Intraexaminer and interexaminer reliability for palpation of the cranial rhythmic impulse at the head and sacrum

Rethinking the Origin of the Primary Respiratory Mechanism

Spheno-occipital synchondrosis (SOS) is the joint regarded as the most important foundation for understanding cranial osteopathy and craniosacral therapy. SOS is the origin of the primary respiratory mechanism (PRM), a movement between the posterior surface of the body of the sphenoid bone and the anterior surface of the base of the occipital bone. From the PRM perspective, an alteration of the position between the two bone surfaces would create cranial and/or craniosacral dysfunction. These positional alterations of the SOS (in adults and children) would determine specific and schematical movements of the bones of the entire skull, whose movements are recognizable by palpation by trained operators. PRM expression is influenced by other elements, such as movement of the cranial bones, inherent movement of the central nervous system, cyclic movement of cerebrospinal fluid (CSF), mechanical tension of the cranial meninges, and passive movement of the sacral bone between the iliac bones. The article reviews the most up-to-date information on the evolution of cranial sutures/joints and meninges in adulthood, the fluctuations of the CSF, brain, and spinal mass movements. Research should reconsider the motivations that induce the operator to discriminate the palpable cranial rhythmic impulse, and probably, to rethink new cranial dysfunctional patterns.

Validation of subjective manual palpation using objective physiological recordings of the cranial rhythmic impulse during osteopathic manipulative intervention

Intermediate (IM) band physiology in skin blood flow exhibits parallels with the primary respiratory mechanism (PRM) or cranial rhythmic impulse (CRI), controversial concepts of osteopathy in the cranial field (OCF). Owing to inconsistent manual palpation results, validity of evidence of PRM/CRI activity has been questionable. We therefore tried to validate manual palpation combining instrumented tracking and algorithmic objectivation of frequencies, amplitudes, and phases. Using a standard OCF intervention, cranial vault hold (CVH), two OCF experts palpated and digitally marked CRI frequencies in 25 healthy adults. Autonomic nervous system (ANS) activity in low frequency (LF) and IM band in photoplethysmographic (PPG) forehead skin recordings was probed with momentary frequency of highest amplitude (MFHA) and wavelet amplitude spectra (WAS) in examiners and participants. Palpation errors and frequency expectation bias during CVH were analyzed for phases of MFHA and CRI. Palpated CRI frequencies (0.05-0.08 Hz) correlated highly with mean MFHA frequencies with 1:1 ratio in 77% of participants (LF-responders; 0.072 Hz) and with 2:1 ratio in 23% of participants (IM-responders; 0.147 Hz). WAS analysis in both groups revealed integer number (harmonic) waves in (very) low and IM bands in > 98% of palpated intervals. Phase analyses in participants and examiners suggested synchronization between MFHA and CRI in a subset of LF-responders. IM band physiology in forehead PPG may offer a sensible physiological correlate of palpated CRI activity. Possible coordination or synchronization effects with additional physiological signals and between examiners and participants should be investigated in future studies.

Cranial osteopathic techniques and electroencephalogram (EEG) alpha power: a controlled crossover trial

CONTEXT

Osteopathic tradition in the cranial field (OCF) stated that the primary respiratory mechanism (PRM) relies on the anatomical links between the occiput and sacrum. Few studies investigated this relationship with inconsistent results. No studies investigated the occiput-sacrum connection from a neurophysiological perspective.

OBJECTIVES

This study aims to determine whether the sacral technique (ST), compared to the compression of the fourth ventricle (CV4) technique, can affect brain alpha-band power (AABP) as an indicator of a neurophysiological connection between the occiput and sacrum.

METHODS

Healthy students, 22-30 years old for men and 20-30 years old for women, were enrolled in the study and randomized into eight interventions groups. Each group received a combination of active techniques (CV4 or ST) and the corresponding sham techniques (sham compression of the fourth ventricle [sCV4] or sham sacral technique [sST] ), organized in two experimental sessions divided by a 4 h washout period. AABP was continuously recorded by electroencephalogram (EEG) of the occipital area in the first 10 min of resting state, during each intervention (active technique time) and after 10 min (post-active technique time), for a total of approximately 50 min per session. Analysis was carried out utilizing a repeated-measure ANOVA within the linear general model framework, consisting of a within-subject factor of time and a within-subject factor of treatment (CV4/ST).

