??? Conversations with an Osteopath

[byronselorme]

I have been in some discussions with a local Osteopath. He is an interesting fellow and I get confused about where he is coming from quite frequently. He seems to discourse quite a bit about scientific credibility. But I get the sense that he actually doesn't really believe in science. He hasn't said so directly.

A recent conversation I have had with him has left me a bit confused. I don't know whether it is me who isn't explaining things clearly or him who is changing the conversation.

Maybe some of you here can help me correct my language or understanding or point out if he is misdirecting.

Byron: In regards to our discussion about what can be felt in the body with the hands;
Have a read through this article here: http://www.somasimple.com/forums/showthread.php?t=3886.
Jason Silvernail is a pretty darn good writer on these types of topics.
While he doesn't specifically go into detail about hands, I think his points on inter and intra -rater reliability are cogent.
I find the fact that he is challenging his own profession for which he has devoted many hours and dollars to become credentialed in gives his points some extra power.

I have to do more digging to find some points on the exact point I was making.

Osteo: That was a good post by Jason. I think he is absolutely right about interrater reliability. There seem to be studies around regarding chiropractic evaluation of the spine, showing poor interrater reliability. But I haven't had a chence to read the studies so I can't comment on the methodology.

There is a need for osteopathic palpation studies. Actually I am planning for my thesis - considering an interrater reliability study with regards to diagnosing lesions within a bone.

Honestly I don't know what the study will show. Maybe that no one agrees what a bony lesion feels like in osteopathy. That would be a kick in the pants. Or maybe it would show that they identify them reliably. We'll see in a couple of years if I can get the study approved.

Either way it will be good to know.

Byron: You are so right that it is good to know.
The sooner we can focus on the things that are effective and reliable the better.
The really painful thing I have noticed, I'm sure you have to, is how long some groups or organizations hold on to expired ideas, just can't let them go.
I try to look at Yoga the hardest because it is where I am the most likely to deceive myself.

Osteo: Food for thought, if you want to go all the way in the direction of effective and reliable, why not stay away from therapy altogether and just stick with pain medications?

Medications are easy to study, provide a list of effects and side effects that can be measured, and are capable of eliminating pain and inflammation more quickly than any type of therapy.

What's the point of debating about the most effective and reliable therapy when prescription medications are the most effective and reliable of all?

The drug companies beat you to this argument decades ago, they have a lock on it!

Here's how I see it. You can either have a recipe treatment, the same for everyone (drugs) and have lots of research behind it. OR you can have treatments tailored to each patient's physiology and individual case (manual therapy) that does not stand up to randomized double-blind placebo controlled studies, because as soon as you turn manual therapy into standardized treatments, they don't seem to work.

But you can't have both! I don't yet know of a recipe book therapy that is applied the same way to everyone, stops pain and proves statistically significant in randomized double-blind placebo controlled studies (p less than or equal to 0.05).

If you want reliable, take a pill!

Byron:
Hmmm. Wouldn't you say that exercise is effective and reliable? That everyone gains benefit from it's application?
I think that would challenge your statement of "If you want reliable, take a pill!". Of course it may not resolve issues but it does improve outcomes.



To be sure, medication is mostly short term, reliable and effective treatment in many cases, but I would also say that it has to be tailored as well. Being tailored does not mean that you can't evaluate effectiveness and reliability. With manual therapy, the question is who is going to benefit from this? At this point there is not a great deal of screening available so it does seem like a bit of poking around in the dark. But does that mean we should not consider it possible even? I also like to remember that medication has afforded a great increase in lifespan, despite the villianizing it regularly gets. But lots of drawbacks and risks as well. Like you put so well in your comments on vaccinations.



You are right that RCT's don't evaluate manual therapy very well.


I think we know by now that pain is a complex, many faceted thing. Complicated by biopsychosocial factors. This you also covered well when you mentioned evaluating the whole person emotional, spiritual etc. This is also very relevant in the application of Yoga as a therapy.

But we do still learn about ineffective and unreliable treatments. As you mentioned also below about chiropractic adjustments, or more specifically High Velocity Low Amplitude (HVLA) manipulations have been problematic. There is some research starting to point to certain populations (which are identified through a screening process) that benefit from this. The rest just don't fair well. If the screening were not developed it would seem like hit or miss with each person as to whether it was effective or not.


"What's the point of debating about the most effective and reliable therapy when prescription medications are the most effective and reliable of all? "
I wouldn't say that they have resolved the source of the problem, so I guess our definitions of effective are not in alignment.

"I don't yet know of a recipe book therapy that is applied the same way to everyone, stops pain and proves statistically significant in randomized double-blind placebo controlled studies (p less than or equal to 0.05)."

Can't argue with you there. Maybe we never will. But ineffective therapy can be identified and eliminated.
Good food for thought. Thank you!

Osteo: From your previous email:

>>There is some research starting to point to certain populations (which are identified through a screening process) that benefit from this. The rest just don't fair well. If the screening were not developed it would seem like hit or miss with each person as to whether it was effective or not.


I think you absolutely nailed it with this statement. If the population is properly screened, results are statistically significant. With this statement, you are actually making my argument for me.

You have just captured the essence of manual therapy. Find the people who actually need the techniques you do, and do them. If their physiology is sufficiently deviated from "normal" you have a chance at a measurable outcome.

I mentioned that I thought you put too much faith in statistical significance supporting your choice of therapy, I actually believe that more than ever at the moment, for the following reason: in order to have statistical significance you need one of two conditions, either a very large sample size to demonstrate a small treatment effect, or a very large treatment effect with a small population.

Of course to increase the power, you would have a large treatment effect on a large population, but then one of the two factors will be overkill.

Then all you need is the statistician to apply the right statistical algorithm to show significance when applied to your data.

The advantage drug companies have is they can more easily achieve a large sample size due to a standardized application of the medication and a deep pool of financial resources. So they only need to demonstrate a relatively small effect to have supporting research published in the literature.

Therapists doing research bend over backwards to identify a sample size of 24 subjects. Then they spend 1 to 3 years of their lives (at least at the CCO) working on these subjects at no charge, with whatever valid measuring tool they could afford.

So a required element of any RCT therapy study is a very large, consistent treatment effect across a small pool of subjects, since a large sample size is simply not realistic for such a clinical trial.


