Time and time again I read something about “cranial osteopathy”, which seems to describe something which is nothing like what I do. It is often assumed that we sit there “head-holding”. I saw a description this week that we claim to”magnetize the blood”. I’m not surprised that there is such confusion, even amongst osteopaths. I find it confusing and I’ve been doing it for twenty years. And let’s face it, there is a curious lack of consensus, openness and clarity about what we do. And that matters a bit right now because we are under intense scrutiny and, incredibly, our right to practise the safest and most gentle techniques is being undermined. Many of our critics seem to be basing what they say on what they have read online, or what craniosacral therapists have written. And they have looked at poor and ill-advised studies, none of which bear much relation to what most osteopaths out there are doing.
My usual “scared-of-repercussions-disclaimer” now follows: This is a totally personal view. I am no authority. I’m not qualified to write this piece in any way. I’m no spokesperson for the cranial world. I am no high ranking personage in that world, despite my best-but-inadequate efforts and intentions, but I have been an observer and participant of that world for a long time now. People more senior than me could tell you more accurately what they do, but you will have to ask them to do that. I might not be able to tell you exactly how cranial works, but I think I can tell you what it’s not, and correct some commonly held misconceptions and misinformation.
So let’s get on and bust some myths.
What is cranial NOT?
It is not a completely different treatment modality from “structural”
There is a continuum of osteopathic techniques, from the stronger, coarser and more direct, to the subtler, gentler, lighter and more indirect. They are all based on osteopathic principles, freeing restrictions, restoring comfortable anatomical relationships, taking pressure off co pressed areas and so on, and I would argue that they affect the body on different levels from gross to subtle, and mainly differ in their strength and direction of application. Different patients and situations need different kinds of treatment, and the best osteopaths can do all kinds. To be a good all rounder is the ideal, but good all rounders are as rare in osteopathy as in the English cricket team. Most osteopaths find their place somewhere along the spectrum. Some at the extremely mechanistic end often can’t feel or understand the subtler end, and might dismiss it as flaky, self-delusional or ineffectual; some at the other extreme might feel that the stronger ones are often too forceful and lack insight and sensitivity and understanding of the body. However most osteopaths are happy to live and let live. Hopefully patients end up selecting the practitioner, by trial and error, that works for them. There is not normal osteopathy (physical therapy) and weird osteopathy (faith healing). There is just osteopathy. The marketing of certain techniques as the unappealingly-named craniosacral therapy has caused some people to wrongly think that they form a distinct discipline ( a view apparently shared by the CAP and ASA) which might not be helpful.
It is not all about the head
Can we get this cleared up once and for all. Osteopaths don’t just do cranial from the head or to the head. They do sometimes, but you can do it anywhere on the body, just like all of osteopathy. Yes “cranial” osteopathy is very badly named and that label is not even used by many osteopaths due to the misleading impression it gives. (I am wincing every time I use the word, but it is there now, and is a convenient shorthand.) It follows the great tradition of wrong-naming in osteopathy– a discipline which is not about diseases of bones. Yes, like the Holy Roman Empire which was famously neither Holy, nor Roman, nor an Empire, cranial osteopathy is not about diseases of bones of heads. It is not primarily to treat headaches or cranial symptomatology! Some osteopaths have seemed surprised that I treat adults with low back pain with “cranial”. Of course I do! What else?
It is not synonymous with paediatric osteopathy
The other oddness that I come across is that when I say that I am interested in cranial, people think I mean treating children. Don’t get me wrong. I love children. I even have two of my own. Children are beacons of love. But I don’t always find children and babies that easy to treat. And I have lost count of the number of times I have been working in a clinic and been pigeonholed into specializing in treating children. Yes it’s best to use gentle techniques to treat children, where excessive force is inadvisable, but they’re also great to treat adults. There is not a divide – structural for adults, cranial for children – as some seem to think. One of the best places to develop skills is at the OCC, a children’s clinic, so possibly this is also why cranial has become associated only with paediatrics.
It is not the easy option
“Some girls do cranial because they’re not confident of manipulating.” – this was said to me by an osteopathy lecturer. “All you do is sit with hands on head.” No no no no no. I went into osteopathy because I had benefitted so much from osteopathy, including these techniques you might call cranial, that I realised I had found a career in which I could be on a neverending learning curve, and which had the depth to keep me interested, the potential to be on the cutting edge of healthcare, and the power to do immense good. I have a low boredom threshold, and would find most jobs pretty tedious. I would find clicking and rubbing all day pretty tedious. Between us, I find biomechanics dry and dull. I didn’t mind learning to manipulate and massage; they are handy skills, but they haven’t provided the ongoing fascination of developing cranial skills. It is absolutely not easy. And it takes years. I still use lots of massage techniques, partly because I like them, partly because they are also effective, but partly because they are much easier than cranial, and skill level in cranial has to be very high before you can rely on it completely.
Studies showing palpatory unreliability do not invalidate it as a technique
Palpatory unreliability is not confined to cranial. Even with findings like muscle hypertonicity or leg length difference (phenomena which nobody would dispute actually exist) I believe interreliability to be poor to the point that the worth of much of our gross physical examination is being questionned. With much more subtle phenomena, (and sorry for repeating myself,) trying to test for interexaminer reliability is like blindfolding two people in a field and asking them to agree on the direction of the breeze. They are both experiencing a real phenomenon, but it would not be easy to agree on the description for measuring purposes.
