This is an edited version of one of 3 articles which you can find on Jo’s website. It was originally published in Sutherland Cranial Magazine. Jo spoke most inspiringly at last weekend’s Sutherland Cranial College conference, and I hope that more of her recent work is soon to be given a wider audience.
This essay is, essentially, an argument for including more osteopathy in the cranial field in undergraduate programmes, while recognizing the obstacles to that happening. As you read, bear in mind that her wish is essentially for 2 things, neither of which seem particularly controversial.
- Greater detailed anatomy (e.g. the cranium)
- More teaching of indirect techniques
I am guessing that indirect techniques include strain counterstrain and functional technique, amongst others. I personally feel that I would have benefited hugely as a clinician had I had more training in that type of treatment.
The UK Osteopathic Profession – Strengths and Weaknesses, by Jo Wildy
There is an argument that a comprehensive and tangibly taught osteopathic training in the cranial field, integrated into the UK undergraduate programme, would encourage a more extensive knowledge in anatomy combined with the practical development of listening skills and the using of indirect techniques. These skills, in themselves, promote the need of the student to apply an osteopathic philosophy in their patient approach and it is worth posing the question of whether the current undergraduate programmes currently neglect and undervalue these skills.
What would need to happen first?
The UK osteopathic profession working in the cranial field might need to identify its’ strengths and weaknesses. By acting on their strengths and addressing their weaknesses it may be possible to integrate into their work into the undergraduate programmes, achieve parity of esteem with other osteopathic approaches and contribute more to the development and forward drive of the osteopathic profession as a whole.
Criticisms of osteopathy in the cranial field
The osteopathic profession practising in the cranial field stands accused of a number of weaknesses, namely that the treatment is:
- clinically ineffective,
- ‘magical thinking’.
It is high time that these points are aired one by one, analysed and discussed. The strengths of this osteopathic approach, not least its popularity and success as a somewhat sectarian part of the profession, also needs discussion and some analysis.
But first: ”Cranial osteopath” – a misnomer and an unpopular title.
For the purpose of this article, the description ‘cranial osteopath’ is chosen as the name commonly used by both patients and practitioners to describe osteopaths who work using Sutherland’s concept of the Primary Respiratory Mechanism (PRM). However it is is a misnomer. Osteopaths who practice in the cranial field treat the whole body including the head. They have trained initially in structural osteopathy and many use both direct and indirect techniques, work with both voluntary and involuntary motion and do not like to be seen as a separate discipline.
Why is the title used then?
Because UK osteopaths have to gain their ‘cranial osteopathic’ skills and training through post-graduate study and therefore need to distinguish themselves from those untrained in this approach.
How can we be free of this unpopular title?
If all undergraduate students were all trained to the same high standard in all approaches – musculoskeletal, cranial and visceral anatomy and the use of direct and indirect approaches it would eliminate the need to use unpopular titles. .
Criticism #1: Cranial Osteopathy is Unscientific
Anyone familiar with Jung, or indeed in touch with their own humanity, knows that we are thinking, feeling, sensing, intuitive beings. A well rounded person is developed in all of these functions. In the 17th century, however, the scientific revolution critically took science away from the other disciplines, travelling along the ‘thinking’ dimension and consciously dismissing ‘feeling’, ‘intuition’ and ‘sensing’ as scientifically unworthy.
Palpation is subjective
But in order for an osteopath to assess and treat his patient, he uses the skill that is the premise of being an osteopath. He palpates. It is subjective – a feeling – and therefore can be dismissed as being of no scientific value. To make matters worse, ‘cranial osteopaths’ use even subtler perception (intuition and sensing) and actively encourage themselves not to analyse or interpret at the point of trying to engage and interact with their patient..
How does the cranial osteopath actually treat?
The therapeutic rationale of a ‘cranial osteopath’ is to find a point of balance from where the body has the potential to reorganise. On talking of balance it is possible to think beyond the 3 dimensions. There is front to back, left to right, top to bottom, but thinking beyond the three dimensions there is also deep to superficial, psyche to soma, the parts to the whole, the whole body to its surroundings and the dimension of time in terms of past, present and future. A ‘cranial osteopath’ will use the principles of treatment – exaggeration, direct action, decompression – in a suggestive, supportive way rather than an assertive manner, to help the body to find that point of balance. Having done that, the practitioner is passive, as it is time to witness the body at work. The practitioner is guided by their patient at this stage in the osteopathic intervention and for this to happen he must relinquish control and a full understanding of what is happening and why. Diagnosis and treatments merge.
