Craniosacral Treatment

Case Study 5
 

 
 
(Crombie, I., Croft P. et al, 1999)
 

HYPOTHESIS:
Craniosacral treatment will alleviate temporomandibular dysfunction symptoms.

Carrie Kause | Manual Osteopathic Therapists Program | June 6, 2020

Discussion Page 14
Conclusion Page 15
Bibliography Page 15

ABSTRACT

2
 People can experience many symptoms of pain or discomfort in multiple areas at once.

In our clinic we have clients who experience multiple symptoms over time; one or two

symptoms diminish, but then may come back with the other symptoms are still present. The

symptoms become a chronic issue resulting in other symptoms such as stress when the client

does not experience long term results. A specific example of this is temporomandibular

dysfunction (TMD) symptoms. A client experiencing TMD may encounter multiple symptoms.

Symptoms not only include pain at the joint itself, but also dysfunctions in other areas of the

body such as headaches, back pain, postural dysfunctions, and stress. The question is which

came first the chicken or the egg? Are the symptoms for TMD or is TMD symptoms from

another lesion? As many lesions can cause similar symptoms, finding a treatment that can

facilitate the body to heal itself through self regulation would be beneficial. Learning

craniosacral techniques as a manual osteopathic student developed an interest to further explore

how temporomandibular dysfunction could be influenced by craniosacral techniques as both the

temporal and mandible bone are not only the location of the temporomandibular joint, but are

also an area of treatment for craniosacral therapy.

The purpose of the case study was to determine if treating a client diagnosed with a

temporomandibular disorder with craniosacral techniques would reduce symptoms. The client

was specifically chosen for this case study with the following criteria: she had been diagnosed

with temporomandibular disorder by her orthodontist, she has tried multiple treatments such as

physiotherapy, intra-oral massage, muscle energy techniques and acupuncture. All treatments

were successful for a reduction in symptoms short term, but no long-term results have occurred.

The results of the case study were positive with a reduction in symptoms typically

experienced with TMD plus a reduction in other symptoms the client was also experiencing that

3
were not identified as direct symptoms of the disorder. Continued treatment over time and a

longer period of recording results would confirm the reliability of the case study results.

INTRODUCTION

In 2015, temporomandibular joint disorder (TMD) pain symptoms were found to be the

third most chronic pain condition after tension headaches and back pain worldwide (Maisa

Soares, M. & Rizzatti-Barbosa, C. 2015). Approximately, 33% of the Canadian population have

at least one TMD symptom with 3.6 - 7 percent of the population seeking medical treatment due

to severity of symptoms. People between twenty and forty years old were most prevalent with

symptoms (Wright,2010). According to the American Dental Association, "...the sex distribution

of pain is approximately twice as common in females as males." (Lipton, J et al. 1993).

The mandible bone is connected to the temporal bone at the temporomandibular joint.

It is a hinge joint that allows movement of depression and elevation, protraction, and retraction,

and lateral deviation of the mandible. Movement of the mandible includes the following muscles.

masseter, temporalis, diagastric, lateral and medial pterygoid, and the suprahyoid muscles. The

primary ligament is the temporomandibular ligament and accessory ligaments include the

stylomandibular and sphenomandibular (Biel, A. & Dorn, R. 2010).

Temporomandibular disorder (TMD) symptoms include joint and muscle pain and

headaches. Chronic symptoms of pain or difficulty moving the jaw may affect talking, eating and

swallowing.  This may affect a person’s overall sense of well-being leading to depression

or anxiety. Signs of dysfunction include joint sounds (popping, clicking, and grating). The jaw

may visually lock in an open or closed position. The most common cause is muscle tension and

4
spasm often triggered by stress and anxiety. Stress related habits of clenching or grinding

teeth, nail biting and excessive gum chewing can tire the jaw muscles and create a cycle

of pain. Muscle tension surrounding the temporomandibular joint can also be caused by

internal joint structure issues. This can include problems with how the joint is shaped, a

degenerative disease, displacement of the disc that cushions the joint, and scar tissue or

bone damage by an injury to the jaw or face (Husney, A. MD, O'Brien, B. MD, and el.,

2018). The consequence and impact on a person with temporomandibular pain can be long-term

and affect the psychological state and social well-being of the symptomatic person. Persistent

pain can affect all aspects of their life including their social and family life, work and

recreation (Raghavendra, P et al. 2016).

