Cranial Field Research Articles

IMG-26. USING [18F]FET-PET/CT SCAN TO DIFFERENTIATE RADIONECROSIS FROM RECURRENCE/NEW TUMOURS: THE CASE OF A CNS SARCOMA

Abstract CASE REPORT A 5-year-old girl diagnosed with a posterior fossa standard-risk medulloblastoma underwent surgery followed by proton therapy (PT) 23.4 Gy(RBE) (1.8 Gy(RBE)/fr) to the craniospinal axis plus a boost of 30.6 Gy(RBE) (1.8 Gy(RBE)/fr) to the tumor bed and maintenance chemotherapy according to HIT-SIOP PNET 4 protocol. The patient remained disease-free for 4 years after the end of treatmen. MRI showed a new left temporo-occipital lesion 8x10x10 mm which was irradiated from cranial field during the craniospinal phase but outside of the boost area, consistent with inoperable recurrence. She was then re-irradiated with a second course of PT 50.4 Gy(RBE) (1.8 Gy(RBE)/fr) and subsequently started on temozolomide. Periodic MRI scans showed progressive reduction of the lesion for 10 months, when new lesion progression occurred within the re-irradiated fieled. Considering the stable clinical conditions of the patient, the minimal size of the lesion, and the uncertain nature between actinic damage or cancer, a watchful waiting approach was adopted. Few months later, the area increased. [18F]FET-PET/CT evaluation documented an uptake of the drug compatible with metabolically active lesion. A biopsy was performed, and histology showed a CNS sarcoma. Genetical testing excluded cancer predisposition syndromes. Chemotherapy with bevacizumab and irinotecan was started, but the MRI showed significant progression of the disease and the patient died 6 months after the diagnosis. CONCLUSION MRI is the main diagnostic method in the follow up of CNS neoplasms, but it has limitations in discriminating recurrences/secondary tumours and tissue changes due to previous treatments, particularly radiotherapy. Recently, the use of [18F]FET-PET/CT is being investigated, but literature is still poor in children and most cases refer to high-grade gliomas. It is desirable to study it further, as it may play a relevant role in differentiating equivocal cases, as in our patient.

Neurophysiology, Neuro-Immune Interactions, and Mechanobiology in Osteopathy in the Cranial Field: An Evidence-Informed Perspective for a Scientific Rationale

(1) Background: Osteopathy in the cranial field (OCF) is a distinctive approach within osteopathy, focusing on the cranial region’s manual manipulation. Nevertheless, OCF fosters doubt in the scientific community because it refers to out-of-date models. This perspective paper critically analyzes the current knowledge in the fields of neurophysiology and mechanobiology to propose an evidence-informed rationale for OCF. (2) Methods: The reporting framework used in the current perspective article obeyed the guidelines for writing a commentary. (3) Results: The article’s main findings focus on the tactile stimulation of exocranial receptors and their implications in the management of craniofacial algic-dysfunctional syndromes implementing OCF. (4) Conclusions: By establishing an evidence-based rationale for OCF, this research aims to guide future directions in OCF and contribute to a more patient-centered and effective approach to health and wellbeing.

Examination of “The Tide,” CRI, and Physiologic Respiration: A Mathematical Analysis

Abstract This study seeks to examine the inter-relationship of what William Garner Sutherland, DO called “The Tide,” the Cranial Rhythmic Impulse (CRI) palpated by practitioners of Osteopathy in the Cranial Field (OCF), and physiologic or pulmonary respiration. This study is different in that it proposes a mathematical analysis of these several phenomena to reconcile whether these are part of the same overarching natural wave or they are distinct. The pertinent medical literature is reviewed. The mathematics of Fourier analysis is briefly described. This study performed “reverse” Fourier analysis, that is, the combination of the various periodic signals into one periodic signal, across the range of normal physiological data values. Stochastic techniques were then applied to resolve these probabilistic data into 1 overarching periodic signal. From the mathematical analysis, it is not mathematically possible for “The Tide” to be in the range of the fundamental frequencies of the CRI, pulmonary respiration, and the Traube-Hering-Mayer oscillations that derive from it and are its harmonics. This mathematical analysis cannot be construed as negating the existence of “The Tide,” rather merely eliminates these fundamental frequencies as being “The Tide.” “The Tide” must be something else. More research is indicated.

