The Great Debate of Osteopathy continues..

[Luke Rickards]

In the Septemebr 2005 issue of IJOM, editor Robert Moran wrote:

There are few topics within the osteopathic profession that are as contentious as the debate about osteopathy in the cranial field (OCF). Reading the ‘Letters to the Editor’ of the various association newsletters suggests that as a profession we are firmly divided on the issue of OCF as a mainstream part of osteopathy.

The debate continues in the latest issue with a response to Steve Hartman's recent letter.

The letter rightly states, "The ‘‘cranial’’ model is far from perfect, and osteopaths are beginning to accept shortcomings of the current theory. In the UK some have suggested different hypotheses and alternative explanations (8,9). Unfortunately though, they neglected to cite another hypothesis that was published in the JOM in 2003.

Luke

[bernard]

Luke,

It seems that the Osteopathic world is indentical to the PT one.
Discordes and "scientific" against "empiric" members that are unable to discuss with a same language: Where is the patient in the tale?

[matt c]

Hi Louke, as you know we agree on our view of the "cranial" model we were taught at uni, so it will be interesting to see what aussie cranial osteos make of these new cranial models
Unfortunately i cant access any of the links on your post? anyone know why?

[bernard]

Unfortunately i cant access any of the links on your post? anyone know why?

Hi Matt,

Just read this important topic.

Join the SomaSimplers' Group!

[Luke Rickards]

Matt,
As far as I can see, the only changes that the cranial community will make are those that are 'trendy', just like all those who have now switched to the Biodynamic cranial model - it won't be because of validity or plausability.

Barrett,
I wonder if the 'repackaging' of Simple Contact for physios will also be relevant for cranial osteopaths, or perhaps a separate package will be necessary to appeal to this group.

[sam.mccarthy]

hi luke, a quick alternate view. osteopaths are obsessed with defining themselves in opposition to chiropractors, physiotherapists, and md's. let us not as a collective of people that are attempting to enquire into the why's and how's of this field fall into the same trap. it is endlessly boring. let us spend our time instead using our intensly inquisitive natures to ask if these working hypothesis are indeed flawed as most of us believe, what the hell is going on under our hands????? working models are just that and in time people will look back at us and think how primitive we are too! there will always be acolytes and nepotism and charlatans in every industry and then there will just be amazing people whose love of inquiry keeps them endlessly fascinated by this field. mr dorko and mr sutherland and mr still are all part of that collective history!!!! the why is far more interesting than the who!!

[Luke Rickards]

Sam,

let us not as a collective of people that are attempting to enquire into the why's and how's of this field fall into the same trap.

This has never been alternative to my view.

[fapt]

Originally Posted by bernard

Hi Matt,

Just read this important topic.

Join the SomaSimplers' Group!

Hi bernard,
Oh my GoD
I don't know this function in my CP user...
Thanks....
I will join the group...

And I had never known that if you have not post this information.

[bernard]

Lin,
Do not worry, you're already a somasimpler.

[Luke Rickards]

Here is Hartman's rejoinder to Maddick and Korth -

In my letter to the editor,1 I suggested that evidence on cranial osteopathy does not support its inclusion on osteopathic licensing examinations. In their critical response,2 Maddick and Korth said: “… it seems unfair to single out just this one area of the profession [because]… lack of evidence… also applies to many other osteopathic techniques…”. Does this broader deficiency suggest that cranial osteopathy should be spared standard scientific scrutiny or that practitioners of osteopathic techniques, in general, have work to do?

After citing recent disappointing findings of Ernst and Canter3 regarding efficacy of spinal manipulation, Maddick and Korth said: “There are no reviews of ‘cranial osteopathy’ that have failed to demonstrate efficacy in the same way.” Is this because outcome studies have shown cranial osteopathy to be clinically effective or because, after most of a century, there remain no properly done outcome studies to review?

They said that: “The number of osteopaths who find cranial technique effective, and the numbers of patients who believe that they benefit from it, is evidence enough that to withdraw or restrict its use would be damaging to osteopathy.” Available evidence suggests to me that proposed mechanisms for cranial osteopathy are biologically anomalous and that there is no reason to believe these techniques ever will be proven scientifically to be clinically effective. Based on this conclusion, in the piece inspiring this exchange, I advised that, instead of cranial osteopathy, practitioners should “base their practice and teaching on biomedical standards of the 21st century.” As a scientist, would it be ethical for me to withhold such recommendations because they might “be damaging to osteopathy”? I can understand that practitioners might have this concern but where do the precious health and limited financial resources of patients enter the equation?

