“I wonder whether what is considered ‘alternative’ today that may become tomorrow’s ‘standard of care,'” speculated a pathologist. (Cohen, B)
The concept of Osteopathy in the Cranial Field (OCF) was first coined by Sutherland and followed by several others such as Becker, R. Upledger, J. and many more.
The principles established by these authors involve theories regarding the Primary Respiratory Mechanism (PRM) and the Cranial Rhythmic Impulse (CRI) which will not be discussed in this essay.
The scope of this write up will focus on discussing research papers which 1) compare the findings of cranial bone and neural tissue motion as well as CRI using medical imaging; 2) have clinical findings regarding OCF 3) and evaluate the articles which mention that OCF should, or should not, be included in the Osteopathic Curriculum. In order to do this discussions and conclusions of these articles will be evaluated but research methods will only be mentioned when appropriate.
Cranial Osteopathy: fact or fiction
There is a wide array of papers stating that the PRM (CRI) is palpable. But only a few set of papers show scientific proof of these findings.
Discussion in favor of OCF
When considering if cranial bones move, several studies using MRI scans, prove that there is movement of neural tissues which cause variations of intracranial pressure. Linking these intracranial pressure changes to the findings of Oleski (2002) -who demonstrated that an increase in intracranial pressure (in cadavers) leads to cranial bone motion- one could assume that cranial osteopaths could palpate this motion. Recent research, using MRI scans, performed by Crow, W. et al. (2009) has shown in accordance with [a]these findings that due to intracranial volume changes there is an expansion and contraction of the total intracraneal area. But according to the authors the imagery exceeds the resolution of the MRI considering that higher resolution could show further findings.
Some studies have shown correlations between infrared findings and cranial palpation (Zanakis et al. 1996) and others have shown correlations between low and very-low frequency Traube Hering Meyer (THM) oscillations and CRI. (Nelson, K. et al in 2006). Nelson’s experiment removed the high frequency cardiac component (above 0.5 Hz) and analyzed the low and very-low frequencies with the following findings finally published in the Foundations of Osteopathic Medicine (FOM) 3rd Edition:
Protocol 1 demonstrated a correlation between the low-frequency bloodflow velocities and the CRI. Protocol 2 demonstrated that cranial manipulations affect bloodflow velocities and baroreflex activity therefore influencing the ANS. Protocol 2 also demonstrated that control palpation can be used as sham. Protocol 3 demonstrated, using CV4 that cranial manipulation can affect bloodflow velocities on demand of the practitioner, resulting also in heartbeat changes. Protocol 4 demonstrated that the duration for a result in a CV4 was of 4.43 +/- 2.22 minutes. Findings which are consistent with those of Beker, R. And also that OCF has an effect on the ANS Protocol 5 shows that most practitioners palpate the CRI at two low-frequency bloodflow velocities.
There are few quality research papers, in support of OCF regarding treatment, published in peer reviewed, scientific or medical journals. In spite of this a few number of them are supporting this science in the management of otitis media, colic in babies, postural plagiocephaly and others.
Degenhardt, B. et al. (2006) showed in a pilot study (with only 8 subjects) that Osteopathic Manipulative Treatment might change the progression of otitis media. In spite of this the NICE guidelines discourage the use of OCF for the management of otitis media with effusion (NICE).
Hayden, C. et al (2006) evaluated the positive effects of OCF in decreasing crying time and improvement in sleep in infants treated with Cranial Osteopathy. The power of Hayden’s study is not large using only 28 infants; but it adds to the study of Kotzampaltiris, P. et al. (2009) with 139 patients witch suggest that altered CRI in the first 2 weeks of life may lead to excessive crying.
Amiel-Tison, C. et al (2008) postulated that cranial osteopathy has its place in treating postural plagiocephaly due to its functional and esthetical implications. But when structural malformations are present such as craniosynostosis, cranial osteopathy is not effective.
