Cranial Sacral Treatment
July 1999; Volume 1: 59-63
By John M. McPartland, DO, MS
Cranial sacral treatment (CST) is a gentle form of body manipulation. Gentle manipulation of the cranium is said to serve many functions: disengagement of sutures jammed by trauma, releasing cranial nerves impinged within their foramenae, realigning dural membranes, reducing venous stasis, and improving the flow of cerebrospinal fluid.
CST was originally developed by William Sutherland, an American osteopath. Sutherland began studying cranial anatomy in 1899, and began teaching "cranial osteopathy" in 1929.1 Sutherland developed his methods de novo, apparently unaware that ancient Greeks practiced therapeutic cranial manipulation.2 Recent authors3 have claimed that cranial manipulation was also practiced in Asia, but this claim has been disputed.4 CST remained the esoteric tool of osteopaths for many decades, but CST is now used by MDs, chiropractors, physical therapists, and massage therapists. This sudden surge in interest and utilization is primarily due to the Upledger Institute, which has taught CranioSacral TherapyTM to more than 25,000 people since 1985.5
Most anatomy courses teach that sutures between skull bones ossify in childhood. In fact, recent histological studies have shown that most cranial sutures never obliterate.6 One review of cranial bone motion found that published research is "scant and inconclusive" but concedes that "animal and human studies demonstrate a potential for small magnitude motion."7
Living sutures contain ligaments, blood vessels, and nerves. Collagen fibers traverse sutures, connecting the external periosteum with the internal dura mater. In other words, the dura is directly accessible to external forces. In the suboccipital region, for instance, the outer surface of the dura attaches to the inner surface of the posterior atlanto-occipital membrane (PAOM) via a fine connective tissue bridge.8 The outer surface of the PAOM, in turn, is fused to the deep surfaces of the paired rectus capitis posterior minor muscles (RCPMs), near their conjoined origin upon the atlas.
Thus, the RCPMs have fascial continuity with the dura via the PAOM. Whiplash injuries of the RCPMs often result in dural headaches and neck pain. In one study, whiplashed individuals with chronic pain exhibited atrophy of the RCPMs (seen by magnetic resonance imaging); this led to a loss in postural balance, as measured on a force platform (a plate mounted flush with the floor that tracks forces moving upon it, such as gravity, torque, and shear).9
Within the skull, the dura infolds upon itself, forming an internal support for brain tissue, called the "reciprocal tension membrane,"1 but better known as the falx and the tentorium. The dura also forms a sleeve running down the spinal column and attaches to the sacrum. The entire system is interconnected.
CST theory holds that distortion of any part of the dura transmits forces across the whole. Contours of the 22 cranial bones, their interlocking articulations, and the reciprocal tension membrane limit cranial motion to specific directions. These movements may become dysfunctional, which forces the skull, its connective tissue, and the brain itself into strain patterns. Causes of dysfunction may be external, such as trauma, or internal, such as sinus infections. Malaligned temporal bones, for example, are said to give rise to temporomandibular joint syndrome, headache, and dizziness, and to predispose children to otitis.10 Many cranial nerves exit the skull at sutures; if restricted they may vitiate distal tissues, including all the organs innervated by the vagus.
CST is usually performed with the patient supine. The practitioner sits at the head of the examination table and carefully palpates cranial bones for mobility, motion tests for strain patterns, and checks sutures for tenderness. Treatment is applied with the hands, using very light pressure. The technique does not involve the quick thrusts and "popping" noises characteristic of thrust-style manipulation. CST movement is very slow and gentle, similar to what some practitioners call "indirect myofascial release."
