Susannah Reid

Hip Unsteadiness: Mrs W previously did not think twice about standing on her left leg to get dressed and put shoes on. She felt very frustrated when her doctor told her she has a healthy hip and shouldn’t feel unsteady and she should be able to walk and dance no issue.

Hip Discomfort: Regarding her left hip discomfort, she put it down to her old car accident but it had become more disruptive to her walking since the recent fall.

Concussion: Mrs W felt that her concussion should be resolved by now based on what the emergency room doctor and her doctor had told her. She still noticed frequent head pressure, eye strain and trouble getting out to be social.

Mrs W expressed high motivation to get better as she is normally very active, walking five kilometers each day and salsa dancing three times per week. The experience of discomfort and unsteadiness with walking more than 15 minutes and standing on one leg without holding on was highly threatening to her sense of self. When asked about her greatest fear with regard to her meaningful complaints, Mrs W expressed a deep fear that her hip discomfort and unsteadiness would stop her from being active and cause her to have a hip replacement.

1. Standing screen
2. Left one leg stance

In order to arrive at an accurate assessment of mobility of the cranial dura, the walking cranium first required attention. Resynchronization of the left and right sides of the cranium was done in supine by holding the right temporal bone in posterior rotation and allowing the left temporal bone to catch up to the position of the right temporal as it transitioned into posterior rotation. The symmetrical movement of the two bones was then manually facilitated and followed for several phases to ensure balance and entrainment of the rhythm. This was confirmed by checking both the cranium and the second thoracic ring position to see if a walking cranium and/or an infinity sign recurred/persisted, and it did not. TR2 was now consistently in a left rotated/right translated position, with a congruent manubrium. This ensured good drainage of the venous system through the upper thorax. When this all was completed, the cranium was in a consistent, but incongruent left ICT with a R rotated sphenoid.

Next, intra-cranial dural mobility (cerebral falx and cerebellar tentorium) was assessed followed by an assessment of the intra-spinal dural mobility. The sphenoid and ICT were co-corrected manually and passive listening on the release of this correction revealed a vector of pull from the right anterior part of the cerebellar tentorium. It should be noted that correction of the right side was difficult and the perception was of a short hard articular restriction, one area being the sphenotemporal suture and the other being the craniofacial junction.

The spinal dural extensibility was assessed by holding the cranium corrected while a diaphragmatic breath, a contraction of the pelvic floor muscles and a straight leg raise were instructed. In this case, the tension on the spinal dura created a caudal pull on the sphenoid with both the diaphragmatic breath and the pelvic floor contraction. This suggests the spinal dura as the next place to treat with manual therapy and exercises to encourage extensibility of the dural system, once the cranial dura was released. Other dural tests, such as the slump and upper limb tension tests, were not performed as they were not specific to the meaningful task of walking, but may be useful at a later time to understand the full extent of the dural involvement. Further dural assessment tests using Barral methods were used to confirm the findings of this ISM assessment.

Dural system impairment secondary to an upregulated sympathetic nervous system.

Mrs. W presented with a dural system impairment in both the spinal and cranial regions. From working with the patient it became clear that the dura did not have adequate extensibility, which became more obvious as she stood on her left leg. Correction of the infinity sign did not last between the first and second sessions and the whole dural system felt to be under tension. Upregulation of the autonomic nervous system is hard to measure subjectively, but in hindsight using an objective measure such as HRV could have been useful.

Mrs W was hit as a pedestrian at 16 years old and had a pelvic surgery in her 30s. Overall, her body compensated well and allowed her to be active, although hypervigilant when out walking. After the fall on ice in 2021, she did not recover completely and this failure to recover has been very distressing for her. When starting from a clean slate our body is very good at compensating and adapting to changes that result from injury and fall. As more injuries, surgeries, infections occur, the adaptability of the body is reduced. For some, this reduced capacity to adapt can become threatening to the nervous system. For this patient, there was a persistent threat of being hit by a car and perseveration on the hip being damaged and requiring hip replacement.

According to Porges Polyvagal theory, there are three states available to the ANS when faced with threat; the social engagement state (ventral vagal), the sympathetic nervous system (SNS) state and the dorsal vagal (DV) state. These states are not in conscious awareness; rather they occur automatically. In health, an individual should be anchored in the ventral vagal state; one of safety and connection. From this anchored state, the ANS can move into and out of the SNS or DV states throughout the day. As long as they can return to the safe ventral state quickly, there is no persistent stress, or threat. In response to threat, the social engagement, or ventral vagal system is activated first. This low level phase uses non-verbal cues of neuroception inside and outside the body (listening to tone of voice, posture, gestures, context of experience, feedback from the gut) to determine if the situation is safe. If the situation is determined by the ANS to be unsafe, the next survival state is engaged; and the sympathetic nervous system responds. This is a state associated with doing things; fighting or running away, and is key to our survival. In fight or flight the person prepares to deal directly with a threat by putting up a defense of some form or by leaving the situation. Note that this phase should be short term as is very stressful both psychologically and physiologically to maintain this level of activation. When the threat level is very high, or there is no activity (flight or fight) possible, the dorsal vagal state can arrive. Here, the person withdraws, disconnects, or dissociates, from the situation as this minimizes suffering in the face of severe, sometimes life threatening danger.