The Canadian Dental Association treatment recommendations are prescribed medication,

physiotherapy, splints prescribed by a dentist, dental procedures such as shaving down teeth or

extracting teeth. Self-care such as rest, ice or heat backs and eating soft foods are also

recommended as treatment (Canadian Dental Association, 2020). Some alternative treatments

include nutrition and supplements, chiropractic, acupuncture, intraoral massage, biofeedback,

osteorarticulation, mental health services and craniosacral therapy (Bronfort, G et al. 2010).

Craniosacral techniques help restore a balanced craniosacral rhythm which in turn can

help change neurological patterns of the brain and therefore affect the rest of the body.

According to Upledger and Vredevoogd, the nervous, musculoskeletal, vascular, lymphatic,

endocrine, and respiratory system may be influenced by and have a close relationship with the

craniosacral system (Upledger & Vredevoogd, 1983). Some of the craniosacral treatments use

direct contact in hand placement with the temporal and mandible bones which are in turn

connected to the temporomandibular joint. This direct connection was one reason the therapist

5
came up with the hypothesis that craniosacral treatments would have direct indirect to reduce the

symptoms of temporomandibular dysfunction.

 
METHODS
One client participated in the case study. The 18-year old client first noticed symptoms of jaw

pain at the temporomandibular joint in 2017. After first five years of wearing orthodontic

appliances including spacers, retainers and braces the temporomandibular joint began to lock and

the client was referred to a specialist as the opening of the mandible was under 25 mm. She

wore an appliance for a total of eight years. The client has received intra

oral massage therapy, acupuncture, and physiotherapy treatments for TMD.  All have provided

temporary relief, but the client expressed discomfort in receiving those procedures.

Physiotherapy using muscle energy techniques had the longest positive outcomes for the

reduction of symptoms when going every three weeks for a period of three months.  The cost

was not covered by insurance and was no longer a viable option. M was diagnosed with general

anxiety disorder in 2018 and currently takes prescribed medication, exercises daily and practices

yoga as treatment. Current symptoms include locking and clicking at the temporomandibular

joint region on the right side. Bilateral joint pain, and a decreased opening of the mandible

compared to after previous treatments. Other symptoms that the client is experiencing is

occasional headaches (two to three a month), pain above the right eye, pain between the scapula,

tenderness above the right hip, intermittent pain in the glute area and radiating down her right

leg. She was also experiencing increased tiredness and irritability and trouble sleeping for more

than three hours at a time.

was provided by the client. Their identity was assured to be protected. Short and long-term goals

6
were discussed with the client and the goals along with the assessment results were included in

the client's charts. Short term goals included a reduction in symptoms immediately on the

completion with a non-invasive treatment. Long term goals included options for continue care

with the therapist and directed self- care to maintain any reductions in temporomandibular joint

disorder symptoms.

The client received one sixty-minute treatment including a general, structural, and

functional assessment and craniosacral treatments. Reassessment occurred immediately

after the treatment and a reassessment of symptoms again twenty-four hours later. The client has

received treatment for this condition previously from the therapist so intake forms were checked

for updates or modifications.

The client's physical assessment included: 

a. Global assessment performed in standing, sitting, and prone positions. This was used

to identify visual postural and general dysfunctions. 

b. Mitchell's Testing structural assessment in standing, sitting, prone and supine positions to

identify lesions in the pelvis, vertebrae, and limbs in neutral, flexion and extension.

c. Functional assessment for passive range of motion of the lower limb using

passive techniques in supine and prone positions to identify lesions in both inert and

contractile tissues.

d. Functional assessment using muscle energy techniques in prone and supine positions to

identify fatigue and lesions of contractile tissue (Chaitow 1996).

e. The opening measurement between the first incisor and Mandibular depression

was measured and recorded before and after treatment as well as structural and functional

assessments after treatment were performed and any changes were noted.

7
The assessments were recorded in the client's chart. General Osteopathic, Mobilization, Muscle

Energy Techniques, and Specific adjustment techniques were not applied as not to affect the

results of craniosacral treatment.

The therapist then applied craniosacral therapy (CST) methods with client in supine position

as follows: 

Listening Stations (to assess the Craniosacral rhythm of the whole body)

This is done bilaterally. The therapist asks to be shown the craniosacral rhythm. Hands placed

gently on listening stations with 5 grams of pressure.

