La manipulation fasciale ou « Neuro-connective » a pour origine les études et la pratique clinique du Kinésithérapeute Luigi Stecco, qui a élaboré une approche valide du traitement des dysfonctionnements et des symptomatologie de l’appareil locomoteur.


En anatomie, on peut observer que le tissu conjonctif dense fascial représente une structure continuelle en ce qui concerne la longitudinalité du tronc et des membres et en ce qui concerne l’horizontalité des sections à tous les niveaux. Il recouvre et pénètre chaque niveau musculaire, en fournissant des insertions à environ 30 % des fibres musculaires dans l’ensemble du corps.


Cela permet à la structure fasciale de connecter des fibres musculaires appartenant à des muscles différents mais qui agissent ensemble du point de vue fonctionnel pendant les différentes coordinations motrices segmentaires et globales. La présence dans le fascia d’éléments fondamentaux pour l’actuation du mouvement (fuseaux neuromusculaires, organes de Golgi et corpuscules récepteurs) fait de cette structure une référence utile du point de vue perceptivo-moteur pour le Système Nerveux Central et pour la coordination périphérique dans les trois plans de l’espace.

Des facteurs internes et externes, mécaniques ou chimiques, sont capables d’avoir une incidence sur l’homéostase normale du fascia en stimulant les composantes du tissu conjonctif lui-même (fibres, substance fondamentale et cellules) en produisant une réaction protectrice d’épaississement, superposition et densification. Tout cela donne lieu à une structuration des liaisons transversales inter et intra fasciales non résorbable capable d’altérer l’équilibre des tensions myo-fasciales qui est à la base d’une douleur dans le segment articulaire géré par les dits moteurs musculaires.

Dans la plupart des travaux, le fascia musculaire profond est décrit comme une bande de tissus conjonctif dense qui recouvre les muscles (Moore, 2001) et qui assure exclusivement une fonction de support inerte (Kuslick), ou bien de séparation ou de remplissage.
Plus récemment, le fascia a suscité un intérêt particulier chez les chercheurs et est considérée comme déterminant dans plusieurs pathologies.


Des études très récentes considèrent le fascia comme un élément important en ce qui concerne la biomécanique musculaire, la coordination motrice périphérique, la proprioception et la régulation de la posture.
Wheater (Young et al., 2006) décrit le fascia comme « un squelette flexible, sur lequel sont ancrées les fibres musculaires ». Ce tissu conjonctif est en continuité avec celui des tendons et des insertions musculaires. Sa fonction est de distribuer et diriger les forces du mouvement par rapport aux os, à la peau….de façon appropriée».

Divers auteurs parmi lesquels Vleeming, Snijders, Stoeckart et Mens ont décrit comment la tension du Grand Fessier va se transférer au membre inférieur à travers le trait iléo-tibial et comment ce dernier est mis en tension par l’expansion du vaste latéral durant sa contraction.
Au cours du cycle de la marche, il y a sans aucun doute une séquence très importante de tensions myo-fasciales. Dans ce cycle, le trait iléo-tibial et le fascia lata se comportent comme des ressorts fondamentaux pour les articulations et pour l’accumulation d’énergie.

D’autres auteurs ont décrit une innervation spécifique du fascia profond. Plus précisément, Stilwell (1957), Hinsch et al. (1963) et Yahia et al. (1992) ont mis en évidence plusieurs terminaisons nerveuses libres dans le fascia thoraco-lombaire ; Staubersand et Li Y Zum (1996) dans le fascia crural et Stecco (2006) dans le fascia brachial. Chez les patients présentant une lombalgie chronique, on a découvert à la fois une altération de la structure histologique (phlogoses et micro-calcifications) et une altération du degré d’innervation du fascia thoraco-lombaire. Tout ceci permet d’envisager un rôle éthio-pathologique important du fascia en ce qui concerne la douleur lombaire (Bednar et al., 1995). Pans (2001), Rodrigues (2002) et Rosch (2003) ont démontré chez des patients souffrant d’une hernie inguinale que le fascia transverse présente une texture de fibres collagènes désorganisées avec une augmentation des fibres isolées, des altérations structurales quantitatives et qualitatives en ce qui concerne les fibres élastiques et une augmentation de la vascularisation par rapport aux individus sains.
 
