Well, as the Halloween box goes back up into the loft, and I wonder if it’s too early to start buying mince pies, those long hot midsummer days are receding far into the distance, so just to take you back there, here is my report from Day 2 at the Sutherland Cranial Conference in Reading.
Following a disturbed night, in which the delegates found themselves cruelly awoken from their slumber by a most disorientating and persistent fire alarm, and then congregated outside in their pyjamas circa 2am, the bleary eyed crew assembled with somewhat dis-sembled autonomic nervous systems, but nevertheless renewed vigour for another stimulating learning experience.
Steve Vogel – the landscape of research
It was interesting to see a couple of faces from outside the usual “cranial” world at this conference, and while Steve Vogel has made brief appearances in this sphere, such as when he taught the research methodology part of my MSc, I have seen him more in the scientific/skeptical/EBM camp. He was on the team that produced the new NICE guidelines, after all. And given the attitude of many osteopaths towards this camp, he understandably felt like the kitten below about giving a lecture on research to a roomful of cranial osteopaths.
He gave a great survey of research methods, but the thing that I found really interesting was his survey of the room when he asked for a show of hands: Who, here, uses Facebook, he asked? Only about 6 hands went up. Now, I am the hypocritical kind of person who longs for a self-sufficient, off-grid small holding, but abandons the attempt at growing lettuce as “too-hard-work” at the first sign of slugs. In the same vein, I view the growing atomisation of human attention and the personal alienation wrought by social media with horror, whilst at the same time spending much of my spare time scrolling through Twitter. But it is no exaggeration to say that through social media my osteopathic interest, personal connections, knowledge and skills have been transformed and grown out of all recognition. How do these disconnected people pass their day without pondering questions like – where does David Poulter actually live? How does Daniel Gerber find the time to treat patients between tweets? Has Adam Meakins gone too far this time? But additionally they are missing out on zeitgeisty issues: current thinking on exercise, whether pain education works, the evidence on adverse events, the rise of narrative medicine, the best sort of research for person-centred healthcare, the importance of language, how to do motivational interviewing; the effect of ‘false positive’ imaging results. I can’t help but see the sharing of information, done properly, and across the different professions, as a force for good.
Workshop: Converting an idea into a research project
We then broke into groups to look at how to actually do real research. I chose this workshop as I have research ideas literally coming out of my ears, and subsequently disappearing into the ether without even being jotted down on the back of an envelope. I love the idea of research but have trouble actually doing it, for several reasons:
- it’s quite “fiddly”
- I’m not sure my mind has the requisite forensic bent
- I think I’d get bored before the end
- nobody would probably read it anyway
However these clearly are very poor reasons not to do research; one might even call them excuses. But a few bricks from those psychological walls began to be gently dismantled by Geethanjali Bahal, Maria Larrain and Brian McKenna, who not only seem to understand research in depth and detail, but were really encouraging in sharing their own enjoyment. These people positively LOVE research, and don’t even think it’s too difficult to attempt; Maria revealed that she is happy to get up at 5am to work on her own projects, because it’s such “good fun”.
Aside from the general encouragement they helped practically by
- Reminding us that NCOR are there for all of our help and support. Despite having been going to NCOR hubs for years, I hadn’t quite understood just how readily available help was. Got an idea? Drop them a line. This is their job and they are a fountain of research wisdom and advice.
- Helping us to make it seem less daunting by breaking the process down and, a bit like being in a 12 step support group, you just take it one stage at a time. Here are some of the stages:
- Identify what you would like to study
- Develop your research question
- Speak to people
- Literature searches
- Fine tune your question
- Conduct a preliminary review of existing evidence
- Decide search terms
- Book search
- Cochrane Database
- Create a timeline for your study
- Construct your research proposal – make decisions about practical aspects e.g.
- methodology – decide on recruitment/analysis
- Get feedback (e.g.NCOR)
- Get ethics approval
- Do the study
Ok, two things might be apparent here. One is that I have possibly got the steps in the wrong order, and the other is that, much like painting the spare room, it’s 90% preparation, 10% perspiration. My particular idea was: finding out from patients who have had cranial osteopathy, what exactly they think we are doing and how it works – i.e. “patients’ conceptualizations of cranial osteopathy”. And maybe one day I will get round to doing this. I had visualized maybe phoning up a few people who’ve had cranial, inviting them round to my front room with a plate of assorted biscuits, and asking them what they think is happening when we treat them, then recording my interpretation of what they said. That clearly is not sufficiently rigorous to make it into IJOM.
