Long live the placebo effect?

Long live the placebo effect?

The placebo effect has a negative reputation, but that is not entirely justified. In complementary and alternative medicine (CAM) it is also seen as the self-healing capacity of the body. What exactly is the placebo effect and how can we osteopaths make good use of it?

By Sander Kales

Much of the effect of an osteopathic treatment is due to what we unknowingly do. Up to 75 percent of the relief of pain and depression complaints after a biomedical treatment is due to the placebo effect (Dieppe 2016).

The placebo is often seen as an inert substance; a pill that contains nothing effective. The placebo effect is that which follows the administration of a substance or a procedure. A placebo treatment is therefore not only about fake pills, but also about symbols, rituals and interactions.

McQueen reviewed placebo effects and postulates that the effect decreases as disease and depression worsen (2013). Placebo effects also appeared to vary enormously with different diseases.

The reverse also applies: the same placebo effect appears to be found for treatments from different healthcare providers. That was the opinion of doctor John Lie during the NVO Migraine congress of 2018. The effect of acupuncture versus a dummy treatment in the treatment of migraine turned out to be just as large as that of osteopathy versus a dummy treatment. Lie therefore concluded that the same underlying treatment mechanisms must be at work. That there is indeed an influence of placebo on physical functioning is also apparent from the negative “placebo” effect: the nocebo (Kaptchuk 2015). In short, not the treatment but something else improves the complaints of patients.

The placebo effect can partially explained by distinguishing between disease and illness. Disease is a biological dysfunction that can be explained pathophysiologically, a disorder is a condition. A placebo treatment primarily affects the condition and not the disease, McQueen states.

Although it can do a lot for the patient, a placebo treatment only provides relief and not a  cure. What is at the origin of the pain complaints, such as tumors, is not reduced.

    “The severity of the symptoms is partly determined by the experience of the patient”

The healing relationship

Apparently there is such a thing as effective medication and a healing relationship. In ancient times the phenomenon of healing was already known, and often it was mostly the intention to relieve another person of his suffering. Over time this developed into Complementary and Alternative Medicine (CAM) with rituals, beliefs and treatments. Today, according to the American National Institute of Health, CAM can be subdivided into five subareas: alternative medical systems (such as acupuncture, homeopathy), biologically based therapies (dietetics, phytotherapy), manipulative and body-oriented therapies (chiropractic, osteopathy, massage), energetic therapies (therapeutic touch, Reiki) and body-mind interventions (meditation, hypnotherapy) (Staud 2011).

With the development of the medical sciences, CAM developed further as well. In its search for the effective treatments, the medical sciences eventually left behind “bloodletting” and mercury treatments, and with that healing was also forgotten. Placebo got a bad name.

The word placebo literally means: to satisfy. It comes from a Latin psalm from the 14th century the Placebo Domino: I will satisfy the Lord. Henry Beecher made this concept popular in 1955 with his book “the Placebo effect.” He stated that the placebo is a threat to medical science and is therefore unethical. In randomized controlled studies (RCTs) today, the effect of placebo’s is not measured but filtered out (Staud 2011).

    “The placebo effect van be seen as the self-healing capacity of the patient”

CAM

But what applies to regular medicine does not apply to Complementary and Alternative Medicine. After all, CAM is not related to tumor treatment, but more often to the experience of complaints. Because the severity of complaints is also partly determined by the experience of the patient. In CAM, the placebo effect is therefore seen as the self-healing capacity of the patient, the third principle in osteopathy.

According to renowned CAM researcher Ernst (1995), the effect of a CAM intervention does not only consist of a specific treatment effect, but also of non-specific effects such as the placebo effect, a natural healing effect and various other phenomena. But what exactly does the placebo (treatment plus effect) consist of? Or vice versa: how is it that CAM practitioners score so well on placebo effects?

According to Stub (2017) researcher at the Integrative Health Care center in Norway, CAM is provided by health care practitioners who listen, confirm, give hope – and do this in a pleasant environment. They generally have more time than their colleagues from mainstream medicine. In addition, these health care providers believe in the effectiveness of their approach. All of these factors influence the placebo effect.