 
La « Manipulation Fasciale » a construit sur l’anatomie et la physiologie du fascia les principes du traitement des problèmes musculo-squelettiques.
Cette conception s’avère être un support intéressant pour l’activité de prévention des pathologies dans le domaine du sport et en général.
Ce type d’approche prévoit quatre étapes fondamentales :

1. une récolte soigneuse des données concernant le patient ;
2. la formulation d’une hypothèse de traitement ;
3. une double vérification des hypothèses : vérifications sur le plan moteur (tests fonctionnels) et au niveau de la palpation des Centres de Coordination (CC), points dans lesquels on trouve la résultante des vecteurs musculaires appliqués à une articulation ;
4. le traitement en lui-même.

 
L’intervention en terme de manipulation a pour but d’individualiser de façon précise la présence d’une densification sur le CC due à la superposition de néo-collagène, et permet de redonner au fascia la bonne élasticité et souplesse. Cela permet au kinésithérapeute et au patient d’évaluer immédiatement, à la fin de la séance, le résultat de l’intervention.

La formation Facial manipulation est dorénavant disponible en France

Pour plus de renseignements, cliquer ICI

Lorsque des tensions, ou encore des adhésions compriment les éléments vasculo-nerveux proches, et provoque des douleurs, le nombre de techniques reste peu dense

Le septum antéromédial intermusculaire ou " vasto adductor membrane" correspond à la partie conjonctive qui couvre la fin du canal des adducteurs et le début du hiatus des adducteurs.

LE HIATIUS DES ADDUCTEURS

A proximité de ce hiatus, là où transitent des éléments vasulonerveux tels que veines et artères fémorales, le grand addcuteur peut par sa tension pathologique, venir gêner ces structures, source alors de douleurs.

Le protocle sous jacent est alors proposé.

Il faudra accompagner ce traitement du protocole myo-Détensif® du gracile et du vaste interne, ainsi que pratiquer la technique de crochetage Ekman Therapie®.

Ce protocole myo-Détensif®  consiste à placer le patient en décubitus dorsal, légère flexion de hanche, genou fléchit.

- Placez votre contact en densité sur le hiatus et tout en l'augmentant demandez au patient activement de majorer la flexion de hanche tout en l'amenant en position d'abudction

A répéter plusieurs fois

Le canal des adducteurs

Formé par le sartorius, le vaste interne, les adducteurs, il contient les veine et artère fémorales et le nerf saphène. Chacune de ces structures peuvent provoquer des symptômes locaux ou en core à distance par pression sur ces élements vasculonerveux.

Il sera nécessaire donc de vérifier la liberté tissulaire de chacun.

Le patient est en décubitus dorsal, hanche fléchit et en rotation externe légère, genou flechit

Le contact est placé sur la sartorius

Maintenez la tension pendant que la patient dans l'ordre

- étend sa hanche, 

- la place en rotation interne

- étend son genou t

- abducte sa  hanche.

DENOUAGE DU GRAND ADDUCTEUR

Le patient se tient  debout, genou légèrement fléchi. Tenez vous  accroupi ou assis face à votre patient.

Placez votre contact  par trois doigts sur le bord postérieur de la corde du grand adducteur, face interne de la cuisse. Accrochez ensuite tout le corps musculaire pour le mettre en tension et faites  sauter le grand adducteur sur plusieurs centimètres en crochetant la corde.

Ces exemples ne sont bien sûrs pas exhaustifs. les protocoles myo-Détensifs® compris dans la thérapie intégrative, apportent de réelle solution novatrice sur l' aspect myo-tissulaire.

Nous conseillons en parallèle d'utiliser des techniques de mobilisation assistée des tissus mous tels que Ekman Thérapie®.

Selon une étude de George, Tepe, Bussold, Keuss et Prater en 2006 sur 5 sujets présentant un syndrôme du tunnel carpien, les techniques manuelles type pin-and-stretch (protocoles myo-détensifs) ont été étudiées.

Le magazine soft tissue therapy est téléchargeable dans notre rubrique téléchargement.