So where does that leave us? The general public has to try different therapies on their own, and see if they work for them specifically. Then they make an informed decision to continue or discontinue.

The proof is in the pudding Byron! If a therapist is not helping anyone, they will not be a therapist for very long. If a therapist is gainfully employed as a chiropractor, or osteopath or physiotherapist or athletic therapist (for example), they must be doing something right.

I like to ask people the question, do you think millions of people are all crazy and you're the only sane one, or the other way around?

There are probably occasions when it's the former. But I am always wary of people who think they know some secret that the whole world is ignorant about. Most of the time the collective wisdom of the population is more valuable that one person's opinion. At least I think so.

Any thoughts would be appreciated.

[Bas Asselbergs]

Byron, you are not wrong. He or she has a bit of understanding of part of the scientific process.

So where does that leave us? The general public has to try different therapies on their own, and see if they work for them specifically. Then they make an informed decision to continue or discontinue.

The proof is in the pudding Byron! If a therapist is not helping anyone, they will not be a therapist for very long. If a therapist is gainfully employed as a chiropractor, or osteopath or physiotherapist or athletic therapist (for example), they must be doing something right.

I like to ask people the question, do you think millions of people are all crazy and you're the only sane one, or the other way around?

There are probably occasions when it's the former. But I am always wary of people who think they know some secret that the whole world is ignorant about. Most of the time the collective wisdom of the population is more valuable that one person's opinion. At least I think so.

The bolds are mine.
There is NOT a "single" person who has developed the scientific support for the neuromatrix, the perceptual fallacies of our brains ("I can feel it! I'm sure!"), or the ONE thing humans have in common: the brain.
There is not "one person's opinion" for the neuromatrix model.
There is NO secret: there are financial interests, power-issues, ignorance, misguided ideas etcetera that block the widespread acceptance of a openly known concept and openly published books, articles, research and lectures.

When people are left to their own devices, they will continue to buy into whoever provides the best sales-job: NOT guided by their "common sense". The number of people buying into snake oil kept quite a few hucksters in business. Were they "doing something right"?

[Barrett Dorko]

The proof is in the pudding Byron! If a therapist is not helping anyone, they will not be a therapist for very long. If a therapist is gainfully employed as a chiropractor, or osteopath or physiotherapist or athletic therapist (for example), they must be doing something right.

Total crap.

[byronselorme]

Thanks Bas,

I was going to use John R Brinkley as an example. Pope Brock's book Charlatan tells a great story about popularity and public opinion regarding a particularly sensitive topic in men.

I loved the book.

With my Osteo above. It was the ideas that he had about screening that got me confused (perhaps I used the wrong word). My understanding was that there were types of manipulative therapy that could be useful for a certain population of pt. If they fit a few indicators, there was a better chance for success. That seemed pretty rational to me. He seems to have attempted to use that to hang me with. That was my biggest confusion. That and his comments about statistics and algorithms.

[Jon Newman]

Byron: There is some research starting to point to certain populations (which are identified through a screening process) that benefit from this. The rest just don't fair well. If the screening were not developed it would seem like hit or miss with each person as to whether it was effective or not.


Osteo: I think you absolutely nailed it with this statement. If the population is properly screened, results are statistically significant. With this statement, you are actually making my argument for me.

I think you're correct Byron that you're using the word incorrectly. It would seem the osteopath isn't using it correctly either and doesn't understand what the CPR for manipulation (I'm assuming that this what is being referenced) is telling us. Or maybe I'm the one not understanding. I'd welcome any correction reagarding my past interpretations.

For a start, here is the Wikipedia entry on medical screening. For another source, consider the Educata course mentioned by Cory here.

[byronselorme]

You are the link master Jon. That link of Cory's is excellent.
Screening never felt like the right word, but I am sure there is a right one?

I was searching for Jason's post on RCT's, for some reason I am not having much luck.

[Jon Newman]

Originally Posted by byronselorme

You are the link master Jon. That link of Cory's is excellent.
Screening never felt like the right word, but I am sure there is a right one?

I was searching for Jason's post on RCT's, for some reason I am not having much luck.

If you're referring to the clinical prediction rule then I'd refer to it as a clinical prediction rule. It could also be classified as triage according to the Educata course.

I'm not sure what post of Jason's you're speaking about but his most recent comments on RCTs that I recall are here.

[byronselorme]

If anyone can help me disentangle this argument I would be grateful.

You have just captured the essence of manual therapy. Find the people who actually need the techniques you do, and do them. If their physiology is sufficiently deviated from "normal" you have a chance at a measurable outcome.

I mentioned that I thought you put too much faith in statistical significance supporting your choice of therapy, I actually believe that more than ever at the moment, for the following reason: in order to have statistical significance you need one of two conditions, either a very large sample size to demonstrate a small treatment effect, or a very large treatment effect with a small population.

Of course to increase the power, you would have a large treatment effect on a large population, but then one of the two factors will be overkill.

Then all you need is the statistician to apply the right statistical algorithm to show significance when applied to your data.

The advantage drug companies have is they can more easily achieve a large sample size due to a standardized application of the medication and a deep pool of financial resources. So they only need to demonstrate a relatively small effect to have supporting research published in the literature.

Therapists doing research bend over backwards to identify a sample size of 24 subjects. Then they spend 1 to 3 years of their lives (at least at the CCO) working on these subjects at no charge, with whatever valid measuring tool they could afford.

So a required element of any RCT therapy study is a very large, consistent treatment effect across a small pool of subjects, since a large sample size is simply not realistic for such a clinical trial.

What he is trying to say (I think) is that Evidence Based Medicine is only valid for the pharmaceutical industry and relies on statistics to prove the medication valid. And that Evidence, and more specifically statistics are not a useful way of evaluating whether a manual therapy is valid. You have to use a try and see approach.

I am pretty sure he is way off base here but this issue he has with statistics is kind of confusing.

Any thoughts?

[Diane]

Originally Posted by byronselorme

If anyone can help me disentangle this argument I would be grateful.




What he is trying to say (I think) is that Evidence Based Medicine is only valid for the pharmaceutical industry and relies on statistics to prove the medication valid. And that Evidence, and more specifically statistics are not a useful way of evaluating whether a manual therapy is valid. You have to use a try and see approach.

