Craniosacral therapy

Craniosacral therapy (CST), or cranial-sacral therapy, is an alternative therapy used by occupational therapists, physiotherapists, massage therapists, naturopaths, and chiropractors. Craniosacral therapy was developed by Dr. John Upledger around 1983, and is loosely based on osteopathy in the cranial field (OCF), which was developed in 1899 by William Garner Sutherland. In the United States, OCF, or cranial osteopathy, as it is more commonly known, can only be practiced by fully licensed physicians (DOs, MDs and, in some states licensed naturopathic physicians, or NDs) and dentists. Cranial osteopathy is considered an extension of osteopathic medicine, and its training is therefore strictly regulated by the osteopathic medical profession and its governing bodies.

The settled scientific consensus is that craniosacral therapy is pseudoscience, and its practice is quackery. Medical research has concluded that there is no evidence for the therapy's effectiveness.

History and conceptual basis

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.

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 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. 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.

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.

Treatment

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. Patients often report feelings 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.

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%.

Primary respiratory mechanism

The Primary Respiratory Mechanism (PRM) has been summarized in five ideas.

Inherent motility of the central nervous system

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).

Fluctuation of the cerebrospinal fluid

There is research which demonstrates examiners are unable to measure craniosacral motion reliably, as indicated by a lack of inter-rater agreement among examiners. 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, 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.

Mobility of the intracranial and intraspinal dural membranes

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.

Mobility of the cranial bones

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. 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, 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. 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 (the eighth decade of life has been reported); some studies have found that the sutures never rigidly fuse. According to Gray's Anatomy, "[w]hen such sutures are tied by sutural ligament and periosteum, almost complete immobility results".

Systematic reviews

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." Further studies were carried out between 1999 and 2011.

In 2011 a systematic review concluded that the evidence base surrounding craniosacral therapy and its efficacy is sparse and composed of studies with heterogeneous design. The authors of this review stated that currently available evidence was insufficient to draw conclusions and that further study is needed to better evaluate if craniosacral therapy has therapeutic benefit.

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". 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." 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."