Craniosacral therapy (also called CST, also spelled Cranial Sacral bodywork or therapy) is an alternative medicine therapy used by osteopaths, massage therapists, naturopaths, and chiropractors. It was invented from whole cloth in 1899 by William Garner Sutherland.[1]
A craniosacral therapy session involves the therapist placing their hands on the patient, which allows them to "tune into the craniosacral rhythm".[2] Craniosacral therapists claim to treat mental stress, neck and back pain, migraines, TMJ Syndrome, and for chronic pain conditions such as fibromyalgia.[3][4][5]
A systematic review conducted in 1999 "did not find valid scientific evidence that craniosacral therapy provides a benefit to patients", noting that "[t]he available health outcome research consists of low grade of evidence derived from weak study designs" and "[a]dverse events have been reported in head-injured patients following craniosacral therapy."[6]
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Cranial Osteopathy was originated by osteopath William Sutherland (1873-1954) in 1898-1900. While looking at a disarticulated skull, Sutherland was struck by the idea that the cranial sutures of the temporal bones where they meet the parietal bones were "beveled, like the gills of a fish, indicating articular mobility for a respiratory mechanism."[7]
Sutherland hypothesised the dural membranes act as 'guy-wires' for the movement of the cranial bones, holding tension for the opposite motion. He used the term reciprocal tension membrane system (RTM) to describe the three Cartesian axes held in reciprocal tension, or tensegrity, creating the cyclic movement of inhalation and exhalation of the cranium. The RTM as described by Sutherland includes the spinal dura, with an attachment to the sacrum. After his hypothesis of the supposed cranial mechanism, Sutherland further hypothesised that the sacrum moves synchronously with the cranial bones. Sutherland began to teach this work to other osteopaths from about the 1930s, and continued to do so until his death. His work was largely rejected by the mainstream osteopathic profession as it challenged some of the closely held beliefs among practitioners of the time. Osteopathy, in turn, lacks mainstream medical support.
In the 1940s the American School of Osteopathy started a post-graduate course called 'Osteopathy in the Cranial Field' directed by Sutherland, and was followed by other schools. This new branch of practice became known as "cranial osteopathy". As this form of osteopathy began to spread Sutherland trained more teachers to meet the demand, notably Drs Viola Frymann, Edna Lay, Howard Lippincott, Anne Wales, Chester Handy and Rollin Becker.
From 1975 to 1983, osteopathic physician John E. Upledger and neurophysiologist and histologist Ernest W. Retzlaff worked at Michigan State University as clinical researchers and professors. They set up a team of anatomists, physiologists, biophysicists, and bioengineers to investigate the purported pulse and study further Sutherland's theory of cranial bone movement. Upledger and Retzlaff went on to publish their results, which they interpreted as support for both the concept of cranial bone movement and the concept of a cranial rhythm.[8][9][10] Later reviews of these studies have concluded that their research is of insufficient quality to provide conclusive proof for the effectiveness of craniosacral therapy and the existence of cranial bone movement.[6]
Upledger developed his own treatment style, and when he started to teach his work to a group of students who were not osteopaths he generated the term 'CranioSacral therapy', based on the corresponding movement between cranium and sacrum.
The Primary Respiratory Mechanism (PRM) has been summarized in five ideas.
The postulated intracranial fluid fluctuation is described by practitioners as an interaction between four main components: arterial blood, capillary blood (brain volume), venous blood and cerebrospinal fluid (CSF).[11][12]
Sutherland used the term "Tide" to describe the inherent fluctuation of fluids in the Primary Respiratory Mechanism. Tide alludes to the concept of ebbing and flowing, but also the contrast between waves on the shore having one rhythm, with the longer rate of lunar tides below. The Tide incorporates not only fluctuation of the CSF, but of a slow oscillation in all the tissues of the body, including the skull.
