Cranial Manipulative Therapy

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Some Notes on Cranial Manipulative Therapy

William T. Jarvis, Ph.D. Cranial osteopathyalso known as craniosacral therapywas developed by William G. Sutherland, DO, who published the first article on this subject in the early 1930s. Cranio refers to the head, sacral to the base of the spine. The "craniosacral system" encloses the spinal cord, cerebrospinal fluid, meninges, and bones of the skull and spine. Craniosacral proponents claim: The human brain makes rhythmic movements at a rate of 10 to 14 cycles per minute, a periodicity unrelated to breathing or heart rate. Small cranial pulsations can be felt with the fingertips. Interference with the normal flow of cerebrospinal fluid is a common cause of disease. Freeing up these restrictions allow the body to return to normal. This is accomplished by tapping the the skull with fingertips (the "tap" is a solid, attention-getting, nonpainful blow to the side of the head). Today's leading proponent is John Upledger, DO, who operates the Upledger Institute of Palm Beach Gardens, Florida. Upledger has published several articles on craniopathy, but his work is not generally recognized as valid by the scientific medical community. The most comprehensive criticism was published in 1999 by the British Columbia Office of Health Technology Assessment (BCOHTA), which concluded that the theory is invalid and that practitioners cannot reliably measure what they claim to be modifying [1]. Dental Usage Viola Frymann, DO, has promoted cranial osteopathy among dentists; and cranial manipulative therapy is now practiced by a small number of fringe dentists who refer to themselves as "holistic" practitioners. Following a continuing education course presented by Dr. Frymann, Stanley M. Sokolow, DDS, wrote an open letter describing the course that was published in the Santa Clara County Dental Society's newsletter. Dr. Sokolow's letter provides both insight and thoughtful criticism of cranial osteopathy: I have just come home from the continuing education course by Dr. Viola Frymann, sponsored by the Mid-Peninsula Dental Society. Those of you who were there will remember that I am the orthodontist who asked all of those pointed questions. I would like you and the other members of our Society to know that am disappointed by the behavior of almost everyone there, with he commendable exception of Dr. Robert Lundquist. By granting us a license to practice, the public trusts us to apply knowledge to treatment of their dental problems. This implies that we must critically examine new ideas, decide if there is rational evidence for them, reject the bunk, and apply the knowledge that sifts through. After observing so many of the audience accept or not challenge the unsubstantiated, illogical statements of Dr. Frymann, I am shocked. Those who actually accept her arguments should read a book on epistemology and the philosophy of science, that then rethink her logic. For those who have not heard about Dr. Frymann's field, Cranial Osteopathy, here are a few of its tenets which I had to question:

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1. The human brain makes rhythmic movements at a rate of 10 to 14 cycles per minute, a periodicity unrelated to the breathing or heart beat. (The entire field of scientific neurophysiology, with all of its high-tech instrument, has not yet observed the fundamental rhythm, but cranial osteopaths can feel the small pulsations of the skull with their finger tips. They can't explain the motive force, though.) 2. The brain thus rhythmically moves the cranial bones. These movements at the most are on the order of .0005 to .0010 inch, but cranial osteopaths don't need to measure or record them because their trained fingers are more sensitive than any instrument man can devise. (When I said that all sciences attempt to quantify, and that there are measuring instruments far more precise than any human senses, many in the audience came to Dr. Frymann's defense.) 3. Restrictions at the sutures, which interfere with the normal pulsation, are a common cause of disease, deformity, and dysfunction. Manipulation of the cranial bones by the trained osteopath's hands can "free up" these restrictions and allow the body to return toward normal. (Her only evidence is anecdotal: isolated case reports; no pretreatment/posttreatment measurements, no statistics, no control groups.) 4. Conventional orthodontic appliances (such as the Edgewise appliance) "bind" the halves of the maxilla together, thus restricting cranial bone motion and causing innumerable dysfunctions, including impaired vision. Dr. Frymann claims orthodontic retainers don't bind the maxilla, os therefore, she recommends removal of orthodontic appliances as part of her osteopathic treatment.(Acrylic retainers are far more rigid than the transpalatal elasticity of the Edgewise arch. The force required to change the width of an archwire by .0005 to .0010 inch must be on the order of micrograms. She could not give any evidence of "binding.") Acceptance of these conjectures as fact, without challenge, is a professional disgrace. Even when asked, Dr. Frymann could not produce any scientific evidence to back up her claims. I'll be delighted to buy any one of her disciples the finest meal in our area if he or she can show me any good experimental data that supports Dr. Frymann's statements. Cranial osteopathy, like applied kinesiology, has gained some degree of acceptance among dentists. Those who believe, do so with a religious fervor. Recognize it for what it is: faith healing, not medical science [2]. In 1992 and 2000, the Osteopathic Medical Board of California placed Frymann on probation for exdangering the lives of two infants whom she treated with cranial manipulation instead of appropriate medical care [3]. Chiropractic Usage Cranial manipulative therapy is also practiced by a small faction of chiropractors. Chiropractors call their version craniopathy, but the mechanisms are the same for practical purposes. The osteopaths credit W.G. Sutherland, DO with the theory and application the technique. He presented it at a meeting of the American Osteopathic Association in 1932 [4] The chiropractors credit Nephi Cottam, DC, with discovery and development of the technique "in the 1920s." His son Calvin Cottam, DC, acknowledged that cranial osteopathy and chiropractic craniopathy were essentially the same thing, but said that his father's first professional seminar on the topic was on January 27, 1929, and Sutherland's was eight months later on September 27, 1929 [5]. Chiropractic journals carry articles about craniopathy, but do not provide scientific

