Craniosacral Therapy By Karen Swisher

Throughout the ages, mankind has sought out ways to relieve pain and dysfunction in the human body. Advances in this area have been made through specific scientific research, direct and indirect theories and experiments, and even by accident. Relief from pain and dysfunction can come in the form of surgery, medicines, physical therapeutic exercise or massage as well as psychological interventions, just to name a few. Craniosacral therapy is a theory based intervention developed to decrease pain and dysfunction for a wide range of conditions and increase overall health and wellness. However, scientific research and evidence questions the validity of its claims (1-4). The purpose of this report is to describe what craniosacral therapy is and discuss if it is a reliable and valid intervention to be used in the field of physical therapy. Craniosacral therapy was pioneered and developed by Osteopathic Physician John E. Upledger. In 1970 Dr. Upledger was assisting in a neck surgery where he first observed what he describes as rhythmic motion of the cerebral spinal fluid. At the time, none of Upledgers colleagues or any of the medical texts could explain this discovery. He pursued his curiosity by studying the research of Dr. William Sutherland who specialized in cranial osteopathy in the early 1900s. Dr. Sutherland had explored the idea that the bones of the skull were structured to allow for movement. Dr. Sutherlands concept remained at odds with beliefs of the scientific and medical community for decades following but Dr. Upledger believed that if Dr. Sutherlands

theory of cranial movement was correct, this would make probable and help to explain the existence of the cerebral spinal fluid rhythm he encountered in surgery (5) It was then that Dr. Upledger set out to scientifically confirm that cranial bone movement did exist. Dr. Upledger served as a clinical researcher and Professor of Biomechanics at Michigan State University from 1975-1983, where he supervised a team of anatomists, physiologists, biophysicists and bioengineers in research and testing. According to Dr. Upledger, Dr. Sutherlands early theory was not only confirmed, but led to clarification of the mechanisms behind this motion the craniosacral system. The craniosacral system is described as all structures which are in contact with the cerebral spinal fluid, including the brain, the spinal cord, and their protective membrane. Dr. Upledgers continued work in this area led to his development of craniosacral therapy(5). The theory behind craniosacral therapy is that few structures have as much influence over the body as the brain and spinal cord which make up the central nervous system, and the central nervous system is heavily influenced by the craniosacral system - the membranes and fluid that surround, protect and nourish the brain and spinal cord. As we endure the everyday stresses and strains, our body compensates and this can cause the body tissues to tighten and distort the craniosacral system. These distortions can result in tension forming around and spinal cord resulting in restrictions which can inhibit a healthy performance of the central nervous system and potentially all the other systems with which it interacts. By normalizing the environment around the brain and spinal cord, the bodys ability to self correct is enhanced. It is on this premise that craniosacral therapy claims to address such a wide range of conditions

which include migraines, headaches, chronic neck and back pain, autism, stress and tension related disorders, motor coordination disorders, infant and childhood disorders, brain and spinal cord injuries, chronic fatigue, fibromyalgia, TMJ syndrome, scoliosis, central nervous system disorders, learning disabilities, ADD/ADHA, post traumatic stress disorder, orthopedic problems and many others (5). Craniosacral therapy claims to be able to detect and correct these restrictions in movement through a simple hands on approach. The practitioner uses his or her hands to evaluate the craniosacral system through gentle placement of the hands in various locations on the body, such as the head and back, to test the rhythm and ease of motion of the cerebral spinal fluid pulsing around the brain and spinal cord. The technique uses a soft touch, generally no greater that 5 grams, which is about the weight of a nickel. The practitioner uses these soft touch techniques to release the restrictions in the soft tissues that influence the craniosacral system. This practice is not recommended for conditions where a slight variation and/or increase in intracranial pressure would cause instability. In fact, research has shown that this has had an adverse effect on patients recovering from a traumatic brain injury (1). Craniosacral practitioners can range from physiotherapists, chiropractors, dentists and osteopathic, medical or naturopathic physicians, as well as other regulated and unregulated health-care practitioners. The techniques are taught through a craniosacral therapy course and are available to any layperson interested. To be a practitioner however, one may need to have a license to touch in order to practice. Licensing varies state to state (5).

