vault hold omm

Vault Hold OMM: The How and Why

What is the Vault Hold

The Vault hold in OMM is the positioning of your hands on either side of the head.

There are very specific finger placements that you need to know to perform the Vault hold.

Not only do you need to know them to perform the Vault hold, but you will likely be tested on the finger placements on every exam in DO School.

Here are the finger placements:

  • Index finger: Over the Greater wing of the Sphenoid
  • Middle Finger: Anterior to the ear, in the temporal area
  • Ring Finger: Posterior to the ear over the mastoid
  • Pinky: On the Occiput, near the squamous suture

Also, check out the image of this for a visual.

vault hold omm


The Vault hold is so essential to all other things you have to do in OMM.

It is how you diagnose and treat all cranial dysfunctions.

More importantly, there are a lot of simple and straightforward questions that you will be able to answer just by knowing the finger placement, seriously you will come across questions asking you about the finger placement in the vault hold.

Above, we have already gone over most of the details you need to know to get the positioning right and to get questions right.

Below, there are more answers to common questions related to the vault hold, and OMM in general.

What is the Cranial Rhythmic Impulse (CRI)

The Cranial Rhythmic Impulse (CRI) is the palpatory feeling of widening and narrowing of the skull when you are in the vault hold.

Many people don’t realize that the skull has inherent motion that is based on the fluctuations in the cerebrospinal fluid, this is the CRI.

It is most easily palpated in the vault hold.

A typical CRI is 8-14.

If the CRI is <8 or >14 then there could be a pathology, and this is often a test point. This is one of the OMM topics covered in depth in my course.

What is the Sphenobasilar Synnchodrosis (SBS)

The Sphenobasilar Synchondrosis or  SBS, is the “joint” or connection between the sphenoid and the occiput.

The importance of the SBS in cranial OMM is understated most times. It is the point at which all movement and diagnosis’s of cranial dysfunctions is based off of.

For example, flexion of the SBS is based off of the sphenoid and the occiput “flexing” towards each other over the top of the SBS.

Then when we describe a cranial dysfunction, we typically do it in relation of what the sphenoid is doing about the SBS.

So, you need to know what the SBS is, and more importantly what bones back up the articulation of it.

Cranial Sacral Rhythm: The details

The cranial sacral rhythm is essentially the same thing as the CRI that we discussed above.

The main difference is that this includes the sacrum in the description.

There is a connection from the skull to the base of the sacrum, this connection is a physical one made of dura.

As the cranial bones move throughout the CRI, the sacrum moves as well.

Important things to know are:

  • As the SBS flexes, then the sacrum extends or counter nutates.
  • As the SBS extends, the sacrum flexes or nutates.
  • Counter nutate and nutate are just “technical” terms for flexion or extension.
  • Also, remember that there is a connection between the cranium and the sacrum, and that it is dura that attaches at the level of S2 on the sacrum.

The Different Cranial Strain Patterns

Here is a list of the basic cranial strain patterns:

Each one of these has specific findings that help you diagnose them.

Truth be told, cranial is one of those sections that a lot of students sometimes just don’t worry about.

The amount of cranial is variable on exams, so sometimes you may only get a few questions.

If you are comfortable with cranial and it doesn’t just confuse you like it does many students, then by all means study it and know it so you can get more test points.

If you aren’t comfortable with cranial, but want to study it then check out CPM OMM. IT distills it down to the bare essentials.

If you aren’t comfortable with cranial, and don’t want to study it… then make sure you are GREAT in all other areas to make up for the lost cranial points.

** CPM OMM block**

Is Cranial on the COMLEX

Cranial is on the COMLEX. Each one of them actually.

It is one of the topics listed on the NBOME’s website, which tells you the topics covered on each exam.

How Much OMT is on the COMLEX

This is so variable from one test to the next.

A good rule of thumb is to expect there to be OMT on the COMLEX, and prep accordingly.

This includes doing questions and reviewing the essentials.

The tough thing is that OMT can be weaved into any topic really.  So, defining a percentage of OMT is not accurate no matter what others say, simply because it can be added ot any question.

Chapmans points can be used to “help” diagnose problems in questions, and they are so easy to throw into the question stem.

Essentially, it comes down to.. just know your OMM.

Concluding this discussion about the Vault hold in OMM

The vault hold is one of those things that you just gotta know.

It can easily get you points on test day, and that is the real reason to know it.

As a resident physician, I have yet to perform the vault hold. It just isn’t practical or scientifiacally backed in practice.

As a student, you need to know it because it can be extremely low hanging fruit on your exams.

Thanks for reading

I hope it has been helpful

Sean Kiesel, DO, MBA

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