According to the UK General Osteopathic Council, osteopathy is a system of diagnosis and treatment for a wide range of medical conditions. It works with the structure and function of the body, and is based on the principle that the well-being of an individual depends on the skeleton, muscles, ligaments and connective tissues functioning smoothly together.
To an osteopath, for your body to work well, its structure must also work well. So osteopaths work to restore your body to a state of balance, where possible without the use of drugs or surgery. Osteopaths use touch, physical manipulation, stretching and massage to increase the mobility of joints, to relieve muscle tension, to enhance the blood and nerve supply to tissues, and to help your body’s own healing mechanisms. They may also provide advice on posture and exercise to aid recovery, promote health and prevent symptoms recurring.
In case this sounds a bit vague to you, and in case you wonder what this “wide range of conditions” might be, rest assured, you are not alone. So let’s try to be a little more concrete and clear up some of the confusion around this profession. There are two very different types of osteopaths: US osteopaths are virtually identical with conventionally trained physicians; their qualification is equivalent to those of medical practitioners and they can, for instance, specialise to become GPs or neurologists or surgeons etc. Elsewhere, osteopaths are non-medically qualified alternative practitioners. In the UK, they are regulated by statute, in other counties not. And as to the “wide range of conditions”, I am not aware of any disease or symptom for which the evidence is convincing.
Osteopaths most commonly treat patients suffering from Chronic Non-Specific Low Back Pain (CNSLBP) using a set of non-drug interventions, particularly manual therapies such as spinal mobilisation and manipulation. The question is how well are these techniques supported by reliable evidence. To answer it, we must not cherry-pick our evidence but we need to consider the totality of the reliable studies; in other words, we need an up-to-date systematic review. Such an assessment of clinical research into osteopathic intervention for CNSLBP was recently published by Australian experts.
A thorough search of the literature in multiple electronic databases was undertaken, and all articles were included that reported clinical trials; had adult participants; tested the effectiveness and/or efficacy of osteopathic manual therapies applied by osteopaths, and had a study condition of CNSLBP. The quality of the trials was assessed using the Cochrane criteria. Initial searches located 809 papers, 772 of which were excluded on the basis of abstract alone. The remaining 37 papers were subjected to a detailed analysis of the full text, which resulted in 35 further articles being excluded. There were thus only two studies assessing the effectiveness of manual therapies applied by osteopaths in adult patients with CNSLBP. The results of one trial suggested that the osteopathic intervention was similar in effect to a sham intervention, and the other implies equivalence of effect between osteopathic intervention, exercise and physiotherapy.
I guess, this comes as a bit of a surprise to many consumers who have been told over and over again by osteopaths and their supporters that the evidence is sound. Personally, I am not at all surprised because, two years ago, we published a similar review, albeit with a wider spectrum of conditions, namely any type of musculoskeletal pain. We managed to include a total of 16 RCTs. Five of them suggested that osteopathy leads to a significantly stronger reduction of musculoskeletal pain than a range of control interventions. However, 11 RCTs indicated that osteopathy, compared to controls, generates no change in musculoskeletal pain. At the time, we felt that these data fail to produce compelling evidence for the effectiveness of osteopathy as a treatment of musculoskeletal pain.
This lack of convincing evidence is in sharp contrast to the image of osteopaths as back pain specialists. The UK General Osteopathic council, for instance, sates that Osteopaths’ patients include the young, older people, manual workers, office professionals, pregnant women, children and sports people. Patients seek treatment for a wide variety of conditions, including back pain…In addition, thousands of websites try to convince the consumer that osteopathy is a well-proven therapy for chronic low back pain – not to mention the many other conditions for which the evidence is even less sound.
As so often in alternative medicine, these claims seem to be based more on wishful thinking than on reliable evidence. And as so often, the victims of bogus claims are the consumers who are being misled into making wrong therapeutic decisions, wasting money, and delaying recovery from illness.
251 Responses to Osteopathy is based on little more than wishful thinking
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Edzard, I agree with you about the evidence you cite. I guess you could have gone further and mentioned the widely recognised problems with the reliability and validity of the diagnostic tests used in all fields of physical medicine, irrespective of their flavour … from the orthodox to the alternative and everything in between.
The other thing worth mentioning is your title. I find it vague in contrast to the precision of the the subsequent post. What do you mean exactly by “little more”? There is sophistry in the use of that phrase because there is no quantification of it … I’m left unsure of what you mean intellectually, but you succeed with the emotional punch.
You cite the GOsC as stating that the ‘well-being of the person depends on the health of the musculoskeletal system’ … and I must say I don’t find that to be ‘wishful thinking’. When my msk system isn’t healthy, my well-being suffers. Doesn’t yours?
The other foundational ideas that are taught as the basis for osteopathy are:
– the idea that the body is a unit .. and this isn’t wishful thinking.
– the idea that structure and function are inter-related … and this isn’t wishful thinking.
– the other idea that the body has self-regulatory systems is probably naive given how often these systems go astray … I think it needs some revision as one of the ‘bases for osteopathy’.
In any case, what prompted me to correspond with you is that I feel your headline doesn’t reflect the evidence, and this does your argument an injustice. Your title fails to acknowledge that osteopathy and osteopaths do more than manual therapy, and it superficially sums up an entire profession on the basis of a few clinical trials that study a single intervention for a single pain complaint.
Having said that, I reiterate that I agree with your assessment of the evidence. I’m not sure that making joints go pop or that stretching people or holding them in various positions is the most effective way to approach pain problems. Certainly, the evidence doesn’t support it, or if there is any, then the effect size is small.
When I have had spinal pain, the only evidence that mattered to me was that manual therapy simply didn’t help me. I was far better off with active movement and getting back into life.
Would you agree with me that this situation you describe is evident in many fields of medicine – whether it be orthodox or alternative?
Take the benzodiazipine treatment of anxiety for example. There’s a bunch of wishful thinking if you’ve ever seen it. Yet, we don’t say that the profession of “pharmacology is based on little more than wishful thinking” just because of the large body of evidence pointing to the fact that many pharmacological interventions are ineffective and don’t work as advertised.
It is true, the burden of proof of effectiveness lies with the osteopaths for osteopathic treatment. There is a serious lack of research on the diagnostic procedures used not only by osteopaths, but by chiropractors, physiotherapists and sports physicians etc. There are many conditions claimed to be benefited by manual therapy for which there is no evidence or negative evidence. What a conundrum.
You finish off your post with only one out of 4 possible outcomes from consulting with an osteopath – or any practitioner for that matter. I believe people need to be aware of the 4, not just the 1. A person could go to any practitioner, and:
1. be given an ineffective treatment, but still have a positive outcome
2. be given an ineffective treatment, and have a negative outcome (the only condition you listed above)
3. be given an effective treatment and have a positive outcome (the one we all agree is desirable)
4. be given an effective treatment and have a negative outcome (unfortunately, it happens in the real world).
Each of these is a probability of some magnitude.
There is lot’s of wishful thinking in osteopathy … and chiropractic … and physiotherapy … and podiatry … and surgery … and psychiatry … and dietetics … and diagnostic imaging … and general practice. There are also lot’s of people in each of these fields who care deeply for the people who consult with them, who struggle professionally with the uncertainty of dealing with enigmatic pain problems, and who, with all the wishful thinking they can muster, try their best to help.
I support you in your aim to get rid of all the stuff that simply doesn’t work. Rid the textbooks and curriculums of those things proven to be unreliable, invalid, or ineffectual. And do it in ALL fields of medicine – orthodox or otherwise. But let’s not be so hard in these negotiations that we forget the people involved in these professions with vague headlines … something I no doubt have been guilty of also.
thanks, you make many points; let me try to answer them very briefly.
1) diagnostic tests were not my subject here, but I had pervious posts dealing with them.
2) titles are just titles! I chose them to attract attention to the issue at hand, not to be precise or comprehensive.
3) of course, the msk needs to be fine, but the quote is odd, in my view, in that it implies the msk system is everything or the most important. if you have psoriasis, diabetes, lung cancer or any matter of other conditions, msk is not very important.
4) the idea that the body is a unit is a mere platitude in this context. every branch of medicine has adopted it. to put this on the OGC’s website in this way is, in my view, vague at best and pathetic at worst.
5) roughly the same applies to the idea that structure and function are inter-related.
6) the idea that the body has self-regulatory systems is probably naïve – I agree.
7) Would you agree with me that this situation you describe is evident in many fields of medicine – whether it be orthodox or alternative? no! osteopaths predominantly treat backs with manipulation/mobilisation. I am not aware of any conventional health care profession where the predominant treatment is backed by such poor evidence. if you are, please tell me.
8) There are many conditions claimed to be benefited by manual therapy for which there is no evidence or negative evidence. I agree.
9) You finish off your post with only one out of 4 possible outcomes from consulting with an osteopath….. ??? I am not sure that this is correct; my post was about the clinical evidence for osteopathy, not about the outcomes patients might experience from effective or ineffective treatments.
10) There are also lot’s of people in each of these fields who care deeply for the people who consult with them… I do not doubt that. however, it was NOT the point of my post.
11) And do it in ALL fields of medicine – orthodox or otherwise… absolutely! my field is alt med and this is why I do what I do. many others do similar things in conventional medicine, as you know. in alt med, there are only very few who do critical evaluation, i’m afraid.
12) vague headlines…???? I don’t find mine vague; see also above.
Thanks for your reply. I acknowledge that my reply to your post was about your title and not so much about the content. When I got here, it turned out I was already aware of the content, and so my focus turned to how you got me here, and how you are trying to influence readers with this post, and your blog in general.
As a person with lots of information to read online, I was ‘attracted’ to your journalistic headline, not because it contains any facts that one can quantify, but because of the emotional intent you sought to create by choosing that headline. In short, you sucked me in, and now I have to determine whether it was worth my while.
1. Diagnostic tests. Because of your title, I thought your topic would be about Osteopathy, which includes diagnosis. It wasn’t. You only talked about a few clinical trials to do with manipulation and back pain. Therefore, I got nothing new here and less than I expected.
2. Titles. Yes they are titles and yours attracted me, which is the very point. Unfortunately, the title doesn’t help your work … you might like it, your followers might like it, but I found your post was not RELATED to the title and so therefore on that basis, you either win me as a reader, or lose me. If you are only concerned with writing for an audience who already agrees with you, then keep up with those kinds of titles and your audience will applaude you. However, you wont maximize your influence by doing that. Take my feedback or leave it … it’s up to you.
3. I can understand that you think it’s odd.
4/5/6. I also agree with your comments about the general ‘platitudes’. The problem with these general principles is that they make perfect sense as a basis, however they get extrapolated out to make all sorts of implausible claims, or at worst to continue to defend diagnostic tests or treatments which have been consistently proven to be not useful.
7. That would take a long and drawn out conversation, preferably over a Chianti in somewhere like Montepulciano. As a start we could look at the surgical procedures used in pain medicine.
8. 🙂
9. I was referring to a sentence in your closing paragraph: “And as so often, the victims of bogus claims are the consumers who are being misled into making wrong therapeutic decisions, wasting money, and delaying recovery from illness.”
I guess I’m not sure what you mean by “so often”. Do you have any data on that?
10. It might not have been the point of your post, but it is relevant based on your Title, which is what caused me to come here and read it in the first place. Your titles are the reason I might come back here in the future. Are you training me to doubt your titles or trust them?
11. Yes, agreed. Critical evaluation is hard work. It requires constant vigilance. It also requires the humility, on a daily basis, to accept that we’ve been wrong about something. And those who engage in critical evaluation, and only find and publicise bad news, will limit their influence. People mostly want solutions, not problems.
12. I’m glad you don’t find your headline vague. I do find your headline vague, and I presume you wrote it for me, not you?
Regards,
Nic
I think you provide a perfect example of an osteopath who finds it hard to swallow critique – even though you know it is justified.
you go on about the title and thus distract from the issues.
the title is ok! you dislike it because you are defending osteopathy and your belief system.
the whole thing then gets rather farcical when you want a reference for my wording “so often”.
imagine that: osteopaths are making bogus claims many hundred times on websites etc. without providing adequate references, and once someone dares to expose their incessant attempts to mislead the public, he is asked to provide a reference for a turn of phrase such as “so often”. this really takes the biscuit (and I do not have a reference for that either).
And you Proffessor Ernst have shown us the perfect example of how you are unable to take any for of critique. Your response to Nics comments is just an angry tirade that has totally missed the point he was trying to make.
These types of responses that you more and more frequently make may well be the reason for the recent dip in people actually bothering to comment on here anymore. (Apart from your usual fans that is)
angry triade?
yes, I sometimes do get a bit angry. and I think this is well justified vis a vis an entire profession indulging for many years knowingly in bogus claims.
There are lots of conditions in modern medicine that are not really ‘treated’. Psoriasis isn’t treated, it is suppressed by using medication that reverse transports metabolites back into extracellular spaces. Asthma isn’t treated, the symptoms are suppressed by using similar medication too, the atopic pathway is an iatrogenic disease.
Flu vaccine is notoriously unreliable and systematic reviews by Cochrane have shown the claims by the NHS to be implausible at best.
Your obsession with medical peer review is rather interesting considering many of the ex editors of the world’s most prestigious medical journals think that at least 50% of what is published is utter nonsense.
Nic, you may be interested in the AllTrials initiative. Prominent supporters include Ben Goldacre, Sense About Science, the BMJ, the James Lind Initiative and the Centre for Evidence-based Medicine.
