PT Classroom - Working Wonders Outside the Treatment Box with CranioSacral Therapy

by Mariann Sisco, PT, CST-D

Mariann Sisco PT, CST-D, is a practicing physical therapist of 34 years. In addition to maintaining a private practice, Mariann is a Certified Instructor for the Upledger Institute, teaching CranioSacral Therapy internationally. She also served as a staff clinician working alongside Dr. John E. Upledger at the Upledger Institute Healthplex Clinical Services in Florida. Mariann shares her knowledge of Visceral Manipulation as a Certified Presenter for the Barral Institute. Fueled by her personal belief that you cannot diagnose the power of the human spirit, she applies her expertise utilizing manual therapy for patients who have not responded to traditional medicine. Mariann’s broad range of clinical experience, post-graduate education and entertaining teaching style make her a sought-after instructor in both the clinical and classroom settings. Mariann was awarded the first Clinical Educator of the Year by the University of New Mexico Physical Therapy School. Mariann is also an examiner for the CST Techniques Certification Program.

Working Wonders Outside the Treatment Box with

CranioSacral Therapy

CranioSacral Therapy (CST) is often misunderstood in the scientific world of evidence-based medicine. The problem is partly because of different interpretations of what CST entails and partly because of a lack of understanding of various researchers as to the core principles involved in the evaluation and treatment of the craniosacral system (CSS).12345 Many healthcare practitioners study CST and include it in their skill set6, and patients often seek out CST when traditional medical practices fail.7

Although not a panacea, CST experiences have been catalogued in a book titled Working Wonders.8 Wonder is defined as a cause of astonishment at something new to one’s experience.9 CST was certainly new to my experience over 35 years ago and to this day. I continue to marvel in astonishment at the results that can be achieved through this light-touch therapy. Although wonder is not commonly associated with evidence-based medicine, it does indeed fuel scientific inquiry. Ralph Waldo Emerson referred to wonder as “the seed of our science,”10 while Abraham Heschel described wonder as the “the root of knowledge.”11 Experiencing wonder invites the question “why?”—which leads to scientific inquiry.

Anatomical root of CranioSacral Therapy

To explore the wonder of CST, a brief overview of the anatomy of the CSS is in order. The cranium is lined with dura mater, which not only encircles the inner surfaces of the cranial bones but also folds in on itself. This creates the falx cerebri, tentorium cerebelli and the falx cerebelli, otherwise known as the intracranial membrane (ICM). The firm attachment of the falx cerebelli at the foramen magnum of the occiput continues inferiorly with attachments on the posterior bodies of C1 and C2. It continues in the inferior direction without any attachments until it anchors at the S2 segment as the pia portion of the filum terminale within the sacral canal. It exits out of the sacral canal and continues as the external dural segment of the filum terminale blending with the periosteum of the coccyx (figures 1a,b,c).12,13 In addition, the dura mater extends out through the intervertebral foramina with the spinal nerves as the dural sleeves. The dural sleeves attach on the vertebral bodies, blending with the paravertebral fascial tissue.14 These anatomical attachments help give credence to the continuity of the fascia and are why CST has such far-reaching effects.15



For the purposes of this article, movement of the cranial bones is assumed. Scientific validity of cranial bone movement is explored in depth in the article “CranioSacral Therapy… What is it Really?16 and can be located through this website.

The core principle of honoring and listening to the experiences held in the tissues is key to the success of CST.17 Sometimes the unique pattern of injury does not fit within the confines of the traditional physical therapy paradigm. Following the tissues engages the patient’s self-correcting mechanism, which allows the therapist to discover the unique way the body organized the traumatic forces that so often lead to chronic symptoms. This process assists the patient in unraveling the trauma, leading to more homeostasis.18,19,20

A case of restored hearing
An experience I had teaching CST 1, an entry-level class, illustrates this point. Over the course of four days, students are taught a 10-Step Protocol of light touch techniques that can be safely practiced on patients while assisting an overall opening of the fascial envelope of the patient’s body. These techniques include addressing transverse planes of fascia within the torso, neck, and head. Also included in the class are gentle decompression techniques of the boney attachments of the dural tube at the occiput and sacrum. On the third day, specific techniques to facilitate the release of sutural and intracranial membranes are addressed. On the fourth day, students perform a 10-Step Protocol in its entirety on each other. As a final exercise, students do a mini evaluation and treatment of the CSS working outside of the protocol.21

Two of my students, Stephanie and Liz, performed the concluding exercise on each other during class. During the practice lab, Liz had found the sphenobasilar jointnot to be expressing the craniosacral rhythm optimally. She correctly chose to apply the sphenoid technique to Stephanie. While decompressing the sphenoid from the occiput, Stephanie felt a very sharp pain and heard a pop on the left side of her head, near her ear. The pain radiated into her ear. Although the pain was momentary, it frightened her as well as Liz, who was fearful she had harmed Stephanie. It was at this point that the two of them signaled me to their table. It was clear to me that Liz had used the appropriate technique. At this point, Stephanie was pain free, so I assured them that the self-correcting mechanism was at work.