Discussion against OCF
Hanten, W. et al mentioned in 1998 that “the origins of this rhythm are unknown, and palpatory findings lack scientific support”. The following examples evaluate the validity of OCF:
Five papers published in PubMed between 1994 and 2004 have tested the reliability, the inter-rater reliability, inter-examiner simultaneous palpation of head and sacrum, and head and pelvis (Sommerfeld, P. et al 2004); and the relationships between the CRI and the cardiac and respiratory rates. The findings in these articles conclude that: 1) The rate of the CRI is not palpated consistently between two examiners (Hanten, W. et al 1998; Wirth-Pattullo, V. 1994; Rogers, J. et al 1998; Moran, R. et al 2001; Sommerfeld, P. et al 2004). 2) “Interexaminer reliability for simultaneous palpation at the head and the sacrum was poor to nonexistent” (Moran RW, et al 2001; Rogers JS, et al. 1998). 3) It appears that a subject’s CRI is not related to the heart or respiratory rates of the subject or the examiner. (Hanten WP, et al 1998, Wirth-Pattullo V 1994; Sommerfeld P, et al. 2004). This third finding agrees with those found by Nelson, K. et al. 2011 where the CRI measured with THM waves has isolated the frequencies of the heart and lungs. 4) the results don’t seem to relate to the ‘core-link’ established by craniosacral practitioners (Moran RW, et al. 2001). 5) the CRI palpated could, in some cases, be the practitioners rhythm (Sommerfeld P, et al. 2004). It should be noted here that more experienced practitioners seem to palpate more accurately than less experienced ones (Nelson, et al. 2011 Protocol 6) and few of these papers mention that their practitioners are qualified osteopaths, using instead physiotherapists with experience in OCF.
Hartman, S. and Norton, M. (both working in the College of Osteopathic Medicine in the University of New England) have published several articles together and separately regarding the validity of OCF. Their first article published in 2002 regarding interexaminer reliability in cranial osteopathy concludes that 1) there is no evidence of the PRM, 2) Upledger’s studies are flawed, and 3) there is not scientific evidence in treatment using OCF.
In the same year Hartman et al. (2002) wrote a letter to the editor of the Physical Therapy magazine stating that they have observed in their laboratory that the PRM is invalid due to the inability of movement of the neural tissue. This collides with the findings of Greitz, et al. (1992), Enzmann, et al. (1992), Poncelet, et al (1992), Mikulis, et al. (1994) who proved the movement of neural tissues during cardiac cycles.
Hartman and Norton state again that Upledger’s model is speculative and that movements at the SBS and vault are impossible due to ossification of the joints. This ossification is acknowledged by Cook, A. (2005) but, on a theoretical basis, he disagrees with it because of the ability of the SBS’s suture to accommodate movement of the Sphenoid bone. Also it should be noted that external stress applied to sutures between cranial bones defines collagen fiber arrangements on experimental ‘bone-suture complex’ (Jasinoski, S. et al. 2010) where function defines structure. A point confirmed by Sabini, R. et al. (2006) -who showed differences in ossification of bone sutures depending on muscular pull.
Hartman and Norton move on to evaluate interexaminer reliability considering that it is almost nonexistent agreeing with the findings of Hanten, W. et al (1998); Wirth-Pattullo, V. (1994); Rogers, J. et al (1998); Moran, R. et al (2001); Sommerfeld, P. et al (2004); further stating that even if movement was present the relation to health is non present.
Later in 2004 Hartman and Norton published another article reviewing the chapter by King, H. the FOM (2nd Ed.) stating that a great part of the article was over-interpreted or miss-interpreted and that relevant studies where not taken into account.
Following this Hartman, S. published an article, in 2006 in the Chiropractic and Manual Therapies magazine, clearly stating that the PRM is flawed, there is no evidence of efficacy in treatment and that OCF is becoming somehow a cult rather than a medical procedure. This agrees with the findings in a systematic review by Green[b], C. et al. (1999) who conclude that although there might be movements between the cranial bones it is unlikely that practitioner may palpate it and there is no evidence of its clinical application. Harman, S. suggests that until OCF has been scientifically proven, using adequate placebo-randomized control trials, and treatment methods have been demonstrated; OCF should be removed from teaching curricula, insurance companies shouldn’t pay for treatments and patients should invest their money in science-based biomedical model. Agreeing again with Green, C. et al. who suggest that better methods to evaluate the benefits of cranial osteopathy should be designed.
