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.”

.

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.

The researchers found that observing the beneficial effects in the demonstrator induced substantial placebo analgesic responses, which were positively correlated with empathy scores. Moreover, observational social learning produced placebo responses that were similar to those induced by directly experiencing the benefit through the conditioning procedure, whereas verbal suggestions alone produced significantly smaller effects. These findings show that placebo analgesia is finely tuned by social observation and suggest that different forms of learning take part in the placebo phenomenon.

Colloca L, Benedetti F. Placebo analgesia induced by social observational learning. Pain. 2009 Jul;144(1-2):28-34. Epub 2009 Mar 10.

Linton et al.¹ explain that reassurance is a complex process involving interactions between patient experience, thoughts, beliefs, and emotions and occurring within a dynamic interaction between the patient and a practitioner. Reassurance is achieved if the patient changes their understanding, thoughts and/or behaviour. The method of reassuring is the behaviour of the practitioner and includes the provision of information, instruction and persuasion.

Reassurance is commonly provided in the form of potentially corrective information, and may involve physical explanations for symptoms, results of diagnostic tests, or prognosis. Although such information may be accurate it does not guarantee that patients will respond with reduced fear and changed behaviours. For example, evidence from a cited study demonstrates that when patients receive information that is not directly related to their concerns or experience the information as a lack of understanding of the legitimacy of their complaint (“don’t worry, it’s not serious”) they respond by elaborating or asserting the symptoms more vigorously. Reassurance was accepted only when it included an explanation that was relevant to the patient’s concerns and linked physical and psychological factors.

The complexity of patient characteristics may influence the effects of providing reassurance, and the authors suggest that this may explain the inconsistencies in the current literature. For example, the effectiveness of information as reassurance can vary according the a patient’s level of health anxiety, with those experiencing higher levels responding less to attempts at reassurance. Furthermore, some studies have shown that reassurance, such as stressing the mildness of a problem and the likelihood of recovery, can actually increase disability and fear of future pain. Reassurance may also complicate a patient’s problems by reinforcing safety-seeking behaviours such as requests for information and diagnostic tests.

According to Linton et al.,¹ the current literature indicates that evidence for the effects of reassurance on pain-related problems is limited and inconsistent. They suggest that general recommendations for reassurance appear premature and a better understanding is needed. Although providing didactic information may help reduce fear and change behaviours in some patients and in some situations, direct attempts to change thoughts or beliefs by providing reassurance in the form of information may not be as effective as experience based methods; for example, direct (in vivo) exposure or direct verification procedures.

The authors also point to evidence suggestive that providing empathy and enhancing acceptance, rather than attempting to suppress fear and anxiety, may be an appropriate alternative in reducing the development of avoidance and other restrictive behaviours. A more solid evidence base for utilising reassurance in clinical practice must await further research.

1. Linton SJ, McCracken LM, Vlaeyen JW. Reassurance: help or hinder in the treatment of pain. Pain. 2008;134:5-8.

In the absence of an accepted gold standard, physical diagnostic tests should demonstrate inter-rater reliability in order to be considered clinically useful. Myburgh et al.3 have recently published the first systematic review of reliability studies examining evidence for the use of manual palpation for identifying MTPs. The reviewers used a comprehensive search strategy across relevant medical databases and the reference lists of related articles. The search revealed eleven relevant studies, however five studies were subsequently excluded because they did not use appropriate statistical measures of agreement. The remaining six studies were then assessed for internal validity and reproducibility according to predetermined quality criteria.

The included studies examined the use of manual diagnosis for MTPs in a variety of settings, populations, conditions and clinicians. This heterogeneity limited pooled analysis of the results. In addition, none of the studies used completely overlapping diagnostic criteria, and no single muscle was observed in more than two studies. The results of the quality analysis indicated two studies to be of high quality, one of moderate quality, and three of low quality.  None of the MTP criteria were found to have a high level of evidence. At best, the current literature suggests moderate evidence for the reliability of local tenderness in the trapezius, and pain referral at gluteus medius and quadratus lumborum; however a single reliable criteria is insufficient to diagnose a MTP according to commonly cited diagnostic criteria. The authors concluded that the current evidence supporting the reliability of diagnostic palpation for MTPs is weak and further high quality studies are required.

The clinical uncertainties surrounding MTP diagnosis present challenges to the interpretation of all research on MTPs. In the absence of an accurate diagnosis, the results of any epidemiological, pathophysiologic or clinical investigation will be misleading.1 A potent example of this is seen in the subsequent issue of the same journal, where Ettlin et al.4 report on the prevalence of cervical MTPs in four different clinical populations and a group of healthy controls. Having assumed that identification of each of the MTP characteristics is reliable, the researchers state that a clinically relevant MTP was present if three out four listed criteria were met. However, using this methodology it is possible that the diagnostic process would identify presentations other than MTPs, such as non-specific muscle pain, pain of peripheral nerve trunk origin, underlying joint sensitivity, secondary hyperalgesia, or even normal intramuscular physiology. It also explains their report of active MTPs in up to one third of the pain-free controls, which should be considered impossible considering that active MTPs are symptomatic by definition.

Until both consensus and reliability of diagnostic criteria for identifying MTPs are achieved and implemented in research studies, data on the validity, prevalence, aetiology and treatment of MTPs should be interpreted with prudence.

1. Tough EA, White AR, Richards S, Campbell J. Variability of criteria used to diagnose myofascial trigger point pain syndrome: Evidence from a review of the literature. Clinical Journal of Pain 2007;23:278-286.
2. Rickards LD. The effectiveness of non-invasive treatments for active myofascial trigger point pain: a systematic review of the literature. International Journal of Osteopathic Medicine 2006;9:120-136.
3. Myburgh C, Larsen AH, Hartvigsen J. A systematic, critical review of manual palpation for identifying myofascial trigger points: Evidence and clinical significance. Archives of Physical Medicine and Rehabilitation 2008;89:1169-1176.
4. Ettlin T, Schuster C, Stoffel R, Brüderlin A, Kischka U. A distinct pattern of myofascial findings in patients after whiplash injury. Archives of Physical Medicine and Rehabilitation 2008;89:1290-93.