Cranial Manipulation and Tooth Fairy Science

Tooth Fairy Science is science that studies a phenomenon that doesn’t exist. You can do studies on the Tooth Fairy; for instance, comparing how much money she leaves to kids in different socioeconomic groups. You can do studies on the memory of homeopathic water. You can do studies on the therapeutic effects of smoothing out wrinkles in the imaginary human energy field with therapeutic touch. Or you can do studies of craniosacral therapy. “Therapeutic Effects of Cranial Osteopathic Manipulative Medicine: A Systematic Review,” by Jakel and Hauenschild, was published 2011 in the Journal of the American Osteopathic Medical Association. It is a perfect example of Tooth Fairy Science.

In the 1930s, William G. Sutherland, DO looked at a disarticulated skull and noticed that the sutures were beveled, like the gills of a fish. He concluded that this indicated articular mobility for a respiratory mechanism. He invented cranial osteopathic manipulation to allegedly move the bones of the skull relative to each other for therapeutic benefit.

In the 1970s, John E. Upledger developed this idea further, inventing craniosacral therapy (CST). It postulates rhythmic fluctuations of the cerebrospinal fluid (CSF), mobility of the cranial bones and dural membranes, and involuntary motion of the sacrum. The CST practitioner palpates the skull, senses pulsations transmitted to the skull by the CSF, gently moves the skull bones relative to each other, and thereby releases restrictions to the flow of CSF, which somehow restores health in an astounding variety of human illnesses.

The thinking of CST practitioners is illustrated by this statement quoted by Edzard Ernst:

When a self-development issue is linked to the illness, it is enough for that issue to be acknowledged by the client (without any further discussion unless the client desires it) for the body to release the memory of that issue – sensed by the therapist as tightness, tension, inertia within the body’s systems – so that the healing can proceed.

Several treatment sessions may still be needed, especially if the condition is a long lasting one. Our bodies’ self-healing mechanisms rely on a combination of the various fluid systems of the body (blood and lymph flow and the fluid nature of the cells making up all the organs and systems within our bodies) and the body’s energy fields. Our hearts generate their own electrical signal independently of the control of our brains. Such signals travel around the body through the blood and other fluid systems. Blood is an excellent conductor of electricity and, when electricity flows through a conductor, magnetic fields are created. It is with these fields that the craniosacral therapist works.

These same fields store the memory of the events of our life – rather like the hard disk on a computer – but these memories can only be accessed when the underlying Body intelligence ‘decides’ it is needed as part of the healing process. There is absolutely no danger, therefore, of more being revealed than is strictly necessary to encourage the client back onto their self development route and to enable healing to take place.

Upledger’s odyssey

I first became aware of Dr. Upledger in 2003, when he was the subject of the first article I ever published, in Skeptical Inquirer. The text of that article is available online. You might enjoy reading the full article. In it, I described Dr. Upledger’s epiphany as he reported it: 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.

That was bad enough, but then he really got carried away. He discovered energy cysts, sound therapy, healing energy that he could transmit from one hand to the other through the patient’s body, dolphin therapy where dolphins touched the therapist and the therapist touched the patient, and the patient’s “Inner Physician,” one of which appeared to the patient in the form of a seagull and asked to be introduced as “Mermaid.”

I got the title of my article “Wired to the Kitchen Sink” from Upledger’s treatment of a patient who had “excess energy.” He grounded her big toe to a drainpipe with copper wire to remove the energy, and it worked to relieve her chronic pain. So he had her husband connect her to the kitchen sink with a thirty-foot length of copper grounding wire so she could get around the house.

The JAOA systematic review

The authors of the review assume their Tooth Fairy is real. They assert that osteopathic manipulation affects the primary CSF respiratory mechanism though techniques that accomplish things like compressing the fourth ventricle. They say that research so far has focused on the reliability of palpation. They cite osteopathic books and articles, including a 1939 book by Sutherland, none of which actually support the reliability of palpation. And they do not mention the several studies showing that palpation is unreliable.