The placebo effect is therefore achieved by having faith and belief in the healing process. Patients undergoing CAM therapy experience being seen as a whole. This holistic approach is perceived by patients as empowering and instructive with regard to their own recovery capacity. This contextual healing is seen as the placebo treatment. Dieppe (2016) states that mainstream medicine should applaud the ability of CAM practitioners to achieve a strong placebo and learn from it.

There is also a demonstrable neurophysiological effect with placebo effect. When undergoing a placebo treatment, Finness (2010) measured changes in brain activity. It is therefore clearer to replace placebo treatment as a concept with “mental attunement to the context of treatment”. This mental tuning gives the relief of pain.

According to Harvard brain researcher Hashmi (2018), mental attunement consists of internal (expectation) factors within the patient and external (relational) factors, regarding the therapist and the patient.

The internal relational factors consist of: patient expectations, pain beliefs, satisfaction and health beliefs. The external relational treatment factors, also referred to as non-specific factors, consist of beliefs from the osteopath, the therapeutic relationship and feedback, rituals, conditioning. Together they are also called “common factors”.

As an osteopath, how do I optimize the process of mentally tuning in?

The osteopathic therapist-patient relationship

The professional competence profile for osteopaths in the Netherlands (NVO 2014) states that an osteopath communicates effectively verbally and non-verbally to build a relationship, to conduct a conversation and to be able to report. An osteopath must learn to build a good relationship by listening, recognizing verbal and non-verbal communication, giving space, learning to recognize feelings and, in the meantime, taking into account the uniqueness of the patient.

The British Osteopathic Association (G.O.C. Standards, 2000) states that the osteopath enters into an empathetic relationship with the patient. They believe that the osteopath should be critical and able to reflect on himself. Touching creates an intimate contact and non-verbal communication is therefore important.

The German osteopath Mayer (20165) describes in her thesis that the osteopath-patient relationship consists of the following five components: the work agreement, transference-countertransference relationship, the restorative development-oriented relationship, the congruence I-other (empathic capacity) and the transpersonal relationship (self-awareness, third-person perspective). It is important to keep all five components in mind during the treatment process.

Professor Sturmberg (2013), specialist in the field of complex systems in health care, summarizes these relationships by stating that a healing relationship consists of three components: competencies (clinical wisdom, mindful, emotional self-regulation and self-confidence), processes (appreciation, connecting and surrendering) and outcomes (hope, trust, being known, PROM and PREM). You can train the competencies, observe the processes and try to get feedback (for example through peer review) and evaluate the outcomes.

In summary, one can state that an osteopathic relationship must contain a number of aspects: competencies of the osteopath, good processes (working relationship, non-verbal communication, transfer-versus-transfer, affect regulating and subject relationship) and of course the desired outcomes. These aspects may then result in an improvement of the non-specific/general treatment factors. What do these skills look like in the osteopathic process?

The diagnostic phase

The osteopath-patient relationship starts with a diagnostic phase. Within osteopathy we work with the five explanatory models of complaints according to the ECOP (Hruby, 2019). The fifth model is the biopsychosocial model. The definition according to Romano is: “The biopsychosocial approach systematically takes into account biological, psychological and social factors and their complex interaction in understanding health, disease and healthcare.”

It appears that the osteopath is inclined to focus primarily on a biomedical and a structural analysis of the demand for help in everyday practice. They are much less inclined to approach the demand for help from the biopsychosocial model (Sampath 2020). According to osteopath Abrosimoff, this leads to osteopaths having a paternalistic attitude towards their clients (“I’ll fix it”). And that attitude has a negative effect on all relational aspects that would actually increase the effect of a treatment (2020).

