integration with medicine – the scope of cranial work · introduction historical perspective as...

INTRODUCTION

Historical perspective

As indicated in Chapter 1, the modern beginningsof cranial manipulation derive from the osteo-pathic tradition as interpreted by William GarnerSutherland. And so, in part, the scope of cranialwork is embedded in that of osteopathic medicine.Yet many in the osteopathic profession in generalhave been slow to accept and implement thispoint of view. Despite osteopathy’s ambivalence,a variety of manual practitioners have beenattracted to and have developed aspects of cranialmanipulation. Historically, then, many practitionershave practiced cranial technique outside theirculture’s definition of ‘medicine’.

In a parallel development, those practitionersworking in manual medicine, physical medicineand rehabilitation, sports medicine and Americanosteopathic medicine have to varying degreesintegrated manual philosophy and techniquesinto orthopedic and disease model medicalproblem solving. This chapter deals with the some-times controversial topic of osteopathic medicalintegration and its relevance in cranial work bothin America and Europe. It also addresses the issueof how this integration affects the definition oftreatment goals and the choice of techniques.

Historically, the scope of osteopathic work andthought has developed nearly independently ondifferent continents and varied in its expression

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Chapter 3

Integration with medicine – thescope of cranial workZachary Comeaux

CHAPTER CONTENTS

Introduction 67

Defining osteopathy in the cranial field 69

Formats for medical integration 71

Integrated osteopathic treatment – includingcranial 77

Case examples 78

Conclusion 90

References 90

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even within countries. Despite common inspira-tions, there has been variation in philosophicalfocus. In several quarters the search has concen-trated on finding and treating the ‘osteopathiclesion’, which has been variously defined. Theemphasis has often been on the articularcomponents of the body, the joints. More recently,at least in American circles and in that sphere ofinfluence, the goal of treatment has been toidentify and treat somatic dysfunction, defined asan impairment of body function caused bystructural distortion but possibly involving otherbody systems. These may be due to congenitalconditions or may be acquired through trauma,strain or adaptation. This represents an approachthat is broader than a biomechanical one.

In other settings, including among the studentsof J M Littlejohn DO, the British physician whoworked with the founder of osteopathy, A T Stilland who propagated osteopathy beyond America,there has been considerable focus on normalizingphysiology and function. (Littlejohn’s point ofview will be discussed further below.) In thissetting a general protocol is often used in whichany variation from normal is corrected until thewhole works more harmoniously. Currently thereexists a muddle of methods and schools in theUSA, Europe and Australia, competing forattention in defining what is and what is not anosteopathic treatment approach. The point beingmade is that priorities in intent of treatment haveshifted with time, depending on how one definesthe patient’s problem – i.e. is it structural orfunctional?

As implied above, the scope of osteopathicpractice has varied according to cultural andpolitical setting. Early in its history in America,the osteopathic profession fought for, and received,legal recognition as a fully privileged professionon a par with medical doctors. Partly this occurredbecause of the strong contribution to health caregiven to communities in the rural mid-West wherethe profession arose. Through these events, osteo-pathic medicine has assimilated and contributedto many protocols in standard medical practice,since its practitioners were free to practice the fullscope of medicine. Whether this development isviewed as an advance or as a corruption of pureosteopathy has been bitterly debated but it

remains as a fact, influencing the health care ofmillions of people.

The progression toward legal recognition andlicensure of osteopathy has been variable through-out the world and continues to evolve. Thesedifferent national or regional expressions of osteo-pathic philosophy have fostered different opinionsabout the integration of medical concepts intoosteopathic practice.

Additionally, in the USA, the separation of JohnUpledger DO from the greater osteopathicprofessional community, in teaching craniosacraltherapy to the general professional and lay public,has served as a stimulus for the osteopathicprofession to be more proactive in teaching cranialmethods, while making treatment available to abroader population. With these events, however,has come a greater variation in medical competencyor commitment to osteopathic principles amongthose treating under the name ‘cranial’. Cranio-sacral therapists come from many backgroundsand apply craniosacral principles to complementother aspects of their work. Since they are notnecessarily medically trained, their awareness ofother aspects of the patient’s medical conditionwill be highly variable.

Chiropractic is another practice tradition thathas included the cranial area in its treatmentprotocol. Although many practitioners incorporatethe methods taught as craniosacral therapy, aderived system of sacro-occipital technique (SOT)has evolved out of the work of BertrandDeJarnette (DeJarnette 1934, 1935) who blendedSutherland’s original research with his ownsystematic thought. DeJarnette’s work then wasincorporated into the system of applied kinesiology,as formulated by George Goodheart and adaptedby others. The latter method varied from manualdiagnosis by adding formulaic testing protocols,simultaneously with active muscle testing, inmaking diagnoses (Walther 1988) (see Ch. 5).

And so, it becomes apparent that cranial workin particular has been introduced into practicedifferently, at numerous locations and times.Hence, the flavor and particulars of application ofthe work vary according to the intent and bias ofthe introductory contact, teaching in new culturalcontexts, as well as the practical needs andprofessional definition of the students. This leads

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to the certainty that there is no single authoritativevoice for cranial practice. There is no ‘right’ or‘wrong’ cranial approach, whether it is bio-mechanical in its focus and methodology or more‘energy’ oriented. At present, despite heateddebate, neither of these extremes has a clearevidence base and both seem equally effective inclinical practice, when appropriately applied.

Current focus

This chapter aims to clarify an appreciation of thedevelopment of cranial manipulation as it evolvedin an osteopathic context and to provide anopportunity for the reader to reflect on thepotential scope of application of cranial conceptsin his/her own particular health-care practice. Ofspecial relevance is the interface between osteo-pathic philosophy and contemporary medicine asit affects cranial practices. The particular issue ofintegrated osteopathic thought and how it affectsperceptions, judgments and treatment strategiesin applying cranial concepts will be addressed ina cultural and historic review.

• Does the head behave according to its own setof dynamics or is it part of the rest of the body?

• What are the clinical consequences of one(cranial) approach or another likely to be?

• Should the focus be on key symptoms andrestrictions or should there be a more globalapproach to the patient?

• When is it appropriate to blend information,diagnosis and treatment deriving from manualmedical or orthopedic contexts?

These questions are becoming more crucial asphysicians of manual medicine around the worldadopt osteopathic techniques.

The issue of scope of practice and manner oftreatment depends on the way one defines thepatient as a person. One intriguing area ofexploration and redefinition is referred to as thebiodynamic model of the patient. This area will betouched on here but addressed more extensivelyin Chapter 4.

The author, while practicing as an Americanosteopathic physician, with full medical privileges,will try to set aside bias and assume the positionof a moderator, pointing out examples, advantages,

disadvantages, benefits and limitations of imple-menting cranial concepts in a medically integratedapproach to the patient.

DEFINING OSTEOPATHY IN THE CRANIAL FIELD

The dialectic: a drugless science

Osteopathy’s founder, Andrew Taylor Still,described an approach to medical care minimizingthe use of the harmful drugs of his day and alsosurgery. His intent was clear: to establish acomplete system of health care based on dis-covering and assisting the natural functioning ofbody systems by optimizing structural integrity.His scope was universal, including the study ofanatomy, physiology, spirituality, philosophy andtheology as they applied to the patient. Thepursuit of knowledge, of science, was paramountin diagnosing and treating (Still 1992, p. 6; 1902, p. 44; 1899, p. 16).

He gave his students a philosophy but not ahandbook of techniques. Briefly this included theconviction that much of patient symptoms andillness depended on distortions of anatomicpositions of bones or tension in fascia. This in turnled to congestion or edema, compression of nervesand interruption of free flow in blood vessels. Hismain strategy in treatment was to find thesedistortions and correct them in whatever fashionwas necessary and to then allow the body toresume the natural function of healthy management.

In leaving this life he gave admonitions whichprovide the roots of division. He told his osteo-pathic progeny to ‘keep it pure’ (Truhlar 1950),meaning not to adulterate their practice with theuse of drugs. But he also encouraged them tointegrate current scientific knowledge into theirunderstanding of their patient. Despite hisdisagreements with Drs Littlejohn and Smith(another Scottish physician) regarding the role ofphysiology in the curriculum, physiologicalprinciples are woven through Still’s writings. Whenthese two recommended teaching physiology, Stillproclaimed that osteopathy was solely based onthe understanding of anatomy. But he went on toinclude physiology as a subset of anatomy and in

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practice he observed, speculated and integratedphysiological processes into his approach todesigning interventions. More will be said in Box 3.1 regarding J M Littlejohn, the father ofosteopathy in England.

Sowing and reaping: the varied growth ofosteopathic ideas

A variety of historic events have contributed tothe dispersal of Still’s thought and its growth andcultivation. This has certainly affected osteopathyin the cranial field. Professionally this hasgenerated disagreement and factions; politically ithas evolved into nationally distinct circumstancesof practice privilege, training and registrationrequirements within osteopathy. Additionally, thevalue of the concepts has been noted by manyoutside osteopathy, in physical therapy, kinesio-therapy and physical medicine, who haveintegrated aspects of osteopathic concepts intotheir practice methods. Physical therapy hasincorporated strain/counterstrain and muscleenergy techniques that have their origins withosteopathic practitioners and teachers. The use ofdirect articular manipulation or thrust techniques,as used in chiropractic, is argued as being linearlyderived from Still’s teaching (Trowbridge 1991).All these developments have been a backgroundfor the definition of cranial work today.