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.

Osteopathy in the Cranial Field as a Method to Enhance Brain Injury Recovery: A Preliminary Study.

The clinical burden of traumatic brain injury (TBI) continues to grow worldwide, with patients often developing chronic neurological, behavorial, and cognitive deficits. Treatment and management strategies remain a key challenge, given that they target the symptoms and not the underlying pathological response. To advance pre-clinical research and therapeutic developments, there is a need to study treatment strategies that improve brain injury recovery. Cranial osteopathic manipulative medicine (cOMM) is a non-invasive and non-pharmacological strategy that has been shown to improve quality of life for several medical conditions and injuries, and may be able to treat TBI and reduce subsequent symptoms. In this study, we aimed to evaluate the neurobiological effect of cOMM on the injury response and its potential to alleviate symptoms. We investigated the ability of cOMM to enhance fluid transport by quantifying fluorescent tracer clearance throughout the brain. Further, using an in vivo TBI model, male rats were exposed to a repeated blast overpressure that was followed by cOMM treatment 24 h later. Our findings indicated that cOMM treatment attenuated acute and subacute anxiety-like behaviors. Post-mortem pathological examination in the hippocampus, pre-frontal, and motor cortices indicated improvements in glial pathology in cOMM-treated animals compared to the untreated injury group. Overall, this is the first study to explore cOMM as a treatment option for brain injury, demonstrating its capability to improve TBI outcomes.

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

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. 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. 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 4h washout period. AABP was continuously recorded by electroencephalogram (EEG) of the occipital area in the first 10min of resting state, during each intervention (active technique time) and after 10min (post-active technique time), for a total of approximately 50min 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). 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 10min 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. 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.

Osteopathy in the Cranial Field from a Systems Theory Perspective

A proposition is made for scientific substantiation of “Primary respiration” and related concepts, including suggestions for future research. For research and support, the field of mathematics, artificial intelligence, chaos theory and complex systems thinking can be of fundamental and essential value.

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.

Long-Term Outcomes and Sequelae Analysis of Intracranial Germinoma: Need to Reduce the Extended-Field Radiotherapy Volume and Dose to Minimize Late Sequelae.

PurposeWe aimed to refine the radiotherapy (RT) volume and dose for intracranial germinoma considering recurrences and long-term toxicities.Materials and MethodsTotal 189 patients with intracranial germinoma were treated with RT alone (n=50) and RT with upfront chemotherapy (CRT) (n=139). All cases were confirmed histologically. RT fields comprised the extended-field and involved-field only for primary site. The extended-field, including craniospinal, whole brain (WB), and whole ventricle (WV) for cranial field, is followed by involved-field boost. The median follow-up duration was 115 months.ResultsThe relapses developed in 13 patients (6.9%). For the extended-field, cranial RT dose down to 18 Gy exhibited no cranial recurrence in 34 patients. In CRT, 74 patients (56.5%) showed complete response to chemotherapy and no involved-field recurrence with low-dose RT of 30 Gy. WV RT with chemotherapy for the basal ganglia or thalamus germinoma showed no recurrence. Secondary malignancy developed in 10 patients (5.3%) with a latency of 20 years (range, 4 to 26 years) and caused mortalities in six. WB or craniospinal field rather than WV or involved-field significantly increased the rate of hormone deficiencies, and secondary malignancy. RT dose for extended-field correlated significantly with the rate of hormone deficiencies, secondary malignancy, and neurocognitive dysfunction.ConclusionDe-intensifying extended-field rather than involved-field or total scheme of RT will be critical to decrease the late toxicities. Upfront chemotherapy could be beneficial for the patients with complete response to minimize the RT dose down to 30 Gy. Prospective trials focused on de-intensification of the extended-field RT are warranted.