1. Dorsum of feet
2. Heals of feet
3. Anterior Superior Iliac Spine (ASIS)
4. Lower Ribcage
5. Shoulders

Diaphragm assessment and release

a. Pelvic diaphragm release – therapist's posterior hand placed under the client at S1/S2
and

therapist’s anterior hand placed just superior to clients’ pubic tubercle up to the belly

button. Holding until tissue release was felt. 

b. Respiratory Diaphragm release - therapist sitting at lateral side of table with palm of

hand on posterior aspect of client and palm of the other hand on anterior aspect of client.

Pressure between therapist’s posterior and anterior hands was just enough to feel

client’s tissue pushing back. Therapist’s intent also directed energy between the two

palms. 

c. Thoracic diaphragm release – therapist's posterior hand placed under the client's C7-
T1
and second digit and thumb of the top hand placed on both clavicles with the rest of the

8
 hand resting on the manubrium. Holing until tissue release was felt. 

d. Hyoid diaphragm release – therapist's posterior hand placed under the cervical spine

touching the client's occiput and C1 /C2. The anterior hand of therapist was under the

client's chin gently grasping the hyoid bone with the thumb and second finger. Lifting

anterior and slightly inferior. Holding until tissue release was felt.

Vault Hold #1 was applied with the client supine and the therapist sitting at the cephalad end of

the table, to assess the craniosacral wave for ‘SQAR’. (Symmetry of movement on left vs right.

Quality of movement; Amplitude of movement; Rate – timing of flexion vs extension vs pause

in between). 

Dural Tube Traction from Occiput -therapist sits at the side of client laying supine. The palm

of both hands cradled the occiput and gently added 5 grams of pressure in the cephalad direction.

Occipital Cranial Base release – therapist sat at cephalad end of table.

a) both hands together and under clients’ occiput. Gentle anterior pressure towards C1 was

applied up to a total of five grams pressure.

b) Therapists’ fingers moved posterior to C1, hands held together. Wrists and fingers

pointing straight towards the eyes creating a platform and lifting the occiput off the palms

of the hands. Waiting until the head drops back into the palms.

c) Therapist placed index fingers on C1 and fingers 3 and 4 contact the occiput.

Decompress the occiput from C1, tractioning the occipital in the superior direction.

d) With therapist’s finger pads on the occiput and client’s head resting in the palms of both

hands, laterally spread fingers.

Temporal Bone Evaluation – therapist sat at cephalad end of table

a) Circumferential motion – On both sides place middle finger into the external auditor

9
 meatus with the index fingers on the zygomatic processes of the temporal bones and the

ring fingers on the mastoid processes. Assess SQAR and follow the rotation until

synchronized.

b) Medial-Lateral Wobble – Bilaterally place thumbs on the mastoid processes, and the

finger pads resting on the occiput. Palpate SQAR and follow the flexion/extension of the

temporal bones until synchronized.

Occipital-Mastoid Release – one hand stabilized the occiput. The other hand wraps around the

cartilage of one ear (same side as the hand) and applies gentle traction in a posterolateral

direction (45 degrees) until a floating and separation of the temporal bone is felt. The technique

was applied to the other ear.

Ears pull – Bilaterally the therapist placed thumb of each hand in the inferior aspect of the

client’s ear and gently apply traction bilaterally in a posterolateral direction. Follow the

movement until synchronized.

TMJ Compression/Decompression The therapist sat at cephalad end of the table.

a) Compression - Working bilaterally, the 3rd and 4th digit were placed on the ramus

of the mandible. Gentle superior compression was applied until full compression was felt.

b) Decompression – Therapists hands placed in the same position as in TMJ

compression step above. Gentle pressure in the caudal direction was applied to the mandible

until the therapist felt it float freely.

Sphenobasilar Decompression

De-compression - The client was supine, and the therapist sat at cephalad end of the

table holding client in Vault Hold #3. The therapist’s thumbs were placed on the great
wings

10
 of the sphenoid and fingers were wrapped posteriorly around the occiput. Follow the

cranial rhythm extension, neutral, flexion, neutral, extension, neutral. The therapist then

applied gentle pressure to the sphenoid medially and anteriorly (towards the ceiling) until

the sphenoid floats freely.

Hard Palate Evaluation and Balancing - therapist wore a glove on the hand placed in the

mouth.

