Tuesday, November 11, 2008

The Compression Triad: A CranioSacral Treatment Construct

By Kailas, LMT, NCTMB, CST, Cert. Ayu. CranioSacral Therapist and Certified Ayurvedic Practitioner in Los Angeles

The Compression Triad is a treatment construct in CranioSacral Therapy which addresses involved lumbosacral, Atlanto-occipital, and sphenobasilar compression. Sequential decompression of these regions can often correct elusive idiopathic and chronic symptoms which are not easily resolved by treating the areas individually.

Due to their complex structural-kinematic and energetic relationships these three regions mirror movement and strain patterns through the craniosacral system, and therefore tension in one area can be a contributing factor to restriction and pain in another.

CranioSacral Therapy provides the Ten Step Protocol, an optimized sequence which treats the entire craniosacral system and its adjuncts through the release of connective tissue, sutural, and osseous structures, throughout the body. The Ten Step Protocol includes decompression the lumbosacral (L5-S1) articulation, followed by the Atlanto-occipital joint, and the sphenobasilar synchondrosis, at the base of the cranium.

Basic Anatomy of the Compression Triad

The Lumbosacral Junction

The sacrum forms a stable platform onto which the lumbar spine intersects the pelvis. This junction possesses a limited range of motion compared with the vertebral column, which it supports. The pivotal junction at L5-S1 absorbs stress from many angles, and is prone to compression, lumbar disc prolapse(1), spondylolisthesis, and spondylosis.

The L5 vertebral body and lumbosacral disc are somewhat wedge-shaped, and contribute to the lordotic curve of the lumbar spine which acts in part as a shock-absorber to compressive forces that would otherwise be transmitted directly to the sacrum and pelvis. The left and right zygapophysial joints and lumbosacral disc are also angled to resist forward slippage.(2)

The lumbosacral junction is considered an ideal center of gravity and a gyroscopic balance(3) for the human body. Compression of this region can impair sacral movement and cause craniosacral system dysfunction by interfering with the movement of the dural tube, which has its caudal osseous attachment at S2, and with the synchronous movement between the sacrum and the occiput.

The largest nerve of the body, the sciatic, emerges from the joined fibers of the lumbar plexus (L4-L5) and sacral plexus (S1-S3), and is most commonly compromised by compression of the nerve roots at the lumbosacral junction.

Energetically, acupuncture meridians Urinary Bladder 26 (Gate of the Source) and Governing Vessel 3 are at the lumbosacral junction. This junction at the 24th vertebra represents the division of heaven and earth.(4)

The Atlanto-occipital Joint

The atlanto-occipital joint is formed between the occiput and the first cervical vertebra, or atlas, and provides flexion and extension of the head. It should be noted that the atlanto-occipital joint is deeply related to the atlantoaxial joint, the primary mechanical structure responsible for rotating the head, and the temporomandibular joint, the hinge on which the mandible moves. These joints influence each other in function as well as dysfunction and compression of the zygapophysial joints of the atlas with the condyles of the occiput can produce a broad range of symptoms.

The atlas is a streamlined, ring-shaped vertebra, lacking a vertebral body and spinous process, upon which the cranium sits. It supports the weight of the cranium through two lateral masses which carry superior and inferior articular facets. Directed bilaterally and caudally from each lateral mass, are elongated transverse processes. The vertebral canal spaciously accommodates the medulla spinalis.

It articulates with the most inferior point of the occiput, the occipital condyles, which are located immediately lateral to the anterior half of the foramen magnum, among numerous significant cervical muscular and membranous attachments including rectus capitis posterior minor which is continuous with the dura, and the dural fibers which are continuous with the cervical fascia. (5)

Energetically, the Window of Sky meridian point Governing Vessel 16 (Wind Palace) is directly behind the atlas. Level with and lateral to GV 16 is Gall Bladder 20 (Wind Pool). This region is also regarded as the entry point of spirit into the body, or “shikha” in the yoga system.

The Sphenobasilar Synchondrosis

The first osseous component of craniosacral mechanics is the x-wing-shaped sphenoid bone at the center of the cranium. The posterior region of the body of the sphenoid, the dorsum sellae, slopes caudally, and a portion called the clivus fits into a groove in the anterior articular aspect of the basilar part of the occiput. This synchondrosis bridged with cartilage and ligamentous connective tissue(6) is considered the center of craniosacral flexion and extension.

The fibers of the periosteum of the cranial base, the dural membranes, and the adventitial connective tissue supporting the vertebral venous plexii are all continuous to varying degrees, and swath the entire region. Directly posterior to the sphenobasilar synchondrosis these membranes form a thick attachment around the foramen magnum, where the dural membranes descend through the spine along with the medulla spinalis. 

A multitude of forces deform these membranes, the sphenobasilar synchondrosis, and the cranial base into dysfunctional patterns or relationships, which, in addition to compression, are considered as core pathological models in CranioSacral Therapy.