Abstract 12540: Neural Crest Cell-derived Wnt5a Regulates Planar Cell Polarity in Cranial Second Heart Field Progenitor Cells

Introduction: Wnt5a is a known regulator of planar cell polarity (PCP) signaling in second heart field (SHF) progenitor cells. It is generally believed that Wnt5a ligands are secreted by the SHF; however, SHF-specific conditional deletion of Wnt5a does not recapitulate outflow tract (OFT) defects observed in global Wnt5a mutants. Hypothesis: Given the proximity and interaction between neural crest cells (NCC) and cranial SHF that contributes to the developing OFT, we hypothesize that NCC may serve as an additional source of Wnt5a for SHF progenitors. Methods: Wnt5a was conditionally deleted in the neural crest using transgenic Wnt1-cre mice. Embryos were harvested from control and mutant litter mates and immunofluoresence, in situ hybridization, and hematoxylin-eosin stains were performed on histologic sections using standard techniques. India ink injections were performed to evaluate pharyngeal arch artery and outflow tract morphology in whole mount embryos. Results: Wnt1-cre driven conditional deletion of Wnt5a in NCC did not impact NCC survival or migration into the developing OFT. However, SHF cells in mutant E10.5 embryos showed altered PCP signaling with reduced phalloidin and laminin expression. The resulting loss in polarized directional movement of the SHF led to reduced incorporation into and elongation of the developing OFT. The shortened OFT was mal-aligned resulting in fully penetrant double outlet right ventricle (DORV) at E14.5. In addition, maturation of pharyngeal arch arteries was also impaired such that all mutants express pharyngeal arch artery defects, including aortic arch abnormalities and aberrant right subclavian artery. In contrast, there was no observed effect on PCP in the more caudal SHF cells, and none of the mutant embryos had inflow tract or venous pole defects. Conclusions: Our results demonstrate that NCC are a novel source of Wnt5a. NCC-derived Wnt5a is critically required to regulate PCP signals in the most cranial SHF regulating the development of the OFT and pharyngeal arch arteries.

Direct measurement of the rhythmic motions of the human head identifies a third rhythm

IntroductionCentral to the osteopathic cranial field, and at the same time controversial, is the concept of a unique rhythmic movement believed to originate from a primary respiratory mechanism (PRM). Further, the PRM is reported to manifest as a cranial rhythmic impulse (CRI) on the living human skull. This study explores the rhythmic oscillations of the human head measured directly as physical movements. The aim is to investigate the existence of a third rhythm distinct from the head movements caused by respiratory breathing and arterial pulsing, in an objective and purely experimental study. ExperimentalIn 50 healthy individuals, rhythmic oscillations of the head were measured in real-time for 42 min in a supine resting state without any intervention. A newly developed machine for tracking rhythmic movements was used for measurements. ResultsIn all individuals, a third rhythm was distinguished as separate from the arterial and respiratory rhythm at all times. The third rhythm was observed as a dynamic physiological phenomenon with a narrow range in resting healthy individuals with a mean of 6.16 cycles/minute (4.25–7.07). The significant contribution to the amplitude of the measured movements was the respiratory breathing and this third rhythm, whereas the contribution from the arterial pulsing were minor. ConclusionThe present study demonstrates the existence, and normative range of a third physical rhythm detected on the human head. Having developed an objective approach to studying this third rhythm might form the future basis for clinical and physiological studies of craniosacral function and dysfunction.

A Pilot Study of Jugular Compression (Queckenstedt maneuver) for Cranial Movement Perception.

Osteopathy in the cranial field (OCF) is among the most controversial topics of osteopathic practice. The mechanism by which cranial movement (CM) occurs is poorly understood, but includes speculation that intracranial pressure can generate a movement of the cranial bones. If this model is valid, an increase in intracranial pressure produced by bilateral compression of internal jugular veins, or the Queckenstedt maneuver (Q-test), should be detectable. To determine whether osteopaths can perceive a palpable change in CM when the Q-test is applied. Blindfolded osteopaths experienced in OCF evaluated the CM of volunteers as a trained clinician applied the Q-test. The osteopaths reported any change in CM amplitude during 3 different 1-minute periods. The total number of variations perceived in each period (PV) by all osteopaths on all volunteers was analyzed. The Kruskal Wallis test was used to evaluate the differences between the test periods. The Mann-Whitney test was used for a pairwise comparison. Statistical significance was set at P≤.05. Eight osteopaths participated in this study and evaluated the CM of 6 volunteers. A Kruskal-Wallis test of the PV between monitoring periods revealed a statistically significant difference (P<.001). A Mann-Whitney Test showed there was a significant increase in PV between the compression period and the 2 other monitoring periods (base P=.003 and expectation P=.009). Osteopaths could detect a change in the amplitude of CM after the Q-test was applied. Although this was a small-scale pilot study, our data represent a starting point for understanding whether an intracranial or an extracranial mechanism is responsible for the CM.