RESULTS

Forty healthy volunteers (mean age ± SD, 23.73±1.43 years; range, 21-26 years; 16 male and 24 female) were enrolled in the study and completed the study protocol. ANOVA revealed a time × treatment interaction effect statistically significant (F=791.4; p<0.001). A particularly high increase in mean AABP magnitude was recorded during the 10 min post-CV4, compared to both the CV4 and post-sCV4 application (p<0.001). During all the times analyzed for ST and sST application, no statistically significant differences were registered with respect to the resting state.

CONCLUSIONS

The ST does not produce immediate changes on occipital AABP brain activity. CV4, as previous evidence supported, generates immediate effects, suggesting that a different biological basis for OCF therapy's connection between the head and sacrum should be explored.

Objectivation of an Educational Model in Cranial Osteopathy Based on Experience

Background and Objectives: The techniques directed to the cranial field in osteopathy are the most questioned due to the lack of scientific evidence. In osteopathic practice, manual palpation is essential and, therefore, measuring reliability is fundamental. The objective of this study is to assess the precision and objectification of an educational model in cranial osteopathy based on experience. Materials and Methods: A reliability study was conducted in a cadaver skull where a strain gauge was placed on the sphenobasilar synchondrosis (SBS) of the base of the skull. Three cranial osteopathic techniques (lateral compression, anteroposterior compression, and compression maneuver of the mastoids) were performed 25 times by osteopaths with different degrees of experience (5–10 years, 1–5 years, <1 year). Measurements were computed for each of the three techniques of each group in comparison with the osteopath with >15 years of experience. Data were analyzed to check for inter- and intra-observer reliability using intra-class correlation coefficients (ICC). Results: Reliability in osteopaths with 5–10 years’ experience (observer 1 and observer 2) performing all three techniques was higher (p < 0.001) than the osteopath with >15 years’ experience. Little or no reliability were observed in osteopaths with less experience. Conclusions: The experience of the osteopaths determines the reliability and effectiveness of the cranial techniques, a fundamental part in objectifying these techniques. This model can help implement objective training in cranial osteopathy formation.

Moderate to Substantial Inter-Rater Reliability in the Assessment of Cranial Bone Mobility Restrictions

Background: The World Health Organization benchmarks for osteopathic training consider cranial osteopathy as an important manual skill. Studies of cranial manual therapy have exhibited poor reliability. The aim of this study was to investigate the inter-rater reliability of the manual mobility tests of the spheno-occipital synchondrosis (SOS), and the temporal, parietal, and frontal bones, as assessed in osteopathic manual therapy. Methods: Twenty-one adults were assessed on a single day by three experienced osteopaths using a standard assessment protocol. Before data collection, the osteopaths participated in a consensus training, which included establishing the criteria for identifying a cranial bone mobility restriction; the application of the seven-step palpation method; a pretesting practice; a fine-tuning palpation training; and a calibration period before the assessment of the subjects. Three subjects were assessed simultaneously with the evaluators rotating to assess each subject. The evaluators were blinded to the subject by a curtain, and each other's assessments. Each bone was rated as restricted or not restricted. The authors applied the Landis and Koch classification to describe the magnitude of inter-rater reliability. Results: Moderate reliability was established for a lateral strain of the SOS (Fleiss' generalized kappa 0.48), substantial reliability was established for the other SOS strain patterns (Fleiss' generalized kappa 0.62-0.75), and almost perfect reliability for temporal, parietal, and frontal bone (Fleiss' generalized kappa 0.81-0.96). Conclusion: The results demonstrate consistency when three experienced osteopaths evaluate cranial bone mobility restrictions. The results highlight the importance of consensus training and rigorous methodology in manual therapy reliability studies.