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information. Craniopathy was renamed Sacro-Occipital Technique by chiropractor Major B. DeJarnette, who associated with Dr. Sutherland in the 1920s. New York chiropractor, Carl A. Ferreri, developed a version of cranial manipulative therapy that he named "Neural Organizational Technique" (NOT), for treating dyslexia, other learning disabilities, bedwetting, nightmares, scoliosis, Down's Syndrome, cerebral palsy, color-blindness, and various other problems. According to Ferreri, the bones of the skull move with respiration through a complicated arrangement of connective tissue bands. He theorized that dyslexia is caused by faulty motion in three of the four motions of the sphenoid bone in the center of the skull, and at least one of the temporal bones. Learning disabilities, he said, involve only two sphenoid motions and no temporal bone faults. Misalignment of the skull bones can also result in "ocular lock" making reading difficult, according to Ferreri. Ferreri also described a "disequilibrium" involving a problem in the "cloacal reflexes" located in the pelvis which allegedly coordinate with the visual and labyrinthine righting systems. NOT relied on the invalid muscle-testing procedures of applied kinesiology to persuade people that improvement was occurring. Despite an absence of scientific evidence, and lack of endorsement by any recognized organization that deals with learning disorders, Ferreri was able to convince the school psychologist, Roy Krause, of the Del Norte school district (Crescent City, Calif) that his method held promise for the learning disabled children of his district. Krause convinced the school board to allow Ferreri to set up a research project in which chiropractors would manipulate children's skulls in an attempt to rid them of their learning difficulties. Rather than focusing upon a single type of problem, the children included a mix of disorders. The method involved holding the child in a headlock and pressing on the roof of their mouths with the hope a achieving a click. Thumbs were also pressed into the children's eye-sockets. Parents were assured that the method would only possibly cause "momentary and temporary discomfort" in the consent forms they were asked to sign. The reality turned out to be far different. One parent, who helped restrain her child during therapy, testified that the chiropractors applied such tremendous pressure to her son's skull and roof of mouth that they would break into a sweat and shake with exertion. Children were exposed to such pain that children who had never had seizures, had them now. Children with a history of seizures, were having increased episodes of these. A lawsuit brought against Ferreri by the parents resulted in a $565,000 judgment for damages, plus attorney's fees. The Del Norte experience is worthy of detailed study because it represents a classic example of how convincing a pseudoscientific procedure can be at the outset, coupled with how unacceptable can be its outcomes when records are kept. Unfortunately, most often, a pseudoscience's reputation is built on the initial illusory personal experiences, and generally there is no systematic study done to follow-up. This was not the case at Del Norte, and the outcomes outrageous. Osteopathic Attitudes Several papers have been published on the alleged mechanisms of cranial manipulation, but fail to answer the important consumer health questions of safety and efficacy. In 1987, I mailed the following questions to researchers at Michigan State University College of Osteopathic Medicine (MSUCOM): Is cranial osteopathy a valid therapeutic procedure for any condition? Should cranial osteopathy be marketed to the public as a preventive or therapeutic procedure? Should cranial osteopathy be limited to experimentation only? Are students at MSUCOM taught cranial osteopathy procedures? If so, how are they directed to use the procedure? [6] Having received no response from MSUCOM, I sent the following questions to the American Osteopathic