Similarly aspects of physical medicine, manualmanipulation and movement therapies have beenimported into osteopathic methodology. Musclechains, incorporated from Godelieve Denys-Struyfand the meziarists (Denys-Struyf 1979), andeffleurage and other soft tissue techniques frommassage traditions are examples. The techniquesof Jean Pierre Barral (1998), Vladimir Janda(Bullock-Saxton & Janda 1993) and Robert Maigne(1996) are other examples. It should be apparentfrom this discussion that ownership of an idea byone professional group is a moot point. Goodideas are freely traded and implemented byconscientious practitioners within the scope oftheir talent, experience and practice. Reverence forthe particularities of the experience and context ofapplication of the authors from which we learnought to be presumed. But an appreciation of thishistory moves us off center into the broader arena

of appropriate adaptation of ideas in treatment,within the context of an individual’s knowledge,licensure and experience and the patient’s need.

In this context, then, let us look at some of thethreads of diversity which in the past have causeddivision but which influence how cranial conceptshave been or may logically be used in osteopathicand other manual treatment.

General versus specific: where to start?

In classical philosophy there is an issue called theproblem of the one and the many. Do we under-stand the world or any part of it by summing upan understanding of the particulars or do weapproach the particular from a conceptual under-standing of the whole? In the end it appears thatboth approaches have their advantages andlimitations.

The same dilemma follows us in beginning ourapproach to the patient with a complaint, whetherback pain, headache or sinus congestion. Thesame diversity of approaches exists. In cranialwork, our practical and philosophical biases, orthose of our teachers, translate into a preferencefor beginning with the general or specific featuresof the patient. Some consider the manipulation of the dynamics associated with the primaryrespiratory mechanism as adequate for manage-ment of all health problems. They then extend theprinciples first learned in the cranial field to otherregions, even the body as a whole. Others proceedfrom the other direction, by applying articularapproaches, learned in dealing with the body as awhole, to problems in the cranial area.

Still is sometimes quoted as saying that thecerebral spinal fluid is ‘the highest knownelement’ (Still 1902, p. 44). He had such a deepappreciation of the importance of the neural co-ordinative system, as well as the nutritiveaspect of all body fluids. The primacy of thecranial dynamic is further underscored in thewritings of William Sutherland (Sutherland 1990,p. 13). He was amazed at the degree of treatmentsuccess he was able to achieve on himself as anexperimental subject and on others in clinicalpractice, through application of his personallydiscovered methods. As a result he somewhatspecialized in difficult cases, with which he had


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success. Several of his students, including ViolaFrymann, Beryl Arbuckle and Robert Fulford,extended this specialization in the particularapplication to problematic cases, using cranialmethodology (Arbuckle 1977, Comeaux 2002,Fulford 1996, King 1998).

In extending the cranial approach – the principlesof subtle motion, ligamentous-membranous con-nectivity and respiratory effects – to working witharticular as well as soft tissue elsewhere in thebody, some students of Sutherland reformulatedtheir teacher’s thoughts under the title ligamentousarticular release (Speece & Crow 2001). RollinBecker, another student, described a protocol forlistening to the soft tissues of the body as ‘takingthem where they want to go’.

Using our palpatory skills to read this living bodyphysiology, we’re allowing this patient’s bodyphysiology to show its patterns of health. (Becker1997, p. 219)

Another student of Sutherland’s, Robert Fulford,interpreted the subtle relationships of the bodyunder the theme of energetic or bio-electric effectsor influences (Comeaux 2002). In each of theseapproaches there is the recognized need to bothaccept the general orientation of cranial work, towork directly on the cranium as indicated but toalso work with other osteopathic principles, inother parts of the body, as the need arose. In thiscontext, the idea of integrating cranial techniqueswith other trains of thought is not new.

FORMATS FOR MEDICAL INTEGRATION

American osteopathic integration: theintroduction of medical concepts

Still opened the American School of Osteopathy toconvey his teaching in 1892. As with any newintellectual movement which has economic orpolitical consequence, the early days of Americanosteopathy were steeped in struggle and intrigue.Politically there was an immediate awareness ofthe need to gain legal recognition and licensure ineach of the United States. This was done in amanner that would preserve the philosophicaldistinctiveness of osteopathy. However, the

smoldering tumult in Still’s mind, over the scopeand definition of osteopathic practice, ignited aconflagration among his early followers.

In starting his school, Still benefited from the interest and help of William Smith MD, agraduate of the University of Edinburgh,Scotland, who contributed greatly to the teachingof anatomy. Additionally, his program wasenriched by the knowledge of physiology broughtby J M Littlejohn, who had previous degrees indivinity and law and a Master of Arts fromUniversity of Glasgow (Berchtold 1975). Littlejohn,who, like many, came to Kirksville as a patient,stayed to learn the basics of osteopathy. A well-educated man, he saw the biological significanceof Still’s teaching and was hired both as thesecond dean of the school and to head thedepartment of physiology, where he began animalresearch (Trowbridge 1991, p. 174).

As these and other recruited geniuses began toexpress their ideas, independent of their teacher,Arthur Hildreth, a family friend and initialstudent of Still, was charged with correcting thesituation (Hildreth 1942). Smith was dismissedand Littlejohn relieved as dean. With his intent toleave, Littlejohn was moved to ask for recognitionfor his academic work and requested not a Doctorof Osteopathy degree, as was conventional, but a‘Doctor of Medicine, Osteopathic’ degree. Theconflict unresolved, he left and founded whatremains today as the Chicago College of Osteopathy,before returning to England. Littlejohn’s requestwas the earliest attempt at full medical privilegein the osteopathic tradition.

Another early controversy stemmed from therole of surgery in this fledgling medical profession.While remaining adamant about the non-scientificuse of drugs, as such was the case in his day, Stillallowed for surgery when necessary to save life.Surgery related to anatomy and anatomy was toremain the guiding principle of osteopathicpractice. Physiology was recognized by Still assubsidiary to anatomy, that should be modifiedwhen necessary through structural manipulation.Surgery was, in a broader sense, an extension ofmanipulation.

The original ASO Hospital (1906), followed bythe founding of the Laughlin OsteopathicHospital by Still’s son-in-law, George Laughlin,


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institutionalized this practice (Walter 1992, p. 59).This brought the profession further under the jurisdiction of governmental review, from the point of view of public safety. The standard by which these activities were judged were those of contemporary medical and surgicalpractice. Additionally, the Still–Hildreth MemorialSanatorium was another institution in which theprofession would undertake the integration ofpractices compatible with the medical standardsof the day.

Medicine in general would be revolutionized inthe 1930s and 1940s by the introduction ofantibiotic medications. The Journal of the AmericanOsteopathic Association in the 1940s demonstrated asignificant assimilation or intrusion of popularmedical culture. The issue of this author’s birthmonth includes advertisements for neo-synephrinedecongestant, ampicillin and even one representinga physician’s recommendation to calm the nervesby smoking Camel cigarettes.

Furthermore, local tensions remained asosteopathic physicians attempted to gain practiceprivilege in allopathic hospitals in order to followtheir patients. Additional pressure was applied forinclusion as medics in the armed forces, thatfinally came during the Korean War.

Through the 1970s and 1980s a sense of urgencyfor recognition of the professional practiceprivileges of general practitioners and theascending specialty of family medicine, led to ageneral popular appreciation of the full scope of competency of osteopathic education andpractice. Internal pressures within the professionled to the renaming of most degrees granted by osteopathic institutions, from Doctor ofOsteopathy to Doctor of Osteopathic Medicineand the proper term of address of the graduates toosteopathic physicians rather than osteopaths(Gevitz 1982).

For those cherishing parity with MDs above all else, this has led to a diminution of manualdiagnostic skill and application of traditionalosteopathic principles in treatment. However, tothose who value the contribution to health of complete diagnosis, including palpatory assess-ment and incorporating manual treatment and itsbenefits into medical care, there has been anadvancement of the quality of medical care.

Although osteopathic medicine in the USA isheavily influenced by the scientific paradigmwhich advocates the biochemical and molecularapproach to medicine, which supports pharmaco-therapy, many in osteopathic medicine arebeginning to revisit and test the concepts oftraditional osteopathy, including osteopathy inthe cranial field.

There is a trend in medicine emphasizingevidence-based practice. Independent researchsupports or finds feasible many of the teach-ing espoused by Sutherland (Hargans 1998,Moskalenko et al 2003). Additionally, osteopathicresearchers are evaluating the physiological lawsand phenomena that support osteopathic diagnosisand treatment (Comeaux 2003, Nelson et al 2002).

Still’s basic premise that medicine should bescientific cannot be contested. The currentemphasis on evidence-based medicine is quitecompatible with this and should allow theinclusion of osteopathic medicine in standardmedical care. With maturation of medical scientificunderstanding beyond the macroscopic worldavailable to Still’s contemporaries, osteopathicphilosophy should support scientific technologiesthat enhance the harmony of natural processes.

The challenge to modern osteopathic thinkers isto follow this wave of maturation, respecting thevast ocean of scientific biological informationwhile still valuing the hand, the mind and theheart as conductors of interpersonal experience,that are clinically usable to cultivate health in thepatient. This transition of paradigms is confusingto all of us. However, the integration of osteo-pathic manual diagnosis and treatment intogeneral medical practice, most importantly inprimary care, brings a wealth of potential benefitsthat are often only partially appreciated. The casestudies below will explore some of this richness.

