Post Hoc Ergo Propter Hoc
I fully expected that at my age (don’t ask) I would no longer be searching for a place within my profession. With all the study and practice I’ve been through, I assumed that I would have arrived and the rest simply window dressing.
Manual osteopathy promised that I would find the answers to any question I had about the human body, and how to treat its various maladies. There was something mystical and exciting about the concept of using hands to ‘listen’ and to ‘heal’.
I was told time and again that people sought out the manual osteopath because other manual professions were wanting in their approach, and that we would be successful where they couldn’t be. Those other professions didn’t understand what it was like to fathom the depths of how structure and function were inexplicably intertwined, that one could not exist without the other and disease would absolutely exist when these elements were not in balance.
“The phrase ‘structure governs function’, then, could also be written as ‘anatomy governs physiology’. If one is to understand Still’s approach, one must appreciate how soft tissue biomechanics within the body relates to physiological efficiency and therefore how problems within soft tissue movement and dynamics relate to pathophysiology.” Stone, C.Science in the Art of Osteopathy: Osteopathic Principles and Practice, 1999. p. 125
The study of anatomy is preeminent in osteopathic manual education and practice, and fundamental to the application of its treatment. This basic construct of anatomy affected by palpation is a primary part of the traditional formulae evoked in a treatment that purports to unimpede self-healing functions that were impeded.
Except, increasingly, studies like this one show that assuming a linear relationship of effect between structure/function or anatomy/physiology is incorrect.
Look How Far We’ve Come
This structure/function orthodoxy is an organizing principle, and like most unexamined preconceptions it has not changed since inception, acting instead as an impediment for conceptual and actual growth. Vision is limited to only those concepts that fit within the organizing principle. Momentum is decelerated, or even seemingly reversed, especially in comparison to the leaps and bounds being made around it via the scientific process – an organizing principle to be sure, but with the act of examination as its only constancy.
In Canada, the unregulated mecca of osteopathic manual practice, private schools outdo themselves to claim the mantle of being authentic because they teach from this tradition. One school evokes the No True Scotsman fallacy:
“Osteopathy starts and ends with its founder, Andrew Taylor Still. Still’s principles drove the movement. This doesn’t mean discounting those who came after Still. All osteopaths must be studied. The key is to examine their work and highlight the evidence of osteopathic principles, because if it isn’t rooted in Stillian principles it isn’t osteopathy.”http://www.canadianosteopathy.ca/classical-osteopathy/
At my alma mater the mission is stated on the landing page of their site:
“2) preserve the vision, values, philosophy, and principles of traditional osteopathy;”http://www.osteopathy-canada.com/
The most recent new school that advertises a *modern* osteopathic education states:
“Our outstanding faculty serves to both maintain current standards and preserve authentic osteopathic philosophy.”http://www.academyosteopathic.com/
Given that the current standards are based on an established orthodoxy, authentic osteopathic philosophy will most definitively be preserved, but the case for what is meant by modern education is unclear.
Of Barrels, And The Fish In Them
This meshing together of structure, function and palpation taught in a framework that places traditional thinking above critical thinking and current science has resulted in many and varied, often extraordinary, treatment claims made by manual osteopathic practitioners.
Cranial osteopathy is perhaps the easiest example to provide of an extraordinary claim.Cranial osteopathy is used for a wide range of problems in both children and adults including constipation, irritable bowel syndrome, seizures, scoliosis, migraine headaches, disturbed sleep cycles, … Continue reading Despite many years of reasonable, unanswered criticism and research that clearly shows evidence of absence of both plausible mechanism and clinical outcome, the practice has not only expanded in popularity, but has become enmeshed with non-osteopathic modalities, such as massage therapy, despite not being supported by science. Craniosacral therapy: a systematic review of the clinical evidence
In 2006 Steve Hartman published an article highly critical of the state of cranial osteopathic presumption, and given the title – Cranial osteopathy: its fate seems clearCranial osteopathy: its fate seems clear – probably thought that with it the debate about the legitimacy of the craniosacral mechanism would soon be done and dusted.