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Association (AOA): Does the AOA consider cranial osteopathy to be a valid preventive or therapeutic procedure for any condition? If so, which conditions? Should cranial osteopathy be marketed to the public as a preventive or therapeutic procedure (ie, as opposed to being classified as "experimental" meaning that patients should be informed of its unproven value and not charged a fee for the service? Do osteopathic colleges teach cranial osteopathy procedures? If so, how are students directed to use them? [7] The AOA also failed to acknowledge my letter or respond to these questions. Conversations with faculty members at two osteopathic colleges brought the commonly-held opinion that the mainstream DOs do not believe in cranial osteopathy, but do not want to make the matter an open issue. Apparently, cranial osteopathy is more a belief system than a science. This seems to support Dr. Sokolow's view that it is a form of faith healing. Conclusions The term "cranial manipulative therapy" covers more than a single theory or application. Although cranial osteopathy can point to some basic research, it falls far short of what is needed to establish a scientific foothold. Chiropractic applications are woefully lacking in any substantive research. All lack evidence that they are safe and effective for specific conditions, and because of they involve intense physical contact by a practitioner, and expectations on the part of both the provider and patient, all have potential as a form of suggestive therapy. This has been pointed out to NCAHF by practitioners who have used the "skull tap" as a method of conditioning. Hands-on techniques seem to have a special ability to deceive both practitioners and patients. Another factor to be considered is the nature of the conditions being treated. With behavioral problems, merely taking a new approach to them may change things. When attention is diverted from the misbehaving individual to an effort to improve the situation, good things may happen. If improvement is noted, the client is apt to accept the explanation offered. But do measurable improvements occur, and do they last? People often provide testimonials during the emotional "honeymoon" of a new approach, rather than waiting to judge the long-term effects that really count. References 1. Kazanjian A and others. A systematic review and appraisal of the scientific evidence on craniosacral therapy. BCOHTA, May 1999. 2. Sokolow SM. An open letter on Dr. Viola Frymann's course. Elevator, 1983;18(7):5, 1983. 3. Barrett S. Some Notes on Viola M. Fryman, D.O. Quackwatch, Jan 26, 2003. 4. Morey LW. Use of cranial manipulative therapy. Osteopathic Medicine, July, 1978, pp 43+. 5. Cottam C. Use your head: the beginnings of cranial/facial adjusting-- the original craniopathy," The Digest of Chiropractic Economics, July/August, 1988, pp 30-34. 6. Jarvis WT. Letters to Upledger and Retzlaff, June 12, 1987. 7. Letter dated August 12, 1988. Additional Resources A study of the rhythmic motions of the living cranium (Frymann) Journal of the American Osteopathic

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Association 70:928-45, 1971. A preliminary study of cranial bone movement in the squirrel monkey (Michael) Journal of the American Osteopathic Association 74:866-873, 1975. Craniosacral mechanisms (Retzlaff) Journal of the American Osteopathic Association 76:288-289, 1976. The detection of relative movements of cranial bones (St.Pierre) Journal of the American Osteopathic Association 76:289, 1976. Uses of cranial manipulative therapy (Morey) Osteopathic Medicine, July, 1978, pp.43+ The relationship of craniosacral examination findings in grade school children with developmental problems (Upledger) Journal of the American Osteopathic Association 77:760-776, 1978. Mechano-electric patterns during craniosacral osteopathic diagnosis and treatment (Upledger) Journal of the American Osteopathic Association 78:782-791, 1979. Manipulative medicine in dentistry: a new potential for diagnosis and treatment (Harakal) J Craniomandibular Pract 3:63-68, 1984. CraniopathyA path to health (Ben-kiki) Health Freedom News May, 1984 Free cranial clinic for newborns (Ross chiropractic) promotional flyer explaining craniopathy, 1988. Richard Bernard: craniopathist in Marin (Kester) Independent Journal, undated. (Feature article describing the claims of chiropractor Richard Bernard) Hartman SE, Norton JM. Interexaminer reliability and cranial osteopathy. Scientific Review of Alternative Medicine 6(1):23-34, 2002. Neural Organizational Technique Dyslexia and learning disabilities cured (Ferreri) Health Freedom News Oct, 1983, pp.38-89. (The original article that duped Roy Krause.) Dyslexia and learning disabilities: update (Ferreri) Health Freedom News, Feb, 1984, pp.34-5. The Crescent City cure (Cooke) Hippocrates, Nov-Dec, 1988, pp.61+ (Detailed account of the Del Norte experience with pictures. Well written, many first-person quotations) Neural Organizational Technique, treatment or torture? (Worrall) Skeptical Inquirer 15(Fall):40-50, 1990. (Thorough description and scientific analysis by a clinical professor of optometry at the University of California Berkeley who tracks various methods that allege to help developmentally handicapped children. Dr. Worrall is also an member of the NCAHF board of directors) Ferreri defends protocol in face of media attacks. The Chiropractic Journal, June, 1988 AK takes heat as NOT draws fire; Dr. Goodheart stresses that controversial method is not AK. The Chiropractic Journal, Dec, 1988 Neural Organizational Technique: What is it? (Ferreri) The Chiropractic Journal, April, 1989 Recommended Books Butler K. A Consumer's Guide to "Alternative Medicine." Prometheus, 1992. Magner G. Chiropractic: The Victim's Perspective. Prometheus, 1995. Raso J. "Alternative" Healthcare: A Comprehensive Guide. Prometheus, 1994 Zwicky, Hafner, Barrett, Jarvis. Reader's Guide to "Alternative" Health Methods. American Medical Assoc., 1993. Copyright Notice 2001 National Council Against Health Fraud. With proper citation, this article may be reproduced for

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This article was posted on September 11, 2001.

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