Massage therapists are exceptionally positioned to capitalize on the combination of their massage therapy skills coupled with the use of Cranial Positional Release Therapy for conditions that affect the cranium and sacrum.
Treatment of the cranium and its articulating structure, the sacrum, requires a gentle approach—and the myofascial manipulation skills and a sensitivity of touch that massage therapists often possess place them in an exceptional position for use of Positional Release Therapy (PRT) to treat these structures.
Mechanisms at Play?
Steve E. Hartman, in his 2006 editorial titled “Cranial osteopathy: its fate seems clear,” which ran in the journal Chiropractic and Osteopathy, pointed out that evaluation and treatment of the cranium and its influence on sacral mobility has been fraught with controversy since the introduction of William Garner Sutherland’s work in 1939, “The Cranial Bowl,” and calling for a departure or significant revision of Sutherland’s Craniosacral Respiration Theory.
Sutherland proposed that the practitioner could palpate and manipulate cerebrospinal fluid dynamics, that the cranium possessed a respiratory cycle of 12 palpatory cycles per minute, and that this respiratory cycle and concomitant cerebrospinal fluid (CSF) cycle could be manipulated through cranial bone osteopathic manipulation. However, there has been no credible evidence to substantiate this theoretical model to date.
In 2020 Bruno Bordoni and colleagues provided a thorough examination of the evidence, and the physiology of CSF structure and function, as well as its underlying metaphysics and neurodynamics to determine if it was plausible if the cranial practitioner could in fact both identify and manipulate CSF fluid flow through cranial manipulation.
Based on their examination, published in The Cuerus Journal of Medical Science, titled “The cranial bowl in the new millennium and Sutherland’s legacy for osteopathic medicine: Part 1 and Part 2,” they also did not find any credible evidence to support the use of Sutherland’s craniosacral evaluation or treatment techniques and have called for a revision of the theory and practice of craniosacral therapy.
However, Heidemarie Haller, Gustav Dobos and Holger Cramer, in “The use and benefits of Craniosacral Therapy in primary health care: A prospective cohort study,” published in 2001 in the journal Complementary Therapies in Medicine, have provided some limited evidence that craniosacral therapy may have some use in the primary care setting. They, and myself, however, believe there may be other mechanisms at play that are producing these positive outcomes as well as what cranial practitioners are feeling in their evaluation and treatment.
The Mechanical Coupling Theory
Cranial tissues and those that connect to the cranium, such as the trapezium, are like any other tissue in the body and are susceptible to development of tender and trigger points, resulting in somatic dysfunction.
The cranium is susceptible to the development of somatic dysfunction, which for a better term are twisted, compressed tissues that are neurologically stuck in a nonfunctional position, much like a twisted rope or knotted necklace.
These twisted tissues produce a fasciculation response, or neurologic twitch, which I propose is what the practitioner is feeling, versus a brain or cranial respiration cycle. This twitch, or fasciculation, is a result of neurological, structural and chemical dysregulation of the tissues on a macro and micro scale. (What is interesting about this twitch, or fasciculatory sensation felt under the practitioner’s fingers, is that it is often in the range of 12-14Hz per minute, which aligns with the frequency range postulated in Sutherland’s craniosacral respiration theory.)
Tissues often become trapped in a twisted position, affecting their ability to uncouple from one another, entrapping localized nerves, producing pain, reducing strength and mobility, and affecting both somatic and autonomic homeostasis.
The Mechanical Coupling Theory as outlined in my book, “Clinical Guide to Positional Release Therapy” proposes that somatic dysfunction is produced from multiple influences. The theory works to shine a light on not only how our tissues become stuck but also how somatic dysfunction is produced.
When Massage Creates Pain
Another important concept to consider is that the cranium rests on the base of the sacrum, and alterations of their biomechanics and position will affect one another, which is possibly why clients often report relief at their lumbosacral junction when their cranium is treated. An example of this is the production of headaches, a common condition treated by massage therapists.
While there are many possible sources of headache production—whether from forward-head posture, post-concussive syndrome, sacral torsion, sacroiliac joint dysfunction, cervicogenic influences, nutrition, trauma, stress or other issues—clients often present with painful myofascial tender and trigger points at the cranium and its articulating structures, which often move them to seek such complementary therapies as craniosacral therapy.