In a randomised controlled trial Wyatt, K. et al (2011) evaluated the effect of OCF on 142 children, ages between 5-12, suffering from cerebral palsy. This study reported no statistical difference between control and experiment groups; regarding motor function, child health questionnaire, pain, sleep or carer’s quality of lie. Colliding with the findings of Charlotte Winger Weaver (King, H. 2011) who established the relation of basicranium lesions and neuropsychiatric disorders and Arbuckle, B.’s application of OCF on children suffering from cerebral palsy.
One question that arises is why do patients get better or spend hundreds of pounds in cranial osteopathy. Hartman, S. (2009) comes up with an answer to why ineffective treatments seem helpful. First of all he considers that symptoms may improve without treatment for several reasons such as the self healing mechanism of the body, placebo, expectation, etc. Second he considers that patients and practitioners tend to fall in confirmation biases wanting to believe or expecting treatments to be effective, therefore looking for success rather than questioning outcomes. He argues that practitioners, after previous efficacy, expect success in following treatments and guide post-treatment patients answers to confirm this success; self nourishing a misconception of effectiveness based on expectations. He states that randomized controlled trials, with sham treatments, are the only way of controlling treatment outcome; concluding that ‘alternative’ or ‘complementary’ medicine, based on trial-error and patient-practitioner experience, has no place in modern medicine against randomized control trials. In spite of this the findings of Nelson, K. et al. (2011) in their second protocol show that sham cranial osteopathy can be used as a control procedure.
Although OCF is widely discussed in the literature there is little scientific evidence that supports the theories behind the practice. Most of the research in favor of OCF is either regarded to be unscientific or the powers are too low to support it.
Hartman, S. (2009)[c] questions why is treatment considered (erroneously) as the source of recovery neglecting the fact that it might be a placebo or the body’s inherent ability to recover. He reveals that these factors can lead to an erroneous perception of efficacy of treatment and that they should be expected. It is the opinion of the author of this essay that if the practitioner acknowledges these factors, expects them to happen in treatment and does not try to justify with inaccurate science; he will contribute, acting as a still point, in decreasing the total lesion of the patient; possibly empowering the patient’s self healing mechanism.
Hartman, Norton, Green and others have suggested that better methods should be developed to research the validity of OCF. It seems to the author of this essay that there are contradictions in the literature regarding neural tissue motion and that the findings of Nelson, Degenhardt, Hayden, etc. should be sufficient to foster the governments to invest money in non invasive methods of treatment, such as OCF, in the management of many conditions which involve infants with colic, ottitis media, headaches and also conditions where OCF could have effects on the ANS as described by Nelson, et al. (2011).
Finally the author of this text would like to state that ‘absence of evidence is not evidence of absence’ and considering all the new findings, especially those by Nelson et al. (2011), it would be a mistake to remove Cranial Osteopathy from the curriculum and/or from the medical care system; limiting the scope of treatment available to the population. In spite of this, the author of this write up does agree with Hartman, Norton and Green that further research is needed to evaluate the true benefits of cranial osteopathy and any other treatment method.
This post was originally a course work for the IVM paper in the ESO. Although I give an overview of the current literature it doesn’t mean that I agree with all of what is written. I have tried to be as objective as possible.
If any of the authors feels that my interpretation was wrong or would like it removed; please contact me as soon as possible.
Amiel-Tison C et al (2008) Cranial osteopathy as a complementary treatment of postural plagiocephaly. CHU. PubMed. [online] Available at: http://www.ncbi.nlm.nih.gov/pubmed/18822256 (accessed 25 November 2011)
Arbuckle, B. The Selected Writings of Beryl E. Arbuckle, D.O., FACOP. Indianapolis, IN: American Academy of Osteopathy.
Avezaat, C. et al (1986) Clinical observations on the relationship between cerebrospinal fluid pulse pressure and intracranial pressure. Acta Neurochir (Wien) 1986;79(1):13-29.