Interrater Reliability of Osteopathic Sacral Palpatory Diagnostic Tests Among Osteopathy Students

Context

Somatic dysfunctions are a key element of osteopathic practice. The evaluation of somatic dysfunctions is achieved by assessment of the TART (tissue texture abnormality, asymmetry, restriction of motion, tenderness) parameters. The reliability of a diagnostic method is the crux of successful treatment. Interrater reliability of osteopathic palpatory diagnostic tests have been studied on different anatomical areas, but there are no studies on the evaluation of all of the TART parameters on the sacrum.

Objective

To evaluate the interrater reliability of osteopathic sacral palpatory diagnostic tests. The hypothesis was that 3 trained osteopathy students at the end of their curriculum could achieve at least moderate agreement on osteopathic sacral palpatory diagnostic tests.

Methods

Three students from the Centre pour l’Étude, la Recherche et la Diffusion Ostéopathiques school in Rome, Italy, at the end of their curriculum participated as raters and received consensus training. Eligible subjects among students of the same school were recruited on a voluntary basis to be tested. All of the raters tested the sacrum by evaluating the TART parameters on every subject for 3 minutes. Raters were blinded to the other raters’ findings. Interrater reliability was evaluated using Fleiss κ statistics.

Results

Fifty-two subjects (20 women) were enrolled in the study. Mean (SD) age was 25.9 (7.03) years; height, 1.73 (0.09) ms; weight, 68.73 (14.2) kg; and body mass index, 22.66 (3.58). Agreement was fair for tissue texture abnormality (κ=0.28), asymmetry (κ=0.29), restriction of motion (κ=0.32), and tenderness (κ=0.34); agreement was slight for landmark position (κ=0.06) and diagnosis of somatic dysfunction (κ=0.17).

Conclusion

Results showed a level of agreement ranging from slight to fair in the assessment of the TART parameters among raters, who were in their last year of osteopathy school. The tenderness parameter was the most reliable. Our findings are consistent with other interrater reliability studies carried out in different body regions, contributing to show an overall heterogeneous level of diagnostic reliability in osteopathy.

Reliability of diagnosis and clinical efficacy of visceral osteopathy: a systematic review

Background

In 2010, the World Health Organization published benchmarks for training in osteopathy in which osteopathic visceral techniques are included. The purpose of this study was to identify and critically appraise the scientific literature concerning the reliability of diagnosis and the clinical efficacy of techniques used in visceral osteopathy.

Methods

Databases MEDLINE, OSTMED.DR, the Cochrane Library, Osteopathic Research Web, Google Scholar, Journal of American Osteopathic Association (JAOA) website, International Journal of Osteopathic Medicine (IJOM) website, and the catalog of Académie d’ostéopathie de France website were searched through December 2017. Only inter-rater reliability studies including at least two raters or the intra-rater reliability studies including at least two assessments by the same rater were included. For efficacy studies, only randomized-controlled-trials (RCT) or crossover studies on unhealthy subjects (any condition, duration and outcome) were included. Risk of bias was determined using a modified version of the quality appraisal tool for studies of diagnostic reliability (QAREL) in reliability studies. For the efficacy studies, the Cochrane risk of bias tool was used to assess their methodological design. Two authors performed data extraction and analysis.

Results

Eight reliability studies and six efficacy studies were included. The analysis of reliability studies shows that the diagnostic techniques used in visceral osteopathy are unreliable. Regarding efficacy studies, the least biased study shows no significant difference for the main outcome. The main risks of bias found in the included studies were due to the absence of blinding of the examiners, an unsuitable statistical method or an absence of primary study outcome.

Conclusions

The results of the systematic review lead us to conclude that well-conducted and sound evidence on the reliability and the efficacy of techniques in visceral osteopathy is absent.

Trial registration

The review is registered PROSPERO 12th of December 2016. Registration number is CRD4201605286.

Electronic supplementary material

The online version of this article (10.1186/s12906-018-2098-8) contains supplementary material, which is available to authorized users.

