In this post, we are going to discuss scientific and philosophical issues at a fairly sophisticated level. In this way, it can sound like discussions you might hear in a dorm room, or at a bar, or at a party somewhere, where people chat, and explore ideas, and can move on to another topic if this one proves boring or difficult or painful.
We don't have that luxury here.
This conversation is necessary, because at least 4 lives have been ruined forever.
A previously-healthy 3-month-old baby girl is now dead.
The girl's parents have been left behind to pick up the pieces of their lives.
A therapist's career is in ruins, and he has to live with the knowledge that he killed an infant through his actions.
Because massage is so often associated with craniosacral therapy (CST), both in the minds of the public and through how therapists represent themselves, we need to clearly address this issue and resolve where we come down on the side of professional ethics, client protection, and good information.
Let's never forget that we're not just making conversation here. While it doesn't usually rise to the level of a life-and-death issue, as it does in this case, this engagement is vitally important, as are the answers we decide upon, because they do have a major impact--both on our clients' quality of life, and on where massage goes (or doesn't go) as a profession.
Source: http://anaximperator.files.wordpress.com/2010/01/baby.jpg accessed 19 December 2011
A conversation on the role that CST played in the death of a healthy baby girl in the Netherlands a few years ago is taking place on Facebook and elsewhere in the blogosphere now.
The facts of the matter are spelled out in the blog post here.
Infant Dies after “Craniosacral” Therapy
140 Comments Posted by beatis on May 7, 2009
In the Dutch Medical Journal, authors from the University Hospital St. Radboud in Nijmegen, Netherlands, report a tragic case history of an infant dying after being treated by a craniosacral therapist.
Deceased infant after “craniosacral manipulations” of neck and vertebral column
(Transl Beatis)
A formerly healthy, three-month-old girl died after manipulation of the neck and the vertebral column by a so called “craniosacral therapist.” During continued and deep bending of the neck, the patient developed incontinence of faeces, atonia [complete limpness of muscles] and respiratory arrest [no breathing] followed by aystolia [no cardiac activity, "flatline"]. Based on findings at the physical examination of the body, an additional MRI examination and the autopsy, it is likely that the cause of death was a local neurovascular or a mechanic respiratory-induced problem. This is the second report of infant death after forced manipulation of the neck. As long as there is no scientific evidence for the efficacy and safety of forced manipulation of the neck and the vertebral column, we advise against this treatment for newborns and infants. [Definitions of medical terminology added--RST.]
The words "craniosacral", "craniosacral manipulations", and "craniosacral therapist" are in quotes, because there is controversy about whether this treatment was really considered CST or not.
The original blog poster states in a comment that
The therapist was an officially trained Upledger craniosacral therapist. The practice where he was employed gives craniosacral therapies according to the principles of John Upledger.
So whether or not the treatment he performed was actually CST in the strict sense, the parents had every reason to believe it was CST as it was represented to them.
For massage to develop into a client-centered healthcare profession, we therefore have to consider the effects of the information we provide on the client who is receiving that information.
What are we doing to ensure that--from the point of view of the client--the information provided by MTs:
-
is accurate, to the best of our ability and collective knowledge?
-
is understandable and usable by the client?
-
does no harm to the client?
-
empowers the client to make fully-informed decisions?
It is not enough for a profession to simply say "caveat emptor" ("let the buyer beware"). We have to carefully consider on what basis we provide correct and accurate information to our clients, and how we present it to make sure that the communication works on both sides.
The Massage Therapy Body of Knowledge (MTBoK) does not mention CST at all, and I agree with them that CST is an entirely separate practice from massage therapy.
They do mention that
The list of therapies and disciplines described above [in the lists of what is in scope of practice and what is outside of scope of practice] is not exhaustive. Though it represents practices that are not within the scope of practice for massage therapy, they may provide benefit for the client/patient. Massage therapists can and often do learn and obtain appropriate licensing and certification to practice and add these disciplines to their “tool bags” within their practice. Massage therapists are expected to meet all legal expectations and requirements of the jurisdiction in which they practice their disciplines prior to implementing them in practice.
To this, I would add a recommendation that--in the process of training in additional disciplines to add to their "tool bags"--that MTs also reject any claims from those disciplines that are counterfactual and/or harmful.
"Primum non nocere"--"first, do no harm"--should be an absolute requirement for adding any additional techniques to the practice of massage.
It does not seem particularly controversial that the science of anatomy is considered foundational knowledge for MTs. The MTBoK, NCETMB/NCETM, MBLEx, Canadian standards of knowledge, and UK standards of knowledge all have sections dedicated to outlining the anatomy knowledge requirements that they consider appropriate expectations for entry-level MTs.
Knowing anatomy means more than just regurgitating names and numbers on a test. It means understanding at a deep level how the body works in an integrated way, and recognizing when claims made in the name of anatomy are false.
If massage therapy is to evolve into a healthcare profession, with the privileges and obligations that accompany that status, then we have to make a commitment to seeking the truth about the material physical natural world.