Perspectives on Compression in CranioSacral Therapy

The inherent continuum of the dural membranes, fascia, and soft connective tissue provides the CranioSacral Therapist with a gestalt model through which craniosacral system dysfunctions and their often obscure symptoms can be evaluated and treated. In this model osseous tissue is regarded as subject to the viscioelastic properties of soft tissue, and mechanical effects produced by fluid dynamics and hydraulic pressure.

Compression of structures or tissues alters these relationships, and can produce pathological conditions throughout the continuum, the forces of which are transmitted to the osseous anchors, sutures, joints, and bones via connective tissue including the dura, and fluid pressure, especially craniosacral fluid.

Palpable changes in the Symmetry, Quality, Amplitude, and Rate (SQUAR) of the craniosacral rhythm, dysfunctions of craniosacral motion, tissue tonus and mobility, and patterns of bioenergy, are all utilized during clinical evaluation and treatment by a CranioSacral Therapist.

The Compression Triad is a robust and open construct that is "clinically significant when the physician is searching for the causes underlying craniosacral system dysfunction. Correction of osseous dysfunction is often temporary. The dysfunction continues to recur until the physician identifies and successfully treats the cause of abnormal soft tissue or dural membrane tensions.” (7)

Evaluation and Treatment Using the Compression Triad

A CranioSacral Therapist should therefore first evaluate the craniosacral rhythm and using the Ten Step Protocol, release soft tissues and mobilize osseous structures, until they can accurately evaluate the cranial base for compression. Dr. Upledger states, “Always look for cranial base compression, no matter what the patient’s complaint nor how unlikely it may seem that the clinical symptom or syndrome could be etiologically related to cranial base compression.” (8)
While the Compression Triad explicitly treats anteroposterior impaction of the sphenobasilar synchondrosis, it implicitly includes compression of any osseous, sutural, or meningeal structures in any direction within the cranial base.(9) The Ten Step Protocol includes decompression and balance of the bones, falx, and tentoria via sphenoidal, temporal, and frontal bone decompression.

The CranioSacral Therapist evaluates compression of the sphenobasilar synchondrosis via the two-phase sphenoidal compression-decompression technique using the third vault hold. During the compression phase of the technique, any existing lesions are exaggerated and will induce transient motion, which in some cases will self-correct these lesions.

During the decompression phase, the sphenoid is tractioned anteriorly until the occiput settles caudally into the therapist’s hand. If it does not settle easily, the sphenobasilar synchondrosis may be fused compressed or the tentoria may be restricted, and the evaluation is repeated until the therapist determines if a anteroposterior compression lesion exists, and completes treatment of it through the decompression phase of the technique.

Decompression of the sphenobasilar synchondrosis and cranial base improves craniosacral system motion, reciprocal membrane balance, brain movement, nerve function, and fluid exchange within the cranium. It has been shown to directly alleviate emotional imbalances such as idiopathic endogenous depression, reduce childhood hyperkinesis, and help overcome childhood learning disabilities in addition to promoting reciprocal decompression throughout the Triad of Compression.
Sphenobasilar compression may be caused by direct trauma to the head, birth trauma and forceps delivery, lumbosacral compression, meningeal inflammation and tension, and other factors.

The atlanto-occipital joint is evaluated and treated simultaneously through a two-phase technique, in the Ten Step Protocol, during the steps for diaphragm release. The therapist sitting at the head of the supine client, places the palmar surfaces of their cupped hands beneath the occiput, and with fingertips placed caudal to the inferior nuchal line, palpates the altanto-occipital joint through the covering of muscular and other soft tissue.(10) The fingers are raised perpendicular to the treatment table, so the fingertips become a fulcrum directly behind the atlas. The weight of the client’s head causes the tissues to soften, and the atlas to distract anteriorly.

The second phase of the technique involves shifting focus to the occipital condyles once the atlas is free, and encouraging the spreading of the condyles. This technique should only be performed after the thoracic inlet diaphragm release to ensure venous drainage from the cranium is not restricted as backpressure may cause a headache. At the conclusion of the technique, the therapist gently removes their hands and the client’s head is returned to the table.

Decompression of the atlanto-occipital joint releases the zygapophysial facets of the atlas, occipital condyles, basioociput, and foramen magnum from compressive caudal traction onto the vertebral column caused by dural tension, or muscular hypertonus. Compression is caused by the weight of the head, poor posture, trauma, lumbosacral compression, and other forces. Increased freedom of cervical motion, release of adaptive muscular hypertrophy, improved circulation, and the release of impinged nerve roots are some positive effects of atlanto-occipital decompression, in addition to promoting reciprocal decompression throughout the Triad of Compression.