I am pretty sure he is way off base here but this issue he has with statistics is kind of confusing.

Any thoughts?

Unfortunately, I don't think he is "wrong" about evidence-based thinking. The technicalities he laid out are correct, as far as I know.
What is frustrating is that he (likely) uses that "objectification" to avoid thinking any deeper about what is likely to really be going on with treatment, to avoid having to logically wrestle, to avoid any cuts to himself from his own inner Occam's Razor.
I went there, wrestled for years, got cut a lot, but learned from every cut. My only offering at this point is a reasonably coherent set of ideas. I doubt these will ever be testable in any scientific sense, but if they ever are, I think they'd stand as an argument against any logic inherent within any particular manual therapy notion anywhere along the spectrum, from the most insane "energy" therapy to the most Byzantine heavy joint-based ortho type manual therapy. I call all manual therapy systems "operator models". (Then I go ahead and teach one, but that's another story. At least I've figured out the difference between what sort of therapeutic contact is "operator" and what kind of therapeutic contact is "interactor". I hope. And I hope mine is more interactive than operative.)

Manual therapy and its treatment models

[byronselorme]

Thanks Diane.

I absolutely get what you are saying about that. He has since sent me another email where he is using the analogy of a parent and an infant. The parent being the therapist.

I'll grant that he was trying to emphasize a point but that analogy is completely Operator. I don't think he knows there is a distinction yet so I plan to attempt sorting that out with him.

It is like he is on the edge of getting it, so I am trying not to get caught up in these detail he start losing me in.

I guess my big question is this.

There is Science Based Medicine - which expects a plausible mechanism to support the proposed treatment, and there is Evidence Based Medicine - which expects a certain result when the conditions of the treatment are controlled in a reasonable way to prevent confounding factors from contributing to the effectiveness of the treatment.

Are statistics the only way to evaluate the EBM approach? And if so, is there no useful value in these statistics.

I think Jason wrote about this quite well. It does seem to me that EBM can eliminate a lot of useless ideas that have no plausible SBM behind it.

If I am way off base, or spending too much time in the wrong direction just let me know.

Thanks

[Bas Asselbergs]

Are statistics the only way to evaluate the EBM approach? And if so, is there no useful value in these statistics.

In short: yes. Outcome based research depends on statistics to evaluate the change in parameters.
EBM should be preceeded by SBM - then its value would be more scientific.

[Diane]

Originally Posted by byronselorme

I guess my big question is this.

There is Science Based Medicine - which expects a plausible mechanism to support the proposed treatment, and there is Evidence Based Medicine - which expects a certain result when the conditions of the treatment are controlled in a reasonable way to prevent confounding factors from contributing to the effectiveness of the treatment.

Are statistics the only way to evaluate the EBM approach? And if so, is there no useful value in these statistics.

As far as I know, yes, statistics are the only way to "evaluate" any approach. Statistics = EBM, as far as I know. But, as Harriet Hall points out, this makes EBM tooth-fairy science. You can measure all sorts of outcomes and validate those outcomes, measure whether leaving a tooth in a baggie is better as opposed to leaving it in a kleenex, have the amount of money left be an outcome, but none of all that careful measuring tells you anything at all about whether or not the tooth fairy is a plausible concept to begin with.

[byronselorme]

I absolutely get why SBM is so important. You can see by my signature line "Science Based Yoga Educator" that I take that distinction seriously.

That is why I am getting confused with the Placeholder II thread.

And when Barrett writes about the Jugglers endurance challenge, obviously that is a different type of evidence in which a sample size of n=1 is more than enough.

I believe Jason S has a thread around here somewhere about the need for SBM and EBM to help sort out what is relevant.

So if EBM type statistics show that a particular treatment is not valid or effective or reliable, why shouldn't I accept that if the research is compelling enough or the SBM type of explanation is dodgy enough?

A therapist shouldn't have to keep doing the try it and see approach or use therapies that they believe work.

I feel like I almost have this sorted. Thank you for your help so far.

[amacs]

Hi Byron

if I may interject, EBM can be abused as noted by Diane a la H. Hall. However it is not the same as saying all EBM is of no value, much of it is but there needs to be some recognition of a prior plausible mechanism. EBM can only (indeed much of science) can only work in probabilities so stats become necessary. What the initial post risks is that while it seems to recognizes that this is difficult rather than acknowledging the difficulty the implicit suggestion is that we can get away without bothering. FOr my money that is not acceptable and amounts trying to have your cake (yeah research is valuable) and eat it (it is too hard to apply int the therapeutic setting so we don't bother). I may be doing the writer a disservice or overstating the case they have made. By its nature EBM does try to work deductively from hypothesis to (probable) conclusion. However sometimes science works inductively and quite compellingly e.g. apples fall downward due to gravity.

hope that helps

regards

ANdy

[byronselorme]

ANdy,

That is very helpful and it is what I have been trying to say, although you really got to the heart of what I have been fumbling with.

I get the sense from my discussions with this therapist that they want their cake and eat it to as you say.

When I mentioned effective and reliable I think it was used against me to discredit statistics but where I meant it was, say for example, hand washing before surgery. I realize there are some numbers to crunch but I don't think algorithms were necessary to help illuminate that it was effective and reliable.

I am sure with some digging I could find some more examples like that.

[byronselorme]

Oh and it was not an interjection on your part. I am inviting comments exactly like yours.

[Diane]

What ANdy said.

What sux most about trying to build an EB under manual therapy is that
1. In order to build it, conceptualizations (operator models, with names that came along with them, names that exclude prior plausibility in many cases) must be tested.
2. The names that came along without prior plausibility, and that do NOT gain any, when juxtaposed against neuroscience, get shoehorned into the EB.
3. The names by which MTs recognize their own operator models continue to be based on implausibility, but now they've gained credence by acquiring an EB. They go on to confuse ongoing new generations of MTs.
4. None of this is EB's fault. EB is just a way of creating and organizing data.
5. The sux-factor grows unabated. It's like a central sensitivity that grows instead of abating. It's like runaway chronic pain. It's like the unfortunates who end up with three times more Substance P than normal inside their spinal cord.
6. The manual therapists of all branches of the human primate social grooming family tree including acupuncturists and trigger pointalists, all sore spot pokers/rubbers/stabbers/mobers/releasers/manipers realize this and rub their hands, thinking of all the wonderful things science is doing for them (once someone actually gets around to doing some of it). They'll be able to charge more, still delude everyone with their made-up mesodermal stories, and still ignore neuroscience.