After suggesting that the cranial rhythmic impulse “as an objective reliable rate is highly unlikely” and “is not the basis of cranial theory,” Maddick and Korth said that: “The absence of the CRI… is not sufficient to invalidate the clinical effectiveness of the cranial approach.” Of course not; however, Sutherland's still very popular mechanism4 and others so far proposed are so biologically outlandish that the burden of proof for efficacy surely lies with practitioners. Seven decades of emphatic assertion—but no data—have taxed the patience of many scientists and osteopathic physicians.

I am hopeful that cranial practitioners and members of the larger osteopathic community will examine relevant data with a critical eye, let the data “speak for itself,” and act on the basis of what they determine. If they conclude, as I have, that cranial osteopathy should be left behind, then, as I have said elsewhere5: “Cranial osteopathy has so long maintained its place in the osteopathic fabric that great personal and political courage now will be required to remove it.” Good luck.

[Jason Silvernail]

Some more nails in the craniosacral coffin...

These from the November issue of the Journal of Orthopedic and Sports Physical Therapy....

[Diane]

I just read these papers Jason, and found myself nodding along throughout.
Especially, I agree with the bit that states (paraphrased) that other explanations for these procedures must be developed, and that an unsupportable theory should not only not be used to explain the work to patients, it should be discarded completely.
Personally I think the term dermoneuromodulation suffices as a substitute. I'm still working on the biological model, but you can bet it won't be based on anything mesodermal.

[Luke Rickards]

Thanks for those Jason.

[dswayze]

I've seen Canter and Ernst work cited a few times here on this site and elsewhere and came across this:

Chiropr Osteopat. 2006 Aug 3;14:14. Links
Review conclusions by Ernst and Canter regarding spinal manipulation refuted.

• Bronfort G,
• Haas M,
• Moher D,
• Bouter L,
• van Tulder M,
• Triano J,
• Assendelft WJ,
• Evans R,
• Dagenais S,
• Rosner A.

Northwestern Health Sciences University, 2501 W 84th St, Bloomington, MN 55431, USA. gbronfort@nwhealth.edu.
ABSTRACT: In the April 2006 issue of the Journal of Royal Society of Medicine, Ernst and Canter authored a review of the most recent systematic reviews on the effectiveness of spinal manipulation for any condition. The authors concluded that, except for back pain, spinal manipulation is not an effective intervention for any condition and, because of potential side effects, cannot be recommended for use at all in clinical practice. Based on a critical appraisal of their review, the authors of this commentary seriously challenge the conclusions by Ernst and Canter, who did not adhere to standard systematic review methodology, thus threatening the validity of their conclusions. There was no systematic assessment of the literature pertaining to the hazards of manipulation, including comparison to other therapies. Hence, their claim that the risks of manipulation outweigh the benefits, and thus spinal manipulation cannot be recommended as treatment for any condition, was not supported by the data analyzed. Their conclusions are misleading and not based on evidence that allow discrediting of a large body of professionals using spinal manipulation.

[Diane]

Here is a piece I've written for the upcoming issue of the CPPSG newsletter. I was inspired by the two articles Jason posted higher up in this thread.

What is truly happening when we put our hands on heads, and slide scalp over bone?

The abstract provided above is from a paper recently published in The Journal Of Orthopaedic and Sports Physical Therapy.³ An accompanying editorial⁵ by orthopaedic PT researchers suggested that:

(Italics mine.)

While I agree completely with the need to scientifically study and reject the implausible hypotheses associated with the equally implausible underlying theory of craniosacral therapy (even if it requires the sacrifice of rabbits to do so) I do not entirely support the editorial statement quoted above. I think it doesn't quite hit the mark - it completely leaves out the phenomenon of persistent pain, a condition in its own right, which can occur completely divorced from any "specific musculoskeletal condition." In fact, it usually does. Why? Because persistent pain problems are nervous system based, perhaps connected to movement dysfunction but not “musculoskeletal” (orthopaedic) “conditions”. I do NOT agree therefore, that everything in PT or in manual therapy provided by PT must be elucidated or defined according to "musculoskeletal" dictates, by being “proven effective for specific musculoskeletal conditions.” I think the orthopaedic PTs have made a category error in their editorial, understandable given their focus on mesodermal derivatives (i.e., bones, joints, muscles), and I am writing this to challenge their assumptions, as well as to support the Downey report in its challenge of craniosacral theory as being an invalid construct.³

Regarding theory, there are perfectly acceptable neurological mechanisms to account for the rumored efficacy and clinical usefulness (pain relief, increased sense of well-being) of the procedures associated with craniosacral therapy (CST). Perhaps it's time we rationally deconstruct this infamous form of manual treatment and take a slow look at what might be happening in the nervous system that is on the receiving end of the application.