Thus, the concept of somatic dysfunction in osteopathy does not take into account the psychosocial dimensions of complaints. Fryer even states that this notion is outdated and reinforces the belief in a structural biomedical cause of pain. The osteopath “makes or heals” instead of “guiding the change” (2016). Osteopath and clinical psychologist Calsius notes that there is a latent danger of reducing the psychological reality of the patient to the somatic explanation paradigm of osteopathy (2018).

The treatment phase

The biopsychosocial model is non-theoretical and purely descriptive. It provides a framework for the diagnostic phase, but doesn’t give a guideline for the treatment phase. However, various osteopaths have also looked into the treatment phase.

The osteopath can modulate the autonomic nervous system, based on tone and lifestyle stressors change (Kolb 2020). However, this falls within the biomedical paternalistic “I will make it” approach.

According to the osteopath Barrington, touching during an osteopathic treatment has a number of facets: supportive, preparatory, informative, caring, therapeutic intervention, awareness of information, safety and exchange (2014). Touching therefore contains many relational aspects that can promote the treatment relationship and thus also ensure the non-specific treatment effect.

It is then necessary to integrate osteopathic touching with verbal communication, to make transference and resistance phenomena transparent. Mayer (2015) conducted qualitative interviews with osteopaths and showed that the person who sees himself as a mediator between the patient and his “healthy” parts, places less emphasis on verbal communication than the therapist who sees himself as a supervisor of the process.

    “By paying more attention to the factors that contribute to the osteopath-patient relationship, we can increase our effectiveness”

Resume

The osteopathic intervention has a number of effects, including the placebo, or the mental alignment with the treatment. The osteopathic treatment does not contain a separate biopsychosocial approach, but it does arise from the treatment relationship. Touch is an important aspect of this. This touch requires more verbal communication and awareness of the relational factors. By paying more attention to the factors that contribute to the osteopath-patient relationship, we can increase our effectiveness.

The NVO congress will elaborate on the biopsychosocial working method of the osteopath, and includes the following speakers:

1. Joeri Calsius, osteopath and clinical psychologist, presents a conceptual model for integrated bodywork from a somato-psychic perspective.

1. Hedda Lausberg, neurologist and psychiatrist, has worked out non-verbal communication so that there are concrete tools that contribute to improved patient contact.

1. Eva Banninger, professor of clinical psychology, shows through video contribution what happens in transfer-opposite transfer phenomena (see recent newsletter).

1. From the Mental Health Care (GGZ), Rogier Hoenders will show the limits but especially the possibilities for an integrated approach.

1. Red flags: disorder or serious pathology.

1. Yellow flags: psychosocial indicators that show an increased risk for progression to longer-term distress, inability and pain.

1. Blue flags: work and employer perception of health and work.

1. Black flags: context and environment, such as other people, systems and policies

1. Orange flags: psychiatric symptoms.

1. Abrosimoff M, Rajendran De, “Tell me your story” – How osteopaths apply the BPD model when managing low back pain – A qualitative study, International Journal of Osteopathic Medicine (2020).

1. Barrington, Contacting with Clarity – The communicative purposes of osteopathic touch, 2014, Master of Osteopathy, Unitec New Zealand.

1. Bialosky 2017, Placebo Mechanisms or Manual Therapy: A Sheep in Wolf’s Clothing? J Orthop Sports Phys Ther 2017; 47 (5): 301-304. doi: 10.2519 / jospt.2017.0604.

1. Calsius, Experiential Bodywork Course, Panta Rhei, 2018.

1. Clarke, R.J., Depression, Anxiety and Positive Outlook among patients presenting to an osteopathic training clinic: A prospective survey, Master of Osteopathy, Unitec Institute of Technology, 2010.

1. Dieppe, P., & Rahtz, E. (2016). Placebos, CAM and Healing: P + X + Y. Int J Complement Alt Med, 4 (2), 00114.

1. Dugailly, P.M., Fassin, S., Maroye, L., Evers, L., Klein, P., & Feipel, V. (2014). Effect of a general osteopathic treatment on body satisfaction, global self-perception and anxiety: A randomized trial in asymptomatic female students. International journal of Osteopathic medicine, 17 (2), 94-101.

