Даказательная мануальная медицина.
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Автор:  Вадим Асадулин [ Вт апр 08, 2008 7:39 am ]
Заголовок сообщения:  Даказательная мануальная медицина.

В течение многих лет я сотрудничаю с мануальными терапевтами, вижу клинический эффект от применения различных методик.
Ортодоксальная академическая медицина отрицает эффективность этих воздействий.
Why Craniosacral Therapy Is Silly. Stephen Barrett, M.D.
Craniosacral therapy is one of many terms used to describe a various methods based on fanciful claims that:
• The human brain makes rhythmic movements at a rate of 10 to 14 cycles per minute, a periodicity unrelated to breathing or heart rate.
• Small cranial pulsations can be felt with the fingertips.
• Restriction of movement of the cranial sutures (where the skull bones meet) interfere with the normal flow of cerebrospinal fluid (the fluid that surrounds the brain and spinal cord) and cause disease.
• Diseases can be diagnosed by detecting aberrations in this rhythm.
• Pain (especially of the jaw joint) and many other ailments can be remedied by pressing on the skull bones.
Most practitioners are osteopaths, massage therapists, chiropractors, dentists, or physical therapists. The other terms used to describe what they do include cranial osteopathy, cranial therapy, bio cranial therapy, and two chiropractic variants called craniopathy and sacro occipital technique (SOT).
Dubious Claims
Craniosacral therapy was originated by osteopath William G. Sutherland, who published his first article on this subject in the early 1930s. Today's leading proponent is John Upledger, DO, who operates the Upledger Institute of Palm Beach Gardens, Florida. Various Institute publications have claimed:
CranioSacral Therapy is a gentle, noninvasive manipulative technique. Seldom does the therapist apply pressure that exceeds five grams or the equivalent weight of a nickel. Examination is done by testing for movement in various parts of the system. Often, when movement testing is completed, the restriction has been removed and the system is able to self-correct [1].
The rhythm of the craniosacral system can be detected in much the same way as the rhythms of the cardiovascular and respiratory systems. But unlike those body systems, both evaluation and correction of the craniosacral system can be accomplished through palpation. CranioSacral Therapy is used for a myriad of health problems, including headaches, neck and back pain, TMJ dysfunction, chronic fatigue, motor-coordination difficulties, eye problems, endogenous depression, hyperactivity, attention deficit disorder, central nervous system disorders, and many other conditions [2].
Practitioners today rely on CranioSacral Therapy to improve the functioning of the central nervous system, eliminate the negative effects of stress, strengthen resistance to disease, and enhance overall health [3].
Using a soft touch generally no greater than 5 grams, or about the weight of a nickel, practitioners release restrictions in the craniosacral system to improve the functioning of the central nervous system. By complementing the body's natural healing processes, CST is increasingly used as a preventive health measure for its ability to bolster resistance to disease, and is effective for a wide range of medical problems associated with pain and dysfunction, including: migraine headaches; chronic neck and back pain; motor-coordination impairments; colic; autism; central nervous system disorders; orthopedic problems; traumatic brain and spinal cord injuries; scoliosis; infantile disorders; learning disabilities; chronic fatigue; emotional difficulties; stress and tension-related problems; fibromyalgia and other connective-tissue disorders; temporomandibular joint syndrome (TMJ); neurovascular or immune disorders; post-traumatic stress disorder; post-surgical dysfunction [4].
The Upledger Institute also advocates and teaches "visceral manipulation," a bizarre treatment system whose practitioners are claimed to detect "rhythmic motions" of the intestines and other internal organs and to manipulate them to "improve the functioning of individual organs, the systems the organs function within, and the structural integrity of the entire body." [5]
Weird Beliefs
Some of Upledger's beliefs are among the strangest I have ever encountered. Chapter 2 of his book, CranoSacral Therapy: Touchstone of Natural Healing, he describes, how he discovered and communicates with what he calls the patient's "Inner Physician":
By connecting deeply with a patient while doing CranioSacral Therapy, it was possible in most cases to solicit contact with the patient's Inner Physician. It also became clear that the Inner Physician could take any for m the patient could imagine —an image, a voice or a feeling. Usually once the image of the Inner Physician appeared, it was ready to dialog with me and answer questions about the underlying causes of the patient's health problems and what can be done to resolve them. It also became clear that when the conversation with the Inner Physician was authentic, the craniosacral system went into a holding pattern [6].