Proceedings #49: Management of Trigeminal Autonomic Cephalgia with Cranial Peripheral Nerve and Peripheral Field Stimulation

Proceedings #49: Management of Trigeminal Autonomic Cephalgia with Cranial Peripheral Nerve and Peripheral Field Stimulation

A low gradient junction technique of craniospinal irradiation using volumetric-modulated arc therapy and its advantages over the conventional therapy

A technique using volumetric-modulated arc therapy (VMAT) fields for craniospinal irradiation with low dose gradients at the field junction was tested for its sensitivity to positional inaccuracy. It was compared against the conventional three-dimensional (3D) conformal radiotherapy in terms of dose uniformity at the junction. Treatment plans generated for ten patients who received craniospinal irradiation (35Gy in 21 fractions) by VMAT technique at our centre were included in this study. For these patients, 3D conformal radiotherapy plans were also generated in addition to the VMAT treatment plans. Intentional shifting of the cranial field in the superior and then in the inferior directions was done, creating a gap or overlap between the fields. Consequent changes in dose distributions in these two plans to positional inaccuracies were studied. The 3D conformal radiotherapy plans showed large dose variations at the junction due to positional shifts as compared to the VMAT plans. With a 5mm superior shift of the cranial field isocentre creating a gap between the cranial and spinal fields, the magnitudes of under-dosing were 13.9±3.6Gy and 4.8±2.0Gy for 3D conformal radiotherapy and VMAT respectively. When the cranial field was moved by 5mm inferiorly creating an overlap between the fields, overdose to the effects of 10.3±4.0Gy and 4.9±1.3Gy were observed for the 3D conformal radiotherapy plans and VMAT plans respectively. The VMAT technique is insensitive to longitudinal setup errors (1–3mm) in patients because of the existence of low dose gradients at the junction between fields. This is unlike the 3D conformal radiotherapy plans which have steep dose gradients at the field edges and thus are highly sensitive to setup errors. Such an advantage for VMAT circumvents the need for dose feathering often practiced with the 3D conformal radiotherapy technique and makes the technique simpler to follow.

Effectiveness of osteopathic manipulative treatment versus osteopathy in the cranial field in temporomandibular disorders – a pilot study