”Unscientific” methods of diagnosis and treatment
Although a ‘cranial osteopath’ can examine his patients structurally before and after treatment, and is competent in clinical screening procedures, the actual methods of diagnosis and treatment could be regarded as scientifically unworthy. We must acknowledge this publicly and clearly. It is a fact that severely hampers any contribution that cranial osteopathy can make towards science in terms of an allopathically orientated diagnosis and treatment.
In his book The Grand Design Stephen Hawking points out how great thinkers of Ancient Greece, such as Democritus, Archimedes and Aristotle, were insightful but they were not scientists as we think of scientists today. He explains that the tools or scientific methods needed to support their ideas were not available in their era. This author would suggest that Sutherland was insightful and the science emerging in this 21st century is starting to give credence to his concepts..
What is involuntary motion (IVM) ?
Sutherland dedicated a lifetime of study to a fascinating phenomenon, constantly disparaged by the majority of his colleagues. He tried to describe and explain his understanding of what he observed by breaking it down into 5 concepts. These concepts have been pulled apart and individually criticised without the understanding that they come as a package to explain a very simple phenomenon of a rhythmic shape change that occurs at all levels from the molecules, nucleus, cells, organs, limbs, whole body – and which is an expression of health in motion in a hierarchical system. That expression of health in motion, through the whole body as a unit, relies on a functional midline. It was this functional midline that Sutherland compartmentalised to rationalise the physical body (cranial bones and sacrum), the shape it holds (membranes) and the fields of force operating within it (fluid motion and embryological development within the CNS).4 This rhythmic shape change, the involuntary motion (IVM), is the first thing “cranial osteopaths” need to be able to explain in scientific terms. It is no good saying they are osteopaths who work with the IVM if they cannot explain IVM in rational terms. “Cellular breathing” (although I use this descriptor myself) is not sufficient. ‘Cranial osteopaths’ regard this Involuntary Motion (IVM) as an indicator of health and where absent, as an indicator of dis-ease.
How can we bring Sutherland’s theories into the 21st century?
Cranial osteopaths may not yet have the complete answer, but, as Colin Dove has said, they need to be practising their skills around a modern day theory. (5,6) It is not a case of exchanging Sutherland’s theory for anything else; rather, bringing it into the 21st century. Until osteopaths develop a modernised theory around which their approach is based, the profession is not able to communicate with others.
It seems to me that pieces of the jigsaw are emerging from different fields of science and, on gathering the pieces together, it is possible to see the start of that picture emerging.
What is relevant is that science today is changing tack. Up until recently, thought processes were based on logic and sequential analysis of what can be seen and measured, but now quantum science is telling us to come away from preconceived ideas, and think in far more dimensions – to think beyond reason. The biomechanical models set in 3 dimensions are very helpful for those that are biomechanical practitioners, however the more subtle involuntary motion and palpatory experience of the response of our patients to a more subtle clinical intervention requires a different scientific reasoning and one that is starting to emerge today. Hawking also explains that it is not necessarily a singular explanation for a singular theory. Rather there can be a number of explanations that merge towards a more complete understanding. (3) Where previously, different scientific specialisms have isolated themselves from one another they are now realising that if they come together, pictures rather than facts emerge. “There is a wholesale merging of minds between the life, engineering and physical sciences – billed as critical to helping researchers answer the most profound questions….. … The Convergent Revolution is a paradigm shift”. 7 Osteopathy is rooted in the laws of nature and to understand the laws of nature requires the asking of the most profound questions.
Potential avenues of scientific research
Where biomechanical colleagues are sharing in and benefiting from scientific advances developing in medicine and manual therapy, “cranial osteopaths” need to embrace developments along alternative avenues. Cell biology, quantum physics, evolutionary biology, neurology, psychology, embryology, mathematics, philosophy and socio economics all bear relevance when looking at complex systems and their emergent behaviours. Various osteopaths with enquiring minds have looked at a number of these disciplines, individually or in combination, and used knowledge and advances made in these fields to try and explain the IVM and the inexplicable forces, natural forces, with which a cranial osteopath interacts and initiates a response..8,9,10,11,12,13,14,15,16.
