It is hard to Sokalize alternative medicine. The closest has been buttock reflexology/acupuncture, but that is a tame example.  Given the propensity for projections of the human body to appear on the iris, hand, foot, tongue, and ear, postulating a similar pattern on the buttocks are simple variations on a common SCAM (Supplements, Complementary and Alternative Medicine) theme. The buttocks?  Not really different from any of the other focal acupunctures.  Most of SCAM does not concern itself with application of reality  and physiology, anatomy, biochemistry, etc can all be expected to be ignored with virtually all SCAM modalities.

Every time I think the heights (or depths) of absurdity has been reached, I discover a Braco the Starer or Himalayan Salt Inhalers. This blog is not affiliated with the British Medical Journal in any way, and although this is being published near Christmas, I want no one think that what follows is a hoax.  I am not, I repeat not,  making up what follows. It is not fiction. Well, it is fiction, but not written by me and believed and practiced by some who really should know better.

Craniosacral Therapy
Like many SCAM modalities, from Reiki to Chiropractic,  Craniosacral Therapy (CST) was invented? discovered? fabricated? pulled out of the a..,  well, er, Drs Novella and Gorski want this to be a professional blog *, so lets say, a three letter word that starts with ‘a’. Air. It was pulled out of the air by William Garner Sutherland.

While a student at the American School of Osteopathy in 1899, Dr. Sutherland pondered the fine details of a separated or “disarticulated” skull. He wondered about the function of this complex architecture. Dr. Still taught that every structure exists because it performs a particular function. While looking at a temporal bone, a flash of inspiration struck Dr. Sutherland: “Beveled like the gills of a fish, indicating respiratory motion for an articular mechanism.

Here is a picture of a temporal bone:


Here is a cranial suture:

And here is a fish gill:

I guess  drug use was more popular than I thought back in the day. Maybe I am not able to get the right photograph of gills to see the connection. You? Do you see the connection, or do you lack the “unique genius” of  Dr. Sutherland ? Because the temporal bones are beveled like fish gills (!), the bones of the head are supposed to move relative to each other (!) with respiration (!).  That is the insight that lead to CST. I wonder if the abstract announcing his discovery would have been accepted at the  International Conference on Integrative Medicine.  It makes gluteal reflexology appear reasonable in comparison.

Dr. Sutherlands’ insight did not stop there.  He synthesized his observations into “The Primary Respiratory Mechanism”:

This Primary Respiratory Mechanism has five basic components:

1) The inherent rhythmic motion of the brain and spinal cord.
2) The fluctuation of the cerebrospinal fluid (CSF) that bathes and nourishes the brain and spina l cord.
3) The shifting tensions of the membranous envelope (dura mater) surrounding the brain and spinal cord. This entire membranous structure acts as a unit and is called a “Reciprocal Tension Membrane.”
4) The inherent rhythmic motion of the cranial bones.
5) The involuntary motion of the sacrum (tailbone) between the ilia (hip bones).

I don’t know that means.  I read the words, I think about what I understand about anatomy and physiology, I reread the above and I got nothing. A word salad, it appears to be all sound and fury, signifying nothing. Repeat.  It is not meant to be fiction.

To make it more mysterious, or fanciful, the CSF has tides:

“1) the cranial rhythmic impulse; a more superficial rhythm expressed at an average rate of 8-12 cycles per minute,
2) the mid-tide; a tidal rhythm that carries ordering forces into the body expressed at a slower rate of approximately 2.5 cycles per minute and
3) the long tide; a deep and slow rhythmic impulse expressed about once every 100 seconds. The long tide is considered to be the first stirring of life and motion as the Breath of Life emerges from a deeper ground of stillness at the center of our being.”

I know topic was the death of MacBeth’s wife but Act 5, Scene 5, lines 26-28 keeps running in my head. It is an explanation of physiology that would be right at home on Dr. Oz’s site, but has no relationship to any known anatomy or physiology. Other explanations of the tides make no sense to me, containing nothing I can recognize as content amongst what appears to be a word salad.  Although I suspect CST would appeal to Bloodline aliens.

I do not think there is a SCAM where the practitioners deny the evidence in their hands.  There are videos of CST therapists saying that, unlike what is taught in medical school, the bones of the skull are not fused and articulate.  They say this with Yorick in their hands, a skull evidently never contemplated.  If you have ever held a skull in your hands, or been in a neurosurgical case,  it is evident that the cranium is notable for the rock solid joinings of bones.  The metaphor is thick skulled, is it not?  It is not fish-gilled skulled.

Acupuncturists may blather about meridians and homeopathists drivel on about the memory of water, but at least they do not hold the dis-confirming evidence in their hands, denying its existence.  I have seen patients deny an obvious tumor or the symptoms of advanced AIDS.  Look at that skull in your hands.  The bones do not move. To have a whole field of SCAM based on the denial of palpable reality is most curious.  As Marx said, sort of,  “Who are you going to believe, Sutherland or your lying eyes?”

