Cranial manipulative (craniosacral) therapy is oneof the fastest growing areas of manual medicine interms of the numbers of practitioners and therapistslearning and applying different versions of itsmethodology. An institute which teaches one ofthe main divisions of cranial manipulation, JohnUpledger’s craniosacral therapy (Upledger 1996,Upledger & Vredevoogd 1983), claims to haveinstructed, between 1985 and 1995, some 25 000individuals (mainly licensed massage therapists)in the USA alone. In the experience of the author,many of those who have acquired such trainingappear to utilize the methods as part of whatever else they do clinically, while only a small pro-portion devote their entire practice to craniosacralwork.

With its modern roots in cranial osteopathy, asdeveloped by Sutherland (Sutherland 1939) in theearly years of the 20th century, and with paralleland sometimes derivative approaches includingcraniopathy (Cottam 1956) and sacro-occipitaltechnique (SOT) (DeJarnette 1975/1978), cranialmanipulation has become an area of debate,hypothesis and a significant degree of confusionregarding the theories which underpin the methods.

In this second edition chapters have beenprepared by experts from different disciplines that specifically examine the perspectives of sacro-occipital technique (SOT), as well as differentaspects of the osteopathic and dental variations of cranial manipulation (see Chs 3, 4, 5 and 11).

1

Chapter 1

A brief historical perspective

CHAPTER CONTENTS

Historical perspective 2

Summary 11

References 12

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Many practitioners and therapists, oftenattracted by the dramatic and frequent successesclaimed for these methods, remain unconvincedas to the ‘science’ of cranial manipulation andconfused by the real and apparent discrepanciesin the theories and explanations which surroundit. It is hoped that these additions, together withthe revisions throughout the original first editiontext, will help to clarify and, where necessary,demystify the mechanisms involved.

This text will examine both proven andhypothetical aspects of cranial manipulation andwill endeavor to guide the reader through thetangle of what is known, what is ‘believed’ andwhat is safe in the treatment of dysfunctionaffecting the soft and hard tissues of the cranium– and the myriad functions and systems that theseappear to influence.

The format of the book, following a briefhistorical overview, will continue with an examin-ation of the main theoretical concepts whichunderpin cranial manipulation and the researchwhich supports (or fails to support) these theories.It is following this introduction that the newchapters have been placed, after which subsequentchapters offer: descriptions of what cranial motionsoccur at the various sutural articulations; a dis-cussion of the possible clinical repercussions ofcranial restrictions; an expanded illustratedsegment offering guidance on assessment andpalpation techniques as well as interpretation offindings resulting from these methods. Finally,safe therapeutic measures for the treatment ofidentifiable patterns of dysfunction involving thecraniosacral mechanisms will be presented.

Note

No text can possibly replace taught and practicedmanual techniques of assessment and treatment:the intention of this book is to provide infor-mation and supportive material which should beutilized in conjunction with reputable training inthe methods described.

Not just one mechanism

• In discussing cranial mechanisms a number ofoverlapping processes need to be considered.We will find at times that we are speaking

orthopedically – for example, about mechanicalbony restrictions or ligamentous or fascialstructural and functional anomalies.

• At other times discussion of abnormalities willinvolve more subtle factors, dysfunctionalsituations where interference with normalpulsatile activities or soft tissue propertiesseems to have occurred and which have noeasy, ‘gross’, structural or orthopedic corollary.

• In other discussions it will be necessary toexplore the possibility that bio-electromagneticenergy factors permeate all mechanical,functional and dysfunctional processes andthat in some instances there seems to be no wayof making sense of craniosacral treatmentwithout hypothesizing energetic involvement.

• The skeptical perspective, which argues thatcranial motion is a mirage and that the mainbenefit of cranial therapy results from theplacebo effect, will also be discussed.

• Gross mechanical, subtle pulsatile or energyimbalances – which of these (if any) are wefeeling and which are we using? The answers tothese questions should become clearer as weexplore the theories and practices whichsurround cranial manipulation.

HISTORICAL PERSPECTIVE

Greenman & McPartland (1995) succinctlysummarize the origins of modern cranial mani-pulative study.

