Dar et al.1 have recently conducted a study with aim of determining the prevalence of SIJ fusion using 3-D CT imaging. The study examined 287 consecutive patients (159 male, 128 female) referred to a hospital radiology department for a variety of abdominal complaints. The patients ranged from 22-93 years. Patients with spinal diseases, such as spondyloarthropathy and diffuse idiopathic hyperostosis (DISH), were excluded. Unfortunately, information on low back pain status was not reported. 3-D images of pelvises were obtained using a 64-slice CT scanner, and volume rendering sections of 1-2mm thickness. Multiplanar reformation was used to detect whether the fusion was intra- or extra-articular. The SIJs of each image were divided into six equal areas and the presence, side and location of fusions were recorded. Assessment was made by two radiologists who were blind to each others results and the interexaminer agreement was substantial.

SIJ fusion was found in 16.7% of subjects and was far more prevalent in males (27.7%) than females (2.3%). All fusions were extra-articular. Fusion in males was strongly correlated with age: 5.6% in the 20-39y.a. cohort, 15.85% in the 40-59y.a. cohort, 31.1% in the 60-79y.a. cohort, 46.7% in individuals aged over 80. Fusion among females was not significantly correlated with age. Fusion was present bilaterally in 11.9% of males. Diffuse fusion was present in 7.5% of males, four cases were bilateral. The superior region was involved in all male individuals manifesting the phenomenon. No fusions were isolated to the inferior part of the joint. Fusion of the females was at just above and under the arcuate line at the most anterior point of the joint.

The results of this study accord with previous skeletal and cadaver studies and demonstrate that SIJ fusion is common. Further, it is clearly an age and gender biased phenomenon. The authors suggest that manual therapists who frequently utilise manipulation techniques aimed at addressing sacroiliac articular mobility or that result in forces across the sacroiliac joint should be aware of the limited potential for compliance at this joint in older males. The risk of injury may be far greater than the potential benefits of manually applied forces during the treatment of SIJ dysfunction in this population.

1.    Dar G, Khamis S, Peleg S, Masharawi Y, Steinburg N, Peled N, Latimer B, Hershkovitz I. Sacroiliac joint fusion and the implications for manual therapy diagnosis and treatment. Manual Therapy. 2008;13:155-58.

The researchers conducted a literature search on PubMed, the Cochrane Library and on www.fasciaresearch.com. They also conducted an assessment of the rationale for the treatment within the studies. The search on PubMed resulted in 71 references, but only 23 were about manual MFR. A similar search in The Cochrane Library gave 13 hits, 5 about MFR and all of these already included in the 23 PubMed references. No futher supplements were found at www.fasciaresearch.com.

According to their results:

No studies were found with which to determine reliability of the diagnostic method. Four randomised controlled studies of the treatment were identified. Two of the efficacy studies comprised several different modalities of treatment, so that no conclusions could be drawn. In one further study, the numbers were too small to allow safe conclusions; in the other, the myofascial release treatment was inferior to an isometric contract-relax technique. Overall, no good evidence of efficacy has been shown.

The current evidence did not allow conclusions on the diagnostic criteria and methods or demonstrate any efficacy of myofascial release. Remvig et al. strongly recommended that “reliability studies be performed on diagnostic tests for myofascial dysfunction (tightness/looseness), so that efficacy studies can be performed on a more solid diagnostic foundation”.

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In the latest issue of the International Journal of Osteopathic Medicine there is fascinating article discussing the likely origin of most of Sutherland’s cranial osteopathy concepts. According to the author, Theodore Jordan, in 1744 a well known 17th century physician-turned-mystic, Emanuel Swedenborg, published a text titled The Brain, which described ideas similar to the first four of the five components of Sutherland’s cranial concept.1 It is known that Sutherland had a copy of a 1882 translation of this text, and on a few occasions he had made reference to Swedenborg’s ideas, even comparing Andrew Taylor Still’s anatomical study of “the handiwork of his Maker-the body” to Swedenborg’s search for the “seat of the soul” within the human brain. It appears that Sutherland integrated a significant portion of Swedenborg’s anatomically-based paradigm of rhythmic brain-body interaction into osteopathy as he developed cranial osteopathy.

This knowledge will be a revelation to many osteopaths, as it was to the editors of IJOM. However, it appears that it is not unique. A quick search on Google revealed a free access copy of the annual address delivered at the Annual Meeting of the Swedenborg Scientific Association on April 26, 2008 by David B. Fuller. This 32-page paper details a comprehensive overview of Swedenborg’s paradigm of the brain and nervous system and a comparison to Sutherland’s cranial concept.

For many osteopaths, the extent of anecdotal evidence supporting both the descriptive model and clinical outcomes is interpreted as sufficiently compelling to justify continued use of OCF treatments in clinical practice. Unfortunately, substantiating evidence of the commonly accepted explanatory models of OCF is yet to be established. In this regard, Jordan’s closing comment is worth careful consideration:

“Critical dialogue regarding cranial osteopathy is a crucial component that can only strengthen the osteopathic profession. The PRM model has been part of osteopathic thought for over 60 years. To understand that it is based on an abandoned eighteenth century physiological hypothesis will hopefully propel the osteopathic profession to open a dialogue that will serve to advance our science.”

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1. Jordan T. Swedenborg’s influence on Sutherland’s ‘Primary Respiratory Mechanism’ model in cranial osteopathy. International Journal of Osteopathic Medicine. 2009;12(3):100-105.