Craniosacral therapy

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Craniosacral therapy (CST), or cranial-sacral therapy, is a form of bodywork or alternative therapy focused primarily on the concept of "primary respiration" and regulating the flow of cerebrospinal fluid by using therapeutic touch to manipulate the synarthrodial joints of the cranium. To do this, a practitioner will apply light touches to a patient's skull, face, spine and pelvis.[1] Craniosacral therapy was developed by John Upledger, D.O. in the 1970s, and is loosely based on osteopathy in the cranial field (OCF), which was developed in the 1930s by William Garner Sutherland.[1][2]

According to the American Cancer Society, although CST may relieve the symptoms of stress or tension, "available scientific evidence does not support claims that craniosacral therapy helps in treating cancer or any other disease".[1] CST is pseudoscience[3] and its practice has been called quackery.[4]

History and conceptual basis[edit]

Cranial Osteopathy, a forerunner of CST, 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.[5]

John Upledger devised CST. Comparing it to cranial osteopathy he wrote: "Dr. Sutherland's discovery regarding the flexibility of skull sutures led to the early research behind CranioSacral Therapy – and both approaches affect the cranium, sacrum and coccyx – the similarities end there."[6]

From 1970 to 1983, Upledger and neurophysiologist and histologist Ernest W. Retzlaff worked at Michigan State University as clinical researchers and professors. They assembled a research team to investigate the purported pulse and further study 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.[7][8][9] Later reviews of these studies have concluded that their research did not meet enduring standards to offer conclusive proof for the effectiveness of craniosacral therapy and the existence of cranial bone movement.[10]

Practitioners of craniosacral therapy assert that there are small, rhythmic motions of the cranial bones attributed to cerebrospinal fluid pressure or arterial pressure. The premise of CST is that palpation of the cranium can be used to detect this rhythmic movement of the cranial bones and selective pressures may be used to manipulate the cranial bones to achieve a therapeutic result. However, the degree of mobility and compliance of the cranial bones is considered controversial and is a critically important concept in craniosacral therapy.[11]

Treatment[edit]

The therapist lightly palpates the patient's body, and focuses intently on the communicated movements. A practitioner's feeling of being in tune with a patient is described as entrainment.[12] Patients often report feelings of deep relaxation during and after the treatment session, and may feel light-headed. This is popularly associated[by whom?] with increases in endorphins, but research shows the effects may actually be brought about by the endocannabinoid system.[13]

There are few reports of adverse events from CST treatment. In one study of craniosacral manipulation in patients with traumatic brain syndrome, the incidence of adverse effects from treatment was 5%.[14]

Primary respiratory mechanism[edit]

The Primary Respiratory Mechanism (PRM), the mechanism originally proposed by Sutherland, has been summarized in five ideas:[5]

  • Inherent motility of the central nervous system
  • Fluctuation of the cerebrospinal fluid
  • Mobility of the intracranial and intraspinal dural membranes
  • Mobility of the cranial bones
  • Involuntary motion of the sacrum between the ilia

Inherent motility of the central nervous system[edit]

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).[15][16]

Fluctuation of the cerebrospinal fluid[edit]

There is research which demonstrates examiners are unable to measure craniosacral motion reliably, as indicated by a lack of inter-rater agreement among examiners.[17] 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,[12] a principle which lacks scientific support. The subject of whether or not craniosacral motion can be reliably palpated remains a subject of debate with studies producing mixed results.[18][19]

Mobility of the intracranial and intraspinal dural membranes[edit]

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.[20]

Mobility of the cranial bones[edit]

The extent to which cranial bones are able to move is considered controversial and studies of the existence and degree of cranial motion have yielded mixed findings.[11] Cranial sutures are the areas in which the eight cranial bones are joined. During infancy, the cranial bones are not rigidly fused to each other,[21] but are instead bound together by a membrane known as a fontanelle where two sutures join. Between the first and second year of life, the cranial bones begin to move together and fuse as a normal part of development.[11] Studies examining the age of the closure of the cranial sutures have reported mixed findings. Closure has been reported to occur during adolescence while other studies indicate greater individual variability in the timing of this closure with fusion of the lambdoid suture, sagittal suture, and coronal sutures taking place in the fourth decade of life, but complete fusion of all sutures not occurring until advanced age[22] (the eighth decade of life has been reported);[11] some studies have found that the sutures never rigidly fuse.[11] According to Gray's Anatomy, "[w]hen such sutures are tied by sutural ligament and periosteum, almost complete immobility results".[23]

