Cranial Osteopathy


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An introduction to cranial osteopathy

Cranial treatment


The ‘Still Point’ phenomena


An introduction to cranial osteopathy

Cranial osteopathy is a refined and subtle type of osteopathic treatment that uses very gentle manipulative pressure to encourage changes throughout the body, including the head. Cranial Osteopaths treat the whole body not just the head.

In 1899 William Garner Sutherland, a student of Andrew Taylor Still, observed that the 26 bones of the skull were connected by modified joints which permitted a tiny degree of physiological motion expressed through the skull and its membranes, fluids and brain within. This motion can also be felt throughout the body, similar to a very refined form of breathing. This minute rhythmical shape change has come to be seen as the body’s (and cranium’s) response to the "breath of life" or "primary respiratory mechanism", and an expression of the individual’s state of health and well-being. Unlike flexing an arm or taking a deep breath, this motion is beyond our voluntary control, and so is called "involuntary motion". 

One of the fundamental principles of osteopathy is that "the living body is a self-correcting, self-regulating, self-healing mechanism", constantly working to establish its optimum level of health. This principle is particularly emphasised in cranial osteopathy, wherein the practitioner seeks to be as receptive as possible to the intelligence of the "inner physician", in order to sense how the body is seeking to rebalance itself. This informs the practitioner’s mind and hands as to the body's state of health, and what support or intervention the system requires to re-establish balance and harmony, restoring the freedom it needs to get on with its job of self-healing.

The primary concern of the Cranial Osteopath is therefore to learn to listen. The treatment process arises out of this attitude of quiet respect and receptive attention.


Cranial treatment

Osteopaths are taught a variety of methods and techniques, ranging from the well known ‘high velocity thrust’ manipulation with its dramatic clicks, to the very gently applied methods used by so called ‘Cranial Osteopaths’. Osteopaths vary their treatment methods, depending on their own preference and individual patients’ problems. Osteopaths may have different specialities including sports injuries, paediatrics, and visceral (treating the internal organs of the body). Cranial osteopathy embraces all of these.

Osteopaths use their highly trained palpatory skills to detect areas of tension or restriction in the body, and to gently release them to restore a state of balance within the musculoskeletal system of the body.

An Osteopath takes a detailed medical history from the patient followed by a careful examination. He will make a diagnosis of what is causing the symptoms, and try to put together the ‘story’ of why they have developed. Using very subtle and gentle techniques, the accumulated stresses and strains in the body are gradually released. The aim is to relieve the current symptoms and also improve the underlying health of the tissues as far as possible in order that they do not recur. This type of treatment is suitable for everyone from newborn babies to the very elderly, being extremely gentle.

Patients may feel sensations of pressure or warmth, either under the osteopaths hands or elsewhere. Most patients feel that gradually the tension is being drawn out of their body and they become deeply relaxed. Osteopathic treatment is aimed not only at the relief of symptoms, but towards helping the body function better in all respects. Patients often report an improvement in general well being, energy levels, sleep patterns and also in areas of symptoms other that those that brought them to the osteopath in the first place.



"Osteopathy is a science with possibilities as great as the magnitude of the heavens. It is a science dealing with the natural forces of the body. We work as Osteopaths with the traditional principle in mind that the natural tendency in the patients body is alway towards the normal. There is much to discover in the science of Osteopathy by working with the forces within that manifest the healing processes. These forces within the patient are greater than any blind force that can be brought to bear from without" 


William Garner Sutherland DO                                                                       



Dr. Sutherland (1873-1954) was a student of Andrew Taylor Still (circa 1900) who took Dr. Still's admonition to "dig deeper" very seriously. As a student Dr. Sutherland had an inspiration that the bony cranium was capable of respiratory motion. He initially did not understand its implications, but could not let the idea go. Throughout his years of practice, with diligent research and study, he continuously developed a revolutionary expansion of the osteopathic concept.


Dr. Sutherland called his discovery "Osteopathy In The Cranial Field", implying that he did not create anything new; he had simply applied osteopathic thinking and principles to the cranium. Though it did not fully emerge until much later in Sutherland's life, at the core of his new understanding lies the concept of PRIMARY RESPIRATION.