One thing to bear in mind, though. The problems identified with medicine generally relate to individual drugs, not to entire fields. For example, there may well be debate over whether individual NSAIDs work for symptomatic relief of rheumatoid arthritis, but there is credible reason to believe they will work (COX inhibition) and sound evidence that they do work, with debate centred mainly on how well they work, adverse effects and individual drugs.
We have seen what happens when chiropractors embrace evidence, methodological rigour and the scientific method: they become, in effect, doctors, as in the US.
It seems to me that if you want to practice manipulative and other therapies for the symptomatic relief of chronic nonspecific pain, you should study physiotherapy. The weakness of osteopathy, chiropractic and the like is that they have only one theory – when all you have is a hammer, every problem tends to look like a nail. Physiotherapists have, in my experience, a much broader understanding of anatomy, a much wider choice of therapies, and a much lower tendency to promote pseudoscience.
It is not very hard to find osteopaths engaged in pseudoscientific nonsense such as cranial osteopathy, anti-vaccination rhetoric, germ theory denialism and the like. There is a tendency in fields not founded in empirically testable fact, to underplay the importance of the scientific method in separating truth from illusion.
It is just as easy to find physiotherapist engaged in BS.
From the website of the governing body for physios
http://www.csp.org.uk/professional-networks/acpem
true, but this article happened to discuss a new publication on OSTEOPATHY.
Thanks Guy … you do open a can of worms though. 🙂
Personally, I’m as critical of the physios as I am of the chiropractors and my own profession of osteopathy. The last seminar I went to had a sports physician who was so full of absolute rubbish it make me want to be sick. And don’t get me started on the ortho surgeons in a local hospital who are still doing knee debridements on older men with ‘grumbly knees’. What I find particularly distasteful about that is the surgeons have a particularly high level of authority, and therefore influence, over their patients.
I”m not sure what it’s like in the UK, but here in Australia, the number of physio’s who offer trigger point therapy and acupuncture is growing. Yet is a systematic review I published, my co-authors and I concluded that even the medical experts who proclaim the efficacy of trigger point therapy can’t reliability identify the trigger points.
One prominent physiotherapist who teaches trigger point therapy has written a number of ‘reviews’ of the evidence and when it comes to the diagnosis section, completely excludes the systematic reviews that conclude that people can’t reliably identify trigger points, and instead, only cites the ONE positive study from 1997 and that we found flawed anyway.
Guy … this situation, the one that Edzard localises to Osteopathy in this post, is in all fields associated with the diagnosis and treatment of pain problems. Some professionals might appear to be ‘more legitimate’ than others – perhaps because of their historical alignment with medicine – but look closely and you’ll find the same problems.
So, my approach changed a decade ago. I concluded that fighting the professions was rather futile – at least it wasn’t a battle I thought I could win. I simply became more interested in studying and understanding the neurobiology of pain and finding a solution that could be integrated into the knowledge base of ALL of the professions that consult people in pain.
I agree. It’s not hard to find psudoscientific nonsense. That’s rather easy to spot. What’s more difficult to spot in my experience is the scientific nonsense … the trigger point example is just ONE example. They can’t reliably find them. The evidence of efficacy is absent (last time I looked). Yet, there are all sorts of biologically and scientifically plausible ‘mechanisms’ that are trotted out to support the whole concept … and I’ve watched hundreds of smart people fall for this … because it appears scientific and because medical doctors do it.
We know from studies in behavior and influence that smart people are still easily fooled … especially by authority.
even if it was a problem of “all fields..” [which it is not], it would be no reason to address it in osteopathy.
Nic, I do hope you’re not falling into the fallacious argument that problems with medicine justify quackery?
There is no realistic dispute over whether giving a measurable amount of a pharmacologically active substance, can have an objective effect on the body. Arguments centre around the evidence base for individual drugs and treatments, not the validity (or otherwise) of the entire field.
Ironically, the problems with medicine tend to be revealed by exactly the same kind of science that shows entire fields (e.g. homeopathy, acupuncture) to be baseless. For some reason those whose quackery is exposed by scientific inquiry seem to believe that science is only reliable when it finds a problem with a drug, not when it finds a drug to be effective or when it finds a form of quackery not to be.
Thanks Guy, no, Im not falling for that fallacy.
Hi Guy
Just re read your post and cracked up laughing. The great Proff. is slagging manips/mobs because the studies show that they are no better for reducing pain than pills, placebo, or exercises, yet you feel that it would be better for an Osteopath to study Physio and then practice this “usless” therapy….I guess the Proff would then accept it as being OK. Fuuny thing that I noticed in most of the studies showing that manips/mobs don`t work much better than doing nothing….it appears that Physios are the ones applying the treatment. May be the studies have shown that Physios can`t manipulate???…it is another way to look at it, don`t you think???
Not sure about your last paragraph. The AOA endorses vacc, is comfortable with the “germ theory”, and encorages current best practice. All I know is….every second physio around me is either studying, or practising cranio sacral tech, numerous forms of manips, mobs, massage, stretching etc….so are they unscientific quacks as well? I hope not, because I send them numerous patients of mine that require expert exercise and self managed advice.
” All I know is….every second physio around me is either studying, or practising cranio sacral tech, numerous forms of manips, mobs, massage, stretching etc….so are they unscientific quacks as well?” if that is true (somehow I doubt it is), yes.
The proliferation of quackery in paramedical private practice is a direct result of the desire to build up the practice and make money, magnified by a population with money to spend. Cranio-sacral therapy is pure quacker, based on incorrect physiology, and with no valid evidence of effect, no matter who sells it. Well-meaning middle-class parents get sucked in by good marketing.
We are all ready to criticise pharma companies, but profiterring and outright scams are well and truly rife in the “wellness” industry.
Most forms of therapy for CNSLBP have problems. Consider for example Lederman’s paper on the Myth of Core Stability an approach which is used extensively by most professions including osteopaths and physiotherapists. http://www.cpdo.net/Lederman_The_myth_of_core_stability.pdf.
true, but this does not excuse anyone or any profession from making false claims, don’t you think?
Hi, Just found a copy of an old September 1996 leaflet ” Clinical Guidelines for the management of Acute Low Back Pain” . The contributing organisations in production of this leaflet were the Royal college of General Practitioners, Chartered Society of Physiotherapy, Osteopathic Association of Great Britain, British Chiropractic Association and National Back Pain Association. It also detailed supportive evidence levels.
Although concerning Acute low back pain, which recommended manipulation in the first six weeks for short term improvement in pain and activity levels and higher patient satisfaction, it also referred to chronic low back pain. It stated “The evidence is inconclusive that manipulation produces clinically significant improvement in chronic low back pain” The groups involved obviously agreed on this at the time.
Some 17 years later not much has changed. The study in your article by the Australian Experts concluded “There are only two studies assessing the effect of the manual therapy intervention applied by osteopathic clinicians in adults with CNSLBP”. Although Osteopathic manual therapy may also involve forms of mobilisation and soft tissue relaxation only two studies could be found? More need to be done.
What about acute low back pain?
I have not recently researched this question systematically, but I would not be all that surprised, if the evidence was similarly poor
Edzard, allow me to save you the time of a cochrane search.
Rubinstein SM, et al Spinal manipulative therapy for acute low-back pain (Review). Cochrane Database. Issue 9, 2012.
Here is the last sentence of the plain language summary.
“Overall, we found generally low to very low quality evidence suggesting that Spinal Manipulative Therapy (SMT) is no more effective in the treatment of patients with acute low-back pain than inert interventions, sham (or fake) SMT, or when added to another treatment such as standard medical care. SMT also appears to be no more effective than other recommended therapies. SMT appears to be safe when compared to other treatment options but other considerations include costs of care.”
And by the way, soon after this was published I personally organised and advertised a live webinar for osteopaths to take them through this important document. I invited a guest biostatistician who is an experienced in performing cochrane reviews to provide a more detailed analysis. We walked them through the paper, and the ramifications of the findings, and the limitations of the review, which were only minor.
So, now that you’re aware of just ONE of the actions and forums that osteopaths are involved with that demonstrate our interest in research and how it applies in practice, how would you revise some of the sweeping statements you’ve made about ‘osteopaths’ in your post or comments?
well done!
how would I revise?
I wouldn’t.
one swallow does not make a summer – another sweeping statement and it has not even got a reference!
How can they treat ‘pain’ when there is no diagnosis? Surely that is quackery?
There is no diagnosis of 85%of low back pain, whether you go to an orthopaedic consultant or to a quack. It simply is not understood in most cases. So lack of a diagnosis does not make a strong basis for criticism.
Hi Edzard. It’s OK. We’re more similar that you might imagine. Let me unequivocally state that I am interested in moving things forward as based on good quality evidence. I have zero tolerance for people who continue to use unreliable tests, invalid tests or ineffective treatments and who should know better.
I don’t follow it hard to swallow critique. That’s why I agreed with the evidence you cite in your post. In fact, as an osteopath I don’t find that evidence critical, because I accept it. The issues you raise are old hat, not new and yes, based on your title I came here thinking I would see a thorough discussion of the basis of osteopathy. As YOUR READER I was disappointed. Can you swallow that critique?
It’s your blog … you can title things as you wish … it all depends on what you’re trying to achieve with this blog, and in general, with your particular crusade.
As I pointed out, but you refrained from addressing, if you only appeal to people who already agree with you, then you will fail to actually influence those whom you wish would change.
It doesn’t get farcical at all to ask you for data. If you establish a requirement for others, then you do your best to abide by it yourself. When you attack an entire profession, justified or not, you can’t expect to get away with the quips you’ve made without someone pointing them out.
I agree with you entirely about the claims made by all manner of practitioners on their horrible websites. I agree with you entirely, and as a parent I feel particularly nauseous with claims about the treatment of children. Parents are an incredibly vulnerable group …
But yes, I expect you to have precision in what you say … of find a better way to say it.
Having spoken with many hundreds of practitioners, I think there are at least two groups. Those who know better and therefore do mislead people, and those who, with full integrity, believe what they believe, and so mislead people, not on purpose, but unwittingly.
One of my favourite (anonymous) quotes is, “When an honest man who is mistaken hears the truth, he either ceases to be mistaken or ceases to be honest.”
This has been interesting. I leave you with a personal question Edzard, which I really don’t want you to answer except privately … do you feel you are being the most effective you can be with your communications? What is your aim? Who are you trying to influence? Personally, I believe we can all get better at communication when it comes to highly emotive topics such as you raise in your title.
Attacking is one approach. Maybe it’s even a necessary approach. Time will tell how effective it is.
as you probably know, I have tried most other ways to get essential messages across, e.g.14 annual conferences at Exeter where osteopaths and other alt med people were regularly present, about 600 lectures, ~ 1000 peer-reviewed article etc. now I am trying a blog and I feel that needs to be different from my previous attempt.
anyway, I herewith invite you to draft a few alternative headlines for my post, and we shall see whether they are any better.
Agreed.
thanks
Dear Edzard,
How you make difference between osteopath manual therapy and physical therapy manual therapy? Why you won’t include physical therapy in you articles. Or do name make it evidence based in your opinion?
Walter Lee
MD, DO, PT
the article I discuss is about osteopathy;
if I find an interesting new paper on physio, I will tackle this subject too.
so, my title was not to the satisfaction of some osteopaths!
fair enough! they do have rather obvious conflicts of interest, don’t they.
i have invited them to suggest titles they like, and they will suggest some shortly.
in order to avoid my title being branded as extreme, let me formulate some alternative titles that are even less likely to please osteos:
OSTEOPATHY: NOTHING BUT WISHFUL THINKING
OSTEOPATHS MAKE BOGUS CLAIMS AND THEY SEEM TO EVEN KNOW IT
IS IT NOT TIME THAT OSTEOPATHS STOP IRRESPONSIBLY UNFOUNDED CLAIMS?
OSTEOPATHY = NOT EVIDENCE
OSTEOPATHY = A CYNICAL MOCKERY OF EBM?
i could go on but i am sure the reader gets the point i am trying to make: the title i have chosen was everything but extreme considering the dismal state of the evidence for osteopathy. my title was fairly moderate – and, judging from the number of tweets it got, it was jolly effective in getting the message out.
i look forward to the promised suggestions by osteopaths.
Hi Edzard,
It appears you are referring to me when it comes to a presumed conflict of interest. I wont take the bait and will instead focus on the issues.
There a well known problem in advertising, where advertisers run a campaign that captures lot’s of attention, but then the campaign doesn’t deliver what the advertisers actually wanted. They get eyeballs, but no action.
Put another way, the number of tweets you get are about as good a measure of your blogs effectiveness as craniosacral is as an objective measure of well-being.
As Osteopaths, we do have to accept the current evidence about the lack of effectiveness for manipulative therapies. It is what it is. We are left with a difficult situation in which, like many practices, the evidence doesn’t match the daily experience.
Of course, you and I know that this daily experience is biased by things like, patient preferences, biased practitioners, the failures that don’t return for treatment … all leading the practitioner at the coal face to overestimate the effectiveness of the treatment. Then there’s natural history, and the powerful non-specific effects of touch, empathy, reassurance, positive expectation, and education … all of which many osteopaths provide and would consider to be a part of an osteopathic treatment.
From the way you write, it appears as if you still presume that Osteopathy = Manipulation. That’s like saying GP = Antibiotics.
In any case, when it comes to manipulation, you also have to throw into the mix the percentage of unknown but likely people who do respond in some positive way to the specific action of the manipulation. But we can’t detect these folks – not currently – and the two studies you refer to can’t either. Any legitimate responses get washed out entirely by the large numbers of people who don’t respond.
