One Therapists Skeptical View of Three Treatments: Evidence Review

January 25, 2017 - by Maggie Henjum - in Treatment & Prevention

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Reader Beware: Controversial Topics But Hopeful to Stimulate Healthy Discussion and Debate

Craniosacral Therapy

Craniosacral therapy (CST) was developed by John Upledger, D.O. in the 1970s. I wanted to pull in plain view the description of what the technique is to discuss first. The therapist palpates the patient’s body, and focuses intently on the communicated movements. CST focuses on the primary respiratory mechanism, which is summarized as five ideas. These include: Inherent motility of the central nervous system, fluctuation of the cerebrospinal fluid, mobility of the intracranial and intraspinal dural membranes, mobility of the cranial bones, and involuntary motion of the sacrum between the ilia.3

Another description was provided in the editorial by Dr. Flynn et al, craniosacral therapy or CST is ‘‘a systematic approach to evaluating and treating dysfunction occurring within the articulations of the skull.’  CST practitioners have upheld the belief that restrictions, misalignments, and immobility of the cranial sutures and tension of the intracranial meninges directly impact the health of the individual.”  Foundational construct of this technique seems to be built off of faulty and misleading information – so I will attempt to relinquish my personal bias on CST.

Lets delve into the five constructs of CST. First, I have no idea what the inherent motility of the central nervous system really means, so let’s skip that and run over to the fluctuation of cerebrospinal fluid and mobility of the membranes and cranial bones.

A study by Downey et al did review reliability of the palpatory techniques and discovered poor reliability ranging from –0.09 to 0.59.2 Although, as stated by Dr. Flynn et al, most palpation in the body we are fair to poor at, unless we are assessing painful segments in the spine etc.1 Regardless of how reliable we are at the technique, it does feel like an elaborate placebo.  Placing hands on a patient to  “perceive the rhythmic impulse resulting from the widening and narrowing of the skull at rates described variously as 10 to 14 cycles per minute” seems to be built off of a bit of quackery.  Downey et al looked at the changes in intercranial pressure and suture movement in rabbits with pressures used in CST and found no change in either measurement again providing evidence that this technique’s theory is in fact faulty.2

Lastly, this technique is used to fix the faulty movement between the sacrum and the ilium.  Well, this seems difficult as we repeatedly find that there is little to no movement at the sacrum and ilium.  A 2008 systematic review states that numerous RSA studies continue to find motion at the SIJ is “limited to minute amounts of rotation and of translation that we feel may be sub-clinically detectable.”  This is why using sacroiliac joint dynamic tests are becoming less useful to clinical practice.  Again, built construct off of false premise of mechanical and osteopathic basis.

Again, I don’t think CST has any substantial evidence that demonstrates it is valid – even with theoretical discussions. I guess we can discuss if it is effective next. There is a systematic review stating that with review of 7 articles, it reduced pain and improved general wellbeing of patients with CST.3 Although, without a definition that this is providing any change in the cranial structures, or that cranial placement has any effect on pain – doesn’t this review just show that placebo is a powerful tool – maybe?  I have to agree with Dr. Flynn et al that – with professional responsibility to align our treatments with evidence raises CST it is a poor use of treatment time. I am actually ok with treatments that are less research based, just as long as they base their construct of how they work off of plausible findings.

References:

1)     Flynn, T. W., Cleland, J. a, & Schaible, P. (2006). Craniosacral therapy and professional responsibility. The Journal of orthopaedic and sports physical therapy36(11), 834–6. doi:10.2519/jospt.2006.0112

2)     Downey PA, Barbano T, Kapur-Wadhwa R, Sciote JJ, Siegel MI, Mooney MP. Craniosacral Therapy: The Effects of Cranial Manipulation on Intracranial Pressure and Cranial Bone Movement. J Orthop Sports Phys Ther 2006;36(11):845-853.

3)     Jakel A, Hauenschild P. A Systematic Review to Evaluate the Clinical Benefits of Craniosacral Therapy. Complementary Therapies in Medicine. 2012; 20: 456-465.

4)     Goode, A., Hegedus, E. J., Sizer, P., Brismee, J.-M., Linberg, A., & Cook, C. E. (2008). Three-dimensional movements of the sacroiliac joint: a systematic review of the literature and assessment of clinical utility. The Journal of manual & manipulative therapy16(1), 25–38. Retrieved fromhttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2565116&tool=pmcentrez&rendertype=abstract

 

Myofacial Release

Myofascial release is described as a manual technique to mobilize soft tissue.  There are numerous ways practitioners implement myofascial release, therefore it is challenging to narrow down a singular view of this technique. I enjoyed Remvig et al’s overview of this technique. They started with definition of fascial layers that are “connective sheets around single muscles, so-called epimysium, but they are also present as intermuscular septa, and as sheets surrounding groups of muscles and merge into the muscle tendons, joint capsules and/orthe periosteum.”  Their conclusion from literature was this: “there is evidence that fascias contain contractile elements and that they can contract through pharmacological and mechanical stimulation. However, there is no documentation of any relaxation due to a reduction of inherent tone”2  Fascias can be exposed to overuse or overloaded due to the vascular and neural supply and as stated by Remvig et al, but not all subfascial tissue has nociceptive substances.2  Therefore, these chemical and mechanical stimuli can cause sensitization of peripheral nerve endings and activate receptors that may cause some central sensitization which can cause the referred pain and increase excitability of nociceptors and cause hyperalgesia.4

