Craniosacral Therapy: A Case Study In Nonsense

Craniosacral therapy is a form of light touch manual therapy that was designed by Dr. John E. Upledger in the 70s and 80s.  According to the Upledger Institute:

“CST is a gentle, hands-on method of evaluating and enhancing the functioning of a physiological body system called the craniosacral system – comprised of the membranes and cerebrospinal fluid that surround and protect the brain and spinal cord.  Using a soft touch generally no greater than 5 grams, or about the weight of a nickel, practitioners release restrictions in the craniosacral system to improve the functioning of the central nervous system. By complementing the body’s natural healing processes, CST is increasingly used as a preventive health measure for its ability to bolster resistance to disease, and is effective for a wide range of medical problems associated with pain and dysfunction, including..”

The quote goes on to list a variety of conditions that are typically difficult for the average musculoskeletal practitioner to manage, as well as conditions that are emotionally challenging for patients, including traumatic brain injuries, dementia, fibromyalgia, and even autism.  It is hard to assess exactly what’s being claimed here.  C. Green sums it up thusly; “craniosacral therapy is based on the theory that movement restrictions at the cranial sutures of the skull negatively affect rhythmic impulses conveyed through the cerebral spinal fluid from the cranium to the sacrum,” and these restrictions are in some way related to various health conditions (Green, 1999).  

And it is the job of the craniosacral practitioner to clear these restrictions and get a person feeling better.  Luckily, it is somewhat hard to gauge how much our profession has welcomed this.  The APTA has no position statement on it, we didn’t learn it in school, and there are not any mainstream therapists promoting it that I know of.  However, disturbingly, it has slowly gained some traction.  It is not hard to find a craniosacral therapist in my area.  “Craniosacral” is a clickable box in the “plan” section for a widely-used EMR that we use at work.  Before we take a look at how craniosacral therapy has risen to the popularity it has, let’s take a quick look at the research first.

The Lowest Hanging Fruit

Craniosacral therapy is somewhat of a low hanging fruit; the claims proposed are so outlandish on their face that it does not pass the biological plausibility test.  Obviously some people think it does, so, very quickly, what does the science say?

• Cranial bones can’t move with the level of force suggested, or much at all (Downey, 2006)
• Craniosacral rate, if that is even a real phenomenon, can’t be accurately palpated (Wirth-Pattullo, 1994) (Rogers, 1998) (Moran, 2001)
• Cranial bone alignment has nothing to do with health outcomes (Green, 1999)
• Leaving biological plausibility to the side, there is not a robust body of placebo-controlled trials showing clinical benefits (Jakel, 2012)

And here are a few excellent quotes:

“Evidence for the efficacy of CST is absent and the biological mechanisms of cranial manipulation resulting in changes to cerebrospinal fluid pressures appear invalid.” (Downey, 2006)

“Despite more than 50 years of investigation and the promotion of CST by some practitioners, there remains a void in credible evidence supporting the ability of these techniques to alter the movement of the cranial sutures or improve patient-centered outcomes.” (Flynn, 2006)

“The available research was not able to demonstrate, conclusively, a causal relationship between restrictions/misalignments in the movement of cranial bones and health.” (Green, 1999)

“Another possibility is that craniosacral motion may be an artifact of the examiners’ imagination rather than a measurable phenomenon.” (Rogers, 1998)

“Craniosacral motion may not exist and might be imagined by the evaluator.” (Wirth-Pattullo, 1994)

The theory behind craniosacral therapy is absolute nonsense.  There is no debate on this one.  We have no reason to believe ANY of the claims put forth.  However, some therapists do it, and patients like it, and that is worth investigating.

(Psuedo)Science and (Pseudo)Effectiveness

Craniosacral therapy has rightfully not gotten a wide audience.  Unfortunately though, it has captured more physical therapists and patients that I am comfortable with.  What makes demonstrable nonsense so appealing to patients and therapists?

• The world of health is scary and uncertain.  Medical professionals do not always have answers and explanations for what is happening (See Tolerating Uncertainty – The Next Medical Revolution? by Arabella Simpkin and Richard M. Schwartzstein). This sets up a situation where a patient with a complex medical problem does not have adequate answers.  

• Explanations are powerful, especially when they are novel, against the “medical orthodoxy,” or there are conspiracies against the proponents of it.  When patients have complex medical problems, an explanation that is new, appears credible, and can succinctly answer all questions from a patient will be appealing.

• It is easy to make something sound science-y.  The average person doesn’t know what cerebrospinal fluid is or if cranial bones can move, or what cranial bones are. Any healthcare practitioner can take real concepts in anatomy and physiology and distort them enough purposefully or arbitrarily to create something that is internally consistent, but not in touch with reality.  (See Bret Contreras’ excellent article How To Become A Functional Movement Guru In 40 Easy Steps.)  Pseudoscience is believable to anyone who doesn’t have experience with real science.