Placed bottom gloved second digit and third digits gently flat resting on the top bite and the top

hand placed on the sphenoid. The hand on the sphenoid follows the cranial rhythm like

sphenoid decompression. Follow extension, neutral, flexion, neutral, extension, neutral. The

therapist then stabilized the sphenoid. The fingers involved in the month followed the greatest

movement, going to the barrier, nudging, and waiting for further release. The movement was

followed back to neutral and then moved into the smallest movement, going to the barrier and

nudging. Following back to neutral and then released. This was done in flexion and extension,

torsion (rotating left and right), shear (lateral movement to the right and left) and disimpaction.

drawing the whole bite in the anterior direction toward the ceiling, while bracing the sphenoid.
 
Vomer – therapist wore a glove on the hand placed in the mouth.

Place second digit gently on the vomer (roof of the mouth) and the top hand placed on both

sphenoid. The hand on the sphenoid follows the cranial rhythm like sphenoid

decompression. Follow extension, neutral, flexion, neutral, extension, neutral. The therapist then

stabilized the sphenoid. The treatment involved following the greatest movement, going to the

barrier, nudging and waiting for further release. The movement was followed back to neutral

and then moved into the smallest movement, going to the barrier and nudging. Following back

to neutral and then released. This was done in flexion and extension, torsion (rotating left and

11
right), shear (lateral movement to the right and left) and disimpaction, drawing the vomer in the

anterior direction toward the ceiling, while bracing the sphenoid.

Palatines –Therapist wore a glove and stand at cephalad to the client.

Place second digit on one side of the maxilla on top of the teeth. Going to the end where the

therapist felt the last tooth, the therapist slid off to the inside of the mouth into the palatine. Felt

with intention, the therapist moved superior, lateral, medial, bring it back to neutral and then

bring it back inferior. The technique is applied to the other side.

Rebalance hard palate in flexion and extension. (Manary, D. DC, MOT & Diminutto, D. RMT,

BSC, CCSE, CST-T., 2020)

time management was demonstrated in the write up of the case study. Delayed write up caused

decreased recall in research evidence to support case study. The client was not charged for the

treatment as they were a family member. Due to the Covid-19 pandemic the MOT was required

to self distance and temporarily discontinue treatments with clients.  As the case study recipient

was part of the MOT household, the client was able to receive treatment that would otherwise be

unavailable during this time and the MOT was able to continue practising craniosacral

treatment. The client had the benefit of receiving treatment for a condition that treatment

otherwise would be unattainable due to it being considered a non-emergency condition. The

therapist benefited by having a client to work as treatment was only permitted to family members

in the same household during the state of emergency.

RESULTS

12
 
Table 1. Summary Table for Pain at the Temporomandibular Joint
 
 Pain scale out of /10 Pre- Post Treatment 24 hours
Treatment Post
Treatment
Right side 8/10 4/10 0/10
Left side 7/10 6/10 1/10
 
 
 
Table 2. Summary Table for AROM Depression of Mandible
 
  Pre-Treatment Post Treatment 24 hours
Post Treatment
Measurement of opening in mm 32 mm 40 mm 47 mm
 
 
 
Table 3. Summary Table for Additional Symptoms
 
Location / nature of symptoms. Pre-Treatment Post Treatment 24 hours
Post
Treatment
Head Pain above Right Pain above Right None
eye eye
Jaw      
Clicking Audible Audible Audible
Upper back pain Between None None
  scapula
Lower back pain      
Quadratus lumborum Right side Right side None
region Radiating down Decreased intensity None
SI joint back of leg
Cranial nerve symptoms      
Headache None Yes, felt bilaterally None
front cranial region
Systemic      
Fatigue Yes Yes No
Irritability Yes No No
Insomnia Waking up every N/A Slept 6 hours
3 hours straight
 
 
After the craniosacral treatment, the client’s pain felt at the temporomandibular joint decreases

13
and the mouth opening measurement with active mandible depression increased. Other changes

noted were there was no pain between the scapula, decreased sciatic pain felt in the gluteal

region and the client felt relaxed instead of irritable. A new symptom of a headache presented

itself immediately after treatment though. Twenty-four hours later the client felt no pain at the

joint and the client achieved a further increased opening of the mandible. Other positive

changes in symptoms were no headache present, no pain above the left eye and right quadratus

lumbar region, the client slept for six hours straight that night, and the client no longer felt

irritable.
 