After the students completed this final trade, I spent time addressing any lingering questions. While answering a question from another student, I noticed Stephanie crying. Concerned, I inquired if she was okay. Stephanie nodded her head that she was fine. Once I completed answering the student’s question, I returned to Stephanie and asked if there was anything she would like to share. Stephanie then reported that she had been deaf in her left ear for 27 years. Toward the end of class she noticed a “clear feeling” in her ear. She covered her functioning ear and noticed that she could hear me speaking. Her tears were of gratitude.

A week later I checked in with Stephanie. She reported that she continued to have improved hearing. Although words were slightly muffled, she could hear and understand what peoplewere saying. Stephanie told me that the day after class ended she developed low back pain (LBP). Over the course of a week, she additionally experienced twitching in her left eye and forehead along with intermittent dizziness. After one week, all of the symptoms subsided except for the LBP. I reminded her about the connection of the dura mater from the sphenoid to the sacrum and suggested that Stephanie schedule a CST session to address her LBP.

As Stephanie (age 52) and I talked further, she shared the story of her hearing loss. At age 25, she woke up one day unable to hear. She had no cold or sinus infection. She was hospitalized for four days and given medication to help amplify sound. This was all to no avail. Radiographs and nerve testing revealed nothing, yet her hearing was completely gone. When I inquired about any previous trauma, Stephanie said she had fallen off of a truck moving at about 15 mph and had landed on her occiput when she was 15 years old.

By most accounts, Stephanie’s CST experience was indeed a moment of wonder for her as well as for her treating therapist, the other students and me. However, when we study the anatomy involved, we begin to trace the effects of Stephanie’s experience—this “seed of science,” as Ralph Waldo Emerson so elegantly put in prose.

It is possible that Stephanie’s trauma at age 15 created changes in the positioning of her cranial bones that finally resulted in altering the function of cranial nerve VIII, the vestibulocochlear nerve, traveling through the temporal bone that articulates with the occiput. The 10-Step Protocol addressed the bones attaching to the dura mater providing a general release of the cranium. Then the shorter version of treatment addressed the sphenobasilar joint and tentorium more specifically. This was enough to release restrictions contributing to the malfunctioning of CN VIII.

In this case, traditional medicine, despite “best practices,” was not successful.22 Taking the time to listen to the tissue through our hands and to learn how they were expressing the adaptations and results of this particular trauma yielded a positive outcome.

Research continues

CST is not a remedy for all hearing loss. However, when CST is applied while the practitioner adheres to the core principle of listening to the body and treating what he/she finds, positive change is possible.23,24 Sometimes the outcomes result in wonder or astonishment as to the potential of this gentle yet specific therapy.25 These “working wonders” are the impetus for more research into how this holistic therapy can contribute to the practice of modern medicine while honoring the uniqueness of each individual.26,27,28,29,30,31,32,33,34,35

The wonder of the “seeds” of case reports are establishing “roots” into more refined scientific data to allow for more individuals to benefit from CST.36,37,38 These evidence-based efforts help us as physical therapists to bring even more hope and healing to our patients who rely on our expertise to improve function.