The definition of the Primary Respiratory Mechanism (PRM):

Primary:it is a system that comes "first." It underlies all of life's processes and gives dynamism, form, and substance to all of anatomy and physiology.


Respiratory:It is the spark that gives rise to the breath, as it moves through the tissues. It is the foundation of metabolism. It has both an inhalation and exhalation phase.


Mechanism:It is a system composed of many parts that work together to create a whole, greater than the sum of the parts.

The beauty of primary respiration, is the ability to experience it directly. It is not simply a sublime concept. In the hands of a skilled practitioner, one connects directly with primary respiration to bring about a therapeutic response. It is the guiding principle; it is the inherent intelligence within.


Five Components of The Primary Respiratory Mechanism (PRM):


1 - The inherent motility of the brain and spinal cord

The brain and spinal cord undulate rhythmically like a jellyfish. As the brain coils and uncoils, the cavities within the brain (ventricles) and around the brain (cisterns) change shape. During the inhalation phase (flexion) the brain (and bony cranium) gets shorter and wider. During the exhalation phase (extension) the brain (and bony cranium) gets taller and narrower.


2 - The fluctuation of the cerebrospinal fluid (CSF)

It is well established that the cerebrospinal fluid (surrounding the brain and spinal cord and filling the ventricles) fluctuates rhythmically. This rhythmic fluctuation can be visually observed (and pressure changes measured) during a typical spinal tap, and has been documented by numerous research studies.

An idea unique to osteopathy describes CSF movement throughout the body, passing along the spinal nerve sheaths and through extra-cranial lymphatics. Though initially controversial, this component of the osteopathic concept is now being strongly supported by recent neuro-science research.


The CSF is considered to play a very potent nutritive role for all the tissues of the body. In his later years, Dr. Sutherland was so impressed with the potency of CSF, he would refer to it as "Liquid Light."


3 - The dynamic shifting of tensions in the Dura Mater

The meninges are the membranes that surround the brain and spinal cord, and contain the cerebrospinal fluid. The Dura Mater is the toughest and most outer layer of the meninges. The Dura Mater also has an internal architecture comprised of 3 sickles. One runs back to front (called the falx cerebri) and separates the two cerebral hemispheres. There are two other sickles, one on each side of the falx (called the tentorium cerebelli) that also run from the back to the front, somewhat parallel to the floor (when you are standing straight). The tentorium cerebelli gets its name from being "tent" shaped. The dura covering the outside of the brain then attaches firmly to the foramen magnum (the passage in the base of the cranium for the spinal cord) and upper cervical (neck) vertebrae, surrounds the spinal cord and descends to attach to the sacrum (in the pelvis) at the 2nd sacral segment.


These dural membranes are under constant tension. They are taut. Because of the tension through them, we refer to the Dura Mater as a ‘Reciprocal Tension Membrane’ (RTM). If you pull on one end of the membrane, that pull is transmitted throughout. The Dura maintains the structural integrity of the bony cranium (as it attaches into the bones). Movement of the brain, and CSF becomes translated into the membranes as a dynamic shifting of the reciprocal tension.


So, when the head is traumatized, the dural membranes may become twisted and compressed. The fulcrum, around which the rhythmic movement is organized, becomes deranged. Often these membranes are the primary seat of the cranial dysfunction, actively distorting the bones they support.


4 - The articular mobility of the cranial bones.

There are 22 bones in the cranium (not including the mandible or ossicles of the ear). They meet at the suture lines. These bones form in membrane and cartilage. At birth the bones are not fully formed and are in fact quite far apart from one another. As the infant is squeezed through the birth canal, the bones slide over one another and re-expand afterwards to resume their normal positions. This physiologic compressibility allows for maximum brain capacity and minimizes brain damage. During fetal development and after birth, the brain is constantly undulating and CSF is constantly fluctuating. This movement is transmitted through the membranes out to the bones. As the bones gradually grow to approximate one another they remain in constant motion. This movement keeps the sutures patent (open). The sutures contain blood vessels, nerve fibers, and connective tissue, just like any joint. The amount of movement is very tiny, 100ths of an inch.


