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.
To conclude
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.
osteofm 
I’m kind of baffled because this blog is unlike so many of your other blogs. You stopped questioning and resorted to the kind of egocentric thinking that is indicative of the traditional osteopathic mindset.
Of course I’m one of the critics and also one of those who have tried to dial cranial back from the mythical abyss by stripping it down to the neurophysiology of touch. Granted I didn’t go far enough in clarifying what I was getting at so let me just say that what we osteopaths don’t know about touch could fill several libraries full of books. There are absolute physical and psychological outcomes from the application of touch and before we imagine that we can feel “fulcrums shifting, and embryological seams opening and shutting, and intelligent forces at work” we should probably rule out what those touch outcomes are first. I’m am a skeptic and I have felt all of those things. Confirmation bias favours information that will underpin existing beliefs, but if the observed outcome at the end of a treatment is that a patient has less pain, moves and feels better then why make up convoluted stories to explain that state when known neurological, psychological and physiological supporting information exists? Occam’s Razor – embryological seams opening or known neurophysiological effects? What’s more likely?
It’s not all about us. What we think we feel only matters to us. What the patient feels is an entirely different story and that relies on their interpretation of our touch, not ours. Their interpretation relies on their biological systems, not ours.
All of the things you’ve said cranial is not, you can find somewhere that it is. It started with the observations of one man proposing an extraordinary mechanism of cranial bone mobility that even then didn’t have biological or biomechanical plausibility. Given it’s origins it so hard to imagine that the osteopathic theory of cranial treatment wouldn’t lend itself to all manner of woo?
It is confirmed that palpation reliability cannot be measured, so that applies to cranial as well. There are several cranial palpation studies that help make up the body of research that exists as evidence that palpation reliability does not exist. It’s a done deal, in fact its been done so many times over that it is now a waste of resources to continue doing the same types of studies in the hopes of getting a different outcome. So if we are talking about reliability of feeling a supposed mechanism (osteopathically explained cranial) then it is invalidated.
You say: “During a recent Explain Pain course, I was stimulated to wonder if we are actually directly treating the proprioceptive map somehow?” I’m not going to assume I know what you mean, but because the same paragraph included biodynamics I’m not sure it isn’t metaphysical and that would be completely antithetical to the point of the Explain Pain course. Could we be affecting the somatosensory map with touch – well, yes. Touch has a neurophysiological effect, there are MRI studies. And really if you are not well versed in neuroscience then you should take the time. We have taken so much time already learning anatomy, physiology, biomechanics, techniques and palpation only to resort to making up reasons why outcomes exist, or to explain what we feel precisely because these subjects are wholly incomplete without neuroscience. We can’t move, feel or perceive anything without neurology.
You ask the question: “But how do we really effect such change with such light, but attentive touch then?” I hope you don’t think this is assumption but I’ve added a curated list of references (there are so many more) that might help answer that. My personal favourite is the last one -and by way of introduction to that, this might be a good place to start – http://forwardthinkingpt.com/2012/03/12/dermoneuromodulation-what-another-technique/.
“The Power of Touch” on Psychology Today: https://www.psychologytoday.com/articles/201303/the-power-touch
“The Science of Touch and Emotion” on Berkeley Science Review: http://berkeleysciencereview.com/the-science-of-touch-and-emotion/
“Acute Pain Is Eased With the Touch of A Hand” on PHYSORG: https://www.ucl.ac.uk/news/news-articles/1009/10092401
“Scientists Identify Key Cells in Touch Sensation” on Scicasts: http://newsroom.cumc.columbia.edu/blog/2014/04/06/columbia-scientists-identify-key-cells-touch-sensation/
“A Mind About Touch”, a 5 min vid on Brainfacts: http://www.brainfacts.org/sensing-thinking-behaving/senses-and-perception/articles/2013/a-mind-about-touch/. Excellent, except that it conflates nociceptors as pain receptors.
“The Skin As A Social Organ”, open access in Experimental Brain Research: http://his.se/PageFiles/2807/India_Morrison_3.pdf
“The Social and Personality Neuroscience of Empathy For Pain and Touch”, open access in Frontiers in Human Neuroscience: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3724165/
Palpatory Pareidolia – https://www.painscience.com/articles/palpatory-pareidolia.php
There is no skill in manual therapy: https://thesportsphysio.wordpress.com/2014/06/16/there-is-no-skill-in-manual-therapy-2/
Diane Jacobs’ Dermoneuromodulation references (55 pages) https://docs.google.com/document/d/1FJ9jWwUIcEr7kJ07DJMitYW3C0nLHJU_cJoO_U2Rx28/edit
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Thanks Monica. Yes there are huge gaps in my knowledge and the neuroscience is the route I would choose to go down next. As I said I still find it confusing. I am on a steep learning curve. (Partly why I was a bit nervous to write this.) Thanks for the list of references. Good to have some thorough scholars out there! Ive read a couple of them which I loved so good to have been supplied with a complete, targeted reading list. It would be great to think just touch was effecting all these changes, without any extra skill or effort, but in my experience cultivating a quality of attention is sometimes key and works a lot better. does this make it metaphysical?