Purpose: Temporomandibular disorders are a common musculoskeletal condition causing severe pain, physical and psychological disability. The effect and evidence of osteopathic manipulative treatment and osteopathy in the cranial field is scarce and their use are controversial. The purpose of this pilot study was to evaluate the effectiveness of osteopathic manipulative treatment and osteopathy in the cranial field in temporomandibular disorders.Methods: A randomized clinical trial in patients with temporomandibular disorders was performed. Forty female subjects with long-term temporomandibular disorders (>3 months) were included. At enrollment, subjects were randomly assigned into two groups: (1) osteopathic manipulative treatment group (20 female patients) and (2) osteopathy in the cranial field group (20 female patients). Examination was performed at baseline (E0) and at the end of the last treatment (E1), consisting of subjective pain intensity with the Visual Analog Scale, Helkimo Index and SF-36 Health Survey. Subjects had five treatments, once a week. 36 subjects completed the study (33.7 ± 10.3 y).Results: Patients in both groups showed significant reduction in Visual Analog Scale score (osteopathic manipulative treatment group: p = 0.001; osteopathy in the cranial field group: p< 0.001), Helkimo Index (osteopathic manipulative treatment group: p = 0.02; osteopathy in the cranial field group: p = 0.003) and a significant improvement in the SF-36 Health Survey – subscale “Bodily Pain” (osteopathic manipulative treatment group: p = 0.04; osteopathy in the cranial field group: p = 0.007) after five treatments (E1). All subjects (n = 36) also showed significant improvements in the above named parameters after five treatments (E1): Visual Analog Scale score (p< 0.001), Helkimo Index (p< 0.001), SF-36 Health Survey – subscale “Bodily Pain” (p = 0.001). The differences between the two groups were not statistically significant for any of the three target parameters.Conclusion: Both therapeutic modalities had similar clinical results. The findings of this pilot trial support the use of osteopathic manipulative treatment and osteopathy in the cranial field as an effective treatment modality in patients with temporomandibular disorders. The positive results in both treatment groups should encourage further research on osteopathic manipulative treatment and osteopathy in the cranial field and support the importance of an interdisciplinary collaboration in patients with temporomandibular disorders.Implications for rehabilitationTemporomandibular disorders are the second most prevalent musculoskeletal condition with a negative impact on physical and psychological factors.There are a variety of options to treat temporomandibular disorders.This pilot study demonstrates the reduction of pain, the improvement of temporomandibular joint dysfunction and the positive impact on quality of life after osteopathic manipulative treatment and osteopathy in the cranial field.Our findings support the use of osteopathic manipulative treatment and osteopathy in the cranial field and should encourage further research on osteopathic manipulative treatment and osteopathy in the cranial field in patients with temporomandibular disorders.Rehabilitation experts should consider osteopathic manipulative treatment and osteopathy in the cranial field as a beneficial treatment option for temporomandibular disorders.

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

ContextIn 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.ObjectivesTo 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.MethodsRelevant 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 selectionRegarding 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 ResultsIn 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 analysisRisk 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.ResultsFor 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.ConclusionOur 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.

Effect of osteopathy in the cranial field on visual function--a pilot study.

The effects of osteopathy in the cranial field on visual function-particularly on changes in the visual field and on the binocular alignment of the eyes-have been poorly characterized in the literature. The authors examined whether osteopathy in the cranial field resulted in an immediate, measurable change in visual function among a sample of adults with cranial asymmetry. Randomized controlled double-blinded pilot clinical trial. Adult volunteers between ages 18 and 35 years who were free of strabismus or active ocular or systemic disease were recruited. Inclusion criteria were refractive error ranging between six diopters of myopia and five diopters of hyperopia, regular astigmatism of any amount, and cranial somatic dysfunction. All subjects were randomly assigned to the treatment or control group. The treatment group received a single intervention of osteopathy in the cranial field to correct cranial dysfunction. The control group received light pressure of a few ounces of force applied to the cranium without osteopathic manipulative treatment. Preintervention and postintervention optometric examinations consisted of distant visual acuity testing, Donder push-up (ie, accommodative system) testing, local stereoacuity testing, pupillary size measurements, and vergence system (ie, cover test with prism neutralization, near point of convergence) testing. Global stereoacuity testing and retinoscopy were performed only in preintervention to determine whether subjects met inclusion criteria. Analysis of variance (ANOVA) was performed for all ocular measures. Twenty-nine subjects completed the trial-15 in the treatment group and 14 in the control group. A hierarchical ANOVA revealed statistically significant effects within the treatment group and within the control group (P <.05) in distance visual acuity of the right eye (OD) and left eye (OS), local stereoacuity, pupillary size measured under dim illumination OD and OS, and near point of convergence break and recovery. For the treatment group vs the control group, a statistically significant effect was observed in pupillary size measured under bright illumination OS (P <.05). The present study suggests that osteopathy in the cranial field may result in beneficial effects on visual function in adults with cranial asymmetry. However, this finding requires additional investigation with a larger sample size and longer intervention and follow-up periods. (ClinicalTrials.gov number NCT00510562).

Quantification of Motion Palpation.

