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Abstract The cranial rhythmic impulse is a palpable, rhythmic fluctuation believed to be synchronous with the primary respiratory mechanism. The precise physiologic mechanism of the cranial rhythmic impulse is not fully understood.
Based on traditional and current views of the cranial rhythmic impulse, animal studies, and clinical findings in patients with chronic fatigue syndrome, the author argues that the cranial rhythmic impulse is the rhythm produced by a combination of cerebrospinal fluid drainage from the neuraxis (brain and spinal cord) and pulsations of central lymphatic drainage induced by the sympathetic nervous system. In addition, evidence is provided to demonstrate that a disturbed, palpable, and visible neurolymphatic process leads to chronic fatigue syndrome.
This process may also explain the pathophysiologic mechanisms leading to other disease states. Finally, the author's proposed manual treatment protocol for patients with chronic fatigue syndrome is described. Central to the principles of osteopathic medicine in the cranial field is the presence of the primary respiratory mechanism, which involves a separate palpable rhythmic motion in addition to the motion of normal breathing., Also referred to as the cranial rhythmic impulse (CRI), the primary respiratory mechanism is palpable throughout the body.
Woods and Woods, who coined the term “CRI,” recorded the average rate of the CRI as 12.47 beats, or cycles, per minute (bpm), with the rate for healthy adults ranging from 10 bpm to 14 bpm. This rate has been quoted by several authorities in the cranial field. Other studies, relying on palpation of the CRI, have recorded values between 3 bpm and 9 bpm. Nelson and coauthors recorded a mean palpated CRI rate of 4.54 bpm. They suggested that the common neurophysiologic pathway for many low-frequency oscillations exists via activity of the sympathetic nervous system.
A number of attempts have been made to explain the CRI., Nelson suggested that the intrinsic movements of cranial bones, fascia, and organs may be caused by local venomotor pulsation, the reflection of which may be palpable at the skin surface. However, the absence of contractile tissue in the veins and sinuses of the brain makes this theory difficult to accept. The cerebral veins are unique in that they possess no muscular tissue in their thin walls and have no valves. Any palpable venous pulsations in the head are possibly mere remnants of larger vasometric pulsations of the inferior vena cava and iliac vein. The cerebral veins descend from the brain into the subarachnoid space by penetrating the arachnoidea mater and the meningeal layer of the dura mater, thereby draining into the cranial venous sinuses. However, as proposed by Vern and colleagues, other underlying processes may also be at work.
Their experiments, which directly measured cortical cytochrome- c oxidase redox fluctuations in unanesthetized cats, “.strongly suggest that the cyclic increases in cortical oxidative metabolism represent the primary oscillatory process, followed by reflex hemodynamic changes.”. Contrary to the traditional concept that lymph has no pump of its own, the main lymphatic vessels are now known to be under sympathetic control., When the smooth muscle wall of the thoracic duct is stimulated, a wave of contraction is produced that aids lymphatic drainage into the subclavian vein. This drainage, in turn, produces negative pressure along the lymphatics, further assisting the process. The resulting peristaltic wave within the normal human thoracic duct was found to occur at 4 bpm with a maximum pressure of approximately 10 mm Hg, building up to 50 mm Hg when obstructed. Although it has been established that the central nervous system does not contain a true lymphatic system, there is considerable evidence for a robust fluid drainage system that is in many ways analogous to that of the lymphatic. Through this system, cerebrospinal fluid drains into the facial and spinal lymphatics.
Sutherland emphasized the importance of the choroid plexus in the chemical exchange between cerebrospinal fluid and the blood, but he also stressed the role played by the lymphatics in the drainage of toxins from the neuraxis. In 1869, Schwalbe demonstrated in rabbits that there was a connection between the subarachnoid spaces and cervical lymphatics. Sutherland postulated that gentle pumping action caused by one or more bones around the facial sinuses drains the mucus that is produced in the goblet cells of the sinus epithelial lining. This drainage facilitates the wafting action of ciliated epithelium, forcing the mucus into the nasopharynx. When mechanical or other forces damage this mechanism, the sinus is less able to drain mucus.
As a result, the mucus pools and thickens, rendering the patient prone to infection. The nasal mucosa may then become continually inflamed with an abundance of purulent mucus and associated enlargement of the tonsilla pharyngea.
Speransky first described the existence of a direct link between the cerebrospinal fluid, nasal lymphatics, and cervical lymphatic vessels. It has since been determined that lymphatic vessels in the submucosa of the nasal sinuses are the initial recipients of the drainage of cerebrospinal fluid through the cribriform plate.
Quinke hypothesized in 1872 that there was drainage of cerebrospinal fluid from the subarachnoid spaces through small passages along the nerve roots. Other researchers - have shown a small but significant drainage that takes place via the dural lymphatics, which run parallel to the spinal cord.
Tracer material injected into the brain's cerebrospinal fluid in rabbits accumulates in the cuffs around the spinal nerve roots, which form a link between the subarachnoid spaces and the lymphatics. It has also been shown in rabbits that there is a flow of fluid from the brain to the deep lymph nodes of the neck, as well as a flow of fluid from the nasal mucosa to the brain. The system of cerebrospinal fluid drainage in humans is believed to be similar to that in other mammals, though the cerebrospinal fluid's lymphatic component is proportionally much smaller in humans., As in other mammals, the drainage of cerebrospinal fluid in humans includes pathways from the cranial and spinal subarachnoid spaces across the arachnoid villi. The pathways then continue to the dural sinuses and along the cranial nerves—mostly via olfactory pathways through the cribriform perforations—and along the spinal nerves to the lymphatics.
