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Osteopathy in the cranial field (abbreviated OCF, also called cranial osteopathy or cranial-sacral osteopathy) is a method of alternative medicine used by osteopaths who assess and enhance the function of the patient's health by accessing their primary respiratory mechanism and working with various rythms inherent in the connective tissue and fluid systems of the body. Some published work suggests that the involuntary motion palpated by osteopaths using OCF is a function of the cardiovascular system. By working with the whole body, including the cranium, osteopaths can remove restrictions in the flow of cerebrospinal fluid and other bodily fluids, relieving stress, decreasing pain, and enhancing overall health.

Although well-established, use of cranial techniques is a contested issue within the osteopathic profession; it is not known what proportion of osteopaths are practitioners. Opponents claim that OCF has been shown to be without scientific basis, and some studies that support OCF have been criticized for poor methodology.

Practice
Cranial osteopaths are trained to feel a very subtle, rhythmic shape change that is present throughout the head and body. This is known as the involuntary mechanism, or the cranial rhythm. The movement is very subtle, and it takes practitioners with a very finely developed sense of touch to feel it. This rhythm was first described in the early 1900s by Dr. William G. Sutherland. The theory underlying cranial osteopathy is rejected by many osteopaths and orthodox medical doctors because it was previously understood that cranial bones fuse by the end of adolescence. Histological studies have however demonstrated the presence of Sharpey's fibres between the adjacent bones forming the sutural margins, and it is known that these specialised fibres form only at areas where tissue movement is allowed. It is accepted by most modern osteopaths working in the cranial field that the spheno-basilar symphysis (a large joint in the skull base) does indeed ossify (turn to bone) and the original principles of OCF have thus evolved in light of increasing knowledge. Tuition of OCF refers to movement remaining within the thin bone of the sutures, and that flexibility within living bone occurs, in contrast to dried specimen bones. The brain does pulsate, but some research suggests this is related to the cardiovascular system. The same study looked at inter-operator reliability of palpating the 'cranial rhythm' and found there to be little agreement, although modern understandings in the cranial field describe a number of simultaneous rhythms with differing rates, relating to different aspects of function.

How this mechanism is related to health and disease is not established. Many without direct experience of the benefits of treatment dismiss cranial osteopathy as pseudo-science. However, OCF is increasingly being recognised as especially suitable for newborn babies and young children, with particularly good results in the treatment of colic and crying. It is claimed that as their bones have not fully fused and hardened, they are more susceptible to the treatment. All in all, this practice appears to be popular with patients with an increasing demand for experienced practitioners.

History
OCF was originated by osteopathic doctor William Sutherland DO (1873-1954), who studied under the founder of osteopathy, Andrew Taylor Still, at the first American School of Osteopathy (now Kirksville College of Osteopathic Medicine) in 1898-1900. While looking at a disarticulated skull, Sutherland was struck by the idea that the sutures of the temporal bones where they meet the sphenoid bones were "beveled, like the gills of a fish, indicating articular mobility for a respiratory mechanism." The idea that the bones of the skull could move was contrary to contemporary anatomical belief. Sutherland spent many years attempting to disprove his theory, applying forces to his own cranium and creating significant disturbances in his own physiology, he placed himself at significant risk of never being able to find a path back to health. Through self sacrifice over 50 years of diligent study, Dr. Sutherland discovered the principles of OCF. Research on himself and on his patients led him to conclude that the bones of the skull do move along their sutures, and any hindrance in movement may be associated with a dysfunction.

After confirming the presence of movement between the bones of the skull, Sutherland evolved the idea that the dural membranes act as 'guy-wires' for the movement of the cranial bones, holding tension for the opposing motion. He used the term reciprocal tension membrane system (RTM) to describe the three Cartesian axes held in reciprocal tension, or tensegrity, creating the cyclic movement of inhalation and exhalation of the cranium. He called this breathing movement the primary respiratory mechanism, and later described its origin as the Breath of Life, from the Book of Genesis (2:7). This was an acknowledgment of the vital force as a fundamental aspect of osteopathic philosophy.

The RTM as described by Sutherland includes the spinal dura, with an attachment to to the sacrum. In his observation of the cranial mechanism, Sutherland found that the sacrum moves synchronously with the cranial bones. The mechanical relationship between motion in the sacrum and the parietal bones has since been confirmed in experiments using electrodes measuring capacitance across parietal sutures of the squirrel monkey.

Sutherland began to teach this work to other osteopaths from about the 1930s, and continued to do so tirelessly until his death. His work was at first largely rejected by the mainstream osteopathic profession as it challenged some closely held beliefs among practitioners of the time. His clinical results were however impressive and he began to attract a small group of osteopathic physicians who studied with him.

In the 1940s the American School of Osteopathy started a post-graduate course called 'Osteopathy in the Cranial Field' directed by Sutherland, and was followed by other schools. This new branch of practice became known as cranial osteopathy. As knowledge of this form of treatment began to spread, Sutherland trained more teachers to meet the demand, notably Drs Viola Frymann, Edna Lay, Howard Lippincott, Anne Wales, Chester Handy and Rollin Becker.