Dr. Upledger has published several articles in the journal Massage Today advocating the use of craniosacral therapy for a myriad of problems but research states that there are significant flaws in how it is portrayed and practiced and current research does not support the claims that craniosacral therapy makes. Systematic reviews have found that the available studies supporting craniosacral therapy as being effective in altering health outcomes have a low ranking according to standard principles for judging the quality of studies. One of the stumbling blocks in craniosacral therapy is the validity and reliability of the assessment made by craniosacral practitioners. There is currently no scientific based assessment for feeling restrictions in cerebral spinal fluid movement. This brings to question the interrater reliability in performing such an assessment. Current and better designed studies were consistent in not finding the assessment of craniosacral rhythm reliable. Research also states that there is simply no evidence that restriction in the movement of the cranial system impedes the flow of cerebral spinal fluid or that movement at the cranial sutures can be achieved manually. (1). There is also lack of evidence that supports that claim that craniosacral therapy has a direct effect in improving specific dependent measures related to remediation of problems or deficiencies (4). Craniosacral therapy is considered by many as an alternative or complimentary approach to health care while others believe that it is not medicine at all. The National Council Against Health Fraud formally declared its opposition to craniosacral therapy in 1998, noting that it was more of a belief system than a science. Due to lack of empirical evidence in the value of Craniosacral therapy techniques, it has been characterized by some to be medical fiction(3) Other researchers were so critical that they advocated removing references of craniosacral

therapy from courses of study at colleges of osteopathic medicine and related questions removed from the licensing examination (4). Dr. Upledger claims that the patient outcomes give credibility to his claims versus scientific tests, stating that craniosacral therapy can never be validly tested in a scientific way with the standard controls over internal and external validity. A systematic review to evaluate the effectiveness of craniosacral therapy suggested that 5 out of 6 studies supporting the effectiveness of craniosacral therapy were associated with a high risk of bias. The research also noted that the 5 studies suggesting positive effects were of low quality using the Jadad score, while the 1 high quality trial failed demonstrate effectiveness of craniosacral therapy (2). Similar findings were expressed in another systematic review that stated the available studies supporting the effectiveness of craniosacral therapy were of the lowest (Level 3) grade evidence as rated by the Canadian Task Force on Preventive Health Care and deemed poor quality when judged using standard critical appraisal criteria (1). The conclusion of this report is that craniosacral therapy lacks scientific evidence to supports its claim that manual manipulation of the craniosacral system can have a positive effect on the range of conditions suggested or be a preventative benefit to overall health. With regard to the field of physical therapy, this lack of evidence questions the use of craniosacral therapy as a valid intervention for improving patient outcomes.

Annotated Bibliography

1 C. Green, C.W. Martin, K. Bassett, A Kazanjian A Systematic Review of Craniosacral Therapy:

Biological Plausibility, Assessment Reliability and Clinical Effectiveness Complementary Therapies in Medicine (1999), 7, 201-207 This is a highly cited article that evaluates available studies on multiple databases to review critically the scientific basis of craniosacral therapy as a therapeutic intervention. It evaluates craniosacral interventions and health outcomes, validity of craniosacral assessment and Pathophysiology of the craniosacral system.

2 E. Ernst (2012), Craniosacral therapy: a systematic review of the clinical evidence. Focus on Alternative and Complementary Therapies, 17: 197-201. Reviews reports available via an electronic search across three databases, complemented by extensive hand-searching of departmental files and bibliographies. The review evaluates trials claiming positive result of the effectiveness of craniosacral therapy and judges the methods used by established standards. 3 S. Hartman, J. Norton (2002), Craniosacral therapy is not medicine Physical Therapy Journal, vol.82 no. 11:1146-1147. Two PhD researchers challenge the claims of the alternative medicine, craniosacral therapy, claiming that there is no scientific research supporting the clinical value of craniosacral techniques. They dismiss Dr. Sutherland s claim of Primary Respiratory Mechanism as invalid and that interrelater reliability is almost zero. In their opinion, craniosacral therapy should not be taught to students and categorize craniosacral therapy as medical fiction. 4 T. Zane, (2011), A Review of Crainosacral Therapy- Science, Fads and Applied Behavior Analysis The Current Repertoire-Newsletter of the Cambridge Center for Behavioral Studies, Fall 2011. The author who claims to be a proponent of evidence based practice, addresses six assumptions that craniosacral therapy is based. The author seeks out evidence based reports to support these assumptions but fails to find any. These assumptions are, 1) that the human brain pulsates unrelated to breathing or heart rate, 2)a person can feel such pulsations with ones fingertips, 3) the craniosacral system can move and be moved by touching and massaging, 4) restrictions of the natural movements of the cranial system restrict or prevent flow of cerebral spinal fluid, 5)these presumed difficulties result in numerous problems, 6) with 5 grams of pressure, practitioners can remove restrictions and generate movement that results in improved function. 5. Upledger Institute International (2013), www.upledger.com. The website of the developer of craniosacral therapy explains what craniosacral therapy is and how it works. It explains the benefits of craniosacral therapy and the various conditions that it claims to improve. It also gives listings for classes and explains how one can become a practitioner of craniosacral therapy.