These are some thoughts I have on the topic (I’m sure others can add more):

1. According to Neuromatrix theory⁶ (Ron Melzack), the "body-self neuromatrix" "comprises sensory, affective, and cognitive neuromodules." Continuously through time, inputs into the system will be processed by this neuromatrix, and output such as stress regulation, action programs (including reflexive motor activity), and pain perception, will ensue. There are three "motor" systems involved: voluntary, autonomic, and neuroendocrine (Brain Architecture⁷, Larry Swanson) working independently/interdependently/continuously (with one exception: the voluntary system during sleep). The application of a set of therapeutic hands on the head will be interpreted by the neuromatrix as helpful or harmful, depending on multiple historical factors such as the patient's beliefs and experience. At the very least, because manual treatment to the head (or anywhere else) is primarily a sensory-discriminative input into a nervous system, frequently a sensitized one, it is imperative that it be non-nociceptive, devoid of threat - five grams is indeed sufficient to facilitate change if we base our intervention on neuromatrix theory. In short, the nervous system is more of a verb than a noun.

2. Contact on the back of the head stimulates mechanoreceptors – mechanically stimulated sensory information travels in through cutaneous nerves (the occipital nerves, cutaneous branches from upper cervical spinal nerve roots) to dorsal root ganglia. From there, benign exteroceptive (arising from outside the body) input is handled by the CNS, both at a spinal cord level and at a sensory cortex level⁷. Part of this input is processed non-consciously, resulting in motor output that is reflexive (e.g., increase in blood flow to scalp and associated cutaneous neural tunnels, outward to the rest of the body), and the rest of the input is evaluated by the sensory cortex/conscious awareness of the patient, where it filters through all parts of the brain, reaching into the cognitive-evaluative and motivational-affective aspects of an awake individual's central nervous system, as well as to all the motor output parts yet again.

The trigeminal ganglion receives and processes any exteroceptive input from the skin on the front of the head/face. The trigeminal ganglion is like a dorsal root ganglion, except that it is also a central nervous system structure, and is intimately connected to other CNS processors and effectors.

Exteroceptive sensation will quickly get the attention of the nervous system, and be scrutinized by it, as will any novel stimuli², for any potential threat before it will be accepted as neutral, comforting, pleasure inducing, educative in a kinesthetic sense, as naturally as interceptive (arising from within the body) sensation.

3. Any sort of therapeutically contexted physical contact can catalyze change in a nervous system. The practitioner's job is to have an idea what a good result might consist of, seek out and enhance and teach patients the characteristics of "correction" - i.e., warmth, softening, a sense of surprise and effortless movement⁴ (Barrett Dorko) during and directly after a session. The patient's job is to be willing to seek out and accommodate lasting change. An ethical practitioner must be willing to remain a mere catalyst, encouraging development of self-efficacy, not "maintenance" dependence.

4. Patrick Wall said, "A placebo is not something that is administered TO a patient, it is something that is elicited FROM a patient."⁸

5. The therapeutic container or relationship is the responsibility of the practitioner. It will serve to establish a physical and psychological safe "crucible" in which a lasting "reaction" can occur, after which time it should dissolve, never perpetuated as a “maintenance” scheme fostering dependency. Part of the attached responsibility of a practitioner is to strive for truth and clarity, be accurate as possible in setting out facts of treatment and pain education. Perpetuating implausible hypotheses/ memeplexes¹ when science suggests otherwise is not ethical in a therapeutic relationship and not acceptable from a professional standpoint. Using metaphor to illustrate an idea or a kinesthetic perception is perfectly acceptable - the practitioner must self-educate to know the difference, draw a line, and then toe it.

6. Neuroscience and pain science can be drawn on to defend the use of any procedure used in physio/physical/manual therapy. There is no need to resort to anti-scientific or pseudo-scientific constructs to explain soft tissue treatment techniques to patients (or hard-tissue treatment techniques either); eventually the faulty memes that accompany useful procedures must all be eliminated, discarded, replaced by better ones.

We can support professional and science-based use of gentle forms of manual therapy by doing valid and reproducible outcome studies; we will thereby continually improve this profession, help one another treat our patients meaningfully and respectfully, teach them to battle pain through understanding it, and enjoy increased amounts of our already widespread credibility.