One cannot overestimate the importance of a flexible and mobile occiput to fluid exchange at the confluence of the sinuses at the internal occipital protuberance, the vertebral and basilar artery, or at the jugular foramena, through which the jugular vein passes. In addition to the jugular vein, the glossopharyngeal, vagus, and accessory cranial nerves traverse these foramena.

The lumbosacral junction is one of the first places therapists evaluate for compression and osseous mobility when a client presents with low back pain, sciatica, or if the client has been diagnosed with scoliosis, spondylolysthesis, spondylosis, herniated or prolapsed intervertebral discs, trauma, postural or gait problems.

However, according to the gestalt view underlying the Compression Triad and CranioSacral Therapy in general, these complaints may be symptomatic of compression anywhere in the craniosacral system, and have referring effects throughout the body. Therefore these complaints should be treated via the entire body.

To evaluate and treat compression at L5-S1, the therapist sits at the supine client’s side, and places one hand with permission between and beneath the client’s lower extremities, cupping the sacrum in their relaxed palm, with the tips of the fingers contacting the sacral base. The other hand is placed beneath the lumbosacral junction with the fingers stabilizing L5. Light caudal traction is applied to the sacrum. When the dural tube and lumbosacral joint decompress, the sacrum will float caudally.

In the Ten Step Protocol, the CranioSacral Therapist evaluates and treats compression of the lumbosacral junction after releasing the transverse diaphragms and before treating the pelvis and dural tube. It must be emphasized that the mobility of the dural tube is central to success in the treatment of compression via the Triad of Compression construct.

The Dural Tube and the Compression Triad

Between the lumbosacral and atlanto-occipital joints, the forces and effects of compression and their referred effects in other connective tissue can be pinpointed through the evaluation of the mobility of the dural tube.

Restrictions in dural tube mobility will reinforce dysfunctions in the Triad of Compression, and via the “memory” inherent in the viscous-elastic nature of connective tissue, will cause temporarily freed osseous structures to re-compress.

The dural tube can be evaluated during treatment to ensure there are no remaining restrictions by applying gentle palpatory traction from the occiput or sacrum. The rule of thumb is that if the osseous structure begins to release, but a feeling of elasticity remains in its movement, instead of a free-floating quality, there is a viscous-elastic restriction and the connective tissue must be treated until the restriction has been completely released.

Summary of Indications for Treatment of Compression

The client’s complaint and/or diagnosed conditions which lead to evaluation for compression and subsequent treatment include:

- Joint and back pain, compression, and restriction of movement

- Degenerative diseases of the vertebrae and intervertebral disks

- Idiopathic Endogenous Depression

- Childhood hyperkinesis, autism, behavioral, or learning disabilities

- Direct trauma

- Birth trauma and forceps delivery

- Meningeal inflammation, headaches, and tension

- Psychogenic emotional trauma

- Paresthesia

- Postural and gait problems

- Weakening and atrophy of soft tissues

- Fatigue and energy problems

- Breathing problems including reduced air intake

- Hypertrophy of muscle and soft tissue

- Tingling, tinnitus, and related effects of nerve root compression

- Restricted dural tube mobility

In addition to the client’s complaint, indications for treatment of compression lesions are known to the therapist during the sequence of evaluations in the Ten Step Protocol or through whole body evaluation methods such as arcing, fascial glide, facilitated segments, and via the client’s Inner Physician.

The CranioSacral Therapist must keep an open mind, because the cause of craniosacral system compression dysfunctions may “ultimately be found in the abdominal cavity, in an extremity or elsewhere in the patient. We cannot and should not attempt to limit the scope of our investigation to the confines of the craniosacral system alone.(11)


1 Spinal Cord Diseases. Engler, Gordon L.; Cole, Jonathan; Merton, William Louis. Informa Health Care, 1998. Page 554.

2 Clinical Anatomy of the Lumbar Spine and Sacrum. Bogduk, Niolai and Endres, Stephen M. Elsevier Health Sciences, 2005.

3 http://www.chiroweb.com/mpacms/dc/article.php?id=37500

4 Jung and Yoga: The Psyche-Body Connection. Harris, Judith. Inner City Books, 2000.

5 Cranial Manipulation Theory and Practice. Chaitlow, Leon. Elsevier Health Sciences. 1999. Page 112.

6 Osteopathy. Parsons, Jon, and Marcer, Nicholas. Elsevier Health Sciences. 2005. Page 202.

7  Upledger, John E., and Vredevoogd, Jon D., CranioSacral Therapy, Eastland Press, 1983. Page 96.

8 Ibid., at 122.

9 Ibid.

10 Alternately, the atlas can be palpated through its transverse process, located about 1 cm. below and in front of the apex of the mastoid process. It is essential that the atlas, and not the axis is targeted via this technique. Due to the extensive soft tissue covering the joint, this can sometimes be difficult. See Gray’s Anatomy at


11 Upledger, John E., and Vredevoogd, Jon D., CranioSacral Therapy, Eastland Press, 1983. Page 96.