It’s not all about a basic cranial rhythm, or pulse
Many studies cite failure to agree on a cranial rhythm as a reason to dismiss cranial. I never feel the cranial rhythm which is so often quoted as the basic characteristic of this sort of treatment, and which I started off being taught at undergraduate level. I noticed straightaway that even the tutors who taught us would disagree about the rate, so it never seemed very reliable. I used to think I could feel it, but I reckon I might have been creating that feeling by trying to palpate for it. As soon as I graduated and got into a really excellent clinic, learning from highly experienced osteopaths, I realised that nobody ever referred to it. It’s a red herring. I can’t believe that studies looking at its detection were even performed, and these studies – examining something that most osteopaths I know don’t use – are still cited as evidence against these techniques. I can’t even remember how many pulses a minute there were meant to be.
It is not the same thing as faith healing
Hands up, I actually enrolled in a spiritual healing course (with the most reputable organisation I could find), wondering if I might find an easier way to do cranial. (As I have said before, it’s hard work and requires study, discipline and dedication. I wanted a short cut.) I discovered that they are not the same. I don’t want to knock it, but spiritual healing is basic, formulaic, generic and not therapeutically potent in the same way that osteopathy is. I believe it has its uses on some levels, (probably not in the realm of physical symptomatology in any but the most indirect way,) but it is different from what we do. The two should not be confused.
It is not the preserve of neurotic women and new age loons.
I have treated all sorts with cranial. Big, solid, city bankers, skeptical GPs, cleaners, teachers, pilots, sommeliers, deeply unimaginative tradesmen. Plenty of people of perfectly sound mind and grounded feet have specifically requested the inclusion of cranial in a treatment (not necessarily knowing that that’s what it is called, just recognizing that that is the part that felt potent). Cranial osteopathy is not especially attractive to weak, mad and stupid people. It is not the preserve of the “lunatic fringe”.
It is not an ineffective therapy which relies on the placebo effect, or the effect of touch
OK, I know we need to get some stats, but for me cranial reaches the parts other osteopathy cannot reach. Often it works when nothing else has. I have tried, in clinics where I felt that cranial was not well tolerated, to treat people using just direct techniques. When I failed to get results, I gave in and resorted to cranial; then things began to happen.
Worryingly, I have noticed a notion creeping in more and more, amongst researchers, and even amongst osteopaths, defending our use of these techniques by asking: So what if it’s just touch? Can’t we make that a legitimate treatment? Well, as someone who has felt fulcrums shifting, and embryological seams opening and shutting, and intelligent forces at work – [awareness alert: I know I am opening myself up to ridicule, and accusations of self-delusion] – I just can’t believe that these are just general relaxation responses. There are sophisticated therapeutic phenomena I have felt as tangibly as the feel of the keyboard I am tapping on right now, and the therapeutic benefits have matched them. These are very precise, specific processes which I can feel happening. (I would love to have a skeptic feel these things, but unless they were freakishly gifted, they would have to suspend their disbelief and practise for many years before they developed their attention and sensitivity to the point that they were able to sense these things as well as we can. It takes a long time even to get confident about palpating muscle tone, or recognising inflamed tissue, so something that seems obvious to us, a stuck sacrum, or heavy membranous tone, will sound like the Emperor’s new clothes to them. )
But how do we really effect such change with such light, but attentive touch then? I’m pretty sure something to do with consciousness is involved, maybe something along the lines of Antonio Damasio’s theory of second order brain maps. During a recent Explain Pain course, I was stimulated to wonder if we are actually directly treating the proprioceptive map somehow? Biodynamics is full of interesting ideas about the developmental forces in the embryo. Are we palpating those regenerative forces – the actual healing forces in the body? I think that’s possible. I’m not well-versed enough in neuroscience or embryology to take these ideas any further, but these are the avenues I’d research if I had the time and capacity. The trouble is, attention and consciousness are key features of these hypotheses, and nobody really understands those very well.
So forgive me for splurging out this rant in a slightly fed-up stream of consciousness way. It comes from feeling that many, many people, often the most vocal and critical ones, have got completely the wrong end of the stick, and nobody has put them straight about their most basic misunderstandings. I can only conclude by honestly admitting that I don’t understand why we haven’t collectively been researching efficacy of treatment, and I find it hard to explain exactly how this sort of treatment works. But I’d find the same difficulty explaining EXACTLY how massage works, and exactly what the evidence is for including that in a neck pain treatment, or functional, or articulation, or strain counterstrain, or even HVT. But nobody asks me to justify that. The sort of people that hate anything not rational, material or easily explainable have targeted the subtle end of our techniques because from the outside it looks like some dodgy mind-body-spirit festival kind of nonsense, and they just can’t stand that. Do you know what? Neither can I stand that. The lack of evidence has made me sometimes insecure in practice, and I admit I am sympathetic to calls for more evidence, but I still don’t doubt that the efficacy of these techniques done properly goes way beyond relaxation which comes from a lie down, a chat and a caring touch. And my integrity will not allow me to say otherwise.