tratto da
http://www.ghrnet.org/index.php/jct/article/view/861/963
una ricerca a cura di
Massimo Armeni, Institute for Craniosacral Therapies, Norma, Italy
Veronica Bravi, Still Osteopathic Institute, Rome, Italy
Stefania D’Emidio, Department of Neurosciences, Physical Medicine
and Neurorehabilitation Operative Unit, San Filippo Neri Hospital – Salus Infirmorum Clinic, Rome, Italy
Massimo Leggio, Department of Cardiovascular, Cardiac Rehabilitation
Operative Unit, San Filippo Neri Hospital – Salus Infirmorum Clinic, Rome, Italy
scarica il .pdf della ricerca
ABSTRACT
Although there are dissenting opinions, the “classic” craniosacral
therapy has gained a role in the management and treatment of
clinical problems for which the traditional therapeutic strategies led
to fluctuating results. Similarly, the biodynamic craniosacral therapy
perspective, which involves the intrinsic healing power of the life
breath, has been emphasised. Hemodynamic and cardiopulmonary
parameters are above all influenced by the heart and brain centres,
besides peripheral resistance. Considering the small number of
scientific studies on this topic existing in literature, we focused on the
anatomical aspects and neurophysiological or vascular connections
that can be influenced by craniosacral therapy, aiming to investigate
the potential effects on cardiovascular physiology through anatomic
links. As far as the spinal neurophysiological complex is concerned,
the nervous system preganglionic neurons are located in a cell
column in the intermediate area of the lateral horn of the spinal cord;
this area is called the intermediolateral cell column. The important
vascular effects mediated by the sympathetic chain neurons are only
TOPIC HIGHLIGHT
Craniosacral Approach to the Cardiovascular Physiology:
Characteristics, Mechanism and Therapeutic Perspectives
Massimo Armeni, Veronica Bravi, Stefania D’Emidio, Massimo Leggio
165
Journal of Cardiol Ther 2014 October 10 1(8): 165-168
ISSN 2309-6861(print), ISSN 2312-122X(online)
Online Submissions: http://www.ghrnet.org/index./jct/
doi:10.6051/j.issn.2309-6861.2014.01.52
© 2014 ACT. All rights reserved.
Journal of Cardiology and Therapy
ipsilateral. The right and left columns have different effects on the
heart: the right primarily innervates the sinoatrial node, and the left
innervates the atrioventricular node; therefore, an increase in the
parasympathicotonia and vagal hypertonia induced by biodynamic
craniosacral therapy at the superior centres and the suprasegmental
nuclei level can directly lead to a reduction in the frequency of firing
of sinoatrial and atrioventricular nodes, modifying the hemodynamic
and ventilatory parameters. Even if further in-depth studies are
necessary to confirm our hypothesis and experiences, this therapeutic
perspective could potentially provide a robust tool to approach the
cardiovascular patophysiology.
© 2014 ACT. All rights reserved.
Key words: Craniosacral approach; Cardiovascular physiology; Autonomic
nervous system; Complementary medicine; Clinical benefit
Armeni M, Bravi V, D’Emidio S, Leggio M. Craniosacral Approach
to the Cardiovascular Physiology: Characteristics, Mechanism and
Therapeutic Perspectives. Journal of Cardiology and Therapy 2014;
1(8): 165-168 Available from: URL: http://www.ghrnet.org/index.
php/jct/article/view/861
INTRODUCTION
Although there are dissenting opinions[1-11], the “classic” craniosacral
therapy (CST) has gained a role in the management and treatment
of clinical problems for which the traditional therapeutic strategies
led to fluctuating results. Similarly, the biodynamic CST perspective,
which involves the intrinsic healing power of the life breath, has been
emphasised.
Few recent scientific studies have been conducted to explore the
effects of CST on specific parameters concerning physical exercise,
although the literature includes publications on the effects of the
classic CST, which are sometimes discordant for several clinical
problems[12-17]. However, the craniosacral system is the most intimate
in the human body and it is there that we should focus our attention
Armeni M et al. Craniosacral Cardiovascular Approach
© 2014 ACT. All rights reserved. 166
in the aim to provide the resources for an healthy body.