The chapter goes on to describe Upledger's care of a four-month-old French baby who was "as floppy as a rag doll." Although the baby had never been exposed to English, Upledger decided to see whether the baby's "Inner Physician" would communicate with him via the craniosacral system:
I requested aloud in English that the craniosacral rhythm stop if the answer to a question was "yes" and not stop if the answer was "no." The rhythm stopped for about ten seconds. I took this as an indication that I was being understood. I then asked if it was possible during this session for the rhythm to stop only in response to my question and not for other reasons, such as body position, etc., The rhythm stopped again. I was feeling more confident. I proceeded [6].
Using "yes-no answers," Upledger says, he pinpointed the problem as "a toxin that was inhaled by the mother . . . over a period of about two-and-a-half hours while cleaning the grease off an antique automobile engine" during the fourth month of pregnancy. After "asking many particulars" about what he should do, Upledger was told to "pump the parietal bones that form a large part of the roof of the skull, and to pass a lot of my energy through the brain from the back of the skull to the front." As he did this, Upledger frequently checked with the baby's "Inner Physician." After about an hour, Upledger says, the baby began to move normally [6].
In July 2003, a Pennsylvania chiropractor was convicted of insurance fraud in connection with the death of a 30-year-old epileptic woman whom she treated with cranial therapy. Court documents indicated that the patient died of severe seizures after following the chiropractor's advice to stop taking her anticonvulsive medication. The fraud involved submitting insurance claims falsely describing Upledger's "meningeal balancing" as spinal manipulation [7].
Related Systems
British osteopath Robert Boyd, who developed a variant he calls Bio Cranial Therapy, which—according to the International Bio Cranial Web site—is "extremely helpful" for "chronic fatigue syndrome (CFS); varicosity and varicose ulcers; tinnitus; bladder prolapse; prostate disorders; Meniere's syndrome; cardiovascular disturbances including hypertension, angina; skin disorders (psoriasis, eczema, acne etc); female disorders (dysmenorrhoea, PMS (PMT), menorrhagia etc); arthritis and rheumatic disorders; fibromyalgia and heel spurs; gastric disorders (hiatus hernia, ulceration, colitis); asthma and a range of bronchial disorders including bronchiectasis and emphysema." [8]
Sacro-occiptal technique (SOT) combines theories about spinal fluid pressure with chiropractic theories about spinal "nerve pressure" as a cause of ill health. Chiropractors who advocate SOT claim to detect "blockages" by feeling the skull and spine and measuring leg lengths [9].
The Scientific Viewpoint
I do not believe that craniosacral therapy has any therapeutic value. Its underlying theory is false because the bones of the skull fuse by the end of adolescence and no research has ever demonstrated that manual manipulation can move the individual cranial bones [10]. Nor do I believe that "the rhythms of the craniosacral system can be felt as clearly as the rhythms of the cardiovascular and respiratory systems," as is claimed by another Upledger Institute brochure [11]. The brain does pulsate, but this is exclusively related to the cardiovascular system [12], and no relationship between brain pulsation and general health has been demonstrated.
A few years ago, three physical therapists who examined the same 12 patients diagnosed significantly different "craniosacral rates," which is the expected outcome of measuring a nonexistent phenomenon [13]. Another study compared the "craniosacral rate" measured at the head and feet of 28 adults by two examiners and found that the results were highly inconsistent [14].