Evaluation of New Zealand osteopathy patients experiences of their treatment

OBJECTIVES

To investigate the experiences of patients seeking osteopathy treatment in New Zealand; and to describe their perceptions of osteopathic treatment.

DESIGN

Survey-based research design.

SETTING

Private osteopathy practices.

MAIN OUTCOME MEASURES

Demographic survey and the Patient Perception Measure-Osteopathy (PPM-O).

RESULTS

Twelve osteopaths were recruited as practitioners. Responses from 107 patients were analysed. Approximately 75% of patients reported receiving a 'mostly cranial' treatment approach. The majority of patients (96.2%) indicated that osteopathic treatment helped their condition. The most frequently experienced sensation was 'relaxed'. A positive relationship was observed between the PPM-O and demographic variables.

CONCLUSIONS

This is the first study to report on New Zealand osteopathy patient's experience of their treatment. The sensations and emotions experienced are largely consistent with previous Australian research. Predominantly positive perceptions of osteopathic treatment were reported. The current study provides some evidence of the construct validity of the PPM-O in a New Zealand patient population.

Reliability of Diagnosis and Clinical Efficacy of Cranial Osteopathy: A Systematic Review

CONTEXT

In 2010, the World Health Organization released benchmarks for training in osteopathy in which they considered cranial osteopathy as an important osteopathic skill. However, the evidence supporting the reliability of diagnosis and the efficacy of treatment in this field appears scientifically weak and inconsistent.

OBJECTIVES

To identify and critically evaluate the scientific literature dealing with the reliability of diagnosis and the clinical efficacy of techniques and therapeutic strategies used in cranial osteopathy.

METHODS

Relevant keywords were used to search the electronic databases MEDLINE, PEDro, OSTMED.DR, Cochrane Library, and in Google Scholar, Journal of American Osteopathy Association and International Journal of Osteopathic Medicine websites. Searches were conducted up to end June 2016 with no date restriction as to when the studies were completed. As a complementary approach we explored the bibliography of included articles and consulted available previous reviews dealing with this topic.

STUDY SELECTION

Regarding diagnostic processes in cranial osteopathy, we analyzed studies that compared the results obtained by at least two examiners or by the same examiner on at least two occasions. For efficacy studies, only randomized-controlled-trials or crossover-studies were eligible. We excluded articles that were not in English or French, and for which the full-text version was not openly available. We also excluded studies with unsuitable study design, in which there was no clear indication of the use of techniques or therapeutic strategies concerning the cranial field, looked at combined treatments, used a non-human examiner and subjects or used healthy subjects for efficacy studies. There was no restriction regarding the type of disease.

SEARCH RESULTS

In our electronic search we found 1280 references concerning reliability of diagnosis studies plus four references via our complementary strategy. Based on the title 18 articles were selected for analysis. Nine were retained after applying our exclusion criteria. Regarding efficacy, we extracted 556 references from the databases plus 14 references through our complementary strategy. Based on the title 46 articles were selected. Thirty two articles were not retained on the grounds of our exclusion criteria.

DATA EXTRACTION AND ANALYSIS

Risk of bias in reliability studies was assessed using a modified version of the quality appraisal tool for studies of diagnostic reliability. The methodological quality of the efficacy studies was assessed using the Cochrane risk of bias tool. Two screeners conducted these analyses.

RESULTS

For reliability studies, our analysis leads us to conclude that the diagnostic procedures used in cranial osteopathy are unreliable in many ways. For efficacy studies, the Cochrane risk of bias tool we used shows that 2 studies had a high risk of bias, 9 were rated as having major doubt regarding risk of bias and 3 had a low risk of bias. In the 3 studies with a low risk of bias alternative interpretations of the results, such as a non-specific effect of treatment, were not considered.

CONCLUSION

Our results demonstrate, consistently with those of previous reviews, that methodologically strong evidence on the reliability of diagnostic procedures and the efficacy of techniques and therapeutic strategies in cranial osteopathy is almost non-existent.

