Research Case Report June 29, 2009
International Professional School of Bodywork http://www.ipsb.edu, firstname.lastname@example.org, (858) 505-1100
The author wishes to acknowledge Dorothy Mahrie for her guidance and helpful advice given throughout this case report project.
Objective: This study investigated the effects of CranioSacral Therapy (CST) on structural imbalance and the reduction of chronic pain.
Method: A 23 year old male experiencing chronic pain from the mid-back shooting up the spine, and radiating out through the upper girdle region. Five CST sessions were given once a week for five weeks, each treatment lasted for 1 hour. Each bodywork session began with three initial check-in phases to determine where to begin the specific CST holds. The client recorded his pain daily on a number scale and the practitioner measured his structural alignment.
Results: The client experienced a significant reduction in pain following the first session, and stayed at that level throughout the rest of the treatments. There was no measurable change in the clients physical structure, although many of the inner structures shifted and aligned to create ease.
Conclusion: This case study has shown that Craniosacral Therapy improves inner body awareness, decreases chronic pain, and creates a feeling of balance and alignment throughout one’s being.
Key Words: CranioSacral Therapy, Chronic Back Pain, Alignment, Upledger, Osteopathy
Chronic pain has been defined by the International Association for the Study of Pain (IASP) as continuous or recurrent pain that persists for longer than the normal time of healing, generally about three months (Merskey, 1994). Chronic pain can range from mild tissue irritation to intense suffering and disability affecting an individual’s entire body, psyche and life. The perception of pain often persists long after the injured tissue has healed. This can cause compensatory patterns that continue to maintain the sensation of pain, eventually leading to abnormal somatic and visceral changes that frequently mask the primary cause of the chronic pain (Wanveer, 2006).
An estimated two-thirds of American adults suffer from back pain — a condition almost as prevalent as the common cold. When the pain lingers, making it hard to get comfortable or do simple activities, this is chronic pain. Acute or Chronic, the causes of back pain are sometimes unknown (Deyo, 2007). Precipitating factors that can cause back pain include mechanical problems, such as the way the spine moves or the way you feel when your spine moves a certain way. Spasms, muscle tension, and ruptured or herniated discs can cause chronic pain. Injuries can cause back pain and muscle strains or ligament sprains; they can occur from twisting or lifting improperly. Acquired conditions and diseases such as arthritis, osteoarthritis, scoliosis, also lead to chronic back pain. Although the many causes of back pain are usually physical, emotional stress can play a role in how severe pain is and how long it lasts. Most back pain, acute or chronic, is treated with a wide range of medications available over the counter, or by a doctor’s prescription. In more extreme cases corsets and braces are used, injections of anesthetic or steroid medications are used and sometimes even surgery is needed (NIAMS, 2005).
Webster’s Dictionary defines alignment as an “arrangement in a straight line.” When referring to the body we look at the way the bones fit in relationship to one another. Ideal alignment creates an easy feeling throughout the musculoskeletal system. A balanced posture is one in which positioning is centered and relaxed for all the joints of the body. With joints in non-awkward positions, muscles relax, and unnecessary tension can be released. Tension can lead to pain, discomfort, lack of range of motion along with other uncomfortable situations. The mid-line is an imaginary line down the center of the body which provides a reference for viewing the positions of the ears, shoulders, spine, hips, knees, ankles, feet, and the very specific cranial bones. Looking to the midline shows one the relationship between theses structures, and gives information on where imbalances exist. When all is in line with the midline, alignment is improved and therefore tension is reduced and systems flow freely on the straight line known as alignment.
Craniosacral therapy (CST) is a gentle, non-invasive, hands-on alternative medicine procedure for evaluating and enhancing the body’s own natural healing mechanism. The focus of this work is on the craniosacral system, a physiological system which consists of the membranes and cerebrospinal fluid that surround the brain and spinal cord. This system extends from the bones of the skull, face and mouth, which make up the cranium, down the spine to the sacrum and coccyx, our tail bone (Mahrie, 2004). The craniosacral system is a very important system in our body and directly influences the performance of the brain and spinal cord, having a direct affect on the central nervous system. Imbalances or restrictions anywhere in this system could cause any number of sensory, motor or neurological challenges. Balancing the craniosacral system frees the movement of the cerebrospinal fluid, improving brain and spinal cord function along with improvement of the other body systems (Mahrie, 2004). CST has addressed many symptoms, such as musculoskeletal imbalance, myofascial dysfunction, chronic fatigue, immune system dysfunction, autonomic nervous system dysfunction, elevated heart rate, high blood pressure, endocrine system dysfunction, stress, anxiety, brain and spinal cord injuries, sleep difficulties and chronic neck and back pain (Wanveer, 2006).
