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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. A craniosacral therapy session involves the therapist placing their hands on the patient, which they claim allows them to "tune into the craniosacral rhythm".[1] The practitioner gently works with the spine and the skull and its cranial sutures, diaphragms, and fascia. In this way, the restrictions of nerve passages are said to be eased, the movement of cerebrospinal fluid through the spinal cord is said to be optimized, and misaligned bones are said to be restored to their proper position. Craniosacral therapists use the therapy to treat mental stress, neck and back pain, migraines, TMJ Syndrome, and for chronic pain conditions such as fibromyalgia.[2][3][4] Several studies have reported that there is little scientific support for the underlying theoretical model for which no properly randomized, blinded, and placebo-controlled outcome studies have ever been published.[5][6]


Cranial Osteopathy was originated by physician William Sutherland, DO (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 stated 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 observation of the cranial mechanism, Sutherland stated 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 at first largely rejected by the mainstream osteopathic profession as it challenged some of the closely held beliefs among practitioners of the time.

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 knowledge of this form of treatment 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.

The Cranial Academy was established in the US in 1947, and continues to teach DOs, MDs, and Dentists "an expansion of the general principles of osteopathy"[8] including a special understanding of the central nervous system and primary respiration.

Towards the end of his life Sutherland believed that he began to sense a "power" which generated corrections from inside his patients' bodies without the influence of external forces applied by him as the therapist. Similar to Qi and Prana, this contact with, what he perceived to be the Breath of Life changed his entire treatment focus to one of spiritual reverence and subtle touch.[9] This spiritual approach to the work has come to be known as both 'biodynamic' craniosacral therapy and 'biodynamic' osteopathy, and has had further contributions from practitioners such as Becker and James Jealous (biodynamic osteopathy), and Franklyn Sills (biodynamic craniosacral therapy). The biodynamic approach recognizes that embryological forces direct the embryonic cells to create the shape of the body, and places importance on recognition of these formative patterns for maximum therapeutic benefit, as this enhances the ability of the patient to access their health as an expression of the original intention of their existence.

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 pulse he had observed 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.[10][11][12] 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.[13]

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. He continues to teach this approach worldwide through the Upledger Institute in West Palm Beach, Florida. Craniosacral therapists often (although not exclusively) work more directly with the emotional and psychological aspects of the patient than osteopaths working in the cranial field[citation needed].

Craniosacral Therapy Associations have been formed in the UK,[14] North America,[15] and Australia.[16]

The primary respiratory mechanism

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

Inherent motility of the central nervous system

The inherent motion of the brain is described as a "dynamo," beginning with the cerebellum.[17] The postulated intracranial fluid fluctuation can be described as an interaction between four main components: arterial blood, capillary blood (brain volume), venous blood and cerebrospinal fluid (CSF).[18][19] The function of such a mechanism is postulated by Lee[17] as being based on a fulcrum created by the root of the cerebellum and its hemispheres moving in opposite directions, resulting in an increase in pressure which squeezes the third ventricle. The pulsation is described as essentially a recurrent expression of the embryological development of the brain.[17]

Fluctuation of the cerebrospinal fluid

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.

Practitioners work with cycles of various rates:

  • 10-14 cycles per minute - the original "Cranial Rhythmic Impulse" (CRI)[20] (also described as 6-14 times per minute)[17]
  • 2-3 cycles per minute - the "mid-Tide"
  • 6 cycles every 10 minutes - the "long Tide"

In 1960 Lundberg made a continuous recording of intracranial activities of traumatised patients, finding three waves, one of which Lee believes resembles the CRI.[21]

There is research which demonstrates examiners are unable to measure craniosacral motion reliably, as indicated by a lack of interrater agreement among examiners.[22] 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,[23] a principle which lacks scientific support. Another study[24] reports craniosacral motion cannot be reliably palpated.

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.[25]

It has been theorized that during[attribution needed] 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.

Mobility of the cranial bones

Cranial sutures are almost immobile after fusion, inhibiting movement between cranial bones. According to Lee (2005),[26] this understanding arose in the mid-1900s and was misinterpreted from the work of authors hoping to correlate suture closure with the chronological age of a skull in archaeological specimens. Lee suggests the authors found there was no correlation between suture closure and the chronological age of the individual, and also most skulls demonstrated no suture closure at all except as structural evidence of pathological physical trauma. Lee cites many references giving evidence for mobility in human skulls,[26] and modern anatomy books suggest incomplete fusion of some sutures. According to Gray's Anatomy, "[w]hen such sutures are tied by sutural ligament and periosteum, almost complete immobility results"[27], which would make moving these fused bones with gentle massage extremely improbable.