Complementary medicine in chronic pain treatment

This article discusses several issues related to therapies that are considered "complementary" or "alternative" to conventional medicine. A definition of "complementary and alternative medicine" (CAM) is considered in the context of the evolving health care field of complementary medicine. A rationale for pain physicians and clinicians to understand these treatments of chronic pain is presented. The challenges of an evidence-based approach to incorporating CAM therapies are explored. Finally, a brief survey of the evidence that supports several widely available and commonly used complementary therapies for chronic pain is provided.

Sensations experienced and patients' perceptions of osteopathy in the cranial field treatment

Osteopathy in the cranial field is an approach used by manual and physical therapists. However, there is minimal information in the literature about patient experiences of this treatment. The present study was undertaken to explore patients' experiences of osteopathy in the cranial field. Patients completed the Patient Perception Measure-Osteopathy in the Cranial Field and identified sensations they experienced during treatment. Additional measures of anxiety, depression, Satisfaction With Life, and Meaningfulness of Daily Activity were completed. The Patient Perception Measure-Osteopathy in the Cranial Field was internally consistent (Cronbach's α = .85). The most frequently experienced sensations of osteopathy in the cranial field patients were "relaxed," "releasing," and "unwinding." Satisfaction With Life and Meaningfulness of Daily Activity were positively associated with Patient Perception Measure-Osteopathy in the Cranial Field scores. Negative associations were observed between the Patient Perception Measure-Osteopathy in the Cranial Field and depression. Psychometric properties of the Patient Perception Measure-Osteopathy in the Cranial Field require further testing. The observed associations of Satisfaction With Life and depression with patients' perceptions of osteopathy in the cranial field treatment needs to be tested in larger clinical manual therapy cohorts.

Review of methods used by chiropractors to determine the site for applying manipulation

Background

With the development of increasing evidence for the use of manipulation in the management of musculoskeletal conditions, there is growing interest in identifying the appropriate indications for care. Recently, attempts have been made to develop clinical prediction rules, however the validity of these clinical prediction rules remains unclear and their impact on care delivery has yet to be established. The current study was designed to evaluate the literature on the validity and reliability of the more common methods used by doctors of chiropractic to inform the choice of the site at which to apply spinal manipulation.

Methods

Structured searches were conducted in Medline, PubMed, CINAHL and ICL, supported by hand searches of archives, to identify studies of the diagnostic reliability and validity of common methods used to identify the site of treatment application. To be included, studies were to present original data from studies of human subjects and be designed to address the region or location of care delivery. Only English language manuscripts from peer-reviewed journals were included. The quality of evidence was ranked using QUADAS for validity and QAREL for reliability, as appropriate. Data were extracted and synthesized, and were evaluated in terms of strength of evidence and the degree to which the evidence was favourable for clinical use of the method under investigation.

Results

A total of 2594 titles were screened from which 201 articles met all inclusion criteria. The spectrum of manuscript quality was quite broad, as was the degree to which the evidence favoured clinical application of the diagnostic methods reviewed. The most convincing favourable evidence was for methods which confirmed or provoked pain at a specific spinal segmental level or region. There was also high quality evidence supporting the use, with limitations, of static and motion palpation, and measures of leg length inequality. Evidence of mixed quality supported the use, with limitations, of postural evaluation. The evidence was unclear on the applicability of measures of stiffness and the use of spinal x-rays. The evidence was of mixed quality, but unfavourable for the use of manual muscle testing, skin conductance, surface electromyography and skin temperature measurement.

Conclusions

A considerable range of methods is in use for determining where in the spine to administer spinal manipulation. The currently published evidence falls across a spectrum ranging from strongly favourable to strongly unfavourable in regard to using these methods. In general, the stronger and more favourable evidence is for those procedures which take a direct measure of the presumptive site of care– methods involving pain provocation upon palpation or localized tissue examination. Procedures which involve some indirect assessment for identifying the manipulable lesion of the spine–such as skin conductance or thermography–tend not to be supported by the available evidence.