CST practitioners take another step away from conventional medicine by describing a phenomenon called the "cranial rhythmic impulse" (CRI). The CRI is a palpable pulsation, much like the respiratory excursion of the chest, but sensed as a broadening and narrowing of the head. Clinical studies report a palpable CRI rate of 6-12 cycles/min in healthy humans, independent of cardiac or diaphragmatic rhythms.10,11 This rate has been corroborated by CRI studies using mechanical and electronic devices.12,13 However, two small studies (each utilizing two practitioners of craniosacral therapy) found little interexaminer reliability (meaning that the two practitioners did not agree on the rate).14,15 These studies also looked at intraexaminer reliability (meaning the consistency of one examiner’s findings in the same patient); one found good intraexaminer reliability14 and the other (which compared examiner ratings of the CRI at the head and at the feet) did not.15
The determination of CRI is said to decrease in a variety of conditions, including coma,11 traumatic brain injury,16 psychological disturbances,10 emotional exhaustion,11 malnutrition,11 and many other maladies. CRI is said to accelerate in cases of acute fever,10 and in hyperkinetic and autistic children.11
If it does exist, what is its origin? The functional origin of the CRI remains unknown but fluctuations are usually attributed to pulse waves of cerebrospinal fluid (CSF). Magoun first suggested that rhythmic variations of CSF production by the choroid plexus may generate the CRI.10 However, the rate of choroid plexus pulsations is much faster than the CRI and appears to be synchronous with cardiac systole.17 An alternative theory is that CRI is due to glial cell pulsations (these pulsations were observed in a 1951 study often quoted by CRI proponents).18 But glial cells pulsate at a completely different rhythm than the CRI.
A new theory suggests that CRI represents a summation signal, a "harmonic frequency" of many palpable biological pulsations, including the cardiac pulse, diaphragmatic respiration, waves of CSF produced by the choroid plexus, pulsating glial cells, oscillations in cerebral blood velocity, Traube-Hering modulations (change in cerebral blood pressure that varies on a beat-to-beat basis), rhythmically contractile lymphatic vessels, and many other oscillations.19 Furthermore, the CRI may not be the fundamental harmonic. Sutherland alluded to deeper, slower, more subtle rhythms around 1948. He poetically described ocean waves moving rhythmically through water (the CRI), and deeper tides moving through water and waves, "the Breath of Life, a fluid within a fluid."1 Incidentally, Sutherland borrowed these seaside metaphors from Rachel Carson, and quoted her.
Some CST practitioners wander yet further afield from the physical realm and attribute the CRI to patterns of electromagnetic energy. Indeed, electrical fields generated by cortical neurons exhibit rhythmicity.20 These rhythms may be linked to cortical oxidative metabolism, which oscillates at 9 cycles/min.21 Others claim the source of this "subtle energy" is an external, universal energy matrix, organized in the body by fluid forces (perhaps electromagnetic water hydrogen bonds).22 This idea is similar to the "water imprint" theory of homeopathic researchers. Practitioners of this lysergic school of osteopathy apparently palpate bioenergetic fields with "an undefined seventh sense," as described by yoga practitioners.11
Although heavy on theory, CST is light on evidence; no randomized controlled clinical trials of CST were identified. Those critical of CST claim it lacks efficacy,23 and it is true that the two main texts10,11 in the field refer mainly to anecdotal reports. Studies do exist, although these mainly consist of case series and uncontrolled studies (and most of these have been published only as abstracts).
One pilot study, reported only in abstract form, found that CST induced uterine contractions in post-term pregnancies;24 another descriptive study, also published as an abstract, reported a similar effect.25 A retrospective, case-control study sought to determine whether women who received chiropractic and craniosacral therapy during pregnancy had fewer obstetric interventions.26 No difference in rates of obstetric intervention were found in 35 women who received chiropractic care and craniosacral therapy (for any reason during pregnancy) and a matched sample within the same county.
An uncontrolled pilot study of infants with suckling dysfunctions found a positive effect of CST.27 A controlled trial found a positive effect of CST on neurological development in children, as measured with Houles Profile of Development scale.28
Several controlled (open or single-blind) trials found a beneficial effect of CST on autonomic function.29-31 Uncontrolled studies that found a benefit of CST include a study of trigeminal neuralgia32 and one of torticollis.33 Other uncontrolled studies reported only as abstracts include two studies on headache;34,35 a study of tinnitus;36 and a study of Bell’s palsy:37 all found a benefit for CST.
Because its manipulations are very gentle, CST has been applied to patients where more aggressive manipulation may not be indicated, e.g., pregnant women, newborns, and hospitalized patients in critical care units. Contraindications to CST include recent skull fractures, acute intracranial hemorrhages, and intracranial aneurysms.11
Significant side effects from CST, however, have been described in the literature. Rare complications include headache, dizziness, emotional swings, psychiatric disturbances, nausea, vomiting, diarrhea, cardiac palpitations, and a case of opisthotonos (tetanic spasm in which the head and feet are bent backward and the body bowed forward).16 Breaking the opisthotonos required paralysis with intravenous pancuronium bromide, supported by mechanical ventilation. Another series of nine case reports described depression, confusion, diplopia, vertigo, loss of consciousness, trigeminal nerve damage, hypopituitarism, brainstem dysfunction, opisthotonos, tonic-clonic seizure, and miscarriage of a 12-week pregnancy.5 Two-thirds of the cases involved women. More than half of the cases involved patients with recent trauma (usually car accidents) or serious diseases (e.g., brain cancer), which may have predisposed them to side effects. A majority of cases involved lay practitioners.
