Osteopathic Palpation – A tale of cognitive dissonance

posted in: News 8

If you haven’t already guessed, osteopathic palpation is sort of my thing.

I did a palpation thesis, twice. Both times as part of osteopathic study. Neither study was published, though the bigger of the two was approved by the IJOM for publication if I could just fix the tiny problem with the statistics. And by tiny I mean somewhat insurmountable.

Still, it was a fun study to do. And by fun I mean … .

My thesis partner and I built a hydrodynamic model. I really wanted that word in there. Hydrodynamic. Great word. The model was made up of a constructed silicone bladder attached to a syringe pump, filled with water and run by a computer.  It was a closed system designed to increase and decrease the volume of water in the bladder so that participants in the study could feel or not feel volume changes at the surface. I nicknamed the model MONARK – a mash of my name and my thesis partner’s name.

 

MONARK elements

Our goal was to test the osteopathic palpation ability claims related to assessment and treatment of minute – in the range of microns minute – rhythms of the body that apparently manifest themselves almost everywhere at a relatively rhythmic rate known as the primary respiratory mechanism (PRM) [1]Liem, T. (2009). Cranial osteopathy: A practical textbook. Seattle, WA: Eastland Press, Inc..

 

MONARK clinic set up

Theoretically, the movement of the MONARK could only be only generally extended to the PRM phenomenon because it expressed minute and differing volume changes at a particular rate. Ultimately inconclusive measurement attempts of the MONARK suggested this movement was in the range of microns for even the largest volume change variable.

 

How big is a micron

 

Even if unsuccessful, at least measurement attempts could be made on the model using a variety of tools, including the X-Box game system. Baseline measurement of the rate and extent of the small, often described as micron level small [2]Liem, T. (2009). Cranial osteopathy: A practical textbook. Seattle, WA: Eastland Press, Inc.; Paoletti, S. (2006). The fasciae: Anatomy, dysfunction & treatment. Seattle: Eastland Press, Inc. motions that have been hypothesized to emanate from the human body do not exist.

My literature review was 38 pages long, included at least 25 palpation studies of various types and concluded that palpation reliability for pretty much any subjective palpation assessment, whether on human or model was unable to be established.

I did at the time what most osteopathic manual practitioners still do when faced with evidence they don’t want to consider, I came to the conclusion that the ‘right’ study hadn’t been done yet. By finding ‘fatal’ flaws in all of the studies, including mine, I was able to dismiss these studies one by one as relevant to the osteopathic palpation skills I knew were lurking there, but for which science had not come up with sensitive enough ways of measuring.

This is a very convenient way of doing things in order to maintain the belief that as an osteopathically trained practitioner I had what could only be described as seriously fine palpation skills. I needed these skills and they were integral to my identity. By ignoring what could, through a different lens, be evidence that seriously fine palpation skills are really not a universal trait no matter what my training, I could avoid the unpleasant sensation of cognitive dissonance and achieve a sort of cognitive consistency. For a little while.

No research topic I can think of in manual therapy has been repeated as many times and in as many different ways as palpation reliability. Yet despite this plethora of studies many, probably a majority, in the osteopathic community interpret the research as I did – as though no positive result is actually the same as no result, or as if the research had not been done at all. In other words the many studies have not disproven the hypothesis that palpation reliability exists and, therefore, there is an absence of evidence that is not evidence of absence.

In reality, there are so many palpation reliability studies, including some that are ‘good enough’ to be included in systematic reviews that the ‘fatal’ flaw argument is not a reasonable one. The call for more research in palpation studies is a constant one but at some point, there also has to be a conclusion drawn on the research already done.

Collectively the results of these various studies, even flawed in some ways, show that palpation reliability cannot be established with any confidence. Therefore the research is not an absence of evidence, but more likely evidence of absence. There is evidence that palpation reliability does not exist, even if there are some promising blips in specific instances.

Cog Dis Strong Yoda

The cognitive dissonance is strong if your profession stakes its reputation and a significant basis for existing on being able to reliably feel movements that cannot be reliably felt.

But is it really about what we feel, or is it about the stories we tell ourselves and each other?

The rumblings from the medical and scientific community are not necessarily about palpation specifically, but about the larger health-related claims that stem from an ego-driven sense of self and profession. And those rumblings are getting louderruder and more dismissive of those palpation driven beliefs. There is less and less disengaging of the scientific community from CAM profession claims and more and more head-on challenge.

As it stands the manual osteopathic community is unable to meet the burden of proof required to make such heady palpation claims and by extension the healthcare claims shaped from them.