1. Ernst, E., & Resch, K. L. (1995). Concept of true and perceived placebo effects. Bmj, 311 (7004), 551-553.

1. Finniss, D.G., Kaptchuk, T.J., Miller, F., & Benedetti, F. (2010). Placebo effects: biological, clinical and ethical advances. Lancet, 375 (9715), 686.

1. General Osteopathic Council, Standard of Proficiency, 2000.

1. Greco, C.M., Yu, L., Johnston, K.L., Dodds, N.E., Morone, N.E., Glick, R.M., & Colditz, J. (2016). Measuring nonspecific factors in treatment: item banks that assess the healthcare experience and attitudes from the patient’s perspective. Quality of Life Research, 25 (7), 1625-1634.

1. Hall AM, Ferreira PH, Maher CG, et al. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: a systematic review. 2010; 90: 1099–1110.] Phys Ther.

1. Hashmi, J.A. (2018). Placebo effect: Theory, mechanisms and teleological roots. In International review of neurobiology (Vol. 139, pp. 233-253). Academic Press.

1. Hruby, R.J., Tozzi, P., (2017). The five osteopathic models: Rationale, application, integration: from an evidence-based to a person-centered osteopathy.

1. Kaptchuk, T. J., & Miller, F. G. (2015). Placebo effects in medicine. N Engl J Med, 373 (1), 8-9.

1. Kendall, N., Linton, S.J., and Main, C.J. 1997 Guide to assessing psychosocial yellow flags in acute low back pain: Risk factors for long term disability and work loss. Accident rehabilitation and Compensation Insurance of New Zealand and the National Health Committee, Wellington, New Zealand.

1. Kolb, W.H., McDevitt, A.W., Young, J., & Shamus, E. (2020). The evolution of manual therapy education: what are we waiting for?

1. Mayer, Sharon, Towards a relational understanding of embodied therapeutic relationships: a qualitative study of body-focused practitioner’s experiences, 2015.

1. McQueen, D., Cohen, S., St John-Smith, P., & Rampes, H. (2013). Rethinking placebo in psychiatry: the range of placebo effects. Advances in psychiatric treatment, 19 (3), 162-170.

1. Miciak, Maxi, A review of the psychotherapeutic common factor model and its application in physical therapy: the need to consider general effects in physical therapy practice; Scand J Caring Sci; 2012; 26; 394–403.

1. NFP, Professional Competence Profile of Psychomatic Physical Therapy, KNGF-NFP, May 2009 edition.

1. Novy, Regina, Therapist-Patient-Relationship in Osteopathy; How do osteopaths form their relationship to patients? A qualitative study, Master Thesis Danube University Krems at the Wiener Schule für Osteopathy (Vienna School of Osteopathy), Vienna, May 2007.

1. NVO, Professional profile Osteopathy, version 2014.

1. Sampath, K.K., Darlow, B., Tumilty, S., Shillito, W., Hanses, M., Devan, H., & Thomson, O. P. (2020). Barriers and facilitators experienced by osteopaths in implementing a biopsychosocial (BPD) framework of care when managing people with musculoskeletal pain – A mixed methods systematic review protocol. International Journal of Osteopathic Medicine.

1. Staud, R. (2011). Effectiveness of CAM therapy: understanding the evidence. Rheumatic Disease Clinics, 37 (1), 9-17.

1. Stub, T., Foss, N., & Liodden, I. (2017). “Placebo effect is probably what we refer to as patient healing power”: A qualitative pilot study examining how Norwegian complementary therapists reflect on their practice. BMC complementary and alternative medicine, 17 (1), 1-10.

1. Sturmberg, Joachim P., and Carmel Martin, eds. Handbook of systems and complexity in health. Springer Science & Business Media, 2013.

