The standard textbook used in many schools of osteopathic medicine includes a lamentable chapter on cranial manipulation. It is clearly biased and fails to meet the minimal standards of science-based medicine. Craniosacral manipulation therapy is bogus, and it should no longer be taught to DOs or feature on their exams.
Craniosacral therapy (CST) is practiced by DOs and others, including some massage therapists, chiropractors, dentists, and physical therapists. It is a hands-on therapy that claims to manipulate the skull bones to relieve pain and remedy many other ailments. It claims that a rhythm exists in the flow of the fluid that surrounds the brain and spinal cord and that practitioners can reliably detect that rhythm by palpation. These claims are not true: the bones of the skull are fused and don’t move, there is no such rhythm in the cerebrospinal fluid, and palpation is unreliable.
The origin of CST
I wrote about the origin of craniosacral therapy (CST) in an article for Skeptical Inquirer titled “Wired to the Kitchen Sink”. In the 1970s, a doctor of osteopathic medicine named John Upledger had an epiphany:
He was assisting a neurosurgeon by holding the dura (membrane surrounding the brain and spinal cord) steady while the surgeon removed a calcified plaque. He wasn’t doing a very good job of holding still. The surgeon complained. Most of us would have thought our own muscles were at fault; however, Upledger observed that the dura was fluctuating up and down at about ten cycles per minute, overcoming his attempts to hold it still. Nobody had ever observed this before, not even neurosurgeons…He tried mobilizing the cranial bones through hands-on manipulation and convinced himself he could feel the bones move one-sixteenth of an inch or more. Patients with autism, seizures, cerebral palsy, headaches, dyslexia, colic, asthma, and other diseases reported dramatic improvement. He found that well people treated with monthly adjustments reported more energy, felt happier, and were sick less often.
Basically, he allowed himself to be deceived by an illusion, and he failed to recognize that subjective patient reports of improvement may be due to a placebo response.
Criticism of CST: not based on science
I wrote another SBM article in 2013 showing that osteopathic research on CST was Tooth Fairy Science.
Edzard Ernst did a systematic review of randomized clinical trials and concluded that craniosacral therapy was bogus. He said, “The notion that CST is associated with more than non‐specific effects is not based on evidence from rigorous RCTs.” And he said “to anyone understanding a bit of physiology, anatomy etc. CST looks like pure nonsense.”
PainScience.com reviewed CST and concluded:
There is good, recent scientific evidence that the most important and basic assumption about how CST works is just not true: craniosacral therapists cannot actually move the bones of the skull enough to affect the pressure or circulation of the fluid surrounding the brain and spinal column. Although CST fluid does circulate, we know that it’s pumped almost entirely by respiration, not skull movement.
Wikipedia doesn’t mince words. It says CST is based on fundamental misconceptions about the physiology of the human skull; it calls CST pseudoscience and quackery. And it describes several reports of harm; at least two deaths have been attributed to CST.
A 2002 article in The Scientific Review of Alternative Medicine by Hartman and Norton (two professors at schools of osteopathic medicine) examined the inter-examiner reliability of craniosacral osteopathy. They found that the reliability was zero and the proposed mechanism was invalid. They found that there was little science in any aspect of cranial osteopathy:
- There is no scientific support for major elements of the primary respiratory mechanism (PRM)
- The only publication purporting to show diagnostic reliability with sufficient detail to permit evaluation is deeply flawed and stands alone against 5 other reports that show reliabilities of essentially zero; and
- There is no scientific evidence of treatment efficacy.
Without careful scientific controls, weaknesses of perception and interpretation can fool both practitioners and patients into believing that a treatment is effective when it is not. We believe that these and other natural human psychosocial influences help to explain how cranial osteopathy has achieved the 21st century without scientific support of any kind.
They recommended that:
cranial osteopathy should be removed from the curricula of colleges of osteopathic medicine and from osteopathic licensing examinations.
On Quackwatch, Stephen Barrett went even further. After explaining “Why Cranial Therapy Is Silly” he said,
I believe that most practitioners of craniosacral therapy have such poor judgment that they should be delicensed.
It wasn’t removed
Nobody listened. Nineteen years later, Hartman and Norton’s recommendation continues to be ignored. The most current, comprehensive osteopathic text available is Foundations of Osteopathic Medicine. This standard text is now in its 4th edition. It is not only endorsed by the American Osteopathic Association but is published under its auspices. It is a required text in many osteopathic schools. (The actual number of schools that require it can’t be determined, since many schools don’t list their required textbooks.) It features an entire chapter on CST, which it calls Osteopathic Cranial Manipulative Medicine (OCMM). That’s just another name for CST, focusing on its use in osteopathic medicine (and presumably excluding discussion of its use by other practitioners like chiropractors).
The textbook’s chapter on OCMM
The author of chapter 38 in the 4th edition, “Osteopathic Cranial Manipulative Medicine”, is Hollis King, who is a “double doc:” he earned a doctorate in osteopathic medicine from the Texas College of Osteopathic Medicine and a PhD in clinical psychology from Louisiana State University. (Doc Doc Goose comes to mind). He starts by covering the history and development of OCMM, then covers the proposed mechanism of action. (Proposed, not proven.) He claims that:
Midline bones (the sphenoid, occiput, ethmoid, vomer, and sacrum) move through a flexion phase and an extension phase around a transverse axis, while paired bones move through external and internal rotation. They are moved through this biphasic cycle in response to the pull or influence of the dural membranes, which are influenced by the coiling and uncoiling of the CNS and the fluctuation of the CSF…The overall motion of the cranium is similar to the motion of the chest during respiration.
