Manual cranial therapy as it is taught in the CRAFTA® education.

What is cranial manual therapy?

In the CRAFTA® education, cranial manual therapy means: assessment and treatment of the cranium (head) and the face with passive movements (movements executed by the therapist). During the examination three parameters are examined: resistance, rebounce and sensory response.

• Resistance: is the start and the quality of the pressure, which is analyzed during the increased pressure of the passive movements (Maitland et al 2013)
• Rebound: a reaction of the cranial bone tissue on a change in tension by an external force like a passive movement This reaction is based on the cranial architecture and the transducing of forces between the bone structures. This is called the  stresstransducer system (Oudhof 2001, Proffit 2013).
• Personal (individual) response These may be devided in
  • Sensory responses the personal experienced by the person during performing of cranial passive movement, e.g. pain, dizziness, tinnitus, heavy body feeling and others.
  • Physical responses; the body, physical responses related with the cranial passive movement  like skin redness, changed muscle  tone , nasal respiration, motor endurance

Clinical it is registrated that his responses can be classified in presentation in during the time. Sensory and physical responses may be manifest during the treatment (i) , may have a latency (ii)  ( Within 6 hours ,24 hours or after a few days) and  may be accumulating   during or after the treatment.

These three parameters will first be examined through six standard tests. In the following, specific regional tests, related to the findings out of the six standard tests, can be performed. Abnormal findings like increased resistance, reduced rebounce or the reproduction of the patient’s symptoms (sensory responses) may provide information or clues, supporting clinical patterns. These clinical patterns might stem from, e.g. post–traumatic headache, a unilateral subjective tinnitus, face trauma, chronic (pseudo) sinusitis or paediatric ear pain.

The parameters are based on the evidence from cranial growth models and research out of the scientific fields of orthodontics, plastic and neural surgery (Smith and Josell 1986, Proffit   2013) and the latest pathobiological knowledge from pain science and the innervation of cranial tissue (Schueler et al 2013).Messlinger

What is the difference between cranial manual therapy (CM) and craniosacral therapy (CS)?

There is strong clinical evidence that cranial passive movements may change complaints and function in human beings. For an excellent overview of different other models it is referred to Chiatow , Cranial Manipulation . Theory and Practice” (Chiatow 2005). Most of them are driven by the cranial sacral rhythm. This is a cyclic movement of all body tissue related to the movement of the spinal fluid. It is called the primary respiratory mechanism. This is different from the CM.

• CM is based on growth studies coming from the fields of orthodontics, plastic and neuro surgery. This is in contrast to the ideas of CS and the primary respiratory mechanism.
• CS is based on biomechanical/anatomical models. CM is orientated on functional/biological/ pragmatic models.
• The treatment goals are different
  • CM assessment and management techniques look for clinical signs (Resistance, Rebounce, and Sensory Response). CS is very focused on changes in structures and systems (suture, ventricle, psycho-emotional systems).
  • CM always combines craniofacial functions like for example eye movements, respiratory and tongue exercises/ training. CS stays passive because of the “self-healing’ mechanism of the body.

Cranial manual therapy aims not……

• to mobilize sutures, as it is known from studies that several kilograms are needed to achieve minimal sutural movement (Downey et al 2005)
• to push out ventricles and to base the effects on the cranial sacral rhythm due to the lack of evidence (Sommerfield et al 2004 )
• to leave the patient passive with a “wait and see” approach after the treatment

Cranial manual therapy aims to …

• carry out a systematic analyses of the abnormal  tension in the cranial bones related to the patient’s complaints, which are  expressed in three parameters (resistance, rebounce and sensory response). It is based on pain mechanisms and classification of pain ideas.
• support biological function of the cranial tissue during growth and to reduce (multiple minor) nociception in the craniofacial area. Further, it aims to restore its function (normal stress-transducing ) and to stimulate craniofacial organ functions

Is there evidence for cranial manual therapy?

It is advocated that stress and strain function of cranial bones may be influenced by craniofacial (dys-) functions (Gabutti and Draper 2014).

Further, it is stated that pericranial tissues can directly influence meningeal nociception associated with symptoms like headache ( Schueler 2014). However, a systematic effect study based on this background is lacking. In a systematic review by Krützkamp et al (2014) about the outcomes of the treatment of the craniofacial tissue by passive movements, 37 studies were identified related to orthodontic splint therapy, craniosacral or manual therapy as passive interventions. All had a poor methodological quality and small groups. Only very little evidence could be identified concerning the outcome of all therapy approaches on headaches and psychogenic problems.

In 2018 Hanskamp have finished an inter-reliability study of the 6 standard tests, which are taught in the CRAFTA education.

Furthermore, the research question is addressed if the techniques can discriminate between volunteers with and without TMD and neck pain. This article is published in 2019 

( Is there a difference in response to manual cranial bone tissue techniques between participants with cervical and/or temporomandibular complaints versus a control group? An explorative study, Handkamp M, Armijo-Olivio S, von Piekartz H. J, JBMT , 2019 )

References

• Chiatow L , Cranial Manipulation Theory and Practice , 2nd Edition, 2005, Elsevier, Chruchil Livingstone, Edinghburgh
• Downey PA1, Barbano T, Kapur-Wadhwa R, Sciote JJ, Siegel MI, Mooney MP. Craniosacral therapy: the effects of cranial manipulation on intracranial pressure and cranial bone movement. J Orthop Sports Phys Ther. 2006 Nov;36(11):845-53.
• Gabutti, M ,Draper-Rodi J Osteopathic decapitation: Why do we consider the head differently from the rest of the body? New perspectives for an evidence-informed osteopathic approach to the head International Journal of Osteopathic Medicine (2014) 17-23
• Krützkamp L, D Möller, von Piekartz H. Influence of Passive Movements to the Cranium systematic Literature review. Manuelle Therapie 2014; 18: 183–192
• Maitland G, Hengeveld E, Banks K, English K. Vertebral manipulation, 6^th ed. Oxford: Butterworth-Heinemann; 2013
• Meßlinger, K., Schüler, M., Dux, M., Neuhuber, W. L., De Col, R. Innervation extracranialer Gewebe durch Kollateralen von Hirnhautafferenzen. Neue Einsichten in die Entsehung und Therapie von Kopfschmerzen. Manuelle Medizin, 54(5), 307-314; 2016
• Oudhof H. Skull growth in relation to mechanical stimulation. In: von Piekartz H, Bryden L. Cranialfacial Dysfunction and Pain, Assessment, Manual Therapy and Management. Oxford: Butterworth-Heinemann; 2001
• Proffit WR. Contemporary Orthodontics. 5nd St. Louis: Mosby Year Book; 2013

• Schueler M1, Messlinger K, Dux M, Neuhuber WL, De Col R. Extracranial projections of meningeal afferents and their impact on meningeal nociception and headache 2013, Sep;154(9):1622-31
• Sommerfeld P1, Kaider A, Klein P. Inter- and intraexaminer reliability in palpation of the "primary respiratory mechanism" within the "cranial concept". Man Ther. 2004 Feb;9(1):22-
• Smith R, Josell The plan of the human face: a test of three general concepts. Am J Orthod. 1984 Feb;85(2):103-8.