IJOM March 2016 – the digested read

This edtion of IJOM includes a letter to the editor which looks like yet more debate about indirect/cranial/gentle interactive techniques, a couple of studies involving Prader-Willi syndrome  and quite a bit about touch, patient experience and the complexity of osteopathy and clinical practice. There’s plenty to get our teeth into, plus the promise of learning just what “Advanced Myofascial Techniques” might consist of in the book review section.

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Due to a computer glitch I could only read the abstract of this, but that was pretty good in itself.  Almost unbelievably “there has been no published research to date that qualifies the experience of osteopathic touch within a treatment session”.  But this, to me, is what osteopathy is all about.  Three osteopaths treated five patients and the patients were then interviewed about their experience.  Their comments were analysed and conclusions drawn.  In brief, according to this admittedly small sample, we make patients feel cared for, secure, validated and supported.  Good to remember that this aspect of treatment is still at work, doing good therapy,  whenever  we get caught up in worrying if we’re on the right muscle or whether a shoulder is ever going to let go.

What I learnt

  1. There is a type of research called “phenomenological” and the aim is to describe experience as it is actually lived by the person.  It began as a philosophy promoted/propagated/advocated? by a man called Edmund Husserl who argued that “our only certainty is our experience of our world”
  2. You can analyse their data using the principles of “hermeneutic phenomenology” – this has nothing to do with snails or hermaphrodites.

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Two groups: 1) undergraduate students and 2) postgraduate osteopaths were compared.  The groups comprised 1) 22 physical therapy undergraduates from a Brazilian branch of the Madrid School of Osteopathy and 2) 17 physical therapists with a 5-year postgraduate school education in osteopathy.  The way they tested them was by getting them to feel two geometric figures with the dominant hand.  No peeking allowed!  These figures were 2D, 13square millimetres, PVC, square structures with 1mm geometrical sunken reliefs.  The subjects had three minutes then they had to draw them.   They were then scored on how accurate they were, how long they took and how difficult they said they found it.  Reassuringly, the postgrads were better than the undergrads, although I wasn’t quite clear what stage the undergraduates were at – (there’s a big difference between week 1 and final week).  It wasn’t clear though whether the postgrads were better due to more training or just five years of clinical experience.

What I learnt

  1. The Madrid School of Osteopathy has branches in Europe, South and Central America and Israel. 

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Helping to fill another gap in the field of osteopathic research, this study looks at the osteopath’s process of figuring out what is going on with a patient and deciding what to do about it (aka clinical reasoning).  Three self-defined ‘structural’ osteopaths, trained in the UK, but teaching in New Zealand, were videoed taking case histories and examining seven acute LBP patients.  They then viewed the recordings, and added a commentary which was also recorded.  The transcripts were analysed extensively to map what styles of reasoning the osteopaths were using throught the consultation.  Three main styles were found:

  1. Pattern recognition – e.g. recognising things that you know from experience.  e.g. They have come in with a very stiff shoulder.  You immediately know that frozen shoulder is a differential.
  2. Hypothetico-deductive reasoning – refining and testing hypotheses in response to what the patient says.  e.g. this movement doesn’t hurt?  You were symptom free during the holiday?  There is a family history of ankylosing spondylitis?  Mmm, I’ll adjust my differential diagnosis acordingly. Palpation played a key role here.
  3. Collaborative reasoning, i.e. involving the patient.  This is very “now”.  The phrase no decision about me without me is something of an NHS mantra.  It is also often referred to as the practitioner-patient partnership.  It is likely that osteopaths have already been quite good at that, but it is good to see it evident here.  All the consultations here ended with collaborative reasoning.

Apparently these three osteopaths (albeit not a very diverse sample) are similar to other health professionals in their reasoning.

What I learnt

  1. Osteopaths use palpation as a significant diagnostic tool
  2. The phenomenon of an observer affecting the thing being observed simply by the act of observing it can be abbreviated to “The Hawthorne Effect”, a charming but serious scientific phrase I will now try to use at every available opportunity.

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Prader-Willi syndrome is a rare and challenging genetic disorder, which makes you permanently hungry.  Carers often have to put locks on cupboard doors and weigh out food because no drug or treatment has been found to switch off that feeling.  Besides this which sounds pretty bad in itself there are also  physical issues such as low muscle tone, along with behavioural problems and developmental delay.  The life of someone with Prader-WIlli syndrome is far from easy. This study by a group of Italians found positive effects of JUST ONE 45-minute session of OMT on gait and posture, mostly in terms of knee and ankle positioning during walking.

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This is billed as a Masterclass into qualitative research into the subjective experience of persistent LBP.  It is an interesting read in its entirety, putting into words what we might know or guess already, but the recommendations for practitioners at the end are extremely useful.  In abbreviated form here they are:

  1. Patients want to understand why they have pain, so the ability to explain pain mechanisms is “imperative”, and patients can understand it better than most clinicains think.
  2. Practical pain management strategies tailored to the individual are important to counter feelings of helplessness.
  3. Treatments reinforcing body awareness and coordination are useful for patients who might feel a loss of a sense of the body’s integrity.  [Maybe these are the ones who say “I’m falling apart”]
  4. Give patients time to talk and understand (which I think we tend to do as a profession)
  5. Consider how your own beliefs and language might impact the patient.  Careful with the words you use.
  6. Patients appreciate clear explanations of your examinations and findings, and value you if you do this.
  7. “Treatment failure may be an unavoidable step” on the path to acceptance of persistent pain.  Your role might then be to explain and facilitate a necessary transition into self-management.
  8. Some patients like to hand over all the responsibility to you; others like to participate in a collaborative partnership.