Cranio-sacral manipulation was first introducedinto the osteopathic profession in the 1930s.Instruction in the field began in the 1940s. Thepioneering work of William Garner Sutherland(described in Upledger & Vredevoogd 1983)included years of research into the anatomy of theskull, clinical observation of skull mobility innormal asymptomatic patients, and abnormalcranial mobility in patients with a variety ofsymptoms. Sutherland evaluated the response ofapplication of restrictive and compressive forcesto the skull [commonly his own]. He postulatedthe primary respiratory mechanism, consisting of

A BRIEF HISTORICAL PERSPECTIVE2

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five elements, as the essential components of theclinically palpable cranial rhythmic impulse (CRI).

The five key elements which Sutherland proposedwere:

• inherent motility of the brain and spinal cord• fluctuating cerebrospinal fluid• motility of intracranial and spinal membranes

(meninges, dura, etc.)• mobility of the bones of the skull• involuntary sacral motion between the ilia.

The validity of these concepts, which are funda-mental to much of modern cranial manipulationas currently taught, need to be examined, evalu-ated and understood before palpation, assessmentand treatment methods of this region can beusefully discussed and outlined.

The examination of these concepts whichfollows in the next and later chapters will addressthe following questions.

1. Is there palpable mobility at the cranial suturesand articulations and if so, what is the signifi-cance of such mobility in health terms?

2. What are the reciprocal tension membranesand is there a linking mechanism betweencranial and sacral motion?

3. Does a cranial rhythmic impulse (CRI) exist and if so, what is it and, especially, what is its relationship with cerebrospinal fluidfluctuations and flow?

4. What are the forces moving cranial structuresand so producing the CRI? Most importantly,are these forces primary or is movement theresult of a combination of normal physiologicalfunctions such as respiration and cardio-vascular rhythms?

In discussing these elements individually there isbound to be some overlap in the areas covered.For example, the concept of cranial sutures beingmobile is meaningless without evidence of ‘some-thing’ which can and does move them; also theview of there being a ‘cranial rhythmic impulse’demands that the possible mechanism(s) drivingsuch an impulse be investigated as well as theconsensus, if any, as to what that rhythmic rateshould normally be.

These cranial fundamentals need to be examined,both together and as independent phenomena,and as a result the research studies cited anddiscussed are likely to overlap.

Tables are provided to summarize aspects ofthe research and the reviews in order to give asense of the variety of sources of research evidence(largely osteopathic but with some neurological,dental, biomechanical and anatomical research aswell) along with a view of the chronology of thesestudies.

Is it really necessary to explore the theories thatunderpin much cranial therapy? Methods thathave been widely used for over 60 years, based onbeliefs many of which, as yet, lack verification,clearly require an attempt at clarification in thelight of current research and knowledge.

There already exist variations of cranial mani-pulation that detach from the traditional beliefsderiving from Sutherland’s work. There is, forexample, the use of cranial manipulation, mainlyby physiotherapists, working with craniofacialdysfunction. The authors of a key book describingthe methods used state that while studying theliterature, ‘We quickly found that there was nostandardization of manual cranial techniques, notto mention fundamental clinical proof. … One ofour basic objectives was to initiate the stan-dardization of cranial manual techniques withinmanual therapy for various patient groups’ (vonPiekartz & Bryden 2001).

Aspects of this work will be referred toperiodically throughout this text.

Note

It is necessary at the outset to say that, unlessclearly stated to the contrary, all the discussionsrelating to cranial motion refer to adult humans.In some instances infant and animal studies willbe referred to and this will be clearly stated.

Cranial structures and their mobility

There is little if any debate relating to thepliability, indeed the plasticity, of infant skulls anddysfunctional states affecting infants in generaland neonates in particular will be discussed in aseparate section of the book (see Appendix 2).

Historical perspective 3

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However, in order for cranial manipulation, ascurrently taught and practiced, to be takenseriously it is necessary to establish whether ornot there is evidence of verifiable motion betweenthe cranial bones during and throughout adult life.

Sutherland (described in Upledger & Vredevoogd1983) observed mobile articulation between thecranial bones almost 100 years ago and researchedthe concept for the rest of his life. He alsodescribed the influence of the intracranial ligamentsand fascia on cranial motion, which he suggestedacted (at least in part, for they certainly have otherfunctions) to balance motion within the skull.

He further suggested that there existed what hetermed a ‘primary respiratory mechanism’ whichwas the motive force for cranial motion. Thismechanism, he believed, was the result of theinfluence of a rhythmic action of the brain whichled to repetitive dilatation and contraction ofcerebral ventricles and which was thereby instru-mental in the pumping of cerebrospinal fluid.

