Craniosacral therapy: a systematic review of the clinical evidence

The Neurophysiological Effects of Craniosacral Treatment on Heart Rate Variability: A Systematic Review of Literature and Meta-Analysis

Craniosacral treatment (CST) is an osteopathic technique grounded in the assumption that there is an intrinsic, fine movement of the cerebrospinal fluid. This rhythmic movement can be utilized for diagnostic and therapeutic purposes by palpation and manipulation of the skull, spine, and associated connective tissues. Therapeutic benefit is likely due to action on the autonomic nervous system (ANS), specifically through the vagus nerve. Current literature on the neurophysiological effects of CST is limited, which has contributed to controversy regarding its effectiveness. Heart rate variability (HRV) as a measure of cardiovascular stress and autonomic system activity is thus proposed as a tool to evaluate the neurophysiologic effects of CST. HRV can be analyzed in two different bands, high-frequency (HF) and low-frequency (LF) power associated with a parasympathetic and sympathetic response. In this meta-analysis, we provide a brief introduction to CST, analyze three primary studies, and summarize the therapeutic benefits and pitfalls of this alternative treatment on the ANS. A significant negative HF standardized mean difference after CST was observed; standardized mean difference = -0.46; 95% CI (-0.79,-0.14). No significant effect on LF power was observed. We conclude that CST does provide a moderate short-term increase in parasympathetic activity. These findings suggest that CST may be used to treat patients with an overactive sympathetic state. Further studies should be conducted for comparison against a control group to eliminate the possibility of a placebo effect and to elucidate long-term effects.

Clinical Effectiveness of Craniosacral Therapy in Patients with Headache Disorders: A Systematic Review and Meta-analysis

OBJECTIVES

To analyze the effectiveness of craniosacral therapy in improving pain and disability among patients with headache disorders.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Physiotherapy Evidence Database, Scopus, Cochrane Library, Web of Science, and Osteopathic Medicine Digital Library databases were searched in March 2023.

REVIEW METHODS

Two independent reviewers searched the databases and extracted data from randomized controlled trials comparing craniosacral therapy with control or sham interventions. The same reviewers assessed the methodological quality and the risk of bias using the PEDro scale and the Cochrane Collaboration tool, respectively. Grading of recommendations, assessment, development, and evaluations was used to rate the certainty of the evidence. Meta-analyses were conducted using random effects models using RevMan 5.4 software.

RESULTS

The searches retrieved 735 studies, and four studies were finally included. The craniosacral therapy provided statistically significant but clinically unimportant change on pain intensity (Mean difference = -1.10; 95% CI: -1.85, -0.35; I2: 44%), and no change on disability or headache effect (Standardized Mean Difference = -0.34; 95% CI -0.70, 0.01; I2: 26%). The certainty of the evidence was downgraded to very low.

CONCLUSION

Very low certainty of evidence suggests that craniosacral therapy produces clinically unimportant effects on pain intensity, whereas no significant effects were observed in disability or headache effect.

Effects of CranioSacral therapy upon symptoms of post-acute concussion and Post-Concussion Syndrome: A pilot study

OBJECTIVE

The purpose of this study was to investigate the utilization of CranioSacral Therapy (CST) in patients with Post-Concussion Syndrome (PCS) and capture patient-reported perceptions of clinical outcomes of lived treatment experiences.

DESIGN

Two-part, longitudinal study conducted through a chart review of target group, followed by a Patient-reported Treatment Outcome Survey (PTOS).

PARTICIPANTS

A convenience sample of 212 patients with a historical incidence of head trauma not requiring hospitalization was obtained through medical records department dating back ten years. Inclusion criteria for further chart review (n = 67) was determined by identifying patients with a confirmed concussion directly correlated with presenting symptoms and for which CST was specifically sought as a treatment option. Demographics and patient-determined treatment duration data were analyzed by comparison groups extensively suggested in existing literature: Recovery time since injury as either Post-acute concussion (<6 months) or Post-Concussion Syndrome (PCS) (≥6 months); Athletes (A) or Non-athletes (NA); and traditional gender. Final PTOS group criteria was determined by eliminating confounding issues reporting (n = 47): (A, n = 24 and NA, n = 23).