This movement of the cranial bones is considered controversial. Conventional thinking considers the skull to be fused. The concept of a fused skull is erroneous, dating back to a paper written in 1873, known as "The Monro-Kellie Doctrine." The research supporting this doctrine is over 100 years old and was not very precise. More recent research supports our clinical observations of cranial bone mobility. Gradually, the mobility of the cranial bones is becoming a more widely accepted concept. It has been found in some anatomic specimens that certain cranial sutures have fused. When fusion occurs, however, it is a pathological condition. Sutural fusion occurs because the cranium has received an impact causing the bones to compress, and lose their sutural mobility. When anyjoint in the body becomes immobile, it will fuse. (Put your arm in a sling, and after some time you'll lose motion in your shoulder). In health, the Cranial Sutures are patent and allow for a slight amount of motion.


Furthermore, the bones themselves are actually a very dense fluid. They are living tissue. They are constantly being reabsorbed and recreated. They have inherent flexibilty. Traumatic influences not only compress bones together, but cause them to "stiffen" and lose their fluid nature.


5 - The respiratory motion of the sacrum between the ilia

The sacrum is connected to the cranium via the dural membranes that surround the spinal cord. The dura between the occiput and sacrum is referred to as "the core link." Attached only at the base of the skull and the sacrum at the 2nd sacral segment, the motion of the occiput is transmitted freely to the sacrum. The relationship of the sacrum with the occiput becomes clinically relevant when the cause of headaches may be due to a fall on the tailbone many years previously.


Dr. Sutherland was the first to discover and reason the activity of these well known anatomic structures. This model of physiologic activity provides an introduction to the "therapeutic process," and an introduction to the experience of Primary Respiration.


Each of the parts of the Primary Respiratory Mechanism (PRM) exists only in its relationship to the whole, and this whole exists complete within itself. Like most naturally occurring phenomenon, it is only the human mind that reduces the pieces for observation and study. Yet, a skilled Osteopath is able to perceive and work with any part of this physiologic mechanism. As incredible as this may seem, we feel the bones move, the membranes pull, and the fluids fluctuate.


During treatment each osteopath may find their focus to settle upon a different aspect of this PRM. Some osteopaths naturally engage or are more comfortable with the bones, some with membranes, some with fluid.


"As I sit with my hands upon the patient, I learn how trauma has established itself in the whole person. Then as needed, I move into bone, membrane, fluid, or potency..."  

William Garner Sutherland DO



The ‘Still Point’ phenomena

Still Point was a term used by William Garner Sutherland DO (founder of Cranial Osteopathy) to identify and describe the brief cessation of rhythm attributed to the fluctuation of cerebrospinal fluid (CSF) observed by palpation during osteopathic treatment when a point of balanced membranous tension is achieved.


During the still point, which may last anywhere from a few seconds to several minutes, all parts of the body become quiescent, and then a profound relaxation occurs as the body rebalances itself releasing strain patterns.

A still point is a variable period of time when the usual pulsations of the Cranial Rhythmic Impulse (CRI) cease temporarily. Therefore to understand a still point one must understand the CRI.


The term CRI describes the observed phenomena of cyclical slow body rhythms and pulsations. It is generated by the body and can be palpated by the hands of the osteopath who feels these movements at any point around the body. The CRI is considered to be a fundamental, physiological action motivating the mobility throughout the entire mechanism of fluid, membranous, nervous and osseous tissues. In classical Cranial Osteopathic theory deriving from the work of William Garner Sutherland  (1873-1954), this movement phenomena is thought to originate from the functioning of the Primary Respiratory Mechanism (PRM).


A still point, therefore, is a period of time when the movement of the CRI is not apparent. This temporary cessation of motion can last from a few seconds to minutes, during which time there is a re-balancing of the entire body within the fluid, membranous, nervous and osseous tissue environment.  The fluid level of the body is such an important medium in this process as explained below. From bone to tissue, from organ to vessel, from CNS to nerve root, from cellular to molecular level. It is thought that still points occur spontaneously within the body as well as being able to be induced by the practitioner.