The Cranial Academy was established in the US in 1947, and continues to teach DOs, MDs, and Dentists "an expansion of the general principles of osteopathy" including a special understanding of the central nervous system and primary respiration.

Towards the end of his life Sutherland began to sense a "power" which generated corrections from inside the bodies of his patients without the influence of external forces applied by him as the therapist. Similar to Qi and Prana, this contact with the Breath of Life changed his entire treatment focus to one of spiritual reverence and subtle touch.

In 1953 Sutherland established the Sutherland Cranial Teaching Foundation as a way of providing a continuity for his teaching.

From 1975 to 1983, osteopathic physician John Upledger neurophysiologist and histologist Ernest W. Retzlaff worked at Michigan State University as a clinical researchers and professors. They set up a team of anatomists, physiologists, biophysicists, and bioengineers to investigate the pulse that Upledger had observed and to study further Sutherland's theory of cranial bone movement. Upledger and Retzlaff went on to publish their results, which showed support for both the concept of cranial bone movement and the concept of a cranial rhythm.

Biodynamic osteopathy
The spiritual approach to the work has come to be known as "biodynamic" osteopathy and has had further contributions from practitioners such as Becker and Dr James Jealous. The biodynamic approach recognises that embryological forces direct the embryonic cells to create the shape of the body, and places importance on recognition of these formative patterns for maximum therapeutic benefit, as this enhances the ability of the patient to access their health as an expression of the original intention of their existence.

Biodynamics provides a profound expansion upon OCF.

The Primary Respiratory Mechanism
Craniosacral therapy is originally based on Sutherland's 'Cranial Concept', which proposed a system known as the Primary Respiratory Mechanism (PRM). The basis of PRM function has been summarised in the following five phenomena:
 * Inherent motility of the central nervous system
 * Fluctuation of the cerebrospinal fluid
 * Mobility of the intracranial and intraspinal dural membranes
 * Mobility of the cranial bones
 * Mobility of the sacrum between the ilia

The effect of the above five on the rest of the body is suggested by Magoun as a sixth phenomena.

Inherent motility of the central nervous system

Still described the inherent motion of the brain as a "dynamo," beginning with the cerebellum, a century before electroencephalography (EEG) studies confirmed the presence of this activity. Emanuel Swedenborg was the first to discover inherent motion in the brains of living dogs in the 18th Century. His work has since been verified by human physiologists: according to modern radiological observations the pulsatility of the central nervous system (CNS) is a function of the cardiac cycle, as described by Bergstrand in 1985 using magnetic resonance imaging. The intracranial fluid fluctuation can be seen as an interaction between four main components: arterial blood, capillary blood (brain volume), venous blood and cerebrospinal fluid (CSF). The function of such a mechanism is explained by Lee as being based on a fulcrum created by the root of the cerebellum and its hemispheres moving in opposite directions, resulting in an increase in pressure which squeezes the third ventricle. The pulsation is described as essentially a recurrent expression of the embryological development of the brain. The amplitude and phase of theta rhythms in the cortex of the human brain have been studied using magnetic resonance imaging. High gamma activity has been found to reflect the activation of a local cortical area and is correlated with the blood oxygen level dependent MRI-signal. The much slower theta rhythm is more distributed across the cortex and is associated with novelty, attention, working memory, and exploratory behavior. The strength of the theta-gamma coupling is correlated with variations in a range of cognitive tasks. This suggests a significant physiological role in CNS rhythmical movement.

The motility of the CNS in turn causes a rhythmic fluctuation of the CSF.

Fluctuation of the cerebrospinal fluid

Sutherland used the term "Tide" to describe the inherent fluctuation of fluids in the Primary Respiratory Mechanism. Tide alludes to the concept of ebbing and flowing, but also the contrast between waves on the shore having one rhythm, with the longer rate of lunar tides below. The Tide incorporates not only fluctuation of the CSF, but of a slow oscillation in all the tissues of the body, including the skull.

Practitioners work with cycles of various rates:
 * 10-14 cycles per minute - the original "Cranial Rhythmic Impulse" (CRI) (also described as 6-14 times per minute)
 * 2-3 cycles per minute - the "mid-Tide"
 * 6 cycles every 10 minutes - the "long Tide"

Following on from the work of Swedenborg, Traube and Hering in the 19th Century observed fluctuations in the arterial rates of dogs (the Traube-Hering wave) at similar rates to those reported by cranial practitioners. In 1960 Lundberg made a continuous recording of intracranial activities of traumatised patients, finding three waves, one of which resembles the CRI.

Research has not verified a large correlation in rates detected between examiners working simultaneously on a subject, possibly due to the rate being a product of entrainment between patient and practitioner.