Credibility of low-strength static magnet therapy as an attention control intervention for a randomized controlled study of CranioSacral therapy for migraine headaches

BACKGROUND

Developing valid control groups that generate similar perceptions and expectations to experimental complementary and alternative (CAM) treatments can be challenging. The perceived credibility of treatment and outcome expectancy often contributes to positive clinical responses to CAM therapies, thereby confounding efficacy data. As part of a clinical feasibility study, credibility and expectancy data were obtained from subjects suffering from migraine who received either CranioSacral therapy (CST) or an attention-control, sham, and low-strength magnet (LSSM) intervention.

OBJECTIVE

The objective of this study was to evaluate whether the LSSM intervention generated similar levels of subject credibility and expectancy compared to CST.

DESIGN

This was a two-arm randomized controlled trial.

SUBJECTS

Sixty-five (65) adults with moderate to severe migraine were the subjects of this study.

INTERVENTIONS

After an 8-week baseline, subjects were randomized to eight weekly treatments of either CST (n=36) or LSSM (n=29). The latter involved the use of a magnet-treatment protocol using inactive and low-strength static magnets designed to mimic the CST protocol in terms of setting, visit timing, body positioning, and therapist-subject interaction.

OUTCOME MEASURES

A four-item, self-administered credibility/expectancy questionnaire, based on a validated instrument, was completed after the first visit.

RESULTS

Using a 0-9 rating scale, the mean score for perceived logicality of treatment was significantly less for LSSM (5.03, standard deviation [SD] 2.34) compared to CST (6.64, SD 2.19). Subject confidence that migraine would improve was greater for CST (5.94, SD 2.01) than for LSSM (4.9, SD 2.21), a difference that was not statistically significant. Significantly more subjects receiving CST (6.08, SD 2.27) would confidently recommend treatment to a friend than those receiving LSSM (4.69, SD 2.49).

CONCLUSIONS

Although LSSM did not achieve a comparable level of credibility and expectancy to the CST, several design and implementation factors may have contributed to the disparity. Based on analysis of these factors, the design and implementation of a future study may be improved.

“Complementary and Alternative Medicine Treatments for Children with Autism Spectrum Disorders”

Complementary and alternative medical (CAM) treatments are commonly used for children with autism spectrum disorders. This review discusses the evidence supporting the most frequently used treatments, including categories of mind-body medicine, energy medicine, and biologically based, manipulative, and body-based practices, with the latter two treatments the most commonly selected by families. Clinical providers need to understand the evidence for efficacy (or lack thereof) and potential side effects. Some CAM practices have evidence to reject their use, such as secretin, whereas others have emerging evidence to support their use, such as melatonin. Most treatments have not been adequately studied and do not have evidence to support their use.

Craniosacral therapy for migraine: protocol development for an exploratory controlled clinical trial

Background

Migraine affects approximately 20% of the population. Conventional care for migraine is suboptimal; overuse of medications for the treatment of episodic migraines is a risk factor for developing chronic daily headache. The study of non-pharmaceutical approaches for prevention of migraine headaches is therefore warranted. Craniosacral therapy (CST) is a popular non-pharmacological approach to the treatment or prevention of migraine headaches for which there is limited evidence of safety and efficacy. In this paper, we describe an ongoing feasibility study to assess the safety and efficacy of CST in the treatment of migraine, using a rigorous and innovative randomized controlled study design involving low-strength static magnets (LSSM) as an attention control intervention.

Methods

The trial is designed to test the hypothesis that, compared to those receiving usual care plus a treatment with low-strength static magnets (attention-control complementary therapy), subjects receiving usual medical care plus CST will demonstrate significant improvement in: quality-of-life as measured by the Headache Impact Test (HIT-6); reduced frequency of migraine; and a perception of clinical benefit. Criteria for inclusion are either gender, age > 11, English or Spanish speaking, meeting the International Classification of Headache Disorders (ICHD) criteria for migraine with or without aura, a headache frequency of 5 to 15 per month over at least two years. After an 8 week baseline phase, eligible subjects are randomized to either CST or an attention control intervention, low strength static magnets (LSSM). To evaluate possible therapist bias, videotaped encounters are analyzed to assess for any systematic group differences in interactions with subjects.