So, while I completely acknowledge the data. And while I personally found that manipulation had NO EFFECT on my back pain, other than that the person who did the manipulations hurt me when they performed them, I can still understand why osteopaths in practice have a strong belief, and experience, about the usefulness they have in the care of people with back pain.
I can see that you’re on the attack with your revised titles, and I can understand this is based, in part, on your frustration. Look at the responses you’ve attracted though?
There’s the great saying, ‘If you find yourself in a hole, stop digging’. And you’d say that the osteopaths are in a hole with manipulation, and you can’t understand why they keep on digging. The evidence is there – it’s not effective!
Well, why would you persist with aggravating and provocative titles, that antagonise the very people you hope to change? Clearly, by your own admission above, you’ve been trying this and it hasn’t been effective. So why do you keep doing it? Doesn’t that strike you as behaving in a similar way to the osteopaths who keep using manipulation in CNSLBP?
Do you really want to educate the osteopaths? Do you really want to inspire them to adopt best practice? Do you really want to relieve them of the need to carry out the hard work of manipulating people day in and day out in place of a best practice alternative?
Or, are you just so fed up that you are happy to cite papers and throw up antagonistic headlines that get littered throughout the twittersphere?
If it’s the latter, I wont come back to read what you have to say, because it’s just a front for you to have a go at people without really seeking fundamental change, and to me that’s boring.
If you’re still serious about change, then I might remain interested in what you have to say and the work you’re trying to do.
My suggested title would be something that’s soft on the people, but hard on the issue. You’re clearly taking the ‘hard on the people and hard on the issue’ approach.
“Silver lining in new study for osteopaths shows exercise is as effective as manual therapy for treatment of CNSLBP.”
“New study challenges Osteopaths to develop more effective treatments for patients with CNSLBP”
“Is Osteopathy as Effective as the Osteopaths Claim?: New study demands a closer look”
“New Study Shows Osteopathy, Physiotherapy and Exercise are Equivalent for Patients with CNSLBP”
“Passive Treatment Not Necessary in Patients with CNSLBP: New Study Shows Exercise As Effective as Osteopathy and Physiotherapy”
If I may, I’d like to request that other osteopaths reading this, also submit their own headline suggestions for your original blog post. I don’t want to invite sensational headlines, but serious, considered headlines.
Osteopaths … when you read about the study Edzard quotes … and if we stick to that data and refrain from personifying it … what headline would YOU come up with?
as I said, I have tried various methods to change alt med to the better. during the last 20 years, virtually every change that I have witnessed in this area came not from within any of the disciplines but was brought about by increasing pressure from the outside.
you demonstrate that, with your title-suggestions, you want to use the carrot; with this blog, I am trying the stick.
the point is that THERE ARE MORE THAN ONE METHOD TO BRING ABOUT CHANGE.
There is more than one method to bring about change. A stick represents violence. Bring a stick and people will reactively fight back to protect themselves … and they’ll fight IRRESPECTIVE of the issues just BECAUSE you brought a stick. You’ll find yourself if the most BORING of debates. People will argue against you, to DEFY you, just because you brought a stick.
You say there’s been change bought to bear by ‘external pressure’ yet isn’t alt med flourishing with new students, devotees, blogs, etc? I’d say the ‘stick’ and ‘external pressure’ brought by ‘authority’ has likely INCREASED their resolve, not decreased it.
My prediction? If you use the stick you will waste your time. I don’t think it will work and you will have had to endure more pointless debates and arguments that anyone should have to endure in their entire lives.
Most people going into alt med are going into it to help other people … they just wanna get into a school, pay their fees, pass their exams and get into practice. So, taking a stick to them is useless.
If you want change in ANY system, you have to identify the KEY CONSTRAINT. And the key constraint IS NOT the individual practitioner, but the educational institutions. That’s where they learn what it is to be an Osteopath, or whichever craft they’re learning.
The educational institutions is where change can be initiated; and yet again, if you rock up to their front door with a STICK then that will be like taking a red flag to a bull.
The only other way is to use legislation and force people into ‘submission’. But that’s not real change … even though it might have an effect.
When it comes to chronic low back pain and osteopaths, what do you want Edzard that is positive for the osteopaths and the people with back pain? What would be a great outcome for you, specifically related to chronic low back pain?
1. What would you love to see changed in educational institutions?
2. What would you love to see Osteopaths do in everyday practice?
Give us all something positive to ASPIRE to …?
COME OFF IT!
1) the “stick” in my case was not meant to be violence but gentle pressure building up through disclosing deficits.
2) this type of pressure works mostly on institutions, not individuals 9see what happened in the UK with the BCA!)
3) what do i want? i want to expose bogus, irresponsible, non-evidence based claims and practices, so that more people know about them, so that they gradually change, so that health care of tomorrow is a little better that it is today.
IS THAT POSITIVE ENOUGH FOR YOU?
having considered your titles at length, i have to tell you: i find none of them as fitting as mine for a blog. a blog is not a scientific article, you know. if you want boring titles, go on medline and study the ones of the scientific literature. i believe that you have a very different understanding of the purpose of a blog than i have.
It’s not about whether it’s positive enough for me. I am unaffected by it. You know of course that I’m talking about your approach toward an entire profession.
As it stands are the moment, and you are holding your ground on this, it appears as if your position is:
1. I’m Edzard, and I’m an Alt Med specialist and I’m right because I have some evidence that I’m right.
2. You Osteopaths are bogus, a mockery, you offer no value, you are unscrupulous, you intentionally rip people off, you’re wrong and you have no evidence.
A blog has no universal purpose. It’s purpose is defined by the blogger, which in this case is you. If you choose to use titles which are unjustified, then that’s your choice. Go for it. I encourage you to keep doing what you want to do. It’s your blog. I am merely offering a readers perspective on how ineffective it will be.
Clearly, you think your approach is the best one to take right now.
I wonder, how many people who have read your comments on this post have changed their mind on what they’re going to do TODAY and TOMORROW in practice? What’s your estimate Edzard? Because surely that’s the purpose of your blog, right? To change minds and behavior?
Clearly, and I’ll admit, I have so far been relatively ineffective at changing your approach, although I am grateful that you offered me the opportunity to have a go at re-writing your blog title.
I have one approach when I publish in peer-reviewed journals; the one of science.
I have another one with my blog, newspaper articles etc.; that of journalism.
and I frequently try another one on twitter: sarcasm and humour.
how many minds have I changed?
you tell me; you like to speculate, I don’t.
How about ‘EBM the double standard – if the editors think it’s nonsense who is making sense’
Osteopaths need to do more research!
Hi Gary … yes they do … but it aint that simple. First, there’s only a limited number of highly experienced osteopaths who are also highly experienced researchers. Second, of those, an even smaller number have expertise in clinical epidemiology, diagnostic research, and trial design.
There are few funding opportunities available, and where there is competition, the funds are more likely to go to professions that have more developed research programs, resources and expertise.
None if this is an excuse … nevertheless it does provide just some of the context in which research, and a research culture in osteopathy, has been trying to flourish.
Of course, there is one very important issue. Is it really the ‘osteopaths’ who should be doing more research? Again, that’s like saying that the GP’s need to do more research.
Osteopaths are predominantly practitioners in private practice. So, the solution lies more in collaboration of people within osteopathy who team up with those who do have expertise in diagnostic or experimental trial design.
The other issue is that research outcomes are rather agnostic in terms of professional affiliation. If the osteopaths did happen to demonstrate that a certain manipulation technique was efficacious, then who would ‘own’ that research? Wouldn’t then the physiotherapists, chiropractors and musculoskeletal physicians adopt the same efficacious practice … in fact wouldn’t this be their professional duty?
The alternative pathway entirely, is to acknowledge that osteopaths are also capable of taking on research findings from an array of other disciplines, including closely related ones like physiotherapy, exercise and sports science, behavior change, and psychology.
Edzards portrait of osteopathy as being equivalent to manipulation is blurred by the facts … because osteopathy is osteopathy and manipulation is manipulation. While professional affiliations remain ‘tight’ there is increasing collaboration and cross-pollination of ideas and research between professions. That’s not to say that all cros-pollination is good … bads ideas spread just as fast as good ones.
Take the example I provided of so called ‘trigger point therapy’. Developed by medical doctors, and now mainly advocated by physiotherapists and others, the data on this is telling. The diagnosis is unreliable and there is no valid test available to identify them. Yes, people are specifically injecting them, needling them, and doing other things to them … and the outcome studies show no effectiveness.
Yet, trigger point therapy spreads like the wind, directly from medicine and physio into osteopathy, chiropractic and massage therapy.
Osteopaths need to do more research? Well, only if it’s good quality and meaningful.
you make it sound like a battle between professions. for me quackery is despicable whoever practices it.
My apologies, but I don’t understand your comment.
It is not a battle between professions, but there certainly is competition between individual researchers to get funding. And currently, the funding is awarded on merit – and those with the most experience and past record are NOT the osteopaths who ‘need to do more research’. That’s not a battle, it’s just a simple fact.
I agree with your comment that quackery is despicable whomever practices it. That’s why I don’t even consider there to be ‘alternative medicine’ and ‘orthodox medicine. At the end of 1999, there was a JAMA editorial that said there is no such thing as alternative medicine, complementary med, and orthodox medicine … there was only medicine that was ‘based on evidence’ or ‘not based on evidence’.
Because, as the hilarious comedian Tim Minchin says, “what is alternative medicine that has been proven to work called? It’s called MEDICINE.”
this is not a fact at all! funds are awarded on the merit of the application and this comprises mostly issues such as the rigor of the project and the importance of the research question.
you can call it as you want, but unproven and dis-proven treatments remain what they are. names do not matter all that much, in my view.
Nic Lucas said:
“Osteopaths need to do more research? Well, only if it’s good quality and meaningful.”
So, there’s the BOA, BSO, GOsC, BCOM, LCOM, LSO, COEI, OCC (FPO), etc in the UK. What are these and the other osteopathy organisations round the world doing about research?
“There are few funding opportunities available”
Where do you think funding could be obtained?
good point!
funding has to be generated by the respective professions; it is not a gift that falls into the researchers’ lap. and in order to do this, osteopaths need to develop an interest in research and realise what its purpose is: it is not to promote your business and it is not for confirming your preconceived ideas. it is for testing hypotheses!
to understand that, you need to learn CRITICAL THINKING, and I am afraid that this skill hardly exists in osteopathy or any other alt med profession.
HERE YOU ARE: ANOTHER VERY IMPORTANT RAISON D’ETRE FOR THIS BLOG.
I know the Australian Osteopathic Association spends over $200K on lobbying and over $80K on promotion. Although probably not a large sum in terms of research funding. Perhaps some of this money should be redirected so evidence base could be used when lobbying and promoting in future! Now if all the representative bodies did this!
good point
I agree wholeheartedly. Critical thinking is an essential skill to be taught to all health professionals. After one of my masters degrees, in which I was the only non-medical participant, we covered a full course called Critical Thinking and NONE of the medical participants had covered this in their medical degree. They only had rudimentary skills in critical thinking when they started the program. Many of them commented just how much they had ‘thought’ they were skilled in this area, only to find out how naive they were.
They thought that critical thinking meant just reading the latest Cochrane review … or RCT … but NONE of them had the advanced skills to conduct an full critical appraisal of the evidence and spot the sophistry in so much of it.
My point in relation to your blog post, and this thread of comments, is that advanced critical thinking skills could be improved in ALL professions.
Your focus is what you call ‘alternative medicine’. I have a broader view.
For example – how much does RADIOGRAPHY cost your government? Why don’t radiology reports also come with data about the RELIABILITY and VALIDITY of the elements of the report so that clinicians can make an assessment of how important the various findings on the report actually are? Where is the critical thinking there?
I don’t have exact numbers, but from a health economics point of view, wouldn’t that ONE example I provide above rate as more socially important?
Why is that relevant to your POST? Because you bring a stick to an entire profession, you make sweeping generalisations about ‘Osteopaths’ that cannot be substantiated, which demonstrates a BIAS that you have, but that you try to convince us that you don’t have. The problems that the profession of Osteopathy faces are found in many areas of medicine and health care.
We’re seeking a balanced view Edzard – and your revised titles above, for example, don’t show us that view.
biased view???
your view seems so clouded that you even do not read what I said about what you call MY REVISED TITLES. they were titles I posted to demonstrate that my actual title was far from extreme and not at all how you tried to see it.
LIGHTEN UP MAN!
Its through critical thinking that we know our philosophical approach is true. Theres more to science than objective reductionism. In fact, health has an infinite number of potential factors that RCTs could never test. The “stronger” the scientific “reliability”, the more you remove key relationships that aid recovery and health. This isn’t analysing nuts and bolts but an entire approach. F… your s…. pills and guess work.
poor logic and even worse language!
osteopathy will prevail said:
As opposed to through… good evidence?
Reminds me of this.
Thanks Nic….trigger point reference source?
Here Gary … http:// bit ly/ 15sqjOM [Link disabled by admin due to suspected malware]
Guy
You are such a joke. There are more Physios practising cranio sacral therapy than Osteopaths. Best you stick to commenting within on your own field.
Ed, the saying “those that can do, and those that can`t, teach” applies to you. Best you concentrate on the sewage that is building up in your own field. Pointing the “evidenced based” finger on Osteopaths is hypocritical when your own field is as sick as it is.
At the “coal face” of clinical practice, reading such trash make us clinicians sick.
responses like this speak amply for themselves – I usually do not post them, but today I make an exception.
Wow…you even get to moderate your own site!!!!!….how objective.