Le massage instrumento-assistée augmente les propriétés structurales des ligaments lésés
selon une étude récente parut dans le Journal of Orthopaedic & Sports Physical Therapy (JOSPT).

Dans l’ étude , «  Improves Regional Blood Flow in Healing Knee Ligamentsparut en janvier, Mary T. Carey-Loghmani, PT, MS, MTC, Associate Clinical Professor, School of Physical Therapy, Indiana
University, is the author.

L'article que nous avons fait connaître a été repris dans  Kinésithérapie la revue

Nous vous conseillons de visionner les vidéos et de lire les textes pdf ci dessous.

Instrument-assisted cross-fiber massage accelerates knee ligament healing.

J Orthop Sports Phys Ther. 2009 Jul;39(7):506-14. 

Loghmani MT, Warden SJ. 

Departmento of Physical Therapy, School of Health and Rehabilitation Sciences, Indiana University, Indianapolis, IN, USA. mloghman@iupui.edu  

PLAN DE L'ÉTUDE: Étude contrôlée en laboratoire. 

OBJECTIFS: 

Étudier les effets du massage transversal instrumento-assisté des fibres  sur la cicatrisation après lésions du ligament latéral interne du genou.  

INFORMATIONS GÉNÉRALES: 

Les lésions de ligaments représentent un problème clinique commun et significatif et pour lequel il existe très peu d'interventions établies. Le massage transversales instrumento-assisté des fibres  est une intervention qui pourrait faciliter la guérison au niveau des tissus suite à une lésion de ligament.  

MÉTHODES: 

Des lésions bilatérales du ligament latéral interne du genou ont été créées chez 51 rongeurs, alors que 7 rongeurs, les animaux de contrôle, n'ont pas subi de lésion de ligament. Le massage instrumento-assisté de fibres a commencé une semaine après l'apparition de la lésion, à raison de 3 sessions par semaine d'une minute chacune. Ce massage a été instauré de manière unilatérale (traitement par massage instrumento-assisté de fibres), et le ligament latéral interne du genou, controlatéral, avec lésion, a servi de contrôle interne (non traité). 

Trente et un animaux présentant une lésion ont fait l'objet de 9 traitements par la technique instrumento-assistée, alors que les 20 autres animaux avec lésion ont fait l'objet de 30 traitements. La morphologie et les propriétés biomécaniques des ligaments ont été évaluées à 4 et 12 semaines après l'apparition de la lésion. 

RÉSULTATS: 

Les ligaments traités par massage instrumento-assisté étaient 

- 43,1 % plus solides (P<0,05), 

- 39,7% plus rigides (P<0,01), 

- et pouvaient absorber 57,1 % plus d'énergie avant déficience (P<0,05) que les ligaments controlatéraux, avec lésions, et non traités 4 semaines après l'accident. 

Lors de l'évaluation histologique et d'une myographie électronique par balayage, les ligaments traités par massage instrumento-assisté ont indiqué une meilleure orientation et une meilleure formation de faisceau de fibres collagènes dans la région lésée que les ligaments non traités. On a observé très peu de différences entre les ligaments traités par massage instrumento-assisté et les ligaments controlatéraux non traités 12 semaines après l'apparition de la lésion, bien que les ligaments traités par massage instrumento-assisté se soient avérés 15,4 % plus rigides (P<0,05). 

CONCLUSION: 

La guérison de ligaments accélérée par massage instrumento-assisté a pu avoir des effets favorables sur l'organisation et la formation de collagène, mais a eu un effet minimum sur le résultat final de la guérison.  Ces résultats sont intéressants au niveau clinique, vu qu'il existe très peu d'interventions établies pour les lésions de ligaments, et le massage instrumento-assisté est une méthode de traitement simple et pratique.