7. I leave you with this thought on the subject of complexity:

-John Gribbin, author of Deep Simplicity, speaking of his conversation with James Lovelock.

References:
1. Blackmore, S.; The Meme Machine; Oxford University Press 1999

2. Butler, David; Moseley, Lorimer; Explain Pain: NOIGROUP publications

3. Downey, P.A.; Barbano, T.; Kapur-Wadhwa, R.; Sciote, J.J.; Siegel, M.I.; Mooney, M.P.; Craniosacral Therapy: The Effects of Cranial Manipulation on Intracranial Pressure and Cranial Bone Movement; JOSPT 2006; 36(11):834-836. doi: 10.2519/jospt.2006.2278

4. Dorko, B.; Characteristics of Correction; http://www.barrettdorko.com/articles/characte.htm

5. Flynn, T.W.; Cleland, J.A.; Schaible, P; Craniosacral Therapy and Professional Responsibility; JOSPT 2006; 36(11):834-836. doi: 10.2519/jospt.2006.0112

6. 2003Melzack, Ron; Pain and the neuromatrix in the brain: J Dent Educ. 65(12): 1378-1382 2001 © 2001 American Dental Education Association

7. Swanson, Larry; Brain Architecture: Understanding the Basic Plan: Oxford University Press 2003

8. Wall, P.; Pain: The Science of Suffering; Columbia University Press 2000

[Jon Newman]

Nice job Diane. I look forward to seeing the article in its dress clothes when the newsletter come out. It will be posted here right?

[Diane]

Thanks Jon. Yes the newsletter will, and this inside, maybe edited a bit for length.

[BB]

Very nice Diane! I have a student starting next week, and you can bet she'll be reading this in her first week.

Cory

[Jason Silvernail]

Great article, Diane, well written.
I submit that if they think it's too long they ought to drop something else from the newsletter to make room...

[Barrett Dorko]

Diane,

Since reading this wonderful letter I've been thinking about how I can possibly fit such a thing into my teaching. As yet, I can only conclude that a few key phrases, (well referenced to you, of course) might have to suffice. The trick is to learn the right ones by heart and deliver them at the right moment.

What I see here is a spectacular response to the exhasperated mesodermalist who sneeringly asks, "How is just touching another person going to accomplish anything?"

They don't really expect much of a reply so their guard drops. Little do they know that this very question places them right where I'd hoped they would go.

[Luke Rickards]

Robert Moran's editorial (mentioned in the first post) might add something here.

While I am very sympathetic to your message Diane, I agree with the editor's statement and Moran (BTW, there doesn't actually appear to be a direct challenge to the editor's assumptions on catagorisation in the points raised). Sure, persistent pain can occur completely divorced from direct involvement with musculoskeletal structures, however I don't see how that should preclude examining the effectiveness of CST for all common pain conditions, including peristent pain.

Ultimately (ideally) we should have evidence of effectiveness for what we do. If we abandon all categorisation of chronic painful conditions into a simple 'persistent pain' then this research would become very difficult. You can't realistically run a trial with patients who have 'persistent pain' and include patients with anterior wrist pain or knee pain or mid-thoracic pain or TMJ pain, and expect the results to be useful for managing any of these separately or managing persistent lower back pain, for example. So you have to separate these out, then you have to separate pathological/traumatic from non-pathological, and by now you have a "specific condition" in front of you (even though it may actually be called non-specific .....pain).

Perhaps if he added "neuro" to musculoskeletal it would be more palatable.

I continue to be in awe of your descriptions of the mechanism behind gentle manual therapy.

[Diane]

Hi Luke,
Stated precisely the way you have, I don't disagree either..
What I do disagree with is any simplistic attempt, deliberative or inadvertant, to promote an exaggerated orthopaedic agenda within PT, through lack of thinking in depth about what goes wrong with function.

Forgive me for being picky, but where in the phrase "specific musculoskeletal conditions" (i.e., read "existing insurance compensation categories" ..!) is there any room for consideration of pain or the nervous system? Yes, I would have liked to see "neuro" in there somewhere, and not just as a modifier of "muscular", as if the only real use for a neuro system is to make muscle go, and never any consideration of the role the sensory side of the system plays, or the functional glitches that can happen when the sensing system would seem to have become too dominant in an individual human organism.

I see entirely too much of this shortcut thinking in PT - what I refer to as "mesodermal" thinking. It leads to professional dullness IMO. And I'm pleased you enjoy reading the glimpses into the sensory side of the human nervous system being and doing. To me, this puts the horse back in front of the cart of manual therapy of whatever kind.