The reciprocal tension membranes (mainly thetentorium cerebelli and the falx cerebri) which arethemselves extensions of the meninges, along withother contiguous and continuous dural structures,received detailed attention from Sutherland.

Sutherland described these soft tissues astaking part in a movement sequence which,because of their direct link (via the dura and thecord) between the occiput and the sacrum,produced a total craniosacral movement sequencein which, as cranial motion took place, force wastransmitted via the dura to the sacrum, producingan involuntary motion in it.

These functions and the mechanisms that areclaimed to drive them, as well as the argumentsagainst their validity, will be discussed in depth in the following chapters and key aspects aresummarized in appropriate tables.

The reciprocal tension membranes

If we examine the structure of the cranium weneed to look beyond the obvious osseous structuresand their articulations and come to an under-standing of the soft tissues which relate intimatelywith it, most notably the dural/meningeal foldswhich are seen in cranial theory and practice toplay a vital role (see Box 1.1 for a summary of the

role and attachments of the dural folds which areknown as the reciprocal tension membranes, andsee Fig. 1.1).

Philip Greenman, Professor of Biomechanics atthe College of Osteopathic Medicine, MichiganState University, describes the static and motionpotentials of these membranous intracranial duralduplications, as follows (Greenman 1989).

[They are] continuously under dynamic tension,so that change in one requires adaptive change inanother. In flexion movement [of the cranialmechanism] the tent descends and flattens andthe falx cerebri shortens from before backwards.In extension movement just the reverse occurs.

He goes on to explain that the motion of thecraniosacral system results from a combination ofarticular mobility and alterations in the tensionsof the reciprocal membranes and then makes clearwhat is becoming an increasingly controversialviewpoint when he says:

It is through this membranous attachment thatthe synchronous movement of the cranium andthe sacrum occurs. … The tentorium cerebelli canbe viewed as the diaphragm of the craniosacralmechanism. It descends and flattens during inha-lation as does the thoracoabdominal diaphragm.The pelvic diaphragm is also observed to descendduring inhalation. … One can then view the bodyfrom the perspective of three diaphragms … inhealth these diaphragms should function in asynchronous manner. If dysfunction interfereswith the capacity of any of the three, it is reason-able to assume that the other two will be alteredas well. That is what is observed in clinical practice.

Greenman points out that – via the continuation ofthe intracranial dural folds with the intraspinalmembranes, attached as they are at the foramenmagnum, the upper two or three cervical vertebraeand the sacrum itself – there exists a direct linkbetween cranial and sacral motion (that is, what isknown as the ‘core-link’). The hypothesis thatmovement in the skull produces a traction via thedura which moves the sacrum rhythmically (seeFig. 1.2) is a current belief amongst many schoolsteaching craniosacral therapy. The validity of thisview is seriously questioned and discussed in thenext chapter (Ch. 2).

A BRIEF HISTORICAL PERSPECTIVE4

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Historical perspective 5

The external layer of the dura is continuous with theperiosteum of the skull. Its internal layer forms threeduplications which surround the venous sinuses andcreate dividing barriers for segments of the brain.

Falx cerebri The anterior attachment is to that partof the ethmoid process known as the crista galli, thefrontal bone, both parietals and the squama of theocciput, dividing the skull in two. It encloses the superiorsagittal sinus.

Craniosacral hypothesis suggests that during cranialflexion (‘inhalation’ phase) the falx shortens from front toback and during the extension phase (‘exhalation’) of thecranial cycle, it lengthens from front to back (see Fig. 1.2).

Tentorium cerebelli The ‘tent’ separates thecerebellum from the cerebrum. Its attachments are to the occipital, parietal and temporal bones and to the anterior and posterior clinoid processes of thesphenoid.

The straight sinus is enclosed where the tentoriumcerebelli meets the falx cerebri at the true ‘reciprocaltension membrane’.

During cranial flexion (‘inhalation’) the tent is said todescend and flatten, returning to its neutral positionduring the cranial extension phase (‘exhalation’).

Falx cerebelli This duplication of the dura dividesthe two hemispheres of the cerebellum.