RESULTS

Quantitative data was analyzed via Numerical Analysis, and qualitative data was analyzed via Inductive Content Analysis. Symptoms reported in all charts as well as in the PTOS were consistent with identified PCS subtypes. Utilization of CST revealed that most patients determined the treatment effect upon concussion symptoms within 1-3 sessions. Nearly twice as many sessions were attended in the PCS than post-acute groups. Referral sources, studied for a perspective on local concussion after-care discharge planning, ranged from professional to personal recommendation or self-discovery. A majority of patients met goals of reducing post-acute or PCS as reasons cited by self-determined change-in-status or discharge from service. Patients were asked to indicate on the PTOS which pre- and post-treatment symptoms were helped or not helped by this particular intervention.

CONCLUSIONS

Patient-reported changes of PCS symptoms is critical when evaluating treatment options. CST is an experiential treatment that addresses subjective levels of dysfunction, thus it is the patient deciding the value of an intervention. A sizable portion of patients in all groups reported a positive effect upon their symptoms by CST. Patients indicated personal meaning to CST through their utilization of multiple sessions. A high percentage indicated the likelihood of referring others with PCS for CST. Of the 212 patient charts first studied, the 145 not meeting inclusion criteria suggest some chronic conditions may present as long-term effects of older head injuries. CST is a low-risk, conservative treatment option for PCS sub-types worthy of further clinical study.

Case report: Manual therapies promote resolution of persistent post-concussion symptoms in a 24-year-old athlete

This case report illustrates the treatment outcomes of a collegiate athlete presenting with an 18-month history of post-concussion syndrome who received a series of mixed manual therapies in isolation of other therapy. Persistent symptoms were self-reported as debilitating, contributing to self-removal from participation in school, work, and leisure activities. Patient and parent interviews captured the history of multiple concussions and other sports-related injuries. Neurological screening and activities of daily living were baseline measured. Post-Concussion Symptom Checklist and Headache Impact Test-6™ were utilized to track symptom severity. Treatments applied included craniosacral therapy, manual lymphatic drainage, and glymphatic techniques. Eleven treatment sessions were administered over 3 months. Results indicated restoration of oxygen saturation, normalized pupil reactivity, and satisfactory sleep. Post-concussion syndrome symptom severity was reduced by 87% as reflected by accumulative Post-Concussion Symptom Checklist scores. Relief from chronic headaches was achieved, reflected by Headache Impact Test-6 scores. Restoration of mood and quality of life were reported. A 6-month follow-up revealed symptoms remained abated with full re-engagement of daily activities. The author hypothesized that post-concussion syndrome symptoms were related to compression of craniosacral system structures and lymphatic fluid stagnation that contributed to head pressure pain, severe sleep deprivation, and multiple neurological and psychological symptoms. Positive outcomes over a relatively short period of time without adverse effects suggest these therapies may offer viable options for the treatment of post-concussion syndrome.

Craniosacral therapy for chronic pain: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To systematically assess the evidence of Craniosacral Therapy (CST) for the treatment of chronic pain.

METHODS

PubMed, Central, Scopus, PsycInfo and Cinahl were searched up to August 2018. Randomized controlled trials (RCTs) assessing the effects of CST in chronic pain patients were eligible. Standardized mean differences (SMD) and 95% confidence intervals (CI) were calculated for pain intensity and functional disability (primary outcomes) using Hedges' correction for small samples. Secondary outcomes included physical/mental quality of life, global improvement, and safety. Risk of bias was assessed using the Cochrane tool.