Wanveer (a LMT specializing in Craniosacral therapy) explains chronic pain and how it relates to the brain and spinal cord, showing that there is a need for balance of this system. In this article, Wanveer shows that CranioSacral Therapy can be used to identify and help the body change core patterns contributing to chronic pain. Describing that with chronic pain the sensitivity does not decrease, thus abnormal changes in the structure and function of the tissue innervated by the area of the affected spinal cord neurons maintain the sensation of chronic pain (Wanveer, 2006).
Tan et al. (2007) provides a review on the efficacy of selected Complementary Alternative Medicine (CAM) modalities in the management of chronic pain, reported pain relief from the use of some modalities. Massage therapy was found to be useful for pain relief in numerous chronic pain conditions, particularly low back pain and shoulder pain. The use of Cranial Electrotherapy Stimulation (CES) was tested showing that there is considerable promise as both a complementary modality to other forms of therapeutic interventions to treat particular types of pain. CST and the CV-4 technique were examined for tension-type headaches. Patients who received the CST treatments reported less pain intensity, however additional large scale trials were recommended.
Upledger (1977) examined statistical analysis from 50 craniosacral examinations on 25 schoolchildren to help determine cranial rhythmic impulse, showing how its motion may display dysfunction/damage and whether cranial osteopathic treatment can bring any change to dysfunction. He also examined a collection of photographic evidence supporting the craniosacral examination. A systematic review of 33 studies by Green et al (1999) showed that only seven were based on the effectiveness of the treatment. No other systematic review was found, and relevant, reliable primary data research based on the effectiveness of craniosacral treatment was not found either. Research into clinically measurable patient outcomes after craniosacral therapy treatments is still lacking (Green et al 1999).
The objective of this study is to determine if Craniosacral Therapy (CST) can improve structural alignment to reduce chronic back pain. In CST, the practitioner is taught to be a therapeutic facilitator, not deciding what must be done, rather following the lead of the body. Practitioners are taught that the client’s body has within it the wisdom to solve its own problems. Primarily, all that is asked of the CST practitioner is a supportive presence that offers assistance in the forms of light touch, energy and intention (Upledger, 1996). This study’s treatment protocol is established around this point of view, beginning with three initial check-in phases to determine where to begin treatment on the body. Measurements are made objectively by the practitioner before and after each session using a ruler and a level to assess the clients structure, measuring the structural alignment of the client’s shoulder girdle where the chronic pain begins. The subjective measurement of pain is recorded by the client every day during the study to track changes in the intensity of his chronic pain.
Profile of Client: A 23 year old male bodywork practitioner and student has been experiencing chronic pain from the mid-back, shooting up the spine and radiating out through the upper girdle region (shoulders). Client has a history of rotator cuff tears and dislocations in both right and left shoulders due to many falls and crashes throughout childhood. He broke metatarsal bones of the right foot twice, once in 1999 and again in 2005. He has had rhinoplasty to improve breathing, and his wisdom teeth have been removed. The client does not currently take prescription medications however, he does smoke 2 cigarettes a day, consumes alcohol 2-3 times a week and often self medicates with THC.
The client feels as though he can not stand up straight, and after measuring using a plumb line, this was confirmed. This initial structural assessment using the plumb line revealed that the client has a prominent kyphotic thoracic curve and lordotic cervical curve. His right shoulder is significantly higher than the left, his clavicles do not line up. When lifting arms over his head the shooting pain from the mid-back up the spine increases. Client experiences slightly less than moderate pain on a consistent basis.
The client recently sought chiropractic work, and discovered from x-rays that two cervical vertebrae were fused. He has not returned to the chiropractor since, believing the treatment did not help aside from the x-rays. He has tried acupuncture, physical therapy, osteopathy, and many types of massage and bodywork. Currently, he is receiving massage two to three times a month, and feels that these sessions help relieve pain and discomfort for a short time. He was instructed not to receive other massage and bodywork while involved in this study.