The craniosacral system (CSS) is defined as a recognised,
functioning physiological system, including the membranes and
cerebrospinal fluid surrounding the spinal cord and brain, the bones to
which these membranes attach and connective tissue related to these
membranes. It is intimately related to and influenced by the nervous,
musculoskeletal, vascular, lymphatic, endocrine and respiratory
system of the body. The CSS is characterised by rhythmic, mobile
activity, being distinctively different from the physiological motions
related to breathing and cardiovascular activity[18].
An important component of craniosacral mobility is referred to
as the primary respiratory mechanism, which manifests as palpable
motion of the cranial bones, sacrum, dural membranes, central
nervous system and cerebrospinal fluid (CSF)[19].
On the basis of their palpatory ability, the goal of the therapist
is to identify the mechanism that needs treatment: fluids, fasciae,
membranes, sutures or bones, the five primary constituents of the
primary respiratory system.
THE PARASYMPATHETIC NERVOUS SYSTEM
The parasympathetic nervous system (PSNS) is divided into two
sections: the cranial and sacral components[20-22].
The cranial component consists of the following structures: (1)
The vegetative nuclei of the brainstem; (2) The autonomic fibres that
connect these nuclei to the cranial nerves; (3) The papillary nucleus
of the cranial nerve (III); (4) Tears, the nasal mucus and its cranial
nerve (VII); (5) The superior salivatory nucleus and its cranial nerve
(VII); (6) The inferior salivatory nucleus and its cranial nerve (IX);
(7) The masticatory nucleus, its cranial nerve (V) and the fibres that
connect it to face, conjunctiva and buccal mucosa; (8) The cardiopneumo-
digestive nucleus and its cranial nerve (X).
The sacral component is a vegetative, sensory and motor centre
derived from segments S2-S4 and innervates the sigmoid colon,
rectum, urogenital system, urinary bladder, kidneys, sexual organs
and external genitalia via the pelvic nerve[20-22].
Unlike the sympathetic nervous system (SNS), the PSNS does not
have a monosynaptic connection to the adrenal medulla, which is an
important aspect from the physiological viewpoint[20-22].
Hemodynamic and cardiopulmonary parameters are above
all influenced by the heart and brain centres, besides peripheral
resistance. Considering the small number of scientific studies on this
topic existing in literature, we focused on the anatomical aspects and
neurophysiological or vascular connections that can be influenced by
CST[20-22].
Hypothetically, the neuroanatomical links can modify some
hemodynamic and ventilatory parameters, at rest and/or during
exercise, such as heart rate and heart rate recovery prognostic
index[23-31].
ANATOMY
In the heart, the sinus node artery perfuses the sinoatrial node (SAN),
positioned on the wall of the right atrium, and 80% of this blood
comes from the right coronary artery while 20% comes from the
circumflex artery. The right vagus nerve and the sympathetic system
innervate this node. The atrioventricular node (AVN) is positioned near
the opening of the coronary sinus, between the mitral annulus and the
medial margin of the tricuspid valve; here the perfusion comes from
the fibrous septum branch of the right coronary artery. The bundle of
His is a direct continuation of the atrioventricular node and descends
to the left side of the superior margin of the interventricular septum
(SIV); the bundle has dual blood supply, partially from the AVN
artery and the descending anterior (DA) coronary artery (first septal
perforator branch)[20-22].
Both the right and the left branches originate from the bundle of
His. The right branch continues along the right side of the IVS under
the endocardium and is supplied by both the right coronary and the
DA coronary arteries. The left branch is positioned on the left side
of the SIV in the sub-endocardial layer, from which anterior superior
and posterior inferior fascicles originate. These branches end in very
thin Purkinje fibers[20-22].
As far as the spinal neurophysiological complex is concerned, the
nervous system preganglionic neurons are located in a cell column
in the intermediate area of the lateral horn of the spinal cord; this
area is called the intermediolateral cell column (IML). The column
seamlessly spreads from the midbrain to the sacral spine, although
the autonomic nervous system innervation arises from the sacral
spine corresponding to the T1–L2 segments. The IML sends impulses
only ipsilaterally and is inhibited by the brainstem structures that
are stimulated by ipsilateral cortex and cerebellum; the brain can
be stimulated in order to increase the IML inhibition, and generally
augment the afferent bombardment from the contralateral side.
Arteriolar vasoconstriction, capillary dilatation, piloerection and
perspiration, which occur at the segment level, are the principal
systemic effects of the IML[20-22].