Current cosmopolitan medical culture

Expanded physician interest

To complement the developments cited above, inthe last several years the practice of manualmedicine has become more popular amongphysicians. And so there has been the develop-ment of many national and now international


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Initial introduction of osteopathy Modernosteopathic practice in Europe, the United Kingdom andelsewhere has a different history and a differentcontemporary expression from that of the USA.

Osteopathy has been introduced to Europe in severalsuccessive waves. After being treated, matriculating,being academic dean and chair of the Department ofPhysiology at the American School of Osteopathy,Littlejohn returned to England for a visit in 1903, meetingwith the first osteopaths to land, J J Horn and Dr Walker(Hall & Wernham 1974, p. 9). Returning to America andfounding the Chicago College of Osteopathy, it was notuntil 1917 that he organized the British School ofOsteopathy (BSO) in London. Like Still, Littlejohn was athinker which made him cherish Still’s insights but led todivisive disagreement.

From the following statements on the subject ofphysiology, one can see the divergence of views.

• ‘Physiology is the gateway by which this immensefield of osteopathy is to be entered.’ (Hall & Wernham1974, p. 9)

• ‘A knowledge of anatomy with its application coversevery inch of ground that is necessary to qualify youto become a skillful and successful osteopath …’ (Still1899, p.16)

• ‘Work in physiology at the present are compilations ofmany theories and a few facts.’ (Still 1902, p. 29)

Still described physiology and other disciplines as partsof anatomy: ‘I want to instill and impress it on your mindthat this [physiology] is as much a part of anatomy as awing is part of a chicken’ (Still 1899, p.18).

Though initially semantic, their differences ininterpretation of physiological function of the spine ledto generations of divergent development in practicestyles, as mentioned above. Littlejohn respected thecomplexities behind biomechanics and recognized theindividual differences in function of each of the spinalvertebrae. His system also included dynamic patterns andrelationships involving the spinal complex working as awhole. An individual vertebral segment had a role to playin a complex system of reversing arches, pivots andgravitational lines (Wernham 1956).

Littlejohn had a special interest in physiology, or bodyfunction, as a key to diagnosis and treatment. Largelythrough the popular theories evolved from the work ofHarrison Fryette (1994), many of the systems ofosteopathic work tended to be biomechanical and grossly

articular. The emphasis was more on the keydysfunctional segment, rather than the function of thewhole. And so for a long time the preoccupying issueswere different in the USA and the UK.

Besides teaching osteopathic concepts, Littlejohn’sinitial worries included official recognition and politicalsurvival of the profession. Finally in 1935, havinggraduated 100 students, he approached Parliament formedical professional recognition and was rebuffed. Fromthat time until the 1990s, osteopaths in the UK werelimited in the scope of their practice and deniedrecognition of medical education and medical privileges.

Evaluation of the role of cranial osteopathy, as derivedfrom the work of an American DO, William Sutherland (a graduate of Still’s second class), and the field of cranialosteopathy or myofascial relationships was to wait untilafter Littlejohn’s death in 1947. Littlejohn’s system of curves and pivots stopped at the atlas (Wernham1956, p. 29).

Cranial infiltration in the UK Sutherland hadbegun teaching individual physicians his cranial methodat his office in Redwing, Minnesota in groups of four, for2 weeks at a time. This activity began in the 1940s afterhe had made his thoughts public in 1939 in a small bookcalled The cranial bowl (Sutherland 1939).

Denis Brookes, a DO trained in England, took cranialcourses in America and began teaching cranial techniquesat the BSO. His name appears as a new member of theGeneral Council and Register of Osteopaths in January1950 (Osteopathic Quarterly 1950). Clem Middleton, ayounger colleague of Brookes, also British trained, taughtcranial therapy at the BSO. He noted:

The idea of applying manipulative treatment to theskull seems at first to be rather absurd but the factis that the skull can be manipulated withsurprisingly beneficial results in a number of veryserious ailments. (Middleton 1950)

He goes on: ‘As time goes on the scope of application of“Cranial Osteopathy” will steadily widen’ (Wernham 1957).

Helen Emily Jackson, an American-born graduate ofthe Kirksville College of Osteopathic Medicine in 1935,moved to England through marriage in 1939. She laterstudied in the USA under Sutherland, in 1947 and underBeryl Arbuckle, a student of Sutherland, in 1956.Although not directly associated with a school, she wasalso influential in introducing the cranial concept toEngland (Jackson 2000).

Box 3.1 European osteopathy and cranial concepts

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Second wave of cranial teaching in the UKColin Dove, principal of the BSO from 1968 to 1977(Dove 1977), in the BSO Diamond Jubilee speech recalledhosting and delivering courses and lectures reciprocallywith the Cranial Academy and Sutherland CranialTeaching Foundation (SCTF), while concurrently runninga week’s course in cranial techniques for 36 students atthe BSO. He recounted, in a later summary, the role ofGreg Curry in inviting the SCTF to run a course in Londonusing Frymann, Schooley, Harakal and Woods as teachers.Later he remarked on the positive contributions of Rollin Becker, Robert Fulford, Ann Wales, Herb Miller andJames Jealous in sharing aspects of osteopathic work.

While many osteopaths accepted cranial teaching,many did not. Indeed, Dove’s initial assignment was toinfiltrate the SCTF course, in order to learn enough to beable to reliably and knowledgeably discredit the method.However, he was won over to the approach (CranialLetter 1998). The same period saw the formation of theSociety of Osteopathy Cranial Group, whose newsletterschronicle activities and interests of that time. This group was heavily involved with and supported by John Upledger DO, then a professor at the MichiganState College of Osteopathic Medicine. Upledger’sresearch, theory and practice included applications of theuse of cranial methods with schizophrenic and autisticchildren and comparisons with acupuncture technique.Involvement with the emotional components of diseaseis cited in this attempt to expand the osteopathicsynthesis of methodologies.

One editorial from the Society of Osteopathy CranialGroup newsletter gives testimony to the impact of thiscontact on British osteopathic practice style.

Being educated in the Wernham GOT [generalosteopathic technique] tradition, I am painfullylearning the magic of the minimal dose, not just inhomeopathic terms but also in the osteopathicapproach. This seems to apply to Cranial technique,with what little experience I have so far … my mostcomplex cases are the ones which end up havingcranial treatment and a little seems to go a longway. (Society of Osteopathy Cranial GroupNewsletter, 1964)

This same issue announced an upcoming discussionbetween Upledger and Colin Dove, representing differentpoints of view, while Dove, in another setting, called forunderstanding among British DOs who did and who didnot buy into the cranial model. Intermixed with this

contact with Upledger were members of the SutherlandCranial Teaching Foundation, such as Robert Fulford andRollin Becker (Bel 1999).

At the same time Brookes was training a group ofapproximately 30 British and French DOs in a series ofweekend workshops that ran from 1969 to 1978. Thesepractitioners formed the Cranial Osteopathic Association,that later became the International Cranial Association.

What becomes apparent is the collegial enthusiasm,shared across borders by those interested in this cranialmodel. However, the differences in scope of practicebetween UK- and US-trained DOs heavily influenced thevariety of ways in which practitioners in the two countriescould use this material. Under common law British DOshad no limitations as to what they could do clinically,only barriers to working within the state-funded healthsystem. Since statutory regulation (in the 1990s), theosteopathic title is now protected and access to theNational Health System is now open, with numerous DOsnow employed in both GP and hospital settings, primarilyin the management of musculoskeletal problems.

Examples in the USA provide the contrast. Upledger,for example, derived some of his pressurestat theory ofcranial principles from participating in, or observing,intracranial surgery. American DOs such as Helen EmilyJackson or Beryl Arbuckle, her teacher, were trained andlicensed to be involved in the full practice of pediatricmedicine. American DOs working with neonatalosteopathy may actually have delivered these children aspart of their obstetric practice. These differences wouldensure that, although they had a common enthusiasmand language, the practice experience of American andBritish DOs varied greatly.

One gets the impression that during the 1980s theinterest in cranial technique was swamped by resistanceand interest in more biomechanical techniques. Anexample of the skepticism with which cranial techniquewas met in some quarters is encapsulated in thefollowing quote from Alan Stoddard, DO MD, in his 1986Littlejohn Memorial Lecture, reflecting on his 50 years ofpractice.

My fourth conclusion refers to palpation. Palpatoryskill can be acquired and refined but there arelimits to this method of examination – not merelylimits of sensation but limits of interpretation.Imagination can so easily play a major role inpalpatory diagnosis. I consider that I have acquiredconsiderable skills in this direction yet I cannotdetect the so-called cranial rhythm postulated by

Box 3.1 European osteopathy and cranial concepts—continued

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Sutherland and expounded here at the BSO. My oldfriend and expert in palpatory diagnosis, AudreySmith, cannot feel it either. Is the rhythm of thecranium the same as the silk dresses of the King inthe fairy tale? The silk is spun so finely that only theintellect can see it. No one would admit to beingunintelligent except the little child who declaredthe King had no clothes on. Then everyone agreedwith the child. … Anyone who believes you can alterthe flow of the cerebrospinal fluid by applyingmechanical force to the cranium is gullible indeed.(Stoddard 1986)

A more robust parallel development in British cranialwork, that has had a more linear connection to thepresent, is that of Thomas Dummer at the EuropeanSchool of Osteopathy (ESO) in Maidstone. Dummer’sinterest in osteopathy began with a background inLittlejohn-style techniques. However, his life wasaugmented by travels to Tibet and integration of bio-energetic and subtle physics into osteopathic theoryand practice. In this setting, the ground was fertile forthe planting of cranial thought.