What I learnt

  1. Maybe when treatment fails, it is noone’s fault but an “unavoidable” step on the path to acceptance.  You’re not necessarily bad at your job.
  2. The attitude required to analyse qualitative data is “empathic neutrality”.

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Keri Moore and Brett Vaughan are doing a good job of filling a gap in the literature, by producing a lot of research into how to assess osteoapthic learners.  Apparently there is quite a bit of work in the pipeline but except for in the US there is no consensus on the best way to make sure osteopaths leave college fit for purpose.  This paper is probably of most interest to those in education insitutions.  It is about workplace-based assessment.

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By the same authors as the last paper, this looks at the validity of this workplace-based assessment tool.  Apparently it seems pretty valid, but still needs a bit more research.

What I learnt

  1. There is no gold-standard for the assessment of clinical competence in osteopathy.

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These are not the same authors as the other Prader-Willi study.  This one is from the Philadelphia College of Osteopathic Medicine and is a case report.   An 18 year old female with Prader-Willi syndrome and chronic constipation was treated osteopathically.  Techniques described ranged from muscle energy in the SI region to suboccipital release,  and included paraspinal inhibitions, mesenteric lift and myofascial release of the colon.  Colonic stimulation was also performed and the symmetry of the pelvis and sacrum was normalized.  The mother of the patient was taught colonic stimulation in order to continue this once or twice daily at home.

The patient returned for a follow up one month later and reported a mild improvement in constipation, but still had occasional abdominal pain and rectal tenesmus.  The sacrum felt better to the clinician, although other tensions were still there and the clinician gave her a similar treatment to the first one.  One month later she returned and reported a significant improvement.  She had established regular daily bowel movements with reduction in abdominal pain and rectal tenesmus.  She felt subjectively less bloated and on examination there was substantially reduced hypertonicity throughout.

What I learnt

  1. The prevalence of Prader-Willi is 1:10 000 – 1:30 000 and over a quarter of those suffer constipation.
  2. There is a study in JAMA from 2013 which shows that osteopathy is as effective as pharmaceutical treatment in treating constipation in CP patients.  [Cohen-Lewe A. Osteopathic manipulative treatment for
    colonic inertia. J Am Osteopath Assoc 2013;113:216e20.

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BOOK REVIEWS

Another book about fascia!  You can’t move for book reviews on this fascianable topic.  The author Til Luchau has a Rolfing background.  Although thinking it is slightly lacking on the general anatomic and physiological qualities of the fascia, Valerie Ferreira finds this book user-friendly and clear.  There seem to be lots of photos and descriptions of techniques.  Ferreira particularly likes the exploration of treatment of ankle restrictions, hammer toes, hamstring injuries and plantar fasciitis, pointing out that these are difficult areas to find good techniques for.  There is also a good chapter on treatment for the pelvic girdle.

With a text “almost entirely divided into bullet points”, Brownhill thinks this book is a handy reference book, and suits a systematic and prescriptive approach, but might be too brief for those who want something deeper or more comprehensive.  Different authors have written different sections, and it is divided into anatomic regions so Brownhill feels it lacks consistency and holism.  However he liked the smartphone app and access to an online version via the web.

A LETTER

This is a response to a letter which appeared before I began reading and noting IJOM as thoroughly as I do now, but I do recall that said letter contained a lengthy exposition of the difference between osteopathic physicians and osteopaths, along with a criticism of those who practise “unfalsifiable techniques”.  It was a criticism of what the AACOM’s Educational Council on Osteopathic Principles has apparently now termed OCMM – “Osteopathic Cranial Manipulative Medicine”.  (I can’t say it rolls easily off the tongue, but there you are.)  Dr McGrath, who wrote the original letter,  is one of those who believes that these techniques are purely placebo and any positive study results are a result of regression to the mean (i.e. they would have improved naturally).  Hollis King points out what is often not pointed out, which is that these techniques usually only form a part of a treatment, and indeed often patients need various different techniques so it’s difficult to gauge the effectiveness of each in isolation.  King quotes a few studies showing that OCMM has been shown to improve balance and reduce dizziness,  reduce middle ear effusion, reduce the length of stay of prem babies in ICU and decrease GI dysfunctions.  King admits there is not enough evidence yet, but thinks that these studies will bolster any future systematic review.  King also notes that there is a critical mass of osteopaths who use these techniques, that they are deeply embedded in the world of osteopathy, including its schools, and claims that there isn’t such a big difference between osteopaths and osteopathic physicans as Dr McGrath made out.  Her list of references might be quite useful for anyone looking to make a start on assessing the evidence for OCMM.

 

 

 

 

 

 

 

 

 

 

 

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