1. Association of Haptotherapists (VVH) Professional competence profile GZ-Haptotherapeut version 2010.

1. Zellner, Katrin, Übertragung und Gegenübertragung – Phänomene einer gegenseitigen therapeutischen Beziehung! Eine Hinführung auf das Theme Patients-Therapists-Beziehung mit Bezug zur Osteopathy, Thesis Osteopathy Schule Deutschland, Berlin, 31.08.2014

1. Zhang, W., & Doherty, M. (2018). Efficacy paradox and proportional contextual effect (PCE). Clinical Immunology, 186, 82-86.

1. Zilcha-Mano, S., Roose, S. P., Brown, P. J., & Rutherford, B. R. (2019). Not just nonspecific factors: the roles of alliance and expectancy in treatment, and their neurobiological underpinnings. Frontiers in behavioral neuroscience, 12, 293.

x

In the Netherlands, the psychosomatic physical therapist goes one step further from the osteopath according to his professional competence profile (2009). They see themselves as an instrument in the client’s treatment process. The therapeutic relationship refers to the dialogically embodied contact between client and therapist. This vision requires continuous reflection during the entire treatment process, both on one’s own actions (self-reflection) and on the client’s reaction. Feeling (intuition and experience), empathy and sympathy are required elements in the attitude of the psychosomatic physical therapist (NFP 2009).

The psychosomatic physical therapist examines for red, blue, black and yellow flags, identifies implicit problems and assesses whether the client can actively participate in the process.

This flag system has been postulated by Kendall (1997), among others. The system is a means to map the psychosocial landscape of the patient.

References:

Osteopathy in the Cranial Field: does it work?

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).

Models

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.

B. Subjectivity

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.

Discussion

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.

References 

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Wat kan de osteopaat doen bij whiplash

Het onderstaande verhaal is illustrerend voor patiënten met whiplashklachten. Het is tot stand gekomen dankzij vijfentwintig jaar praktijkervaring met mensen met whiplash, maar ook door de persoonlijke ervaring van de auteur.[/]
De osteopaat ziet veel mensen met een whiplash. Een vijfde van de mensen in de osteopathiepraktijk heeft nekklachten, waarvan weer een vijfde whiplashklachten. Grofweg gezegd heeft 2,5 procent van de patiënten in de osteopathiepraktijk wel eens een whiplash meegemaakt. Whiplash is een beeld dat ons dwingt om functionele onbegrepen klachten te onderzoeken en samen te werken met de verschillende disciplines die op de deelgebieden actief zijn. Dit is nog steeds een uitdaging binnen het huidige gezondheidsstelsel.’

Een voorbeeld

Stel u bent voor de tweede keer in vijf jaar van achteren aangereden. De eerste paar weken bent u nog druk bezig met de afhandeling van de schade, plus dat u op uw werk net in een project zit dat veel van uw tijd in beslag neemt. De eerste weken na het ongeval merkt u wel dat uw nek stijf is en dat uw concentratie minder is. Af en toe bent u licht in het hoofd. Na vier weken besluit u toch eens bij de huisarts langs te gaan. De concentratievermindering, duizeligheid en nekpijn blijven aanwezig, maar u merkt ook dat u lichter slaapt, vaker vermoeid bent, uw kaken gespannen zijn en u gevoeliger bent voor geluid. 

Het medisch circuit in

De huisarts constateert een Whiplash Associated Disorder (WAD) type 2 (nekklachten en andere klachten van het houdings- en bewegingsapparaat) en stuurt u door naar de fysiotherapeut. De fysiotherapeut is een specialist op het gebied van spieren en hij constateert dat uw nek- en kaakspieren gespannen zijn. Er wordt gemasseerd en u krijgt oefeningen mee om uw nekspieren op te rekken. Toch blijven de duizeligheid, de concentratieproblemen, het lichte slapen, de pijn, de vermoeidheid, de gespannen kaak en de gevoeligheid voor geluid aanwezig. 