The Colic Project
We then heard about an ESO study looking at the efficacy of cranial osteopathy in infants with colic. They compared treatment with a control group, and looked at the quality of life and emotional status in parents who are affected by a baby with colic. This ran into problems when not enough babies were recruited via health visitors, but was rejigged with a treatment group and sham-treatment control group, with parent/carers blinded by sitting behind a screen while the treatment/sham was carried out. However following submission and resubmission this paper still hasn’t been published. Further review is possible, however key personnel have moved on, the ESO dept has been restructured, and already there is a better understanding of different research tools which could be used, so it is likely that funds will be allocated to a different, future project. But one of the useful things that I learnt at this conference is that we can learn from every bit of research, even those studies those that don’t end up getting published, and with research in this field still in its infancy, as it were, all provide opportunities for expertise to grow.
The OCC – Paediatric Data Collection
This was a retrospective audit of OCC patients over a 6 month period. Sounds easy enough, doesn’t it? Karen Carroll, one of the OCC’s leading lights, presented this, and, well, it sounds like they bit off, maybe not more than they could chew, but certainly enough to keep them chomping until their jaws were aching. They spent a long time trying to do it really well, with much input from NCOR. NCOR suggested creating a data collection form, which was done, but not quite agreed. For reasons not totally apparent, NCOR were also designing their own paediatric PROM but this was not used for this study, until a later date.
Adverse reactions data was prioritised, as at the time there was a bit of an attack on the imagined dangers of osteopathic treatment of children. The good news is that over 90% patients experienced no reaction. And those that were reported were mild and transient.
Many lessons were learnt from this process:
- Designing your own questionnaire is difficult, so use one that already exists if possible
- the new CPD scheme should try to encourage data collection (tick!)
- while analysing old data might seem easy, it’s not really, and better maybe to start off afresh knowing what data you’re going to collect in a more standardized form
and on a tremendously bright and somewhat poetic note
- research hopes to “shine a light into the darkness”
- trials from enough different angles will start to build the picture of how osteopathy can support health
- research in its “many forms” can help liberate the potential of osteopathy
Closing discussion: A new language for what we do – embodiment and interoception
As the alarm went off yet again, we drifted out the fragrant lawn, where we assembled for our last discussion. I had been tweeting all weekend, but one particular tweet that came out of this discussion drew several emphatic responses in the affirmative:
Should we be talking about embodiment and interoception rather than PRM and occipito-mastoid sutures?
Now this was partly the UCO influence coming through (although one speaker had already told me she felt we would be better not using the term “Primary Respiratory Mechanism”).
UCO host good, productive and engaged researchers. In addition, not only do some of their research people practise in a very “cranial” way, but even the skeptical ones seem genuinely open-minded: truly skeptical rather those who claim to be skeptics but are in fact cynics in disguise. But they seem to be encouraging us to “frame” what is happening quite differently from Magoun or the Biodynamics or Upledger schools. Now I feel a bit nervous about what to write here, because, despite my best efforts in my early career, I am fairly low on the ladder of the “cranial” hierarchy and thus feel unqualified to comment. I also know that different schools have different ways of doing things and there is a fair amount of criticism and rivalry between them. I simply refer people to Ernest Keeling’s answer when I asked him which strand of osteopathy was the truest, and he replied: “They are all aspects of the truth”. Well, having found many of the rationales for what-happens-when-we treat-in-the-way commonly known as “cranial” to be incredibly complicated, sometimes implausible, and without exception downright confusing, I jumped at these two words as a possible signpost to an aspect of the truth that I might finally be able to understand and use. My quick search yielded these:
Interoception – a neuroscientific term – all about the “sense of the internal state of the body”. This is very in vogue in the physio and pain science worlds.
Embodiment – well, the best place I found for an intro to this, having hunted about a little, was Bevis Nathan’s website. He wrote a well-regarded book called “Touch and Emotion in Manual Therapy” which I have yet to read, but if it’s anything like his blog posts – “Sex is a bonding thing”, “Einstein and Anxiety”, “Foetal health helped by breathing exercises” – it sounds like a cracker.
Now for someone like me who likes to keep things simple, likes the backing of solid neuroscience, but also thinks that part of liberating osteopathy’s huge potential is in its role in helping with psychological health and trauma resolution, this sounds like a great avenue to pursue, and a great way to allow all those Sheldon Coopers out there to accept and to practise more of the treatment which I see as a true gift of osteopathy to the world, and one that really needs protecting, preserving and developing.
This conference was a great step in showing how this part of our profession is seriously attempting to increase our attempts to understand exactly what we are doing and asking if, why and how it ‘works’.