To me, this is the heart of what sux about EB for MT.

[Bas Asselbergs]

Byron, I will fall back on an old example of plausibility trumping EB thinking;
the parachute.

Then there is the second example:
firefighting.

Neither of these require outcome studies, large RCTs or any blinding; their usefulness is blatantly obvious. Within natural laws, just like DNM and SC.

[Jason Silvernail]

Byron perhaps you're looking for this?
http://blog.myphysicaltherapyspace.c...ep-models.html

[byronselorme]

Jason, that was not the article I remember reading by you but I think it is even better.
Sometimes it is so hard to be clear about the question I am trying to ask.
This is exactly what I want to get through to my friend but somehow I keep getting caught up in the sticky flypaper.

Thank you everyone for your help. Absolutely unprecedented awesomeness!!

[byronselorme]

Only because I like the challenge of the impossible, feel that Diane shouldn't have to do this all by herself, and I like to hear feedback from y'all here I continue with my friend.
If I am off base on any of my comments I would appreciate course correction.

Out of interest he is developing a thesis on Manual Therapy for Asthma.

Hi Byron,

I’ve attached an article from the publication “Pain”. I haven’t had a chance to read it yet but it showed up as one of the 25 hottest articles in the health field on Elsevier, I figured I’d grab it and send it along.

What a weekend! About 20 hours of searching articles and I’m back at it this morning. Got about 150 that may be relevant to my thesis, but it is a barren wasteland searching for quality (published) RCT’s in the field of Osteopathy.

What a learning experience. How little we know about the specific effects of complementary medicine. I have attached another article from the publication “Chest”. I think this physician from the UK captures the questions around it really well.

What is the general public so happy about with CAM if we can’t seem to capture the specific effects by experimentation? It is certainly due to placebo to some extent, but we don’t know exactly what percentage that might be. It is certainly due to the therapeutic relationship to some extent, but again how much does that account for?

Ernst makes one very excellent point:

“We should, however, remember that absence of evidence must never be confused with evidence of absence for efficacy.”


One thing is for sure, the research in the field of Osteopathy is still in its infancy. Although it has been happening for over 100 years, the vast majority does not meet the standards for peer review and publication. The thesis writers at the CCO will typically fail to prove a specific effect, although usually there are one or two graduates each year who find statistical significance.

I think Ernst has a good point, even if there is a significant placebo effect, that would still be useful in the field of medicine if at least we understood it a bit better.

It is frustrating for someone like myself because these techniques are so exciting in clinic and so disappointing on PubMed. I am only starting to get a glimpse at the disconnect, but there is an “X” factor that we do not understand at this point.

I know you have some theories! I have seen some chiropractic research where the treatment protocol AND the sham protocol both outperformed the control group with asthma. You could draw the conclusion that the fact that the patient has an appointment at your office is more important than the techniques that were performed (non-specific effects). But we still don’t know yet, there needs to be research on that topic as well.

I think a huge part of healing is the patient’s intention to get well. Appointments with any sort of health provider would keep them focused on that intention. Maybe the real importance of the appointments is what it represents to the patient – their intention to get better. Their therapist is their support group for that endeavour, in a sense.

We have to keep in mind, even conventional medicine doesn’t heal a patient. In the end, the patient has to heal the patient. Even surgery and medication do not cure, they simply alter or remove some factor that is keeping the patient from healing themselves. In the end the patient has to do the healing.

Have you seen the study about the results of placebo surgery on the knee versus the actual debridement? How much of conventional medicine is actually placebo? Certainly there is a percentage there as well, even with surgery! I have attached that article as well. From the author:

“This study has also shown the great potential for a placebo effect with surgery, although it is unclear whether this effect is due solely to the natural history of the condition or whether there is some independent effect.”

I am starting to think that many of the effects of medicine is placebo, whether conventional or complementary. The white coat effect seems to do much more than spike someone’s blood pressure at the doctor’s office, if the Moseley et al study tells us anything.

So, is getting people better an art or a science? I think we’re kidding ourselves if we think there is a purely scientific approach to helping people heal. I think the CAM practitioners are more art than science at this point, but they are slowly coming into their own and doing more legitimate research. It will certainly take time from what I’m seeing.

Always interesting!

Reply from me

Thanks for the articles!



I'm so glad you mentioned Ernst. I have enormous respect for him. Here is a Dr who took the time and went through the expense of studying Homeopathy so that he could use it. Having invested such a precious resource it would have been very easy for him to live with the cognitive dissonance and ignore the evidence. But he didn't. He has even become a champion of skeptical inquiry (his book with Simon Singh "Trick or Treatment" is a valuable resource).


I note that the paper of his that you mention is some 13 years old. You should look at what he has been up to lately. In particular he recants the very line that you take of his earlier just yesterday http://blogs.bmj.com/bmj/2012/03/19/...ce-of-absence/

Now I ask you, how often does that happen.

Or here: http://en.wikipedia.org/wiki/Edzard_Ernst
"In a 2008 interview with Media Life Magazine, when Ernst and Simon Singh were asked this question -- "What do you think the future is for alternative medicine?" -- they replied:

For us, there is no such thing as alternative medicine. There is either medicine that is effective or not, medicine that is safe or not. So-called alternative therapies need to be assessed and then classified as good medicines or bogus medicines. Hopefully, in the future, the good medicines will be embraced within conventional medicine and the bogus medicines will be abandoned.[16]"

I have seen the knee debridement study. There is an even crazier one that involved heart surgery in 1959 http://en.wikipedia.org/wiki/Sham_surgery. Imagine the ethical implications of that today.

Regarding placebo. As I understand it, any therapeutic relationship (patient and practitioner) cannot avoid having a placebo / nocebo component. The nocebo is an important one to view as well. I think that the biopsychosocial approach is going to gain more favour as time goes on. What the practitioner says, how they present themselves, the treatment room etc.. all play a factor. With no one factor being the only important one.