What does a practitioner do with the insight that the CSF flows incorrectly and the cranial bones are out of wack? CST

“involves the practitioner “listening through the hands” to the body’s subtle rhythms and any patterns of inertia or congestion. Through the development of subtle palpatory skills the practitioner can read the story of the body, identify places where issues are held and then follow the natural priorities for healing as directed by the patient’s own physiology.”

As I gather from the gibberish of the YouTubes and CST sites, they push the bones of your skull back into place, alter and optimize the flow of CSF and make you better. I think.  Because nothing they say really makes any anatomic or physiologic sense:

The trained practitioner palpates for the sensation of resistance on the skin surface overlying the spine and cranium. Resistance is thought to be indicative of underlying CSF stasis, and following treatment, the absence of drag may indicate that the CSF stasis has been reduced.”

as one of a tedious series of examples.  They can feel the tides and CSF rhythms and alter them. They can change the tides, at least the CSF tides.  I am old school when it comes to altering tides: And te tide and te time þat tu iboren were, schal beon iblescet.  But that is obvious, which is why it is an aphorism.

The cranial rhythmic impulse is an oscillation recognized by many bodywork practitioners, but the functional origin of this impulse remains uncertain. We propose that the cranial rhythmic impulse is the palpable perception of entrainment, a harmonic frequency that incorporates the rhythms of multiple biological oscillators. It is derived primarily from signals between the sympathetic and parasympathetic nervous systems. Entrainment also arises between organisms. The harmonizing of coupled oscillators into a single, dominant frequency is called frequency-selective entrainment. We propose that this phenomenon is the modus operandi of practitioners who use the cranial rhythmic impulse in craniosacral treatment.

Colorless green ideas sleep furiously indeed.   Take an anatomy and physiology that does not exist, then postualte a mechanism of action.  At least in that respect there is not a difference between CST and acupuncture or homeopathy. Except quantum. Where is the quantum. We need quantum.

Practical Uses of Quantum Physics Concepts in CranioSacral Therapy

Adding a few new intentions to your hands-on work is quite simple. All you need to do is incorporate a few principles of quantum physics.
First, we direct our energy into hard, stiff or restricted areas of the client’s body.

Of course, I giggle like the immature person I am. I know. What an infant.  But I giggled a lot writing this entry; truly a field of infinite jest.  Of course, the only real parallel between CST and quantum of any kind are N-Rays, sharing identical reality.

Similar to other SCAMs, there is zero consistency in the ability of CST practitioners to feel the same tides in the same patients.

Two registered osteopaths, both with postgraduate training in diagnosis and treatment, using cranial techniques, palpated 11 normal healthy subjects.
Examiners simultaneously palpated for the CRI at the head and the sacrum of each subject. Examiners indicated the “full flexion” phase of the CRI by activating silent foot switches that were interfaced with a computer. Subject arousal was monitored using heart rate. Examiners were blind to each other’s results and could not communicate during data collection.
Reliability was estimated from calculation of intraclass correlation coefficients (2,1). Intrarater reliability for examiners at either the head or the sacrum was fair to good, significant intraclass correlation coefficients ranging from +0.52 to +0.73. Interexaminer reliability for simultaneous palpation at the head and the sacrum was poor to nonexistent, ICCs ranging from -0.09 to +0.31. There were significant differences between rates of CRI palpated simultaneously at the head and the sacrum.
The results fail to support the construct validity of the “core-link” hypothesis as it is traditionally held by proponents of craniosacral therapy and osteopathy in the cranial field.

Reproductively and the ability to consistently feel the tides has been refuted in more than one trial. King Canute they aren’t.

In reality what do CST practitioners do?  They lightly massage your head.  To treat everything from Downs to headache to PMS.  It is an all purpose diagnostic and therapeutic intervention, like all SCAMs.

There are no shortage of videos demonstrating the techniques of CST, one practitioner states she pushes the bones back into alignment with a 5 gram pressure, the weight of a nickel.  I do not think a nickles worth of pressure would move a skull bone a quantum amount,  not even if dropped off the Empire State Building.

Once I had a colleague (really, a colleague. Not me) who commented he liked to have hair cuts because the scalp massage with the wash and condition was very relaxing, and I will admit that lying on ones back while you head is massaged looks very pleasant, especially if it occurred in the middle of a busy work day and was paid for by Blue Cross.  If you had a process that was due, in part, from stress, I can see where a CST session would be most beneficial. I always return to the example of the relaxing effect of apes mutual grooming, although “in deference to one million years of human evolution, the therapist won’t try to pick fleas off his patient.” Or so one hopes.