• Complementary and Alternative Medicine practitioners genuinely want to help people, and really do care about their patients. If your healthcare provider is loving and caring, that generally improves your experience with them.  Health outcomes are better when you spend time with the patient and build that therapeutic alliance. CAM practitioners are probably in a better position to this with patients because they have the time, and generally treat the patient as a whole.  While mainstream medicine is coming around to this perspective, we are probably not there yet.

• Most therapies have some effects and pain is subjective.  Getting a massage for an hour and half will feel good for most people, both physically and psychologically.  People like the feeling of acupuncture.  The effects are typically hyped up and exaggerated.  The practitioner just has to pull a bait and switch and subconsciously  or consciously persuade the patient that the non-specific effects they feel are in fact due to the the specific nature of the therapy.  

• They are quick to offer courses and certifications.  These therapies are presented as novel ways to help with difficult patients, which is appealing to any physical therapist that cares about the people they treat.  Offering theses courses plays on a therapist’s desire to differentiate themselves from their peers and further their education with something that is not mainstream.

• They are slow on the research.  In the small research section on The Upledger Institute you will find many studies, but none of the ones I sighted above.  Studies contrary to their viewpoint are not acknowledged.  They either give you low quality studies, studies with obvious biases, or they suggest that science itself is the problem.  

• Counterculture is sexy, and science can be boring.  Going against the mainstream can be attractive for both patients and therapists.  It can be alluring for some people to discover potential solutions for difficult problems, and sometimes that can override the appropriate amount of vetting that needs to be done before it is adopted.  Doing science and staying current on the latest research can be an arduous and time-consuming task.

Craniosacral therapy checks all of these boxes

• It is marketed towards patients with conditions that are difficult to deal with clinically and emotionally.  It is especially egregious when it is suggested that craniosacral therapy can help treat something like autism, where parents may be in a very vulnerable and desperate state.  Treatments for autism are not there yet scientifically, and it is morally repugnant and professionally irresponsible to suggest that a craniosacral therapist has anything helpful to contribute. 

• Craniosacral therapists also have a plausible sounding system for explaining things that is based on real anatomical and physiological concepts, but is distorted enough to have no contact with reality.  

• Craniosacral treatments are reported to feel pleasant and relaxing, which opens the door to non-specific effects.  Patient expectation, therapist bias, and placebos are all in play here.

• The homepage of the Upledger Institute makes it very clear that they have classes and certifications available, but the research page is buried.  It takes about 10 minutes to do a research review and find articles suggesting that the theory and claims behind it have no scientific basis.  

The physical therapy profession will have to defend against intrusions of this nature and it is important that we are all at the gates, looking onto the horizon.  We need to be honest with ourselves, and honest with our science.  Some things have absolutely no place in physical therapy, and craniosacral therapy is one of them.  Physical therapy is devalued as a whole when bad evidence is used to justify treatments that don’t make sense in the first place. Craniosacral therapy is not the first or last treatment to be proposed in the healthcare world that has questionable plausibility, underwhelming evidence, happy patients, and eager salesman. It does, however, provide a perfect example of how this type of treatment can catch on.  We need to be on our guard against these trends, and science is our best and only defense.  

References

1. Upledger Institute, https://www.upledger.com/
2. Geen, C., et.al. (1999) A systematic review of craniosacral therapy: biological plausibility, assessment reliability and clinical effectiveness.  Complementary Therapies in Medicine, Volume 7
3. Downey, P., et.al. (2006) Craniosacral Therapy: The Effects of Cranial Manipulation on Intracranial Pressure and Cranial Bone Movement. Journal Of Orthopaedic & Sports Physical Therapy, Volume 36, Number 11
4. 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, Volume 74, Number 10
5. Rogers, J., et.al. (1998) Simultaneous Palpation of the Craniosacral Rate at the Head and Feet: Intrarater and Interrater Reliability and Rate Comparison. Physical Therapy, Volume 78, Number 11
6. Moran, R., et.al. (2001) Intraexaminer and Interexaminer Reliability for Palpation of the Cranial Rhythmic Impulse at the Head and Sacrum.  Journal of Manipulative and Physiological Therapeutics, Volume 24, Number 3
7. Jakel, A., et.al. (2012) A systematic review to evaluate the clinical benefits of craniosacral therapy.  Complementary Therapies in Medicine, Volume 20
8. Flynn, T., et.al. (2006) Craniosacral Therapy and Professional Responsibility.  Journal of Orthopedic & Sports Physical Therapy, Volume 11
9. Contreras, B., (2015) How To Become A Functional Movement Guru In 40 Easy Steps
10. Simpkin, A., (2016) Tolerating Uncertainty – The Next Medical Revolution? The New England Journal of Medicine, Volume 375

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