Since the current ESO derived from the French Schoolof Osteopathy, that history will be included below.

Introduction of cranial concepts to continentalEurope As in the UK, cranial concepts came in throughosteopathic teaching. An early introduction of osteopathicconcepts in 1923 by Major Stirling, in France, was to agroup of medical doctors. In 1957, Paul Geny, a Frenchmassotherapist, opened the first school of osteopathy inFrance, Ecole Européenne d’Osteopathie. Geny was alsoassisted greatly by Denis Brookes, the British-trained DOmentioned earlier (Barillon 2000).

Geny moved the school to London in 1964 to avoidpolitical problems with medical doctors. Eventually theSchool was relocated to rural quarters near Maidstone,Kent. During this transition he was assisted by Francis Peyralade, Parnell Bradbury (an American-trainedDC, practicing in Brighton), as well as Denis Brookes andTom Dummer, mentioned above.

Prior to the move to the UK, Geny hosted a course incranial technique taught by American students ofSutherland, Harold Magoun, Viola Frymann and ThomasSchooley. Many in this class were previously trainedphysicians. The course represented the first osteopathiccranial training in mainland Europe and its graduatesjoined the Cranial Academy.

A side note is that Dr Magoun was initiallyapprehensive about training non-physicians. In order toadvance in the course, he gave the prospective studentsa proficiency test that amounted to a blindfoldedchallenge to identify and describe the form of individualcranial bones (Bel 1999).

A third introductory wave of cranial osteopathyoccurred in Europe during the 1990s and 2000s, with thecontinued travels of Viola Frymann, now nearly the lastliving student of Sutherland.

The program at the ESO has continued to includecourses and speakers incorporating cranial concepts inthe expanded osteopathic model, as is reflected elsewherein this book.

The third wave continues in Europe Theosteopathic community in France has now regrouped totrain under the Centre Internationale d’Osteopathie(CIDO), in Saint Etienne, with other schools emerging.More recently a generation of European osteopaths havebeen introduced to the field through the work of ViolaFrymann who has contributed regularly to the curriculain schools in Germany, Canada and Russia. Thesestudents have received an orientation that cranialosteopathy is the focal concept or one of the foundingconcepts, of osteopathic practice.

This impetus and gradual continued training offoreign students in English osteopathic schools has led toa small but progressively growing group of osteopathspracticing, sometimes without official governmentrecognition, in most European countries, including Spain,Italy and Portugal.

In Belgium the first osteopaths given training anddegrees from the ESO opened offices but did not organizeas the Belgian Society of Osteopathy and Research inManual Therapy until 1976, later to reform as the BelgianSociety of Osteopaths in 1986.

Osteopathy was exported to Russia in 1989 by ViolaFrymann with a cranial emphasis. However, the RussianSchool of Osteopathy was also assisted by the ESO andBSO. Education largely follows the British model.Although many graduates have a prior medical degree,osteopathic training does not grant general medicalprivileges in Russia.

In Germany, since the 1990s the kinesiotherapy andmedical models have competed as the prototype ofosteopathic training and practice. This is also true inFrance, Sweden, Norway and Finland. In Canada, thelargest training stream for osteopaths, the College


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associations of physicians involved in manualmedicine. In the USA and in many other countries,the specialty of physiatry, or physical medicineand rehabilitation, provides a non-osteopathicapproach to musculoskeletal disorders. Many inthat field now value and seek training in osteo-pathic methods to integrate into their style ofpractice. Reportedly in Russia, manual medicinehas been recognized as a separate specialty.However, the route of entry into this area is alsothrough general medical education in the politicaljurisdiction of the practitioner. In many contextsthis brings practitioners into the same topicalarena as the osteopath but with a different, non-osteopathic orientation or philosophical training.Interested practitioners may then seek out osteo-pathic or craniosacral training

Recognizing this trend, organizations such asthe Federation Internationale de Medicine Manuelle(FIMM) have evolved in an effort to developstandards of education and practice. The FIMMnow hosts biannual international conferences forits membership associations from 26 countries.The FIMM was founded in 1958 through theinitiative of Dr Christian Terrier (Switzerland) andrepresentatives from Belgium, Great Britain,France, Scandinavia, Switzerland and WestGermany. In this context, osteopaths, includingthose who practice cranial techniques and thosecoming from other training paths, meet and

discuss ideas that have begun to influenceindividual practice styles.

As a consequence of such sharing, osteopathicpractice, especially among those who have medicaltraining, continues to evolve. Inevitably this willlead to further integration of medical and osteo-pathic concepts (Hutson 2003).

Physician/non-physician mix

In Europe there are continual efforts, by severalgroups, to develop international osteopathicconsortia. American osteopathic organizationshave made efforts to recognize the legitimacy of osteopathy in the international community.Embedded in these developments are discussionsrelative to qualifications required for recognition.

Recent efforts to develop formal internationalrelationships have been made by the two majorAmerican osteopathic political organizations, theAmerican Osteopathic Association (AOA) and theAmerican Academy of Osteopathy (AAO). At the2003 Convocation of the AAO, the committee oninternational relations facilitated the incorporationof the World Osteopathic Health Organizationwhich is open to individual membership, regard-less of practice style or training (www.woho.org).As this chapter is written, the AOA is continuingmeetings toward forming an OsteopathicInternational Alliance which would consist of


d’Etudes Osteopathiques de Montreal, complies with theEnglish model. Started by Phillippe Druelle DO (Frenchtrained) and Jean-Guy Sicotte MD, DO (Canadian medicalgraduate with American osteopathic training), this collegehas expanded to implement programs in Germany(Deutsche Osteopathiche Kolleg) and Switzerland (Swiss International College of Osteopathy). A smallCanadian Osteopathic Association comprises mainlyAmerican-trained osteopathic physicians.

In Asia the introduction of osteopathic techniques has followed a different course. One key figure, Kunihiko Takagi MD, found his Western orthopedictraining lacked correlations with Japanese traditionalmedicine, including acupuncture. Introduction to the

concepts of Robert Fulford DO, a cranially trained DO who developed an interest in bio-energetic medicine, compatible with the Asiatic concept of qi (chi), aroused an interest in him for osteopathicconcepts.

In this rapid review of developments it is apparentthat there is no uniformity as to the teaching ofosteopathic principle and the role of cranial therapy. It isalso apparent that in many settings there is a mix ofphysicians and non-physicians using the ideas andtechniques. While there is a struggle for dominance,regardless of bias, physicians are being trained inosteopathic methods, including cranial concepts andapproaches.


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members with full medical licensure. Such develop-ments will further influence the integration ofosteopathic medicine with relevance to thepractice of osteopathy in the cranial field.

INTEGRATED OSTEOPATHIC TREATMENT –INCLUDING CRANIAL

Current practice

Recognizing that the roots of osteopathic treatmentwere based in the intention to develop a completeapproach to health and that medicine has evolvedover the last 130 years, the following list ofmedical indications and contraindications toosteopathic manipulative treatment is proposed.This list will be followed by illustrative casescenarios. It is realized that in some circles thescenarios will appear as compromised standardsof medical care, whereas to others they mayappear as a corruption of osteopathic practice.Still himself, on several occasions, said there wasnot one way to treat (Still 1992).

The case examples will begin with several thatintegrate palpatory diagnosis and manualtreatment into general medical management.Following this, some case examples will bepresented which more directly involve cranialdiagnostics and treatment as their focus.

The discussion below depends on an acceptanceof the resolution attempted in the paragraphs onspecific and general treatment above. It is theauthor’s belief that there are interactive relation-ships within the body that integrate apparentlyseparate systems, as well as structural inter-relationships which affect systems. If a symptomis a reflection of a breakdown of body function, afailure of adaptation, the elements of the body thatare locally, regionally or systemically most closelyrelated to that area’s normal function can berecruited to clarify the diagnosis and to expeditetreatment. Clinical experience is the best teacherin selecting the local and non-local structures thatwill be most relevant to normalization of localfunction.

Whether or not the pharmaceutical industry iseffective in achieving it, this is also the goal ofmodern pharmacology. While all therapy fallsshort of faithfully replicating natural body

functions, it is the author’s experience that it isoften advantageous to use the complementarybenefits of manipulation, pharmacology, herbalremedies, acupuncture, diet and other lifestyle orbehavioral approaches in any attempt to restorenormal function.

Indications and contraindications

Many of these are relative, depending on thediagnostic acumen of the practitioner, the physio-logical consequences of the therapeutic methodsused and the current goals of treatment. Todemonstrate this point several examples havebeen included, under both the indications andcontraindications, in order to stimulate reflectionand thought.

The suggested applications are derived frompersonal case experience, collegial consensus andthe logical extension of physiological principles.Osteopathy has not advanced to full participationin the evidence-based medicine process because oflack of funds and patient numbers, as well aschallenges in standardization of patient popu-lations. Items marked with an asterisk (*) will beillustrated below, in the case scenarios.

These lists are in no way intended to becomprehensive. They are also not intended tosuggest any application beyond the reader’sprofessional competency or practice license.