Cohen, B. (2011) Is CAM Always a SCAM? Physicians Are Talking. Medscape [online] Available at: http://www.medscape.com/viewarticle/746311 (accessed 3 December 2011)
Cook, A 2005, ‘The mechanics of cranial motion – the sphenobasilar synchondrosis (SBS) revisited’, Journal Of Bodywork & Movement Therapies, 9, 3, pp. 177-188, SPORTDiscus, EBSCOhost. [online] Available at http://www.hummingbird-one.co.uk/pdf/sbs_JBMT.pdf (accessed 1 December 2011)
Crow, W, (2009) Assessment of calvarial structure motion by MRI’, Osteopathic Medicine & Primary Care, 3, CINAHL Plus with Full Text, EBSCOhost, viewed 24 November 2011.
Degenhardt, B. et al (2006) Osteopathic Evaluation and Manipulative Treatment in Reducing the Morbidity of Otitis Media: A Pilot Study. J Am Osteopath Assoc June 1, 2006 vol. 106 no. 6327-334. [online] Available at: http://www.jaoa.org/content/106/6/327.full (accessed 17 November 2011)
DuBolay, G. et al. (1971) Further investigations on pulsatile movements in the cerebrospinal fluid pathways. Acta Radiol Diagnost;13:496-523.
Enzmann, D. et al. (1992) Brain motion: measurement with phase-contrast MR imaging. Radiology. 1992;185:653-660.
Green, C. et al (1999) A systematic Review and critical appraisal of the scientific evidence on craniosacral therapy. British Columbia Office of Health Technology Assessment
Grietz, D. et al. (1992) Pulsatile brain movement and associated hydrodynamics studied by magnetic resonance phase imaging: The Monro-Kellie doctrine revisited. Neuroradiology. 1992; 34:370-380.
Hanten, W. (1998) Craniosacral rhythm: reliability and relationships with cardiac and respiratory rates. J Orthop Sports Phys Ther. 1998 Mar;27(3):213-8. [online] Available at: http://www.ncbi.nlm.nih.gov/pubmed/9513867 (accessed 30 November 2011)
Hartman, S. et al (2002) Interexaminer Reliability and Cranial Osteopathy. The Scientific Review of Alternative Medicine. Vol. 6, NO.1 [online] Available at: http://www.roberthale.net/docs/hartman_cranial_3.pdf (accessed 2 December 2011)
Harman, S. et al (2002) Letter to the Editor. Physical Therapy. Volume 82. Number 11. November 2002 [online]
Hartman, S. et al (2004) A review of King HH and Lay EM, “Osteopathy in the Cranial Field,” in Foundations for Osteopathic Medicine, 2nd Ed. [online] Available at:
http://faculty.une.edu/com/jnorton/PDFfilesCranial/SRAMArticle2005.pdf (accessed 4.11.2011)
Hartman, S. (2006) Cranial osteopathy: its fate seems clear. Chiropr Osteopat. 2006; 14: 10. [online] Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1564028/?tool=pubmed#B7 (accessed 4 December 2011)
Hartman, S. (2009) Why do ineffective treatments seem helpful? A brief review. Chiropractic & Osteopathy 2009, 17:10 doi:10.1186/1746-1340-17-10 [online] Available at: http://chiromt.com/content/pdf/1746-1340-17-10.pdf (accessed 4 December 2011)
Hayden, C. et al (2006) A preliminary assessment of the impact of cranial osteopathy for the relief of infantile colic. Churchdown Osteopaths, Complement Ther Clin Pract. May;12(2):83-90 [online] Available at: http://www.ncbi.nlm.nih.gov/pubmed/16648084 (accessed 5 December 2011)
Jasinoski, S, et al (2010) ‘Mechanics of cranial sutures using the finite element method’,Journal Of Biomechanics, 43, 16, pp. 3104-3111, Academic Search Premier, EBSCOhost, viewed 1 December 2011.
