Osteopathy in the Cranial Field: does it work?
Osteopathy in the Cranial Field (OCF) is a standard component of the toolbox of the osteopath. At the same time it is also the most controversial. More and more reviews appear that are questioning the evidence of OCF.
By Sander Kales, D.O.-MRO, M.Sc.
Published in De Osteopaat Magazine | May 2017 | Vol.18 | Nr.1
Various disciplines are currently involved in the cranial domain: there are about 175 registered mandibular physiotherapists, 150 Craniosacral therapists and 30 Craniofacial physiotherapists in the Netherlands. At the same time, there are increasing doubts about the effectiveness of the treatment of the cranium. What has been researched so far?
Most general reviews of cranium treatment conclude that there is little to no evidence for diagnostic reliability and effectiveness (Green, Hartman, Jakel, May, Rogers and Guillaud).
More specific studies have also been carried out. We explain the most important studies for each explanatory model from the ECOP model. We use the Moran method (2005) which classifies the literature on cranial tests and treatment methods in:
1) Reliability and validity of the tests of dysfunctions according to the models used in osteopathy in the Cranial Field (OCF).
2) Evidence that dysfunctions in the OCF can be linked to poor health outcomes.
3) Evidence of the effectiveness of OCF in changing health outcomes.
We focus on reliability (1) and effectiveness (3).
1. Biomechanical model
The earlier models about OCF from Sutherland (1984) and Magoun (1966) are mechanical models in which the brain fluid is driven by moving skull bones. However, influencing the mobility of skull bones is nonsense, according to Hartman (2002), Greenman (1970) and other authors. Cranial surgeons consider this theory as quackery.
Jayaprakasha (2013) concluded after studying hundreds of skulls that the suture patterns remain plastic until they reach a higher age. Fixation of the sutures, according to Steinmetz (2012) and Gabutti (2014), is due to the myofascial system. Kuchera (2009) indicates that myofascial somatic dysfunction is important in diagnosing the skull.
In addition to local and regional there is a mechanical global picture: this can be seen in posturology and how "strain patterns" (Zink, 1979) have manifested themselves throughout the body. Kroman (2009), an anthropologists, studied skulls and bones and concluded that there is a clear correlation between cranial dysfunctions and dysfunctions in the rest of the skeleton. This indicates a fascial relationship between the body and the skull.
Reliability of testing
A study by Greenman (1970) shows that palpation of the 3D structure is significantly similar to the X-ray images of the skull. Halma (2008) indicates that the intra-rater reliability is significant when determining strain patterns.
This cephalometry can be further refined by means of software and may serve as a measuring instrument for young children, in which it appears that the skull is still malleable (Jayaprakasha 2013, Philippi, 2006).
Effectiveness of the treatment
Lalouze Pol (2009), Lessard (2011), Cazala (2012) and Philippi (2006) have done studies where they mechanically treated the skull post-natally. This treatment to prevent preventive orthodontics is an important indication area for cranial osteopathy in young children and appears to be significantly effective. In contrast, Downey (2004) did not see any effect of a "Frontal Lift" on the sutures in rabbits.
2. The circulatory model
The first models in the OCF based on circulation are from Sutherland, Magoun and Upledger (pressurestat model). In short, they state that the rhythms originate from liquid movements of the liquor. Chu (1998) shows that the pulsations in the liquor are a compilation of the different fluid rhythms. Fergusons (2003) hypothesis is that there are many different rhythms (arterial, venous, lymphatic respiration and liquor). This explains why the inter-assessors reliability would be low, as was found by Norton (1996) and Hartman (2002). Moskalenko (2003) indicated that arterial pulsation is the most prevalent. Furthermore, in his measurements he has seen a rhythm that is separate from the aforementioned rhythms: the intracranial fluctuations of 5-15 cpm. These are a composite of all rhythms. Gard (2009) based his model of cranial rhythms mainly on venous parameters. Gehlen (2017) shows that the collapse of the V. Jugularis has an influence on the liquor circulation by changing posture. De Bakker (2006) states in his review that this system should be viewed from arteries, veins and certainly also the lymphatic system that influence the circulation of liquor. The recent discovery of the Glymphatic system confirms this.
Reliability of the tests
Hartman (2002), Norton (1996), Wirth-Patullo (1994) and Sommerfeld (2004) looked at the intra-rater's reliability of the feeling of the rhythm, and found that this reliability is too low. The pulsations that osteopaths feel on the skull are a compilation of different rhythms. Sergueef (2011) has examined the reliability of CRI / PAM. She does, however, conclude a greater reliability (see also page XXX). Hiort provides an overview of the measuring methods that have been used and concludes that there is little evidence for measuring rhythms. Nelson (2006) states that the rhythm is less important, the position of the bones and the power of the pulsations are important.