J Orthop Sports Phys Ther 2009;39(7):506-514, publié en ligne le 24 février 2009. doi:10.2519/jospt.2009.2997

The term “Cobb Angle” is used worldwide to measure and quantify the magnitude of spinal deformities, especially in the case of scoliosis. The Cobb angle measurement is the “gold standard” of scoliosis evaluation endorsed by Scoliosis Research Society. It is used as the standard measurement to quantify and track the progression of scoliosis. Cobb angle was first described in 1948 by Dr. John R Cobb where he outlined how to measure the angle of the spinal curve. Hence, the term “Cobb Angle” came about, bearing his name.
The forward bending test is usually use to screen for scoliosis before puberty. An X-ray will be performed on the patient if this test is positive and the Cobb angle measured.
How To Measure Cobb Angle?

click for larger view
Locate the most tilted vertebra at the top of the curve and draw a parallel line to the superior vertebral end plate. [Insert picture showing vertebral endplates].
Locate the most tilted vertebra at the bottom of the curve and draw a parallel line to the inferior vertebral end plate.
Erect intersecting perpendicular lines from the two parallel lines.
The angle formed between the two parallel lines is Cobb angle. [Insert pic to show measurement of cobb angle]
What Is The Significance of Cobb Angle?
The Cobb angle is a measure of the curvature of the spine in degress which helps the doctor to determine what type of treatment is necessary. A Cobb angle of 10 degree is regarded as a minimum angulation to define Scoliosis.
A scoliosis curve of 10 to 15 degrees normally do not require any treatment except for regular check-ups with the orthopaedic doctor until the patient has gone through puberty and finished growing as the curvature of the spine usually do not worsen after puberty.
If the scoliosis curve is 20 to 40 degrees, the orthopaedic doctor will generally prescribe a back brace to keep the spine from developing more of a curve. There are several types of braces out in the market, with some worn for 18 to 20 hours a day, others only at night time. Which type of brace the orthopaedic doctor will prescribe will depend on the patient’s lifestyle, and the severity of the curve(s).
Is surgery required?
If the Cobb angle is 40 or 50 degrees or more, surgery may be required to correct the curve. The orthopaedic surgeon will perform a procedure known as spinal fusion to link or “fuse” the vertebrae together so that the spine can no longer continue to curve. Metal rods, screws, hooks and wires will be used to correct the curve and hold everything in line until the bones heal. Teens who have had surgery to correct their scoliosis will usually return to school about a month after surgery, and should be able to gradually return to all normal activities after 6 to 12 months post surgery.

Cyriax Physiotherapy Versus Phonophoresis with Supervised Exercise in Subjects with Lateral Epicondylalgia: A Randomized Clinical Trial

AMIT V. NAGRALE, MPhT; CHRISTOPHER R. HERD, PT, DPT, CSCS; SHYAM GANVIR, MPhT; GOPICHAND RAMTEKE, MPhT

La méthode Cyriax et les frictions transversales profondes en combinaison avec les Mill's manipulations a été comparée avec des séances de ionophorèses.

60 patients âgés de 30 à 60 ans, présentant une atteinte téno-périostée et des symptômes dans le dernier mois.

2 groupes ont été constitué.

Le groupe contrôle fut traité par ionophorèse avec diclofenac durant 5 minutes combinée à des exercices supervisés.

Le second groupe ( expéreimental) fut traité par 10 minutes de MTP Cyriax suivi d'une manipulation de MILL.

Chacun des groupes fut traité 3 fois par semaine pendant 4 semaines.

Les mesures relevées :

- échelle de douleur VAS
- douleur au grip de force
- état fonctionnel mesuré par l'échelle de fonction Tennis Elbow

Tous les résultats démontrent que l'on obtient de meilleurs résultats avec le groupe expérimental ( MTP et Mill).

The Journal of Manual & Manipulative Therapy Vol. 17 No. 3 (2009), 171-178

Une étude " The long posterior sacroiliac ligament: An histological study of morphological relations in the posterior sacroiliac region" publiée en janvier 2009 par Christopher McGrath , Helen Nicholson, Peter Hurst du Department of Anatomy and Structural Biology, Otago University, Dunedin, Nouvelle-Zélande
nous apprend que, par l'étude histologique de ce ligament dans ses rapports dans la région sacro-iliaque postérieure :

- qu'entre les deux extrémités du LLSIP constituant les zones d’ancrage osseux, le ligament est formé par la confluence de trois couches :

- l’aponévrose du muscle sacrolombaire,
- le fascia profond
- l’aponévrose des fessiers.

À la face profonde du fascia profond se trouve une couche de tissu adipeux et conjonctif lâche, qui contient les nerfs clunéaux moyens.

