Using CSR to Direct Treatment

Using the Craniosacral Rhythm to direct treatment and measure recovery

The Upledger CS 1 classes introduce the concept of measuring the craniosacral rhythm and describing its qualities, yet I find that very few practitioners ever actually do this. Measuring the rhythm can help direct therapy to the most significant areas improving the effectiveness of the first treatment. Telling the client your findings helps them develop confidence in the process of craniosacral therapy.


Normal Rhythm

I start this discussion with a description of a normal rhythm because the variation from normal is what indicates generally where treatment is most needed. My experience is that problems with the flexion phase of the rhythm usually involve the viscera and problems with the extension phase usually correlate with spine and skull restrictions. 

The literature states that the cranial rhythm can have a wide range that is considered normal. John Upledger, DO and Jon Vredevoogd in Craniosacral Therapy(Seattle, Eastland Press, 1983) describe it as 6 to 12 cycles per minute. This is based on original research they conducted at Michigan State University. They cite Dr. E A Bunt, MD of South Africa who measured a pulse in the cerebral ventricles at 6 cycles per minute in a normal patient using x-ray tomography. Other sources, such as Dr. Franklyn Sills, DO for example, have a different range. Dr. Sills in Craniosacral Biodynamics (Berkeley, North Atlantic Books, 2001) calls it the cranial rhythmic impulse (CRI) and describes it as being the result of some combination of genetics and conditioning life experiences. So the CRI is said to be at a variable rate of 8 – 14 cycles per minute. Other authors have still other rates for the rhythm. 

If the craniosacral rhythm (CSR) as described in the texts actually involves the circulation of cerebrospinal fluid, and it is palpated with the techniques taught by Dr. Upledger, then a normal cranial rhythm should not be so elusive to describe. I believe that the lack of a clearly defined CSR keeps craniosacral therapy from being accepted by other healthcare professions. The CSR should be like a pulse, something any trained practitioner can palpate and use to assess a patient’s health status. 

I find that trying to calculate the number of cycles per minute while palpating the CSR is quite difficult and usually involves inaccurate fractions. Thus I have adopted the more pragmatic terminology of seconds per cycle as this is readily measured by counting ticks of a clock while palpating a patient. New patients arrive with a wide range of CSR rates and have a number of symptoms, but after treatment the CSR seems to gravitate to a rate that is 10 seconds per cycle with a strong symmetrical range of motion. From observing and documenting CSR in thousands of patients over 25 years of practice, I find that a healthy CSR is actually a remarkably narrow range of 10 seconds per cycle with a variability of +/- 0.5 second. I have documented about 35,000 patient visits and of those I can only recall 5 adult patients that did not resolve to a 10 second cycle. (Infants and young children usually have a slightly faster rhythm of about 8 to 9 seconds for a cycle, but this only lasts until they are about 5-6 years old.) These numbers agree very well with Dr. Bunt’s work.

In the Upledger Institute manuals the acronym SQAR is introduced. The acronym stands for: symmetry, quality, amplitude, and rate; all are ways to quantify the CSR. I find that the more valuable order of these parameters is: rate, amplitude, symmetry, and quality. RASQ, however, is not as easy a mnemonic device unfortunately. By measuring the CSR in some detail noting especially any asymmetry in flexion and extension and from right to left one can determine where to begin treating the patient. The CSR also gives the practitioner a guide to determine the progress of treatment as it returns to normal rate and symmetry. 


I put rate first because it is the easiest to measure. It can serve as a marker of a patient’s overall health status. Many new patients come for treatment with CSR rates that are different than normal sometimes by a very large amount. The range I have seen in practice is a CSR as fast as 4-5 seconds per cycle and the slowest has been 40 seconds per cycle. The patients that have rates that differ from normal by more than 3 seconds per cycle (eg less than 7 seconds for a cycle or more than 13 seconds) usually have moderate symptoms. The ones who are 8 seconds or more than normal (18 seconds or longer for a cycle) often have severe symptoms. These patients are relieved to hear that I have found something in them that is significantly different from normal and that can be associated with their symptoms.