But what does it actually, realistically, practically mean to accept that the palpation skills you assumed to be infinitely precise and true in their diagnostic and treatment abilities for the benefit of patient health are not anywhere as magical as they seem?

The answer to that question might depend on how invested you are in doing the mental gymnastics required to get around the feelings created by dissonance. If that’s possible, and for some it might not be, then it means having different stories to tell.

Interpretation of an idea, observation or feeling requires context but being unaware of that context enables only one way of explaining the outcome. Being able to entertain more than one idea at once is itself a form of awareness practice, but being aware that there are many ideas that can exist parallel to one another is the first step.

For instance, a patient comes to see an osteopathic manual therapist who has only rudimentary knowledge of psychology and neuroscience. The primary complaint is low back pain that has no known mechanism of injury and for which there are no findings on either MRI or x-ray. The patient receives assessment and treatment according to whatever protocol the therapist has been trained to apply. The patient leaves the treatment session with no perception of back pain. The therapist is asked to provide an explanation for what happened and does so by revealing their interpretation of what they felt under their hands – a temporal bone in external rotation, a compacted SBS, a sacrum with little to no vitality that is in torsion, an internally rotated small intestine – then describes their treatment and normalization of the lesioned structures. The therapist believes that along with pain relief, the patient has also undergone anatomical and physiological changes that in turn liberate “an area of the body, whose release then provides a cascading effect of other releases throughout the body.”

Unknown to both patient and therapist their interaction is observed by a psychologist who knows nothing of osteopathic therapy. She observes the patient is lying down comfortably and appears relaxed, the room is dim and quiet. She observes the therapist first talk to and then touch the patient in various places; the head, the abdomen, the pelvis. The patient appears to be relaxed by the touch. At the head, the abdomen and the pelvis the touch is slow and sustained and gentle. Other motions applied to the patient are rhythmic and oscillatory. The psychologist offers a possible explanation of the outcome with relation to the psychosocial interpretation of belief, touch and caring that the patient is receiving.

Unknown to both patient and therapist their interaction is observed by a neuroscientist who knows nothing of osteopathic therapy. The neuroscientist offers a possible explanation of the outcome with relation to the patient’s neurological sensors in skin, muscle and joints that are activated by touch and motion and provide a sensory stimulation to the brain that may help to down-regulate the prior neurological input that may have resulted in the perception of pain.

Three different interpretations exist at the same time and there are undoubtedly more. With just these examples the question is not which interpretation is correct, but which type of interpretation is likely to be less wrong.

You have an osteopathic explanation that relies on improbable levels of palpation interpretation without being able to establish reliability even with a not-insignificant amount of research, versus explanations that are science-based. Though these explanations may not have specific manual research studies behind them, they are supported by known science that can help to explain how neurophysiological or psychosocial factors may play a part in decreasing pain perception related to touch and context.

These less wrong explanations do not make osteopathic treatment or outcome cease to exist, but they do insist it start to tell a different story, one that makes it more modest, more honest and more flexible.

There are many ways to reduce the uncomfortable feelings of dissonance, but there is really only one permanent way.

“Change the conflicting belief so that it is consistent with other beliefs or behaviors. Changing the conflicting cognition is one of the most effective ways of dealing with dissonance, but it is also one of the most difficult. Particularly in the case of deeply held values and beliefs, change can be exceedingly difficult.”[3]http://psychology.about.com/od/cognitivepsychology/f/dissonance.htm

 

References

References
1 Liem, T. (2009). Cranial osteopathy: A practical textbook. Seattle, WA: Eastland Press, Inc.
2 Liem, T. (2009). Cranial osteopathy: A practical textbook. Seattle, WA: Eastland Press, Inc.; Paoletti, S. (2006). The fasciae: Anatomy, dysfunction & treatment. Seattle: Eastland Press, Inc.
3 http://psychology.about.com/od/cognitivepsychology/f/dissonance.htm

8 Responses

  1. April
    | Reply

    I used to regularly practise ashtanga yoga in a particularly vigorous practice with a heavy emphasis on adjustments and touching. One of my yoga teachers used to say that some people come to yoga just to be touched. If the outcome is positive and people feel good, is there anything wrong with that?

    • Monica Noy
      | Reply

      Hi April. Your yoga teacher was probably right and if the outcome is positive that’s a good thing. Likely the people drawn to that class or those who stayed had positive outcomes and felt good, but that’s a pretty small, self-regulated sample. There may have been people who tried it and did not come back because the experience was unpleasant.