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Absolutely fascinating discussion and yes, Monica I agree with you entirely. But good on you Marcia for having the guts to get this whole topic out there on the table for discussion. This is something I grapple with daily. My main issue is raising pain science with the patient (without losing patients).Because so many patients want to hear “Oh yes this is trapped or compressed or restricted and I will release it for you” rather than “your pain is largely the result of CNS sensitivity (and if persistent/chronic its likely to be a whole host of psychosocial triggers) and the aim of my treatment is to reprogram your body’s interpretation of the danger message”. Some people get it. A lot don’t. So glad we are beginning to have these discussions though. Thank you. Have you seen the new book by Observer Science correspondent Jo Marchant – Cure. Really interesting and ties in with this. Hope to meet you both sometime. oh and do you know: paincloud.com – Like-minded therapists sharing ways to get modern pain science out there.
ps Marcia, I am taking inspiration from your great blogging habit. I have been very lazy but plan to get back onto it soon!
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Thank you for articulating so well what a lot of us think but cant find the words to express it.
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Dear Penny
Thanks again for your blog. I don’t know if you are aware that skeptics have just published a very long report on cranial (a month or so ago). The report is flawed I find – some interesting papers were magically missed in their serach, the people who asked for the report definitly have an agenda (the French physio council paid for it) and so on but it is an interesting paper. I don’t know if you read French – if you do, here’s the link: http://cortecs.org/wp-content/uploads/2016/01/CorteX-CNOMK_Ost%C3%A9o-cranio-sacr%C3%A9e_Janvier2016.pdf
I completely agree with you on the fact that cranial is not only from the head or for the head. (Sorry I’m going to do some self-promotion here). I don’t know if you’ve read a paper I co-author on. I’ve attached it to this email.
Speak soon!
Jerry
Jerry Draper-Rodi Clinic tutor and Professional Doctorate student British School of Osteopathy 020 7089 5309 j.rodi@bso.ac.uk
“osteofm” writes:
> osteofm posted: “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 bloo” > > > > >
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Hi again Jerry, that study looks v v interesting and comprehensive. I do have some French so will give it a try. Let me know if there’s an English translation you’ve heard of. I couldn’t see your paper attached to the email. I’d love you to share stuff – don’t think of it as self-promotion! The point of the blog was to get people to share ideas and information, esp to the Facebook page which to my disappointment nobody has ever ever done, but I live in hope. You can always send me your paper via email if you still have my address, or even to osteofm1@gmail.com. Thanks, as you probably can see I am a bit of a beginner in this field compared to you so any comments or pointing In the right direction gratefully received, Penny
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I really enjoyed reading your article, especially how you mentioned that Cranial Rythm was a red herring. From personal practice and thoughts I am wondering if we are not trying to put things in boxes too much when it comes to Osteopathy in the Cranial Field. As osteopaths, our primary concern is to find health in our patients. This can be achieved through many ways as you explained on your article. But are we asking the right questions? What is Health? As a student, I use to to see Health as the quality of the mechanisms that regulate the inside and outside of an organism (homeostasis). Now, more and more in practice this is raising other questions for me, like is there a separation of the “inside” and the “outside” in my patient? Am I (all of us) separated from it as well or is there no separation? What is Health then? What is reality?
I understand this may sound metaphysical or bonkers for some, but this are merely the current questions I tend to ask myself as an osteopath at this time in my practice.
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It sounds like you are seeing reality more like the way it is, non-dual. It would seem that most of mainstream science is due for a major paradigm shift, but is still too attached to the “old ways . . .”
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Great article. Inter-observer reliability and rates of the so-called ‘cranial rhythm’ are explained in the Biodynamic model. Just very briefly, different ‘rates’ relate to different functions which may be present simultaneously, or change according to the palpation of the observer, or change according to the changing state of the subject as for example, they relax. As far as I know there have never been inter-observer reliability studies into rates which have taken into account this model. Simple studies which don’t, have no value and are positively misleading.
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Thanks Paul, yes I have done many courses on the biodynamic model and personally think they have come the closest to understanding what is going on. I do still think that palpably reliability would be quite hard to demonstrate in a study though.
