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Chiropractic Cranial Technique

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Major Bertrand DeJarnette, DO, DC

Major Bertrand DeJarnette, DO, DC
Born December 23, 1899
LaMonte, MO
Died May 31, 1992
St. Mary's Hospital, Nebraska City, NB
Nationality Flag usa.gif United States
Education Chiropractic
Alma mater 1924 he graduated from the Nebraska College of Chiropractic
Occupation Developer of Chiropractic Technique (Sacro Occipital Technique)
Years active 1924 to 1990
Home town Nebraska City, NB
Known for Developer of Sacro Occipital Technique and Cranial Technique Integration
Title Chiropractor, Osteopath
Spouse(s) Todde De Jarnette

Introduction

Cranial therapy is a method of care whose premise is that it is possible to affect the body therapeutically by applying specific force(s) to the skull and related bones. In the 1920s both a chiropractic, Nehpi Cottam, and osteopath, William Sutherland, presented theoretical cranial concepts using different diagnostic and treatment methodology. Sutherland’s work was continued on by the Sutherland Cranial Teaching Foundation and later also by the Cranial Academy. DeJarnette (an osteopath and chiropractor) studied with Sutherland and brought cranial technique to the chiropractic field organized in an indicator based system. In the early 1980s Upledger, a member of the Cranial Academy, wrote a book called “Craniosacral Therapy,” split off from the Cranial Academy, and is currently teaching health practitioners and laypersons. The osteopathic theory and approach is the basis for most cranial techniques used today by osteopaths and chiropractors.

Sutherland's Premises

Cranial therapy as presented by Sutherland has premises, which have been questioned in various papers. [1] [2] [3] The prime tenants of cranial therapy focus on that cranial sutures do not generally completely fuse as we age, that they maintain some degree of flexibility possibly due to their morphology and beveling, that meningeal tissue has extra and endocranial connections whose tension patterns might affect neural tissue, vascular structures, and CSF mixing. Sutherland also postulated an inherent motility of the neural tissue which would lead to a CSF pulsation independent of vascular or pulmonary activity, called the cranial rhythmic impulse (CRI) or primary respiratory motion (PRM) which could be palpated and influenced.

Questioning CRI/PRM Evidence

With regard to evidence supporting cranial therapies what has come to light is that it is difficult for interexaminers to reliably measure the "cranial rhythmic impulse (CRI)" or “primary respiratory motion (PRM)” associated with a CSF pulse wave purportedly independent of vascular or pulmonary influences. At this time the evidence on CRI/PRM is considered tenuous and according to Norton, might be associated with patient-doctor pulse summations or related to various types of pressure variants, which present with different frequency of impulse.[4]

Cranial Therapy and its Biological Plausibility

When evaluating the biological plausibility and efficacy of cranial therapy it is essential to differentiate between the gross mechanical aspects of cranial care, which has documentation that will be presented, and the subtle mechanical aspects, which remain controversial. The subtle mechanical aspects have some researchers questioning the efficacy of cranial therapy [5] [6][7][8][9][10] and others attempting to find answers.[11][12][13][14][15][16][17][18] [19][20]

Chaitow comprehensively discusses a difference between "mechanical (orthopedic) motion, which demonstrates physically measurable motion of and between cranial bones (however infinitesimal)" and relatively subtle cranial rhythms [21] , which he notes at this time, do not fit easily into our arena of evidence-based medicine. [22]

Attempts have been made to organize the data relating to cranial therapy in various research oriented books. Leon Chaitow’s most recent book Cranial Manipulation: Theory and Practice (Second Edition), describes in detail more than 100 studies (employing radiologic, neuro-imaging, dissection, histological, ultrasonography, electrical, and numerous mechanical devises for measurement) showing the movement of the brain and the bones and sutures of the skull. Aside from Chaitow’s book other well-referenced texts include: Osteopathic Manipulative Medicine Approaches to the Primary Respiratory Mechanism [23], The Cranium and its Sutures [24] , Cranial Sutures: Analysis, Morphology & Manipulative Strategies [25], A bibliography of research related to osteopathy in the cranial field [26] , and Clinical Cranial Osteopathy: Selected Readings [27] . While it is acknowledged that there is duplication between some referenced articles in the above texts, they represent a significant amount of data representing the clinical, mechanical, and physiological aspects of cranial therapy to help demonstrate the biological plausibility of cranial therapeutic care.