Indications

Non-cephalic medical presentations benefitingfrom manipulation Most orthopedic complaintsroutinely referred to physical therapy, including:

• Extensor tendonitis• Tennis elbow• Biceps tendonitis• Frozen shoulder• Lumbar strain• Plantar fasciitis*

Peripheral neuropathies

• Carpal tunnel syndrome• Brachial plexus compression/thoracic outlet

syndrome*• Sciatica• Vertebral disk prolapse

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Systemic disease

• Edema including congestive heart failure• Bronchitis, acute and chronic• Hypertension• Chest wall pain.

Non-cephalic medical presentations benefiting fromcranial treatment Structural or general medical

• Myofascial pain syndromes• Cumulative chronic systemic disease• Cancer, palliative phase of treatment

Psychological

• Anxiety, depression*• Post-traumatic stress disorder*• Panic disorder• Anxiety associated with mitral valve prolapse

Developmental

• Growth retardation*• Learning disabilities*• Attention deficit disorder with hyperactivity• Infant colic.

Cephalic-related complaints benefiting fromcranial treatment

• Headache*• Temporomandibular joint dysfunction*• Whiplash-type cervical strain*• Hemiparesis secondary to stroke• Congenital non-synostotic plagiocephaly• Postencephalopathic hemiplegia*• Allergic rhinitis*• Chronic otitis media• Direct cranial trauma without fracture.

Contraindications

Structurally or medically unstable conditions

• Stroke in evolution• Suspicion of subarachnoid hemorrhage• Suspicion of acute fracture, cranial or cervical• Suspicion of cancer not yet diagnosed or staged• Potential for metastasis when cure is still sought• Acute encephalopathy or meningitis• Vertebral disk prolapse• Dizziness, loss of consciousness, blurred vision

with cervical rotation/sidebending

• Local infection, cellulitis or abscess• Untreated fracture.

All conditions beyond the practitioner’s/therapist’straining level.

Prescription: technique selection and dosing

All manipulation has health consequences anddepends on knowledge, experience and judgmentto appropriately select a method and to dose theintensity, duration and frequency of treatment.Many types of treatment, including cranial, allowan operator to be an artist, to work intuitively,modifying the technique for individual patientrequirements.

The issue of individualization of treatments,according to patient need and therapist skill,reiterates what was mentioned regarding indi-cations and contraindications.

These prescriptions are meant to serve assuggestive guidelines, with skill and soundjudgment presumed. They are not intended aspermission for the unqualified to apply a newlylearned technique, nor for a patient to self-prescribe and then go looking for a practitioner.All medicine is, and should remain, seriousbusiness. Medically integrated manipulativepractice is serious business and no part of this textshould be construed as a substitute for trainedmedical judgment.

In no case is it intended to give anyoneintellectual permission to practice outside thescope of their license or training.

CASE EXAMPLES

Explanation and disclaimer

A selection of case examples illustrating theintegration of osteopathic manipulation, includingcranial manipulation, in an otherwise medicalcontext are detailed below. The author hasattempted to describe routine situations, in whichmanipulation has been very useful, with unusualor heroic applications. These are presented to thereader as suggestions for further developing apractice repertoire within the scope of thecurrently held license and training. The descriptions


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are not meant to engender competency or increasepractical skill.

Non-cephalic medical presentations benefitingfrom manipulation

Case 1: Plantar fasciitis

Complaint: JK is a 37-year-old female complainingof recent-onset left foot pain. She believed sheinjured it the previous weekend during a hike thatinvolved unusual exertion.

Examination: Stocky individual, reasonable muscletone, erect carriage with shoulders posterior tocenter of gravity and increased lumbar kyphosis.Posterior view demonstrated pelvic sideshift anddeclination of the sacral base to the left. Hip drop(Gillette) test was positive on the right. Standingflexion test was positive on the left. There was a left lumbar scoliosis pattern with thoraciccompensation and the shoulders were level.

Seated examination revealed a similar scolioticpattern, with positive seated flexion test on theleft. Supine exam revealed tenderness in themedial aspect of the left heel, with an apparentshort leg on the left. Cranial exam revealed a rightsphenoid torsion pattern.

Assessment:

• Plantar fasciitis• Restriction of motion/somatic dysfunction:

lower extremity, pelvis, lumbar, thoracic andcranial.

Treatment sequence: Diagnoses were shared withthe patient with an explanation of functionalinterrelationships between her pain and herpattern of postural and structural imbalance. Hercondition was reinterpreted as a chronic condition,requiring more than acute care, with her symptomreflecting an acute exacerbation. Prognosis andthe need for steady applied effort were described.

The patient was offered an integrated treatmentapproach that included osteopathic manipulativetechnique (including cranial), home exercise, useof an insert heel pad and anti-inflammatorymedication. Although mentioned as a last resort,injectible corticosteroids for symptom relief wereconsidered but dismissed.

The focus of osteopathic manipulation wasthreefold. To convince the patient of our care andknowledge, treatment began with a connectivetissue stretch to the plantar aspect of the foot andthe posterior compartment of the leg. The primaryfocus of the treatment approach was to restoresymmetrical balanced function to the pelvis. Thiswas accomplished using a combination ofconnective tissue releases, muscle energy andoscillatory techniques. By inference, through thecore-link concept, this would imply optimal andsymmetrical cranial function. A home exerciseprotocol was recommended and taught. Thisincluded a leg-over stretch, derived from a yogaspinal twist but with repetitive isometric con-traction added. For the plantar fasciitis, a standingstretch of the posterior lower extremity wasdemonstrated.

Over a 3-week period, the patient used acushioned heel insert and an anti-inflammatorymedication and received three treatments involvingmanipulation. At each visit changes in cranialfunction and other somatic dysfunctional patternswere noted and treated as appropriate. Typicallythis would entail connective tissue stretch of theposterior compartment of the leg and muscleenergy technique applied for the sacral and pelvicfindings. The scoliosis improved with leveling ofthe sacral base. Cranial mobilization includedgentle but direct stretch of the membranes andguidance of the cranial base into free motion.

Improvement of the heel pain was slow at firstand the patient was frustrated. Coaching wascritical to encourage her to persist with the heelcushion and home exercises to complement theoffice treatment. Each visit showed incrementalimprovement in her postural and cranial patternof imbalance.

The early return of cranial symmetry suggestedthat the cranial findings represented a secondaryor accommodative pattern. Cranial work, movingfrom direct manipulation to inductive balancingtechniques, was continued in subsequent sessions,with the intention of monitoring diagnosticchanges as well as treating subtle dysfunctions.

The patient was relieved when a decrease in theintensity of her pain was noted, particularly theabsence of symptoms on rising. Progressively the frequency of visits was decreased and after

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3 months she recognized that she had beensymptom free for several weeks. She wasencouraged to continue the stretching exercises.

Discussion: This case reflects the interrelatednessof the body in diagnosis and treatment. It alsodemonstrates the balance to be struck betweenattending to the patient’s point of view, in theirexperience of symptoms and simultaneouslyattending to the issues of interrelatedness of thebody as a functional unit and the issue of aprimary cause of patterns of adaptation.

In this context structural and functionalfindings in the cranium may reflect a primaryproblem or an adaptive pattern to an underlyingproblem elsewhere. Classically the interconnected-ness has been attributed to the distribution ofdural attachments, resulting in forces beingtransmitted through the cerebrospinal fluid.

However, the ‘core-link’ hypothesis is not theonly unifying concept through which explanationsof interconnectedness can be produced. Severalattempts to systematize the unifying function ofthe connective tissue system, notably the fascia,have been put forward which complement theimplications in Sutherland (1990, p. 273) and Still.Rollin Becker describes the key role of a higherlevel potency which is responsible for the vital mobility underlying all of physiology(Becker 1997, p. 95).

Additionally, the work of Godelieve Denys-Struyfdescribes the functional interrelationship of muscleswhose investing fascia create chains which directthe force and which are expressed in posturalprototype (Fig. 3.1). The prototypes are alsothought to correspond to emotional states, eitherendogenous as personality or acquired as attitude,deriving from thoughts or experience such astrauma. Her primary intervention is posturalretraining, by means of which the person inten-tionally adjusts posture to a more desirable andconsistent pattern (Denys-Struyf 1979).

Myers (2001), with his system of muscle trains,approaches treatment from a different point ofview by conceptualizing the fascial interrelation-ship of a region as functional connections betweennodes, the joints. Rather than seeing the limbs andtrunk as a collection of separate bones andactivating muscles, Myers expresses the structural

interrelationship of parts as if they were elementsof a continuum (a virtual tensegrity structure).The muscles and investing fascia are seen asrailroad tracks, with the enthesis or attachment tobone as ‘train stations’ or important points fortherapeutic intervention.

Schultz (1996), in his book The endless web,expresses in a more basic way the extension of thefascia of the trunk and extremities which mightexpress themselves in injury or pain patterns.However, the point is the same: the continuum ofthe fascial system is often underappreciated inbodywork. Classically, osteopathy, including thatin the cranial field, has always created andpromoted this idea, though admittedly not in a


Figure 3.1 Diagram of muscle chain pattern PA,corresponding to attitude of confrontation. (Reproducedfrom Denys-Struyf 1997.)

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unified manner. This case shows a practicalexample of how these interrelationships arereflected in clinical practice.