King, H. (undated) Research in support of the cranial concept. The Cranial Academy. [online] Available at: http://www.cranialacademy.org/pdf/PRMresearch.pdf (accessed 29.11. 2011)
King, H. (2011) Osteopathy in the Cranial field. In: Foundations of Osteopathic Medicine. 3rd Edition. p729
Kong, L. (2008) Basic Science Review on Circadian Rhythm Biology and Circadian. Ann Acad Med Singapore 2008;37:662-8
Kotzampaltiris, P. et al. (2009) The cranial rhythmic impulse and excessive crying of infancy. Journal of Alternative and Complementary Medicine. 2009 Apr;15(4):341-5. http://www.ncbi.nlm.nih.gov/pubmed/19368513
Maier, S. et al (1994) Brain and cerebrospinal fluid motion: real-time quantification
with M-mode MR imaging. Radiology. 1994;193:477-483.
Mikulis, D. et al. (1994) Oscillatory motion of the normal cervical spinal cord. Radiology. 1994;192:117-121.
Moran, R. et al (2003) Intraexaminer and interexaminer reliability for palpation of the cranial rhythmic impulse at the head and sacrum. Journal of Manipulative and Physiological
NICE guidelines ‘Do not do’ recommendation details
[online] Available at: http://www.nice.org.uk/usingguidance/donotdorecommendations/detail.jsp?action=details&dndid=187 (accessed 27 November 2011)
Nelson, K. et al (2011) Rhythms/Oscillations. In: Foundations of Osteopathic Medicine. 3rd Ed. Physiological Wolters Kuluwer Lippincott Williams & Wilkins. pg 162-190
Oleski, S. (2002) Radiographic evidence of cranial bone mobility. J Craniomandib Pract. 2002;20(1):34-38.
Poncelet, B. et al. Brain parenchyma motion: measurement with cine echo-planar MR imaging. Radiology. 1992;185:645-651.
Therapeutics. Volume 24, Issue 3, March-April 2001, Pages 183-190. [online] Available at: http://www.ncbi.nlm.nih.gov/pubmed/11313614 (accessed 2 December 2011)
Rogers, J. et al (1997) The controversy of cranial bone motion. Journal Orthop Sports Phys Ther. Aug;26(2):95-103. [online] Available at: http://www.ncbi.nlm.nih.gov/pubmed/9243408 (accessed 3 December 2011)
Sabini, R. (2006). Significant differences in patency among cranial sutures. J Am Osteopath Assoc. 2006;106:600-604.
Sommerfeld, P. (2003) Inter- and intraexaminer reliability in palpation of the “primary respiratory mechanism” within the “cranial concept”. Department of Medical Computer Sciences at the University of Vienna, Austria. [online] Available at: http://www.ncbi.nlm.nih.gov/pubmed/14723858 (accessed 29 December 2011)
Vern, B. et al. (1998) Slow oscillations of cytochrome oxidase redox state and
blood volume in unanesthetized cat and rabbit cortex: interhemisheric synchrony. Adv Exp Med Bio. 1998;454:561-570. 12. Dani JW, Chernjavs
Wirth-Pattullo, V. et al (1994) Interrater reliability of craniosacral rate measurements and their relationship with subjects’ and examiners’ heart and respiratory rate measurements. Physical Therapy Ltd, Chicago, IL 60611. Oct;74(10):908-16; discussion 917-20. [online] Available at: http://www.ncbi.nlm.nih.gov/pubmed?term=Wirth-Pattullo (accessed 29 December 2011)
Wyatt K et al (2011) Cranial osteopathy for children with cerebral palsy: a randomised controlled trial. Peninsula College of Medicine and Dentistry, University of Exeter, Exeter, UK. PUBMED [online] Available at: http://www.ncbi.nlm.nih.gov/pubmed/21349889 (accessed 29 December 2011)
Zanakis, M, et al. (1996) Objective measurement of the CRI with manipulation
and palpation of the sacrum [abstract]. J Am Osteopath Assoc 1996;96(9):5 [online] Available at: http://www.ncbi.nlm.nih.gov/pubmed/21349889 (accessed 24 November 2011)