If you have read my previously impassioned pleas for more research in osteopathy, and have gained an insight into my love for my NCOR Research Hub (Haywards Heath division), you might have made the mistake of thinking I know something about research. I might have a strange propensity to do things like pour my tea from a short, wide cup into a tall, thin cup because I simply must know which one actually holds more tea, but the truth is that I don’t actually know a kappa test from a p-value. My interest in research stems from the fact that when a patient says “Do you think you can help with my migraines?” I want to be able to say something like “There’s a good chance. 7 out of 10 people with migraine improve a lot after six osteopathic treatments, and that improvement tends to last at least a year”.
I don’t necessarily want to spend hours poring over research papers, having discovered that my preferred approach of skimming the abstract then jumping straight to the conclusion is not a good one. Many studies we look at in the hub are flawed despite being in reputable peer-reviewed journals, and often the interesting facts are found in the body of the paper. But I still rarely (never?) read papers without the deadline of an impending Hub Meeting. My copy of IJOM used to be expectantly carried around for a few weeks in my bag, before I admitted defeat and consigned it to a growing pile on my bookshelf – the “osteopathy magazine holding zone” – whence it was unlikely to ever see the light of day. Now I don’t get a paper magazine. I have to log in on the o-zone, which makes it even easier to forget/ignore. But as a personal challenge, plus a service to osteofm readers, some of whom I’m guessing also find it a daunting task, I this week decided to go through IJOM, paper by paper, to see what’s in it, what’s interesting, and if I can make any sense of it.
Reassessing the accuracy and reproducibility of Diers formetric measurements in healthy volunteers
- Pages 247-254
This seems to be all about some equipment which comes up with measurements of things like spinal curves, leg lengths and pelvic torsions. If you are of a strongly engineering/biomechanical persuasion and like gadgets (which I am not) this might interest you. Here is a commercial website advertising the equipment. It markets itself as a radiation-free alternative to Xrays, osteopaths are a new “target market” and it can also be used to help diagnoses and treat things such as scolioses, and TMJ dysfunction and help with advice on shoe insoles. In this study a group from Belgium think it could meet an urgent need for objective assessment of the result of osteopathic treatment. The equipment seemed to give better results with better trained operators, (the positioning of the person being crucial), but it gave largely reliable results e.g. for kyphosis and lordosis, less so for torsion. The authors conclude that this might be a good system to use in clinical trials when objective measurements are required.
What I learnt – kyphotic and lordotic angulations are confirmed to be higher in women than men
Osteopathic manipulative treatment for chronic nonspecific neck pain: A systematic review and meta-analysis
- Pages 255-267
Only three studies out of 299 identified were suitable to be included. But of these few, which lacked long term measurements, OMT was suggested to be clinically relevant for reducing pain in patients with chronic nonspecific neck pain.
What I learnt
- there aren’t many high quality RCTs into OMT for neck pain, but the few there are, are positive about short term results.
- If the treatment part of the study is not standardized, and therapists are allowed to treat however they would in the real world, this is sometimes known as the “black box” treatment approach. It makes it hard to understand which bit of the treatment is the “active consitutent”, but means the results can be regarded as valid for everyday practice.
- Blinding is difficult as patients are aware when manual treatment is performed
The hokum of ‘History is more or less bunk’ – A masterclass in historiography
Original Research Article
- Pages 268-277
John O’Brien identifies problems with osteopathic history, not least that little effort has been made to place Still or the profession in context. This is a very thorough and scholarly “how to write osteopathic history” article, packed with interesting perspectives and nuggets of information embedded in the academic advice and guidance. For example, O’Brien assesses Still’s intentions in writing his autobiography to be perceived as a “pioneering alternative medical Abraham Lincoln”. If you want to read just one book on osteopathic history, he recommends Norman Gevitz’s book “The DOs: Osteopathic Medicine in America” (NB this is one of four books he examines, and he does not include nor refer to John Lewis’s new autobiography) .
What I learnt
- Chiropractic arose only 100 miles from Kirksville
- A small group of osteopathic reformers were (quietly) questioning the validity and existence of the osteopathic vertebral lesion as a major cause of dysfunction even while Still was alive, and after his death they became a bit louder and this movement metamorphosed into American Osteopathic Medicine.
- An AMA report (1935 ) predicted the imminent demise of osteopathy and an irresisitible decline in chiropractic.
This is one for the teachers, or rather educators. It’s all about how the final year students at Victoria University are assessed for their clinical competence and fitness to practice.
What I learnt
- The first osteopathic course in Australia was offered in 1986 and there have only been a maximum of three programs running concurrently.
- Teachers, or those involved in education, are now called ‘educators’, in this context at least.
The Osteopathic Clinical Practice Assessment – a pilot study to develop a new workplace-based assessment tool
Original Research Article
- Pages 287-296
Brett Vaughan appears again, this time with Keri Moore looking at a global clinical competency assessment, a tool gaining poularity in the Australian allied health professions. They have adapted one designed for physios, and it is called the Osteopathic Clinical Practice Assessment (OCPA). They tried it with 4th year students in a supervised clinic on campus. They found it useful.
What I learnt
- Students are now called learners.
Safeguarding children in osteopathic practice part 2: Managing concerns about children
Original Research Article
- Pages 297-304
Very readable and interesting study about the importance of communicating concerns about the safety of children. According to these authors if you see many children you will encounter children in need or at risk. An osteopath cannot make a diagnosis of abuse alone, and the study recommends managing suspicions of abuse as a bit like we manage suspicions of pathology, in this case preferably by seeking the advice of a social worker. Don’t be put off by the bad press they’ve had, and don’t think you are going to trigger immediate action. You can have a “what if” conversation with the social worker giving guidance based on an anonymous and hypothetical case, so you can chat it over without fearing any negative consequences. There is also an unambiguous statement that osteopaths should not contact the police for routine advice about a child. You could refer to the GP if you prefer (accompanied by an informal phone call telling them of your concerns) , or go to the NSPCC (in the UK) or similar child protection charity in other countries.