Traditional massage, while helpful, often does not fully resolve the osteopathic lesions (tender or trigger points) in these structures, and forcing them into submission with aggressive massage techniques commonly results in the client being more painful than before treatment. At our clinic, we often see people suffer from cranial conditions that have either not resolved with traditional and craniosacral therapies or whose conditions have become worse under more aggressive therapeutic techniques.
For example, after two years of being pain-free from migraines, a woman returned to our clinic seeking help after deciding to get a massage for shoulder-and-neck tension. The massage therapist employed trigger point pressure therapy on her cranium and shoulders, resulting in return of the migraines to the point of her having them six days a week, throwing up when present, and producing intractable pain in her neck and cranium.
It turned out that this woman had developed thoracic outlet syndrome, which resulted in an elevated thoracic rib. The massage therapist thought the rib was a trigger point and attempted to “mash” it out of her.
Additionally, the client also presented with an anterior innominate rotation (pelvic malalignment), resulting in sacroiliac joint dysfunction and imbalance between the sacrum and cranium. The treatment the massage therapist provided was not only inappropriate for her conditions, but further exacerbated her symptoms.
A gentle, non-painful unwinding therapeutic approach to allow the rib and pelvis to relax and to resolve her resultant cranial somatic dysfunction would have been more appropriate in this situation. So, why did the massage therapy provided to this person not work and, in fact, worsened her condition?
Introducing more pain into the neurological system produces both a negative somatic and autonomic response, often increasing neurological sensitivity or gamma gain, which produces more neurological binding, increases release of inflammatory chemical mediators, and enhances tissue binding or somatic dysfunction.
Not only is this not an ideal environment to create in a client who is already painful and in a heightened neurological state, it also requires a great deal of effort and physical demand on the massage therapist.
Save Your Thumbs
Many massage therapists who have either worked for our clinic or whom I have treated often complain of pain developed from using high pressure or force while engaging in their therapy, particularly at their carpometacarpal joints, or the base of the thumbs.
Positional Release Therapy provides a reduction in pressure on these structures and the body because Positional Release Therapy is very gentle on the practitioner and capitalizes on how the neurological system is designed.
Pushing strongly against inflamed neurological tissues results in a neurological reflexive opposition force not only on the client but also on the therapist. Many massage therapists may have been taught myofascial, massage and trigger point techniques that require a substantial force. These are not needed with Positional Release Therapy.
Positional Release Therapy is a passive, indirect therapy that utilizes manipulation of the muscle spindle and gamma motor neuron system to restore homeostasis in both the somatic and autonomic nervous systems and their related tissues. When Positional Release Therapy is applied to tender or trigger points, they simply unwind, resulting in less pain for the client and therapist.
If massage therapists and other bodyworkers want to extend their careers, utilization of Positional Release Therapy or other indirect therapy techniques are a must. Moreover, massage therapy is ideal to apply after application of Positional Release Therapy.
As found in the 2022 Journal of Physical Medicine and Rehabilitation, Positional Release Therapy promotes production of blood flow and tissue realignment in tissues and massage therapy after release would ideally optimize these outcomes without hurting the client or practitioner.
Superior Clinical Outcomes?
Based on Positional Release Therapy trainings we have provided to massage therapists, we have found massage therapists to have exceptional soft-tissue palpatory skills and the ability to find and manipulate the fasciculatory response at the cranium and sacrum.
Massage therapists often report, after performing Positional Release Therapy on the cranium and sacrum, that it is gentler on their bodies and their clients, resulting in less pain to their client, which improves client compliance.
Additionally, based on patient and client clinical feedback, the combination of Positional Release Therapy and massage for cranial and sacral conditions provides superior and more efficient outcomes than massage or myofascial release alone. While there is some antidotal clinical and emerging research supporting the use of craniosacral therapy, more research is needed to substantiate its continued use as currently practiced.
More specifically, the theories that have established craniosacral use and practice also need further examination and possibly revision, as well as how Positional Release Therapy and massage therapy coupled together appears to produce superior clinical outcomes.
About the Author
Timothy Speicher, PhD, ATC, LAT, PRT-cÒ, EMT is an international author, speaker, influencer, inventor, clinician-scholar, entrepreneur, Athletic Trainer (AT), Strength and Conditioning Specialist (CSCS), Positional Release Therapist (PRT-c®) and Emergency Medical Technician (EMT). He is the founder and owner of the Positional Release Therapy InstituteÒ and Go Strong Core Program,Ò and President of Elevated Performance and Rehabilitation. He wrote “Clinical Guide to Positional Release Therapy.”