Bypassing the question of whether CSF fluctuations exist, and bypassing the subject of reliability, they forge ahead to review randomized controlled trials and observational data to describe the clinical benefit of cranial OMM (osteopathic manipulative medicine) in patients with a variety of pathologic conditions. Note: they want to describe the clinical benefit, not to ask whether there is a real clinical benefit.

Starting with 159 studies, they excluded those that failed to meet the inclusion criteria and ended up with 8 studies: 7 randomized controlled trials (RCTs) and one observational study. The number of subjects ranged from 9 patients to 142 patients. Four studies did not mention the manual techniques used. Treatment duration ranged from 1 minute to 30 minutes, from a single treatment to 6 months. Four studies were in healthy subjects; four used patients with different ages and a variety of conditions, from infants with colic to adults with myopia.

The most common finding was improvement in sleeping patterns. For pain, there was a positive outcome for adults with tension headaches but not for children with cerebral palsy. One study showed reduction of crying and “required parental attention” in infants with colic. Three studies did not have meaningful clinical endpoints (for instance a study of the effect of CV-4 technique on blood velocity).

They actually admit that the available evidence is heterogeneous and insufficient to draw definitive conclusions, but they nevertheless remain convinced that OMM is an effective and clinically beneficial treatment modality for patients of all ages. Their bias is glaringly obvious, and of course they end by calling for further research.

The SRAM analysis

Jakel and Hauenschild do not mention the incisive 2002 study “Interexaminer Reliability and Cranial Osteopathy” published in the Scientific Review of Alternative Medicine (full text available online). It showed that claims of inherent rhythmic motility of the brain and spinal cord are scientifically groundless, that the only fluctuations in CSF are reflections of the patient’s respiration and heart rhythms, and that the skull bones are fused together in adults and cannot move relative to one another. Inter-examiner reliability was non-existent: different examiners reported different “cranial rhythms” for the same subject and each single examiner tended to report very similar rates for every subject examined. So the reported rhythms obviously depended on the examiner and had nothing to do with the patient. They rejected the results of a study by Upledger that allegedly showed interexaminer reliability, offering more likely explanations his apparent success and saying that his study shows extraordinary evidence of careless and poor design.

They comment:

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 achieve the 21st century without scientific support of any kind.

A Later, More Skeptical Systematic Review

A 2012 review by Edzard Ernst found that low quality studies with a high risk of bias suggested positive effects, while the highest quality trial failed to demonstrate effectiveness. He concluded: “The notion that CST is associated with more than non-specific effects is not based on evidence from rigorous RCTs.”

Is it safe?

In most cases it probably is safe. The manipulations are gentle and the treatment may have a relaxing effect. But at least two deaths have been reported, one in an epileptic woman who was treated with cranial therapy and was told to stop her seizure medication, and one in a 2 day old infant who was treated with cranial manipulation in lieu of conventional treatment for a high fever (a life-threatening medical emergency in a child of that age). The cause of death was a subdural hematoma likely due to the manipulations.


Stephen Barrett was right: cranial therapy is silly. Its underlying theory is false, it has no therapeutic value, and its safety is questionable. Systematic reviews like the one by Jakel and Hauenschild are unfortunate because they lend an aura of scientific respectability to nonsensical treatments and encourage wasting money on Tooth Fairy Science.

This article was originally published in the Science-Based Medicine blog.

Dr. Hall is a contributing editor to both Skeptic magazine and the Skeptical Inquirer. She is a weekly contributor to the Science-Based Medicine Blog and is one of its editors. She has also contributed to Quackwatch and to a number of other respected journals and publications. She is the author of Women Aren’t Supposed to Fly: The Memoirs of a Female Flight Surgeon and co-author of the textbook, Consumer Health: A Guide to Intelligent Decisions.

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