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Craniosacral Therapy for Stress-Related Dysautonomia.

Introduction

Dysautonomia, specifically with sympathetic dominance, has been linked to many age-related autoimmune and metabolic immune-mediated inflammatory diseases (IMIDs), including rheumatoid arthritis (RA), Sjogren's, inflammatory bowel syndrome (IBS), type I diabetes, and psoriatic arthritis, to name a few. (2) The pathogenesis of this condition is related to the effects of chronic stress/inflammation on the central nervous system. According to Bellanger and Lorton, "Unresolvable immune stimulation from chronic inflammation leads to a maladaptive disease-inducing and perpetuating sympathetic response in an attempt to maintain allostasis." (2) For patients suffering from dysautonomia, regular daily activities can be very difficult. Normal anoxious stimuli can provoke extreme reactions and perpetuate the cycle of sympathetic overload.

The problem with dysautonomia is that the conventional medical world does not have any treatments that can restore balance to the overall autonomic nervous system. Their treatments are largely related to treating the underlying autoimmune condition or chronic infection or other diagnosis along with palliative symptom-based drug therapies. Instead of focusing solely on the autoimmunity, the chronic infection, or the other "diagnoses" the patient may have, the hypothesis that this case report aims to address is that improving or strengthening the parasympathetic nervous system through craniosacral therapy is a more effective root-cause holistic treatment approach to dysautonomia that results from underlying chronic stress. Once the sympathovagal response has been restored, the body can now focus on fighting the infection or reducing chronic inflammation that underlies most autoimmune conditions and chronic infections.

Craniosacral therapy (CST) has been shown in the literature to improve heart rate variability (HRV), to increase the activity of the parasympathetic nervous system, and to improve the sympathovagal response in patients experiencing subjective discomforts. (1) Furthermore, CST has been shown to reduce sympathetic dominance after an acute 5-minute laboratory induced stressor compared to no treatment. (3) The subjects in the Fornari et al study who received CST after receiving a stressor had marked improvement in parasympathetic tone and a much lower overall Cortisol response compared to the control group who did not receive any treatment after the stressor. (3)

Case Description

JG is a 46-year-old Caucasian male who presented to Bastyr University California (BUC) clinic in November of 2016 with two main concerns: neurological disturbances and irritable bowel symptoms. He described the neurological disturbances as full body tremors with a left frontal lobe migraine triggered by certain beaches, food, or mold exposure. He also experiences brain fog, bilateral tinnitus, and unstable gait (falling to the left) along with his tremor. With the tremor episodes, he also experiences dysarthria and inability to formulate sentences. He reported personality changes that resemble autism. Cholestyramine would clear his mind for one hour after taking it. He had a recent MRI that was clear, and his neurologist diagnosed him with migraine with vestibular disturbances.

He described his irritable bowel symptoms as abdominal discomfort in the form of tightening and cramping, along with pain, in the LLQ (lower left quadrant). He also reported feeling "moody" after eating certain foods and will regularly get diarrhea after the cramping and pain. He had eliminated soy, eggs, gluten, corn, seeds, nuts, nightshades, and high oxalate foods as they all exacerbated the abdominal pain. Butyrate supplementation improved his symptoms along with certain probiotics. Some probiotics upset his stomach.

His review of systems was positive for occasional heart palpitations, Raynaud's in the hands in a cold environment, undigested food in his stools, the inability to extend his arms fully or to flex his fingers fully, enlarged DIPS/PIPS (finger joints) for the past 20 years, left elbow inflamed, dry flaking skin on the face, dandruff on the scalp, anxiety after eating too much sugar, and rhinitis after exposure to mold.

Pertinent past medical history included a positive Lyme diagnosis, RA, and Sjogren's. He tested positive for Lyme disease in 2016 with a positive western blot for IgG and IgA antibodies to Borrelia burgdorferi. He also had a diagnosis of RA from 1990, colitis in 2017 by colonoscopy, and Sjogren's by anti-SSA in 2016. He had a spinal fusion surgery when he was a young adult for his RA.

Pertinent social history included self-reported emotional and physical abuse from his father as a child. He was married with no children.

Current medication list included monolaurin (which he took for immune support), butyrate, fish oil, Migrelief (a botanical medicine extract of feverfew for migraine relief), Mucinex, cholestyramine.
Medication                   Dosage

Monolaurin                   600 mg QD
Sodium butyrate              800 mg QD
Omega-3 Fish oils            2 grams QD
Migrelief                    PRN for headaches
Fexofenadine HCL (Mucinex)   600 mg capsule PRN
Cholestyramine               PRN for mold exposure


Pertinent physical exam findings included a blood pressure of 110/65; a pulse of 69 bpm; oral temperature of 98.1 degrees Fahrenheit. His general appearance was well groomed, but he appeared fatigued. He had hypometric rapid eye saccadestothe left with fatigue after 3 saccadic eye movements; hyperactive bowel sounds in the LLQand LUQ, hypoactive bowel sounds in the RUQ; tenderness to palpation in the LLQ and McBurney's point, along with a tight diaphragm on palpation. His left arm was stuck in flexion, with an inability to fully extend it; his left lateral epicondyle was enlarged and inflamed around the joint; his PIPS/DIPS were inflamed bilaterally. He had reduced flexion and extension on bilateral wrists. He had decreased to pinpoint on his left anterior ankle; his gait was stable, but he had reduced arm swing bilaterally; his heel to toe was stable. He experienced sweating and marked irritability after exposure to a loud noise. His judgment and insight were intact, and his mood was forlorn.