Ainsi,la partie moyenne du LLSIP semble constituer une zone de passage pour les nerfs clunéaux moyens, qui émergent de la région sacrée postérieure pour pénétrer dans la fesse. Les résultats de l'étude histologique laissent penser que les douleurs souvent attribuées à l’articulation sacro-iliaque seraient dues dans certains cas à la compression des nerfs clunéaux moyens dans le LLSIP.


Néanmoins dans tous les cas, l'atteinte de ce ligament provoque des douleurs, qu'elles soient locales , à distance où indirecte ( nerfs clunéaux).

Abstract

Background
Practitioners of manual medicine/manual therapy (MM/MT) who utilize techniques thought to have some impact upon and move the solid structures of the human head have been criticized for lack of evidence of cranial bone motion. The present study utilized magnetic resonance imagery (MRI) technology to address the question of whether or not inherent (non-operator initiated) calvarial structure motion can be assessed.

Methods
Subjects: Twenty healthcare professionals, (physicians, nurses, medical students, pharmacists) between the ages of 24 and 52 were recruited. Seven females (ages 25-47, mean age 36.7) and 13 males (ages 25-53, mean age 31.2) volunteered. Technology: MRI scans were acquired at 450 ms per slice, in a 1.5 Tesla Signa Excite HD closed MRI system. The same scan prescription was repeated serially every 45 seconds to obtain eight serial slices for each subject. Image analysis was accomplished using ImageJ software (ImageJ 1.33 u National Institutes of Health, USA). Data from all eight images for each of the 20 subjects were analyzed to determine the two images with the largest differences in the parameters measured.

Results
Difference values for the measures of area, width, height, major axis, and feret were statistically different whereas the measures for perimeter and minor axis were not. However, only the difference values for area were both statistically different (p < 0.003) and exceeded the resolution threshold of 0.898 mm/pixel.

Discussion
The statistically significant difference value for area is suggestive of inherent motion in calvarial structures, and adds to the body of evidence supportive of biomechanically measurable calvarial structure motion in general. That the total intracranial area appeared to expand and recede was consistent with theory and prior studies suggestive of calvarial structure motion due to intracranial fluid volume changes.

Conclusion
The use of MRI technology was able to demonstrate calvarial structure motion at a level exceeding the resolution threshold, and provides a means for further research on phenomena related to the cranial concept. It may be just a matter of time until increased resolution of MRI technology and image analysis provide the ability to examine more detailed areas of specific cranial bone motion.

Background

Practitioners of manual medicine/manual therapy (MM/MT) who utilize techniques thought to have some impact upon and move the solid structures of the human head have been criticized for the apparent lack of evidence for the capability of cranial structures to move, much less the mechanism of action for such possible motion. Research suggestive of cranial structure motion has been generated in the past decade by physiology and neuroscience researchers concerned with intracranial fluid dynamics [1-6]. National Aeronautics and Space Administration (NASA) supported research, along with research carried out by former Russian Cosmonaut program scientists [7-11] has increased the credibility and potential applicability of MM/MT as it relates to structures of the human head. Recent anatomic research suggested that calvarial sutures remain patent with the degree of patency dependent on the amount of muscular attachment on a particular calvarial bone and the activities of chewing and movement of the head upon vertebral column [12].

Studies on animal subjects have been conducted under conditions which allowed controlled calvarial bone motion production and observation. Adams et al [13] studied parietal bone mobility in adult cats. They used a multiplanar strain gauge to measure parietal bone motion in response to externally applied forces and to changes in intracranial pressure induced by artificial cerebrospinal fluid injected into the subarachnoid space. Measurable motion did occur, with the range being 17 to 70 microns. Lateral head compression induced sagittal suture closure and inward rotation of the parietal bones. Increased intracranial pressure induced a widening of sagittal suture and outward rotation of parietal bones, with the same effect produced by direct pressure on the sagittal suture.

