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.