The client’s desired outcome for this treatment is to feel a straightening in the spine; he would like to lessen the degree of kyphosis in the thoracic region and lordosis in the cervical area. The client feels that with balance in that area, the pain will decrease. He would also like to feel a reduction in the shooting pain from mid-back out to the shoulders.
Treatment Plan: To begin each session, there is an initial intake of how the client is feeling today, a check in of how much pain has been experienced on this day and throughout the past week. Next, the therapist measures alignment — tools for measurement and the procedure are described in the assessment tools section. Next, the client lies supine on the table fully clothed with relaxation music playing. The therapist begins with three initial check-in phases to determine where to begin treatment on the body.
First phase, vector searching, where the therapist looks and feels for energetic misalignments in the structure of the body, feeling for vectors from the feet to the cranium, and then from the cranium to the feet, not yet placing hands on the body. Energetic vectors should be in alignment with the midline of the body. When vectors go off in directions off of the midline this shows imbalances from the energetic body to the physical body. Looking for vectors to show misalignment will help the therapist to determine where to begin the session.
Second phase, feeling through the body for relations of certain areas and systems. The therapist’s position for this phase is having her hands supine cradling the occiput. The therapist is feeling through the body for relationships between certain bones, muscles, the brain and spinal cord, specifically the cranium and pelvis relation, occiput and sacrum relation, specific cranial bones, movement, or lack of movement throughout.
The therapist is also checking for the balance of the inter-cranial membranes, horizontally and vertically. Feeling for these key check-in points and how they relate helps to bring focus to those areas that are not in alignment. The therapist facilitates a neutral space where the body feels comfort and can then find balance and begin to align.
Third phase: feeling for the flow, listening to the body. The therapist in this phase has one hand supine under the sacrum and the other hand supine under the occiput. In this position the therapist can feel the flow of the Cerebrospinal Fluid (CSF), which is the core of our being. CSF is always producing fluid that runs along our brain and spinal cord, constantly pulsating an exchange of information throughout our bodies. In this same phase, the therapist can also feel the craniosacral rhythm (CSR) which is its own unique rhythm in the body. When feeling the CSR, the therapist will gain more information about the flexion and extension of the sacrum, and therefore a better understanding of the relationship of many of the bones that were mentioned in phase two.
After sorting and becoming aware of the information given in these three phases, the therapist then proceeds to the place of the body where they feel a need for more focus. More focus and attention to certain areas, along with hand position, will create comfort and support for the body to begin to unwind and restore itself to a state of balance and flow. Specific hand positions are performed upon the discovery of where the body directs the therapist.
Assessment Tools: The client will record on a 1 to 10 visual analog scale (VAS) the intensity of his pain every day. This charting began one week prior to bodywork sessions and continues throughout the five week study, including days with treatment. On the scale, the left end of the line indicates no pain at all, and the right end indicates worst possible pain. There has been a chart created with the specific amount of scales needed, the start date, dates of treatment, and end date have been indicated. The average of each week was then graphed on a chart to show change.
Using a level and a ruler as tools, the practitioner will determine the differences in shoulder height to measure and record the clients structural alignment. Before and after each session, the therapist uses a level and a ruler to measure the distance from the level to the clavicle. The end of the level is focused at the sternoclavicular notch, and is level (bubble in the middle of center line), the measurements with a ruler are made from the level to the clavicle from this focus point. This will show the differences in alignment of the clavicles, and therefore shoulder alignment.
Report of Client Visits
Session 1: The client arrived reporting a number three on the pain scale, feeling less pain than recorded the week earlier. During the three initial check-in phases, described in the treatment plan, a plethora of information was obtained. The practitioner found vectors branching out to the left, the right shoulder was significantly higher than the left. When feeling from the occiput down through the body she found that the sacrum and occiput were also elevated on the right. The CSF seemed to be flowing at a wonderful pace up until T-5 where it then takes slow circular motions to make its way through the cervical region, and into the cranium.