RESULTS

Ten RCTs of 681 patients with neck and back pain, migraine, headache, fibromyalgia, epicondylitis, and pelvic girdle pain were included. CST showed greater post intervention effects on: pain intensity (SMD = -0.32, 95%CI = [- 0.61,-0.02]) and disability (SMD = -0.58, 95%CI = [- 0.92,-0.24]) compared to treatment as usual; on pain intensity (SMD = -0.63, 95%CI = [- 0.90,-0.37]) and disability (SMD = -0.54, 95%CI = [- 0.81,-0.28]) compared to manual/non-manual sham; and on pain intensity (SMD = -0.53, 95%CI = [- 0.89,-0.16]) and disability (SMD = -0.58, 95%CI = [- 0.95,-0.21]) compared to active manual treatments. At six months, CST showed greater effects on pain intensity (SMD = -0.59, 95%CI = [- 0.99,-0.19]) and disability (SMD = -0.53, 95%CI = [- 0.87,-0.19]) versus sham. Secondary outcomes were all significantly more improved in CST patients than in other groups, except for six-month mental quality of life versus sham. Sensitivity analyses revealed robust effects of CST against most risk of bias domains. Five of the 10 RCTs reported safety data. No serious adverse events occurred. Minor adverse events were equally distributed between the groups.

DISCUSSION

In patients with chronic pain, this meta-analysis suggests significant and robust effects of CST on pain and function lasting up to six months. More RCTs strictly following CONSORT are needed to further corroborate the effects and safety of CST on chronic pain.

PROTOCOL REGISTRATION AT PROSPERO

CRD42018111975.

Compression of the Fourth Ventricle Using a Craniosacral Osteopathic Technique: A Systematic Review of the Clinical Evidence

Compression of the fourth ventricle (CV4) is a well-known osteopathic procedure, utilized by osteopaths, osteopathic physicians, craniosacral therapists, physical therapists, and manual therapists as part of their healthcare practice based on some evidence suggesting impact on nervous system functions. The main objective of the study was to identify randomized controlled trials (RCTs) assessing the clinical benefits of CV4 and to show the evidence supporting clinical prescriptions, guides, and advice in treating. A computerized search of the PubMed, CINAHL Complete, Scopus, Web of Science, and ScienceDirect databases was performed. Two filters were used (article type: RCTs; species: humans). The methodological quality of the trials was assessed using the Downs and Black quality checklist for healthcare intervention studies. Only six studies met the inclusion criteria, of which four were RCTs and two were observational studies. The Downs and Black score ranged from 17 to 24 points out of a maximum of 27 points. The present review revealed the paucity of CV4 research in patients with different clinical problems, as five out of six included studies investigated healthy adults. According to the results of the included studies, CV4 may be beneficial for patients with different functional problems.

Craniosacral Therapy for the Treatment of Chronic Neck Pain: A Randomized Sham-controlled Trial

Objectives:

With growing evidence for the effectiveness of craniosacral therapy (CST) for pain management, the efficacy of CST remains unclear. This study therefore aimed at investigating CST in comparison with sham treatment in chronic nonspecific neck pain patients.

Materials and Methods:

A total of 54 blinded patients were randomized into either 8 weekly units of CST or light-touch sham treatment. Outcomes were assessed before and after treatment (week 8) and again 3 months later (week 20). The primary outcome was the pain intensity on a visual analog scale at week 8; secondary outcomes included pain on movement, pressure pain sensitivity, functional disability, health-related quality of life, well-being, anxiety, depression, stress perception, pain acceptance, body awareness, patients’ global impression of improvement, and safety.

Results:

In comparison with sham, CST patients reported significant and clinically relevant effects on pain intensity at week 8 (−21 mm group difference; 95% confidence interval, −32.6 to −9.4; P=0.001; d=1.02) and at week 20 (−16.8 mm group difference; 95% confidence interval, −27.5 to −6.1; P=0.003; d=0.88). Minimal clinically important differences in pain intensity at week 20 were reported by 78% within the CST group, whereas 48% even had substantial clinical benefit. Significant between-group differences at week 20 were also found for pain on movement, functional disability, physical quality of life, anxiety and patients’ global improvement. Pressure pain sensitivity and body awareness were significantly improved only at week 8. No serious adverse events were reported.