The important vascular effects mediated by the sympathetic chain
neurons are only ipsilateral. The right and left columns have different
effects on the heart: the right IML primarily innervates the SAN and
the left IML innervates the AVN. This last anatomical clarification is
very important in considering the potential direct connection between
the CSS and the origin of cardiac impulses; therefore, an increase in
the parasympathicotonia and vagal hypertonia induced by biodynamic
CST at the superior centres and the suprasegmental nuclei level can
directly lead to a reduction in the frequency of firing (FOF) of SAN
and AVN, modifying the hemodynamic parameters[20-22].
As well known, craniosacral injuries and injuries of the vertebral
axis with interference on the paravertebral ganglionic chain,
originating at the superior dorsal rib level, are physiological injuries
that have a direct perturbatory influence on the autonomic nervous
system (parasympathicotonia or orthosympathicotonia) and vascular
system[20-22].
SEARCH STRATEGY FOR IDENTIFICATION
OF STUDIES
Computerised searching of the following literature databases was
performed: PubMed, Cochrane library. The following clinical
keywords were used to search for the intervention of interest:
“craniosacral therapy, heart rate, heart rate recovery, autonomic
nervous system and cardiovascular physiology”. Candidate articles
were then screened for possible inclusion in this review. Table 1
summarizes some of the studies and their main findings.
BIODYNAMIC CRANIOSACRAL THERAPEUTIC
APPROACH
CST is a non-invasive method, derived from osteopathy, developed
in the 1970s by J. Upledger, MD[32]. It is based on the assumption
that there is a fine rhythmic movement, which pervades the body
and can be discerned by practised therapists under their palpating
hands. This movement can be utilised for diagnostic as well as
therapeutic purposes by regulating the flow of cerebrospinal fluid[33].
167 © 2014 ACT. All rights reserved.
Armeni M et al. Craniosacral Cardiovascular Approach
The focus of craniosacral examination and treatment lies on the
craniosacral structures; these include the bones and connective
tissues (membranes of the brain and spinal cord) of the skull
and spine and the cerebrospinal fluid. Anatomically surrounding
and physiologically sustaining the central nervous system, these
structures have a direct influence on functioning of the autonomic
nervous system[33]. The effects which can be brought about through
CST are achieved through gentle touch in the areas of the skull, face,
spine and pelvis[33]. Treatment is not primarily aimed at symptoms,
but determined by priorities established by the therapist during each
patient examination[33].
CST is mostly applied by trained craniosacral therapists but can
also be performed by osteopaths and other healthcare practitioners
who have undergone the appropriate training. CST is commonly
described as an alternative treatment approach, applying a gentle
manual force to address somatic dysfunctions of the head and the
remainder of the body. The interplay of diagnosis and treatment
is aimed at mobilising the cranial sutures which are abnormally
restricted to physiologic motion. Restrictions in the craniosacral
system are manually identified which include the bones, membranes
and CSF that surround the brain and spinal cord[34].
Focusing the attention on the treatment, all the subjects
experienced a state of rest and relaxation; for biodynamic CST, the
practitioner should have a great deal of tactile experience in injury
normalization.
Accordingly to the existing literature concerning the effect of the
classic CST on several central and cardiopulmonary diseases[1-16] and
the evidence-based medicine derived from these studies as well as
the anatomical and neurophysiologic links previously described, we
focus mainly on the following key points in a complete session cycle
of treatments: (1) Lateral venous sinuses; (2) Torcular heurophili; (3)
Cavernous sinus; (4) Sagittal sinus; (5) O/M horizontal and vertical
arms; (6) Third ventricle; (7) Fourth ventricle; (8) Lateral ventricles.
In particular, the third, fourth, fifth, sixth, seventh, ninth, tenth,
eleventh and twelfth cranial nerve nuclei lie on the fourth ventricle;
the SAN is substantially innervated by the ninth cranial nerve.
Considering that the intracranial circulation flows via the jugular
foramen, we assume that a method focused on the occipito-mastoid
suture release and petro-basilar articulation can relieve the nerve
and the big vessels in order to achieve the correct neurophysiology.
Similarly, the fourth ventricular filling and emptying in still point
techniques have a direct impact on the liquid homeostasis and
nourishment of the aforementioned nuclei, possibly improving
nerve impulses and, consequently, the hemodynamic and ventilatory
parameters.
Table 1 Main studies exploring the reliability of craniosacral therapy and
the effects on autonomic nervous system.