The case draws us into the dilemma ofattending to the patient’s complaint of pain, theirsymptom, while simultaneously looking deeperinto the chain of causation. Both postural andmechanical (articular) interrelationships, withinthe affected region and throughout the body,require consideration. The relationships mayinclude vasculohumeral factors such as inflam-mation. They may include biomechanical con-sideration such as accommodation by regionallycompensating joint surfaces. Additionally, theymay be viewed from the neuromuscular ormyofascial point of view. Whichever perspectiveis chosen, the person is a functional whole that canbe affected from many points within a series offunctional loops. On a more esoteric level, thechaos mathematical models can contribute to ourappreciation of clinical syndromes, as discretephase states organized around a particular attractor(Kelso 1995).

The integration of orthopedic, podiatric andpharmacological approaches to patient care, asillustrated in this case, represents a wide appli-cation of this paradigm. Each intervention, thoughsometimes redundant, can perturb the currentunsatisfactory pattern and encourage normalcy, ina time frame satisfactory to the patient. This isimportant for maintenance of credibility with thepatient, ensuring compliance with the criticalaspects of care that involve their behavioralchanges.

Non-cephalic medical presentations benefitingfrom cranial treatment

Case 2: Cognitive and constitutional delay andlater onset of adolescent growth

Complaint: At the time of consultation CH was a12-year-old boy, alert and active but small in buildand behind his peers in reading skills. He hadslight asthmatic bronchitis, allergic rhinitis andhad taken allergy desensitization shots for 2 years.His mother brought him to a family practiceinitially for the weekly desensitization shots buton one occasion remarked about her dissatisfactionwith his delayed growth and reading problems.

Out of school the child seemed developmentallynormal. He had participated in the routine publichealth immunization schedule and had no seriousperinatal conditions or illnesses. CH was theyoungest of three siblings, delivery having beenrapid after a medically normal but emotionallystressful pregnancy. APGAR scores were 9 and 9.(APGAR is a sum score determined by severalphysiologic parameters including color, cry andheart rate at 1 and 5 minutes after birth – ideal is10 and 10.)

Examination: Physical examination showed a boyof slight build, pale but alert and oriented withgood muscle tone. General musculoskeletal examrevealed no significant abnormalities or restrictions.Cranial exam revealed general symmetry with4/5 strength of cranial rhythmic impulse, as notedon biparietal contact; no frank focal articularrestrictions were apparent. If anything, there wasstiffness and resistance to motion in themembranes.

Assessment:

• Dyslexia/learning disability• Allergic rhinitis• Small for age.

Treatment sequence: A general treatment protocolwas initiated aimed at optimizing respiratory,cranial and bio-energetic function. Much of thisincluded working from a posterosuperior supinevault hold but included application of cranialcompatible principles elsewhere in the body. Apercussion vibrator was also used, as will bedescribed below.

The child was seen intermittently, if possible atthe time of his allergy shots, averaging every otherweek. Over several months the mother noted amarked increase in reading skills and schoolgrades improved. CH went into an adolescentgrowth spurt.

Discussion: Manipulative management integratedinto this child’s care reflects the complexity ofinfluences. Continuation of the allergy desensitiz-ation injections may be seen to reflect a virtual‘schizophrenia’ inherent in medically integratedosteopathic practice, that demands compliancewith politically opposed paradigms of care.

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Osteopathy is viewed by many as being aninherently drugless therapy while, in addition,many are concerned about the adverse effects ofmeddling with the body’s immune system. Oftensuch conflicting approaches occur due to thepatient’s acceptance of the utility of particularmedical methods, such as desensitization injections.Building patient confidence regarding the qualityof care is an important aspect of any treatmentregimen.

The utility of cranial manipulation for anapparently behavioral problem is based on theconcept that, as humans, our behavior is partlygrounded in the physical substrate that isinvolved in co-ordinating the behavior – the brain.It is considered that deficiencies in childhoodbehavior and learning may be due to marginaldysfunction of intracranial processes caused byconstitutional restriction of healthy inherentmotion. Sutherland, Magoun, Arbuckle, Fulfordand Frymann all attest to the importance ofsuccessful resolution of preterm and congenitalstrains in the later full functioning of the child.They all developed protocols for dealing withextreme cases of birth trauma, as well as injuriesproducing only minor immediate disturbance offunction. Learning disability, in this context,reflects a slight, progressively disclosed inhibition

of normal higher human function. Cranialmanipulation is used to optimize function bynormalizing subtle membranous, parenchymaland bony relationships, relative to the brain. Thereis often no evidence of a single glaring focal pointof dysfunction, although sometimes there is onepreviously undiagnosed lesion.

The functional deficit may evidence itself insubtle ways. In general cranial work there is anappreciation of the complementarity of diaphrag-matic respiratory function and cerebrospinal fluidfluctuation. Nelson & Gloneck suggest that theserhythmic phenomena help regulate the physio-logically recognized Traube-Hering-Meyer oscil-lation (Nelson 2002). Based on his experience insubtle palpation, Robert Fulford explained thenormal movement and function as an energeticcomponent of the vital function of an individual.He termed the initiation of this vital process the‘first breath’, which he described as qualitativelyand quantitatively palpable to the trainedindividual. Stressful preterm or birth-relatedevents could possibly limit the quality of thefunction. Arrests or suboptimal expressions of thisfirst breath, the absence of a spirited cry, could bereflected in suboptimal function until corrected. Inaddition to his manual approach, he would use apercussion vibrator, variously applied, to normalize


Figure 3.2 Palpation of the cranium with anterior approach, accommodating reciprocal complementarypolarity, after protocol of Robert Fulford DO. (Reproduced with permission from Comeaux 2002.)

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the electromagnetic relationships of cells andtissues involved in a dysfunction (Comeaux 2002).

In the percussion vibrator a motor drives apadded hand piece, by means of a flexible rotatingshaft. The hand piece applies a short excursionforce perpendicular to the surface of the skin. Thefrequency may be varied from 100 to 4000 strokesper minute and is generally used in the range of40–100 Hz.

A formal protocol, with many considerationsfor modifying treatment, is described in Fulford(1996). The pad is applied over a bony prominenceto disseminate oscillatory force through the targettissue. The vibratory force is intended to entrainthe endogenous vibration of tissue that may havebeen reduced or dampened by trauma or otherstrain.

Cephalic-related complaints benefiting fromcranial manipulation

Case 3: Headache with whiplash

Complaint: BK, an 18-year-old, presented withheadache and neck pain in a family practicesetting 8 days after a motor vehicle accident.Emergency department evaluation included anincomplete cervical spine series which revealedcervical spine straightening; the patient had beendismissed from the emergency department after

he insisted on staff response to his father’scomplaint of pain and an argument ensued. Bothwere injured when their vehicle was rear-endedby a vehicle impacting at high speed. The patientwas a first-year college student and prior to theaccident reported episodic neck stiffness forwhich he received some physical therapy.

Examination: After repeating a cervical spineseries with odontoid view to demonstrate absenceof fracture, the patient was further evaluatedmanually. As is typical of this type of injury, therewere no discrete segmental vertebral restrictionsbut rather diffuse soft tissue tenderness, secondaryto ligamentous and dural strain. The cranial basewas found to be compressed with minimalmobility.

Assessment:

• Headache• Cervical strain• Sphenobasilar compression.

Treatment sequence: Treatment progressed andserial re-presentations of an evolving posturaladaptive pattern were remolded over a 4-monthperiod. Initially work was done to facilitatemobility during the healing phase. Minimal tissuetexture changes in the occipito-atlantal and C1–C2region were addressed by manual traction, focalinhibition, gentle connective tissue release and

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Figure 3.3 Percussion vibrator applied to treat pelvic dysfunction, after the protocol of Robert Fulford DO.(Reproduced with permission from Comeaux 2002.)

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muscle energy technique, using oculocephalogyricreflex activation (Ward 2003). The full length ofthe dura was evaluated and focal restrictions weretreated where appropriate. The cranial basecompression was treated with a traction tech-nique, separating the occiput and the sphenoidwings.

As healing progressed, there was localization ofrestriction in the thoracic inlet region andattention was paid to fascial and rib mobilizationin this region. Eventually the patient resumedclass work with progressively diminishingcomplaints.

Discussion: This case represents a rather straight-forward case of head and cervical strain withoutmore distant problems. However, both the strainpattern and the restrictions were viewed regionally,rather than as local articular dysfunctions.

The dura, the fascia and the cranial-spinal chainrepresent a continuum of structure and function.Cranial mobility and restriction should not beviewed in isolation from the structures with whichthey are continuous.

Objective findings become very valuable in thecontext of automobile accidents, in which litigation,narcotic seeking or other malingering are realpossibilities.

Case 4: Allergic rhinitis

Complaint: CV, a 22-year-old woman, came to afamily practice office complaining of recurrentsore throat and earache. She anticipated a positivestreptococcal screen with a view to receiving anantibiotic. Her symptoms had worsened over theprevious 3 days although she had noted no fever.She indicated recurrence of these symptoms overthe last 4 months, despite using a course ofcephalexin (antibiotic) 2 months previously. Shehad no shortness of breath but reported a cough atnight.

Examination: The patient was a trim female, withslight ‘allergic shiners’ beneath her eyes. Examin-ation of the ears, nose and throat showed theexternal auditory canals to be clear, the tympanicmembranes to be slightly pink with retractionsand no injection or significant fluid in the middleear. The mucosa over the nasal turbinates were

boggy and pale. The throat revealed pharyngealerythema and hyperemia, with no erythema orexudates associated with the pharyngeal arches.

Supine cervical exam revealed adenopathy inthe posterior triangle. No frank segmental rotationswere noted but the right occipito-atlantal arearevealed edema and tension in the rectus capitusposterior major. Cranial mobility was adequateand symmetric.