De fysiotherapeut stuurt u door naar een collega die manueel therapeut is: een specialist op het gebied van gewrichten. De  manueel therapeut constateert dat uw bovenste nekwervels en kaak vast zitten en dat uw borstwervelkolom gespannen is. De behandeling wordt ingezet. Inmiddels bent u vijf maanden verder, de bewegelijkheid van de nek en kaak zijn toegenomen, maar de verminderde concentratie, de vermoeidheid, de duizeligheid, de pijn en de gevoeligheid voor geluid blijven. 

Inmiddels is het op uw werk duidelijk geworden dat u niet meer goed functioneert en men heeft u aangeraden zich ziek te melden. Volgens de bedrijfsarts is whiplash psychosomatisch en hij stuurt u door naar een psycholoog. De procedure met de afhandeling van de schade blijft ook maar voortslepen. Op het schoolplein ontmoet u een ouder die u adviseert om eens bij de osteopaat langs te gaan. 

Naar de osteopaat

De osteopaat is een specialist op het gebied van functionele onbegrepen klachten van het bewegingsapparaat, de bloedvaten, de stofjes in uw lijf en uw zenuwen. Hij kijkt waar u staat op de schaal van ziekte (0) naar gezondheid (10), waarbij eerst uitgesloten wordt dat er niet een duidelijke ziekte c.q. beschadiging aanwezig is. Indien u niet in dit domein valt (0-3) zit u in het domein van de functionele klachten (4-7). Er zijn dus klachten, maar er is geen duidelijk aanwijsbare anatomische oorzaak. Hier was u zelf ook al achter gekomen.

Verder kijkt de osteopaat naar de verbanden tussen de verschillende systemen en niet lineair of reductionistisch (bijvoorbeeld. is het de zenuw > neuroloog, is het de nek > orthopeed, et cetera).

Het eerste consult - klachtenanalyse

Hij onderzoekt u en constateert het volgende: Bij de eerste aanrijding is er al een overprikkeling van uw pijnsysteem (nociceptie) opgetreden. Verder is toen al een verminderde functie van uw oogmotoriek begonnen aangezien u toen al behoefte had aan een bril, maar deze was steeds net niet goed genoeg. Ook had de tandarts toen al geconstateerd dat u toch wel vaak lag te klemmen ’s nachts. De ogen en de kaak worden bezenuwd door hersenzenuwen vanuit de hersenstam, en de osteopaat concludeert dat deze al de afgelopen jaren meer geprikkeld was aangezien u toen ook al fysiotherapie gehad had.

Door de huidige aanrijding is het pijnsysteem verder overprikkeld geraakt en er is sprake van allodunia: normale niet pijnlijke prikkels leiden nu tot pijn. (Kasch, 2016)

Een mogelijke oorzaak van uw duizeligheid kan te vinden zijn in een verstoring van de beweeglijkheid van de bovenste nekwervels, prikkeling van de banden van uw nek door de klap of zelfs verstoring van de werking van uw oogspieren. Deze zaken kunnen ook de oorzaak zijn van de regelmatig vastzittende nek.

Onderzoeken van Curatolo (2011), Jun Li (2014), Oostendorp (1999, 2013), Yacovino, (2013), Sterling (2006) en Nacci (2011) hebben aangetoond dat achtereenvolgens een verstoring van de mobiliteit in de bovenste nekregio door prikkeling van de synoviale gewrichten, irritatie van de ligamentuur en verstoring van de intrinsieke oogmusculatuur oorzaken kunnen zijn van aanhoudende duizeligheid bij postwhiplashklachten.

De osteopaat constateert ook dat uw pupilreflex veranderd is (flutteren: afwisselend openen en dicht gaan als reactie op een lichtprikkel), dit is een overstimulatie van perifere sympathische neuronen. Blijkbaar heeft de pijnprikkel geleid tot een overstimulatie van een zenuwknoop in uw nek (het ganglion cervicale superior) waar het schakelcentrum is voor bijvoorbeeld de doorbloeding naar uw hoofd en de pupilreflex. Naast deze overprikkeling hoog in de nek constateert hij ook dat uw hartritmevariabiliteit veranderd is naar een meer ‘opgejaagd’ beeld  (Passatore, 2006, Brugnoni, 2014, Edwards, 2015). Ook uw tongmotoriek is veranderd, en u had al bemerkt dat af en toe een grote hap doorslikken niet altijd even makkelijk ging (Bordoni, 2015).