Cranial Bone Mobility

There are specific premises that lend cranial therapy biological plausibility. Studies have found that there is cranial bone mobility in humans and mammals [28][29][30][31]. Also there are other studies showing that the cranial sutures do not fuse and that a degree of sutural patency and cranial bone pliability remains in later life[31][32][33] . The very beveling of the cranial sutures anatomically allow for a type of shock absorption effect by the transmission of pressure variants internally as well as tension from the myofascia externally to be dissipated and translated throughout the cranial structure [34][35][36] . For instance, Pick demonstrated on a preliminary MRI investigation that pressure upon the bregma and maxilla changed the shape of the fornix (by 4mm) and corpus collosum (by 5mm)[37] . Whether the transmission of force was through the flexibility of the cranial suture [38] or the bone itself [39] warrants further exploration, but pressures upon the cranium were found to alter the shape of neural tissues.

Cranial Dural Membranes

The dural membranes form the walls of the cranial venous sinuses, help maintain the position of cerebellum, cerebrum and spinal cord, and provide some supportive structure to the cranial capsular matrix by passing through the sutures to become the external periosteum of the cranium [40] .There is support for this functional aspect of the cranial sutures and dural membranes discussed by anatomists focused on cranial morphology [41][42] and the dental profession dealing with orthopedic or orthodontic force translation [43][44] . Perpetuation of stress to the dura via cranial suture stress or dysfunction due to myofascial tensions [45] has been viewed on dissection studies and full color photographs [46]. The connection of muscles (e.g., rectus capitus posterior minor[47] , spinal ligaments (e.g., ligamentum nuchae [48] , ligamentum flava [49] , Hofmann [50], and Trolard [51] ) to the dura, as well as the dentate ligament connecting the spinal cord to the dura, all indicate a relationship between spinal dynamics and its perpetuation into the meningeal fascial tissue. While there is some controversy over dural connections and their affect on cranial function [52] other studies discussed how dysfunctional neural tension could be associated with spondylogenic[53][54][55][56] and other [57][58]myelopathies. Also tension by muscular contraction upon the cranium sufficient to affect the periosteal tissue could also affect or be affected by the trigeminal and neurovascular components within the cranial sutures [59][60][61][62][63] . Current clinical research supporting the cranial manipulative theory has found that altered postural and myofascial function will affect body patterns, and the cranial bones, sutures and related meninges are a part of this closed myofascial kinematic chain [64][65][66][67][68][69][70]

Cranial Suture Fixation

Why might cranial sutural fixation or increased asymmetrical meningeal tension be an issue? There are various theories, including the premise that the CSF is a specialized lymphatic system for the nervous system. Therefore the CSF pressure variants and pulsations that occur throughout the craniospinal system may have an affect on CSF mixing and circulation, and CSF stagnation due to asymmetric dural tensions may have adverse biological repercussions. In the cranium the venous sinuses that function also as a low-pressure system would likewise be affected by dural tension that affected drainage [71][72].