On squirrel monkeys, Michael and Retzlaff [14] performed direct measurement of right parietal bone motion using a screw attachment and a displacement transducer. With the primate's head immobilized in a stereotaxic frame, bone displacement, mean arterial blood pressure, and heart and respiration rates were simultaneously measured. Spontaneous cranial motion and the effects of applying external forces and passive spinal motion were recorded. Results showed two patterns of spontaneous parietal bone motion. One pattern was synchronous with respiration rate. This was superimposed over a second, slower oscillatory pattern consisting of 5-7 cycles per minute that was not attributable to heart rate, respiration rate, or central venous pressure. Force applied to the skull in various locations generally produced motion between the parietal bones.

While not conclusive as to mechanism of action, the animal research showed that calvarial bone movement does occur and may be related to oscillations in physiologic functions such as heart rate and respiration rate. To date the only attempt to correlate calvarial bone motion with a physiologic impetus, in the context of the cranial motion theory of Sutherland known as the primary respiratory mechanism (PRM) [15,16], was by Moskalenko et al [11] who theorized a harmonic effect of vascular and neurological processes as the motive force of the PRM.

In order to establish a greater evidence base demonstrative of cranial/calvarial bone motion, which would then lead to research on the mechanism(s) of action, the utilization of imagery technology was selected. There is precedent for such a path of research. The utilization of x-ray imagery technology to assess cranial structure motion was done in a pilot study on humans [17], and suggested that MM/MT intervention may have the capability to alter cranial bone biomechanical relationships. While magnetic resonance imagery (MRI) technology was used in the Russian research [9,10], corroboration of their findings with a larger number of subjects is needed. Therefore, to further study the proposed and theoretically formulated model of inherent, intrinsic cranial structure motion [15,16], the use of MRI technology to assess cranial structure motion was carried out on healthy human subjects.

Utilizing MRI on healthy human subjects the hypothesis was that eight serial slices through exactly the same calvarial plane over a six minute period would show no deviation on any plane or vector. The null hypothesis was that there would be no difference in measurable dimensions for each subject.

Methods

Subjects
Twenty healthcare professionals, (physicians, nurses, medical students, pharmacists) between the ages of 24 and 52 were recruited. Seven females (ages 25-47, mean age 36.7) and 13 males (ages 25-53, mean age 31.2) volunteered. The age difference was not statistically significant (p = 0.15). Volunteers were excluded if they were pregnant, had a history of surgery of the cranium or face, had metal implants that would preclude use of the MRI, or the radiologist determined that it would be unsafe for the person to participate. This study was reviewed and approved by the Institutional Review Board of Florida East Hospital of Orlando, and the MRI studies were carried out in the Radiology Department of Florida East Hospital of Orlando, FL.

MRI Capability and Utilization
In the present study Serial axial T1-weighted MRI scans were acquired at 450 ms per slice, in combination with a dedicated phased array head coil in a 1.5 Tesla Signa Excite HD closed MRI system (GE Medical Systems, Milwaukee, WI). A single axial T1-weighted scan slice was prescribed at approximate maximum mid-cranial diameter, at the level of the parietal bones as determined by multiplanar T1 gradient-echo localization. The same scan prescription was repeated serially every 45 seconds to obtain eight serial slices. The number of scans and interval between scans were arbitrarily determined as the rate of PRM motion varies between individuals [15,16]. The assumption was that a consistent time interval between scans would provide a stronger, more easily replicated research design, and was likely to provide images which would capture at or near maximum and minimum PRM flexion-extension excursion [15,16].

The MRI protocol, including equipment and technology, was reviewed by the Scientific Review Committee of Florida East Hospital of Orlando, FL which included two radiologists, one of whom specialized in neuroradiology. The radiologists specifically required the use of the GE Medical Systems 1.5 Split Head Coil head mount which met the current standard of practice for elimination of head movement (Figures 1 and 2). The use of this particular head mount raised the concern that the very tight fit on subject's head could reduce or eliminate any possible calvarial motion, however this precaution was required for the project to be approved.