Assessment:

• Allergic rhinitis with secondary pharyngitis• Serous otitis media.

Treatment sequence: It was necessary to beginwhere the patient was concerned, in order toconvince her that the assessment of her conditionwas accurate. An explanation was offered as to a differential diagnosis suggesting irritativepharyngitis, secondary to the postnasal drip ofallergic rhinitis. The acute and chronic aspects ofthis condition were then discussed. The futility ofempiric antibiotics and complementary pharma-ceutical methods of dealing with allergic rhinitiswere also discussed. Although it is a stimulant,use of the appropriate dose of pseudephedrinewas suggested to decrease congestive edema.

While discussing the pros and cons of variousapproaches the patient was asked to lie supine.Treatment involved a stroking or effleurage of theposterior fascia of the neck, as well as stretching tomobilize the fascia of the lower neck and thethoracic inlet (the doorway to the lymphatic ductsas it enters the subclavian vein).

Facial effleurage and a pumping of the mandible(called the Galbreath maneuver: see Fig. 3.4) wereapplied (Ward 2003).

Cranial manipulation followed the pattern andrationale as discussed below. In this case thepatient agreed on a short course of an anti-histamine, as well as over-the-counter pseud-ephedrine.

Discussion: A mundane but frequent complaint,nasopharyngitis can reflect a cranial problem.Though not threatening, the condition has a highprevalence and a significant amount of money is often spent on pharmacological and over-the-counter remedies, all aimed at maskingsymptoms.


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Cranial manipulation can be very helpful.Although the patient was aware of the nasal andthroat drainage, the majority of fluid which entersthe head leaves posteriorly, through the jugularforamen. Treatment of the occipito-atlantal area bygentle stretching, mobilization of the occiput andspreading of the occipitomastoid suture is helpfulin long-term management. Additionally a frontallift, sphenoid flexion, as well as frontonasaltraction and exaggerated flexion of the zygomataall contribute to opening the ostia of the sinusesand the venous and lymphatic channels whichserve them.

Allergic rhinitis represents an enhanced immuneresponse, the result of genetic, developmental andsystemic factors. In the correct environment, theauthor has found homeopathic, as well as medical,desensitization to be of value.

Additionally there is a classic system involvinguse of neuroendocrine tender points (neurolym-phatic or Chapman’s points) (Ward 2003, p. 1051)which can be very helpful in upper respiratorycomplaints such as this. An energetic approach tothese types of problems may reflect the work ofMarcel Vogel, as passed on by Robert Fulford DO(Comeaux 2002).

Case 5: TMJ dysfunction, migraine trigeminalnucleus affected by the temporal bone

Complaint: MC was a 25-year-old female referredfor osteopathic assessment and treatment by herfamily physician for recalcitrant jaw and neck painplus headache. She reported that an automobileaccident had caused the onset of symptoms 8 months previously. In the accident she, as thedriver, collided with one car, looked over her rightshoulder to care for her young daughter in theback seat and was struck by another car.

Initially after the accident she was unable toopen her mouth and lost 18 pounds (~ 9 kg). Hercurrent weight was 137.5 pounds (62.5 kg).Headaches continued intermittently and weredebilitating; they were largely right frontal andtemporal, associated with photophobia.

Prior to presentation the patient had beentreated with physical therapy, with limitedimprovement and was using an orthodonticsplint.

Current medications at the time of presentationincluded hydrocodone/acetaminophen, amitrip-tyline, sertraline, metaxolone and an oralcontraceptive agent.

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Figure 3.4 Galbreath maneuver to normalize Eustachian tube function and minimize serous otitis media.(Reproduced with permission from Steele & Essig-Beatty 2004.)

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Prior to the author seeing the patient, she wasseen by a colleague in the group practice for fivesessions. During this time osteopathic mani-pulation, including cranial therapy, was used.Also, rizatriptan was added in an unsuccessfulattempt to treat migraine-type headaches.

Previous studies: Plain radiographs of the cervicalspine revealed flattening of the normal curvature;dynamic X-rays showed slight ligamentous laxity.No fractures were evident. MRI of the cervical andthoracic spines showed a slight bulge of the inter-vertebral disk at T2, with slight cord flattening.

Examination: The patient was a lean female witha tightly clenched jaw. There was paraspinaltension at multiple levels in the thoracic andlumbar regions, with excessive tension in bilateralmasseter muscles. With the splint removed, thetemporomandibular joint seemed regressedbilaterally. With the splint in place, there was asoft edematous feel, with restriction of motionbilaterally. There was no asymmetry.

Cranially, there was compression of the sacralbase. She pointed to a knot at the back of her neckthat represented the atlanto-occipital area, whichwas tender. C2 was rotated and sidebent right and

flexed. The patient had a depression anterior tothe lambda, presumably reflecting a congenitalfailure of closure of the sutures. She was anxiousabout this feature.

Tissue texture changes and articular asymmetrieswere noted throughout the cervical and thoracicspine and upper ribs. Additionally, the sacrum,though symmetrical, demonstrated limitedrespiratory flexion.

Assessment:

• Cranial dysfunction• Dysfunction of cervical spine• Headache• Temporomandibular joint dysfunction.

Treatment sequence: Initially restrictions, beginningwith the more remote elements of the sacrospinal–cranial complex, were evaluated and treated usinga variety of osteopathic approaches. The temporo-mandibular joint was treated with traction andbalanced ligamentous tension. Associated withthis release were direct cranial mobilizations ofthe zygoma, maxilla and sphenoid.

The cranial base was progressively decom-pressed with traction technique. With greater


Figure 3.5 Temporomandibular decompression technique. (Reproduced with permission from Steele & Essig-Beatty 2004.)

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mobility, restriction of the mandible, the sphenoidand zygoma on the right became more apparent.In addition to treating these restrictions, cervicalmanipulation was applied over several visits,using traction, ligamentous articular release andhigh-velocity thrust techniques.

When anticipated improvement was delayed, acranial computed tomographic (CT) scan andrepeat MRI of the cervical spine were ordered. TheCT was read as normal; the MRI revealed diffusemild, broad-based bulging from C3 to C7 andminor cord flattening.

Additionally, the implications of a chronicallergic rhinitis were evaluated with a course of anantihistamine, loratidine. Trials of periods withand without her mouth splint were tried.

Behavior issues, including overall tension andjaw clenching, were discussed and addressed,with a progressive relaxation method and arelaxation breathing protocol.

After 15 months of following and treating theevolving symptom complex and physical findings,the patient acknowledged she was well enough towithdraw from regular treatment. Seen in public,she looked happy, active and relaxed.

Discussion: This case represents a complexinteraction between social, legal, psychological andbiomechanical features. It involved a case ofwhiplash-type strain, with associated unresolvedfeatures. There was a distinct disadvantage inhaving to enter the case rather late.

Overall, the mandible is rarely addressed inclassic cranial work. In some spheres of chiropracticand applied kinesiology there is recognition ofwhat is called the somatognathic system (Walther1983, p. 343; see also Ch. 5), indicating therelationship of jaw mechanics to other anteriorbody structures. In conventional whiplash strain,most attention is paid to the soft tissues of thecervical spine. However, as an appendage to theanterior skull, the mobile jaw, if abruptly alteredin its inertial state, is capable of straining itssuspensory muscles and ligaments. It is surmisedthat this was the case with this patient, especiallyconsidering the unusual bilateral quality of thetissues around the temporomandibular joint.

Additionally, no element of the biomechanicalsystem is affected in isolation. The mandible is

intimately associated with the temporal bone andalso the occipito-atlantal (OA) area. Resumptionof normal function and relief of pain depend onnormalization of these elements.

Although articular restriction at the TMJ andOA joints and the cervical spine, plus tension inthe associated soft tissues, can cause a tension-type headache, a further potential cause ofheadache in this patient might be atypicalmigraine. Although for many years migraine hasbeen viewed as vascular dysregulation, theprimary cause of this disorder is now consideredto be trigeminal nerve irritation, due to irregula-rities at the ganglion (resting as it does on thetemporal bone) (Tepper 2003). In a cranial context,one could legitimately surmise that temporal boneimbalance, restriction or dysfunction may underliesome cases of migraine. Cranial treatment in sucha context can therefore have many goals and thepotential for offering relief.

This case additionally highlights the regionalrelationships involving the cranium. While in the context of Sutherland and Upledger we cite the core-link concept of cranial and sacral interrelationship, the author finds it helpful to recall that the dura attaches at each ofthe spinal nerve roots and is therefore capable of affecting the motion of each of the spinalsegments. This feature of the craniospinalcomplex requires assessment and normalization ifdysfunctional.

Philosophically and consistent with this clinical observation, Charlotte Weaver (1938)conceptualized the embryonic development of the cranial base as paralleling the development ofthe vertebral segments, with separate ossificationcenters within the adult structure. This develop-mental similarity suggests that spine and craniumare part of a larger integrated system, with similar behavioral characteristics. Treating themas totally separate systems is inappropriate andineffective.

The apparent disparate pattern of symptoms inthis patient suggests these interrelationships. Theclinical challenge is to work through thesesymptoms and findings as if one were untanglinga ball of yarn.