Any particular reason why you believe Prof Ernst shouldn’t moderate abusive comments?
As a practising Osteopath I think it is unhelpful to comment on other professions when clearly Osteopathy has such poor evidence base on CNSLBP. Only 2 papers could be found assessing the effectiveness of of manual therapies applied by osteopaths in adult patients with CNSLBP by the Australian Experts Orrock (Osteopath) and Myers (Complementary medicine researcher). Prof Ernst and the authors do Osteopathy and the public a favour by identifying the deficiency and this might encourage the profession to facilitate research. Clinicians should not feel sick about this rather have the confidence to embrace good research what ever the outcome.
Gary said:
“Prof Ernst and the authors do Osteopathy and the public a favour by identifying the deficiency and this might encourage the profession to facilitate research.”
Agreed.
“Clinicians should not feel sick about this rather have the confidence to embrace good research what ever the outcome.”
The pertinent questions here are, if it is acknowledged that the evidence is so poor:
1. Are osteopaths not aware of the lack of good evidence?
2. What are they doing about it?
3. Until such good evidence is obtained, and if they really want to conduct evidence-based practice (which, after all, is in the best interests of the public) will they stop providing osteopathy for those conditions? If not, why not?
judging from some of the comments so far, osteopaths are doing very little other than finding rather smug excuses for their decade-long inactivity.
Checked with my Association (AOA ) budget of 50k for research and will spend more if applications come in.
not very much?
why are they not able to generate more funds?
The Board of my Association is apparently looking at more as applications for funding arise. Articles like yours might just spur things on. Remember the profession in Australia is relatively small.
“Articles like yours might just spur things on”. thanks! so it does serve a good purpose, perhaps?!? I will write some more then.
Please do so…. as long as it is evidenced based!!!!
I will try – but on this blog I will also have a bit of opinion, humour etc. I hope I will always make clear what is what.
Humour… as long as it is evidenced based!!!!
Thanks for your efforts
It seems to me the huge diversity within manual therapies and individual therapists, osteopaths in particular due to its philosophical standpoint, make generalisation to whole professions meaningless and divisive. To attack a diverse profession makes no sense to me. The fundamental premises of osteopathy do not appear at odds with mainstream medicine, and the title osteopath does not dictate how a patient is treated or what treatment modalities are used. I for example favour active therapies and always assess, treat, and reassess each patient off the couch and encourage self treatment and active coping strategies. I think of myself as evidence informed, as are my patients.
To highlight to patients the lack of both plausibility and evidence of efficacy in treatment modalities such as cranial sacral is the responsibility of all therapists, including those practicing them. Acupuncture is an obvious example. I use dry needling sparingly and even now i am reading literature around the area. If i use this technique I explain the lack evidence supporting it but explain my personal experiences and feedback of other patients and allow the patient informed choice. Is this exploitative?…I still debate this in my own mind.
What helps is open debate between manual therapists who respect each other, enter into debate with humility and accept and try to understand that every philosophical standpoint is often littered with error and weakness….. even EBM.
Twitter is a fantastic resource to disseminate information and opinion, much needed is the busy world of clinical practice. Lets open more debate and make research more readily available. At present osteopathy has neither the wealth of finance or resource to produce quality studies. This needs to be addressed. But please don’t belittle the 5 years I spent studying anatomy, physiology and manual therapy.
right!
and where is this open debate happening? where is a forum of osteopaths who openly admit that their main therapeutic interventions for their main indication are not based on good evidence? and where are the osteopaths who then change their practice? and how would this practice look like? how would it differ from a non-manipulating physiotherapist?
as i said before, for me, this is not about professions; it’s about treatments that demonstrably do more good than harm.
For the last 15 years, a group of my colleagues and I have tried our best to create a forum for this with the publication of the International Journal of Osteopathic Medicine.
You say this is “not about professions”. So, why do you want to give this post a title that makes it about the ‘profession’, and NOT, as you say, “…treatments that demonstrably do more good than harm.”?
according to the original article, it then shouls be TREATMENTS BY OSTEOPATHS. as this is a blog with different language, aims, audience etc. than a science paper, I use the short-cut that is easier to grasp. SO WHAT?
So what? One of the great benefits of a blog is being able to gauge feedback and listen to your audience. Overall, the audience that has responded to you is in agreement with you about the evidence you cite.
Overall, the audience hasn’t liked how you have taken the shortcut and made Osteopathy – a profession with people in it – the subject of your accusations.
Again, I repeat, if you want to influence people positively, don’t attack them under the guise of a ‘shortcut’. It just wont work …
… and how important is that to your end game? Well, ‘messaging’ is ALL you have, and if you take a shortcut and convey the wrong message, then yes, ONE WORD can make all the difference.
you are very patient with me! and I am such a poor pupil! I am so obstinate that I refuse to be taught by an osteopath how to write a pro-osteopathy blog. what is worse, so many people have tried to teach me how to suck eggs and I am still not a good sucker.
Dr Ernst,
Let me declare from the outset that I am a practising osteopath.
Given your stance on the lack of proven efficacy of physical therapy, perhaps you should consider also turning your skeptical attention to orthodox physicians who, it would appear from an increasing number of studies (similar to the one quoted below), are undertaking interventions which are (allegedly) as suspect as the manual therapies you are so fond of critcising. As with Nic Lucas’ comments, I have no problem with your criticisms for the lack of evidence for Osteopathic interventions, but surely one should attempt to give a balanced view of all medical interventions?
Surgery versus physical therapy for a meniscal tear and osteoarthritis
Authors: Katz JN et al
Summary: Outcomes are reported from 351 symptomatic patients aged ≥45 years with a meniscal tear
and evidence of mild-to-moderate OA on imaging, who were randomly assigned to surgery and postoperative
physical therapy or to a standardised physical-therapy regimen (with the option to cross over to surgery at
the discretion of the patient and surgeon). The primary outcome was the between-group difference with
respect to the change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
physical-function score (ranging from 0 to 100, with higher scores indicating more severe symptoms) 6 months
after randomisation. An intention-to-treat analysis at 6 months revealed little difference between the groups
for mean improvement from baseline in the WOMAC score (20.9 points in the surgical group vs 18.5 in the
physical therapy group). At 6 months, 51 active participants in the study who were assigned to physical therapy
alone (30%) had undergone surgery, and 9 patients assigned to surgery (6%) had not undergone surgery.
The results at 12 months were similar to those at 6 months. The frequency of adverse events did not differ
significantly between the groups.
Reference: N Engl J Med 2013;368(18):1675-84
http://www.nejm.org/doi/full/10.1056/NEJMoa1301408
There are similar studies questioning the effectiveness of surgical intervention for arthroscopy and vertebroplasty to name just a few popular surgical strategies. Where are the skeptics when you need them?
my expertise is alt med; that is a big field and i prefer to write about subjects that i understand.
but you are right: there is a lot wrong in other fields as well. do you think that this is a justification for osteopaths to make bogus claims by the thousands?
Given that there are lots of papers comparing the (in)effectiveness of many orthodox interventions with alt med, perhaps you should consider including some of these in your reading list and perhaps occasionally mentioning those outcomes to give your arguments some perspective – at the moment what comes across is an almost religious zeal to lambast the alt med professions while giving scant regard to literature which is often every bit as critical of orthodox medicine. Have you heard of the word “bias”? You might also read up on what is described as “availability bias” – it refers to people believing that if something is in print a lot it must be true. “Selectivity bias” refers to those who choose to sample a subset of evidence and ignore similar evidence which doesn’t suit their argument. I am concerned that you may have overlooked these in your haste to reach a conclusion.
yes, i know; there is lots wrong in other fields as well.
my expertise is in alt med; why do you want me to write about an area which is outside my expertise?
in what way do the wrongs of conventional medicine justify those of osteopathy?
THANK YOU TEACHING ME ABOUT BIAS!
who do you think is more suspect of bias in a discussion about osteopathy – an osteopath who earns his money with osteopath or an academic scientist with no conflicts of interest?
You don’t have the first idea what alt med is – whoever gave you that qualification had no idea either!
You are nothing if not amusing…
Thank you Edzard for such an interesting post!
I too will follow suit declare my colours as a recently qualified osteopath from the UK.
Since studying osteopathy and now being qualified I feel a constant battle between evidence based practice and some of the theory and experiences I have been exposed to. I would like to say I’d be ready to change the way I practice osteopathy in the face of a plethora of excellent research – I hope I would be honest! If that exists then I apologise for my ignorance and please point me in the right direction.
As Nic suggested that osteopathy isn’t just joint manipulations but about education for the patient, a listening ear etc. Shouldn’t we be careful not to throw the baby out with the bath water? If we osteopaths could have a forum/facility to openly critique in a professional manner I would embrace it and actively participate. As a personal desire – if there are openings for the osteopath to become research focused like Nic suggested (as he cited that GP’s don’t actually do their research) I would volunteer as I want to learn more about research methods and positively engage with other scientists rather than war in a realm of opinion.
Thanks again for the lively debate everyone!
Kind regards,
Richard
there is lots of good research; try Cochrane reviews, they are the most reliable, usually independent and up-to-date summaries available.
of course, osteopaths do a lot more than manipulation/manipulation. so do all other health care professionals. I can tell you that a surgeon does a lot more than operate; yet we [have to] judge surgeons mainly by their signature therapy which is surgery.
in any case, I sate it again: this is NOT a battle between professions for me. I simply want to disclose gaps in the evidence and how they are handled. the article at the centre of my post is about osteopathic manipulation/mobilisation for chronic back pain. to me it seems absurd to then suggest I write about how good or bad osteopaths are in listening to or educating patients.
and finally: it is not true what has been said here several times: GPs do plenty of research themselves.
I never said that NO GP’s do research and I’m not sure anyone else did.
I’ve made the mistake in the past of assuming that practitioners should have the same level of interest as I had in ‘research’. I made the mistake of assuming that osteopaths would ‘take up arms’ and get involved in actively doing research to find the truth 😀 Looking back, I can see what a ridiculous assumption that was.
A while back, I had cause for a checkup at the GP. My cholesterol left a little to be desired and the GP pulled out a script for a cholesterol lowering drug. I said, “hang on … based on my age, and other factors, what is my CURRENT relative risk of developing cardiovascular disease?”
The GP DID NOT KNOW what I meant by ‘relative risk’.
She had to rummage around her office to find a risk profile table. When she couldn’t find that, she went to to the heart association website and finally found a risk profile table on their site. When we looked at it in the necessary detail, I was able to point out that my risk was minuscule, and on that basis we decided that the drug wasn’t yet indicated, and that I’d try lifestyle changes before the drug.
This stuff is everywhere Edzard … and yes NONE of that excuses the profession of osteopathy from is duty to provide best practice for patients … and in fact, I think best practice is a boring, average target. I want PRE-EMINENT practice. I want it from all health care providers.
” NONE of that excuses the profession of osteopathy from is duty to provide best practice for patients”
I agree.
moreover, in the good old osteopathic tradition, you cite a personal anecdote, while I cite a systematic review.
So, you’re more superior because you cite a syst rev and I provide an anecdote, whereas if I want accurate scientific titles from you for this post, then you suggest I should instead to go pubmed because blogs are different and don’t need to be all that accurate in their titles and shortcuts are OK?
On the topic of narrative and anecdotes, you might be interested in an excellent article in the JAMA.
Meisel, ZF, Karlawish, J. ,Narrative vs Evidence-Based Medicine—And, Not Or. JAMA, 306; 2011: 2022-2023.
Nic, you have failed to demonstrate (a) why the title is somehow not scientifically accurate and (b) why Edzard is in any way obliged to use academic journal style titles for a personal blog anyway.
Hi Guy,
A) It’s not about being scientifically accurate, but factually and theoretically accurate.
B) I already acknowledged from the start that Edzard can title his posts however he likes. It’s his blog. I was providing feedback from a readers perspective. Most bloggers are happy to have someone show up and take an interest in what they’ve written about. They’re even happier when those people publicize their post to bring attention to it.
Thanks Edzard. I will be sure to check the Cochrane reviews – I had heard they were very good. I can appreciate that a profession is known by its signature therapy – and most people associate osteopaths with back pain! I know you want to disclose gaps in the evidence – so do I, so do all the honest practitioners in the world I presume. I felt also that placing a profession with its signature therapy as an adjunct to other forms of manual therapy is at risk of ostracising it and labelling it at as ‘quackery’ or similar without holding the other forms of therapy (used for treating the same condition) up for review to the same standards. I know you have repeatedly stated that alt med is your forte – but isn’t comparing like with like and not against other approaches counter-productive? Thank you for clarification on the GP’s – I didn’t want to be unfairly/untruthfully commenting – I appreciate you clearing that up.
the fact is that there is very little research comparing head on osteopathy with conventional options. in the [near] absence of such studies, I see little other choice for me to press of a solid evidence base and for single standards throughout health care.
But you are stating that in the absence of such evidence (whether it has been tested to be effective or not) that osteopathy is based on ‘wishful thinking’? Isn’t that making a judgement call without testing to see if it does actually work or not? I think the popular idiom (I unfortunately do not know who to attribute it to) is ‘absence of proof is not proof of absence?’
see my other reply to you.
I looked up that idiom, an interesting point allegedly made by Carl Sagan’s widow that his general position was that ‘science is saying in the absence of evidence, we must withhold judgment’
yes, in theoretical science, this is fairly obvious. in medicine, however, we should in such cases not state or imply that a treatment is evidence-based.