 

DISCUSSION
 
Limitations of the case study include the short duration, only one treatment and the results

applied to short term only. There was no long term follow up to assess if the short-term gains

still applied. The sample size was small including only one participant. A larger sample might

have led to some differences in result. The therapist is inexperienced in the skillset for

craniosacral techniques. The applied techniques and assessment of the craniosacral rhythm could

have be inaccurate. In the article TMJ: Primary Problem, or Tip of the Iceberg, Upledger states,

"My own experience with TMJ dysfunction leads me to believe that the condition is often a

secondary or tertiary manifestation of another problem somewhere in the body"(1). Addressing

structural pelvic lesions along with craniosacral techniques could be another case study to

explore as there is a direct relationship with the sacrum and the sphenobasilar symphysis (Richter

& Hebgen, 51).

Resources for stress management practises such as yoga, mindfulness, and meditation could be

given as well as a mental health resources for stress management. Continued contact with her

14
dentist for checkups and doctor would be encouraged as treatment is focused on the client as a

whole.
 

CONCLUSION

This case study showed that craniosacral techniques demonstrated a reduction in

temporomandibular joint disorder symptoms, including a reduction in TMJ pain and an increase

in the joint range of motion after two treatments of craniosacral therapy. The therapist will

continue to explore and add craniosacral techniques to their treatment of temporomandibular

joint disorder along with previous therapeutic treatments including intraoral massage, muscle

energy and myofascial techniques. However due to the short duration of treatment, small sample

size, and the therapist’s inexperience performing the techniques, the results should be interpreted

with caution.

BIBLIOGRAPHY

1. Biel, A., & Dorn, R. Trail Guide to the Body; A Hands-On Guide to Locating Muscles,

Bones, and More. Bouler, CO, Books of Dicovery, 2010.

2. Brondfort, g., Haas, M., Evans, R., Leininger, B., Triano, J. “Effectiveness of manual

therapies: the UK evidence report. Chiropr Osteopat. 2010; 18:3.

3. Canadian Dental Association, 2020; Date of access: 2020 May 15. https://www.cda-

adc.ca/en/oral_health/talk/complications/temporomandibular_disorder/

4. Chaitow, L, Muscle Energy Techniques, 4th edition, Elsevier, Churchill, Livingstone,

1996. Crombie, I., Croft, P., Linton, S., et al, Epidemiology of Pain. Seattle, WA: IASP

Press; 1999: 171-202.

15
https://en.wikipedia.org/wiki/Oral_medicine#/media/File:Orofacial_pain_Lateral_head_skull.jpg

5. Husney, A. MD., O'Brien, B. MD. Gabica, M MD., Romito. K. MD., Russo, E. MD.,

Christen, A. DDS, MSD, MA, FACD. "What are temporomandibular disorders (TMDs)?"

Myhealth.Alberta.ca Network. 2018; Date of access: 2020 May 15.

https://myhealth.alberta.ca/Health/pages/conditions.aspx?Hwid=hw209469

6. Lipton, J., Ship, J., Larach-Robinson, D. "Estimated prevalence and distribution of

reported orofacial pain in the United States." J Am Dent Assoc. 1993; 124; 115-121.

7. Maisa Soares, G. & Rizzatti-Barbosa, C. "Chronicity factors of temporomandibular

disorders: A critical review of the literature." Braz Oral Res. 2015; 29: pii: S1806-

83242015000100300.

8. Manary, D. DC, MOT. & Diminutto, D. RMT, BSC, CCSE, CST-T. "Involuntary

Mechanism Module." Trainee Guide, MOCC, 2020.

9. Rghavendra, P., Ravi, K., Shruthi, H., Kalavathi, S. "J Oral Maxillofac Pathol. 2016

May-Aug: 20: 272-275. doi: 10.4103/0973-029X.185902.

10. Richter, P. & Hebgen, E. "The Movements and Dysfunctions of the Craniosacral

Mechanism." Trigger Points and Muscle Chains in Osteopathy, Theime; 2008; 51.

11. Wright, E. Manual of temporomandibular disorders, 2nd ed. Ames, la.: Wiley-Blackwell.

2010.

12. Upledger, J. DO. & Vredevoogd, J. MFA. Craniosacral Therapy. Seattle; Eastland Press,
1983: 5-6.
 

16