Nick Handoll wrote his groundbreaking book, The Anatomy of Potency.
Dr Paul Lee has made an outstanding contribution in writing his book Interface.16
Patrick van den Heede (17) talks of integrated morphology incorporating breathtaking detailed and extensive knowledge from many scientific arenas to show us a way of considering body, mind and matter as one.
The EvOst group in Belgium are currently gathering force. Small but collective numbers of key thinkers from around the world are studying the implications of this convergent revolution. They are gathering momentum in their efforts to embrace the philosophy of osteopathy as proposed by AT Still within a current and convergent scientific, philosophical and socio economic model. This is what is needed: a meeting of minds from across the globe and a consensus of opinion formed.
Tensegrity Ingber is a cell biologist exploring tensegrity within the DNA, nucleus, cell and extracellular matrix. “Tensegrity is a building principle that was first described by the architect R. Buckminster Fuller(1961)…… Fuller describes tensegrity systems as structures that stabilize their shape by continuous tension.” At the same time as concentrating on tensegrity at the cellular level, Ingber appreciates the relevance of the hierarchical structure of life and discusses how his findings should mirror themselves at levels of higher organisation, namely tissues, organs and whole body; maybe higher. (18)
The Casimir Effect. Moving briefly across to quantum science here is a quote from an article in New Scientist Feb 2012. “Last year Wilson and his team at the Chalmers University of Technology in Gothenburg, Sweden, provided what seems a particularly egregious case of something for nothing. They claimed to have conjured up light from nowhere simply by squeezing down empty space. That would be the latest manifestation of a quantum quirk known as the Casimir effect: the notion that a perfect vacuum, the very definition of nothingness in the physical world, contains a latent power that can harnessed to move objects and make stuff.”25 AT Still talks of ‘Spirit’ 26 (in terms of life force rather than deity) or the ‘Unknowable’ and Sutherland talks of ‘liquid light ’27. Is the Casimir Effect representative of the ‘unknowable’ or the ‘liquid light’ exerting its influence through mind and matter in the form of motion?
I don’t think it is possible to take osteopathy into science without losing what osteopathy is. However it is possible to bring science into osteopathy and preserve what is vital; an osteopathic philosophy of health and the skills that stand alongside this. It is important to be clear about which way around this is done.
Criticism #2: Osteopathy is Clinically Ineffective
Argument: Osteopathy does not fit the allopathic model and needs judging by different standards. An osteopath trained in the cranial field is trying to achieve something different from those practising an allopathic approach and therefore cannot be judged by allopathic criteria.
Cranial osteopaths might consider, for example, that babies with certain strain patterns through their skulls tend to suffer with ear, nose and throat problems. For example a child with a certain sphenobasilar strain might have a high, narrow palate, meaning their tongue sits on the floor of the mouth due to lack of space. They might develop poor swallowing and breathing habits and turn into mouth breathers. The air hits the lungs cold and oxygen uptake is compromised. Accessory muscles of breathing are activated on a regular if not constant basis affecting posture. The narrow palate leads to teeth crowding, orthodontics and subsequent potential conflict of patterns between the viscerocranium (face) and neurocranium. 29 This brings another host of problems with it. The individual develops dark rings under their eyes, thin lips and anterior head postures. The aging process is visibly as well as systemically accelerated.30
An osteopath will treat a baby with an aim to minimise these strain patterns and to prevent such eventualities, amongst many others. He will aim to minimise the distortions and compressions taken up by the membranes and cartilage prenatally, perinatally and postnatally before such patterns become ossified in bone and reflect far beyond the local trauma. As a by-product, the osteopath may ‘settle’ the baby; symptomatic conditions may improve, eg. colic, reflux, feeding, sleeping and breathing difficulties. The parents assume the osteopath to be treating the symptoms. The cranial osteopath is not treating symptoms; he is treating the baby and the potential for health in the future – something far more profound. The osteopathic professions are not getting this message across and need to develop a consensus on this; a means of communication with the patients.