Authors, year
Green C
et al 1999[5]
Hanten WP
et al 1998[7]
Cutler MJ
et al 2005[10]
Wirth-Pattullo
V et al 1994[12]
Main conclusions
This systematic review found insufficient evidence to
support craniosacral therapy.
The results indicated that a subject’s craniosacral
rhythm is not related to the heart or respiratory rates of
the subject or the examiner.
The current study is the first to demonstrate that cranial
manipulation, specifically the CV4 technique, can alter
sleep latency and directly measured muscle sympathetic
nerve activity in healthy humans. These findings
provide important insight into the possible physiologic
effects of cranial manipulation.
Measurements of craniosacral motion did not appear
to be related to measurements of heart and respiratory
rates, and therapists were not able to measure it reliably.
PERSPECTIVES AND CONCLUSION
Finally, we can surely assert that this treatment can cause
parasympathicotonia and reduced orthosympathicotonia with direct
effects on the IML, together with possible vagal hypertonia; this
could directly reduce the FOF of SAN and AVN, peripheral vascular
resistance and ventilatory parameters, allowing a related heart rate
and heart rate recovery decrease. Even if further in-depth studies are
necessary to confirm our hypothesis and experiences, this therapeutic
perspective could potentially provide a robust tool to approach the
cardiovascular patophysiology.
CONFLICT OF INTERESTS
There are no conflicts of interest with regard to the present study.
REFERENCES
1 Gerdner LA, Hart LK, Zimmerman MB. Craniosacral still point
technique: exploring its effects in individuals with dementia. J
Gerontol Nurs 2008; 34: 36-45
2 Downey PA, 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; 36: 845-853
3 Fernández-de-Las-Peñas C, Alonso-Blanco C, Cuadrado ML,
Miangolarra JC, Barriga FJ, Pareja JA. Are manual therapies effective
in reducing pain from tension-type headache? a systematic
review. Clin J Pain 2006; 22: 278-285
4 Green C, Martin CW, Bassett K, Kazanjian A. A systematic review
of craniosacral therapy: biological plausibility, assessment
reliability and clinical effectiveness. Complement Ther Med 1999;
7: 201-207
5 Hanten WP, Dawson DD, Iwata M, Seiden M, Whitten FG, Zink T.
Craniosacral rhythm: reliability and relationships with cardiac and
respiratory rates. J Orthop Sports Phys Ther. 1998; 27: 213-218.
6 McPartland JM, Mein EA. Entrainment and the cranial rhythmic
impulse. Altern Ther Health Med 1997; 3: 40-45
7 Cutler MJ, Holland BS, Stupski BA, Gamber RG, Smith ML. Cranial
manipulation can alter sleep latency and sympathetic nerve
activity in humans: a pilot study. J Altern Complement Med 2005;
11: 103-108
8 Greenman PE, McPartland JM. Cranial findings and iatrogenesis
from craniosacral manipulation in patients with traumatic brain
syndrome. J Am Osteopath Assoc 1995; 95: 182-188; 191-192
9 Kostopoulos DC, Keramidas G. Changes in elongation of falx
cerebri during craniosacral therapy techniques applied on the skull
of an embalmed cadaver. Cranio 1992; 10: 9-12
10 Ehrett SL. Craniosacral therapy and myofascial release in entrylevel
physical therapy curricula. Phys Ther. 1988; 68: 534-540.
11 Frymann VM. A study of the rhythmic motions of the living cranium.
J Am Osteopath Assoc 1971; 70: 928-945
12 Moran RW, Gibbons P. Intraexaminer and interexaminer reliability
for palpation of the cranial rhythmic impulse at the head and
sacrum. J Manipulative Physiol Ther 2001; 24: 183-190
13 Rogers JS, Witt PL, Gross MT, Hacke JD, Genova PA. Simultaneous
palpation of the craniosacral rate at the head and feet: intrarater
and interrater reliability and rate comparisons. Phys Ther 1998;
78: 1175-1185
14 Rogers JS, Witt PL. The controversy of cranial bone motion. J
Orthop Sports Phys Ther 1997; 26: 95-103
15 Wirth-Pattullo V, Hayes KW. Interrater reliability of craniosacral
rate measurements and their relationship with subjects’ and examiners’
heart and respiratory rate measurements. Phys Ther 1994;