The craniosacral claims that the fused cranial bones can be moved apart by a practitioner's light pressure, and that the craniosacral fluid (CSF) has pulses or rhythmic tides are false. Anyone who does not understand and cannot apply that fact does not really understand basic anatomy, no matter how much they may say that they do.
(UPDATE, 1:59 PM PST: A commenter on Facebook corrects me about the claim:
the CST practitioner is not trying to create movement, he/she is attempting to RESIST or CREATE A BARRIER against motion. it is this that 5 grams of pressure relates to.
I thank you for the correction, and I want to represent the claim accurately, so I appreciate your giving me the opportunity. I think that it does not change the larger point, as the bones do not move in any case.)
To make an unconditional and unambiguous commitment to seeking the truth about the natural world does not mean that we have to be unkind in doing so.
For someone to come to the realization that they have been taught wrong information--even if it wasn't deliberate, even if the teachers were just passing along in good faith the information they had been taught by their teachers, and on back--can be a very serious and painful thing.
This realization can cause moral distress in the person who has to come to terms with it, and it can also cause moral distress in caring and empathetic people who watch them undergo that realization, and see its consequences.
No matter how much we would like to spare them that pain, though, we cannot enable misinformation by pretending that it does not make a difference whether claims are true or false.
As painful as it may be to watch, and as kind and caring and supportive as we want to be, we still have to maintain our commitment to communicating healthcare information that is true, or we are not living up to the obligations of a healthcare profession.
Knowing that someone is angry and in pain and lashing out can make it easier not to take that anger personally, even if it is directed at someone else who is not at fault.
There is a great deal of moral distress occurring in the reactions to this case, and if we understand other people's moral distress--as well as our own--perhaps the understanding that comes out of this can act as a tiny, tiny silver lining on the massive black cloud of the pain that this case has caused.
No blame, no shame--just understanding and kindness, as well as a resolution to always put the interests of the client ahead of our own interest in any particular system of thought.
In watching how people in moral distress react to this case, we can see a lot of defensiveness in trying to salvage CST's incorrect anatomical claims. We can understand why people feel a defensive reaction to new information, because it demands that they must act--either to change, or to vociferously [loudly] defend not changing.
The claim is made that human skull bones are not fused, but actually movable.
The way that science works, if you make a claim, you're responsible for demonstrating the validity of that claim.
However, this claim is easily refuted by producing a skull and demonstrating how tightly fused the bones are.
Rather than accepting that evidence, the advocates of the movable skull bones make an additional claim such as
"holding a post rigor mortis skull in the hand tells us nothing about the living skull. That's just silly."
In addition to being incorrect about the anatomy, they are also attempting to shift the burden of proof.
They are the ones making the claim that cranial bones move at the suture; it is their job to demonstrate it. Instead, they just deny the usefulness of cadaver studies to anatomy. You can understand why they feel the need to do that--because accepting anatomical fact means confronting that they've been taught misinformation, and passed on misinformation themselves.
Even if bones were movable, that would not show that the claims made about CST are true, only that they could be true. But if the bones are not movable, then that shows that the claims cannot be true. In our commitment to anatomical fact, we can also recognize the depth of the impact that fact has on people who were taught otherwise.
A team of physical therapy researchers in Pennsylvania investigated the question of whether living cranial bones could undergo movement, since the CST advocates claimed the dead skulls were not representative.
Obviously, no research ethics board is going to approve this experiment on humans, so they used rabbits to study the question.
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. Journal of Orthopaedic and Sports Physical Therapy. 2006 Nov;36(11):845-53. PMID: 17154138
Abstract: 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.
In summary, they tested the claim that CST-strength forces can move cranial bones at the sutures in live skulls by anesthetizing rabbits, attaching plates to the bones, and pulling on those plates to attempt to move the bones.
They applied forces of 5, 10, 15, and 10 g across the coronal suture, and measured intracranial pressure (ICP) and took X-rays to detect changes in ICP and movements in bone. Additionally, one rabbit had forces from between 100 and 10,000 grams applied.
The single rabbit who had the extra force applied is the only one who showed any movement at all of skull bones, and that was not until 500 grams of force was applied--100 times as much as CST practitioners claim to exert. That much force created 0.30 mm of movement between the bones: one one-hundredth of an inch.
That rabbit showed no change in ICP. All the other rabbits showed neither any change in ICP, nor any bone movement at all.
Although that would seem to show definitively that fused cranial bones don't move, instead of accepting the evidence, some CST advocates go on to make arguments such as:
What the study was measuring was anaesthetised rabbits. Upon what possible basis does one extrapolate a meaningful finding about CST? I don't know that rabbit skulls count here.
Comparative anatomy is a well-established and validated basis for animal modeling of human physiology and disease--in fact, elsewhere at POEM, we are discussing rat studies in Reiki.
The conclusions that the researchers drew from the rat studies is that Reiki is supported, and no one is objecting there that one cannot extrapolate meaningful findings from rats to humans. We are debating only on whether the researchers' interpretations of those findings are correct.