Results

169 individuals have been screened for eligibility, of which 109 were eligible for the study. Five did not qualify during the baseline phase because of inadequate headache frequency. Nineteen have withdrawn from the study after giving consent.

Conclusion

This report endorses the feasibility of undertaking a rigorous randomized clinical trial of CST for migraine using a standardized CST protocol and an innovative control protocol developed for the study. Subjects are able and willing to complete detailed headache diaries during an 8-week baseline period, with few dropouts during the study period, indicating the acceptability of both interventions.

Trial Registration

ClinicalTrials.gov NCT00665236

Cerebrospinal Fluid Pressure in the Anesthetized Rat

OBJECTIVE

The primary aims of this study were to determine the major frequencies and powers of oscillations in cerebrospinal fluid (CSF) pressure in the anesthetized rat, and determine whether the CSF pressure oscillations correlated with the major oscillation frequencies in the cardiovascular and respiratory systems as proposed by some chiropractic theories.

METHODS

The cardiac and ventilatory cycles, and CSF pressure were simultaneously recorded during spontaneous and positive-pressure mechanical ventilation in the anesthetized rat. Power spectra were generated from the raw data to identify the major oscillation frequencies in cardiorespiratory and CSF data sets. Entrainment of CSF pressure with ventilation was tested by mechanically pacing the ventilation over a range of frequencies.

RESULTS

The most powerful oscillation in CSF pressure was coincident with ventilatory chest movement during both spontaneous and mechanically paced ventilation. In 22 of 26 trials, there was also a very weak oscillation in CSF pressure that was entrained to heart rate. In addition, in 21 of 26 trials, it was possible to identify a low-frequency oscillation (<0.25 Hz) in CSF pressure that was coincident with a low-frequency oscillation in the power spectrum of the cardiac cycle.

CONCLUSIONS

This study suggests oscillations in CSF pressure in the anesthetized rat are entrained to and driven by ventilation. The arterial pulse pressure makes little contribution to oscillations in CSF pressure in the immobile, anesthetized rat. This study provides normative, quantitative data on which to develop studies concerning the effects of vertebral movements and spinal posture on CSF dynamics.

Craniosacral therapy: the effects of cranial manipulation on intracranial pressure and cranial bone movement

STUDY DESIGN

Quasi-experimental design.

OBJECTIVES

To determine if physical manipulation of the cranial vault sutures will result in changes of the intracranial pressure (ICP) along with movement at the coronal suture.

BACKGROUND

Craniosacral therapy is used to treat conditions ranging from headache pain to developmental disabilities. However, the biological premise for this technique has been theorized but not substantiated in the literature.

METHODS

Thirteen adult New Zealand white rabbits (oryctolagus cuniculus) were anesthetized and microplates were attached on either side of the coronal suture. Epidural ICP measurements were made using a NeuroMonitor transducer. Distractive loads of 5, 10, 15, and 20 g (simulating a craniosacral frontal lift technique) were applied sequentially across the coronal suture. Baseline and distraction radiographs and ICP were obtained. One animal underwent additional distractive loads between 100 and 10,000 g. Plate separation was measured using a digital caliper from the radiographs. Two-way analysis of variance was used to assess significant differences in ICP and suture movement.

RESULTS

No significant differences were noted between baseline and distraction suture separation (F = 0.045; P>.05) and between baseline and distraction ICP (F = 0.279; P>.05) at any load. In the single animal that underwent additional distractive forces, movement across the coronal suture was not seen until the 500-g force, which produced 0.30 mm of separation but no corresponding ICP changes.

CONCLUSION

Low loads of force, similar to those used clinically when performing a craniosacral frontal lift technique, resulted in no significant changes in coronal suture movement or ICP in rabbits. These results suggest that a different biological basis for craniosacral therapy should be explored.

Complementary medicine in chronic pain treatment

This chapter looks at therapies that are considered "alternative" to conventional medical approaches. A definition of "complementary and alternative" medicine is considered in the context of the complex and clinically challenging field of pain medicine. A rationale for studying unorthodox treatments of chronic pain is presented. The challenges of an evidence-based approach to incorporating complementary therapies are explored, and a brief survey of several commonly available complementary medicine therapies is provided.