A study into cerebral palsy showing improved wellbeing
There was a study carried out to measure whether “cranial osteopathy” was effective at treating Cerebral Palsy – commissioned by Cerebra, a charity that helps to improve the lives of children with brain conditions.33 After a 6 month interval, physiotherapists that were carrying out the study noted that there were no observable benefits in the children that had received “cranial osteopathic treatment”, except one finding that their sense of well being was measurably affected. Interestingly this was dismissed as irrelevant. I would suggest that they look at those children in 5 year or 10 years time. I would look at their “life” rather than some constructed measure of cerebral palsy and its severity. I would also question who or what they will stand against in comparison as whatever they are standing against is a variable in itself. I believe that if “cranial osteopaths” expose themselves to the allopathic way of evaluating effectiveness, they will fail.
38 per cent of parents whose children had received osteopathy rated their children’s overall wellbeing as better compared with 19 per cent of those who had not received osteopathy.
This is, of course, a huge problem if the profession wants osteopathy to be comprehensively covered by the medical insurance companies who place their main emphasis on evidence base and outcome measurement. As a profession it is important to ask the bigger question of whether osteopaths want to sit in pockets of the insurance companies and become part of a huge machine over which they have no influence; forget about the laws of nature (intelligent as they are) and a philosophy on which we rely for our identity. It is a similar problem if the profession want to be incorporated under the NHS who seek the same criteria.
So if someone asks whether cranial osteopaths are clinically effective, I would question, in turn, under what criteria are they asking that question? In truth cranial osteopaths cannot claim to be successful at treating low back pain, migraines, colic, insomnia, depression, sinusitis, vertigo, cerebral palsy. They don’t treat a condition, they initiate a therapeutic response the outcome of which is uncertain. The human body and mind is a complex system and emergence from this system is beyond the control of the osteopath; nature is in charge. The treatment is not, and cannot be, standardized
Is the cranial osteopathic approach effective?” is a different question to “is an individual cranial osteopath effective?”
The effectiveness of the individual practitioner relies on a combination of training and experience. Many osteopaths who say that they treat patients cranially are not highly skilled and some lack any training at all. This is clearly wrong and the only solution to this problem is for a comprehensive cranial osteopathic syllabus to be taught at undergraduate level. An extensive knowledge base with practical training in osteopathy in the cranial field should be a prerequisite for qualifying as an osteopath, as it is in parts of Europe.
In terms of experience, osteopaths only have the opportunity to specialise in the cranial and visceral field at postgraduate level so their clinical introduction is on full fee paying patients. In 1991, following a 5 day introduction to cranial osteopathy course, I applied my newly learnt principles of treatment to my patients. I had the most basic of knowledge, no concept of what I was interacting with or any palpatory skill with which to apply the above. I failed markedly to impress my patients or the principal of the osteopathic practice and reflected badly on the cranial osteopathic profession and the osteopathic profession as a whole. I am sure that I am not alone in this situation.
This is another strong argument for osteopaths to master their skills in listening and indirect techniques at undergraduate level, with supervision and with patients that are aware they are paying a reduced price for an unqualified practitioner.
Criticism #3: Cranial Osteopaths are Magical Thinkers
“Magical Thinkers” Are osteopaths working in the cranial field “magical thinkers” in terms of what they do and what they say? Is it possible to diagnose and treat a patient using listening skills and indirect approaches and effectively initiate a therapeutic response that is of benefit to our patient? My answers are categorically, yes and yes. There is no magical thinking going on, however there is the overwhelming wonder at the human body, its very existence and the life giving force that exists within it, maintains it and surrounds it.
It is only after decades of working as an osteopath in the cranial field that I have developed an overwhelming confidence in this approach; not in myself. Confidence in this system of treating does not come instantly or easily, and nor should it. I have undergone the monumental task of teaching the development of listening skills to the reluctant learners eager to stick with their more tangible active approaches. They make challenging students, but less so than the self- professed healers who believe that “cranial osteopathy” will provide their vehicle for accreditation. (An important point here is that a student might be reluctant to explore this avenue of osteopathy, but that has no correlation with how good they might be at this work and vice versa.)