For further information on research and classes in your area, please visit

Last revised: October 17, 2013
by Mariann Sisco PT, CST-D


1) Wirth-Purtillo V, Hayes KW. Interrater reliability of craniosacral rate measurement and their relationship with subjects and examiners heart and respiratory rate measurements. Physical Therapy. 1994; 74(10):908-16.
2) Rogers JS, Witt PL, Gross MT, Hacke JD, Genova PA. Simultaneous palpation of craniosacral rate at the head and feet: intrarater and interrater reliability and rate comparisons. Physical Therapy. 1999 78(11): 1175-85.
3) Moran RW, Gibbons P. Intraexaminer and interexaminer reliability for palpation of cranial rhythmic impulse the head and sacrum. Journal of Manipulative and Physiological Therapeutics. 2001; 27(3):183-90.
4) Hanten WP, Dawson DD, Iwata M, Seiden M, Whitten FG, Zink T. Craniosacral rhythm: reliability and relationships with cardiac and respirator rates. Journal ofOrthopedic and Sports Physical Therapy. 1998; 27(3):213-8.
5); Video; Beyond the Dura 2012 Conference: Exploring the Future of CST Research Panel Parts 1-2.
6) Upledger Institute: Registration. 11211 Prosperity Farms Rd. Palm Beach Gardens, FL 33410
8) Upledger Institute(ED) Working Wonders Case Studies from Practitioners of CranioSacral Therapy. North Atlantic Books, Berkeley, CA; 2005.
9) Merriam Webster:
10) McCutcheon, Marc (Ed) Rogets Super Thesaurus 2nd Ed. Writer’s Digest Books, Cincinnati, OH; 1998.
11) Ibid
12) CranioSacral Therapy 1 Study Guide. Upledger International, Palm Beach Gardens, FL, 1987.
13) Upledger JE, Vredevoogd JD. CranioSacral Therapy. Eastland Press, Seattle, WA; 1983.
14) Paoletti, S. The Fasciae. Eastland Press, Seattle, WA; 2006.
15) Ibid
16) CyberPT University; PT Related Articles/Manual Therapy: Sisco M. CranioSacral Therapy…What is it Really? 2012 June 20.
17) Barral JP, Crobier A. Manual Therapy for the Peripheral Nerves. Churchill Livingstone Elsevier Philadelphia, PA; 2007.
18) Still AT. Autobiography of A.T. Still. 1897.
19) Barral JP, Crobier A. Manual Therapy for the Peripheral Nerves. Churchill Livingstone Elsevier Philadelphia, PA; 2007.
20) Barral JP, Crobier A. Trauma: An Osteopathic Approach. Eastland Press, Seattle, WA; 1999.
21) Upledger Institute: Prosperity Farms Rd. Palm Beach Gardens, FL 33410
22) Wikipedia:
23) Course Notes: CST 2 Aug 1987; The Brain Speaks Feb 2001, Beyond the Dura Apr 2001.
24) Barral JP, Crobier A. Manual Therapy for the Peripheral Nerves. Churchill Livingstone Elsevier Philadelphia, PA; 2007.
25) Upledger Institute(ED) Working Wonders Case Studies from Practitioners of CranioSacral Therapy. North Atlantic Books, Berkeley, CA; 2005.
26) Raviv G, Shefi S, Nizani D, Achiron A. Effect of craniosacral therapy on lower urinary tract signs and symptoms in multiple sclerosis, Complement Ther Clin Pract. 2009; May; 15(2):72-75. EPub 2009 Jan 30.
27) Castro-Sanchez AM, Mataran-Penarrocha GA, Sanchez-Labraca N, Quesada-Rubio JM, Granero-Molina J, Moreno-Lorenzo C. A randomized controlled trial investigating the effects of craniosacral therapy on pain and heart rate variability in fibromyalgia patients. Clin Rehabil. 2011; Jan 25(1):25-35. EPub 2010 Aug 11.
28) Mataran-Penarrocha GA, Castro-Sanchez AM, Garcia GC, Moreno-Lorenzo C, Carreno TP, Zafra MD. Influence of craniosacral therapy on anxiety, depression and quality of life in patients with fibromyalgia. Evid Based Complement Alternat Med.2009; Sept 3. [Epub ahead of print]
29) Geldschlager S: Osteopathic versus orthopedic treatments for chronic epicndylaropathis humeri radialis: a randomized controlled trial. Forsch Komplementarmed Klass Natuheilkd. 2004; Apr; 11(2):93-7.
30) Mehl-Madrona L, Kligler B, Siverman S, Kynton H, Merrell W. The impact of acupuncture and craniosacral therapy interventions on clinical outcomes in adults with asthma. Explore (NY) 2007; Jan-Feb; 3(1):28-36.
31) Gerdner LA, Hart LK, Zimmerman MB. Craniosacral therapy stillpoint technique: exploring its effects in individuals with dementia. J Gerontol Nurs 2008; Mar:34(3):36-35.
32) Harrison RE, Page JS. Multipractitioner Upledger CranioSacral Therapy: descriptive outcome study 2007-2008. J Altern Complement Med. 2011; Jan;17(1):13-17. Epub 2011 Jan 9.
33) Nourbakhsh MR, Fearon FJ. The effect of oscillating energy manual therapy on lateral epicondylitis: a randomized, placebo-control, double-blinded study. J Hand Ther. 2008; Jan-March; 21(1):4-13.
34) Curtis P, Gaylord SA, Park J, Faurot KR, Coble R, Suchindran C, Coeytaux RR, Wilkinson, L, Mann JD. Credibility of low-strength static magnet therapy as an attention control intervention for a randomized controlled study of CranioSacral Therapy for migraine headaches. J Alter Complement Med. 2011; Aug; 17(8):711-21. Epub 2-11 Jul6.
35) Arnodottir TS, Sigurdardottir AK. Is craniosacral therapy effective for migraine? Tested with HIT-6 Questionnaire. Complement Ther Clin Pract. 2013; Feb; 19(1):11-4.
36) Amir, MA, Mohammad R, Nourbakhsh MR. The effects of cranial manual therapy and myofascial release technique on somatic tinnitus in individuals without otic pathology: two case reports with one year follow up.
37) Kramp ME, Combined manual therapy techniques for the treatment of women with infertility: a case series. J AmOsteopath Assoc. 2012; 112(10):680-685.
38) Kwan CS, Worrilow CC, Koevelman I, Kuklinski JM. Using suboccipital release to control singultus: a unique, safe and effective treatment. Am J Emerg Med. 2012 Mar; 30(3):514.e5-514.e7.

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