Box 1.1 Reciprocal tension membranes – attachments and functions (see Fig. 1.1)

Falx cerebri

Tentorium cerebelli

Tentorial gap

Straight sinus

Sphenoid

Figure 1.1 The reciprocal tension membranes of the cranium and proposed lines of force acting on them during theflexion phase of craniosacral motion.

Box continues

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There exists a model for explaining Greenman’sstatement that ‘change in one requires adaptivechange in another’ when discussing the fascialreciprocal tension membranes inside the skull andtheir linkages to the diaphragms of the body. He

offers the term ‘dynamic tension’. An engineeringdefinition would suggest that these tissues are allpart of a tensegrity structure. See Box 1.2 andFigures 1.3 and 1.4 for a brief explanation oftensegrity.

A BRIEF HISTORICAL PERSPECTIVE6

Diaphragma sellae This covers the sella turcica(‘Turkish saddle’) of the sphenoid, which houses thepituitary gland.

Note1. Tension or restriction in any of these dural

duplications influences all the others since they arecontinuous.

2. They directly influence, and are directly influencedby, all of their osseous attachments.

3. Distortions/restrictions of these soft tissues directlyinfluence venous circulation/drainage.

4. The potential for interference with pituitary functionexists via the influence of the diaphragma sellae.

5. There are constant modifications in the respectivetensions of these membranes with cranial movement(and, for example, in relation to breathing, where thetentorium cerebelli acts in synchrony with thethoracic diaphragm).

Box 1.1 Reciprocal tension membranes – attachments and functions (see Fig. 1.1)—continued

Hypothesized

occipital axis

of rotation

Foramen magnum

Occiput

Spinal dural tube

Sacral axis of

rotation

Sacrum

Falx moves posteriorly

... and inferiorly

Tentorium drawn laterally

Anterior aspect of spinal

dura moves superiorly

... from attachment of

spinal dura to anterior

face of sacral canal at

level of second sacral

segment

... leading to spinal flexion

A

B

C

E

F

D

Flexion phase of craniosacral motion

A

B

C

D

E

F

Figure 1.2 The hypothesized directions of movementduring the flexion phase of craniosacral motion.

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Cranial rhythmic impulse (CRI)

It is a basic precept of all cranial teaching thatthere exists a palpable cranial rhythm, the cranialrhythmic impulse (CRI). This pulsation, whileapparently related to other bodily rhythms(thoracic respiration, cardiac pulsations, etc.) is, incranial theory, seen to be separate and inde-pendent of these.

The CRI (variously known as the ‘primaryrespiratory impulse’ (Brookes 1981, Upledger &Vredevoogd 1983), ‘cranial rhythmic impulse’(Woods & Woods 1961) or ‘Sutherland wave’(Magoun 1976)) is widely assessed and employedas a means of cranial evaluation – since the speed

and rhythmicity, as well as the quality and/oramplitude, of this rhythmic function represent, itis widely believed, a direct means of assessing thestatus of the cranial mechanism.

Any increase or decrease in speed or amplitude,any indication of imbalance or an arrhythmicpattern implies the presence of a problem, often ofa structural nature involving cranial and/or sacralrestrictions, which can be addressed and possiblycorrected by appropriate cranial technique.

There are numerous theories as to just what therhythmic impulse is, many of which are discussedin the next chapter (Ch. 2). As well as a lack of anagreed explanation as to just what these impulses

Historical perspective 7

Tensegrity is a word that derives from the work ofarchitect Buckminster Fuller and his study of geodesicarchitecture. Fuller attempted to understand why ageodesic dome can carry a large load with a minimalamount of building materials. Fuller concluded that it isnot what the structure is made of but rather how itselements distribute and balance mechanical stresses inthree dimensions that determined stability. Fuller realizedthat the dome gains its omnidirectional stability fromcontinuous tension that is resisted locally by a subset of

its structural elements. Detailed research into thestructure of cells shows that they use tensegrity toorganize and mechanically stabilize their cytoskeletonnetwork (Ingber 1993).

Much of the human body utilizes tensegrity totransfer and absorb the mechanical forces it generatesand which are applied to it. The skull and its internalarchitecture can easily be seen to utilize tensegrityprinciples (see Figs 1.3 and 1.4).