Cerebrospinal fluid drains from the human brain in three main pathways: into the sinus arachnoid villi, down the spine into the paravertebral lymphatics, and along the cranial nerves (I, olfactory; II, optic; V, trigeminal; VIII, vestibulocochlear). The cerebrospinal fluid then flows into the facial, cervical, and thoracic lymphatics. Reprinted with permission from: Knopf PM, Cserr HF, Nolan SC, Wu TY, Harling-Berg CJ. Physiology and immunology of lymphatic drainage of interstitial and cerebrospinal fluid from the brain.
Neuropathol Appl Neurobiol. 1995;21:175-180, Blackwell Publishing. Cerebrospinal fluid drains from the human brain in three main pathways: into the sinus arachnoid villi, down the spine into the paravertebral lymphatics, and along the cranial nerves (I, olfactory; II, optic; V, trigeminal; VIII, vestibulocochlear).
The cerebrospinal fluid then flows into the facial, cervical, and thoracic lymphatics. Reprinted with permission from: Knopf PM, Cserr HF, Nolan SC, Wu TY, Harling-Berg CJ. Physiology and immunology of lymphatic drainage of interstitial and cerebrospinal fluid from the brain.
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Neuropathol Appl Neurobiol. 1995;21:175-180, Blackwell Publishing.
Dod 512 Reverb Effects Processor
This bidirectional movement of cerebrospinal fluid is poorly understood. However, the movement is ultimately dependent on the relative pressures in the subarachnoid spaces at different parts of the neuraxis and in the central nervous system's parenchyma. In the rabbit, approximately 30% of the total normal cerebrospinal fluid drainage occurs via these routes, while this proportion is 10% to 15% in the cat. It has also been shown that almost half of the total volume of cerebrospinal fluid in sheep drains into the extracranial lymphatics, especially in the cervical region. In addition, the cerebrospinal fluid drainage into the cervical lymphatic system increases with greater intracranial pressure. Cerebrospinal fluid moves intracranially at the same rate as the beating of the heart. In addition, it normally flows within the ventricular system of the brain at approximately 600 cm per minute.
The approximate blood flow in the carotid bodies in the neck (ie, in 100 g of tissue), just after leaving the heart, is 2000 mL/min (selective perfusion), whereas normal blood flow in the brain is about 65 mL/min (selective cerebral perfusion). The flow of lymph in the thoracic duct is known to be between 1 mL and 2 mL per minute between meals, though it may increase by up to ten times that rate during ingestion and absorption of a meal. These influences of fluid mechanics in drainage are summarized in. There have been various explanations for the CRI focusing on other rhythmic pulses, such as the Traube-Hering-Mayer oscillation, which is associated with blood pressure feedback. It has even been shown that cranial manipulation has an effect on the Traube-Hering-Mayer frequency component of blood flow velocity.
However, clinical assessment of hundreds of patients using palpatory techniques similar to those described by Sutherland has revealed an arrhythmic, restricted, and sometimes almost nonexistent CRI in individuals with CFS. The CRI in these patients was palpated by placing the palmar surfaces of the hands on the parietal bones to determine side-bending or rotation patterns. This palpation was also used to determine proprioception of the occipitoatlantal squamae as a way of analyzing anteroposterior shifts. Clinical findings in these patients coincided with lymphatic pump reversal leading to palpable engorged varicose lymphatics. Besides its importance to the combination of manual techniques recommended for patients with CFS, the lymphatic drainage of the neuraxis also forms the basis of other treatment modalities in osteopathic medicine., However, the manual techniques used in other treatments (eg, abdominal and thoracic pump) as well as the Vodder technique, act primarily to increase sluggish lymphatic flow.
Although retrograde flow is usually presumed to be prevented by valves, this biomechanical protection is not evident in patients with CFS. In these patients, clinical findings, which include photographic evidence, demonstrate that lymphatic reflux can weaken these valves, resulting in palpable varicose lymphatic vessels that are occasionally visible at the skin surface. Also, any treatment that stimulates lymphatic flow carries the risk of advancing the lymph further in the retrograde direction. That is why part of the proposed treatment modality involves direct stimulation of lymphatic drainage using effleurage aimed toward the subclavian veins and against the backflow. An improvement in the main symptoms of CFS coincided with an improvement in central lymphatic drainage—and a stronger, more rhythmic CRI. This finding supports the view that the neurolymphatic flow described in the present article is identical to the CRI. If this view is proven correct in subsequent studies, the ramifications for the future of osteopathic medicine are immense—providing a probable scientific basis for the use of manual treatment not only in patients with CFS, but for those with a variety of other disorders.
Cerebrospinal fluid drains from the human brain in three main pathways: into the sinus arachnoid villi, down the spine into the paravertebral lymphatics, and along the cranial nerves (I, olfactory; II, optic; V, trigeminal; VIII, vestibulocochlear). The cerebrospinal fluid then flows into the facial, cervical, and thoracic lymphatics. Reprinted with permission from: Knopf PM, Cserr HF, Nolan SC, Wu TY, Harling-Berg CJ. Physiology and immunology of lymphatic drainage of interstitial and cerebrospinal fluid from the brain. Neuropathol Appl Neurobiol. 1995;21:175-180, Blackwell Publishing.
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Cerebrospinal fluid drains from the human brain in three main pathways: into the sinus arachnoid villi, down the spine into the paravertebral lymphatics, and along the cranial nerves (I, olfactory; II, optic; V, trigeminal; VIII, vestibulocochlear). The cerebrospinal fluid then flows into the facial, cervical, and thoracic lymphatics. Reprinted with permission from: Knopf PM, Cserr HF, Nolan SC, Wu TY, Harling-Berg CJ. Physiology and immunology of lymphatic drainage of interstitial and cerebrospinal fluid from the brain.
Neuropathol Appl Neurobiol. 1995;21:175-180, Blackwell Publishing.