The palpation of motions is at the heart of the practice of foreign-trained osteopaths. When practicing osteopathic manual therapy (care provided by foreign-trained osteopaths) in the cranial field or osteopathic cranial manipulative medicine, the palpation of small motions (several tens of micrometers) is a key process. However, to the authors' knowledge, the smallest detectable motion has not been identified. To quantify motion detection capacity by passive palpation. Participants were instructed to hold a mechanical device containing a micrometric actuator between their hands and report when they felt motion while 6 series of 27 random motions were generated by the actuator. After each series, if a participant succeeded or failed to detect motion with a confidence level of greater than 98%, the motions in the next series were set to a smaller or larger magnitude, respectively. After 6 series, the individual motion detection capacity was recorded. Statistical significance was set at P=.02. A total of 21 participants were selected, comprising 14 osteopaths and 7 nonosteopaths. The average performance of the sample was 148 μm. Thirteen participants (62%) perceived motions of 200 μm or less, and 7 participants (33%) detected motions of 50 μm or less with bare hands. Osteopathic training did not notably affect the performance. Osteopaths were twice as likely to claim detection of nonexisting motions than to miss existing ones, whereas nonosteopaths were equally subject to both types of errors. The data show human passive palpatory sensitivity to be in the range of several tens of micrometers. This range is comparable to that reported for calvarial motion (10-50 μm).

Immediate changes in electroencephalography activity in individuals with nonspecific chronic low back pain after cranial osteopathic manipulative treatment: study protocol of a randomized, controlled crossover trial.

BackgroundOsteopathic medicine is based on a diagnostic and therapeutic system to treat tissue mobility/ motility dysfunctions in general, using different approaches (depending on the target tissue) known as osteopathic manipulative treatment. Among the available techniques those ones addressed to the cranial field are the most questioned because of the lack of scientific evidence; but the compression of the 4th ventricle technique has been largely studied in clinical trials. Studies have shown that the technique may affect both central and autonomous nervous system, modulating some reflexes (Traube-Hering baro signal), and modifying brain cortex electrical activity through central sensitization in subjects with chronic low back pain. Thus, investigators hypothesize that the compression of the 4th ventricle may modulate peak alpha frequency (eletroencephalographic assessment) and promote physical relaxation in subjects in vigil.Methods/DesignA randomized, controlled crossover trial with blinded assessor was designed to test the hypothesis. A total of 81 participants will be assigned to three treatment conditions, with seven days of washout: (I) compression of the 4th ventricle; (II) sham compression of the fourth ventricle; (III) control (no intervention). The (I) power amplitude and the (II) frequencies of the dominant peak in the alpha band will be the primary outcome measures of the study. All participants will be recruited at the Outpatient Rehabilitation Service of the University Hospital of Brasília – University of Brasília. All the electroencephalographic exams will be conducted by a blinded assessor.DiscussionThe investigators hypothesize that patients with chronic low back pain submitted to the technique would have the peak alpha frequency modulated and, thus, would experience physical relaxation.Trial registrationNCT02111382

A global view of osteopathic practice – mirror or echo chamber?

The Osteopathic International Alliance (OIA) released a report in 2013 entitled, ‘Osteopathy and osteopathic medicine. A global view of practice, patients, education and the contribution to healthcare delivery’. The report was widely circulated by the statutory regulator in New Zealand. It is said to be a representative document by the OIA. Two osteopathic professional streams were identified – osteopathic physicians (and surgeons) and osteopaths. Other than by ancestry, it is apparent that these two streams are not comparable. The claim of a shared ‘core practice’ between the streams is not upheld by the data, which also appear to indicate a dichotomy between a claim of evidence-based practice and the nature of practice itself. The response rate to unpublished surveys does not appear to support the notion that the OIA report is representative of global osteopathic practice. The data within the OIA Report identifies the most frequently utilised form of osteopathic manipulative treatment (OMT) as osteopathy in the cranial field (OCF). These issues are explored further by comparing the bibliographies of a systematic review of cranial osteopathy conducted 12 years ago with a current snap-shot summary (2013) published by the UK National Council for Osteopathic Research. OCF appears to be an unfalsifiable practice that has become professionally institutionalised. Far from being marginalised this practice now holds a central position, one inconsistent with a claim of ethical, evidence-based best practice, and one seemingly endorsed by statutory regulators. From these perspectives then, the report appears closer to an echo chamber of belief than an accurate reflection of contemporary osteopathic practice.