Box 1.2 Tensegrity

TorC

Figure 1.3 A simple model of a tensegrity structure inwhich internal tensions (T) and externally appliedcompression (C) forces are absorbed by the componentsolid and elastic structures by adaptation of form.(Reproduced with permission from Chen C, Ingber D 1999Tensegrity and mechanoregulation: from skeleton tocytoskeleton. Osteoarthritis and Cartilage 7: 81–94.)

Figure 1.4 A tensegrity cell model under differentmechanical loads. This model consisted of a geodesicspherical array of wood dowels and thin elastic threads. Themodel was suspended from above and loaded, from left toright, with 0, 20, 50, 100 or 200 grams weights on a singlestrut at its lower end, demonstrating that a local stressresults in global structural rearrangements throughout theentire structure (Chen & Ingber 1999). Much of the humanbody utilizes tensegrity to transfer and absorb the mechanicalforces it generates and which are applied to it. The skulland its internal architecture can easily be seen to utilizetensegrity principles. (Reprinted with permission fromWang N, Butler JP, Ingber DE 1993 Mechanotransductionacross the cell surface and through the cytoskeleton.Science 260: 1124–1127. Copyright 1993 AAAS.)

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represent, there is also a variation in the stated rateof pulsation which is said to represent normality.

The most basic question relating to the CRI isquite simply, ‘Is it a primary pulsation or does itrepresent a sensation deriving from a combinationof recognizable physiological pulsations, such asheart rate, cardiac contractility, pulmonary bloodflow, cerebral blood flow and movement of lymphand CSF?’.

What drives the cranial rhythm?

Sutherland (1939) had definite ideas as to whatmoves the cranial bones: the cerebrospinal fluidand a pulsating brain.

In 1971 Viola Frymann, herself a respectedpioneer of cranial therapy in the osteopathic arena,offered a personal opinion based on over a quarterof a century of experience in this work.

The perpetual outpouring of impulses from thebrain to maintain postural equilibrium, chemicalhomeostasis, and so on, conceivably may multiplythe activity of individual cells into a rhythmicpattern of the whole brain, small enough to beinvisible to the naked eye, but large enough tomove the cerebrospinal fluid which in turn movesthe delicate articulated cranial mechanism.(Frymann 1971)

Was she right?While recent research partially supports her

view, most studies contradict it. These perspectiveswill be outlined and discussed in Chapter 2.

A host of theories have emerged to explainwhat seems to be an established fact, that theredoes exist a rhythmic impulse, which can bepalpated at the head or almost anywhere on thebody surface, which is apparently independent ofthe major physiological body rhythms (cardio-vascular, respiratory, etc.). These theories will beevaluated in the next chapter (Ch. 2) as will thepotential value of palpation as evidence of anindividual’s cranial rhythm.

What are the clinical implications of cranialdysfunction?

Let us assume, hypothetically speaking, that it ispossible to establish that mobility exists between

cranial bones in normal situations, as well as therebeing a direct connection between such motionand sacral motion and, further, that this motionhas a rhythmicity which is palpable.

What would be the clinical significance ofdysfunction in this mechanism – as evidencedperhaps by articular restrictions between specificcranial joints or alterations in the palpatedrhythmic impulse or imbalances in the ‘normal’cranial–sacral motions? What health repercussionsmight occur, according to cranial theory?

McPartland gives some indications:

Many of the cranial nerves exit the skull frombetween the sutures; if restricted they may causemany kinds of visceral mischief, such as dyspepsia.Misaligned temporal bones can give rise totemporomandibular joint (TMJ) dysfunction,headache, trigeminal neuralgia, dizziness andpredispose children to otitis. (McPartland 1996)

Upledger & Vredevoogd (Upledger 1996) offer along list of possibilities, suggesting that thefollowing conditions can often have craniosacraldysfunction involvement or that craniosacraltreatment can substantially assist in treating them.

• Acute systemic infectious conditions (citing theantifebrile effect of what is known as CV-4(compression of the fourth ventricle) technique– see Ch. 6).

• Localized infection (possibly treated using V-spread technique – a method employed toachieve gentle separation of sutural restrictions– see Ch. 6).

• Acute sprains and strains using a variety oftechniques.

• Chronic pain problems (using techniques suchas CV-4 as well as balancing tissue tension anddural membrane balancing).

• Visceral dysfunction (peptic ulcers, ulcerativebowels, tachycardia, asthma, etc. treated bymeans of normalizing restriction patterns in thecraniosacral system).