I wrote the last paragraph before I did a Pubmed search on the topic.  Lets see if CST helps headaches independent of the incomprehensible blather that underpins the field.  I bet it will be helpful  for anything with a subjective endpoint and I bet that for hard endpoints, CST will do nothing.

There are 56 hits on the Pubmeds using Craniosacral therapy, and there are no even remotely well done studies using CST.  The most interesting predates the NEJM asthma article discussed at length at SBM.

In it

Subjects were randomly assignment to one of five groups: acupuncture, craniosacral therapy, acupuncture and craniosacral, attention control, and waiting list control.
Subjects received 12 sessions of equal length with pretreatment and posttreatment assessment of pulmonary function, asthma quality of life, depression, and anxiety. Medication use was also assessed.

Can you predict the results?  Yep.  Patients were subjectively improved, but their objective asthma was not better.

When treatment was compared with the control group, statistically treatment was significantly better than the control group in improving asthma quality of life, whereas reducing medication use with pulmonary function test results remained the same.

As one would expect from a relaxing head massage. Others are also less than enthusiastic about CST

A three-dimensional evaluative framework with related appraisal criteria: (A) craniosacral interventions and health outcomes; (B) validity of craniosacral assessment; and (C) pathophysiology of the craniosacral system.
The available research on craniosacral treatment effectiveness constitutes low-grade evidence conducted using inadequate research protocols. One study reported negative side effects in outpatients with traumatic brain injury. Low inter-rater reliability ratings were found.
This systematic review and critical appraisal found insufficient evidence to support craniosacral therapy. Research methods that could conclusively evaluate effectiveness have not been applied to date.

Despite the structural integrity of the skull, CRT proponents insist “Eppur si muove“. And there is one time where the bones of the skull are moveable: after head trauma.  Then, perhaps, pushing on the skull, even 5 grams worth, may not he such a good idea.  I have seen enough trauma over the years to be cautious around breaks in human structural integrity.  Not so much with CST:

Although craniosacral manipulation has been found empirically useful in patients with traumatic brain injury, three cases of iatrogenesis occurred. The incidence rate is low (5%), but the practitioner must be prepared to deal with the possibility of adverse reactions.

Why do I think of the word “squelch” when I read the abstract; too much Joe Aberrcombie of late?  It turns out that the adverse reactions from CST are every bit as fanciful as beneficial effects:

These three cases represent a diversity of adverse reactions following craniosacral manipulation. The first patient had exacerbation of vertiginous symptoms during diagnostic evaluation alone. After sphenobasilar decompression, visceral symptoms involving cardiac, respiratory, and gastrointestinal systems arose. This feature suggests either brain stem or vagal effects as a possible source of the symptom complex. The second patient had exacerbation of headache complaint, but, more important, a disturbing psychologic/psychiatric problem, necessitating psychiatric institutional care. The severe total body spastic reaction seen in the third patient continues to defy explanation. The possibility of a brain stem seizure triggered by stimulation of the upper cervical spine and cranial base or posttraumatic cervical dystonian remains plausible. Extensive evaluation failed to demonstrate a specific cause.

It is a tough economy, and jobs are scarce.  For 5 to 12 thousand dollars and 700 hours (150 if you are already a licensed massage therapist) you can be a CST provider.  That’s 88 days of education, about a semesters worth.  And then maybe you can practice at a University Medical Center. Like Ohio. Or Duke. And of course, Dr Oz  has offered CST, so you know it must be nonsense.

There are probably other institutions that offer the raging nonsense that is CRT, but I grow weary of the searching. But it should not be part of any University, since

…we believe that craniosacral therapy bears approximately the same relationship to real medicine that astrology bears to astronomy. That is, this approach to “health care” is medical fiction, and it is not appropriate to teach fiction as part of medical or allied health curricula.

I wonder if Duke or Ohio are going to offer astrological readings or have John Edwards as a Visiting Lecturer.  It would only be a lateral step, not a step backwards.  Seriously.  If your local Hospital or University offers CST, go elsewhere.  They have a demonstrated commitment to the irreparably goofy.

To sum up: CST now beats Braco the starer.  I don’t think The Onion could do better.


*I remain uncertain as to why the editors let these posts through.

Posted by Mark Crislip

Mark Crislip, MD has been a practicing Infectious Disease specialist in Portland, Oregon, since 1990. He is a founder and  the President of the Society for Science-Based Medicine where he blogs under the name sbmsdictator. He has been voted a US News and World Report best US doctor, best ID doctor in Portland Magazine multiple times, has multiple teaching awards and, most importantly,  the ‘Attending Most Likely To Tell It Like It Is’ by the medical residents at his hospital. His growing multi-media empire can be found at