Of cranial osteopathy he states:
“1). As an underlying rationale, the Primary Respiratory Mechanism (including Upledger’s “craniosacral” adaptation)  has failed utterly:
A.Evidence and biological common sense entirely invalidate Sutherland’s mechanism [7, 8].
B. Diagnoses based on this mechanism feature not just low reliability but no reliability. There is no evidence, whatsoever, that different practitioners perceive similar phenomena or even that perceived phenomena are real [7, 8].
Dr. Hartman’s view is reflective of the medical science viewpoint and an eloquent and easy to comprehend synopsis of a state that has changed little since 2006, when his paper was published.
In response to the 2006 paper Andrew F. Maddick of the Osteopathic Centre for Children stated:
“The current explanatory model for cranial techniques is agreed by most rational observers to be untenable, but that does not necessarily mean that cranial technique itself is ineffective.”The flawed cranial model
I happen to agree that cranial techniques may have an effect, but not for the same reasons or the same reported effects as Dr. Maddick.
In response to Dr. Maddick, Dr. Hartman wrote (my emphasis):
“Not just limited scientific evidence for efficacy, but none. Not just limited mechanistic understanding, but none. Not just limited diagnostic reliability, but none. Under the circumstances, ongoing contentions of efficacy are extraordinary claims that should be considered seriously only if accompanied by extraordinary proof.”Reply to “The flawed cranial model”
Please Sir, Can I Have Some More?
In his original paper Dr. Hartman concludes with these words:
“Although I remain hopeful that practitioners and healthcare disciplines wedded to these techniques – especially osteopathy – soon will let evidence guide policy, responsible action will not come without trauma. 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.”
I do not consider myself to have either great personal courage or indeed any osteopathic political influence, after all it is unlikely that I will be one of the osteopaths studied for my adherence to osteopathic principals. However, since I am pot-committed to a profession that I believe could have important and lasting input into the manual therapy field, I have to do something.
I don’t seek to remove cranial osteopathy from the osteopathic fabric, but I do seek to change the accepted presuppositions and extraordinary claims the techniques revolve around. It’s the responsible action given that there is no evidence to support those claims and the plural of anecdote is still not data. It is unethical to continue making these assertions disguised as healthcare claims in the face overwhelming evidence to the contrary.
So, can we finally move on from these cranial flights of fancy and fictional presuppositions? By that I mean the act of continuing to believe something without confirmation, or in the face of evidence to the contrary. Changing opinion, belief and action is a normal function of a changing, science-based landscape and a desired critical thinking outcome.
That’s not to say I don’t have the same information as everyone else. I’ve witnessed positive outcome from providing osteopathic treatment, felt that my life had been transformed in some way by osteopathic cranial and visceral treatment, seen and felt what could only be described as ‘magic’ moments – those times when logic (or at least the available logic) was not able to explain the process or the outcome. I believed strongly in what I felt, and what I saw, and what I heard. I learned many explanations for one phenomena and I believed in the complexity of these elucidations, a complexity far beyond my capacity to remember all of the applications.
I also believe in science, and the thing about science is that it exists whether or not I believe in it and changes whether on not I want it to. Science is inconvenient because it never settles on an answer and asks a lot of questions.
Osteopathic presupposition is not science. It’s a perceived reality based on some elements of scientific inquiry – anatomy, physiology, biomechanics, and selectively dismissive of others – neurology, psychology, chemistry, current medical knowledge. Osteopathy conveniently borrows those sciences that, on their own, can be manipulated to fit the organizing principles and provide answers to questions that were never really asked.
As an osteopathic student I learned much about palpation and strangely nothing about the physiology of touch. I was missing important information that has since changed my perspective on the act of touch itself. Ignoring that information is not an option.
Whither Goest Thou, Osteopathy?
So where does that leave me? The skeptical osteopath and a profession that largely refuses to recognize its own fictions.
“Movements such as osteopathy, homeopathy, and eclecticism, it is generally believed, have a natural life cycle. They are conceived by a crisis in medical care; their youth is marked by a broadening of their ideas; and their decline occurs when whatever distinctive notions they have as to patient management are allowed to wither.”1.The DOs: Osteopathic Medicine in America, Norman Gevitz, 2004; John Hopkins University Press
Though the profession as a whole seems to be actively ignoring the science that questions it, I cannot. Unlike many others in the profession I’m able to be a dissenting voice precisely because of the unregulated nature of my profession and the confusing free-for-all that osteopathic education has become here in Canada. If change is going to happen within the profession, best it happens before regulation if at all possible.