Reception[edit]

In October 2012 Edzard Ernst conducted a systematic review of randomised clinical trials of craniosacral therapy. He concluded that "the notion that CST is associated with more than non-specific effects is not based on evidence from rigorous randomised clinical trials".[24] Commenting specifically on this conclusion Ernst commented on his blog that he had chosen the wording as "a polite and scientific way of saying that CST is bogus."[25] Ernst also commented that the quality of five of the six trials he had reviewed was "deplorably poor," a sentiment prefigured by an earlier (August 2012) review which noted the "moderate methodological quality of the included studies."[5]

Ernst also criticized an earlier, 2011, systematic review performed by Jakel and von Hauenschild for inclusion of observational studies and including studies with healthy volunteers.[24] This review had concluded that the evidence base surrounding craniosacral therapy and its efficacy was sparse and composed of studies with heterogeneous design. The authors of this review had stated that currently available evidence was insufficient to draw conclusions.[26]

The evidence base for CST is sparse and a demonstrated biologically plausible mechanism is lacking. In the absence of rigorous, well-designed randomized controlled trials,[27][28] it has been characterized as pseudoscience,[3] and its practice called quackery.[4]

See also[edit]

References[edit]

  1. ^ a b c "Craniosacral therapy". American Cancer Society. December 2012. Retrieved August 2013. 
  2. ^ "Craniosacral Therapy". UPMC Center for Integrative Medicine. 2012. Retrieved 19 May 2013. 
  3. ^ a b
  4. ^ a b
  5. ^ a b c Jäkel, Anne; Von Hauenschild, Philip (2012). "A systematic review to evaluate the clinical benefits of craniosacral therapy". Complementary Therapies in Medicine 20 (6): 456–65. doi:10.1016/j.ctim.2012.07.009. PMID 23131379. 
  6. ^ Upledger, John E. (2002). "CranioSacral Therapy vs. Cranial Osteopathy: Differences Divide". Massage Today 2 (10). 
  7. ^ Upledger, John E (1995). "Craniosacral Therapy". Physical Therapy 75 (4): 328–30. PMID 7899490. 
  8. ^ Upledger, JE (1978). "The relationship of craniosacral examination findings in grade school children with developmental problems". The Journal of the American Osteopathic Association 77 (10): 760–76. PMID 659282. 
  9. ^ Upledger, JE; Karni, Z (1979). "Mechano-electric patterns during craniosacral osteopathic diagnosis and treatment". The Journal of the American Osteopathic Association 78 (11): 782–91. PMID 582820. 
  10. ^ Green, C.; Martin, C.W.; Bassett, K.; Kazanjian, A. (1999). "A systematic review of craniosacral therapy: Biological plausibility, assessment reliability and clinical effectiveness". Complementary Therapies in Medicine 7 (4): 201–7. doi:10.1016/S0965-2299(99)80002-8. PMID 10709302. 
  11. ^ a b c d e Seimetz, Christina N.; Kemper, Andrew R.; Duma, Stefan M. (2012). "An investigation of cranial motion through a review of biomechanically based skull deformation literature". International Journal of Osteopathic Medicine 15 (4): 152–65. doi:10.1016/j.ijosm.2012.05.001. 
  12. ^ a b McPartland, JM; Mein, EA (1997). "Entrainment and the cranial rhythmic impulse". Alternative therapies in health and medicine 3 (1): 40–5. PMID 8997803. 
  13. ^ McPartland, John M.; Giuffrida, Andrea; King, Jeremy; Skinner, Evelyn; Scotter, John; Musty, Richard E. (2005). "Cannabimimetic Effects of Osteopathic Manipulative Treatment". The Journal of the American Osteopathic Association 105 (6): 283–91. PMID 16118355. 