Effectiveness of the treatment
Even if the osteopath manages to objectify this rhythm, whether it is rhythm or strength (Mokhov 2016), it is still questionable whether it has been found that the cranial treatment significantly improved the rhythms compared to a placebo.
There is still insufficient evidence that the systemic approach to circulation leads to better results compared to isolated treatment of the skull. Richter-Schulz (2010) is therefore of the opinion that the CRI or Primary Respiratory Mechanism (PAM) should be released as a diagnostic tool and that especially the sutures should be tested.
3. Biochemical model
The "Gut Brain axis" is seen as increasingly important. Studying the influence of the microbiome on pathologies such as Alzheimer's is increasing. There is still no evidence for influencing biochemistry. In short, here is no model about the influence of the abdomen on the cranium, no correlations between abdominal symptomatology/ dysfunctions and cranial dysfunctions, and no effect studies that show that a treatment of the abdomen changes the parameters of the cranium.
4. Neurological model
The tissue pressure model of Norton is based on the assumption that the nerve tissue is the motor for the rhythms. Brain tissue provides a pressure and also a rhythm via intracellular fluid. Moskalenko (2013) mentioned the function of the glial cells as a possible explanation for this, as also shown in the Glymphatic system. Richtsmeier (2013) has shown that it is the brain development that determines the shape of the skull.
Reliability of testing
There are no tests for brain and brain nerve functions in osteopathy, but there are neurological function tests. These have been validated.
Effectiveness of the treatment
Especially the CV4 technique has, according to some studies, influence on the functioning of the autonomic nervous system (Buschatzky 2014), (Collard 2009), (Cutler 2005), (Grill 2006). In contrast, Milnes (2007) and Cardoso (2015) found no significant effect of the CV4. The methodology and the results must be further examined in order to arrive at a conclusion.
Duncan (2008) and Raith (2016) examined the influence of cranial treatment on motor functioning. Duncan found an effect, Raith did not. Mataran (2011) showed that sleep and tension in fibromyalgia patients changed after cranial treatments. Sandhouse found an improvement in vision after a viscerocranium treatment.
5. Biopsychosocial model
In the model "the synchronization hypothesis" of McPartland it is indicated that there is a harmonization of electrical and electromagnetic rhythms between osteopath and patient. This has recently been confirmed by Liu (2017) and Stevens (2010). A biophysical exchange takes place, but the information that is exchanged can not be interpreted. Hendryx (2014) states that a bio-energetic model must be added to the ECOP model. The biopsychosocial translates into bioelectromagnetics in the natural sciences, because thinking is seen as an electromagnetic phenomenon of the brain. Stone, Fulford (1997) and Hendrikx (2017) developed models of the bioelectromagnetic field in osteopathy.
Reliability of testing
Testing the bioelectromagnetic field has not yet been investigated in osteopathy. A start has been made with the bio photon emission of the body (van Wijk, 2016). In his new book, Van Wijk will summarize the therapeutic influence (in mid-2018). So there is no question of dysfunctions and a correlation of this with symptomatology.
Thinking and conducting conversations, which falls within the biopsychosocial model, takes place in the subjective domain. We leave the objectifiable. The osteopath is informed and must objectify the subjective experience of the patient. What do I experience with this patient, and is this true or is this a transfer?
When the domain of the psycho-emotional is viewed, it is striking that the boundaries of the domain are determined by psychopathology. It is debatable whether osteopaths know enough of psychopathology to be able to determine whether this is a spontaneously occurring emotional release, as Upledger (2002) states with his Somato-Emotional Release techniques, or a generalized anxiety disorder as a result of, for example, sexual abuse. The osteopath may play an important role here, but must then be trained in psychology and psychopathology to recognize issues such as transference counter-transference, attachment styles and DSM 5 axis 3 problems.
Cranial osteopathy is a combination of techniques. The models which have the possibility of looking at effectiveness and reliability, seem to lie mainly in the circulatory, neurological and bioelectromagnetic domain. Osteopathic clinical reasoning offers osteopaths the possibility to distinguish themselves. Looking locally, regionally and globally from the different models, using a terminology that is universal and not just for osteopaths, can give us a permanent place in the landscape of health care for the cranium.
For references and recommendations see also www.swoo.nl.
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