I agree with you about the art of the patient relationship. Therapists of all kinds spend years improving and perfecting that. I might argue with you that science is a way of validating improving what you know. A basis or foundation for using or improving what you do. As such I don't think that is at odds with the art. Kind of like science improved the materials, manufacturing, reliability of pianos and science helped understand why some notes evoke certain emotions but Beethoven used those to create his Sonata's. Even cooler is that because of the science of musical notation we can hear and enjoy these pieces today, centuries after he is gone.

"I think a huge part of healing is the patient’s intention to get well" - I also think a statement like this is a bit dangerous. Most people want this and a thought like this could lead to blaming the patient which is a really nasty side of the therapeutic relationship.

Keep going, I think there is a great place for Osteopathy, just without the CST and visceral manipulations.

It is always interesting.

his reply

Thank you for the reply! Great stuff.

If only I had the words to describe the use of cranial and visceral techniques. They are already getting results and I have only scratched the surface. You're obviously not a fan, but that's ok. Osteopathy without visceral or CST already exists, it's chiropractic!

I know you're never going to believe me about the potential that exists for palpation development, but every day my hands are showing me more of the story. Had my hand on the sternum of someone 3 months post cardiac arrest and CPR yesterday, very cool. The thought that the palpation could all be my imagination is so far in the rearview mirror at this point it's not even relevant anymore.

But I understand the critique. 10 years ago I would never have believed a word I am saying either. I get where you're coming from. It will never make sense unless you actually enroll in the program and study it. Without actual experience it's all speculation.

It's all good my friend. Osteo can't fix everything, and it's not for everyone. But the version of osteopathy that you are picturing is not osteopathy.

Thanks Byron! Keep 'em coming!

[Bas Asselbergs]

Byron, you need more patience than I have.....
"I only scratched the surface" - if only he knew how correct that assessment of his manual therapy is. He worked on the skin and thinks he is treating organs....because patients "are already getting results".

The chasm is still wide.

[Diane]

Originally Posted by Bas Asselbergs

The chasm is still wide.

And he fills it with equal parts perceptual fantasy and conceptual hallucination.

[Jason Silvernail]

I would say he's pretty far from speaking for the US Osteopathic community. My limited conversations and experience with my DO colleagues in the Army is much different than the picture this gentleman paints. So I think they are as diverse as we are in their outlook, for better or worse.


[From my iPhone, please excuse typing]

[Bas Asselbergs]

Jason, my experience with US osteopaths is that they are vastly different from Canadian and European ones.
US training is much, MUCH closer to MD-level (with added manual and manipulative techniques) and the Canadian and European training, well, it simply isn't.

In Canada the main focus is on cranial, organ and spinal osteopathic techniques for a wide variety of "diagnoses". The assessments are based on the theories that underpin these techniques: testing (palpating mainly) for mal-positioned organs, cranial sutures, spinal/sacral and fascial structures. They are also heavily into "nutritional health and wellness" (naturopathic tendencies).
The modern Canadian DOs can not be called "Doctor", can not prescibe, can not order lab tests or perform injections or internal exams.

A big difference between the US and Canada!

[Frédéric]

Originally Posted by Bas Asselbergs

Jason, my experience with US osteopaths is that they are vastly different from Canadian and European ones.
US training is much, MUCH closer to MD-level (with added manual and manipulative techniques) and the Canadian and European training, well, it simply isn't.

In Canada the main focus is on cranial, organ and spinal osteopathic techniques for a wide variety of "diagnoses". The assessments are based on the theories that underpin these techniques: testing (palpating mainly) for mal-positioned organs, cranial sutures, spinal/sacral and fascial structures. They are also heavily into "nutritional health and wellness" (naturopathic tendencies).
The modern Canadian DOs can not be called "Doctor", can not prescibe, can not order lab tests or perform injections or internal exams.

A big difference between the US and Canada!

And don't have University degrees in Québec and are technicaly violating bill 90 which restrict the act of performing an assessment of an individual with an MSK disorder to physical therapists, MD's, OT's and Chiropractors.

[John W]

My experience is similar to Bas's, with the exception that there are quite a few DO's in Michigan who practice primarily as "manual therapists" out of the Greenman tradition. There's an osteopathic school there, which offers CME that falls into that heavily biomechanical/positional fault model.

Just look at the graphic of that gray-haired guru skillfully guiding the assessment technique of that young DO student!

[byronselorme]

I understood that there was difference between US and Canada on that. I did think that the UK was more like US though?

What really bugs me about the Canadian DO's is their use of "sciencey" words and horribly non scientific practices and training. The Education Facilities are giving people like my friend shovels to dig deep holes with and paper ladders to climb out of the hole.

He had great stories to tell me about his MFR (non Barnesian he assured me) experience.

[John W]

British DO's practice much more like Canadian DO's than MD's. I took a course way back during my residency from a then very internationally well-known DO by the name of Laurie Hartman. He was very adept at cavitating joints. I recall him getting my subtalar joint- or some joint down there below my ankle- to pop.

I was duly impressed at the time. Now, not so much...

[zimney3pt]

Byron,

I thought your Osteo friends comment was interesting:

So, is getting people better an art or a science? I think we’re kidding ourselves if we think there is a purely scientific approach to helping people heal. I think the CAM practitioners are more art than science at this point, but they are slowly coming into their own and doing more legitimate research. It will certainly take time from what I’m seeing.

Just listened to this podcast episode #1 yesterday and liked how he put it, about the PT tag line of "The science of healing and the art of caring". I think we need to be careful not to mix the two. When you say "get people better" we need to define that a little more - there is tissue healing better and "feeling" better. When it comes to healing tissues I think it is absolutely 100% science, when it comes to "feeling" better and caring for someone yes there is art in the relational/social aspects of the interaction.

[Diane]

Bas, US DO's are medical doctors. Everything is the same. Same exams, qualifications, everything, plus the manual training.
In Canada, they are not DO's, just O's. Big difference.

[Frédéric]

Originally Posted by Diane

Bas, US DO's are medical doctors. Everything is the same. Same exams, qualifications, everything, plus the manual training.
In Canada, they are not DO's, just O's. Big difference.