There is research which demonstrates examiners are unable to measure craniosacral motion reliably, as indicated by a lack of interrater agreement among examiners.[13] The authors of this research conclude this "measurement error may be sufficiently large to render many clinical decisions potentially erroneous". Alternative medicine practitioners have interpreted this result as a product of entrainment between patient and practitioner,[14] a principle which lacks scientific support. Another study[15] reports craniosacral motion cannot be reliably palpated.
In 1970, Upledger observed during a surgical procedure on the neck what he described as a slow pulsating movement within the spinal meninges. He attempted to hold the membrane still and found that he could not due to the strength of the action behind the movement.[16]
It has been theorized that during craniosacral treatment the membranes act as a fulcrum for fascial restrictions throughout the body, and craniosacral therapists may perceive a change in quality as a result of disturbance such as infection or allergic irritation.
Cranial sutures are almost immobile after fusion, inhibiting movement between cranial bones. According to Gray's Anatomy, "[w]hen such sutures are tied by sutural ligament and periosteum, almost complete immobility results"[17], which would make moving these fused bones with gentle massage extremely improbable.
A typical craniosacral therapy session is performed with the client fully clothed, in a supine position, and usually lasts about one hour. In the Upledger method of craniosacral therapy, a ten-step protocol serves as a general guideline, which includes (1) analyzing the base (existing) cranial rhythm, (2) creating a still point in that rhythm at the base of the skull, (3) rocking the sacrum, (4) lengthening the spine in the lumbar-sacral region, (5) addressing the pelvic, respiratory and thoracic diaphragms, (6) releasing the hyoid bone in the throat, and (7-10) addressing each one of the cranial bones. The practitioner may use discretion in using which steps are suitable for each client, and may or may not follow them in sequential order, with time restraints and the extent of trauma being factors.
The therapist places their hands lightly on the patient's body, tuning in to the patient by ‘listening’ with their hands or, in Sutherland's words, "with thinking fingers". A practitioner's feeling of being in tune with a patient is described as entrainment.[14] Patients often report a sense of deep relaxation during and after the treatment session, and may feel light-headed. This is popularly associated with increases in endorphins, but research shows the effects may actually be brought about by the endocannabinoid system.[18]
There are few reports of Adverse side effects from CST treatment. In one study of craniosacral manipulation in patients with traumatic brain syndrome, the incidence of adverse effects from treatment was 5%.[19]
A systematic review conducted in 1999 found "insufficient scientific evidence to recommend craniosacral therapy to patients, practitioners or third party payers for any clinical condition."[6] The authors of this review noted:
"in accord with a basic tenet of craniosacral therapy, there is evidence for a craniosacral rhythm, impulse or 'primary respiration' independent of other measurable body rhythms (heart rate, or respiration)... However, these and other studies do not provide any valid evidence that such a craniosacral 'rhythm' or 'pulse' can be reliably perceived by an examiner.[6]
The reason for this finding, according to these reviewers, was a lack of suitable evidence—such as random controlled trials of its effects on health outcomes—in the literature on craniosacral therapy. The found available evidence to be weak methodologically, highly variable, lacking consistency and unable to support "logical 'positive' conclusions regarding craniosacral therapy."[6]
The reviewers concluded:
The issue is not that craniosacral therapy is a 'non mainstream' entity. Rigorous and scientifically defensible studies are clearly possible on all its aspects. If undertaken, such research would be of great value in providing the necessary direction for administrators, practitioners and patients alike.[6]
In the United Kingdom, resulting from a regulation programme facilitated by The Prince's Foundation for Integrated Health, craniosacral therapy is to be regulated on a voluntary basis by the Complementary and Natural Healthcare Council (CNHC, also known as OfQuack) from late 2009 onwards. The standards of competence required for registration are craniosacral therapy techniques plus hands-on practice, anatomy and physiology, business, legal and ethical issues. Registrants must have full public and professional liability insurance and annual continuing professional development is a condition of re-registration.