In my cognitive dissonance blog I gave an example of the possible other reasons why an outcome of decreased pain may occur with a patient after a treatment. Reasons that did not rely on presuppositions, but on known neurological and psychological functions. There were no fictions but there were no absolutes either, which left much more room for the patient to be present. The fix was not dictated by the therapist and what they could do, but by the patient and the way in which they received the information.
Why then does cranial treatment have to be about moving cranial bones in a pattern of mobility that has never been able to be established with a palpatory skill that has been shown to be wholly unreliable? Why does cranial have to be about treating a system of the body, or many systems? Why does cranial have to be about treating a condition or pathology? Why can’t it be about caring touch? Why can’t it be about the way in which that touch is interpreted by the patient through context, through their nervous system?
Why does treatment have to be about what I can do to you, instead of what I can provide for you?
After all, head touching for the most part is quite relaxing. Often deeply so. Why can’t cranial be about a modest claim like relaxation that doesn’t require much more than anecdote for support and doesn’t run the risk of being touted as a treatment for disorders it can’t possibly treat?
It is entirely possible to feel better subjectively, but not be better, objectively Spin City: Using placebos to evaluate objective and subjective responses in asthma Is feeling better not a lofty enough goal for a treatment outcome?
Because really, what is actually achieved by a cranial treatment? Empirically? Verifiable by observation?
At the end of a treatment a patient possibly has less pain and they can move their neck better. For a moment they might be a little bit light headed. They feel taller, more grounded, standing straighter. They look calmer.
Compared to this what is achieved by a cranial treatment, objectively, by measurement?
Of course that outcome depends on the measurement system, and given that there is no evidence that cranial bones move in the way they are osteopathically presupposed to, then subjective perception of measurement through palpation is the best tool we have. Which is a bit of a sticky wicket, given that there is quite a bit of evidence that palpation is a wholly unreliable tool. So any structural/functional changes reported to have occurred by the therapist cannot be taken as true, or even likely, no matter how confidently they are delivered.
But how is it the patient feels better? Well, what if the only part the therapist played in that subjective and observed outcome was to make a clinical decision to apply a particular method of touch and/or movement. What if the choice of touch was gentle, or non-nociceptive in a context where the patient was listened to, the treatment options discussed and education and resources provided that reassured the patient that there was nothing broken about them and that they did not have to relinquish control to a relative stranger to be ‘fixed’.
What if it was their system’s interpretation of that touch and the context in which it was applied that resulted in the observed and or stated outcome?
Imagine that! It was not about the therapist at all, or their seemingly considerable talents and ability applied through finite and alarmingly precise palpatory skills. It was about the wholly fascinating and complex ability of the patient to process and interpret that touch through their own biological systems.
Sometimes Function DOES Govern Structure
Think about this.
Did the treatment somehow resolve a pathology or even change its course? Did it prevent a condition from occurring that might have eventually caused death? Did it boost a complex immune system or facilitate a normal healing process in some clinically relevant way? Well that would be impressive, and given that there is no evidence to support these statements also rabidly egotistical. Perhaps a God Complex doesn’t seem that out of place when a system of treatment is derived from and maintained with traditional orthodoxy.
The osteopathic structure is there and if I wanted it to I could use it to prop up these impressive and extraordinary osteopathic presuppositions and that would be considered normal function.