Op basis van deze bevindingen constateert de osteopaat dat er sprake is van een centrale sensitizatie, dat wil zeggen er is een overprikkeling van het pijnsysteem die geleid heeft tot een uitbreiding van de klachten naar het zogenaamde onwillekeurige zenuwstelsel  (Winkelstein, 2011).

Naast de overprikkeling van het zenuwstelsel is er door de lokale ‘ontstekingsverschijnselen’ van het gewricht en de zenuwen (Curatolo, 2011, Kasch, 2016) een belasting op het Neuro Endocrino Immunologische (NEI) systeem. Dit resulteert in verandering van de cortisol, een hormoon dat wordt afgescheiden in de bijnierschors, en dat ook van invloed is op vermoeidheid en slapen (Gaab, 2005).

De osteopaat legt uit dat het zenuwstelsel na twee posttraumatische nek-ongevallen in vijf jaar overprikkeld is, en dat de prikkel zich ‘gegeneraliseerd’ heeft. Dit is een belangrijk punt bij whiplash; de overgang van acuut naar chronisch. Bij deze overgang wordt in het dagelijks functioneren steeds duidelijker dat u niet meer op 100 procent zit. Dit gegeven breidt zich als een inktvlek uit, u begint te twijfelen of u wel het juiste werk heeft, vrienden merken dat u toch wat vaker afbelt en afwezig bent, kortom: uw psychosociale functioneren lijdt inmiddels ook. Daarnaast levert het onbegrip en de slepende juridische kwestie geen positieve bijdrage.

Na het eerste consult waarin de osteopaat dit alles heeft uitgelegd, gaat u beduusd naar huis. U probeert te bevatten wat hij u zojuist verteld heeft, maar het duizelt u. Toch heeft u tegelijkertijd het gevoel dat er iemand is die naar u in totaliteit kijkt, de tijd neemt en bovenal al die ‘vage’ klachten verklaren kan. Maar wat belangrijker is: wat kan hij er aan doen? Bij het volgende consult besluit u dit aan de orde te brengen.

Aanpak van de osteopaat

Duidelijk is dat het zenuwstelsel rust moet krijgen. Dit varieert van leren te ontspannen (bijvoorbeeld met behulp van mindfullness), herkenning van belasting-belastbaarheid en de aanpassing van uw leven daaraan, tot aan concentratieoefeningen. Hier is een multidisciplinaire aanpak van belang.

Ook moet voor de algehele tonus (sympaticotonus) van de bloedvaten een goed trainingsprogramma opgesteld worden. Tevens zal de osteopaat het autonoom zenuwstelsel trachten te reguleren.

Er moet gekeken worden naar uw NEI-systeem, en waar mogelijk ondersteund door een goed voedingsadvies (lage suikerinname).

Een functioneel optometrisch onderzoek is nodig om uw oogfunctie te beoordelen en hier mogelijk een brilcorrectie voor te doen. Allereerst doet de osteopaat dit onderzoek naast een schedel en hersenzenuw onderzoek en zal daar waar verlies aan mobiliteit is het gaan behandelen.. 

U zal door moeten gaan met de oefeningen voor de bewegelijkheid van de nek (alhoewel de stijve nek dus mogelijk een gevolg is van andere oorzaken, een somato-somatische reflex, Janig 2011). De oefeningen zullen het effect van de mobilisatie die de osteopaat uitvoert moeten ondersteunen.

Effecten

Allemaal mooi en wel, maar wat doet nu precies die osteopathische behandeling? Een Cochrane review laat zien dat er geen eenduidigheid is of een actieve dan wel passieve behandeling beter zou zijn. Er zijn enkele studies naar osteopathie gedaan (Fryer, 2005, Schwerla, 2013, Bordoni, 2014? Giu, 2010, Sun Genese, 2013) waarin er een indicatie is dat osteopathie effect heeft. De vraag is natuurlijk: welk deel van de osteopathische behandeling is dan effectvol? 

