The Beginning: Outrage
As the world's first board-certified paraplegic surgeon and a life member of PVA, I am outraged at [PN's] not only including an article on such an unproven therapy but also giving it cover-story status.
Craniosacral therapy has no place in the treatment of spinal-cord injury/dysfunction (SCI/D). It is in a class of procedures based on faulty, nonscientific theories.
Certainly when a child is born, the membranous bone that eventually forms the skull has wide gaps. Over a period of time these suture lines become more fixed. During skull growth, these lines have some relative capability of movement. This allows for expansion of the skull during growth.
Any significant motion of these sutures lines would represent areas of relative weakness, and patients sustaining head trauma leading to skull fracture would referentially break along these lines. This is not observed to any extent in a population over 10 years of age.
If, as the article explains, cyclic cerebral spinal fluid rhythm is not related to heart or respiratory functions, what causes this ... motion? There are no sources for this pulsatile flow within the central nervous system (CNS). No contractile elements exist within the dura mater or arachnoid. If it is the contention of the proponents of craniosacral therapy that such structures do indeed exist, ... it is their obligation to identify the motor.....
If we are talking about a nearly invisible degree of pulsation, it defies credulity that the practitioners featured in this article could feel these pulsations through the anterior chest wall past the pulsations of the heart, through the bony rib cage or spine, or through the bony layer of the calvarium. If these pulsations cannot be felt, it is equally unplausible that any message of the skin and muscle could be effectively transmitted through all the overlying tissue and bone and somehow realign this as-yet-unidentified motor unit.
As most SCI patients know, the CNS and its components (dura, pia, and arachnoid) end at the T12-L1 level and have no anatomic connection to the sacrum.
I would suggest the proponents of craniosacral therapy ... undergo what all of us have done--the basic science benchwork to document their theory. The term "alternative therapy" implies a legitimacy ... that clearly does not exist. It implies this therapy has undergone the same rigorous examination and study as currently accepted modalities --e.g., in vitro vs. utero fertilization are alternative therapies, as are antibiotic vs. surgical treatment of infection.
To refer to the accumulated body of controlled, peer-reviewed, scientific knowledge as dogma is inappropriate. To refute it by saying that "skull bones do, indeed, have movement potential" gives the impression of controversy where there is none. Movement potential is not the same as movement. The fusion of skull bones is not an axiom; it is an anatomically documented fact, in cadavers and in surgical experience with live patients.
As the author has his Ph.D. and apparently has a strong track record of scientific study, he should understand that anecdotal data, while entertaining and good copy, is not worth the paper it's written on.
The implication that "mainstream" (read "Western") treatments do not stand scientifically rigorous clinical studies is patently untrue. Treatment modalities not based on scientific evidence are rare at best. To imply this is a common occurrence in "mainstream" medicine and to additionally link "mainstream" medicine to quackery such as craniosacral therapy is in no way an appropriate disclaimer. To ... say that anecdotal results are promising leaves the impression of validity where none exists.
With issues such as SCI, where hope far exceeds reality and a certain level of desperation exists, quackery such as this preys on the most susceptible (think about the laetrile scam of cancer patients in the 1970s). To actively promote these unproved and unwarranted treatments not only does immediate harm to your readers but also long-term harm to the standards, legitimacy, and credibility of your publication.
Peter A. Galpin, M.D. Kahului, Hawaii
Author's Response: Merit and Evidence
I expected that my alternative-medicine articles would provoke some reaction from medical professionals. For every negative response, I probably have received ten positive ones.
Although most [of the latter] is from consumers, I have also [had some] from healthcare professionals. For example, PVA's chief SCI physician said "Acupuncture: An Alternative Therapy?" (September 1998) was very well done and informative. A chiropractor states, "This [`The Right Touch?'] was the best lay article of the craniosacral system" he has ever read.
Driven by consumers' desire for healthcare options, the use of alternative treatments has experienced incredible growth. The November 11, 1998, Journal of the American Medical Association (JAMA) reports four in ten adults used alternative therapies last year. Sixty-four percent of U.S. medical schools now offer courses on alternative medicine. Whether or not the alternative therapies work (and many do), individuals with SCI/D have the right to know about them.
Who determines what is harmful? Should it be an expert with Dr. Galpin's credentials and beliefs or an expert like me with just as many credentials but divergent perspectives? Screening information from consumers is ridiculous. Ultimate healthcare responsibility resides with the individual.
PN has never had a shortage of topics concerning conventional medicine. These articles, as are those on alternative modalities, are meant to inform and help individuals with SCI/D in their healthcare decision-making.
Like Dr. Galpin, I believe therapies should be subjected to scientifically rigorous testing. However, such an ideal preferentially favors certain types of treatments and disorders. Given the daunting economics society demands for proving the safety and efficiency of any new treatment, only therapeutics with a reasonably large market and deep-pocket financial sponsors (i.e., drug companies) have a chance. Since many generic alternative modalities cannot be patented, economic incentives are lacking.