A temptation for magical thinking in the early stages of learning
There are students that naturally palpate at the bony level and apply effectively functional techniques. There are students who palpate at the level of the membranes and exert their influence by feeling the patterns and the pull and easing them towards a point of balance. There are other students who instinctively palpate at the level of the fluids and work with the formative forces driving the fluids. When one observes the development of Sutherland, Becker and others through their literature there is a recurrent pattern where they start with the bones, moving onto the membranes, and over further time exploring the fluids and the formative forces that drive them. It seems to be a natural progression and one that assumes that when the practitioner reaches the fluid/energetic level he is advanced or an expert. There is a tendency to accelerate or rush cranial osteopathic students to an advanced fluid/energetic level way ahead of their years or even decades and this can create ‘magical thinking’. It is important to come away from imposing the idea that palpating at this level is the norm and anything less as a failure. That is not to say that this level of diagnosing and treating is invalid. It is the extreme end of a spectrum of different osteopathic approaches, many of which could still be classified as “cranial”.
Understanding comes through experience
It is impossible to understand this work through explanation alone: a practitioner has to experience it and to subsequently evolve. If the UK cranial osteopathic profession wants to become inclusive rather than exclusive they need all osteopaths to experience it, to to get hands on and explore the fantastic anatomy and initiate an interaction with the self healing, self regulating mechanism using indirect techniques.
Bringing science into cranial osteopathy
Cranial osteopaths need science to provide a modern day theory if they want to communicate and integrate themselves with their structural colleagues. Osteopaths working in the cranial field need to take notice of the convergent scientific revolution. This is separate to ‘evaluating the outcomes of cranial treatment’, ‘finding evidence of pulsed cranial fluid affecting physiological parameters’, ‘data collection from practices’. 34 This is completely different. It is about bringing science into osteopathy but being absolutely clear that it is not about making osteopathy scientific.
Full inclusion of cranial osteopathy at undergraduate level
The osteopathic profession needs to push for the study of the cranium and development of listening skills and the use of indirect techniques to be taken seriously at undergraduate level? If there was a full training programme for osteopaths in the cranial field at undergraduate level, it would encourage research projects into investigating some of the more structural reasoning behind their treatment rationale. Some examples might be
- the relationships between SBS strain patterns and long term health – both psychological and physical;
- the relevance of dental occlusion and head and spinal posture;
- the implications of orthodontic intervention and the effect on long term health;
- the development of the upper, middle and lower face and the effect on breathing.
If this was integrated research with a number of students contributing to different aspects of the same study over years, or even decades, it could gather some impact. It would require osteopaths with a comprehensive anatomical knowledge of the cranium, scientifically trained, within educational institutions to oversee these structurally biased studies. Most research that gathers any credence emerges from teams within educational or corporate organisations, working over years, if not decades.
Effectivity If osteopaths working in the cranial field profess to be clinically effective it should be only with the understanding that all osteopaths practising cranially are fully trained. In training the students it is important to reinforce the fact that they do not approach their patients in an allopathic way and therefore cannot justify what they do by allopathic criteria. If the profession do not do this it would be to their inevitable demise.
An examination of the best way to teach cranial osteopathy
If the profession want to be inclusive rather than exclusive and avoid accusations of being magical thinkers, I would suggest that they stop fast tracking students onto the fluid/energetic level and respect and encourage students that apply their applied functional anatomy of the cranium at all levels of palpation and who use all treatment approaches.
Final Word: I would encourage all members of the osteopathic profession to consider Jung’s analysis of the healthy balance between the 4 psychological functions. An osteopath interacting with the PRM may rely intently on intuition, feeling and sensing for a therapeutic intervention, but when his hands are off the patient, he should be thinking, thinking, thinking.
“Reason flows from the blending of rational thought and feeling. If the two functions are torn apart, thinking deteriorates into schizoid intellectual activity and feelings deteriorate into neurotic life-damaging passions”. Eric Fromm.