Well, they still call themselves DO for Diploma in Osteopathy... And they are becoming more and more popular instead of less so.

[Diane]

Originally Posted by Frédéric

Well, they still call themselves DO for Diploma in Osteopathy... And they are becoming more and more popular instead of less so.

This will p**s off the US DOs a whole bunch. Having a bunch of Canadian O's using the "DO" acronym, even if it means something totally different/way less blood sweat tears.

It would be like me impersonating "DPT" qualification with my puny little PT diploma from 40+ years ago.

[smith]

I think MD schools have a better reputation. They do less funny things like try to put "ribs back in place."

[byronselorme]

From my Osteo friend.

You asked me once what the prevailing theory is for the cranial rhythm and CSF movement, since you had a theory that it was an ideomotor effect on behalf of the therapist.

Turns out CSF movement is dealt with in Gray's, and they describe two different rhythms which have already been measured. I have attached the section in Gray's, 39th edition.

That's the thing about Osteopathy, the more you study anatomy the more sense it makes. That's a good sign. We were at the McMaster anatomy lab on Thursday, got a chance to hold a lung. Pretty cool.

Here's a question for you. You are not a believer in the value of visceral manipulation through manual therapy. What is your stance on the value of CPR? If someone went into cardiac arrest in your yoga class, would you stand there and say "don't bother trying to pump the heart with your hands, you can't manipulate the organs from the outside", or would you start doing compressions to pump the heart and giving breaths to pump the lungs?
CPR might be the ultimate example of manual visceral manipulation. What's your opinion on it?

Thanks Byron!

Quoted passage from Gray's Anatomy 39th edition, page 294

The movement of CSF in the extra-axial space is complex and is
characterized by a fast-flow component and a much slower bulk-flow
component. During systole, the major arteries lying in the basal cisterns
and other extra-axial intracranial spaces dilate significantly and exert
pressure effects on the CSF, which cause rapid CSF flow around the
brain out of the cranial cavity and into the upper cervical spine. The
pressure wave which causes this outflow of CSF is dispersed through the
spinal CSF space, which acts as a capacitance vessel. As the blood within
the major arteries passes into the brain in late systole and diastole, CSF
re-enters the skull from the spine. This CSF flow occurs at rapid rates
and is repeated during every heart cycle. In addition, there is a slow bulk
flow of CSF, with a time course measured in hours, which results in
circulation of CSF over the cerebral surface in a superolateral direction.
CSF is absorbed into the venous system through arachnoid villi
associated with the major dural venous sinuses, predominantly the
superior sagittal sinus.

My reply

I held a kidney (plastinated) and a heart at body world. That was pretty cool too. I would love to get into the anatomy lab. Very envious indeed.

hmmm, I don't recall saying that CSF didn't move, that the fluid didn't exist, or that there wasn't a cycle.

Let's look at this closer.

From Gray's:
"This CSF flow occurs at rapid rates and is repeated during every heart cycle. In addition, there is a slow bulk flow of CSF, with a time course measured in hours, which results in circulation of CSF over the cerebral surface in a superolateral direction." (emphasis mine)

I think this would imply that the CS Rhythm is governed by the heart beat, with the rest being an incredibly slow movement that seems to indicate it is not really a pulse that could be palpated. Did you find any other driver of the CSR in Gray's? If the heart beat is the main driver why is CSR usually considered as a different rate or am I mistaken about that?

Also, ideomotor movement occurs in the patient and the therapist. So to sources of the movement, both non-conscious. For fun, try (really try) to sense the rhythm in a rock or some other place where it is unreasonable. You have to overcome a lot to be open to checking this. But is has ended a few Osteopaths insistence on the CSR in the past. I am still not saying that there isn't a way to use what you do in a therapeutic way. I think you keep reading that. All I am saying is that when you get the bad explanation out of the way there is some useful decluttering.

As to your second question. I would never perform CPR on a conscious patient. It is a pretty serious intrusion that isn't particularly effective [from wikipedia: "On average, only 5–10% of people who receive CPR survive.[19] "). The Osteo claim that I am refuting is that Visceral manipulation can be performed on any significantly conscious person (that would protect themselves from any pressure that would change the shape of their organs to any large degree) for a therapeutic effect.

Here is an article debating the rationale behind the methodology on Science Based Medicine: http://www.sciencebasedmedicine.org/...ta/#more-18704
Look forward to your response on this.

[Bas Asselbergs]

Byron, I am also sure that ANY osteopath manipulating organs in the style of chest compressions will fail his Barral-certification.....

[Frédéric]

Originally Posted by Bas Asselbergs

Byron, I am also sure that ANY osteopath manipulating organs in the style of chest compressions will fail his Barral-certification.....

Too funny Bas

[byronselorme]

All I can say is ouch. I think I have received a personal attack and that I cannot think for myself. I will have to reflect on this reply

I believe the question you asked previously was "what is the theory for what drives the primary respiratory mechanism?". I mentioned it was due to CSF fluctuation. Then you asked what theory explained the movement of that fluid. Typically Gray's is used as the authoritative text in anatomy, so I figured this might interest you.

Remember awhile back I sent you a peer reviewed study showing the PRM being related to the patient's blood flow measured using a Doppler? Not sure if you had a chance to read it. Gray's discusses two particular CSF rhythms already proven to be related to blood flow. The Doppler study seems to identify at least one other.

I have tried many times to sense the rhythm of inanimate objects. They aren't there. There is nothing that feels like living tissue, in my experience so far. I'm not sure where you are going with that one. It is a night and day difference, I would enjoy having a conversation with any experienced Osteopath who stopped believing in the cranial rhythm because they felt it in in a rock. Can you send me some contact information?

CPR in a conscious person is another red herring. You use these often in your arguments, as I have pointed out in the past. I proposed CPR as a useful tool for someone in cardiac arrest. You counter by arguing that it is not a useful tool for a conscious person. Since cardiac arrest and consciousness are not compatible (basic first aid), this is a red herring, a diversionary tactic. Also, you failed to answer the question as to whether you would perform CPR or not. It was a simple yes or no that you somehow avoided answering.

Here is my honest opinion on your stance on this issue. It is based on zero experience, no post secondary educational background in health care (that I know of). You have some independent reading and involvement in an online forum. If there are credentials behind your opinions, I sincerely apologize. I don't know the full story behind your interest in this topic as of yet.