Novel treatments for autistic spectrum disorders

In no area of developmental pediatric practice is there more controversy regarding the choice of treatment than related to children with autistic spectrum disorders (ASD). Complementary and alternative medical therapies (CAM) are often elected because they are perceived as treating the cause of symptoms rather than the symptoms themselves. CAM used for autism can be divided by proposed mechanism: immune modulation, gastrointestinal, supplements that affect neurotransmitter function, and nonbiologic intervention. Secretin as a therapy for autism is discussed as an example of how a clinical observation rapidly grew to a widespread treatment before well-designed studies demonstrated absence of effect. The plausibility for behavioral effect was not substantiated by clinical studies. CAM used for treatment of autism is examined in terms of rationale, evidence of efficacy, side effects, and additional commentary. Families and clinicians need access to well-designed clinical evidence to assist them in choice of therapies.

Inter- and intraexaminer reliability in palpation of the "primary respiratory mechanism" within the "cranial concept"

Inevitable subjectivity makes interexaminer reliability of manual assessment procedures a special matter of concern. The cranial concept (CC), one aspect of osteopathy, deals with very subtle changes that have to be palpated. One of the main principles of the CC is the primary respiratory mechanism (PRM), which is hypothesized to be a palpable physiological phenomenon that occurs in rhythmic cycles, called flexion- and extension-phase, which are independent from cardiac and respiratory rates. Palpation of the PRM is one of the first steps in assessment within the CC. An inter- and intraexaminer reliability study design for repeated measures was used in this study. Forty nine healthy subjects were palpated simultaneously twice, once at the head and once at the pelvis. PRM-frequency (f), the mean duration of the flexion phase and the mean ratio of flexion- to extension-phase were used as the main outcome measures. Inter- and intraexaminer reliability and correlations to the respiratory rates were analysed for all three parameters. Inter- as well as intraexaminer agreement could not be described beyond chance agreement, as the range within the 95% limits of agreement (e.g. for f=6.6 cycles/90 s) for all cases resembled the total range of values (e.g. for f=7 cycles/90 s) that were produced. A significant effect of the examiners' respiration was found for both examiners at the pelvis (P=0.004 for one examiner, P <0.0001 for the other examiner), and for one examiner only at the head (P=0.0017). No correlation could be found for the subjects' respiratory rates. In conclusion, PRM-rates could not be palpated reliably and under certain conditions were influenced by the examiners' respiratory rates. These results do not support the hypotheses behind the PRM. The role of PRM palpation for clinical decision making and the models explaining the PRM should therefore be rethought.

The effects of bite line deviation on lateral cervical radiographs when upper cervical joint dysfunction exists: a pilot study

PURPOSE

To demonstrate the impact of inconsistent bite line positioning during pre and post lateral cervical radiographic examinations and to suggest certain additional imaging studies if the bite line cannot be consistently maintained.

METHODS

Radiographic measurements of relative flexion and extension in the atlantal-occipital (AO) and atlantal-axial (AA) joints were taken from neutral lateral cervical and cervical flexion and extension radiographs of 20 subjects.

RESULTS

The average relative AO flexion was -0.9 degrees and 12.0 degrees of extension, while the average relative AA flexion and extension values were 8.5 degrees and 2.8 degrees, respectively. In addition, 12 (60%) of the 20 subjects exhibited paradoxical motion at the AO joint during cervical flexion. Of these 12 subjects, 10 also displayed excessive relative AO extension (beyond 7.5 degrees ).

CONCLUSIONS

If a bite line deviation exists in pre and post lateral cervical radiographic examinations, dynamic cervical flexion and extension radiographs should be taken to calculate the maximum tolerances in the upper cervical spinal joints. If these tolerances are exceeded, the measurement of the cervical lordosis from the back of the second cervical vertebra and seventh cervical vertebra may be altered, thus incorporating the possibility of a 20.3% measurement error on the post lateral cervical radiograph.