• Autonomic nervous system problems such asRaynaud’s syndrome (treated by using CV-4daily).

• Rheumatoid arthritis (CV-4, often applied by afamily member, daily).

• Emotional disorders – especially anxiety (usingspecialized techniques).

A BRIEF HISTORICAL PERSPECTIVE8

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• Scoliosis, which is often seen to be a directresult of craniosacral distortions.

• Visual disturbances – especially strabismuswhich is said to be ‘very amenable to the releaseof abnormal tension patterns in the tentoriumcerebelli’.

• Auditory symptoms such as tinnitus andrecurrent middle ear problems (via mobilizationof the temporal bone).

• Cerebral ischemic episodes, which can be ‘veryfavourably affected by weekly application ofthe parietal lift technique (see Ch. 6) afterthoracic inlet and cranial base restrictions have

been released. We have seen marked improve-ment in syncopal episodes, episodic paresthesias,memory loss and the like, after only three orfour weekly treatments’.

While a great deal of the reporting of success ofcraniosacral therapy remains anecdotal, the sheervolume of these reports and the clinically provenvalue in treating children’s problems utilizingcraniosacral therapy (see discussion of researchstudies in later chapters) make this a compellingdegree of evidence.

Historical perspective 9

In the preface to his excellent book The heart of listening(subtitled A visionary approach to craniosacral work), British-trained osteopath Hugh Milne discusses some ofthe variations currently available on the theme of cranialmanipulation (Milne 1995).

What is now popularly known as ‘craniosacral work’,like any art, can be practiced many different ways.Some osteopaths practice ‘cranial osteopathy’ as atechnical skill that focuses on treating symptoms inten- to twenty-minute sessions. Many chiropractorspractice ‘craniology’ with great mechanical andtactile aptitude in similarly brief visits. Bothchiropractors and osteopaths tend to base theirwork upon the mechanical models of bone movementthey were educated in. Gifted bodyworkers usecraniosacral work as an adjunct to their hour-longsessions. They tend to interpret what they do interms of balance, gravity, muscle tonus and fasciallength. Massage therapists may employ a fewcraniosacral techniques at the end of each session.Exceptionally gifted with tactile sensitivity, theytend to let their hands tell them what to do. Christianhealers touch the head while ‘laying on hands’; theytreat by praying. Psychics use craniosacral work as away to access deep realms of the spirit during‘psychic healing’. Working through visionaryperception, they see what is wrong with the head.In ‘past life regression’, therapists use craniosacraltouch to help induct people into sensitive realms of experience. They work in altered states ofconsciousness, using their extraordinary sensitivityto the body’s electrical field, or chi. My sessions

encompass aspects of each approach mentionedabove, appropriately used, each has its value and itscontribution to healing.

In an attempt to offer some clarity a few further attemptsare made in this section to explain some of the differentways in which cranial therapy is used, and the outcomesanticipated.

1. Cranial osteopathy Based on the originalresearch of William Garner Sutherland, this modeloriginally held to the more mechanistic hypothesis of themotive force(s) driving cranial motion, includingcerebrospinal fluid fluctuation and a ‘primary’ respiratorymechanism. The osteopathic therapeutic approach callsfor osseous as well as reciprocal tension membrane andfluid factors being considered in treatment of identifieddysfunction (Sutherland 1939).

Out of this particular tradition new concepts areappearing, notably as a result of the work of osteopathssuch as John McPartland (McPartland & Mein 1997), whosuggests that the therapeutic effects of much of cranialwork relate directly to a process of entrainment in whichthe healthier influences of the therapist begin to encouragea normalization in the dysfunctional patterns of the patient.This is described in some detail in Chapter 2. Osteopathicthinking in regard to cranial therapy is explored ingreater detail in Chapters 3 and 4. Additional elementsrelative to the cranial osteopathic approach includerecognition of tensegrity features as described in Box 1.2.

2. Craniosacral therapy This is an evolution, by itsdeveloper John Upledger, of cranial osteopathy (Upledger1995). Upledger says:

Box 1.3 Models which attempt to explain cranial therapeutics

Box continues

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A BRIEF HISTORICAL PERSPECTIVE10

The CranioSacral system is a core system in thehuman body. In my view it is the place where body,mind, and spirit reside independently and communallyat the same time. … It is quite fascinating to considerthat all the very deep work is done within the confinesof an anatomically defined physiological system. Itsuggests that the CranioSacral system and thetechniques involved … offer a bridge betweenobjective science and spiritual healing. CranioSacralTherapy accesses the total human being’s self-corrective and self-healing processes. Furtherthe therapeutic approach attempts to maximisepatient/client responsibility for their overall well-being.