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Case 6: Postencephalopathic hemiparesis

Complaint: ES was a 37-year-old male who hadbeen in a long-term convalescent nursing homefor 3 years, after having an acute viral encephalo-pathy which left him with aphasia and paresis,affecting legs and arms bilaterally. A laborer withlimited education, he had been abandoned by hiswife who also took any financial assets he had. Hewas now a ward of the state, with limitedprospects for a better life.

Having experienced a fatalistic approach tocontinued medical care, he was assigned to theauthor to care for his routine adjustment ofantihypertension medications and other needs.Following an offer, he began to be transported tothe author’s office for monthly osteopathictreatment.

Examination: The patient arrived in a motorizedwheelchair and was transferred with partial co-operation to the treatment table. He demon-strated about 20% normal strength in all extremities,with the ability to spontaneously move these.Passive mobility testing was complicated by limbspasticity. Involuntary movement spasticity of theextensor muscle groups predominated, preventingbalance, essential to standing or walking. Hestruggled unsuccessfully to contribute to chair-to-table transfers.

Cranial evaluation revealed a large depressionin the posterior occipital area as a result ofexploratory surgery. CRI was initially verydiminished without a clear rhythm. His stockyneck and spasticity made assessment of thecervical spine almost impossible. He had almostcomplete left arm and leg paresis with greatervoluntary movement of the right limbs. Evenpassive range of motion testing was complicatedby the spasticity. This was a most challengingpatient.

Assessment:

• Postencephalopathic partial quadriparesis• Cranial dysfunction• Complications of surgery• Depression.

Treatment sequence: Treatment was givenintermittently, at monthly intervals, over 3 years.

Monthly, when he was willing, he was transportedby wheelchair from the nearby nursing home. Onsuch occasions treatment was on a conventionaltreatment table. Sometimes he was treated with ananterior approach, in a chair, on monthlymedication rounds at the nursing home.

No formal protocol was developed for treatingthis patient. Cranial treatment initially began usinga CV-4 (see p. 189) or occipital compressiontechnique, along with other inductive techniques,to enhance cranial mobility. An attempt was madeto involve the scarred areas in the mobility pattern.Work ceased for a time when seizures resumedand the patient associated these with beginningthe cranial work. He later returned to treatment.

A second approach involved experimentationwith limb movement. Using the remaining powerof his right arm, more controlled motion wasintroduced by recruiting and involving musclesother than the natural prime movers of the limb.In other words, to flex the arm, rather thancontracting the biceps, he was encouraged to tryto keep the biceps relaxed and to find a morecircuitous route to get his arm to the desired level.He would then be able to use the lateral head ofthe triceps and the deltoid. This strategy workedwith both arm and leg movements. Over severalyears he progressively resumed a fair range of hisprevious movement pattern. This probably had todo with a gradual reassignment of cortical areas ofthe brain to limb movement.

Significant effort was applied to reducingrestriction of fascial and articular motion, utilizingpassive stretch techniques. Stretches needed to beachieved in a way that avoided the spasticcontractions.

As he made incremental gains and sawprogress, he applied himself in heroic fashion tohis efforts. In part he was relieved of his feelingsof oppressive helplessness and began to set goals.He eventually applied for an assisted independentliving arrangement.

Discussion: The osteopathic profession describesits commitment to working with the whole person.Here we had a patient who had experienced amajor health crisis. Additionally he had beenabandoned and legally deprived of his assets, sothat he became a helpless ward of the state.


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Through a bonding between patient and physicianand the patience of all involved, he was able toachieve a more hopeful and self-reliant status.Most of the work involved being creative in theapplication of principles, being persistent andtrusting instinct. Nothing done was technicallycomplex.

Case 7: Post-traumatic stress

Complaint: BB was a 48-year-old female whopresented in a family practice 4 weeks aftersuffering midback strain in a motor vehicleaccident, from which she was not recovering. Sheattributed the location of her pain to the seatbeltrestraint as she was hit by another vehicleobliquely from behind but had turned to the left inresponse to noise. Physical therapy was painfuland her regular physician resorted to a pharma-cological approach (pain medication) only. Thepatient was dissatisfied with this. She presented alitany of complaints of pain in her midback, armsand legs and initially exhibited near-hystericalresponses to almost any contact.

She normally worked as an assistant head tellerin a bank and felt harassed by her employer whowanted her to return to work. She also expressedanger that there must have been somethingdeficient about her medical care thus far, since shehad not sufficiently recovered. She expressedindignation about being involved in the accidentat all. For emotional support she would mostoften come to treatment with another familymember, usually a young daughter.

Examination: The patient had a straightforwardpattern of left sidebending and rotation of herribcage, with a primary spinal segmental dys-function. The OA area was very tender and therewere a series of tissue texture changes throughoutthe cervical spine. Cranial mobility, thoughsymmetrical, was diminished.

On directly but gently attempting to treat theseareas, the patient was disproportionately anxious,protesting about the pain.

Assessment:

• Cranial, cervical and thoracic strain• Anxiety• Post-traumatic stress.

Treatment sequence: Treatment began in the areaof her primary thoracic complaint, with gentlearticular and muscle energy approaches. Againthe patient protested at every approach, howevergentle. By the third visit, it became apparent that her anxiety was presenting an obstacle tocomfortable treatment and also to her expectationof, and acknowledgment of, any improvement.

The patient expressed a need for relief from thepain that became worse with walking, even to theextent of making her nauseous to the point ofvomiting.

Expanded physical examination showed acervical strain pattern, consistent with her injuryhistory. Cranial examination revealed the occipitalcondyles posterior, resisting anterior translationinto cranial base flexion.

There was extreme muscle tension in thesuboccipital area. Cranial monitoring revealedglobal limitation of mobility, consistent withcranial base compression. Even light cranialcontact was reported as causing nausea, as well aspain in her midback. Associations with vagalnerve compression seemed probable. However,discovery of further tender areas sent the patientfurther into a panic over her prognosis.

The initial approach to her emotional state wasto try to help her develop cognitive insight intothe association between findings and symptoms.An attempt was then made to use relaxationbreathing as a way to help her control her panic.Neither effort achieved credibility with thepatient.

Pharmacological therapy was tried temporarily,using anxiolytics as well as several trials of anti-inflammatory and pain medication. Integratedinto this approach were time-lines for tapering, orintermittent use, of the medication.

Despite protests, treatment continued on aweekly or biweekly basis, on her thoracic distortionpattern, using articular, muscle energy and con-nective tissue approaches. Reassurance was givento generate a more positive attitude towardprogress. Additionally, each visit included cranialbalancing, according to the findings of the day,integrated with gentle upper cervical manipulation.Special attention was paid to the disposition of C1and C2 and their relation to the muscles of thesuboccipital triangle.

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Two months after her first visit the patientrequested release to resume her occupation.

Discussion: The role of cranial manipulation wastwofold. One aim was to normalize structure andfunction of the tentorium which supports thediencephalon and the base of the brain. Thesestructures support the tissues of the limbic systemand the thalamic nuclei that relate to inter-pretation of experience and emotional response. Ithas been hypothesized that the experience of post-traumatic cervical strain, ‘whiplash’, may includeneural reflexes involving this area, relating tovision (Levine 1997).

The symptoms of nausea associated with thispatient’s pain could be a centrally initiated vagalreaction to the pain experience. However, theycould also represent symptoms of vagal crowdingat the jugular foramen, at least partly in responseto restriction of the occipitomastoid suture and themuscles of the suboccipital triangle, as mentionedabove.

Additionally there were regional biomechanicalrelationships in her complex injury pattern, whichinvolved the so-called ‘core-link’ (Magoun 1976, p. 337), the linear relationship of the dura belowthe cranial cavity. In conventional cranial workthis is used to describe the relationship betweenthe disposition of the sacrum and the cranial base.However, the responsible connecting structure isthe dural tube, which also attaches at the lateralaspect of the spinal nerves, relative to theirassociated thoracic segmental vertebrae and ribs. These mechanisms become significantlymore complex in the lower thoracic area, with the presence of the thoracoabdominaldiaphragm. Robert Fulford has mentioned theinvolvement of this diaphragm in the ‘shock of trauma’. In this case, the flexion-extensionwhiplash-type injury was compounded by thefolding of the thoracic cage over the seatbelt

restraint. Force was disseminated upward anddownward with the focal area acting as a fulcrum.

CONCLUSION

This chapter has attempted to show the history ofthe development of cranial thought and work inthe context of the osteopathic profession’s attemptto define the scope of its practice, compared to conventional medicine. This development has varied around the world and is continuing to do so.

This discussion is not meant to imply thatcranial work or osteopathy is being subsumedinto medicine and will no longer be recognizable.Rather, it is the author’s premise that there isnatural compatibility between contemporaryphysiological knowledge and osteopathic principles,which can be the key to including the cranialapproach comfortably – to great patient benefit –in regular medical practice. This chapter has usedexcerpts from osteopathy’s long history toillustrate this point.

There are additional aspects of osteopathicprinciples and work that go beyond the definedscope of medicine. In the author’s mind theserepresent a part of the future of cranial work, aswell as of medicine, and need to complement theresearch hitherto performed to validate the cranialconcept. The work of John Upledger with somato-emotional release, the thoughts of Robert FulfordDO and the bio-energetic approach to treatment,the expression of James Jealous DO regarding thesignificance of the ‘long tide’ as well as HughMilne’s (1995) ‘liquid electric’ model all point tothe horizon of our understanding and what hasbeen summarized as the biodynamic model.Aspects of this dimension of cranial work will beaddressed in Chapter 4.


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