Hi, firstly in the interests of full disclosure, I am an Osteopath practising in Australia. The only thing I wanted to add to the debate is that I’m not sure what the advertising laws are in the UK are but here we are very restricted in what we can say. The most important , or relevant ( to this discussion), is that an Osteopath can never claim to help or cure, we can only say ” may” be helpful in the treatment of e.g. low back pain, sports injuries etc etc. So in Australia we certainly can’t “peddle” bogus claims, this obviously apples to websites, and promotional material as well.
I am pleased to hear it! in the UK, there are rules too. yet they seem to be broken so many times each day that the authorities are unable to keep on top of the plethora of bogus claims.
so, tell me, how many reprimands for unsubstantiated claims have the Australian authorities issued?
Nigel
The UK’s Advertising Standards Authority sets general rules, general guidance about healthcare claims and specific guidance about osteopathy:
It should be noted that Bronfort et al. was not a systematic review of the evidence and is seriously flawed. However, that is the guidance as it currently stands.
Interesting blog! Nothing like a heated debate!
Well said James Crossley, I agree with your stance…
I am a third year Osteopathy student studying in Auckland, NZ.
It’s hard to disagree with Edzard’s comments surrounding the lack of evidence for manipulation/mobilsation, although it should not be news for any Osteopath… We are encouraged to utilize Cochrane reviews, and work within the EBM framework.
This blog was targeting the Osteopathic profession, which as far as I am concerned is fair enough given the lack of high quality studies conducted since the introduction of EBM; a time when many professions ‘pulled finger’ and prioritized proving effectiveness. However it is misleading, as treatment outcomes for non-specific chronic low back pain are poor generally; in both manual therapy and surgical interventions. Chronic pain mechanisms are not well understood! Highlighting one professions outcomes associated with this subgroup, without context means very little. Although it’s your blog and you can do what you want I guess… 🙂
I do agree that Osteopathic websites should be careful with the type of language utilized when marketing themselves, although again this is not an issue isolated to Osteopathy. Health supplements, drugs, mainstream medicine… look and you will find misleading claims left, right and center. However, this DOES NOT make it right.
You will find many Osteopath’s who agree that the lack of high quality studies should be addressed; although this is easier said than done as discussed in earlier replies. This discussion is a healthy one, and should be encouraged, by osteopaths and manual therapies in general. However, painting a picture that Osteopaths are actively seeking to dupe vulnerable patients is not true, fair or conducent to remedying the situation… if that is indeed your aim?
Jude Harley said:
Agreed: any discussion about the evidence must be healthy and must be encouraged, particularly when it doesn’t seem to be happening elsewhere.
I don’t think Prof Ernst is saying that osteopaths are ‘actively seeking to dupe vulnerable patients’. However, if the evidence is not there to support what they are doing every day (and therefore earning their living from), and if they are well aware of this lack of evidence, yet continue to advertise and trundle on year after year with nothing being done about this situation in respect of research, then there is something seriously amiss.
You say this is ‘easier said than done’, but I’m not convinced. As I said earlier, there are plethora of osteopathic organisations of all sorts from regulator to trade bodies – with some even having the word ‘research’ in their name – yet there appears to be little enthusiasm to do do that research. Any idea why?
The latest research page from NCOR lists just three projects: Adverse events studies, Standardised Data Collection and Osteopathic patient expectations (OPEn) study. Patient expectations might be important, but there is something in the back of my mind that tells me that there might be a small possibility that results of research like that might be used to supplant the poor evidence base for the basic core osteopathic treatments.
Other research worldwide includes: Osteopathic Manual Medicine Treatment in Autism, Telephone-Delivered Coping Improvement Intervention for HIV Infected Older Adults and Telephone-Delivered Coping Improvement Intervention for HIV Infected Older Adults. I appreciate these are US studies and that osteopathy training is somewhat different over there, but it’s difficult to understand why efforts don’t seem to be focussed on what (apparently) makes osteopathy unique.
Any ideas?
A food critic walks into a restaurant kitchen, eats a raw egg and declares that the ‘spaghetti carbonara inedible’. Forming an opinion on osteopathy based on research on manipulation alone is just as ridiculous. A typical osteopathy treatment can include: 1) discovering how the pain occurred and educating the patient on future avoidance if possible 2) offering advice on alternative activities to avoid recurrence 3) soft tissue massage 4) muscle energy technique or PNF 5) passive stretching 6) manipulation 7) mobilisation 8) active stretching advice 9) strengthening advice 10) empowering the patient to self-manage.
Are all these strategies inneffective? Have these strategies been tested together? Is that even possible?
yes, it’s possible – and the onus is on osteopaths to provide the evidence. until this is the case, osteopathy remains UNPROVEN.
Perhaps if you’re so keen to improve alt med and the best possible care for patients you could design a trial that allows all the 10 points raised by David C, plus others that are pertinant to be tested. So that Osteopathy is on trial rather then one small part of it.
You could publically submit this to GOsC and then sit back and see what happens.
the onus to demonstrate that osteopaths’ claims are more than wishful thinking is not on me but on osteopaths. nevertheless, I would be happy to assist in the design of a trial, if asked.
I don’t think that ‘Osteopathy’ can ever be ‘Proven’, since is is a ‘Profession’ and not a ‘Diagnosis’ or ‘Treatment’. I really think, as an expert in Alt Med, that you need to shift on this. It’s an unattainable AIM.
For example, in a research project I supervised and then published with the student, we showed that a particular type of ‘diagnostic’ approach that osteopaths regularly use for patients who have low back pain, is unreliable.
So, rather than saying ‘Osteopathy remains UNPROVEN’ I would say that we have shown that ONE of the diagnostic approaches is UNRELIABLE. Interestingly, at about the same time, another group in Europe (physiotherapists) conducted and published a similar study with essentially the SAME findings.
So, now we have a number of studies, all of which provide evidence that this diagnostic approach is unreliable.
Kmita, A, Lucas, NP. Reliability of physical examination to assess asymmetry of anatomical landmarks indicative of pelvic somatic dysfunction in subjects with and without low back pain. Int J Osteopath Med, 11; 2008:16-25.
http://tinyurl.com/n4tr5qe
one can test treatments much more easily than professions. but one can also do the latter; just needs a bit more skill and fantasy.
do you publish all your research in your own journal?
No Edzard, not all of my research … and I am not a prolific researcher. I’ve also published in Clin J Epidemiol. Clin J Pain and Manual Therapy.
It has been a challenge starting a scientific journal in a profession such as Osteopathy. It’s all been about trying to get to a critical mass. Since we first started as graduate students in 1997, we have had to continually foster, promote, encourage, pester, and request the few people who are doing research, to submit their work to support this journal.
As one of the editors, I have chosen to support the journal by publishing my own research in that journal, even though, at times, it would have served me to publish in another journal that is indexed in pubmed. And I am not alone in this. I am grateful to many of the authors who have chosen to publish with us to support the journal, when it would also have served their personal careers to publish elsewhere.
We do it because we are committed to the continual development of a research culture within osteopathy, and this is the way we have found we can contribute in the context of all that is going on in our lives.
My dream, if you will, is to have an international journal for osteopaths that achieves two main aims:
1. To provide a suitable place to publish research conducted by osteopaths and therefore establish a body of knowledge, and
2. To provide an example to the profession that fosters a research culture and promotes scientific debate within the profession.
We have been somewhat successful. We’re now in our 15th year of publication. We have an impact factor, it’s small, but we have one. And, we are now attracting articles from all over the world, including the US, which is a great outcome.
On the other hand, we receive little communication from readers, so I haven’t seen a level of discourse within the journal that I would like. There was one series of interesting articles and letters to the editor on the topic of ‘osteopathy in the cranial field’, or ‘cranial osteopathy’.
We have also received fierce criticism that turned into unpleasant personal insults from certain osteopaths who appose our stance and who take the view that you can’t research osteopathy (diagnosis or treatment).
On this topic, I’m sure you and I would find very common ground, however, as I’m sure you’ve experienced, talking with people who appose research is futile. Not only do their views differ so widely from ours on the importance of evidence, but they very often differ in their world view … and probably, right down to issue of existentialism and spirituality.
So, when debating with someone about whether an RCT can really investigate the effect size of a manipulation on a certain outcome measure, this debate might ‘actually’ be clouded by a more fundamental issue such as their belief in God, or not.
I know, it’s not easy. I have founded 3 journals and 2 still exist since ~2/3 decades.
the most difficult thing is to generate articles that are critical about alt med. all too often, “research” is seen by alt med proponents to have the purpose of promotion.
My point is your argument is based on the results of testing one ingredient when you know many more are required and utilised. As a result, your argument is disingenuous.
I know what your point is but you don’t seem to understand mine.
1)if a doc administers a medicine to a patient that is unproven, he too cannot say that he does much more that just giving a pill [ listen, diagnose, empathise, touch etc.], don’t you think?
2)if you claim the osteopathic package is effective, then show us the evidence.
3) if a patient does not want manipulation/mobilisation, why should she see an osteopath? the other things you mention are being provided by other professionals too [and maybe even better]
4) the article I discussed above was on one specific aspect [osteopathic manipulation/mobilisation for chronic LBP]. why should I then go on about something else?
I THINK, I WILL ANSWER THIS QUESTION MYSELF: BECAUSE OSTEOPATHS DO NOT LIKE TO HEAR THAT THEIR SIGNATURE THERAPY IS UNPROVEN
Edzard, what would you have them do, celebrate it?
Of course they don’t like it. Would you expect any less of ANY health professional? How do the surgeons feel when they learn that knee debridement isn’t effective for pain reduction – after years of learning and practicing the knee debridement procedure? Do you think that they celebrate it?
And, in fact, your statement that “Osteopaths do not like to hear that their signature therapy is unproven” is factually incorrect and cannot be substantiated. Because if even ONE osteopath is totally OK with the findings that manipulation isn’t effective in chronic low back pain, then you’re statement becomes FALSE.
I am an Osteopath and I an FINE with the results. I stopped manipulating people with chronic low back pain a DECADE ago.
Your stick is blunt. Sharpen it up.
mainstream journals like the BMJ and thousand others are full with critique of mainstream medicine. show me an alt med journal that does the equivalent. we have repeatedly shown [and published] that alt med journals publish very close to zero % of negative results.
I apologise for being theoretically incorrect by making generalisations which, of course, are always incorrect.
this is a blog, man!
stop splitting hair in order to be clever by half.
When you write in capitals does that mean you are shouting Edzard?
it means I consider the message more important than the rest of the text.
1) When you refer to a ‘Doc’ I assume it’s as you are comparing manipulation (not osteopathy) to traditional medicine. Advances in medicine has seen our lives improve enormously in a relatively short time, however it isn’t so effective at treating CNSLBP. You also know it employs treatments that aren’t always more effective than placebo (see the above thread, antidepressants, etc)
2) It is difficult to provide evidence when there are so many variables,although as a profession we need to improve in this area.
3) Osteopaths are possibly the best trained health professionals who consistently treat in a manner providing all of the treatment methods I listed.
4)You have now changed your argument to ‘Signature therapy’. Who says manipulation is our signature therapy? It is one of many techniques. If your osteopath (or any other practitioner for that matter) is providing manipulation only, then I would seek a different practitioner.
1) yes, all professions are not very successful in treating backs. the honest ones do admit it though.
2) I agree
3) any evidence?
4) I did not write about manipulation but about manipulation/mobilisation [in case I forgot this somewhere, I apologise for the oversight]
Dear all, thank you all for your insights.
It seems obvious to me that all the efforts of all therapies treating pain are lacking any evidence. We certainly cannot accept a patients testimonial that s/he feels less pain – or not – after any treatment since of course such ‘evidence’ is sullied. I propose that equally we cannot accept that these people were in pain in the first place. It’s is only their perception that they are suffering, and such subjective observation is not acceptable.
We can only conclude then that all treatment for self reported back pain – indeed, any pain – is not indicated since we cannot be sure that it exists in the first place.
You don’t like my observation? Why not? Is there a problem with the logic? I think not.
not very funny, in my view.
Hi Anne,
Here’s how I see it.
1. I can, and should, accept that a patient has back pain, because they say so. These days, we can actually verify that they have pain with functional MRI – not that we would – but we could. So, therefore, we could objectively demonstrate a ‘brain’ that is in ‘back pain’.
2. I can, and should, accept that their pain is reduced or gone after ‘treatment’, if they say it is. And, these days, we could actually demonstrate that the pain is gone, at least to some extent on functional MRI.
But the objetive measure of pain isn’t so much the issue. The patients report of pain is just fine for most cases.
3. The point of research is to ask, ‘if their pain is indeed reduced or gone, then why did it reduce?’ Was it due to the manipulation? Or was it due to some other factor?
Because, if it is due to the manipulation, then this would justify the continued use of manipulation. If, however, their pain is gone because of some other factor, and NOT the manipulation, then that’s great news too, because it would mean that we don’t have to manipulate them, and can instead focus on the ‘other’ factor.
Also, let’s just say that a course of manipulation over a 6 week period cost the patient $540 dollars and reduced their pain from 10 to ZERO, but research showed that, on average, the same patient could have achieved the same results from a different ‘treatment’ that only took 2 consultations at a cost of $160 dollars, then we should recommend the less time intensive and less costly alternative. If the patient prefers to pay $540 for manipulation, then this would be a preference we would take into account.
As it stands right now, according to a sizeable body of research, manipulation for people with chronic low back pain – whether provided by medical doctors, osteopaths, chiropractors or physiotherapists – unfortunately doesn’t reduce pain to ZERO. Also, it doesn’t seem to reduce the pain any more effectively than some other approaches, and sham treatments.