 * Mobility of the intracranial and intraspinal dural membranes

The membranes surrounding the brain and separating the left and right halves and the cerebrum from the cerebellum are continuous with the spinal dura, and share the same fluctuating rhythm. In 1970 Upledger observed during a surgical procedure on the neck what he described as a slow pulsating movement within the spinal meninges. He attempted to hold the membrane still and found that he could not due to the strength of the action behind the movement.

In craniosacral treatment the membranes act as a fulcrum for fascial restrictions throughout the body, and craniosacral therapists may perceive a change in quality as a result of disturbance such as infection or allergic irritation.


 * Mobility of the cranial bones

Cranial sutures are often believed to be immobile after fusion, preventing cranial bone movement. This belief arose in the mid-1900s. According to Lee this belief was misinterpreted from the work of authors hoping to correlate suture closure with the chronological age of a skull in archaeological specimens. The authors not only found that there was no correlation between suture closure and the chronological age of the individual, but also that most skulls demonstrated no suture closure at all except as structural evidence of pathological physical trauma. Lee cites many references giving evidence for mobility in human skulls, and modern anatomy books suggest incomplete fusion of some sutures, for example: "Sutural ligaments may effect an almost immovable bond between large areas of bone... but such immobility cannot be effected at narrow edges of bones in the cranial vault," and: "When such sutures are tied by sutural ligament and periosteum, almost complete immobility results."

It is usual in cranial textbooks to say that the motion of the skull is possible during flexion and extension because the sutures are mobile, especially the spenobasilar synchondrosis - the junction between the base of the sphenoid and the occiput. Positional descriptions of cranial lesions traditionally relate to the relationship between the sphenoid and the occiput at this junction. An alternative theory to SBS motion taught in craniosacral training suggests that sutures are "lines of folding", like pre-folded marks on cardboard, rather than necessarily being fully open.


 * Mobility of the sacrum between the ilia

Mobility of the sacroiliac joint is not contested, although the fulcrum of craniosacral movement is through the body of the second sacral vertebra or segment (S2). The cranial concept recognises the link between the sacrum and occiput via the spinal dura, which is attached to the anterior of the sacrum at S2: as the occiput goes into extension the sacrum nutates, and the converse also occurs. The occiput can therefore be influenced by treatment of the sacrum, and vice-versa.

Criticism
Practitioners claim that by using cranial techniques on the body, including the head, they can remove restrictions in the connective tissue system and in the flow of cerebrospinal fluid; relieving stress, decreasing pain, and enhancing overall health. [1] [2] [3] Opponents claim that the therapy has been shown to be without scientific basis, [4] [5] [6] [7] and some studies that support the therapy have been criticized for poor methodology. [8]

Sceptics existing both inside and outside the osteopathic profession level the following criticisms at craniosacral therapy:


 * 'Lack of evidence for the existence of "cranial bone movement''
 * The scientific evidence for cranial bone movement is insufficient to support the theories claimed by craniosacral practitioners. Scientific research supports the theory that the cranial bones fuse during adolescence, making movement impossible. However, this research only points to fusion of the base of the skull which is not contested in craniosacral therapy and does not address movement in the superior plates. As such, this research plays no part in disproving the type of cranial bone movement as postulated by craniosacral therapy.


 * Lack of evidence for the existence of the "cranial rhythm"
 * While evidence exists for cerebrospinal fluid pulsation, one study states it is caused by the functioning of the cardiovascular system and not by the workings of the craniosacral system.


 * Lack of evidence linking "cranial rhythm" to disease
 * No research to date has supported the link between the "cranial rhythm" and general health.


 * Lack of evidence "cranial rhythm" is detectable by practitioners
 * Operator interreliability has been very poor in the studies that have been done. Five studies showed an operator interreliability of zero.
 * The one study showing some operator interreliability has been criticized as deeply flawed in a report to the British Columbia Office of Health Technology Assessment.

Training and accreditation
Osteopathy is protected by statute in both the US and the UK. Cranial osteopathy has no recognised qualification, and any osteopath or osteopathic physician may practice cranial techniques if it is within their scope of competence.

Craniosacral therapy and sacro-occipital technique
Craniosacral therapy is based on the same principles as cranial osteopathy, but practitioners do not have to be qualified osteopaths, and therefore do not always have the same depth of training in the clinical sciences and differential diagnosis. Osteopaths view craniosacral therapy as a simplified therapy derived from OCF first taught by osteopathic physician John Upledger.

In 1983, after years of frustration with the limited penetration of OCF into the osteopathic profession, Dr. Upledger decided to teach cranial osteopathy to non-physicians. He simplified a delivery system for teaching the cranial concept in a manner that was accessible to massage therapists. As a result, the cranial concept is being practiced by significantly more individuals than have ever been educated by the osteopathic profession.

The Cranial Academy claim the differences between cranial osteopathy as practised by osteopathic physicians and craniosacral therapy as practised by craniosacral therapists is often a confusing topic for the public.

Osteopath and chiropractor M.B. Dejarnette also developed craniopathic techniques as a complete chiropractic system known as sacro-occipital technique, or simply "S.O.T."