References – (some have been omitted in the text due to the edit)
- Wildy J Feb 2012 One Leap Forwards or Two Steps Apart. OT
- Harding S 2009 Animate Earth p36
3 .Hawking S 2010 The Grand Design p32, p77
- Sutherland WG 1990 Teachings in the Science of osteopathy Ch2
- Dove C 2004 Rollin Becker memorial Lecture,
- Dove C 2011 SCC Magazine 33:31-32 5
7 .Nelson B July 2011 Scientific American p12
- Handoll N 2000 The anatomy of potency
- Draeger K, van den Heede P, Klessen H 2011 OSTEOPATHIE- ARCHITECTUR DER BALANCE
- Nelson KE, Sergueef N, Glonek T 2001 JAOA. 101(3):163-173, 2006 JAOA 106(6):337-341
- Ferguson A 2003 A review of the physiology of cranial anatomy. IJOM 6(2): 74-84,
- Girardin 2005 Evolutionary Medicine in the Osteopathic Field IJOM 85-93
- Girardin 2012 Handouts for the EvOst
- Hamm D 2011 A Hypothesis to explain the palpatory experience and therapeutic claims in the practice of osteopathy in the cranial field. IJOM 14(4)p149-165
- Oschmann J 2009 Energy Medicine: The Scientific Basis
- Lee P 2005 Interface: Mechanisms of Spirit in Osteopathy
- Ingber DE 1998 The architecture of life. ScientificAmerican:1:48-57
- Brookes M 1999 Hard cell, soft cell. New Scientist 164:41-46
- Pflueger C 2008 The meaning of tensegrity principles for osteopathic medicine. Masterthesis http://www.osteopathicresearch.com/paper_pdf/Pflueger
- Ingber DE May 2011 ubergeek316.fr/2011/05donald-ingber-serendipitous-science.html
- Ingber DE 2003 Tensegrity1. Cell structure and hierarchical systems in biology J Cell Sci 116: 1157-1173
- Pienta KJ Coffey DS 1991 Cellular harmonic information transfer through a tissue tensegrity matrix system. Medical Hypothesis 34:88-95
- Ingber DE 2010 The mechanical control of tissue and organ development. Development 137(9):1407-1420
- Harris D Feb2012 Vacuum Packed. New Scientist p34
- Lee P 2005 Interface: Mechanisms of Spirit in Osteopathy p44
- Sutherland WG 1990 Teachings in the Science of osteopathy p34,228
- Magoun 1976 Osteopathy in the Cranial Field 3rd Ed Ch 7
- Sergueef N 2007 Cranial Osteopathy for Infants, children and adolescents Ch 7.3,7.4,7.6,7.7
- Iyer SR & RR. 2010 Sleep, ageing and stroke. J Assoc Physicians India 58:442-6
- Mirrakhimov AE 2012 Non drowsy obstructive sleep apnoea as a potential cause of resistant hypertension: a case report. BMC Pulm Med 12(1)p16
- Diedrierich NJ et al. 2005 Sleep Apnoea syndrome in Parkinson’s disease. A case control study . Movement Disorders 20 (11) p1413-1418 35.
34.ICRA Newsletter October 2011
Biological tensegrity has had its critics amongst cell biologists.19 Many biomechanics believe tensegrity should remain in the realms of sculpture, physics and engineering from whence it started.20 However it is relevant here to point out that Ingber is the founding member of the Wyss Institute for Biologically Inspired Engineering at Harvard. The Institute has been awarded the biggest grant of $125 million dollars in the history of Harvard. His team are representative of the Convergent Revolution.21
Ingber and his team work from a functional perspective in understanding how structure governs function within life processes. They have demonstrated how physical forces applied to the surface of the cell can affect chemical outcomes both within that cell and in cells distal to it; a phenomenon Ingber explains through connectivity via the extracellular matrix. However the positioning and the angle from which those physical forces are applied is relevant. 22 If it is possible to consider the body and the cell as sharing hierarchal properties does this explain that if a cranial osteopath provides a point of contact to the surface of his patients body, at the correct angle and in the correct position he seemingly has influence on further physical and chemical outcomes distal to the point of contact?
Ingber highlights studies demonstrating how living cells forced to take on different shapes, spherical or flattened, can switch between different genetic programmes.23 Cells spread flat become more likely to divide, whereas round cell activate a death program known as apoptosis. In between these two extremes, normal tissue function is established and maintained. This bears huge implications to cranial osteopaths in terms of the rhythmic shape change between flexion (short and fat) and extension (long and thin) that we see as representative of health; the IVM. Patients unable to express one range of the rhythmic cycle bear the signs of dis-ease.
One of Ingber’s most recent papers describes not only that physical forces play a large part in influencing embryological development but that these same physical forces are potentially responsible for the maintenance of health.24 ‘Cranial osteopaths’ discuss the embryological fields of force persisting on through life as our self healing and self regulating mechanism. Is it these morphogenetic forces that the osteopath interacts with and is guided by. Is this representative of the PRM?
© Copyright – All rights reserved by Joanna Wildy 2011