Recurrent, or persistent, upregulation of the sympathetic nervous system contributes to overall tension in the dura and pressure type headaches, secondary to the impact of the SNS on the vascular system. Mrs W reported the pressure in her head as general in its distribution, versus being localized behind the right eye. The nerves of the sympathetic nervous system innervate the nerves and blood vessels around the dural layers. With increased tone in these blood vessels over time there is increased venous congestion between the layers of the dura. It becomes as though the nervous system, which is coated by the dura and supplied by its veins and nerves is a size too small for the body. This pushes the blood into the lower pressure, higher volume venous system close to the dura known as Batson’s plexus and into the venous plexus around the brain. This is where the backflow of blood pools when there is high sympathetic tone in the arterial blood vessels and this contributes to pressure symptoms and achy pain. Batson’s plexus relates closely with the pelvic and hip area and congestion here could explain some of the discomfort that the patient experiences. Congestion around the dural layers causes the dura to extend, or expand, horizontally. This means there is less capacity in the dura for extensibility. It becomes much harder for the dura to slide and glide longitudinally with daily movement. The discomfort Mrs W experienced could result from an interplay of excessive venous congestion that can’t clear because of sympathetically driven vasoconstriction, the nerves that innervate the dura, and/or the resultant compression of the musculoskeletal system.

The dura is not a stretchy membrane but rather maintains consistent length and is a reciprocal tension membrane. To understand reciprocal tension, imagine someone pulling on the right bottom corner of your T-shirt; the pull will also be felt at your left shoulder and perhaps your right shoulder or left hip. Where the reciprocal tension travels depends on the magnitude of the pull as well as its direction. The dura has a complex structure as its layers form the intricate wrapping around the brain and spinal cord and the sleeves of the peripheral nerves. This means that the area of symptoms can vary depending on the task and the areas that lack extensibility. Symptoms that stem from a dural system impairment can be incredibly frustrating for patients and practitioners unfamiliar with the impairment. Dural system impairment symptoms do have a pattern of staying in the spine or cranium, but often change location and can be very hard to reproduce in the clinic. In Mrs W’s case her hip discomfort is always there to some degree but worsens when walking over 15 minutes. She mentioned that walking slower could temporarily lessen the discomfort. This makes sense given that dural symptoms come on more prominently when this system is pushed beyond its capabilities even outside of the brain and spinal cord area.

Mrs W had tried to be active but the more she tried, the more discomfort she got, leading her to be fearful of a permanent loss of function. This appeared to be a vicious cycle of upregulation, leading to less function and more upregulation over time. When there is overall dural tension due to sympathetic nervous system upregulation there is often a feeling of being ungrounded in the environment and there is a lack of reference points as the thorax, cranium and sometimes pelvis are fluctuating with the out of sync cranial rhythm. Mrs W had great difficulty giving feedback and feeling a change in her body with any of the ISM corrections.

The walking cranium was addressed earlier in the assessment section. The motion of the cranial bones was briefly followed for several cycles to ensure the paradoxical movement was resolved.

As noted earlier in the assessment section, the correct, release and listen technique in the cranium revealed a listening at the anterior cerebellar tentorium that attaches at the superior clinoid process. This suggests reduced extensibility and drainage at this part of the cerebellar tentorium. There also was a hard short listening at the right sphenotemporal suture, suggesting an articular restriction of this suture. This part of the cranium was very hard to decompress. This suture would need to be treated first in order to get a good result with the anterior tentorium technique.

Release of the sphenotemporal suture was completed first, followed with the anterior cerebellar tentorium drainage technique. To facilitate overall drainage of the cranium, the posterior cerebellar tentorium on the right and left sides were treated to decongest the venous sinuses using the V-spread technique. The correct, release and listen technique at the cranium was repeated and the overall movement of the cerebellar tentorium had improved. There remained; however, a feeling of anterior restriction in the cranium, not in the posterior neurocranium, but in the facial area of the viscerocranium. The area between the neurocranium and viscerocranium is referred to in the Barral teachings as the craniofacial junction. This junction is formed posteriorly by the frontal, temporal and sphenoid bones of the cranial vault and anteriorly by the maxilla, ethmoid, vomer, nasal and zygomatic bones. There can be an articular restriction along this junction that can interfere with the intracranial pressure and venous drainage, along with adverse neural mobility in the cranial nerves. Barral listening at the cranium was used to triangulate findings. A technique with finger placement at the maxilla inside the oral cavity and at the zygomatic process of the frontal bone to decompress the craniofacial junction. The goal of this technique was to improve movement at this articulation between the neurocranium and viscerocranium and on reassessment this was improved.