In 1999, after doing a comprehensive review of published studies, the British Columbia Office of Health Technology Assessment (BCOHTA) concluded that the theory is invalid and that practitioners cannot reliably measure what they claim to be modifying. The 68-page report concludes that "there is insufficient evidence to recommend craniosacral therapy to patients, practitioners, or third party payers." [15]
In 2002, two basic science professors at the University of New England College of Osteopathic Medicine concluded:
Our own and previously published findings suggest that the proposed mechanism for cranial osteopathy is invalid and that interexaminer (and, therefore, diagnostic) reliability is approximately zero. Since no properly randomized, blinded, and placebo-controlled outcome studies have been published, we conclude that cranial osteopathy should be removed from curricula of colleges of osteopathic medicine and from osteopathic licensing examinations [10].
I certainly agree! In fact, I believe that most practitioners of craniosacral therapy have such poor judgment that they should be delicensed.
Reader Comment
As a physical therapist and exercise physiologist, I'd like to thank you for your article on "craniosacral therapy". Too many patients and therapists have been duped by this so-called therapy. If these therapist were ever to suggest to any self-respecting neurosurgeon, that they could move the sutures of the skull with ounces of force, they would get laughed right out of the room. I have personally witnessed how saws and drills are needed (with more than a few ounces of force) to alter the structure of the adult skull. To tell patients that you have the ability to analyze the cerebral spinal fluid flow with your fingertips and then "normalize" it by mobilizing the cranial sutures is not just quackery but malpractice. They should lose their license.
1. Discover CranioSacral Therapy. Undated flyer distributed in 1997 by the Upledger Institute.
2. Upledger CranioSacral Therapy I. Brochure for course, November 1997.
3. For serious education in complementary care . . . come to the source. Brochure for course, Upledger Institute, Aug 2001.
4. CranioSacral Therapy. Upledger Institute Web site, accessed Aug 15, 2001.
5. Visceral manipulation. Upledger Institute Web site, accessed Aug 15, 2001.
6. Upledger JE. CranoSacral Therapy: Touchstone of Natural Healing. Berkeley, Caliifornia: North Atlantic Books, 1999, p 51-58.
7. Barrett S. Bizarre therapy leads to patient's death. Chirobase, July 7, 2003.
8. Bio Cranial Therapy in action. International Bio Cranial Web site, accessed Aug 21, 2001.
9. Homola S. Bonesetting, Chiropractic, and Cultism, 1963.
10. Hartman SE, Norton JM. Interexaminer reliability and cranial osteopathy. Scientific Review of Alternative Medicine 6(1):23-34, 2002.
11. Workshop catalog, Upledger Institute, 1995.
12. Ferre JC and others. Cranial osteopathy, delusion or reality? Actualites Odonto-Stomatologiques 44:481-494, 1990.
13. Wirth-Pattullo V, Hayes KW. Interrater reliability of craniosacral rate measurements and their relationship with subjects' and examiners' heart and respiratory rate measurements. Physical Therapy 74:908-16, 1994.
14. Rogers JS and others. Simultaneous palpation of the craniosacral rate at the head and feet: Intrarater and interrater reliability and rate comparisons. Physical Therapy 78:1175-1185, 1998.
15. Kazanjian A and others. A systematic review and appraisal of the scientific evidence on craniosacral therapy. BCOHTA, May 1999] ... anial.html

В «Трактате Желтого императора о внутреннем. Вопросы о простейшем», 2697 г. до н. э., Ци-бо, Небесный Лекарь, который поведал людям об искусстве врачевания сказал: «Если мудрость у тебя есть, тогда доискиваешься до одинакового (ищешь то, что объясняет), а если глуп, то ищешь различия. Потому-то священномудрый делает дела, не проявляя себя в действиях (позволяя им совершаться без своего участия). Он радуется возможностям безмятежного покоя. Он следует желаниям, радуется эмоциональным устремлениям, постоянно размышляя о пустоте всего сущего».
Спор об эффективности того или иного метода воздействия на человека не утихнет никогда.

Попробуем поискать научные аргументы за методы мануальной медицины.

J Hand Ther. 2008 Jan-Mar;21(1).
The effect of oscillating-energy manual therapy on lateral epicondylitis: a randomized, placebo-control, double-blinded study.
Nourbakhsh MR, Fearon FJ.
Department of Physical Therapy, North Georgia College and State University, Dahlonega, Georgia 30597, USA.