He doesn’t provide any credible evidence to support those fanciful claims. Can you imagine the CNS coiling and uncoiling?
He describes the Primary Respiratory Mechanism as having these five components:
- The inherent rhythmic motion of the brain and spinal cord
- Fluctuation of cerebrospinal fluid
- Mobility of intracranial and intraspinal membranes
- Articular mobility of cranial bones
- Involuntary mobility of sacrum between ilia.
He claims these are well established and not controversial – but they are not well established and saying they are controversial would be an understatement. They are not recognized by mainstream anatomists and physiologists and are not mentioned in medical textbooks nor are they taught in medical schools. He cites a 1966 osteopathy textbook as evidence for many of his absurd claims, such as that “The entire CNS shortens and thickens during one phase and lengthens and thins during the other.” Doesn’t he realize that mainstream scientists find such claims laughable?
He speculates about mechanisms of purported physiologic motion and covers studies that he thinks prove the existence of the primary respiratory mechanism. He reproduces fanciful illustrations of speculations about the purported anatomy – from the same 1966 book! He compares the idea that the cranial bones are fused and immobile to an anatomic version of “the world is flat” debate of the last millennium.
He does cite the Hartman and Norton study from The Scientific Review of Alternative Medicine, (twice!). But he fails to mention its primary finding of the lack of interexaminer reliability, which establishes that the palpation by examiners is not objective, is inconsistent, and can’t be relied on for diagnosis. The first time he cites the study is to support his claim that “The most controversial phenomenon of the PRM from a scientific perspective is the concept of palpable cranial bone motion. Misgivings primarily surround the assumed anatomic impossibility of such motion. However, cranial sutures are constructed in a way that allows for motion beyond simple bony compliance.”
The second time he cites the study is in support of his claim that “Commentary that holds to the ‘cranial bones are fused’ perspective is particularly critical of the sphenobasilar junction mobility model.”
Under the heading “Principles of Diagnosis” he says, “Palpation by a well-trained and sensitive physician is the most reliable source of information”. But we know it is not reliable at all.
He acknowledges that the published evidence is insufficient but firmly believes better evidence will be forthcoming. He says from the perspective of practitioners, there is little doubt of the clinical applicability; they see improvement in the patients they treat with CST. In other words, he dismisses scientific evidence and accepts the delusional subjective palpatory findings of CST practitioners and the subjective reports of patients without taking into consideration the effects of suggestion and the possibility of a placebo response.
The research studies he lists include research on cats in space, extrapolation from anomalies, speculation, questionable studies, “plausible models”, and studies that don’t say what he seems to think they say. His bias is obvious. He systematically cherry-picks studies that support his belief system and finds rationalizations to dismiss studies that don’t.
One wonders if King even understands what science is. He says “systematic observation of anatomic relationships palpated by the osteopathic physician, and correlated with changes in the patient’s symptoms, is indeed scientific procedure.” No, that’s not how science works.
King describes applications of CST that he claims are supported by clinical research: otitis media; pregnancy, labor, and delivery; children with learning problems, neurological deficits, delayed academic performance, and seizure disorders; colic; cerebral palsy; gastrointestinal symptoms and length of stay in the neonatal unit for premature infants; dental conditions including TMJ dysfunction and orthodontia; and more.
Adverse events and contraindications
He claims there has been only one report of an adverse event from CST. In reality, there have been many reports of adverse events ranging from dizziness to diarrhea and including two deaths.
He lists these “somatic dysfunctions” that he says can be effectively treated with CST:
- Bell’s palsy
- Cranial neuropathy-nerve entrapment
- Orofacial pain
- Otitis media
- Temporomandibular joint dysfunction and malocclusion
- Feeding difficulties
- Trigeminal neuralgia
He cites a textbook’s contraindications to CST. Absolute contraindications include acute intracranial bleeding, skull fracture, and acute cerebrovascular accident. Relative contraindications: coagulopathies, space occupying lesion in cranium, and increased intracranial pressure.
This is unconscionable nonsense
While this chapter might impress some naïve osteopathy students, it doesn’t stand up to scrutiny by people with critical thinking skills or to those who understand the requirements of science-based medicine.
In the US, a DO is considered to be equivalent to an MD. They take the same exams and do the same residencies to specialize. They are presumed to have equivalent educations. A DO gets additional training in osteopathic manipulation, but many of them seldom or never use those techniques after they graduate.
If DOs expect to continue to be accepted as equal to MDs, it’s time for them to speak out. Their schools must stop teaching OCMM and requiring textbooks that endorse it. Hollis King’s chapter in this standard osteopathic textbook is a travesty and is completely unacceptable. There’s nothing comparable in schools that teach MDs. It’s as if a medical school were to require a textbook teaching the principles and practice of homeopathy and reflexology, or the anatomy and physiology of acupuncture meridians and acupoints.
Conclusion: CST is bogus
Craniosacral manipulation therapy is based on pseudoscience. It is quackery, plain and simple. I have to agree with Stephen Barrett that most practitioners of craniosacral therapy have such poor judgment that they should not be allowed to practice.
This article was originally published in the Science-Based Medicine Blog.