De geïndividualiseerde behandeling, waarbij aandacht is voor het gehele lichaam (ook het bekken, onderrug, borstwervelkolom en het bindweefsel rondom de organen) heeft een effect, maar dit dient verder onderzocht te worden.

De conclusie

Uw klacht is na twee jaar duidelijk minder, u heeft uw werk weer hervat, alleen wanneer u te veel van uzelf vraagt, komen  de concentratieproblemen, de pijn, de duizeligheid en de vermoeidheid nog licht terug. Restklachten zijn er doorgaans nog, echter de mate van belemmering in het dagelijks leven kan wel degelijk beinvloedt worden door osteopathie.

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Referenties:

1. Bordoni, 2016, the tongue after whiplash: case report and osteopathic treatment, International Medical Case Reports Journal 2016:9 179–182 

2. Boniver, 2014, Whiplash associated autonomic effects, Chapter 11, D.C. Alpini et al. (eds.), Whiplash Injuries, 281 DOI 10.1007/978-88-470-5486-8_27 

3. M. Curatolo, 2011, The role of tissue damage in whiplash associated disorders: Discussion paper 1, Spine (Phila Pa 1976). 2011 December 1; 36(25 Suppl): S309–S315 

4. I.J. Edwards et al., 2015, Neck muscle afferents influence oromotor and cardiorespiratory brainstem neural circuits, Brain Struct Funct (2015) 220:1421–1436 

5. G. Fryer, 2005, Research report: The effect of osteopathic treatment on people with chronic and sub-chronic neck pain: A pilot study, International Journal of Osteopathic Medicine (2005) 41-48

6. J. Gaab, 2005, Reduced reactivity and enhanced negative feedback sensitivity of the hypothalamus–pituitary–adrenal axis in chronic whiplash associated disorder, Pain 119 (2005) 219–224 

7. Giu, 2010, Rehabilitation and Osteopathic Manipulative Medicine for a Patient With Dysphagia Secondary to a Hyoid Somatic Dysfunction: A Case Report.

8. Janig, 2011, Functions of the autonomic nervous system, Chapter 2, The science and clinical application of manual therapy, Churchill Livingstone

9. Jun Li , et al., 2014, Sympathetic nerve innervation in cervical posterior longitudinal ligament as a potential causative factor in cervical spondylosis with sympathetic symptoms and preliminary evidence, Medical Hypotheses 82 (2014) 631–635

10. Kasch, 2016, Whiplash injury; perspectives on the development of chronic pain, IASP press, Philadelphia, pg.242

11. Nacci, 2011, Vestibular and stabilometric findings in whiplash injury and minor head trauma, Acta Otorhinolaryngol Ital 2011;31:378-389 

12. Oostendorp, 1999, Dizziness Following Whiplash Injury: A Neuro-Otological Study in Manual Therapy Practice and Therapeutic Implication, The Journal of Manual & Manipulative Therapy Vol. 7 No. 3 (1999), 123 - 130 

13. Passatore, 2006, Influence of sympathetic nervous system on sensorimotor function: whiplash associated disorders (WAD) as a model, Eur J Appl Physiol (2006) 98:423–449 

14. F. Schwerla, 2013,  Osteopathic Treatment of Patients with Long-Term Sequelae of Whiplash Injury: Effect on Neck Pain Disability and Quality of Life, THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 0, Number 0, 2013, pp. 1–7

15. Michele Sterling , 2006, The relationship between sensory and sympathetic nervous system changes and posttraumatic stress reaction following whiplash injury—a prospective study, Journal of Psychosomatic Research 60, p.387–393

16. J. Sun Genese, 2013, Osteopathic Manipulative Treatment for Facial Numbness and Pain After Whiplash Injury, The Journal of the American Osteopathic Association July 2013 | Vol 113 | No. 7 

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