Symptoms of lateral epicondylitis (LE) are attributed to degenerative changes and inflammatory reactions in the common extensor tendon induced by microscopic tears in the tissue after repetitive or overload functions of the wrist and hand extensor muscles. Conventional treatments, provided on the premise of inflammatory basis of LE, have shown 39-80% failure rate. An alternative approach suggests that symptoms of LE could be due to active tender points developed in the origin of hand and wrist extensor muscles after overuse or repetitive movements. Oscillating-energy Manual Therapy (OEMT), also known as V-spread, is a craniosacral manual technique that has been clinically used for treating tender points over the suture lines in the skull. Considering symptoms of LE may result from active tender points, the purpose of this study was to investigate the effect of OEMT on pain, grip strength, and functional abilities of subjects with chronic LE. Twenty-three subjects with chronic LE (>3mo) between ages of 24 and 72 years participated in this study. Before their participation, all subjects were screened to rule out cervical and other pathologies that could possibly contribute to their lateral elbow pain. Subjects who met the inclusion criteria were randomized into treatment and placebo treatment groups by a second (treating) therapist. Subjects were blinded to their group assignment. Subjects in the treatment group received OEMT for six sessions. During each treatment session, first a tender point was located through palpation. After proper hand placement, the therapist focused the direction of the oscillating energy on the localized tender point. Subjects in the placebo group underwent the same procedure, but the direction of the oscillating energy was directed to an area above or below the tender points, not covering the affected area. Jamar Dynamometer, Patient Specific Functional Scale (PSFS), and Numeric Rating Scale (NRS) were used to measure grip strength, functional status, and pain intensity and limited activity due to pain, respectively. The screening therapist who was blinded to the subjects' group assignment performed pretest, posttest, and six-month follow-up measurements. Subjects in the treatment group showed both clinically and statistically significant improvement in grip strength (p=0.03), pain intensity (p=0.006), function (p=0.003), and limited activity due to pain (p=0.025) compared with those in the placebo group. Follow-up data, collected after six months, showed no significant difference between posttest and follow-up measurements in functional activity (p=0.35), pain intensity (p=0.72), and activity limitation due to pain (p=0.34). Of all the subjects contacted for follow-up assessment, 91% maintained improved function and 73% remained pain free for at least six months. OEMT seems to be a viable, effective, and efficient alternative treatment for LE. ... d_RVDocSum
Explore (NY). 2007 Jan-Feb;3(1).
The impact of acupuncture and craniosacral therapy interventions on clinical outcomes in adults with asthma.
Mehl-Madrona L, Kligler B, Silverman S, Lynton H, Merrell W.
Department of Family Medicine, University of Saskatchewan College of Medicine, Saskatoon, SK, Canada.
OBJECTIVE: Synergy has been proposed between modalities operating at different levels of action. Acupuncture and craniosacral therapy are two very different modalities for which synergy has been proposed. This study sought to test for such synergy and to determine if complementary therapies would improve pulmonary function and quality of life for people suffering from asthma, as well as reducing anxiety, depression, and medication usage. DESIGN: Subjects were randomly assignment to one of five groups: acupuncture, craniosacral therapy, acupuncture and craniosacral, attention control, and waiting list control. METHODS: Subjects received 12 sessions of equal length with pretreatment and posttreatment assessment of pulmonary function, asthma quality of life, depression, and anxiety. Medication use was also assessed. RESULTS: Synergy was not demonstrated. When treatment was compared with the control group, statistically treatment was significantly better than the control group in improving asthma quality of life, whereas reducing medication use with pulmonary function test results remained the same. However, the combination of acupuncture and craniosacral treatment was not superior to each therapy alone. In fact, although all active patients received 12 treatment sessions, those who received all treatments from one practitioner had statistically significant reductions in anxiety when compared with those receiving the same number of treatments from multiple practitioners. No effects on depression were found. CONCLUSIONS: Acupuncture and/or craniosacral therapy are potentially useful adjuncts to the conventional care of adults with asthma, but the combination of the two does not provide additional benefit over each therapy alone. ... d_RVDocSum

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