Cranial Nerves and Dural Sleeves

The cranial nerves also carry dural sleeves with them for some distance; therefore any abnormal meningeal tension may be transmitted to a nerve and affect its function. Tension anywhere along the contiguous meninges can therefore be transmitted to the cranial nerves. This is because the peripheral and the central nervous systems are a continuous tissue tract. The neuropathies that may result from cranial bone dysfunction are postulated to be motor and/or sensory, and their severity depends on the amount of compression and neural irritation as well as the amount of ischemic radiculopathy. Breig has shown that problems come about primarily because of the entrapment neuropathy’s effects on the vasculature of the nerve root [54][55][56] . The effects of ischemia on cranial and peripheral nerve tissue have been well studied, and increasing interest in the pathophysiology of nerve compression has indicated that any rise in intrafascicular pressure – as a result of edema, compression, or torsion of the nerve root, for example – can also be damaging to neural tissue and function[53][54][55][56][57][58][73][74][75]. Throughout the cranium there may be a number of sites where cranial nerves may be impinged upon by soft tissue at bony ridges or foraminal openings. These sites may reflect mechanical or physiological changes in neural function, leading to a mechanical subset of cranial neuropathies that have been or can be successfully treated clinically by cranial practitioners[76][77][78][79][80][81][82][83][84][85][86][87][88][89][90][91].

Cranial Bone Palpation

So then the question is can doctors palpate cranial fixation, pressure compliance variants, and craniospinal imbalances? So far the reliability of most manual methods of evaluation and treatment are in question, but the most recent discussion of these studies, pro and con, with reasoned commentary on their implications may be found in Chaitow’s recent book [92]. Currently all investigation into various manual therapeutic treatments whether chiropractic, osteopathic, physical therapy or otherwise indicate that palpation for pain seems to offer the best reliability, whereas most other commonly used evaluation procedures have limited reliability. Therefore the current research suggests that further study in cranial diagnosis and the treatment rendered might best focus (at this time) on patient pain to palpation and its relief following treatment. Sacro occipital cranial techniques as developed by DeJarnette [93] offer specific indicators most related to pain and its relief following treatment that lends itself for the needed future research into the field of cranial therapy. Aside from pain future research should include outcome assessment tools evaluating pre and post treatment for quality of life, increase in functional status, and other objective instruments to determine changes in physiological status.

Training

A cranial manipulative therapy certification program is offered through SOTO-USA. Other chiropractic techniques incorporate aspects of cranial manipulative strategies within their method of analysis and treatment however SOTO-USA has a complete certification program that has been offered both through individual regional seminars as well as through the post-graduate departments of New York Chiropractic College (NYCC), Southern California University of Health Sciences (SCUHS), and Northwestern Health Sciences University.

SOTO-USA's regional seminar program offers individual cranial courses taught by our certified instructors for those who want to learn the basics of cranial analysis and treatment as well as those seeking certification. These courses are offered at varying times throughout the country. Cranial courses through SOTO-USA can be found on the Events and Seminar page. Pediatric programs are offered in conjunction with the ICPA and the Level I spinal and cranial courses are offered internationally through the ICPA, (see course listings here. The final pediatric certification course is offered by SOTO-USA only.

There are three certification levels: certified SOT practitioner (CSP) which requires 44 hours of accredited course work, certified SOT cranial practitioner (CSCP) which requires a (CSP) plus an additional 40 hours of accredited cranial course work, and a certified SOT pediatric practitioner which can be taken separately and requires 32 accredited hours.

SOTO-USA's basic SOT spinal adjusting program is a 24-hour program that is taught in two weekends and includes the anatomy, physiology and philosophy of SOT as well as all evaluation and adjusting procedures for the spine and pelvis. Classes to treat specific extremity distortion patterns and viscerosomatic/somatovisceral reflex imbalance (Chiropractic Manipulative Reflex Technique – CMRT) are part of the CSP certification. Cranial courses can be taken individually dependent on the practitioners needs and each covers a specific area of cranial corrective procedures. Only licensed DC’s or students are allowed to take SOTO-USA's SOT and Cranial courses.

Goals

SOTO-USA is a (501 c3) nonprofit organization formed to promote the awareness, understanding and utilization of the Sacro Occipital Technique method of chiropractic as founded and developed by Dr. Major Bertrand DeJarnette. Their main goals are to educate and instruct chiropractors in the philosophy, art and science of Sacro Occipital Technique (SOT) and to promote evidence informed, clinically significant advances in chiropractic, cranial, and SOT techniques.