How do I interpret this research, given my own experience? As I wrote above, manipulation didn’t help me with chronic back pain, and so the evidence is consistent with my personal experience. In fact, after the manipulations I was left feeling sore at the time and for a few days afterwards.
Also, in practice, I found I could help patients with chronic low back pain, without having to manipulate them – and I used a patient specific functional scale to measure changes in their pain levels and specific functions, so we at least had some objective data.
The approach I used was an active exercise approach combined with education about pain, both of which are entirely consistent with an osteopathic approach to the patient.
And as Edzard and others might point out, this might leave little distinction between what I do in this case, and what other practitioners from other professional groups might do.
But, I am not concerned about that. I am concerned about the patient in pain. It doesn’t matter to me if a physiotherapist, personal trainer, or rehabilitation specialist uses a similar approach. The patient is at the center of all this.
This has been an interesting thread. Thank you for the discourse, which is topical and of significance to osteopathy. The title of the thread, though arguably emotive seems fairly accurate, but such are the many purposes of titles. It is disappointing that the ‘tu quoque’ argument is resorted to so readily by osteopaths.
The GOsC all encompassing statement is much the same kind of waffle one sees elsewhere, for example the NZ draft Capabilities for Osteopathic Practice, in which the preamble hopefully asserts: “The scope of osteopathic practice is identified through its place as a healthcare system for helping people maintain and restore health and well being. This includes many who are suffering a variety of problems and others for example who seek health education and support. This typically includes those with medical pathologies, general health problems, wellness, rehabilitation, injury management, and dysfunction and disease throughout all ages, for all types of people. This wide scope of practice arises through a professional philosophy that places treatment emphasis on the person – not their disease, dysfunction or disorder.”
Prima facie the osteopathic ‘scope of practice’ appears to have little to do with evidence or utility. It arises instead ‘through its place as a healthcare system’ and ‘through professional philosophy’. Bizarrely, it explicitly states that osteopaths do not lay treatment emphasis on disease, dysfunction or disorder. This is frankly rubbish in my view. As a practicing osteopath I understand (just) what may be implied by this language. Others may not. As a scientist on the other hand, this language is worryingly imprecise, lacks intellectual credibility and by all accounts even struggles for consensus amongst practitioners. It creates confusion, fosters inaccurate perceptions and leads to polarisation.
I do consider ‘osteopathy’ per se to be best described as a cultural identity. It has evolved historically along different lines on different continents and in both it struggles to define an identity today. As others have said, in the pursuit of evidence based best practice, those that follow the evidence have more in common with others of similar intent than with colleagues within the same profession that do not. I should add that evidence based practice is not solely preoccupied with ‘the evidence’. Instead, it is a synthesis of best available evidence, patient preference, and practitioner experience and wisdom. Contrary to what some think, it aspires to best practice as a process that is not only centred on the question of evidence, but one which is ethically required. Unfortunately, it seems that osteopathy is at risk of becoming an oxymoron, a living atavism because in clinging to a philosophy as an identity, it so often appears to fail to address all importantly, what it is that it actually does.
I have highlighted this and what I believe is a way forward in the recent issue of the International Journal of Osteopathic Medicine, Volume 16, Issue 1 , Pages 54-61, March 2013. From distinct to indistinct, the life cycle of a medical heresy. Is osteopathic distinctiveness an anachronism? This special issue of the IJOM that focuses on Osteopathic Principles is testament that the profession appears to finally appreciate the value of articulating nebulous issues that lie at the heart of relevance and indeed, continued existence.
Hi Chris, and good to see you chiming in. Glad too that you put the proverbial ‘pen to paper’ for the upcoming edition in IJOM. You’re an example of someone who has consistently supported the journal over time in both your role as a reviewer, and also in your role as a researcher. You published with us in the early days, when publishing elsewhere would have served you better. Much appreciated.
I reflected on your comment about the tu quoque argument. To reiterate my reason to jump into the online fray here was:
1. To offer no objection to the evidence, and
2. To suggest that, in my view, the title would do little to create change within the profession, and indeed would incite anger and resistance.
So, my personal interest here is ‘mind and behavior change’, not the systematic review on CLBP, since I have no quibble with it, and think that it is unremarkable news, as I’m sure you do.
Thank you for tintinnabular acknowledgement Nic!
“I change by becoming aware of what I do. I can make choices based upon reality. http://www.afn.org/~gestalt/gestaltn.htm
Identity and belief are neatly encompassed by cultural identity, often celebrated and accepted without difficulty. They are non-negotiable and like any belief, pointlessly subjected to scientific methodology or questions around falsifiability. They are usually respected or they are simply ignored. They come and go. They evolve in and out of fashion, as they do in meaning. Context appears important. Challenge always engenders disquiet.
And so it is here.
I have a sense that there exists a certain ‘gestalt’ in osteopathic thinking. Osteopaths appear to worry that in the analysis of what they allege to do, the sum of the parts may not add up to the magnificent completeness best expressed by the entity ‘osteopath’, and that somewhere during the investigation an undefinable portion of identity went missing or remained undiscovered.
In osteopathy, identity and practice have been inextricably mixed for far too long, each used as a justification for the other in often defensive and circular reasoning. This is an important weakness today. In the late nineteenth century, a simpler and more brutal way of life appeared more forgiving of the ‘new’ approach that offered an alternative to extant practice of the time. Today, with all that is available to us through accrued research, clinical knowledge and modern technology it is quite simply insufficient to continue to echo the past. Indeed, it is perilous to continued professional existence and would seem to be associated with growing discomfiture, as evidenced in this thread at its title.
As osteopaths we can anticipate that what we do is and will be the subject of study. What we do will be criticized, analyzed and compared. In this lies a measure of reassurance. We are not being entirely ignored! We are in fact being invited to participate. I am certain that the way forward, the way to flourish and the way in which we retain our identity is to embrace the participation. This means we discuss and defend what we do with an open mind free from ‘belief’, we undertake research into what we do, we assemble knowledge relevant to what we do and we dialogue with others who practice in similar ways about what we do and…we change what we do and how we think as the evidence for efficacy would dictate. As for the funding necessary for research, this is I think is very much the lesser of our problems at present and one that is appears to me to be potentially straight-forward to surmount.
As Nic has eloquently stated, The patient is at the center of all this.
I would add that I think participation is the key in a discussion concerned less about who one is, but rather more in what one does or claims to do.
What makes you think that spinal manipulation is the signature therapy of Osteopathy. Tell me ed, have you ever spent a day watching an Osteopath work?
yes
In response to your post of 20 June, 2pm:
1)) You equate ‘listen, empathise, diagnose, touch’ with the prescription of exercise advice, stretching, lifestyle advice and any manual intervention aside from joint manipulation? Really? As this seems to be the basis of your implication that an osteopath performing manipulation as part of a treatment and a GP administering an ineffective or unproven medication have an equal burden of responsibility, I’d say that even you can’t possibly believe your own argument. Addressing a criticism with nonsense does not make your argument more compelling. Far better to concede the point – unless your purpose is to whip up a bit of controversy rather than engage in conversation…
2) The fact that you found several RCTs supporting one technique – manipulation – in the case of non- specific back pain speaks volumes – clearly indicating that more/better research needs to be done in this field. (As, I would point out, many of the osteopaths commenting here have already stated.) At the moment though, with best practice for back pain involving the addressing of psychosocial factors, the patient being encouraged to self manage appropriately, to perform functional exercise safely and to take the time to evaluate the efficacy of treatment regularly, I’d say that my osteopathic management of back pain is well-founded and appropriate.
3) Why would anyone see an osteopath if not for manipulation? I don’t speak for all osteopaths, but if I perform manipulation in a treatment, it takes maybe two minutes of a half hour session – the rest of the time is spent on the ‘other stuff’ that you clearly don’t want to talk about in case it makes osteopathy seem too effective an approach. See above. Who exactly are these ‘other professionals’ that provide the same service? In terms of training, the amount of time allocated to each patient, and a focus upon functional rehabilitation as well as passive therapy, I believe that osteopaths are in a perfect position to assist patients with musculoskeletal complaints.
4) Perhaps this should have been the title of your article then? And the limitations made clear within the article.
1) I did not at all mean to equate these.
2) if you are happy with your methods, all must be well.
3) they are well-trained conventional health care professionals.
Hi Kristy
Ed is dissecting what an Osteopath does in clinical practice and picks a small piece of what we do and critiques one small aspect of what an Osteopathic(and Physio, Chiro) practitioner does. It is impossible to “waste basket” a profession based on a singular part of what they do to achieve the results they achieve. Remember, our clinics are busy due to our results which appear to be positive most of the time. Ed would suggest that we all refer our patients to the local Physiotherapist…well, that`s where a lot of my patients have come from in the first place, not to mention the failed back surgery cases and non responsive corticosteroid injected patients. Or do we all just prescribe NASAIDs to all our patients and increase the already high death rate achieved by such meds (2500plus patients per year in your country alone Ed). After all, the studies do show that there is not much difference in pain scores between NASAIDs and manips, so why don`t we all (physios, Chiros, and Osteos) just push these drugs…or better still, refer them to the overworked local GP to prescribe them…after all…he is the “expert”.
No Ed, you are just a lab rat. If you really want to know if Osteopaths are effective in the management of conditions such as CMLBD, you need to look at in total what an Osteopath does in the management of such conditions. Studies that explore singular outcome measures are not going to show the effect of clinical treatment in the whole.
I do accept this is up to the Osteopathic profession to prove, but with most of the resources generally going into medical research and your pay, it may take some time. So, until then, Osteopaths will have to just have to keep saving their coins and put it towards some poor PHD student on a pathetically small grant. If you come across some extra funding at your institution, or feel compelled to help resolve this problem by contributing yourself, I can provide you with the bank account number of the Australian Osteopathic Association research fund and you can directly deposit. The Aussie dollar is a bit expensive for you Brits at the moment, but that`s just how it is for now.
Meanwhile, you might have a bit of a look at the pile of bodies building up from NASAID deaths, or take a look at the cost and risks of CT guided corticosteroid injections which have receive and “F minus” from the Cochrane bunch, or take a peek at the escalating spinal fusion numbers for CMLBD which has been flogged to death and branded a total flop by both the Cochrane group and people like Nachemson et al. I have had a bit of a peek at this all myself, and and quite comfortable with my Osteopathic model which goes far beyond just cracking someones spine. Oh, and by the way, I have had just completed 30 years in full time clinical practice, and have never contributed to anyone’s death.
I await your expected facetious reply.
too much fallacious thinking to even attempt a reply.
sorry [but I did like someone call me a LAB RAT, prime comedy!]
David Sparavec said:
Why aren’t osteopaths paying for this research?
They are through their membership levies.
It seems like that is wholly inadequate to date. What else are they doing?
To make the obvious point, problems with medicine validate quackery in precisely the same way plane crashes validate magic carpets.
Hey Guy, who are you suggesting are the pilots of these magic carpets. From what Ed says, it`s those that practise any form of manual therapy on patients with CMLBP. I would extend that to medical practitioners who inject corticosteroid injections into the same, or surgeons who fuse segments to reduce the pain, or persons who perscribe NASAIDS for such condition with little to no regard to the ever increasing discovery of side effects and death. The problem remains that all the above have also had sensational results for many sufferers.
I think the real question should be “what type of patient response to what, and what combinations work best”. Most clinicians after a number of years in practise seem to instinctively(scientists hate this word as it is unquantifiable to date…so sorry for using this term Ed) find the combinations which differ from person to person. Maybe this is where the reasearch should be heading. There are some studies already heading this way. It may not be pure science, but then again, we are not working with rats (not intended to be a pun on you Ed 🙂 ).
Meanwhile, most of us clinician will get on our magic carpets on Monday morning and head for work until a more appropriate model is devised. I have a soft spot for the Killim rug myself.
And Ed…wheres that money for the Osteopathic research I`ve been waiting for…you guys must have bags of it.
not even very funny!
just…well, stupid, i’m afraid.
David Sparavec said:
Aren’t osteos providing it?
Why?
stimulated by this exchange, I have just posted another article on osteopathy further up
Hmmm….being punished because we questioned the great Emeritus one. 🙂
punished?
great emeritus?
have your little red pills stopped working?
“But the objective measure of pain isn’t so much the issue. The patients report of pain is just fine for most cases. The point of research is to ask, ‘if their pain is indeed reduced or gone, then why did it reduce?’ Was it due to the manipulation? Or was it due to some other factor?”
I disagree. The objective measure of pain IS THE ONLY issue because that is how we measure the effectiveness and efficacy of treatment once delivered, and that is how we are judged. It may not suit you, but if the subjective measure of pain is unacceptable after treatment, it is unacceptable before.
So although my comments are amusing (except to Prof Ernst) , they are sincere. There is no point to any of this, you may as well ask how many angels can dance on the head of a pin. The vast majority of us do not see patients who have had a functional MRI before treatment, or after, and I question their veracity. The reality of our professional practice is vastly at odds to what researchers are testing and measuring. So what then are they doing? Measuring and judging something that simply does not exist.
That is because very few, if any, (Australian) osteopaths offer only manipulation, or any single type of technique alone. They offer and do MET, STM, massage, counterstrain, stretching, manipulation and I guess plenty of other techniques in physical therapy, as well as reassurance and dare I say, empathy. The Americans may call that Love. (I do not include cranial osteopathy in this.)