Once this information was obtained, the practitioner continued to more focused hand positioning. First, she began with the left hand supine under the sacrum and the right supine under the T-5 to T-6 region. The sacrum shifted from a tilting up to the right position to a more balanced, even rocking of flexion and extension (head-to-toe movement). The CSF then began to flow more freely up to the point of T-5, where the flow seemed stuck. The practitioner continued up the spine with the right hand supine under T-4, 3, 2 and left hand resting, (no more than 5 grams of pressure) on the sternum with fingers branching out toward the clavicles. Finding a blockage with this hold, the awareness of the practitioner began to open, and lead her on to a new area.
The practitioner’s attention was drawn to the arms: they may be forming the blockage in the sternum and T-4-2 area. First, the left arm was held allowing for an unwinding of the humerus in its socket. Having the right hand supine under T-1, and the left hand and arm supporting the clients left arm, the humerus went through slow internal movements that occasionally branched out to look physical. The practitioner then moved to the right arm using the same hand positioning as the left, yet opposite. The right arm began much bigger movements than the left, going in circles, flexing down, extending up, and unrolling. After this the shoulders had significantly relaxed and lowered down to the table.
Next, the therapist at the head of the table held both hands supine between scapulas with arms close together so the client could then rest his head on her forearms comfortably. This allowed the shoulders to open laterally and release to the table even more. This position also gave a connection into the cervical vertebrae and the cranium. The next hold was the left hand under the occiput and the right supine under C-7 and T-1 the head began to unwind rolling from left to right to left again. During this hold the practitioner and the client both felt a large pressure which then turned into an immense pain shooting down the arm. The pain got stronger and more intense, the client was asked to stay with that pain and feel it, and he did. He breathed deeply, and stayed with the pain and eventually, after quite a few minutes, the pain subsided. The practitioner then held the occiput to feel new balances and let the neck unwind a little more, finding that everything felt a lot more centered and flowing, with much less pressure and torque throughout the left side.
The session ended with the balancing position of one hand on the sacrum and the other on the occipital bone to balance and clear the core. Client reported feeling much loser and more expanded after the session.
Session 2: The client arrived reporting a number three on the pain scale, feeling much less pain following the first session. During the three check-in phases the practitioner obtained much information about the same area of blockage discovered in the first session. This area began at the bottom right rib cage, went to the left heart center, then back to the right stopping behind the sternum to turn at an angle to the left shoulder, and then back right into the cranium shifting back upward to the left to the center of the sphenoid bone. Finding this vector and flow of CSF lead the practitioner to a wonderful starting point. She was drawn to the lungs, feeling that both the right and left lobes where turning in towards the heart, perhaps causing the zigzaging feeling throughout the upper girdle, and into the cranium.
The practitioner first placed hands on the sacrum and T-12, feeling the lower body, hips and legs and their connection into the torso. This flow felt wonderful, and she moved onto the zigzag above, beginning at the bottom right lung, one hand under the rib cage, the other on top. Being drawn into this lung, the practitioner and client noticed movement, the lung began to shift and roll down and away from the midline that it had been hugging. This brought attention to the liver, which was also being affected by the roll to the midline. The liver then shifted in this hold along with the bottom of the right lung. The diaphragm was also being affected by the lungs and their roll into the midline, making breathing a challenge for the client. The client and practitioner placed focus on the diaphragm and its relation to the lungs, and it too shifted, moving towards the table and down toward the feet, making room. The practitioner then moved her top hand to the top of the lung just under the top of the left scapula. This allowed the lung to completely unroll, and open up.
Next the left lung drew her in, and felt much different than the right, with much more of a roll to the midline almost suffocating the heart and its circulation. When tuning in to the bottom of the left lung, with one hand under the rib cage and the other on top, the lung shifted and rolled out and down, similar to the right side. As this was happening, the client began to go deeper into an altered state, almost asleep and snoring but could still hear the practitioners words. The lung began to pull the practitioner deeper as well. In this deep space was silence, heavy breathe from the client, and much space holding from the practitioner, leading to a big spontaneous breathe releasing tension in the lung and heart area. After this release the client still in an altered state, the practitioner moved to the thoracic inlet hold, one hand under C-7 through T-2 the other hand with index finger and thumb at the sternoclavicular joints. This structure felt much more open and movable than before, the right clavicle shifted slightly up then down, and the clients breathing pattern changed dramatically. Finding this movement was satisfying and showed that the respiratory system was much involved in the restriction of the upper girdle.