Myofascial trigger points are the neural innervated areas that are supplied with nociceptors and as they react to stressors.Although reliability of diagnosing a myofascial trigger point is shown to be quite low, therapists palpate muscular areas to find areas of tenderness and increased tone.Therapists who perform this technique believe that they are changing this process with pressure and soft tissue techniques to allow tissues to relax back to natural state.  There is one low-quality RCT that reports a positive effect of MFR treatment on situations without myofascial pain and two RCTs of very low quality with MFR as adjunctive therapy.2

Contrarily to CST – this theory of tapping into neural system of myofascial tension seems more plausible.  Personal opinion would be that we may think we perform more to tissue tension than we do. Diagnostic utility of palpation is quite low and some of the statements used in discussion of myofascial release seemed like a leap of faith.  Although, do I think we can improve tissue length and guarding through soft tissue and releasing techniques – maybe.

Somewhat outside the scope of this topic lies dry needling for myofascial pain as a similar construct to this topic.  A recent 2013 systematic review actually states that based on a few high quality RCT’s they recommended dry needling for decreasing pain in patients with myofascial pain syndrome.3

References:

1)     McKenney, K., Elder, A. S., Elder, C., & Hutchins, A. (2013). Myofascial release as a treatment for orthopaedic conditions: a systematic review. Journal of athletic training48(4), 522–7. doi:10.4085/1062-6050-48.3.17

2)     Remvig, L., Ellis, R. M., & Patijn, J. (2008). Myofascial release: an evidence-based treatment approach? International Musculoskeletal Medicine30(1), 29–35. doi:10.1179/175361408X293272

3)     Kietrys, D. M., Palombaro, K. M., Azzaretto, E., Hubler, R., Schaller, B., Schlussel, J. M., & Tucker, M. (2013). Effectiveness of Dry Needling for Upper Quarter Myofascial Pain: A Systematic Review and Meta-analysis. The Journal of orthopaedic and sports physical therapy43(9), 620–634. doi:10.2519/jospt.2013.4666

4)     Lucas N, Macaskill P, Irwig L, Moran R, Bogduk N (2009 Jan). “Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature”. Clin J Pain 25 (1): 80–9.doi:10.1097/AJP.0b013e31817e13b6.PMID 19158550.

5)     Bron, C., & Franssen, J. (2006). Myofascial Trigger Points: An Evidence-Informed Review. Journal of Manual and Manipulative Therapy.14(4), 203–221.

 

ASTYM: Augmented soft tissue mobilization

The ASTYM website states the following as their accepted definition of this technique: “Astym® treatment is a therapy that regenerates healthy soft tissues (muscles, tendons, etc.), and eliminates or reduces unwanted scar tissue that may be causing pain or movement restrictions.  Astym® treatment is highly effective and even works when other approaches routinely fail”2

This seems a bit vague, but a case report on ASTYM provides more detail stating, “ASTM involves the utilization of specially designed instruments that augment a clinician’s ability to perform soft tissue mobilization. The instruments are solid, hand-held devices with angled edges which are guided in a stroking motion along the skin.”4

Instrumented assisted manual therapy has been discussed a lot these past few years.  A 2007 study examined soft tissue modalities of instrumented and manual.  The findings were reported as follows: “after both manual therapy interventions, there were improvements to nerve conduction latencies, wrist strength, and wrist motion.”1 No difference was noted between the two methods. Although I may just be unaware, I do not see any RCT supporting instrument administered soft tissue vs. manual techniques. Some colleagues of mine have stated that instrumented STM causes damage to tissues drawing blood flow and healing, again I find little evidence. I did find 1 study in 1997 that demonstrated some increased fiboblast proliferation in tendonitis with ASTM – although this was in rat models.3   Besides this, I found a few case reports but no strong evidence that the claims made by ASTYM are strongly upheld in literature.

Not pigeon holing this treatment method to being ineffective, as I still administer IASTM occasionally (with the edge, good-reasonably priced tool). This again lies in an under researched area, and a less evidence based approach per say, but the foundational construct in which the technique is built makes sense to me conceptually.  Regardless of what we have found, I do understand that patients with pain that may have tissue limitations a therapist can address these this with their hands, or instrument, it does seem effective, within literature and clinically.  Personally, I think it is a large jump to say that we are eliminating scar tissue that creates pain, but that may be the skeptic in me.

References:

1)     Burke JM, Buchberger DJ, Carey-Loghmani CT, Doughterty PE, Greco DS, Dishman JD. A Pilot Study Comparing Two Manual Therapy Interventions for Carpal Tunnel Syndrome. Journal of Manipulative and Physiological Therapeutics. 2007; 30: 50-61.

2)     Website: http://www.astym.com/Patients/About

3)     Davidson, C., & Ganion, L. (1997). Rat tendon morphologic and functional changes resulting from soft tissue mobilization. Medicine and science …. Retrieved from http://bmhlibrary.info/9139169.pdf

4)     MELHAM, THOMAS J.; SEVIER, THOMAS L.; MALNOFSKI, MICHAEL J.; WILSON, JULIE K.; HELFST, ROBERT H. JR. Chronic ankle pain and fibrosis successfully treated with a new noninvasive augmented soft tissue mobilization technique (ASTM): a case report. Medicine and Science Sports Exercise. Volume 30(6), June 1998, pp 801-804

 

Original post: December 8, 2013

 

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Maggie Henjum

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