Figure 1. GE Medical Systems 1.5 Split Head Coil Mount.
Figure 2. Head mount with human subject in place.
Two dimensional MRI scans, 23 centimeters high and 23 centimeters wide were obtained. Each 2D MRI image contains an array of 256 pixels wide by 256 pixels high. Thus, the image resolution in this case is 0.0898 cm/pixel (23 cm divided by 256 pixels and converted to mm is 0.898 mm/pixel). The images were saved in DICOM format and then converted in TIFFs for importation into ImageJ software (ImageJ 1.33 u National Institutes of Health, USA) for evaluation. The images were thresholded to interactively set lower and upper threshold values between 40 and 255. Figure 3 is representative of the image produced by this step of ImageJ analysis. Then the threshold image was analyzed using the analyze particles command in ImageJ. The minimum pixel size was set at 10 and maximum to 999999 in order to obtain the external contour of the image. Figure 4 is representative of the image produced by this step of ImageJ analysis. Area, perimeter, height and width of a bounding rectangle, major and minor axes of the best fit ellipse, and the feret diameter (longest distance between any two points along the boundary) were calculated using the analyze particles function in ImageJ. Data were imported into an Excel® spreadsheet for analysis. Data from all eight images for each of the 20 subjects were analyzed to determine the two images with the largest differences in the parameters measured. The differences between these two images were recorded and means determined for all 20 subjects.

Figure 3. Threshold image.
Figure 4. Threshold outline.
The study was completed in one day on the same machine. Each subject's head was positioned in the mount as shown (Figures 1 and 2). The head was cradled in the firm rubber device which fit tightly under the cranial base and slightly overlapped the occipito-parietal bone suture. With the subject's head in the head mount, the mount was secured to the table, and subjects were instructed to lie as still as possible for the six minute MRI procedure. Each subject was visually monitored for the entire six minute procedure and there appeared to be no body or head movement at any time by any subject. There were no instances of coughing or other reflexive behaviors which could have caused head movement.

Results

Statistical analysis using a two tailed paired t-test with hypothesis of a difference of zero was performed. Table 1 displays the mean ± the standard deviation differences between the maximum and minimum values for all measures evaluated by ImageJ, confidence intervals and p values. Difference values for the measures of area, width, height, major axis, and feret were statistically significant, whereas the difference values for perimeter and minor axis were not statistically significant. While statistically different, the measures for width, height, major axis, and feret were below the resolution threshold of 0.898 mm/pixel and could not be used reliably to determine changes in cranial shape due to PRM. The difference values for area measure were both statistically different (p < 0.003) and were well above the resolution threshold of 0.898 mm/pixel.

Table 1. Mean difference between the maximum and minimum values for each of the measures evaluated by ImageJ for each subject (N = 20), using a two tailed paired t-test
Discussion

While just under resolution values of 0.898 mm/pixel, the statistically significant difference values for width, height, major axis, and feret may suggest changes in calvarial dimensions worth further examination under more precise and controlled technical conditions, such as with higher resolution MRI capability. Also further advances in the ImageJ technology may result in greater applicability in research designs comparable to the present study.

The statistically significant difference values for area, which were above the resolution threshold limits of the MRI technology available for use in the present study, suggests that calvarial structures may move independent of any external or internally applied forces in normal human subjects. Were it the case that calvarial structures were immobile as might be the case if cranial sutures were completely fused and the calvarial structures incapable of any deformation or boney compliance, then no changes in position, as results in the present study suggest, would be possible.

It was not assumed that the minimum and maximum differences for each dimension represented the full excursion of flexion and extension of the PRM. Nor was there any attempt to equate ImageJ dimensions with MM/MT cranial treatment terminology such as "height" with anterior-posterior calvarial axis, "width" with bi-parietal diameter, and "perimeter" with circumference. However, the calvarial slice image placement was purposely placed over the parietal, temporal and occipital bones, which clinically and in other studies [2-6,18,19] are reported to have the greatest amplitude of change.

The contention of the authors is that the statistically significant difference between the minimum and maximum dimensions, as measured by ImageJ, for area suggest that the calvarial structures moved in some way during the sequence of eight scans over six minutes. No data or observation from the present study is suggestive of mechanism of motion, be it due to bone compliance, due to viscoelastic properties of bone, or motion around cranial sutures. The finding of a mean area change of 122 mm2 (Table 1) at that particular calvarial level could reflect the change in intracranial fluid volume identified in the NASA studies and postulated by Moskalenko et al [11] to account for most of the cranial bone motion implied in the PRM concept. In the NASA studies intracranial fluid volume was directly increased biomechanically in cadavers and in healthy human subjects by tilting them upside down with presumed gravitationally increased intracranial fluid volume, by pooling of either CSF or blood, or both.