74: 908-916; discussion 917-920
© 2014 ACT. All rights reserved. 168
Feher G et al . Troponins in ischaemic stroke
16 Crisera PN. The cytological implications of primary respiration.
Med Hypotheses 2001; 56: 40-51
17 Zegarra-Parodi R, de Chauvigny de Blot P, Rickards LD, Renard
EO. Cranial palpation pressures used by osteopathy students: effects
of standardized protocol training. J Am Osteopath Assoc
2009; 109: 79-85
18 Upledger JE, Vredevoogt. J Craniosacral therapy. Eastland Press,
Seattle; 1983
19 Magoun HI. Osteopathy in the cranial field. The Journal Printing
Company, Kirksville; 1976
20 Hutter OF, Trautwein W. Vagal and sympathetic effects on the
pacemaker fibers in the sinus venosus of the heart. J Gen Physiol
1956; 39: 715-33
21 Wray DW, Formes KJ, Weiss MS, O-Yurvati AH, Raven PB,
Zhang R, Shi X. Vagal cardiac function and arterial blood pressure
stability. Am J Physiol Heart Circ Physiol 2001; 281: H1870-
H1880
22 Henley CE, Ivins D, Mills M, Wen FK, Benjamin BA. Osteopathic
manipulative treatment and its relationship to autonomic
nervous system activity as demonstrated by heart rate variability:
a repeated measures study. Osteopath Med Prim Care 2008; 2: 7.
doi: 10.1186/1750-4732-2-7.
23 Jae SY, Carnethon MR, Heffernan KS, Choi YH, Lee MK, Park
WH, Fernhall B. Slow heart rate recovery after exercise is associated
with carotid atherosclerosis. Atherosclerosis 2008; 196: 256-
261
24 Bosquet L, Gamelin FX, Berthoin S. Reliability of postexercise
heart rate recovery. Int J Sports Med 2008; 29: 238-243
25 Cade WT, Reeds DN, Lassa-Claxton S, Davila-Roman VG, Waggoner
AD, Powderly WG, Yarasheski KE. Post-exercise heart rate
recovery in HIV-positive individuals on highly active antiretroviral
therapy. Early indicator of cardiovascular disease? HIV Med
2008; 9: 96-100
26 Heffernan KS, Jae SY, Fernhall B. Heart rate recovery after exercise
is associated with resting QTc interval in young men. Clin
Auton Res 2007; 17: 356-363
27 Chacko KM, Bauer TA, Dale RA, Dixon JA, Schrier RW, Estacio
RO. Heart rate recovery predicts mortality and cardiovascular
events in patients with type 2 diabetes. Med Sci Sports Exerc
2008; 40: 288-295
28 Heffernan KS, Fahs CA, Shinsako KK, Jae SY, Fernhall B. Heart
rate recovery and heart rate complexity following resistance exercise
training and detraining in young men. Am J Physiol Heart
Circ Physiol 2007; 293: H3180-H3186
29 Singh TP, Rhodes J, Gauvreau K. Determinants of heart rate recovery
following exercise in children. Med Sci Sports Exerc 2008;
40: 601-605
30 Borresen J, Lambert MI. Changes in heart rate recovery in response
to acute changes in training load. Eur J Appl Physiol 2007;
101: 503-511
31 Jae SY, Carnethon MR, Ahn ES, Heffernan KS, Choi YH, Lee
MK, Fernhall B. Association between heart rate recovery after
exercise testing and plasminogen activator inhibitor 1, tissue
plasminogen activator, and fibrinogen in apparently healthy men.
Atherosclerosis. 2008; 197: 415-419
32 Upledger JE. Craniosacral therapy. Phys Ther 1995; 75: 328-330
33 Girsberger W, Bänziger U, Lingg G, Lothaller H, Endler PC.
Heart rate variability and the influence of craniosacral therapy on
autonomous nervous system regulation in persons with subjective
discomforts: a pilot study. J Integr Med 2014; 12: 156-161. doi:
10.1016/S2095-4964(14)60021-2
34 Upledger JE. CranioSacral Therapy. in: DW Novey (Ed.) Clinician’s
complete reference to complementary and alternative medicine.
Mosby, St. Louis, MO; 2000: 381-392.
Peer reviewer: Liang-Miin Tsai, Professor of Medicine, Department
of Internal Medicine, National Cheng Kung University Hospital,
138 Sheng Li Road, Tainan 70428, Taiwan.