Dr. Galpin disagrees with my assertion that many mainstream treatments also have not been well tested. Although he may not agree, others do, including colleagues in his profession.
Without a doubt, some alternative treatments have the potential to be harmful. However, conventional medicine does not hold the "high ground" on safety. For example, the April 15, 1998, JAMA reported that 106,000 people died from adverse drug reactions in hospitals in 1994, making it the fourth to sixth leading cause of death in this country.
In a healthcare crisis, I intend to see a physician. I'm a "card-carrying" member of the mainstream biomedical establishment who has worked at some of the nation's preeminent scientific organizations. As such, it is with professional shame I discovered that almost every alternative treatment has had a history of suppression by the establishment--regardless of merit and evidence. The current state of healthcare in this nation has been determined as much by politics, market-driven factors, and professional chauvinism and dogma as objective science.
This approach has deprived all Americans, including individuals with disabilities, of effective medical treatments.
S. Laurance Johnston, Ph.D. Indian Hills, Colo.
Proponent's Defense: Back to Basics
(Editor's Note: Dr. Upledger is president of The Upledger Institute, Inc., in Florida)
I once shared Dr. Galpin's view on skull-bone movement based on my anatomy training. But when I could not deny the motion I felt under my hands, I set out to find rationale for what I was feeling.
The early anatomical studies that Dr. Ernest Retzlaff and I did at Michigan State University (MSU) failed to produce an answer until we considered the possibility that postmortem changes and the use of chemical preservatives were responsible for the appearance of calcification of the sutures [seams between bones] in question. By studying samples of suture material from surgical patients age 7-57, we found that the capability for motion was present within.
With our work in this area published in a number of scientific journals, such as the Journal of the American Osteopathic Association, I was invited to lecture to a hospital staff in Israel. The physicians there were not impressed with what we considered our breakthrough discovery. I later learned they were familiar with the concept of skull-bone movement, having studied texts such as Anatomica Humana by professor Guieseppi Sperino in 1931. He said that cranial sutures only calcify before death under pathological circumstances. Apparently, Italian and British anatomists have a long-standing disagreement over this issue, although the 30th American edition of Gray's Anatomy acknowledges that some cranial sutures possess potential for movement throughout life.
Our subsequent studies of unembalmed cadavers went on to reveal fascia [tissues] hanging from the free border of the falx cerebri [the projection, of the dura mater--the fibrous membrane forming the outermost covering of the brain and spinal cord--separating the hemispheres of the cerebrum--the largest portion of the brain]. Under the microscope, these fascial tissues proved to be nerve tracts running out of the falx cerebri with brain tissue attached to the free end. These nerve tracts were then shown to be connecting the sagittal suture to the ventricular system of the brain. This observation provided the missing element necessary for understanding craniosacral-system function.
We then formulated the Pressurestat Model, [in which an increase of cerebrospinal fluid (CSF) volume affects sutural expansion]. Recognizing the subtlety of this motion, we set up an experiment at MSU to determine whether people can indeed feel these tissue changes with their hands.
Richard W. Roppell, Ph.D., developed a mock-up skullvault computer programmed to move the various bones in ten different sequences between one and three millimeters. The model was fitted with a 1/4-inch-thick foam covering. In testing the abilities of people to [feel] changes in the model, in general, stenographic pool staff scored higher than the medical students who were skeptical of, or who had not been involved in, hands-on therapy. Other researchers have recorded the craniosacral motion in humans --by craniosacral therapists as well as instrumentation.
Recently, a patient said he had shared a copy of one of my books with a neurosurgeon, Professor Probst. The patient wrote, "Professor Probst tells me that he read it with great interest and learned a lot from it. He further told me that he, too, has witnessed the rhythmic movement of the spinal cord when the dura was not ruptured. He had never given much thought to it, so he was greatly impressed by your findings."
These observations of the craniosacral system were made simply by looking at the body in a different way. I would never have observed the pulsing of the dura mater during surgery if the surgeon had not performed the procedure in such a way that it preserved the integrity of the dural membrane, thus retaining the system's hydraulic properties. The nerve tract would not have been discovered if we hadn't abandoned the usual calvarium cuts in favor of a window cut into the cadaver's head. It required more delicate work to remove the brain tissue while keeping the membrane system intact, but the efforts paid off in fresh insights.
I have some of the benchwork done on the anatomical and physiological underpinnings of craniosacral therapy. I would gladly provide additional information to Dr. Galpin or anyone else.
The growth in craniosacral therapy practice would not have occurred if patients and their therapists were not seeing improvement, particularly in today's healthcare environment. The therapy focuses on uncovering the primary causes of dysfunction rather than symptom suppression.
Craniosacral therapy goes far back into basics with uncomplicated, hands-on techniques.
John E. Upledger, D.O., O.M.M. Palm Beach Gardens, Fla.