I have read the link you sent. Very interesting. I am starting to think that the opinions you are expressing are perhaps not a product of independent thought or reflection, but more a product of the skepticism on these posts. The folks you are so fond of referencing are like jackals, it is incredible. They search relentlessly for any weakness to exploit and exclaim to the world "AHA! SEE!!!".

Perhaps I am wrong in my interpretation. But up to this point, your responses have come across as 1)red herrings and 2)references to posts where other authors are says "AHA! SEE!!!". I don't find either one of these strategies very compelling. You are a difficult man to keep on topic.

Here is a question: do you have any opinions of your own, based on your own experiences or formal education? If possible, can you relay them without diversionary tactics or referencing someone else's blog post?

Thank you Byron! This is an interesting thread of conversation for me, I do respect your opinion very highly, but I have some serious questions about where your opinions are coming from. If your opinions have no depth and you are firmly attached to them, it is a problem I may not be able to help you with.

[Barrett Dorko]

Comparing anyone to a jackal is just insulting.

He doesn't know that skepticism is a method, not a position.

No hope.

[Diane]

Yup, no hope. He is using the rankpulling fallacy to try to intimidate, and it is he who is blind to anything but his own opinion, which is mere opinion dressed up as "theory", or in this case, "treatment concept", that he didn't work out for himself but instead bought and paid for under the assumption it was scientific, probably because someone further upstream declared it to be so.

[byronselorme]

Hey, I won't lie. I am looking to earn a Newman. I thought of Jon repeatedly while composing this reply. I hope his influence is apparent,

I reject your claim that I am not thinking for myself and I think that is out of line with the discussion we are having.
Perhaps I offended you with the comment about sensing the rhythm in a rock. Please understand that was not the reason for including that. So lets see if I can break our last conversation down and return it to you and you tell me if I have missed something or have something inaccurate included.

Cranial Sacral Therapy (CST) depends on a Therapist being able to sense the Primary Respiratory Mechanism's (PRM) pulse or rhythm, I think you and others refer to it as the Cranial Sacral Rhythm (CSR). The Therapist carefully waits until they feel this pulse and then applies very small forces (typically under 5 grams) to the Cranium, Sacrum or some other related area for the same basic expected effect. An influence of the CSR.

Also, as I understand it, the CSR is expected to be detectable and distinct from the Cardiac Rhythm or the Respiratory Rhythm. At least from the study you sent that I did read, they indicated a need to differentiate Cardiac and Respiratory Rhythm from CSR. This would indicate to me that there is some other mechanism besides the Heart or Diaphragm that is expected to be influenced by CST. If that is the case, then there must be something else that drives the CSR. Whatever that is I would expect it to be a detectable group of muscles, channels / tubes, or an organ of some kind. Something capable of affecting the Cerebral Spinal Fluid (CSF) over and above the internal pressure of the body from blood pressure changes, gravity etc.

However, if we use the reference from Gray's we see that the effect on the CSF is two fold (I have not seen reference to the third that you mention. Doppler measurement of Blood Flow does not indicate another mechanism as far as I can see) One being directly in response to the Cardiac Rhythm, the other is a much slower upward and outward flow that takes hours so is not really relevant to what CST proposes. If the CSR is affected by CST then why not just use measures from ECG's, blood pressure, Pulse etc to measure the effect? Also, it would seem very hard to presume that someone in a relaxed quiet position with someone holding them gently in a soothing environment wouldn't just start producing their own relaxation response and it seems inevitable that the gentle touch of the therapist would invoke ideomotor movement. And that is my main critique of the methods proposed mechanism. I am not saying that the Patient doesn't feel better after a session, but I am saying that the explanation for it does not seem to fit.

In terms of the Red Herring. You have brought up CPR so I followed your line of thinking and skipped ahead to save us both time. I expected that your reason for including it was to propose validity to Visceral Manipulation. Of course I would perform CPR, I have been a trained First Aider for almost a decade, but that kind of question was simply leading somewhere. If you really want me to answer yes so that you can respond "AHA! SEE!! Visceral Manipulation has a plausible mechanism" we can still do that. But I think it is like saying Karate helps to support the theory underlying Massage. Just too big of a leap. If you ask most paramedics they will say that if CPR is done right there will usually be a couple broken ribs. Also I pointed out that it is not very effective in and of itself. If someone gets a karate kick in the stomach they will either not see it coming and sustain damage or tighten muscles to protect themselves if they do see it coming. I don't think any conscious person would allow CPR without quite a lot of Conscious and Non-Conscious protective mechanisms kicking in. Thus my statement that I would never perform CPR on a conscious person. If you have brought CPR in for some other reason than I will do a course correction on my line of thinking.

I have never claimed that I have a credentials, and I have stated it several times but for the record I can state it again here. My only reason for being involved in this discussion is that I have an interest in subjects like this. I may enter the Health Care field at some time in the future. For the time being though I am a laymen.

In terms of Osteo's that you may wish to contact we can start here:
Peter Blackaby - UK
Eyal Lederman - UK
Nicholas Lucas - Australia (I think)
Luke Rickards - Australia.

If I come across more I'll send them out to you.

Since it is important to your accusation of me not thinking I have written this email without opening any other reference or linking to any outside sources (aside from listing the names I have provided as per your request). Any mistakes or misunderstandings are clearly my own and I am interested in correcting them with more accurate information if you can provide it.

Talk soon
Byron

[Luke Rickards]

Byron,

I'd be very interested in what your colleague thought of these:

Swedenborg's Brain and Sutherland's Cranial Concept
Swedenborg's influence on Sutherland's ‘Primary Respiratory Mechanism’ model in cranial osteopathy

Of course, I am aware that reading them means that you aren't thinking for yourself.

[Jason Silvernail]

Craniosacral - put up or shut up. http://www.jospt.org/issues/articleI...cle_detail.asp


[From my iPhone, please excuse typing]

[byronselorme]

Thanks guys.

Hey Luke, would you say my explanation is accurate? I cobbled together my understanding of it from years of reading.

Of course, I am aware that reading them means that you aren't thinking for yourself.