As a summary these words should suffice to indicate thedirection craniosacral therapy has taken, away from themechanistic and towards ill-defined areas of thetherapeutic relationship, which attracts many but isanathema to others. Upledger’s training programs are farand away the most popular (worldwide) means oftherapists acquiring basic (and safe if they follow the‘grams only’ rules) cranial skills. A key feature of thework of Upledger (and McPartland and many others) isthe demand that the practitioner/therapist be centered,relaxed and in a virtually meditative state for therapy tobe successful.

3. The somatic model (somatic cranial work)An approach to cranial work has evolved which calls fortherapists to harmonize their biological systems (heartrate, breathing, cranial rhythms, etc.) with those of theirpatients to help in normalization of dysfunction (Norton1991). Norton’s concepts are discussed further in Chapter 4.

Shea (1997) proposes an evolution of this which heexplains as follows.

The somatic model blends eastern and westerntraditions of introspection, interiority, mindfulness,archetypal psychology and cross cultural healing.Somatics involves contact, sensing, excitement, gestaltformation as essential variables in the palpatorysensitivity to not only CRI but also its potency andbreath of life as proposed by Sutherland. To contacta fluid system that contains the primary intelligenceof life requires authentic presence and the capacityto be still within one’s self. These are essentialdisciplines if entrainment is going to happen. Insomatics entrainment or perceptual transference iscalled matching. Matching has three parts 1/awareness of shape, sensations, feeling or a movementin one’s own body; 2/ an inner act of matching or

aligning oneself with this; and 3/ allowingsomething to change. … Then the therapist canmatch up with the client and feel into the client asan entrainment. (Shea 1997)

Somatic cranial work seems to utilize aspects ofSutherland’s original concepts and to focus on fluiddynamics in particular, as well as the cranial bones andmembranes as they relate to what is termed ‘the breathof life’, with particular emphasis on using these foci asmeans of dealing with the effects of shock and traumaon the nervous system.

4. Sacro-occipital technique (SOT) and appliedkinesiology (AK) SOT evolved out of the work ofchiropractor Major Bertrand DeJarnette (DeJarnette1975/1978), who based his methodology on Sutherland’soriginal osteopathic research as well as on many of hisown extremely complex ideas and methods. A furtherevolution through chiropractic was based on the work ofGeorge Goodheart, who modified both Sutherland’s andDeJarnette’s work (Walther 1988). Key points aremonitored on the cranium (for example) while (apparently)associated muscles are tested for strength or weaknessduring particular phases of the breathing cycle, withspecific guidelines as to the subsequent treatmentprotocol being based on the outcome of these tests. Acommon feature of both SOT and AK is the ‘asking’ ofcertain questions of the body (i.e. ‘Is this muscle testingweak or strong, under these particular conditions, whilethis specific point is being pressed/touched?’). Thissomewhat formulaic approach, which provides protocolsbased on the ‘answers’ the body gives to the questions, isextremely popular, particularly in the USA. A detailedevaluation of SOT is to be found in Chapter 5.

5. Eclectic dental and craniofacial approachesA range of applications of cranial manipulation havebeen developed, largely by physiotherapists, chiropractorsand dentists, to deal with dysfunction and pain involvingthe facial bones as well as dentally related abnormalitiesof the facial structures. Dental considerations andapproaches (many of which lean on cranial osteopathic,craniosacral and SOT methodologies) are discussed indetail in Chapter 11. Physiotherapy and orthopedictreatment of craniofacial and craniocervical problemshave avoided particular immersion in the controversialareas discussed earlier in this chapter and have adoptedan eclectic and pragmatic structural/functional approachto manual treatment of congenital and acquired(whiplash, etc.) dysfunctional patterns, involving the

Box 1.3 Models which attempt to explain cranial therapeutics—continued

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SUMMARY

As outlined at the start of this chapter, the fiveelements of the cranial hypothesis which Sutherlandproposed were:

1. an inherent motility of the brain and spinal cord2. fluctuating cerebrospinal fluid3. motility of intracranial and spinal membranes4. mobility of the bones of the skull5. involuntary sacral motion between the ilia.