I know it suits what has colonised the idea of enquiry and science since the C19th to have one result from one cause, one effect from one stimulus, but thats not how the physical world operates in any field of enquiry or any experience. Its an archaic method. It’s like cooking. At the risk of patronising you (can a woman patronise? OK, I’ll matronise you); when I make a lasagna, I collect flour, oil, butter, eggs, meat, cheese, onions, herbs, tomatoes, tomato paste. Now if I put each of those on a plate and eat them in series or a bit here, or even throw it all together and heat it up, I simply don’t get a well made lasagna. I have to actually mix them up in a certain manner and order and with some added skill or talent, both ethereal and immeasurable – as all of us who have followed a Karen Martini recipe and failed, know – we get a lovely, maybe sublime meal. The same goes with wine or coffee, which is why coffee porn is rampant and the search for the greatest coffee a folly. Same ingredients, but different quality results.
As for testing quality i.e. studies in the lab – I can play Layla on the guitar. I follow the chords and pretend I am Eric Clapton, but its just not the same. I don’t think a few new grads, physios or god forbid students have the same skill as an experienced osteopathically inculcated practitioner. Using workers compensation or insurance data, where patients are effectively paid to not be at work and to continue with their ailment, is ridiculous.
The only conclusion can be made by our detractors is that we are all knowingly misguided and delusional, and so by unavoidable extension, we are all lying to our patients. These poor souls pay us $100+ per treatment to be lied to, and they return time and time again for decades, under the illusion of getting better, only to be deceived yet again. Our poor deluded patients mostly seem to stop complaining of pain within three sessions of our lies and deceit and a tsunami of personal charm. Meanwhile, the physio and the GP up the road, each of whom operates under the illusion and Sisyphean burden of EBM are nevertheless ridden with job dissatisfaction from poor outcomes and doubt as any piece of questionably funded research is quickly superseded or contradicted by another. The GP has an 80 to 100 pc subsidy of her practice and cannot financially survive without that subsidy, the physio has the vast majority of his patients under workcover. I don’t need to recite the litany of EB research that has resulted in products that have caused illness, suffering, death, a belated recall and a field day for compensation lawyers. The evidence was there, but it was never there. Its like a Dr Suess story. ‘The boy who was never there’.
No, I know that ALL medicine is operating within the same psychosis, and EBM has become its own self interested and self congratulatory industry. All it says is No. We can’t trust our own senses (except taste, and our love of our loved ones, which are never queried but are just as questionable), and we certainly can’t trust our patients. Our modus is, according to Ernst et al, ridiculous. My patients are delusional and I am a thief. And yet each day we see the reality – the body DOES heal itself. I cut myself badly three months ago, to the bone, ( which was very interesting) and it healed. It was bloody miraculous, really, like a cyborg. I twice got the Sydney gastro this last month and I recovered. Not all humans died once they contracted bubonic plague or influenza or cholera, because they had systems that resisted or recovered, and so here we all are. Of course the body is self regulating and self heals. Of course it works AND FAILS as a coherent and integrated unit, as you would know if you or Prof Ernst had ever watched total body failure unfold in the controlled environs of an ICU.
Osteopathy and all beneficial medicine is a combination of many factors, some measurable, some not. What is a ‘good GP’? What is a ‘good psychiatrist’? A good cook, coffee or guitarist? We all want to know, and we all seek them out and pay them good money. Aren’t we just SO SILLY?
Your own question, Nic, identifies the flaw in your approach. With regard to pain reduction, you say the POINT OF RESEARCH is to ask ‘Was it due to manipulation? or was it due to some other factor’? Well firstly the horse has already bolted, the patient has had the treatment, so how can you know what did the trick? Isn’t that a problem with this type of research? It cannot assess or endorse new therapies, since they have no past and so lack evidence, and it is necessarily reductive. How can you separate the effect of manipulation from the effect of, say, massage and skilled manipulation and my own charming personality? And really DOES IT MATTER? The answer is that it can never be just one stand alone factor or another.
Ergo, there is no point to this (type of) research. The physical world, and osteopathy as an aspect of it, works and collapses in concert. Separate out the components and it stops being what it had been. Observers of natural science have had this as a central tenet of their method for as long as they have been watching tigers in the wild. Why not the observers of our own professional, albeit ‘natural’ world?
So, Anne, can the surgeons ignore the research showing spinal fusion doesn’t work and use the same arguments as you offer?
“Well, you can’t investigate surgery using this research thing, because in the real world, surgery works. Our patients say that they’re better. Our surgery only doesn’t work when we isolate it and put it to the test.”
I for one am glad that these surgical procedures have been investigated and shown not to work. Without EBM, the surgeons would still be ripping people open for nothing.
Do every single one of your patients with back pain get better in three treatments?
And yes, there are studies showing that educating patients to get on with life is effective, without having to tell them that their pelvises have gone walkabout, or other unreliable diagnoses.
My question, re-phrased, is that the purpose of research is to answer the questions of (1) effectiveness, and (2) attribution.
In simpler terms, does a treatment approach work, and if so, to what part of the treatment approach can we attribute the success.
In any case, I feel we are so far apart in our understanding that we won’t resolve it here … or, honestly, ever. It’s not that I have a completely different view about all you say, just some fundamental parts of it.
Well, this has indeed been a lively discussion. My overall opinion, derived from the various proponents of osteopathy, has made me not want to touch this form of treatment, even with a barge pole.
Perhaps I’ve been extremely fortunate to have been under the guidance of excellent GPs and specialists who have the humility to use words and phrases such as: I think…; perhaps; maybe; Shall we investigate this further?; How about trying…?; Your lab tests show…, but these are open to interpretation.; and most importantly “There is currently no known cure for your condition, notwithstanding, we will do our utmost to help in anyway we can (without charging you).”
In total contrast, the sCAM practitioners I’ve seen used words and phrases such as: You have…; You are…; You need…; It was caused by…; This will cure your… — all of which were used without a shred of evidence from established scientific theory or evidence-based well-established medical diagnostic techniques.
The allure of sCAM is a combination of many things including: false promise of hope; white-coat syndrome; appeal to authority; placebo; and letters after the practitioner’s name that are not “simply” MD!
It makes not one iota of difference whether your Tooth Fairy science has been gained from just one day of reading a book or seven years of training plus decades of clinical practise, it is still just Tooth Fairy science until you provide solid empirical evidence:
http://www.skepdic.com/toothfairyscience.html
The ball is stuck firmly in your court despite years of patient waiting [word play intended to hammer home at least two of my salient points].
Why were my comments “just stupid, Ed”. You can`t just make a comment like that and not clarify it. It might be your (biased) blog, but when it`s open to the public as it is, you can`t just pick up your bat and ball and go when you decide the exact direction of the game is not how you want it played.
And no Ed, the “little red pills” you referred to don’t work according to EBM…..oh…I guess being the “great professor’ you are, you already knew that but, for some people, they work really well…could be worth researching.
I meant more osteopathic research please!
Apparently the following study met or exceeded the Cochrane Back Review Group criterion for a medium effect size in relieving chronic low back pain:
Osteopathic Manual Treatment and Ultrasound Therapy for Chronic Low Back Pain: A Randomized Controlled Trialhttp://www.hsc.unt.edu/ORC/Files/AFMPressRelease_2013_03_18_FINAL.pdf
http://annfammed.org/content/11/2/122.full
that’s an interesting study. thanks
Although only one study…perhaps somewhat more than a little more than wishful thinking?
no
Why not just a little more than your title? Conclusion from study “The OMT regimen met or exceeded the Cochrane Back Review Group criterion for a medium effect size in relieving chronic low back pain. It was safe, parsimonious, and well accepted by patients”
http://www.hsc.unt.edu/ORC/Files/AFMPressRelease_2013_03_18_FINAL.pdf
http://annfammed.org/content/11/2/122.full
Hi Gary,
Thanks for bringing this out. It’s great to see the osteopathic profession involved in undertaking research. It demonstrates, again, that there is indeed a research culture within osteopathic medicine internationally. That doesn’t mean it’s a perfect research culture, but there is one.
We’ve had at least one osteopath post a comment on here who argues that we should IGNORE studies like this one by Licciardone because of her arguments that we can’t research osteopathy within an EBM paradigm. If you’re in THAT camp, which I am not, then please stick to your guns and DO NOT use the Liccardone study as providing any evidence whatsoever that OMT may have a therapeutic effect.
Because, if you WERE to be caught using that study to support osteopathy and what you do, it would invalidate your entire argument for why EBM and osteopathy don’t mix.
So, even though it’s a positive study — don’t be tempted to use it as evidence for osteopathy — unless you intend on revising your views about research.
Gary … the ‘you’ in the 2nd, 3rd, and 4th paragraph aren’t directed at ‘you’ of course … but at those who don’t think we can research osteopathic treatment … just making sure we’re clear on that 🙂
Interesting how you missed this one Ed…….one can only speculate, but then again, a person of science never speculates. 🙂
Magic carpet time.
Bye4now (as my teen daughter would write)
oh dear, oh dear, oh dear!
have you understood anything at all?
it was not I who missed it, it was not included in the review I discussed in my post. why? I presume it had not been published when the authors wrote it.
Just interested in your expert opinion on the research paper…no points to make only interested the profession getting its act together on research.
http://annfammed.org/content/11/2/122.full
Prof Edzard,
This are germane issues to our profession and they need to be promoted within the profession and to the public. As an Osteopath who is aware of the lack of convincing evidence for our “signature interventions”, I consult with people everyday who are suffering from a distressing amount of pain. So I do my best to give them effective advice and provide an intervention that might help them based on what evidence and guidelines for their condition are contemporary and published. This can include advice about pharmacological agents that may help (but of course they would have to speak to their chemist or Doctor for actual recommendations). I, and a growing number of Osteopaths, dont feel any kind of particular loyalty to the wishful thinking of a century old medical philosophy, or the techniques for which my profession has become associated with(manip/mobilisation). Im looking for effective interventions in the difficult environment of clinical practice. Sometimes I try things that might be unproven but might be innovative, or might be useless. My problem is more one of a lack of proven strategies for the myriad of clinical presentations. My question is do you see a role for a profession(chiro, MSK physio, Osteo, EP, whoever…) who sees MSK problems in a clinical setting and offers non surgical/pharmacological treatments, or should we just give up and stop trying?
I do see a role for honest clinicians who tell their patients what the evidence says.
I do not see a role for quacks who are not honest and habitually make bogus claims – and I don’t care whether they call themselves osteos, chiros, physios, medics or anything else.
I do see a role for honest clinicians who tell their patients what the evidence says.
I do not see a role for quacks who are not honest and habitually make bogus claims – and I don’t care whether they call themselves osteos, chiros, physios, medics or anything else.
Deary me. It seems that:
# Clinicians of all denominations are abandoning out-moded practices. Their efforts may occasionally be clumsy, but hopefully it’s a step in the right direction.
# Crusty old stalwarts and other zealots are mistaken when they cling to the ideologies of their forebears.
# Everyone agrees that the patient comes first.
# Most agree that scientific inquiry is essential. Those that disagree probably don’t understand it, or throw the baby out with the bathwater.
# Honesty is good, dishonesty is bad.
There doesn’t seem all that much to argue about any more, does there?
As for the title, I understand the format to be:
” ‘Profession’ is based on ‘poor evidence’ ”
whereas more usefully it might be:
“Little evidence that ‘intervention’ for ‘condition/s’ is effective”.
The use of the “profession” in the headline seems antagonistic to me. But then again it would, since I’m an osteopath. Perhaps, however, this has been facilitated by osteopaths ourselves, since we’re often guilty of considering our profession as title, intervention, and panacea all rolled into one.
the profession in the title seems justified to me as the authors of the review were very clear that they assessed manual treatments PERFORMED BY OSTEOPATHS. had I used MANUAL TREATMENT in the titles, this would have been incorrect as it would have included manual treatments by chiros, physios etc.
Thank you, thank you! Edzard for shining a much deserved light on the pseudoscience mumbo jumbo called osteopathy. It is incredible that we subsidise such nonsense, lets get it out of universities and more importantly clear up the confusion that people experience when they see ‘Dr’ so and so on a shingle. Well done on the article I will be making reference when I need to show another side of the issue.
At 18, when tying to decide what profession I would like to join, I looked into Physiotherapy and Osteopathy. I didn’t like the style of teaching for the Physiotherapists and I loved the approach of the Osteopathic University, so I joined.
After a rigorous 4 long years of study with 110 exams and lots of clinical experience, I sought out my first job. For the last two years I have seen lots of patients. 5 of them thought they had simple mechanical aches and pains and would NEVER have seen their doctor about them, as I immediately referred them to their doctor/ A&E they were diagnosed with serious problems (one cauda equina, one angina, one VBI, one severe kidney infection, one abdominal aortic aneurism). Any patients who aren’t seeing an improvement in 2-4 treatments get referred to their GP for further tests. Most patients are relieved to be listened to, thoroughly examined and treated in a way that doesn’t use drugs which make them concerned about looking after their own children, or driving a car. The vast majority of the patients I have seen have got better and are seeing huge improvements in their quality of life.
This approach is representative of all of my university colleagues. We aren’t conning people, we just want our patients to live pain free lives.
To say there is no validity in a profession filled with people who are looking after their patients responsibly is unfair.
What about massage therapists who have MINIMAL training in anatomy/ physiology/ diagnostics / clinical reasoning and claim to treat back pain?