[Luke Rickards]

Hi Byron,

I've lost track of how many attempts OCF fans have made at a plausible explanation for the CSR and the fact that practitioners all appear to feel it at a different rate.

There's a kind of unspoken snobbery in osteopathy that OCF is for real osteopaths who have extra special palpatory skills and want to treat the cause of problems and not symptoms.

No other topic engenders the degree of debate, controversy, defensiveness or criticism that a discussion of OCF will invariably spark. This includes among American DOs who should know better. A study I published along with three French colleagues in the Journal of the American Osteopathic Association a few years ago only hinted that a little science in the topic could be useful and this resulted in the most letters to the editor for a single article in more than 10 years.

You won't beat sense into this guy.

[Barrett Dorko]

Yes Byron.

This is very like telling the Pope not to be Catholic.

[byronselorme]

I know, I know. You guys told me so. Do I at least get my boyscout badge for follow through and technique?
He is taking his marbles and going home. Oh well.

What is interesting is the tactics that I see being employed to undermine my position without directly facing the points I am making. I know everyone else here has had endless experience with this but I have not had much.

Anyhow, thanks to all of you that added your comments. Here is the Dear John letter.

Thank you for getting back to me. I mean no offense (honestly). You have some strong opinions about the validity of my future profession, so I think it is fair to call you out on those opinions, and question their origins. My intention is to examine whether what you are expressing is just the tip of the iceberg with regards to your knowledge, or simply a facade pieced together from other people's opinions. I'm still not sure.

Your argument is typically "this doesn't make sense to me, so I don't believe it". My argument is that none of this has even had a chance to make sense to you because up to this point it has essentially been a hobby. And I do not mean that as an insult, I have had hobbies and they are enriching experiences. However, there is a point during deep study of a topic where you realize just how much you don't know yet. However, there is also a point much earlier in the process where people have just enough information to think they know what's going on. I think there is a saying about how a little bit of information is dangerous.

To me, your world is very flat Byron. History is littered with people who said "it doesn't make sense to me. It can't be done". One good one:

The abdomen, the chest and the brain will forever be shut from the intrusion of the wise and humane surgeon.
- Sir John Eric Ericson, Surgeon to Queen Victoria, 1873

or

There is not the slightest indication that [nuclear energy] will ever be obtainable. It would mean that the atom would have to be shattered at will.

- Albert Einstein, 1932.

Everyone is entitled to an opinion. You and Sir John Eric Ericson have a lot in common. Your conclusions are drawn according to the available scientific evidence of a specific time and place. No one can be faulted for that. The majority of experts in the field probably clapped him on the back and said, "yes, you're right." And look at Einstein's quote, for goodness sakes. The point is, none of us knows, so why put on airs?

You are welcome to say that visceral manipulation and PRM don't make sense to you so you don't believe they exist. However, what I think would be most productive and fair is if you properly qualified your opinion, along the lines of "I have no previous studies or experience in visceral manipulation, I essentially know nothing about it, but it doesn't make sense to me". Then the discussion is framed accordingly and we can proceed on that basis.

Thank you for answering the CPR question. There is a big difference between "skipping ahead" and dancing around the question. I have no previous studies in precognitive abilities, I essentially know nothing about it, but it doesn't make sense to me (see? it's easy). If you give the thread of conversation a chance instead of trying to see 5 moves into the future, you might be surprised.

When you say you would do CPR, it frames in our discussion a little better. It means that with regards to using the hands to create a response in the organs that will help the patient, we are no longer in disagreement. We can now agree that it is possible, that it is widely taught and accepted in this form, and that it is appropriate in the right circumstances.

We now also know that manipulation of certain organs makes sense to you on a mechanical level, it is just a question of the appropriate degree of force. You see, this lands us at a new point in the discussion. I would propose that it is more productive than the skipping ahead method.

I really don't like doing this but I have to say... Karate? Byron. I cannot understand how your brain works. But here is how mine reads your analogy:

CPR - life saving effort. Intention: using compression and ventilation to maintain organ viability for defibrillation attempt

Visceral manipulation in general - Intention: improve function of organ system, benefit patient

Karate - Intention: strike to wound, inflict pain on, incapacitate, or kill opponent to eliminate threat in defense of self

Massage: systematic therapeutic friction, stroking, or kneading of the body

One of these things does not belong in your analogy. I hope we can agree on which one. I've come to the conclusion that there can be no further productive discussion on this topic between the two of us. You appear to be, on a deep level, a conformist (at least judging by this ongoing debate). I would say that I am not. We definitely don't agree on which way the wind is blowing in the world of health care. The Karate comment was just too much for me, how can I argue with that kind of logic? Maybe you're right and the world is flat Byron, who knows? Just keep on saying "it doesn't make sense to me. It can't be done." I love hearing that from people. We'll pick up this conversation again in about 20 years.

It's been a hoot! Let's grab a beer at some point and talk about other things.

Thanks!

[Ken Jakalski]

What is interesting is the tactics that I see being employed to undermine my position without directly facing the points I am making. I know everyone else here has had endless experience with this but I have not had much.

In a recent visit to Paul Ingraham's site, I came across the following regarding his ongoing battles with some of the fascia folk:

"There is a novel theme in the most recent batch of cranky email (other than spelling mistakes and missing the point): a few readers have criticized me for an imaginary lack of “practical” experience. It’s not unusual for people to fixate on my qualifications instead of the subject matter, but this recent emphasis on clinical experience is a fresh twist."

The take home message for me is that many of us either have been-- or eventually will be--experiencing this same kind of undermining.

[Luke Rickards]

There you go, Bryon.

You're a conformist, and he is not.

What else do you need?

[John W]

Wow, Byron! I can't believe he pulled the "conformist" card on you.

I would plead guilty to that charge if it means conforming to the rigors of the scientific method. He, on the other hand, doesn't seem to conform to any principled approach to discovery.

His last reply to you was extremely condescending. I wouldn't even want to have a beer with a guy like that.

By the way, I don't think the quote from Einstein was so much a prediction as much as it was his opinion of the current state of the evidence for nuclear energy. Furthermore, he made this statement just before emigrating from Germany to the U.S. to escape the rise of the Nazis. So, he may have been bluffing a bit. As always, context is critical.