Cranial textbooks propose that motion of the skull is possible during flexion and extension because the sutures are mobile[citation needed]. The sphenobasilar synchondrosis (SBS) - the junction between the base of the sphenoid and the occiput- is thought to fuse by the mid- to late twenties, but still retain limited mobility[citation needed] . An alternative theory to SBS Motion taught in craniosacral training suggests that sutures are "lines of folding", like pre-folded marks on cardboard, rather than necessarily being fully open.[28]

Craniosacral treatment

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.[23] 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.[29]

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%.[30]


There are extensive criticisms of cranialsacral therapy from the scientific and health care professions as to the validity and efficacy of Cranial Type techniques and principles. The following criticisms are cited against this form of therapy.

  • Lack of evidence cranialsacral therapy provides a therapeutic benefit[13]
  • Lack of evidence for the existence of "cranial bone movement":
Scientific evidence does not support the theories for cranial bone movement claimed by craniosacral practitioners. This research shows that partial fusion between cranial bones occurs during growth and development.[31]
  • Lack of evidence for the existence of the "cranial rhythm":
While evidence exists for cerebrospinal fluid pulsation, one study states it is caused by the functioning of the cardiovascular system and not by the workings of the craniosacral system.[32]
  • Lack of evidence linking "cranial rhythm" to disease:
Research to date to support the link between the "cranial rhythm" and general health is cited as "low grade" and "unacceptable to meet scientific measures".[6]
  • Lack of evidence "cranial rhythm" is detectable by practitioners:

While studies have reported evidence of the existence of the primary respiratory rhythm, the link between any such mechanism and states of health or disease has also been contested. One meta-analysis from the British Columbia Office of Health Technology Assessment (BCOHTA) concluded that "there is evidence for a craniosacral rhythm, impulse or 'primary respiration' independent of other measurable body rhythms", however it was noted that "these and other studies do not provide any valid evidence that such a craniosacral 'rhythm' or 'pulse' can be reliably perceived by an examiner" and that "The influence of this craniosacral rhythm on health or disease states is completely unknown."[6] The examiners concluded (1) there is little science in any aspect of cranial of the PRM; (2) the only publication purporting to show diagnostic reliability with sufficient detail to permit evaluation is deeply flawed and stands alone against other reports that show reliabilities of zero; and (3) there is no scientific evidence of treatment efficacy.[6]

Operator interreliability has been very poor in studies that have been done. Five studies showed an operator interreliability of zero.[5] In a report to the British Columbia Office of Health Technology Assessment one study in this report shows some operator interreliability but has been criticized as deeply flawed.[13]


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) 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.


