How to be an evidence-based cranial osteopath

The enigmatic case of cranial osteopathy: Evidence versus clinical practice

  • Pages 1-4 IJOM September 2016
  • Rafael Zegarra-Parodi, Francesco Cerritelli

Well, and doesn’t this sound intriguing?  It’s the opening piece in the most recent IJOM and seems to have been prompted by the big French physiotherapists’ study of Osteopathy in the Cranial Field (OCF).  The authors made a pretty thorough examination of all the research relating to OCF to date, and decided there wasn’t much and therefore advised French physios not to use cranial techniques in practice.  It was only published in January (2016) and it is in French.  I haven’t read it but I have looked at it, fairly uncomprehendingly.  (Interesting fact:  “Cranial” in French is “cranienne”.  It’s not a beautiful word even in French!)

There’s only a tiny bit of evidence for OCF

The authors acknowledge that this is a bit of a problem in osteopathy where OCF is, in fact, a very popular and widely used approach, despite the fact that 1) there is very little RCT-type evidence in favour of OCF, (although this might be in part due to the difficulty and unsuitability of a methodology  suited to pharmacological interventions for specific pathologies, and 2) the principles articulated back in 1944 are impossible according to our current understanding of physiology.  Current scientific thinking does allow that there might be some cranial bone and suture deflection due to muscular contractions which are amenable to palpation.  (To someone who has been quite immersed in what people call ‘cranial’ for many years it all seems to be missing the point to me, but that’s another matter.  No time to get into that now, you’ll be relieved to hear)

Can you even be a strictly EBM practitioner in osteopathy?

Reading on, they do actually show that there is a teensy little bit of evidence.  The most recent study they mention is about neck pain and was published recently in the Clinical Journal of Pain.But in any case, OCF techniques are not alone in osteopathy (or manual therapy, or indeed medicine) for having little high-quality evidence.  The authors suggest that only practicing EBM is pretty difficult in general for osteopaths, and suggest we might use “evidence-informed” practice.  Meaning:  we are guided, but not bound by, the evidence.

The dilemma

Yes you do spell dilemma with 2 Ms.  I’ve just looked it up.  The authors acknowledge that there is a dilemma for the practitioner here.  It seems to boil down to this:  if you want to be a responsible and conscientious practitioner, do you go ahead with a treatment like OCF  that you are sure (based on your own and your colleagues’ extensive experience), sure is highly effective and not harmful for that patient, and in your clinical judgement is what that particular patient will probably benefit from more than any other technique. Or do you refuse to give a treatment that you have enormous personal confidence in simply because there are not enough scientifically valid trials to support it (which could well be due to the limitations of the science, not the treatment).  That might feel like deliberately withholding the help you can give.

The solution

Ask the patient.  This is Rafael and Francesco’s sensible suggestion .  Yes, you can explain to the patient that you would like to use OCF techniques, explain that you have seen this type of treatment work very well, that there are not many trials conclusively showing it works, that if it does work we don’t know exactly how yet, but that they can try it and decide for themselves.  It’s UP TO THEM.  Yes, this is actually the very essence of a patient-centred approach and is totally in line with the principles of EBM (specifically the third principle expounded by Sackett et al in the BMJ in 1996.)  This is how to practise OCF, be evidence-informed, have happy, empowered patients, and sleep easily at night.

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5 thoughts on “How to be an evidence-based cranial osteopath

  1. Hi Penny … I tried google translate. Not such much. But here’s the funny thing about this. There is evidence to be had that lightly touching someone on the head in various different ways will have an effect. It is not direct evidence, it has to be extrapolated from the science (neurology and psychology for the most part), and the effect is, compared to what is claimed of cranial treatment, quite modest.

    The question then, when trying to establish an evidence base, is what are we attempting to establish an evidence base for?

    You ask about using a technique that you are “… sure is highly effective and not harmful for that patient…” My question for this relates to my question above – What is this technique highly effective for?

    The crux of the problem with CST and evidence is that the whole thing is based on, not just extraordinary claims of a complex mechanism that can’t be shown to either exist or have clinical relevance, but extraordinary claims of effect on complex conditions that absolutely can’t be shown in the trials that have been attempted.

    Cranial as a technique or series of techniques does not have to be relegated to the dustbin, but it also cannot continue to exist in the past, based on hypothesis that have since inception been shown to be wrong – or wrong enough that four of the five elements of PRM from osteopathy in the cranial field can’t be established. It’s time to move on from looking for research to support an (incorrect) answer we already have, and begin to ask some questions for which we might actually be able to find a ‘more likely to be occurring’ answer.

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  2. Hi Monica.. Thanks for the comment. Yes I agree pretty much with what you say. Sorry it’s taken me so long to reply. As an aside, the way I, and most osteopaths I know, practise cranial is not especially by touching the head, although it seems to be how most of us begin. Sometimes it’s hardly about touching at al. It is very much a whole body/person treatment, so there is a chance we are talking slightly at cross purposes about what we are doing, (which, let’s face it, is part of the problem when we talk about “cranial”. What are we really talking about, is it that distinct from things like functional, and is everyone even doing the same thing?) And yes I agree that we have to stop regarding it as some sort of miracle cure for everything from cerebral palsy to frozen shoulder to depression, and discuss and evaluate more what is happening when we treat like this, and for which conditions or patients might it be helpful.

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  3. Hi Penny, don’t believe everything you read – the French Physio study was deeply flawed. Take a look at the response to this editorial in the March 2017 edition of IJOM for a fuller discussion about this tricky topic.

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    • Thanks Mary. I have been meaning to get round to reading the French study via some kind of google translate service, but will take a look at that editorial for sure. Thanks for directing me to it.

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