  14. ^ Greenman, PE; McPartland, JM (1995). "Cranial findings and iatrogenesis from craniosacral manipulation in patients with traumatic brain syndrome". The Journal of the American Osteopathic Association 95 (3): 182–8; 191–2. PMID 7751168. 
  15. ^ Greitz, D; Franck, A; Nordell, B (1993). "On the pulsatile nature of intracranial and spinal CSF-circulation demonstrated by MR imaging". Acta radiologica 34 (4): 321–8. PMID 8318291. 
  16. ^ Greitz, D.; Wirestam, R.; Franck, A.; Nordell, B.; Thomsen, C.; Ståhlberg, F. (1992). "Pulsatile brain movement and associated hydrodynamics studied by magnetic resonance phase imaging". Neuroradiology 34 (5): 370–80. doi:10.1007/BF00596493. PMID 1407513. 
  17. ^ Wirth-Pattullo, V; Hayes, KW (1994). "Interrater reliability of craniosacral rate measurements and their relationship with subjects' and examiners' heart and respiratory rate measurements". Physical therapy 74 (10): 908–16; discussion 917–20. PMID 8090842. 
  18. ^ Rogers, Joseph S; Witt, Philip L; Gross, Michael T; Hacke, Jon D; Genova, Perry A (1998). "Simultaneous Palpation of the Craniosacral Rate at the Head and Feet: Intrarater and Interrater Reliability and Rate Comparisons". Physical Therapy 78 (11): 1175–85. PMID 9806622. 
  19. ^ Halma, Kelly D.; Degenhardt, Brian F.; Snider, Karen T.; Johnson, Jane C.; Flaim, M. Schaun; Bradshaw, Danielle (2008). "Intraobserver Reliability of Cranial Strain Patterns as Evaluated by Osteopathic Physicians: A Pilot Study". The Journal of the American Osteopathic Association 108 (9): 493–502. PMID 18806078. 
  20. ^ Upledger, J E; Vredevoogd, J. (1983). Craniosacral Therapy. Eastland Press. ISBN 0-939616-01-7. [page needed]
  21. ^ Herring, Susan W. (2008). "Mechanical Influences on Suture Development and Patency". In Rice, David P. Craniofacial Sutures: Development, Disease and Treatment. Frontiers of Oral Biology 12. Karger. pp. 41–56. doi:10.1159/000115031. ISBN 978-3-8055-8326-8. PMC 2826139. PMID 18391494. 
  22. ^ Morriss-Kay, Gillian M.; Wilkie, Andrew O. M. (2005). "Growth of the normal skull vault and its alteration in craniosynostosis: Insights from human genetics and experimental studies". Journal of Anatomy 207 (5): 637–53. doi:10.1111/j.1469-7580.2005.00475.x. PMC 1571561. PMID 16313397. 
  23. ^ Williams, P L; Warwick, R; Dyson, M; Bannister, L H. (1989). Gray's Anatomy (37th ed.). Edinburgh: Churchill Livingstone. p. 468. ISBN 0-443-02588-6. 
  24. ^ a b Ernst, Edzard (2012). "Craniosacral therapy: A systematic review of the clinical evidence". Focus on Alternative and Complementary Therapies 17 (4): 197–201. doi:10.1111/j.2042-7166.2012.01174.x. 
  25. ^ Ernst, Edzard (2012). "Up the garden path: craniosacral therapy". Retrieved 15 December 2012. 
  26. ^ Jäkel, Anne; Von Hauenschild, Phillip (2011). "Therapeutic Effects of Cranial Osteopathic Manipulative Medicine: A Systematic Review". The Journal of the American Osteopathic Association 111 (12): 685–93. PMID 22182954. 
  27. ^ Agency for Healthcare Research and Quality (2012). "Best evidence statement (BESt). Craniosacral therapy for children with autism and/or sensory processing disorder". U.S. Department of Health & Human Services. Retrieved 19 May 2013. 
  28. ^ "Craniosacral Therapy". Blue Cross Blue Shield of Tennessee Medical Policy Manual. Blue Cross Blue Shield of Tennessee. 2012. Retrieved 19 May 2013. 

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