  1. The Craniosacral Therapy Association of the UK
  2. The Upledger Institute (2001). Craniosacral Therapy. Retrieved March 27, 2004.
  3. Ferrett, Mij (1998). What Is Craniosacral Therapy?. Retrieved March 27, 2004.
  4. The Sutherland Society General information on Cranial Osteopathy. Retrieved January 24, 2006.
  5. 5.0 5.1 Hartman SE, Norton JM (2002). Interexaminer reliability and cranial osteopathy. Sci Rev Alt Med 6 (1): 23–34.
  6. 6.0 6.1 6.2 6.3 A systematic review and critical appraisal of the scientific evidence on craniosacral therapy
  7. Sutherland A (1962). With Thinking Fingers. Indianapolis, IN: Cranial Academy, 13.
  8. The Cranial Academy. Retrieved 10 July 2006.
  9. The Cranial Academy Osteopathy in the Cranial Field. Retrieved January 24, 2006.
  10. (1995). Craniosacral therapy. Physical therapy 75 (4): 328–30.
  11. (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.
  12. (1979). Mechano-electric patterns during craniosacral osteopathic diagnosis and treatment. The Journal of the American Osteopathic Association 78 (11): 782–91.
  13. 13.0 13.1 13.2 Green C, Martin CW, Bassett K, Kazanjian A (1999). A systematic review of craniosacral therapy: biological plausibility, assessment reliability and clinical effectiveness. Complement Ther Med 7 (4): 201–7. An earlier version of the paper is available without a subscription: Green C, Martin CW, Bassett K, Kazanjian A (1999). "A systematic review and critical appraisal of the scientific evidence on craniosacral therapy" (PDF). BCOHTA 99:1J. British Columbia Office of Health Technology Assessment. Retrieved on 2007-10-08.
  14. Craniosacral Therapy Association of the UK. Retrieved 10 July 2006.
  15. Craniosacral Therapy Association of North America. Retrieved 10 July 2006.
  16. Craniosacral Therapy Association of Australia. Retrieved 10 July 2006.
  17. 17.0 17.1 17.2 17.3 Lee R P. Interface: Mechanisms of Spirit in Osteopathy. Portland, OR: Stillness Press, 2005, pp. 193-8. ISBN 0-9675851-3-9. Cite error: Invalid <ref> tag; name "Lee2" defined multiple times with different content Cite error: Invalid <ref> tag; name "Lee2" defined multiple times with different content Cite error: Invalid <ref> tag; name "Lee2" defined multiple times with different content
  18. Greitz D, Franck A, Nordell B. On the pulsatile nature of intracranial and spinal CSF-circulation demonstrated by MR imaging. Acta Radiol. 1993 Jul;34(4):321-8. PMID 8318291.
  19. Greitz D, Wirestam R, Franck A et al. Pulsatile brain movement and associated hydrodynamics studied by magnetic resonance phase imaging. The Monro-Kellie doctrine revisited. Neuroradiology. 1992;34(5):370-80. PMID 1407513.
  20. Magoun H I (ed.), Osteopathy in the Cranial Field. The Cranial Academy, 3rd edn, 1976, p. 25.
  21. Lundberg N. Continuous recording and conrold of ventricular fluid pressure in neurosurgical practice. Acta Psychiat Neurol Scand, 36:suppl 149, 1960. Quoted in Lee R P. Interface: Mechanisms of Spirit in Osteopathy. Portland, OR: Stillness Press, 2005, p. 199. ISBN 0-9675851-3-9.
  22. Wirth-Pattullo V, Hayes KW. Interrater reliability of craniosacral rate measurements and their relationship with subjects' and examiners' heart and respiratory rate measurements. Phys Ther. 1994 Oct;74(10):908-16; discussion 917-20. PMID 8090842
  23. 23.0 23.1 McPartland JM, Mein EA. Entrainment and the cranial rhythmic impulse. Altern Ther Health Med. 1997 Jan;3(1):40-5. PMID 8997803
  24. JS Rogers, PL Witt, MT Gross, JD Hacke, and PA Genova. "Simultaneous palpation of the craniosacral rate at the head and feet: intrarater and interrater reliability and rate comparisons" PHYS THER. Vol. 78, No. 11, November 1998, pp. 1175-1185
  25. Upledger J E, Vredevoogd J. 1983 Craniosacral Therapy Eastland Press. ISBN 0-939616-01-7
  26. 26.0 26.1 Lee R P. Interface: Mechanisms of Spirit in Osteopathy. Portland, OR: Stillness Press, 2005, 130-33. ISBN 0-9675851-3-9.
  27. Williams P L, Warwick R, Dyson M, Bannister L H. Gray's Anatomy. Churchill Livingstone, Edinburgh, 37th edn, 1989, p. 468. ISBN 0-443-02588-6
  28. Cook, Andrew, An alternative to Sphenobasilar Synchondrosis (SBS) Motion. Self-published online, September 2005. PDF
  29. McPartland JM, Giuffrida A, King J et al. Cannabimimetic effects of osteopathic manipulative treatment. J Am Osteopath Assoc. 2005 Jun;105(6):283-91. PMID 16118355
  30. Greenman PE, McPartland JM. Cranial findings and iatrogenesis from craniosacral manipulation in patients with traumatic brain syndrome. J Am Osteopath Assoc. 1995 Mar;95(3):182-8; 191-2. PMID 7751168
  31. (1995). Suture closure in the human chondrocranium: CT assessment.. Radiology 196 (3): 747–56.
  32. (1990). Cranial osteopathy, delusion or reality?. Actualites odonto-stomatologiques 44 (171): 481–94.

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