Only I gave up writing fiction years ago.
|↑1||Stone, C.Science in the Art of Osteopathy: Osteopathic Principles and Practice, 1999. p. 125|
|↑5||Cranial osteopathy is used for a wide range of problems in both children and adults including constipation, irritable bowel syndrome, seizures, scoliosis, migraine headaches, disturbed sleep cycles, asthma, neck pain, sinus infections, TMJ syndrome, Ménière’s disease and ear problems, and for children with attention deficit hyperactivity disorder (ADHD) who have experienced birth trauma or head trauma. http://www.drweil.com/drw/u/ART03223/Cranial-Osteopathy-Craniosacral-Therapy.html|
|↑6||Craniosacral therapy: a systematic review of the clinical evidence|
|↑7||Cranial osteopathy: its fate seems clear|
|↑8||The flawed cranial model|
|↑9||Reply to “The flawed cranial model”|
|↑10||1.The DOs: Osteopathic Medicine in America, Norman Gevitz, 2004; John Hopkins University Press|
|↑11||Spin City: Using placebos to evaluate objective and subjective responses in asthma|
A bold and erudite commentary. You won’t be popular but I don’t think you mind that. Well done and I look forward to more like this.
Thanks Mark. I’ll take bold and erudite over popular any day!
You write very stylishly Monica, but I confess to little gushing over this particular piece. I would love to see a more rounded commentary. Viz:
* Your “fiction of osteopathic pre-supposition” considers only cranial osteopathy. I have read other commentary by you – some on this forum – which appears to do the same. I would love you to broaden the goal posts, because I don’t think you are simply an “anti-cranial” bod (which some might be forgiven for imagining) but you have a more useful axe to grind, broader comments to make, that perhaps we all need listen to.
* You detailed some of Steve Hartman’s withering comments against cranial but when it came to Andrew Maddick’s response, you gave it almost no space. Why?
* In citing Hartman, you quoted, “After most of a century, no successful, properly controlled outcome analyses have been published. Practitioners have no scientific evidence that their therapeutic actions – however grounded in biology (or metaphysics) – have any direct effect on patient health.” Absence of evidence is not evidence of absence and I respectfully suggest that Hartman does not deserve quoting for thinking otherwise!
* You wrote (and I agree) – “It is entirely possible to feel better subjectively, but not be better, objectively”. You continue, “Is feeling better not a lofty enough goal for a treatment outcome?” Yup, I reckon so! But why do you then argue along lines that run in diametric obverse? This is confused. “Because really, what is actually achieved by a cranial treatment? Empirically? …. [G]iven that there is no evidence that cranial bones move in the way they are osteopathically presupposed to, then subjective perception of measurement through palpation is the best tool we have …” Eh? Is this just an attack on cranial? After all, what happened to the patient feeling better subjectively – and possibly objectively?
No gush from me, but I will follow your future articles with interest.
Thanks Joyya. That’s a lot to think about and I’ll get back to you. By the way, I don’t always expect gush but when I get it I enjoy it. I also love a good conversation, and looking forward to it with you.
Hi Joyaa, some thoughts in reply to your questions.
Though I have also made comment on phenomena like PRM, the critiques of cranial are not being addressed, which is one of the reasons why I highlight Steve Hartman’s paper over the reply from Maddick.
Though there may be some papers that show a modicum of movement within the sutures, that does not extend to movement of the cranial bones as described by the osteopathic literature. So Steve Hartman is not wrong. There is no evidence – none – and the proposed osteopathic mechanism is still biologically implausible. His comments are withering for a reason.
In terms of absence of evidence not being evidence of absence, well I disagree. There is evidence of absence of movement of cranial bones as osteopathically described – it cannot be established. There is evidence of absence of palpation reliability – the senses we can supposedly trust have been shown to be untrustworthy in a multitude of studies. Not just palpation studies, but neurological and psychological studies as well. So no, we cannot trust our senses and nor should we if we claim that those senses can be used to diagnose and/or treat a condition that is otherwise immeasurable.
I’m not quite sure about your last comment. Measuring patient outcome is valuable. That’s what most RCTs are doing, but that doesn’t equate to the mechanism being the reason for that outcome, especially if the mechanism is unknown. IF outcome could be established, that would be a good goal, but so far the results have been less than stellar.
Good work, Monica. Excellent read. And yes I too have had life-changing experience with cranial, and just wish we could all try to be more honest about getting to the truth of what we are actually doing and how and in what situations it works.
Thanks Penny,that’s really the short of it isn’t it. Stepping back and starting again from a perspective of inquiry.
Chiropractors have the same problem with their “adjusting subluxation” theory!