It is recommended that future studies of this nature, using any imagery technology should use a stable marker in the image field to provide a reference point within the plane of reconstruction as well as orthogonal to it. The authors also acknowledge that MRI image resolution in the present study, while high quality and the best available at the research site, may not accurately identify changes less than the presumed 100 micron to 1.2 mm diameter changes found in other studies [4,5,9,19].

Conclusion

The possible shortcomings notwithstanding, the data presented in the present study suggest that calvarial structures have motion characteristics that can be identified by MRI technology. It may be just a matter of time until increased resolution of MRI technology and image analysis provide the ability to examine more detailed areas of specific cranial bone motion and provide a reliable means for cranial bone motion research.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

HK and WC conceived of the study. HK obtained external funding and drafted the manuscript. WC obtained and coordinated support from Florida Hospital East Orlando for MRI studies. VG participated in study design, provided facility for preliminary imaging study and manuscript review for MRI technical accuracy. RP participated in the design and performed the imagery analysis and statistical analysis. All authors read and approved the final manuscript.

Acknowledgements

Funding for this study came from The Cranial Academy. Funding and use of MRI services was provided by Florida Hospital East Orlando, FL. Support for research design and biostatistics was provided by The Osteopathic Research Center at the University of North Texas Health Science Center.

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L'ÉTUDE " Spinal and sacroiliac assessment and treatment techniques used by osteopathic physicians in the United States" par Gary Fryer, Christopher M Morse et Jane C Johnson permet d'avoir un recul sur les pratiques de 172 praticiens spécialisés en ostéopathie sur le sujet.
Ces praticiens, homme dans la majorité, avec en moyenne 15 ans d'expérience. Cette étude consistait à relever, selon les pratiques de praticiens questionnés

- les tests des dysfonctions rachidiennes utilisés

- les techniques thérapeutiques utilisées pour ces dysfonctions

- les tests du pelvis et des sacro-iliaques utilisés

- les techniques utilisées pour ces dysfonctions


- les tests des dysfonctions rachidiennes utilisés

- palpation des spinaux 98%
- asymétrie des apophyses transverses 89%
- test de mobilité des transverses 80% , des asymétries rachidiennes 70% , des glissements 69% craniens 68%.
- skin rolling test 6%
- percussion test 9%

-89 % des praticiens connaissent les lois de Fryette
- 60% d 'entre eux les trouvent utiles dans les test des dysfonctions rachidiennes.
- 21% d'entre eux les trouvent unitilisables.

Les techniques utilisées

- 78 % des techniques de "myofascial release"
- 77% des technqiues des tissus mous
- 71% d'auto-étirements
- 46% autres ( hammer percussion, viscéral, acupuncture...)
- autres hlvs, still... sur tbaleau ci contre.


Tests utilisés pour le bassin et les sacro-iliaques:


- repère des asymétries de
- EIAS (87%),
- base sacrée ( 82%)
- EIPS (81%)
- sulcus sacrées (78%)
- crêtes iliaques ( 77%)
- angle inféro-latéraux du sacrum ( 74%)
- autres ( 20 réponses avec test de L5, musculature pelvienne et lombaire, ligament ilio-lombaire)

- tests des mouvements
- compression EIAS ( 68%)
- TFD ( 54%)
- tests sacrés ( 46%)
- test de Gillet ( 12%)
- sphynx test 23%
- 15 réponses autres ( test de FAER, Gaenslen, Trendelenburg..)


Traitements des dysfonctions pelviennes et SI

- energie musculaire 70%
- myofascial release 67 %
- auto-étirements 66%
- exercices de renforcement 58%
- technqiue des tissus mous 58 %
- HLVA indirecte 8%
- 22 réponses autres ( hammer percussion, neuromusculaire, acupuncture...)

Les techniques thérapeutiques les plus utilisées des praticiens ostéopathes aux USA sont favorablement des méthodes " douces". D'après cette étude les techniques dites HLVA, Still... structurelles, sont moins utilisées , et dépendent du nombre d'années de pratiques et du sexe