To end the session the practitioner allowed the neck to unwind, connecting the new respiratory flow into the cranium. Finally, a hold for the balancing of movement between the viscerocranium and the neurocranium created space between those two areas, and they found their relation to the midline.
Session 3: The client arrived reporting a number four on the pain scale; feeling a little fatigue today. During the initial check-in phases, the practitioner found a vector going from the mid-back around T-12 up to the right shoulder, the right shoulder is higher than the left. The CSF flow maintained the same pattern, feeling like a roll to the right. The occiput, sacrum, scapulas and spheniod bones made the same upward movement to the right.
The practitioner started with the right hand supine under the sacrum, and the left under T-12 and the lower part of the rib cage. The sacrum rocked up and down, and right to left a few times with a big connection into the ribs, rolling from right to left and slightly down. She then moved to the right rib cage, one hand on behind and the other in front, allowing space for the rib cage to shift down and slightly out away from it’s close hug to the spine. This lead the practitioner to the right arm which felt locked into the shoulder girdle. She lead the arm to it’s vector and it began to unwind and release finding its place of stillness and comfort.
Next, the therapist at the head of the table held both hands supine between scapulas with arms close together so the client could then rest his head on her forearms comfortably. This allowed the shoulders to open laterally, and release to the table even more. This position also gave a connection into the cervical vertebrae and the cranium. She then held the occiput to allow the neck to unwind, during which she was draw to the cranial bones, mainly the sphenoid bone. Feeling a torsion and twist to the left, the right wing of the bone felt much higher and very stuck between the other cranial bones. This being the case the practitioner then held and released the temporal bones, parietals and frontal, opening space for the sphenoid to move more freely. Lastly, holding space for the viscerocranium and nuerocranium, which involves holding the sphenoid to separate the neurocranium, and the zygoma bones as the viscerocranium, allowing for separation between these two structures gave her and the client a balanced feeling in the cranium.
Session 4: The client arrived reporting a four on the pain scale feeling much better since the previous session. He is feeling a lot more open in the upper girdle region where the pain resides, and he has noticed a large connection between the right side of the neck and his right arm. This wonderful piece of awareness brought by the client gave the practitioner a sense that CST creates body awareness. In the check-in phases the practitioner noticed the vector to the right not feeling as strong as before. During the feeling of CSF, she found the flow to be more of a turn and roll to the right, rather than the ridged flow as in the prior sessions. The client agreed on this information feeling a much less rigid flow himself.
The practitioner began with one hand supine under the sacrum, and the other under the mid-back around T-12 and the last rib area. This allowed the sacrum to shift into a neutral place and guided the practitioner to where the flow rolls to the right. This started the next position being at the T-12 area, and the other hand at C-7 T-1, allowing the roll to move left quite a bit.
Next, she moved to the neck, allowing it to unwind in big, slow movements, left to right for about 15 minutes. These shifts gave the client great relief, and created connection for the practitioner into the cranium, mainly the cranial membranes feeling them in the same roll-to-the-right pattern. The client found a connection into his rib cage, around to T-11-12 area, feeling that this area was very stuck and painful; when his neck moved to the right the sensation increased. Following this information the practitioner moved one hand to that thoracic area and the other to the occiput. The ribs then rolled out and up and back down as the occiput followed the movements, this lead to a still point and large release, a subtle, silent pop and click into relaxation.
Moving to the cranium, she held the cranial membranes; first the tentorium to balance it with the new flow coming up the spine, and then the falx cerebri. These structures also felt as if they rolled to the right. This hold allowed the membranes to match the rib cage and spine feeling much more balanced. The practitioner ended holding the sacrum and occiput, feeling much less of a roll to the right, and a great balance between all the structures.
Session 5: The client arrived reporting a six on the pain scale, the week was long and he was feeling tired. The past few days had brought him awareness and pain to the right lower portion of the rib cage however, on this day it felt better. In the check-in phases the practitioner noticed a new feeling, the right shoulder seemed relaxed and lower and the left pressing down. The cranial bones and sacrum felt pressed downward on the left feeling, as did the vector. In the flow phase the CSF felt still like a roll to the right, but not as intense as the past sessions. The check-ins lead the practitioner to the cranium, but before going right to the skull, the thoracic outlet felt a need for release. She held this position for quite some time feeling a great opening across the chest.