Current lab tests also showed high antibody titers to EBV and HHV6.
Lab Test      Result

EBV titres    IgG Early Ag-26.9
              IgG Ab VCA >600
              IgG nuclear Ag >600
HHV6 titres    4.89


Potential diagnoses included Lyme disease, RA, Sjogren's, and mold exposure. Dysautonomia due to chronic stress was the working diagnosis due to his reaction to noise with sweating and irritability, his history of abuse as a child, his autoimmune conditions, as well as his chronic infections.

Treatment was eleven weeks of 20-to-40-minute sessions of craniosacral therapy performed once per week by one student clinician.

Outcome was measured by subjective patient reports and objective student clinician observations. The patient reported feeling stronger with more overall vitality. He stated he felt more emotionally clear and was able to reconnect with his spirituality. He stated he was able to reconnect with family and friends in a way that he had not been able to in many years. He stated he experienced less anxiety with leaving the house (for fear of having a tremor). He reported less brain fog, less anger, and more joy than he has felt in the last 20 years. He reported experiencing the tremors more subtly and with less frequency; additionally, the tremors appeared more subclinical and did not reach their full potential.

The student clinician observations included a much lighter and more joyous demeanor. The patient smiled for the first time and cried what he called "tears of joy" after the eighth treatment. The patient reported looking forward to each weekly treatment and was distraught when the student clinician informed him that the quarter was coming to an end and he would start receiving treatments from a different clinician. Unfortunately, he stopped coming to the clinic and refused to receive craniosacral therapy from a different student clinician.

Discussion

In an exhaustive review of the literature on both PubMed and Embase using the search term "craniosacral therapy," only three research studies specifically looked at the autonomic nervous system (ANS) effects of craniosacral therapy. For these studies, the ANS outputs were measured using HRV. In one research study, compared to a placebo, a single session of craniosacral therapy induced a faster recovery of HRV, an increased parasympathetic activity, and a reduced sympathetic output after an acute mental stressor. (3) Another study demonstrated improved HRV and sympatho-vagal response after only two 30 minute CST sessions in patients who were stressed, anxious, or weak. Compared to the control group who received only a rest period of 30 minutes, the patients who received the CST treatment had significant improvement in their HRV and in their parasympathetic nervous system tone as measured by HRV parameters taken from EKG readings. (1)

Limitations include the practitioner to practitioner variability with the CST treatments, the difficulty in standardizing subjective reported outcomes, the limited number of test subjects in the research studies, and the limited number of research studies specifically on CST and dysautonomia. More research on the use of CST as a therapeutic modality for treating underlying chronic stress that results in dysautonomia is certainly needed and warranted. This is a simple, yet profoundly impactful therapy that may provide help for patients with multiple autoimmune conditions and multiple chronic infections by reducing the underlying chronic stress and sympathetic dysregulation.

For patient JG, HRV measurements were not taken; therefore, the sympatho-vagal response was measured subjectively using patient reports of experiencing fewer neurological tremors that reduced in severity. Other measurements included subjective patient reports of feeling more joyous and less anxious overall. If the patient were to be treated again, it would be ideal to include more objective outcomes with the use of HRV measurements.

Conclusion

CST can be an impactful therapy for a 46-year-old male patient experiencing neurological tremors, sweating from noxious stimuli, and overall hypersensitivity to his surroundings which all fit under the umbrella of dysautonomia due to chronic stress. After eleven CST weekly sessions, he reported more joy in his life, less frequency of the tremors, and the ability to reconnect to his friends, family, and spirituality.

References

(1.) Girsberger W, et al. Heart rate variability and the influence of craniosacral therapy on autonomous nervous system regulation in persons with subjective discomforts: A pilot study. J Chinese Integr Med. 2014;12(3):156-161.

(2.) Bellinger DL, Lorton D. Sympathetic nerve hyperactivity in the spleen: Causal for nonpathogenic-driven chronic immune-mediated inflammatory diseases. IntJ MolSci. 2018;19(4).

(3.) Fornari M, Carnevali L, Sgoifo A. Single Osteopathic Manipulative Therapy Session Dampens Acute Autonomic and Neuroendocrine Responses to Mental Stress in Healthy Male Participants. J Am Osteopath Assoc. 2017;117(9):559.

by Kim Love

Kim Love is a fifth-year medical student at Bastyr University California. She is a mother to a fun-loving, energetic three-and-a-half year old and the wife to a wonderful US Marine. She herself is a former Marine and has a passion to one day serve the military community with naturopathic medicine and all that it has to offer. She loves traveling, spending time outdoors, camping, and being with family.
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Author:Love, Kim
Publication:Townsend Letter
Article Type:Report
Geographic Code:1USA
Date:Jun 1, 2019
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