Discussion:

CST was both specifically effective and safe in reducing neck pain intensity and may improve functional disability and the quality of life up to 3 months after intervention.

Reliability of Diagnosis and Clinical Efficacy of Cranial Osteopathy: A Systematic Review

CONTEXT

In 2010, the World Health Organization released benchmarks for training in osteopathy in which they considered cranial osteopathy as an important osteopathic skill. However, the evidence supporting the reliability of diagnosis and the efficacy of treatment in this field appears scientifically weak and inconsistent.

OBJECTIVES

To identify and critically evaluate the scientific literature dealing with the reliability of diagnosis and the clinical efficacy of techniques and therapeutic strategies used in cranial osteopathy.

METHODS

Relevant keywords were used to search the electronic databases MEDLINE, PEDro, OSTMED.DR, Cochrane Library, and in Google Scholar, Journal of American Osteopathy Association and International Journal of Osteopathic Medicine websites. Searches were conducted up to end June 2016 with no date restriction as to when the studies were completed. As a complementary approach we explored the bibliography of included articles and consulted available previous reviews dealing with this topic.

STUDY SELECTION

Regarding diagnostic processes in cranial osteopathy, we analyzed studies that compared the results obtained by at least two examiners or by the same examiner on at least two occasions. For efficacy studies, only randomized-controlled-trials or crossover-studies were eligible. We excluded articles that were not in English or French, and for which the full-text version was not openly available. We also excluded studies with unsuitable study design, in which there was no clear indication of the use of techniques or therapeutic strategies concerning the cranial field, looked at combined treatments, used a non-human examiner and subjects or used healthy subjects for efficacy studies. There was no restriction regarding the type of disease.

SEARCH RESULTS

In our electronic search we found 1280 references concerning reliability of diagnosis studies plus four references via our complementary strategy. Based on the title 18 articles were selected for analysis. Nine were retained after applying our exclusion criteria. Regarding efficacy, we extracted 556 references from the databases plus 14 references through our complementary strategy. Based on the title 46 articles were selected. Thirty two articles were not retained on the grounds of our exclusion criteria.

DATA EXTRACTION AND ANALYSIS

Risk of bias in reliability studies was assessed using a modified version of the quality appraisal tool for studies of diagnostic reliability. The methodological quality of the efficacy studies was assessed using the Cochrane risk of bias tool. Two screeners conducted these analyses.

RESULTS

For reliability studies, our analysis leads us to conclude that the diagnostic procedures used in cranial osteopathy are unreliable in many ways. For efficacy studies, the Cochrane risk of bias tool we used shows that 2 studies had a high risk of bias, 9 were rated as having major doubt regarding risk of bias and 3 had a low risk of bias. In the 3 studies with a low risk of bias alternative interpretations of the results, such as a non-specific effect of treatment, were not considered.

CONCLUSION

Our results demonstrate, consistently with those of previous reviews, that methodologically strong evidence on the reliability of diagnostic procedures and the efficacy of techniques and therapeutic strategies in cranial osteopathy is almost non-existent.

Integrative oncology: really the best of both worlds?

Over the past two decades there has been a growing acceptance of 'integrative oncology', also known as complementary and alternative medicine (CAM), in cancer care and research at academic medical centres and medical schools. Proponents of integrative oncology argue that it is based in science and provides the 'best of both worlds' by combining science-based treatments and 'holistic' medicine. However, a close examination of the methodologies indicates that, from a standpoint of basic science, the vast majority of 'integrative' treatments are supported by little, if any, scientific evidence. What are the consequences of this integration? Is there any harm? Are there any potential benefits?