What I learnt
- A quarter of young adults were abused at some point during their childhood; almost a third of children are bullied.
- There is a natural tendency for clinicians to downplay suspicions and over-identify with parents.
- Scimitar syndrome: A rare explanation for a common symptom with an osteopathic approach
- Original Research Article
- Pages 305-311
Scimitar Syndrome is a rare congential heart defect (there is an anomalous vein shaped like a curved sword, hence the name). It is commonly associated with pneumonia.
The abstract says that OMT (Osteopathic manipulative treatment) has been proven, YES PROVEN, to improve the clinical course in hospitalized patients with pneumonia. There is a study – Multicenter Osteopathic Pneumonia Study in the Elderly (double-blinded, RCT, ticks all the sciencey boxes) acronymed as MOPSE. I’m pronouncing it like the Beatrix Potter bunny rabbit, Mopsy, obviously (who wouldn’t?) . It demonstrated that the use of OMT
significantly improved the outcome of pneumonia in the hospitalized patient by reducing length of stay, duration of intravenous antibiotics and associated respiratory failure or death
Great, huh! I didn’t know about that and glad I do now.
This scimitar study is a case report about a 68 year old lady admitted to hospital, really not very well, with previously undiagnosed scimitar syndrome and infection. Alongside antibiotics and supportive care, fairly manual OMT was applied (techniques fully described here) and she got very much better within a week. It’s a really interesting study. You couldn’t present it to NICE as evidence, as the most they can say in conclusion is
In this case, the use of osteopathic
manipulation likely more rapidly ameliorated
symptoms and shortened hospital stay
but it’s great to see some researchers broadening and deepening the current literature. It’s the first study of the use of OMT for Scimitar Syndrome.
What I learnt
- There’s a proper RCT from 2010 in the US showing that osteopathy helps elderly hospitalized pneumonia patients. This is the reference, although I couldn’t link to it:
Noll DR, Degenhardt BF, Morley TF, Blais FX, Hortos KA,
Hensel K, et al. Efficacy of osteopathic manipulation as an
adjunctive treatment for hospitalized patients with pneumonia:
a randomized controlled trial. Osteopath Med Prim
A systematic review suggests inflammation could favour spontaneous lumbar disc herniation regression especially for more severe stages of herniation.
- Pages 312-313
Spontaneous regression of herniated discs were visible in just over half of cases. However nearly all sequestered discs (96%) spontaneously regressed, compared to very few bulging discs (13%). But be warned – there is not necessarily a direct correlation with clinical outcomes, and probably lots of severe herniations went to surgery rather than wait around for the follow up study.
Are reductions in passive knee extension or flexion associated with radiological changes suggestive of osteoarthritis?
- Pages 313-314
Fiona Hendry discusses a study looking at whether some of the pain during passive knee movements is caused by soft tissue changes. There could be a role for osteopaths for pain reduction and soft tissue treatment.
Stuart Walker summarizes a study into the acceleration characteristics of manipulation at the cervical, thoracic and lumbar spinal levels. It seems to be looking at one chiropractor’s thrusts, and found that it differed mostly in amplitude, not speed, depending on the different levels. Most forceful was lumbar roll, then cervical, then thoracic, although other studies have shown it in this order: cervical, thoracic and then lumbar.
Conditioned placebo analgesia persists when subjects know they are receiving a placebo
- Pages 315-316
Raiher talks about placebo pain relief, and the question of how important either expectations or conditioning are. To take it back to Pavlov, if you could have spoken doggy language and simply told the dogs that food would arrive when the bell rang, would they have even needed conditioning, and would it have affected how much they salivated? He discovers that conditioning does strengthen the placebo effect, that when subjects discover they have been using a placebo this does not stop the placebo effect happening, and that an initial experience can create persistent beliefs which are subsequently difficult to reverse. Interestingly this echoes David Nutt’s findings about recreational drug experiences: if you have a great, positive first acid trip, for example, you are likely to go on to enjoy and use it many more times; the very first experience has a disproportionately significant effect on your attitude towards a drug.
How does style of mentoring supervision affect talent development among trainee doctors?
- Pages 316-317
A summary of a study examining which style of mentoring brings out the talent in young Malaysian medical students. Fairly unsurprisingly students preferred coaching and mentoring supervision over abusive supervision, but fairly surprisingly, abusive supervision does not negatively affect talent development. Don’t tell your tutor.
Fascial Dysfunction; Manual Therapy Approaches
- Pages 318-319
This is a review of a book by Leon Chaitow, divided into 2 sections: 1 – the function and characteristics of fascia, and 2 -treatment approaches thought to affect fascia. London warns that some readers may be disappointed with a lack of criticality with regards to therapeutic effects and clinical outcomes i.e. don’t expect loads of references to studies which back up the theories.
Functional Atlas of the Human Fascial System
This book is an “exquisitely prepared anatomical reference book that can answer many of the fascia related questions posed by students and practitioners” with over 330 high quality illustrations. The author, Carla Stecco, inclues an alternative explanation for somatic referred pain on the basis of anatomical continuity and describes “fascial densification”, a newish term describing increased fascial density and reduction in the sliding of fascial layers. According to Hutchison this is likely to become the standard ‘go to’ resource for anyone interested in the anatomy of fascia.
So there we go, an interesting array of material, useful for CPD and just generally feeling like you know what’s going on.