[Luke Rickards]

I'm sorry Diane, I didn't know that "specific musculoskeletal conditions" meant "existing insurance compensation categories".

[Diane]

No need to apologize, Luke, - how on earth would you have known that's what it really means? In N.America anyway? A situation which tends to generate a huge degree of obtuseness in the treatment world here ...

It's something I've come to recognize as a set of intersecting or interacting or nested or encapsulated social forces that I (inside my own head) call "the mesodermal agenda." It irritates me that people can only get paid if they think in mesodermal categories. It further irritates me that people allow this "being paid" factor to drive their own thinking. It completely pisses me off when everyone in an entire profession is expected by those who consider themselves "leaders" to conform to this way of thinking about the human organism, as if it were a) the only way to think, and b) even remotely accurate.

I am further annoyed to pieces when the country I live in adopted such notions decades ago, even when it didn't have to, thereby impacting the Canadian provision of PT outpatient private practice treatment unnecessarily, swept along by the orthopaedic "specific musculoskeletal condition" wave (although we are completely direct access here in this province, and off insurance, thank goodness, for the last 6 years, beyond the clutches of mesodermalism, those of us who want to be). I still find my hackles going up when I think of all the UN-learning and DE-programming there is to do in the aftermath.

Meanwhile, I've re-tooled a book diagram to illustrate the relative importance of skin (and thus ectoderm/nervous system), and how impossible it is to avoid or circumvent in manual treatment.

[Jon Newman]

Hi Luke,

I'm not at my usual computer but I got "the jumbles" (my official term) that others mentioned last time you posted an article. This article might benefit from whatever treatment you gave the last article.

[bernard]

I get the same problem, Luke.

[Luke Rickards]

Try again.

[bernard]

Idem, sorry: this version is made for some alien readers.

[nari]

I get the same result, too, Luke.

Weird.


Nari

[Diane]

It opens fine for me..

[bernard]

Luke,
The copy you sent by email makes the same problems and I tried on another computer without success.

Perhaps the problem occurs only with PCs?

[Luke Rickards]

What a shame!

[bernard]

Since Diane is able to see it correctly and save it in the same way, there is a chance that her copy may work?

[Luke Rickards]

Diane has a Mac too.

[bernard]

I know but we must have a trial.

[Diane]

I'll try attaching it and we'll see what happens.

[bernard]

The same thing, unfortunately.

[Jon Newman]

I could download it this time. It might be a PC--Mac conflict.

[bernard]

Originally Posted by Jon Newman

It might be a PC--Mac conflict.

I thought the war ended some time ago.

[Luke Rickards]

Here is the latest challenge to the cranial construct.

[BB]

I wanted to revive this thread because we never discussed the most recent article that Luke posted and I'm curious of people's thoughts on a few things.

It is no surprise that there is no support for cranio, but I'm frankly surprised by the lack of galvanic skin response. Galvanic skin response is a way to examine sympathetic response. I had thought to myself before that this would be an interesting way to study handling.

What do you all make of this lack of galvanic skin response to the touch provided in this study?

[Diane]

When I read the article, I thought I saw that it doubled. In the graph. Between phase 1 and 5. What would be considered a good shift?

[Luke Rickards]

Hi Cory,

A few of considerations occur to me.

1. This study was performed on asymptomatic people. Increased sympathetic tone may not have been present and therefore statistically significant reductions may be unrealistic.
2. The touch used in this study was not employed in the knowledge that corrective movements, which may have a more profound effect on sympathetic tone, are present and should be allowed to emerge.
3. As discussed, recent literature suggests that galvanic skin response is complex and may have little correlation with other perimeters representing sympathetic activity.

[christophb]

A GSR only be able to measure a relative increase/decrease in sympathetic response... as Luke said in asymptomatic individuals there may be no change. In a polygraph the GSR is measured along with BP, HR, and RR to measure anxiety/autonomic response taking into account a few more systems. That being said, it would be interesting to see if coercive and heavy manual techinques resulted in GSR change.

Chris

[BB]

OK. Thanks gang. I'll now re-read the article.

[Luke Rickards]

The latest installment of the cranial debate in IJOM is about to be published. There are several excellent arguments that extend well beyond the deconstruction of OCF in Hartman's reply here. It's well worth the read.

[Bas Asselbergs]

Luke, this was enlightening! Maddick's letter did more harm his image as a scientist than support osteopathy....And I LOVE Hartman's choice of words when describing the cranio-sacral mechanisms: "prescientific".... Priceless.