The spinal dura was treated next by anchoring the C0-C2 dural attachments and the caudal dural attachment at S2 to facilitate venous drainage from cranium to sacrum. Once completed, the cranium rested in a left ICT with a congruent left rotated sphenoid. Following this, several Barral nerve plexi and phrenic nerve techniques were used in the thoracic and abdominal region to reduce sympathetic outflow.

Sympathetic nervous system upregulation was determined to be an important part of this story. As such, diaphragmatic breathing was taught in the first session. Breathing exercises are an accessible and effective way to intervene in the autonomic nervous system. The autonomic nervous system has opposing two branches: the sympathetic and parasympathetic nervous systems. The sympathetic nervous system, often referred to as the fight or flight system, increases breathing rate, heart rate, and systolic blood pressure through vasoconstriction of the arterial system. Digestion and bodily functions are suppressed, pupils constrict, and the visual field narrows to focus in on the threat. In a situation of acute threat, this pushes blood to the muscles and away from the organs to allow us to act fast and hopefully survive the situation. There is a third sympathetic response referred to as freeze. This occurs when the threat is deemed to be too large to fight or flee or there is no way of escaping. The bodily response is to stop and essentially play dead. The sympathetic arousal promotes decreased sensation of pain. Deployed in the right situation and in the short term sympathetic responses are helpful, but they are detrimental to the health and homeostasis of the body in the long term.

With regard to the dural and epineural systems, having chronic vasoconstriction of the arterial system pushes more blood into the venous plexus and cisterns around the brain and spine. In the acute case, the muscles are in use for fight or flight and we need the arterial constriction to move the blood to the contractile tissue. In long term sympathetic nervous system activation, the muscles are not active to the same degree as in an acute threat. Such long term activation becomes very fatiguing, neurally and hormonally to a system that is not switching into the necessary recovery state of the parasympathetic nervous system.

The parasympathetic nervous system facilitates rest and digest recovery responses; its activation lowers resting heart rate, breathing rate and systolic blood pressure. From a dural congestion perspective it allows the venous system to hold less of the blood by promoting vasodilation of the arterial system.

Breathing was taught as a focused 3 second inhale into the lower rib rage versus into the upper chest and prolonging the exhale for at least 6 seconds the parasympathetic (rest and digest) branch of the autonomic nervous system is activated and the sympathetic fight and flight responses are deactivated. The diaphragm rests at the level of the 7th rib in its highest position at the end of an exhale and has its attachments via the crus down to L1,L2,L3 and ribs 7-12. The crura are formed by the median arcuate ligaments and from an arch for the aorta, azygos vein, thoracic lymphatic duct. Good activation of the lateral movement of the diaphragm promotes both lymphatic and venous return which aids in reducing congestion around the dura.

Home exercise, education and referral:

• Inhale to hum when feeling overwhelmed in a social setting or at work. A long exhale and hum combination increases parasympathetic drive.
• A daily breathing practice consisting of 10 minutes per day of long exhale diaphragmatic breathing. Mrs. W was instructed to inhale for 3 seconds and exhale for 6 seconds. This could be done in isolation or as part of a meditation practice.
• Referral to a counselor who specializes in the integration of trauma was provided after discussion with Mrs W regarding her perceived stress level, supports and coping strategies.
• Self-dural drainage three times per day using distraction of the temporal bones, combined with lateral costal breath for 2 minutes, then with contraction of the pelvic floor.

The self-dural drainage technique is intended to facilitate decongestion of the dural system. By distracting gently at the temporal bones the layers of the tentorium are gently stretched which encourages fluid between these layers to clear.

The lateral costal breathing and pelvic floor contractions both use muscular diaphragms to provide a vertical extension to the spinal dura. Diane Lee has often compared draining the spinal dura to a cake decorator with holes in the side as this is a helpful analogy. The cake decorator maintains its same length but gets wider as it’s filled with icing. When icing a cake the decorator is gently squeezed and elongated to allow the icing to come out and the decorator narrows as it slackens and empties.

The diaphragm lies close to the thoracic narrowing of the spinal dura at T8-9. This narrowing at T8-9 is a common site of dural congestion and has a common pattern of achy persistent pain between the shoulder blades. The pelvic floor is the lower muscular diaphragm and dural congestion in this area can refer to the hips, pelvis and lower back regions.