Flexion and extension restrictions are some of the first discrepancies for which treatments are taught in the craniosacral therapy materials. My observation is that they tell a lot about which systems are causing the most drag on the craniosacral system of the patient. 


When extension is restricted and altered from the normal it usually feels shortened or jammed. I have even seen a rhythm in which the body did not appear to extend at all, but rather just went back into flexion immediately from neutral. I find that the restriction of extension usually indicates the skeletal system has significant restrictions. I find the most common sites to be the skull, the pelvis and the upper cervical spine. Restoring normal flexibility to sutures or joints that have been jammed or restricted reduces the sense of pressure in the patient and returns the CSR to a normal rate and depth for extension. 


Usually when flexion is altered from its normal healthy range of motion it is elongated. In other words the flexion phase of the CSR will take more time than extension. The amplitude of the motion may feel much larger or there can be a sense of struggle as the rhythm attempts to go through flexion. I have found that when this is the case the restrictions that most affect the CSR are in the viscera. Visceral manipulation of the most restricted organs will cause the CSR to return to a more symmetrical rhythm without ever treating the skull. When there is more than one organ involved the CSR will gradually change as each restriction is removed. Sometimes this will reveal problems with the extension phase that were obscured before. Of course it is possible for patients to have both flexion and extension problems at the same time.


In my practice I localize the visceral strain on the CSR from the occiput.  The method (borrowed from SOT chiropractic) uses the fibers of the trapezius muscle where they insert on the occiput along with the superior rectus capitus oblique muscle as indicators. The trapezius fibers are broken into 6 stripes spanning from the mastoid processes to the central occiput; each stripe is about the width of a finger. The stripes, or fibers function as indicators pointing to fascial restrictions in the viscera at the diaphragm. This system gives the practitioner a quick way to find an organ strain. Once the organ is treated, not only does the CSR return to normal, but also the indicating fiber becomes noticeably less tight and tender. (Great for suboccipital headaches.)


   Left to Right Differences

There can be palpable differences in range of movement between the two sides of the skull. A common cranial distortion is for the temporal bones to rotate relative to each other in what is called a cranial torsion. Often in this situation one mastoid process will be palpated to move in an inferior direction on flexion. This points to a tension or strain in the fascia lower on the same side of the body. Most often it involves the mediastinum, diaphragm and adjacent organs on that side. The temporal torsion is also closely associated with similar torsions in the pelvis and so will be seen in patients with low back symptoms. 

Screening Test

A simple screening exam indicating the need for craniosacral therapy can be derived from the temporal torsion; one mastoid will appear lower than the other when compared with the level of the eyes. 

The sphenoid will drop inferiorly on one side on flexion when there is a restriction affecting the esophagus and posterior throat structures. This is a common finding in cases of gastro-esophageal reflux.


Among patients there can be a significant variation in amplitude of the CSR. Some patients seem to have very quiet, shallow rhythms and others have exaggerated, elongated rhythms. I have not seen any correlation between the amplitude of the overall rhythm and gender or size. I suspect that the amplitude is a product of the general elasticity of the patient’s tissues.



The CSR may exhibit many qualities that are difficult to describe. The texture of the movement can relate to the type of resistance in the tissues at the area of restriction. More often I find my notes trying to describe the force with which the rhythm moves: descriptors such as struggling, surging, forced, pressured come to mind. Occasionally the flexion and extension will be felt to go in different directions from the midline. The bend or wobble can indicate which side of the body is having the most difficulty or point to different problems for each phase.



Asymmetries in CSR can lead the practitioner quickly to areas that need treatment. Flexion problems usually indicate visceral strain. Extension problems are usually skeletal restrictions. Variations in overall rate relate to the patient’s sense of vitality. The change of the rhythm can be quantified and used as a marker of the progress of treatment. Treatment will be more effective in fewer visits as the therapist is better able to identify the crucial elements affecting the rhythm. The informed patient will identify the CSR as another marker of health like pulse and blood pressure.           By Russ W Kalen, DC, CST   August 2013

© Craniosacral Specialists 2013