In a continuing effort to offer the latest information in addition to the Clinical Symposium, SOTO-USA offers special opportunities for hands-on teaching of Sacro Occipital Technique to licensed chiropractors and chiropractic students. SOTO-USA has annual research conferences where doctors in clinical practice can learn how to write and present their findings in a profession research format both in conference proceedings at with platform presentations in front of peers for review and questions. SOTO-USA has regularly contributed to chiropractic and interdisciplinary research conferences to support both chiropractic and further investigate SOT, cranial, and TMD and its related methodologies.

SOTO - USA looks to not only lead the chiropractic profession into the 21st century but to champion the concept that through understanding and cooperation between all disciplines, excellence in patient care can be achieved. For example, SOTO-USA is the only chiropractic-based organization in the American Alliance of TMD Organization, an alliance of primarily dental organizations (17,000 members) treating patients with TMJ disorders. To SOTO-USA the future of chiropractic and healthcare will take place with interdisciplinary and co-management of patients in cooperation with our allied healthcare partners.

Future Cranial Therapy Research

Who will do this research? Commonly the onus is placed upon those performing cranial therapeutic care to support the necessity of their care. The dilemma is that those performing these procedures in clinical practice are not the ones capable or knowledgeable to perform extensive forays into costly and complex research studies. In reality most clinicians are primarily practitioners who attempt to share in the literature what has been found in a typical office setting. Practitioners of cranial therapy have been published in peer-reviewed literature and at research conferences (See SOT Table 1), but most practitioners are not “true” researchers. Ideally this is not an excuse but a call for help and collaborative efforts.

At this time we are left with an extensive (but preliminary) clinical evidence base of cranial therapeutic interventions for patient health, little indication of procedure risk [94], and sufficient biological plausibility to warrant continued use of this modality for patient care. Since alternatives to cranial therapy tend to be pharmaceutical and/or surgical, or other common options such as benign neglect, most of the clinical success of cranial therapy has been patient driven. In our present day and age patients demand results from the care rendered, want low risk procedures, and prefer to enjoy the process, when possible. The gentle caring touch a patient receives along with the expertise from a cranial practitioner is currently satisfying a group of patients seeking this care, and often paying out of their own “pocket” for this care. Cranial practitioners are being sought for care by patients “in need” looking for alternatives to the more invasive traditional options.

Most of the manual therapeutic procedures currently rendered can be criticized for having limited validity and reliability, yet manual therapies appear to offer clinical value with low risk as compared to other possible therapeutic interventions. As our research community assumes that randomized controlled studies (RCTs) are the gold standard to determine the reliability and validity of a manual therapeutic intervention the development of a proper sham procedure and eliminating doctor patient interactions becomes problematic.

It is possible that RCTs will not be considered the answer to the study of our manual therapeutic procedures and that observational studies and outcome assessment with large case series or cohort studies might offer possible alternatives. The need to understand the clinical success found with manipulative therapies might shift away from reductionist methods of analysis to observational studies [95][96][97], which might be more effective at helping to build a complementary healthcare evidence base[98].

Cranial therapeutic care is in its infancy stage of research regardless of its large amount of studies (SOT Table 1). There are many questions that need to be answered such as whether the various methods of care do what they purport to be doing. Is there reliability between practitioners? What aspect of the care has a placebo effect? Can further objective outcome assessment studies be performed which will help us better understand the purported phenomena? However like most of our manual health procedures its risk is low, so if some benefit can be demonstrated it is worth further exploration.

Table 1. Cranial Manipulative Therapy Published Papers

Link to papers

References

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External Links

  1. Other research compilations and an assortment of SOT Cranial books can be found here:SOTO.Org Website
  2. SOTO-USA - SOT Research Conferences
  3. 4th Annual SOT Research Conference
  4. 3rd Annual SOT Research Conference
  5. 2nd Annual SOT Research Conference
  6. 1st Annual SOT Research Conference