Then, she began the cranial work. She started with holding the occiput and sphenoid, feeling them shift left to right and down to the left quite a few times, sometimes even moving towards each other. Eventually, the two bones went into a flexion and extension pattern to begin to match the sacrum in the same pattern. She then felt a connection into the left arm/side body, rib cage area. The client agreed with this connection. Feeling like the left side wanted to come up to meet the right side, she went to the arm and put it into its vector, held space for that and a stillness occurred and then let her go.
She was then draw back to the cranium, first releasing the parietal bones and then the temporal bones and tentorium membrane. Holding the temporals and then the temporal ear pull, when thumbs are inserted into the ear at the auditory meatus. This allowed for a wonderful horizontal release in the skull connecting down to the shoulders/scapulas and pelvis. After much release and balance of the larger bones of the skull she was drawn to the inner structures of the ethmoid and vomer bones, feeling their pressure on the sphenoid, creating some of the downward pressure on the left side. The practitioner held the vomer and ethmoid and then the vomer and atlanto-occipital area, finding a great drop of the vomer down and back in the roof of the mouth. Creating lots of space and allowing the left side to open and feel more free.
Again, holding the viscerocranium and nuerocranium to feel the relation between these structures after much of the cranium had released. She and the client felt a wonderful balance between these two areas with much relief in the surrounding, inner structures. To finish the cranium work she held interlocked fingers of both hands over the midline of the frontal bone. Allowing for midline alignment of the cranial bones, brain and membrane system. When this aligned and balanced, the client felt a great connection to his thoracic area, feeling clarity and alignment throughout his structure.
Results, Discussion and Conclusion
After receiving Craniosacral Therapy once a week for five weeks, chronic pain has been slightly reduced. An average rate of pain on a weekly basis (as shown in figure 1) was taken from the clients records, recorded on a visual analog scale daily throughout the bodywork sessions.
The pain was recorded starting the week before session one and ending after the last session was completed. The client reported the largest change following the first session. With a baseline average of 6.3 for the week prior to treatment, a significant decrease after session 1 brought the clients report to a four, and then in the second week, and a 3.8 for the third. The average increased at week four, and then back to a decrease following the fifth session. After much consideration of daily activities and everyday habits, the practitioner believes that everyday movements may be causing the majority of the pain and structural imbalances. Further acknowledgement and awareness to shift these habits may have an impact in the reduction of pain in the future. The client reported feeling much less pain and discomfort than before the bodywork sessions.
The measurement of structural alignment did not show a significant change, however, this does not mean that nothing changed at all. The height of the left and right clavicles did not show a measurable change (as shown in figure 2).
In craniosacral therapy, the outside structural changes are so subtle that a large visual change is challenging to see through physical measurement. The subtle shifts on the inside are what made the client report feeling more aligned and balanced. The shifts in the inner structures, such as the organs, the brain, membranes of the brain and dural tube surrounding the spinal cord, created a balance throughout the body. As explained in the report of client sessions, many of the sessions lead the practitioner into the organs and membrane systems rather than to the outside structures of bone and muscle. CST deals with the energetic vectors and their alignment to the physical being. In the treatment protocol the practitioner begins by looking for the energetic vectors of the body, vectors cannot be measured with a ruler. By assisting the body into it’s energetic vector and allowing it to feel comfort and release held patterns, the client will feel a result of relief and balance. Creating alignment of the inner-most structures, though not visually measurable on the outside, things did shift and result in comfort on the inside projecting out.
These results show that CST can reduce chronic pain and improve the alignment of the inner structures of the body. How does the inner structure affects the outer physical structural alignment? This question needs further investigation. The practitioner may have needed pictures to see physical changes in the shoulder girdle of this client. Or, perhaps a better tool for measurement of this particular structure.
This case study has shown that Craniosacral Therapy improves inner body awareness, decreases chronic pain and creates a wonderful feeling of balance and alignment throughout one’s being. By holding a space of neutral energy, the practitioner was able to facilitate a comfortable space for the body to unwind and realign it’s inner structures, thus, reflecting out to the client’s outside physical movements, and an improved overall well-being.
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International Professional School of Bodywork http://www.ipsb.edu, email@example.com, (858) 505-1100