      In a health care setting where where patients are paying for touch in the hopes that it can help their pain or dysfunction, we have an ethical obligation to not make promises we can’t keep or to tell them there is something wrong with them (that only we can fix) based on interpreting touch, especially when it is known that diagnostic accuracy from palpation is not reliable.

      The question you ask though is really related to the question of “what’s the harm?”. This article might illuminate that side of things a bit better than I can. https://www.sciencebasedmedicine.org/whats-the-harm/

  2. Teddy McCann
    | Reply

    Monica,

    You have an amazing gift to write in a clear, precise and understandable style! Especially for someone, like myself, who doesn’t read a lot scientific research.

    However, thanks to the great work of a LinkedIn connection, Bodhi Harraldsson, I have plans to start reading and thinking more critically of the work that has not only been recently published, but also testing “old research” -stuff that has been assumed to be fact just because another, self-proclaimed prominent, therapist professes it to be true.

    I have always shrugged off the idea of soft-tissue “research” for three reasons.

    1. I didn’t think that I was “book-smart” enough to understand the material being covered and didn’t want to put the effort in.

    2. The little research that I have come across through articles or conversations over the years just didn’t add up.

    As you touched on in the article above, I too, have felt that certain data has been handpicked to present and corroborate the outcomes that the industry was seeking in order to provide validity to their work….which obviously, and for good reason is starting to backfire.

    3. Until reading this article, I had always just told my clients “If I can’t feel it, I can’t help it.” -Which, I have always known to be false anyways. I help a lot of people without knowing why.

    Unfortunately, my nonsensical comment has just rattled out of my mouth so often that it has become “easy” to go with…instead of actually digging into research or testing my own thoughts and methods to see if there may be a better way!

    For example, I am really interested in some recent research about neuroplasticity and pain.

    Enough rambling on here…

    I really enjoyed your down to earth approach to data and its interpretation.

    I look forward to reading more of your writing and sincerely hope that “the powers that be” will be “enlightened” by your work as well!

    “Being able to entertain more than one idea at once is itself a form of awareness practice, but being aware that there are many ideas that can exist parallel to one another is the first step”. -Monica Noy

    • Monica Noy
      | Reply

      Thanks Teddy. A long time ago I fancied myself a writer but fiction was not really my thing, so I’m glad some of that time spent knocking my head against the typewriter (I told you it was a while ago) is being put to good use. I’m not so sure the “powers that be” will even stop to read this … its the sound of crickets around here. I really appreciate your comments. Keep up with the pain science study, turns out humans are fascinating enough without having to speculate.

  3. Minki Kim
    | Reply

    I’m a trained Structural Integrator or rolfing practitioner and we were taught that fascia was the means for the positive change we facilitated in our clients. The more and more pain science I read, I realized this is more than likely not the case.

    It’s amazing how much a practitioner can rely on faith or their certain brand of manual therapy as their explanatory model. It really is about being ‘less wrong.’

    Though you may not have the ear to the powers that be, you certainly have mine.

    • Monica Noy
      | Reply

      Thanks. It is amazing how pain science will mess up everything your thought you knew, or at least everything you thought you know how to explain.

  4. Kevin Clifford
    | Reply

    its a funny thing. If you were to tell someone that you knew a person who could read a book with their fingers they would think you mad, at first…until you reminded them about braille and that the person you were referring to was sight impaired. Then it’s all okay, we are prepared to believe anything after that – except of course that osteopaths can feel disturbances within the body by touch alone.

    We have some way to go here, but establishing the possibility that palpation is authentic would be a good start. Whilst braille is self-evident of tactile acuity we still don’t have anyway of calibrating palpation to a standardised measuring device. The use of functional MRIf could be useful here as an opener for a more positive discussion amongst peers.

    • Monica Noy
      | Reply

      Hi Kevin, thanks for commenting.
      You make an interesting point. Fine motor skills can obviously be trained for braille where 64 possible combinations of up to 6 raised dots are possible. But I would argue that braille is a fairly specific and comparatively static skill with clearly defined and finite possibilities.

      The same could not be said for manual therapy palpation, which is dynamic and in an osteopathic sense is really about a therapist-centered interpretation. I’m not saying osteopaths can’t feel anything via touch or palpation but I am pointing out that what we claim to be able to feel (our interpretation) goes beyond what is measurable by science and those claims are therefore unsupported.

      At the same time the neuroscience that is out there, including fMRI studies that show the neuronal effect of touch on the somatosensory system, is either being overlook or completely ignored. Touch effect on the somatosensory system of the patient doesn’t rely on the kind of therapist interpretation that osteopaths apply, and it is supported by neuroscience.

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