How do these propositions stand up to examin-ation? The evidence which will be produced andargued in the next and subsequent chapters willindicate the following.

1. Inherent motility of the brain has been proven;however, the impact of this function on cranialbone mobility is possibly less than Sutherlandimagined. Its motion probably contributestowards the composite of forces/pulses whichit has been suggested produce the cranialrhythmic impulse (CRI).

2. The CSF fluctuates but its role remains unclearin terms of cranial motion. Whether it helpsdrive the observed motion of the brain orwhether its motion is a byproduct of cranial(and brain) motion remains uncertain. This

fluid pulsation seems likely to be at least onefactor in the CRI phenomenon.

3. The intracranial membranous structures (falxcerebri, tentorium cerebelli, etc.) are clearlyimportant since they attach strongly to theinternal skull and give shape to the venoussinuses. Dysfunction involving the cranialbones has to influence the status of these softtissue structures which strongly attach tothem, and vice versa. To what degree theyinfluence sacral motion is debatable. They willbe seen in later sections of this book to beuseful in assessment and treatment protocols.

4. The bones of the skull can undoubtedly moveat their sutures. Whether this capacity is simplya plasticity which allows accommodation tointra- and extracranial forces or whether theconstant rhythmical motion, the CRI, drives adistinct sequence of cranial motion is debatable.The clinical implications of restrictions of thecranial articulations seem to be proven, althoughdispute exists as to precise implications. The‘normal’ CRI rate and the significance of thisalso remain very much in dispute.

5. There seems to be involuntary motion of thesacrum between the ilium but the means

Summary 11

bones and soft tissues of the head and neck (Vernon2001, von Piekartz & Bryden 2002). Some of the methodsused are discussed in later chapters.

Poly-vagal concept Two different oscillations in thecardiovascular system coexist; one is associated withblood pressure variations while the other seems to relateto respiratory sinus arrhythmia (RSA - heart ratevariability in response to breathing cycles).

Sahar (2001) has proposed that RSA is controlled bysympathetic and vagal influences, and that it appear torepresent the state of regulation of the autonomic nervoussystem.

Porges (2001) argues that these blood flow oscillationsexpress the ‘ventral’ vagus complex. Unlike the ‘dorsalvagus’ (unmyelinated and phylogenetically earlier), themyelinated ventral vagus complex is a more recentmammalian development that can rapidly regulate

cardiac output. The autonomic nervous system can alsobe influenced by the slower Traube–Hering–Mayer waves(Sahar 2001). Cranial therapy appears to strongly modifythese influences. (Nelson et al, 2001). See Ch. 4 for moreon this.

Conclusion There exists a purely mechanistic cranialmodel (incorporating, knowingly or unknowingly, theprinciples of tensegrity) , as well as various modificationswhich focus on the ‘fluid/electric’ aspects of the bodywhich range from the partly mechanistic to the almosttotally ‘energetic’ and spiritual. The focus of this book isto attempt to make sense of the theories underpinningthese approaches as well as to encourage greaterincorporation, into whichever model is being used, ofsome additional respect for the soft and hard tissuecomponents and functions that – in health – make upthe flexible cranium.

Box 1.3 Models which attempt to explain cranial therapeutics—continued

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whereby this occurs remains unclear (or atleast unproven), as does the significance of thismotion in terms of cranial mechanics. It isdebatable as to whether there is indeedsynchronicity between cranial and sacralmotion (Moran & Gibbons 2001).

In the next chapter (Ch. 2) the most importantissues surrounding cranial theory and practicewill be reviewed in the light of research to date.

Questions will be asked which will cover themajor conundrums surrounding cranial therapybeliefs – is there cranial motion between the bonesand if so, what moves the bones?

What, if anything, is the ‘CRI’ and is there a‘normal’ range of these pulsations?

Does cranial motion induce sacral motion andvice versa, and if so, what part do reciprocaltension membranes play?

The questions will be raised and, as far ascurrent research allows, answered. While thisinvestigation will reveal some firm answers, adegree of confusion will undoubtedly remain,since some of the research evidence is equivocal,with documentation emerging which bothsupports and contradicts some of the areas ofdebate.

A BRIEF HISTORICAL PERSPECTIVE12

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