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I agree. And wouldn’t tell us anything we didn’t already know.
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osteofm,
Kudos to you for daring to speak plainly in what is increasingly a polarised landscape. You confusion is understandable, given both the esoteric language that cranialists employ, which creates a rather masonic enclave within the profession, and also the fact that within cranial osteopathy there are significant differences between groups that focus on tensegrity and structure, on liquid flows, on energy fields, and lastly on spiritual and creational matters.
I will take issue slightly with your first segue. The continuum of techniques is not best described in force terms. There are techniques that “speak” better to muscle tissues, and techniques that “speak” better to cartilage or joint capsules. Other than those technical differences, the amount of force applied is normally determined by the degree of restriction and the requirement to reach a point where the tissues or mechanism yields. It is most common to have a release that commences with “gross” forces, as you put it, and terminates in extremely subtle interactions. That makes many of the distinctions between different techniques rather artificial, with the exception of thrust techniques, which do not have the ongoing interactive nature of most osteopathic techniques. So the idea that osteopaths can “choose” what forces they are going to work as a career choice with is misconceived, but I accept that many practitioners do actually do this.
I am not sure what you mean by craniosacral therapy. In the US and in my native NZ, craniosacral therapy is practiced by non-osteopath practitioners, and is a source of some consternation to the profession.
There are, in my opinion, some distinctions in cranial practice. Those who work with the energy field of the body or with the cranial rhythm exclusively form one loose coalescence, as opposed to those who work with cartilage tissues like the meninges, tentorium and global tensegrity. The first group tend to work with the cranium and sacrum as their principal fulcrums. As I have discussed in my texts “Rethinking Osteopathic Practice”, there is a problem for the first group in that all the research points to the cranial rhythm being an expression of Traube-Hering-Meyer fluctuations, and it is significant that the vast majority of cranial papers show autonomic outcomes for cranial interventions.
So not only are cranial “dysfunction” patterns secondary to what is happening elsewhere, they may only be a side-issue anyway, and bringing them to a “stillpoint” may merely be the practitioner creating a quiescent ANS; quite credible, but hardly earth-shattering, because a lie-down for 30 minutes will do that anyway.
The other group tend to work fluently around all body structures, using techniques that incorporate ongoing dialogue with the tissues, static holds and positioning, and perseverance until a discernible lessening of tension, of torsion, of resistance, or tonus is satisfactory. They may well work to some plan that incorporates tensegrity concepts. Working like that, their techniques are not materially different from “functional” or “strain-counterstrain” or any other of the various interventions that have been catalogued over the decades.
So overwhelmingly I agree with your frustration. I use “cranial” techniques and approaches constantly within a practice that is largely a specialist chronic and orthopedic practice. The structural techniques such as HVT do have a minor role, but in every case the technique is determined by what input the tissues require, not what my sensibilities are. And so the profession has made a rod for its own back in allowing these artificial distinctions to gain credibility, and to entertain the notion that a practitioner can choose what field they are going to work in. Part of that notion is the concept that gentler is better, and robust is coarse.
This notion makes as much sense as someone training to be a concert pianist for years, and then saying they will just play Haydn because they like the lightness and the trills. Would they be taken seriously?
Greg Wade DO
Auckland
New Zealand
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Thanks Greg. The whole point of the blog was to try to unravel my confusion about osteopathy and you have certainly helped there. I am going to re read your comment carefully and slowly because it seems to contain a great deal of sense. Yes I was a bit iffy about describing the continuum of techniques in terms of force, but I wrote this piece really fast and might have taken more time had I known how much attention it would get. I am not sure about this but I think I might have met you years ago. Your name is familiar. I briefly worked in takapuna for fi Jamison back in the day, well 1999, might have been then. Thanks v much for your v erudite and informed comment anyway, and I will look out for Rethinking Osteopathy in Practice. Cheers, Penny
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Penny, I remember Fi well. I think she is now involved in supplements following a bad accident that stopped her working over a plinth. Feel free to exchange more ideas. GW
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Thanks v much Greg.
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From a commentator above “What we think we feel only matters to us”
What we think and feel is what creates the basis for our treatment and development as practitioners.
Are you throwing out the work of Becker, Still, Walesl and Jealous when you say that feeling fulcrums, seams etc when you say “we should rule out those touch outcomes first” ? If so, there wouldn’t be an osteopathic curriculum. The engagement of the life process in a patient is at the heart of what osteopathy is.
This isn’t an egocentric article. It speaks to curiosity and trying to find a sense of place. It is human and courageous. Thank you osteofm for posting.
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Thanks very much Caro, really appreciate your comment. Penny
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