There is scant clinical trial evidence supporting the use of craniosacral therapy, although there are some intriguing results from uncontrolled studies. While double-blind studies of any hands-on therapy (including surgery) are difficult to perform, well-designed, single-blind, controlled trials should certainly be conducted in craniosacral therapy. There is evidence that CST can cause significant physiological changes, and also that the therapy can cause complications if poorly performed.
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8. McPartland JM, Brodeur RR. The rectus capitis posterior minor: A small but important suboccipital muscle. J Bodywork Movement Ther 1999;3:30-35.
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16. Greenman PE, McPartland JM. Cranial findings and latrogenesis from craniosacral manipulation in patients with traumatic brain syndrome. J Am Osteopath Assoc 1995;95:182-192.
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18. Lumsden CE, Pomerat CM. Normal oligodendrocytes in tissue culture. Experimental Cell Research 1951;2:103-114.
19. McPartland JM, Mein EA. Entrainment and the cranial rhythmic impulse. Altern Ther Health Med 1997;3:40-44.
20. Llinas R. Is dyslexia a dyschronia? Ann NY Acad Sci 1993;682:48-56.
21. Vern BA, et al. Low-frequency oscillations of cortical oxidative metabolism in waking and sleep. J Cerebral Blood Flow Metab 1988;8:215-226.
22. McPartland JM. "Foreward." In: Chaitow L, ed. Cranial Manipulation. Edinburgh: Churchill Livingstone; 1999: vii-ix.
23. Ferre JC, Barbin JY. The osteopathic cranial concept: Fact or fiction? Surgical Radiologic Anatomy 1991;13:165-170.
24. Gitlin RS, Wolf DL. Uterine contractions following osteopathic cranial manipulation: A pilot study. J Am Osteopath Assoc 1992;92:1183.
25. Spiering N. Manipulative procedures utilized during obstetrical delivery [abstract]. J Am Osteopath Assoc 1980;80:219.
26. Phillips CJ, Meyer JJ. Chiropractic care, including craniosacral therapy, during pregnancy: A static-group comparison of obstetric interventions during labor and delivery. J Manipulative Physiol Ther 1995;18: 525-529.
27. Fravel MRPP. A pilot study: Osteopathic treatment of infants with a suckling dysfunction. AAO Journal 1998;8:25-33.
28. Frymann VM, et al. Effect of osteopathic medical management on neurologic development in children. J Am Osteopath Assoc 1992;92:729-744.
29. Cooper GJ, Kilmore M. Compression of the fourth ventricle and its effects on circulation and respiration. The Cranial Letter 1994;47:7-8.
30. Purdy WR, et al. Suboccipital dermatomyotomic stimulation and digital blood flow. J Am Osteopath Assoc 1996;96:285-289.
31. Robbins HJ, et al. Craniosacral manipulation and touch induce autonomically mediate cardiopulmonary responses: Preliminary report [abstract]. J Am Osteopath Assoc 1996;96:490.
32. Lay EM. The osteopathic management of trigeminal neuralgia. J Am Osteopath Assoc 1975;74:373-389.
33. Bilkey WJ. Cranial suture manipulation in the treatment of torticollis. J Manual Med 1992;6:212-214.
34. Hussar CJ, et al. Combined osteopathic and dental treatment of cephalgia [abstract]. J Am Osteopath Assoc 1985;85:605-606.
35. White WK, et al. The relation of the craniofacial bones to specific somatic dysfunctions: A clinical study of the effects of manipulation [abstract]. J Am Osteopath Assoc 1985;85:603-604.
36. Ikner CL, et al. Objective monitoring of osteopathic manipulative treatment in tinnitus patients [abstract]. J Am Osteopath Assoc 1986;86:124.
37. Hallihan MR, et al. A prospective clinical study on the efficacy of osteopathic manipulative treatment for Bell’s palsy patients [abstract]. J Am Osteopath Assoc 1984;84:125.
CST theory holds that distortion of any part of the dura transmits forces across the whole.