Physiological considerations

Jim Jealous DO, who brought us biodynamics, states:


“The geometric configuration of the human body, as well as the metabolic processes, are present before the CNS develops (shown in the two photos above).... The innate wisdom is not contained within cellular structure.... The Original design and function is in the fluids of the embryo....The forces of embryogenesis become the forces of healing in adults.”


Let us consider the nature of water. Water moves. It is lively, constantly changing. Water has a close affinity with all of life. It is a primal substance. Water allows for growth, propagation and metamorphosis. Water embraces everything; a universal element shared by all. Water is nature’s regulator. It is balanced and water balances all it comes into contact with. Water has the power to cleanse, purify, and heal. 


Human Beings are comprised mostly of water. Bones are 20% water. As newborns, water comprises a significant proportion of our bodies (75-80%). As Adults our total body water decreases to about 60%. By the age of 60 years the our total body water decreases to about 50%. As we age... we dry out.


Fluid Exchange is vital to normal physiology. All the processes of life occur because fluids flow: Through channels, across membranes, and within open spaces. Should the flow of fluids stagnate, all of life becomes diminished and health is compromised. 


Cerebrospinal fluid (CSF) surrounds our brain and spinal cord. A mere 140 ml of fluid bathes the brain and fills the ventricles (internal cavities of the brain).

This CSF replenishes itself 3-4 times each day. Once thought only to provide buoyancy, CSF has now been discovered to provide important nutrient functions. Not only are essential substances made available, but harmful substances are cleared away. CSF establishes a stable and specialized fluid environment for nerve cells.


There are no lymphatic vessels within the Central Nervous System (CNS). The brain and spinal cord are instead cleaned by the rapid creation and absorption of the CSF. This circulation of CSF was once thought to be a “closed” system. Studies, however, now reveal that CSF is in direct communication with the lymphatic system of the rest of the body, via the nerve rootlets which flow out of the spinal cord 'into the periphery' at every level of the CNS.


Osteopathic considerations

Fluid exchange is essential to health. The practical application of this principle in daily practice is fundamental to Osteopathy. 100 years before today’s research confirmed his understanding, Dr. Still knew:


“The rule of artery and vein is universal in all living beings, and the osteopath must know that and abide by its rulings, or he will not succeed as a healer. 


The cerebrospinal fluid is the highest known element that is contained in the human body, and unless the brain furnishes this fluid in abundance, a disabled condition of the body will remain. He who is able to reason will see that this great river of life must be tapped and the withering fields irrigated at once, or the harvest of health be forever lost.”


The lymphatics consume more of the finer fluids of the brain than the whole viscera combined... The lymphatics are universally connected with the spinal cord and all the other nerves... and all drink from the waters of the brain.”


We know the fluids of the body comprise 60-70% of the total body weight. We know these fluids inhabit multiple compartments. These fluids are not only in a continuous state of communication, but they are also in flux. There is constant interchange and renewal.


One of Dr. Sutherland’s main contributions was the discovery of the fluctuant nature of cerebrospinal fluid. The CSF is not simply circulating. The CSF fluctuates. Fluctuation is defined as: “The motion of a fluid contained within a cavity, observed by palpation or percussion.”


Dr. Still spoke of the lymphatics drinking from the waters of the brain. We know that CSF renews itself up to 3.5 times per day. This is a system that is constantly flushing itself out. Dr. Rollin Becker spoke about the fluctuation of the CSF being perceived as a total body fluctuation because it perfuses the lymphatics. It is with this understanding... almost a poetic appreciation of anatomy and physiology that we can begin to place our hands upon our patients and perceive a single unit of function: A Fluid Body.


This Fluid Body has shape and texture. It is alive. It is filled with potency: A power to heal and transform. Becoming familiar with “normal” is essential. The quality of the fluctuation is far more important than the rate. In health there is a palpatory sense of full amplitude, a sense of vitality, and living dynamics. As a practitioner, we ask ourselves: “Does this mechanism feel alive or tired? ...and ultimately, what is the quality of the primary function of life within this given patient?”


Somewhere within, the still point exists and manifests itself throughout all life processes. There is cause and effect in each person’s history of a changing developmental process - throughout life. The Still Point is an ever changing and shifting phenomena, which is an innate and integral part of life, influencing the healing processes within us all.