But again, to accept that comparative anatomy validates the findings of the rabbit study would mean that a foundational claim in CST has been conclusively disproven. This fact causes moral distress, and so people--understandably--seek to deny it, rather than to face the consequences of that distress.
One of the CST advocates in the blogosphere took refuge in a God-of-the-gaps argument:
"Comparative anatomy is fine, we are talking about how many species of mammals to compare? It's a nice notion but impractical in my opinion."
The name of the God-of-the-gaps fallacy [logical error] refers to its history of being used to try to preserve supernatural explanations as science began to provide material answers for more and more phenomena in the physical natural world.
As more ground was covered by material explanations, advocates of supernatural explanations used arguments of the form:
-
There is a gap in understanding of some aspect of the natural world.
-
Therefore the cause must be supernatural. [1]
Although the CST claim is not a supernatural argument, the form is the same:
-
There is a gap between species--rabbit to human--in this study.
-
Therefore, the rabbit skull findings cannot be applied to humans, and the study does not disprove CST's claims about human anatomy.
This fallacy is why I advocate evolutionary biology as foundational knowledge in the MT prerequisites and curriculum, although I acknowledge the time and financial restraints, as well as the political resistance. I am providing an e-Book on the subject here to help with those logistic problems.
Comparative anatomy has dealt with this problem for centuries, and it's been facilitated since the mid-19th century by the explanatory power of the theory of evolution.
If someone doesn't understand how evolution works, then it looks as described--like an intractable task of comparing species one at a time, with impossible combinatorics.
Understanding the evolutionary implications of the vertebrate skull, on the other hand--and its similarities and differences across different vertebrate species, such as rabbits and humans--provides the power of abstraction and validated inferences across species that cuts the Gordian knot of the intractability of working only two species at a time.
This argument is very similar to Creationist arguments against evolution, and even as we understand why the argument is not valid, we can also recognize the distress that drives people to cling to invalid arguments such as these.
Yet at the same time as some people are fighting so fiercely to defend beliefs that have been refuted, there are other people who accept that what they were taught has been disproven, and so they are doing the work to learn what they missed out on the first time around.
It is only fair to give them a shout-out for the strength and courage it takes to make that decision and commit to that work. It is awesome when someone can summon that strength of character, and it deserves to be recognized.
That brings us from the moral distress of CST practitioners on the internet clutching at any straw to defend disproven claims to our own moral distress.
I have a hypothesis--I've never formally studied it, so I can't say I know it, but I think it is true, nevertheless.
I think that, as a group, MTs are especially caring people.
I think we're a tenderhearted bunch, and that it pains us to see other people in distress.
Professionalization is going to cause distress as it unfolds. There is just no way around that fact; we've seen it over and over again in other healthcare fields as they underwent a similar process.
Professionalization is going to create winners and losers in the fields of ideas, whether we like that fact or not. Many widely-taught claims, like movable cranial bones, are not going to withstand the scrutiny of evidence-based examination.
We have to come to terms with that fact, as much as we might prefer for every idea to be a winner.
As individuals, if we choose to, we can, in order to avoid our own moral distress, accept every idea that someone claims, whether it is justified or not. Individuals have a choice about how to behave, and if we do that, there is nothing to stop us from doing so.
Or, we can choose to confront our own moral distress, accept the way that the natural world operates, and learn how to come to terms with the effects of the suffering that we witness.
On the other hand, as a group--if we really want to become a profession--we do not have the luxury of that choice. We have to commit to seeking what is true, and to rejecting claims that don't make the cut.
In order to be client-centered, we have to provide good information, and--what is more--to make that information accessible and understandable to the client.
In no way, however, does that necessary commitment to what is true mean that we cannot be kind along the way.
In not accepting untrue claims, we can always be kind to the person making the claim, in awareness that lashing out is not directed as us personally, and that the person is grieving the loss of a worldview, and of trust in those who taught it.
An update to the story of the 3-month-old girl who died reinforces the importance of our putting the client first:
The case has been subject of investigation by the Netherlands Health Care Inspectorate and the Public Prosecutors Office. The Inspectorate decided not to press charges against the craniosacral therapist, after he promised never to apply this treatment again. [2]
The moral of this story is that, by the time the authorities get involved, it is already too late, and they cannot be relied upon to act for the client even if they do get involved.
It is up to us, from within ourselves, to act in a client-centered manner by:
-
paying attention to feedback from our client, and putting that feedback first, ahead of any mental models we may have committed to. In this case, it means that when the baby "lost faeces" and gasped for air, the therapist should have checked to see how the baby was doing, rather than continuing the "treatment" for another 10 minutes;
-
make sure that our mental model is validated as much as possible by the evidence, and provides reality checks to monitor what is truly going on in a session, and to test our beliefs against; and
-
committing to validated claims and rejecting claims that have been refuted for the sake of our clients, even while acknowledging that we recognize the distress and turmoil that the process of professionalization is causing to other practitioners who have to reassess what they have been taught, and to start out on yet another learning journey. This means understanding how the burden of proof works, and what it means when a claim is refuted.
cheers, to Diane Jacobs!
