
2.2 TERMINOLOGY
The classic mnemonic devices of the past will
The nomenclature and numeration of the also have to be updated one day!
cranial nerves date from 1664 (Willis). The
12 pairs of cranial nerves are distinguished
according to purely descriptive criteria. They 2.3 EMBRYOLOGICAL FEATURES
are numbered from I to XII anterior to poste-
As a rule, the spinal nerves have a metameric
rior, and named according to their form
and symmetrical arrangement, each somite
(trigeminal), their destination (facial, glosso-
having a corresponding dorsal and ventral
pharyngeal) or function (olfactory, optic,
nerve. The ventral nerve is a motor nerve,
auditory). Since the 18th century, compara-
while the dorsal nerve is sensory. The cranial
tive embryology and neurology have brought
nerves more or less conserve this arrangement
to light certain inaccuracies in these designa-
of ventral and dorsal nerves, but their meta-
tions. For example:
meres often fade away.
• The accessory (spinal or XI) and At the level of the trunk, the segmental
hypoglossal (XII) nerves, although they distribution of the vertebral column nerves is 7
Theoretical principles
Table 2.1 Corresponding names of cranial nerves
New nomenclature Old nomenclature Anatomical name
Olfactory nerve (I) N. olfactorii
Optic nerve (II) N. opticus
Oculomotor nerve (III) Common ocular motor N. oculomotorius
Trochlear nerve (IV) Pathetic nerve N. trochlearis
Trigeminal nerve (V) N. trigeminus
Abducent nerve (VI) External ocular motor nerve N. abducens
Facial nerve (VII) N. facialis
Vestibulocochlear nerve (VIII) Acoustic nerve N. vestibulocochlearis
Glossopharyngeal nerve (IX) N. glossopharyngeus
Vagus nerve (X) Pneumogastric nerve N. vagus
Accessory nerve (XI) Spinal nerve N. accessorius
Hypoglossal nerve (XII) Greater hypoglossal nerve N. hypoglossus
Table 2.2 New and old nomenclature
New designation Old designation Origin Destination
Communicating Superfi cial lesser petrosal n. VII Otic ganglion
branch of lesser
petrosal n.
Greater petrosal n. Superfi cial greater petrosal n. VII Pterygopalatine ganglion
Lesser petrosal n. Lesser deep petrosal n. Tympanic n. (IX) Otic ganglion
Deep petrosal n. Greater deep petrosal n. Carotid plexus Pterygopalatine ganglion
Tympanic n. Nerve of Jacobson IX Tympanic cavity
relatively simple to imagine. At fi rst glance, • the pro-encephalon, which subdivides
the organization of the cranial nerves appears into the diencephalon (endocrine
more complicated. A few rudimentaries of function) and the telencephalon (thought
embryology will help us to visualize and processes)
understand their arrangement more easily. • the mesencephalon
• the rhombencephalon (hindbrain),
2.3.1 The neural tube which forms the metencephalon
(cerebellum) and the myelencephalon
Near the end of the fi rst month of gestation
(medulla oblongata).
the neural tube is formed from 3–5 vesicles
(Fig. 2.1), which later on fashion the brain Each of these vesicles is connected to one
and its annexations (the cerebellum and brain or more pairs of what will become the cranial
8 stem): nerves, arranged from right to left.