After two years of nocturnal back pain and various visits and sessions to a pyhsio I went to my local Osteo. 20 mins of a 45min session paid for. A £51 bill. No more info than a GP visit and being told they won’t work on me until they have an MRI. The holistic approach was non existent. The marketing was very appealing. The practice left me feeling very let down. To be honest I feel robbed…and stupid for walking in…
I totally support that osteopathy is based on more than wishing thinking. I use to be of that opinion so when I developed growing pain on my lower back about 5 years ago, I simply quit my job as a sale assistant as there was loads of standing involved and heavy load handling, however the back pain continued immensely until a couple of months ago when I met my sister’s friend, Anthony Agius, he convinced me to try a session at City Healing. After just a session, I was mad at myself for taking this long to try it and being so skeptical of it. I have no doubt that it works
Samson said:
Unfortunately, you have supplied no good evidence nor reasoning why anyone should agree with you.
After weeks of severe pain from trapped nerve in neck, being on medication for pain relief, being referred to neck and back specialists, not being able to drive because of the pain in my arm and under arm, going to hospital when it got really bad for stronger medication, all stemmed from exacerbation of asthma I thought I don’t how much longer I could have dealt with the pain. Whist waiting to go further up the ladder I decided to go see an osteopath on my friends advice. After my first session I went home still in pain but obviously hopeful for some pain relief which the osteopath said would come in a day or so and to use ice packs if able to.
I just want to say that in two days after being in agony for 4 weeks I am able to smile and able to drive for short periods, I’m in a lot less pain and my outlook for getting back to work is more positive now. For me I just want to hug my osteopath which I will do when I see her on my next session because she released the pressure and gave me pain relief which is all I wanted. Personally it is working for me and when a professional talks you through every step on what their and doing and why it makes all the difference.
Michaela, unfortunately your experience will be dismissed as coincidence/wishful thinking by many people here. This is one of the inherant problems with an over-reliance on the scientific method. I’m glad you found something that worked for you, and that you were treated as an individual, as a human being.
Tom Kennedy said:
No, it will be discounted because it is unverified and unverifiable.
No, it is one of its strengths: it tries hard to eliminate biases.
hmmm…seems that its weakness is that is discounts the unverified and unverifiable.
I said I totally supported the notion because it worked… for me. It is far more based than wishful thinking which I thought it was at that a time. I am pain free now after 5 year, there might be other factors to consider but it did work for me and I’m glad it did.
You admit that you are aware that there may be other factors to consider then completely reject them out of hand by maintaining that it was the osteopathy treatment that worked for you. I’m glad you are pain free, but what we don’t know is whether the osteopathy treatment had anything to do with it.
So am I , without any woo. Just time and training 😉 Had I taken some altmed potions I am sure I would have attributed at least some of the improvement to it.
Anyone read the book ‘Complications’ by Dr Atul Gwande? I think every profession hides behind a lack of evidence in most forms of its practice.
Is good diagnosis AND treatment good evidence based science? If this is the case; and its good practice for NSAIDS to be given to acute LBP sufferers’, What happens if a patient has a stomach ulcer and cannot take NSAIDS? Is the next decision based on good science or an educated guess by the perscriber as what to do next?!?
All very thought provoking stuff. I don’t think orthodox medicine is anymore scientific than complimentary/alternative medicine. There is a lot of presumptions and educated guess work in all of them. Its probably due to the fact that orthodox medicine is under pinned by pharma, that has been proven to underpinned by mercy finances, that it can carry out more established research than alt/comp therapy when ultimately no money can be made.
Those who do practise manual therapy (osteopathy/chiro or orthopedic manual therapy) correctly know by experience that increadible results do happen, yet the human being as a whole is complex and unique. Our aparato locomotor…..that which makes us move, needs biomechanical mantenence and when this does not occur problems arise.
THE REST IS AS LIVE RELATIVE, but it is this uniqie feature that other disciplines don`t offer.
To proof its working is not easy but there is a lot of experience around, since it is most of all an emperical science.
based upon many years of profound study of course
You haven’t done quite enough research. I used the services of an Osteopathic vet. She works mainly on horses but treats dog and cats one day every two weeks. My dod could not move his head to the right and couldn’t look up. His anxiety was so great that his fur was tight to hos body even around his neck where most dogs have loose skin and fur. My dog left the treatment with all of these issues resolved. I didn’t even KNOW the fur thing was created by his anxiety so how could I wish for it? Or was it my dog’s wishful thinking?
After seeing the results on my dog, I got a referral for another practitioner. My lower back pain and siatica that I have has for 20 years is gone (for 2 years now).
Do you make a living spouting off your uninformed opinions or is this your passion? Maybe you need a treatment.
I believe in evidence
you seem to prefer anecdotes and ad hominem attacks
Oh dear.
Oh dear this seems to be a case of science proving that the bumble-bee can’t fly, and arrogantly blaming the bumble-bee for getting it wrong.
There is a mismatch between the prof’s research outcomes and what millions of intelligent, savvy people experience every day in real life. It is not too much to suppose it is the professor who has got it wrong and that he needs to take his own approach back to the drawing board. The very least he can do is a sincere, unbiased, scientific attempt to own and explain the mismatch, but after years of waiting, I am not holding out.
My personal journey with osteopathy began as a very satisfied patient, whereas previously I had been left high and dry by conventional medicine. That was my ‘Victor Kyam’ moment, I was so impressed I joined the profession. And many years later I still appreciate the benefits both short and long term. Am I deluded? As a consumer I don’t really care if anybody thinks so – if I am qualified to say I have symptoms and seek help then I am qualified to know if my condition has improved. I don’t need a medical rubber stamp on my experience.
I can’t say for sure if all my patients improve but many tell me they have and many attribute it directly to their treatment. For this I am genuinely grateful. Ultimately, this is purely a consumer issue – I am not harming or deceiving people and they are happy to decide for themselves if what I offer is of value to them. Nobody is asking for their money back. Quite the contrary, they are referring others for help
If Prof Ernst thinks we are all wrong, as consumers, practitioners and expert consumers also (both trained in the field and happily benefitting from our own product – something you wouldn’t expect to see in colorectal surgery, for instance), then all I can say is he is missing out due to his own scepticism. The first stage in science is observation, followed by hypothesis formation – the rest follows from that. The prof would be welcome to suspend disbelief and come for a course of treatment and simply see what happens before making judgements about it. Then he might be in a better position to form sensible research questions, and he might at that stage find evidence that was truly useful.
Until then there is simply no point arguing about it.
do me a favour and look up FALLACY and then find ARGUMENTUM AD POPULUM and then try to think a bit.
Of course; anything to help. An illustration would be where the bumblebee is foolish enough to think it can fly, even though it hasn’t got any qualifications.
very funny
Nothing like avoiding the issue and changing the subject. Your analogy fails as badly as your logic. I help people ease their anxiety (some say so anyway) as well by teaching them to knit (for some the anxiety only increases and they usually give it up), but I only charge them for the knitting lesson, not any health benefits–implied or real. If I had no ethics I guess I’d call myself a Fiber Therapist and write a book and set up a website claiming to “heal” people.
“The first stage in science is observation, followed by hypothesis formation – the rest follows from that. ” Not quite enough, I’m afraid. Having reached the stage of hypothesis formation the rest is the important bit: designing experiments that (ideally) will disprove the hypothesis. If the hypothesis emerges unscathed from the experiment, then its chances of being true have risen.
In the context “the rest follows from that” involves systematically counting the numbers of patients who do and do not claim to benefit from a particular treatment, documenting exactly what was wrong before treatment and in what way and for how long it was put right. The double-blind, placebo-controlled clinical trial is ultimately the least worst experimental design we have to study whether an intervention really works.
The case you make is pure ‘ad populum’ fallacy, on a par with being convinced certain films, foods, types of music are genuinely good because you know a lot of people who say so.
Oops! Second para should have read “In the present context…”
a) We are medically trained
b) We are complimentary, not alternative, clinicians.
c) Some drugs are prescribed for CNSLBP that have no proven efficacy: many people with CNSLBP are prescribed antidepressants after NSAIDs/paracetamol don’t work. Admittedly, they are often prescribed for their antinocioceptive qualities vs their antidepressant qualities; however, there is “no clear evidence that antidepressants are more effective than placebo in the management of patients with chronic low back pain” (Urquhart, D. M., Hoving, J. L., Assendelft, W.-W. J. J. et al, 2008). They also often cause side effects. Older adults are more likely to suffer from NSAID-related side effects and the PPI’s often co-prescribed again, cause side effects. PPIs can also affect other medications prescribed to older adults.
d) I guess, this comes as a bit of a surprise to many consumers who have been told over and over again by their doctor that their medication will help them. Once this cycle begins, the only way forward is long-term medication, with progressively higher doses and increased likelihood of side effects without really attempting to look at the cause of the problem
e) I don’t know any Osteopaths that claim there is a wealth of research for manual therapy in general, or a specific technique. For a start, there are many techniques used in different ways which all should really be investigated vs sham, control and other techniques; for many different conditions.
f) “the image of osteopaths as back pain specialists” has not be formed by us bragging, (obviously some people advertise in such a way; which is no different to how a private medical doctor or surgeon advertises their MSK- treating properties…) it has, in my opinion, been formed by a client seeking manual therapy, seeing an osteopath by choice or chance, having their body examined and treated, feeling better and then telling their friends that their osteo fixed their back. Osteopathy was first used in hospitals to compliment medicine before drugs did the job faster. (Except, they don’t really do the job, just patch over the rust while it continues to spread).
g) as a primary care practitioner swarm to ‘first do no harm’ my conscience is clear treating someone to the best of my ever-increasing knowledge, than seeking to merely decrease their symptoms.
h) Google says there are, “About 1,180,000 results” for me typing this into the search engine: “private injections uk low back pain” one result stated that “The Government’s drug rationing watchdog says “therapeutic” injections of steroids, such as cortisone, which are used to reduce inflammation, should no longer be offered to patients suffering from persistent lower back pain when the cause is not known.” A much bigger problem than osteopaths suggesting we may be able to help with a few conditions (clearly defined by the GOsC).
i) There are “About 19,500,000 results” for low back pain private surgery.’ Should we tell them they can’t advertise their services because surgery isn’t always beneficial, can cause haemorrhage, infection, worse pain and mobility, disability or death? Should we stop them from advertising because certain surgeons favour certain procedures meaning they may not receive the best one for them? Or because imaging-related findings are not always the cause of the back pain? Or because surgery may not be any better than placebo either.
j) People have the right to choose. Many people prefer a non-invasive technique as a first-line of treatment and rightly so considering all the potential risk factors.
k) the biggest delay to recovery is the improper use of medications that are prescribed just to get the patient out the door! “The he victims of bogus claims are the consumers” (or NHS patients) “who are being misled” into having unnecessary surgery and worsening their future health through polypharmacy.
Dee
You’re not sounding particularly complimentary to me…
Edzard,
There is something about the drive of your agenda to discredit osteopathy that generates the opposite reflex in me, and the suspicion that you have something to gain in annihilating osteopathy. I do wonder how or why alt med came to be your specific expertise. Most of the counter arguments I’ve read on here seem, on the other hand, humble, well balanced, less disparaging, yet open to critique.
Among my friends & family, I don’t even know anyone who is more comprehensibly sceptical than I am myself: I consider my body to be unique, and every treatment is subject to doubt and to the onus to prove itself (probably the result of a lot of treatments that haven’t worked any more convincingly than time). This is one of the reasons why the few times I have seen an osteopath, I have chosen one who was also a physiotherapist. or vice versa, e.g. when prescribed 6 sessions of physiotherapy by my GP. Generally, a physio/osteopath would go about the physiotherapy as prescribed, but offer the option of osteo, suggesting it might help. My experience every time has been positive, and very often almost immediate. I would not hesitate to go back. I have also never heard of a bad experience of osteopathy from anyone I know who has used it, although I am sure some are themselves prone to “wishful thinking”.
That said, if “wishful thinking” itself can provide improvement to a broad sample of patients, maybe it has mechanisms that are worth exploring & it should be on the medical curriculum?
GeorgeS said:
Rather than imagining unfounded and unevidenced ulterior motives, perhaps you could say what it is Prof Ernst get wrong in his analysis of the evidence for osteopathy?
Perhaps you could read a few other of prof Ernst’s posts here – you’ve find the answer to your question in plain view, so you will have to wonder no more.
It is not they humility with which an argument is put that makes it compelling; it is its veracity and the strength of the evidence provided.
Great definition of the meaning, and purpose of Osteopathy. To add tho the definition, the first part Osteo actually has its meaning derived from Latin, meaning bones. This discipline of medicine lays a lot of emphasis on bone structure and motor movement of the skeletal structure. Provided you have good posture, your overall health should benefit from it.
Edzard,
there are more to human than our body as a unit. those factors are the sources of health and disease. isn’t it great to have professions like the art of Osteopathy which acknowledge that and do not limit themselves to evidence? isn’t it great that Osteopaths can work very differently with different patient? therapeutic communication, calming the patient,rebalancing their status and the magnificent Cranial therapy are within those things which has no evidence but apples to a LIVING BEING and in addition Osteopaths use their critical thinking to rebalance MSK structure according to patient lifestyle. the very existence of Osteopathy is to be apart from orthodox medical’s approach as treatment the unit of body only.osteopaths attend the health of the PERSON as well as the body as a unit.
i am sure you know there is no evidence that you have a soul! but you do!
are you trying to give osteopathy a bad name?
No.i am expanding the prespective.
i am trying to highlight that osteopaths offers an space for “thinking outside the box” in addition to their educated opinions and unlike others i have no intention to fit the profession “in fixation “.
Dynamic critical thinking and priorising the range of differencial diagnosis demand a different set of rules to play.a very difficult and expensive one for evidence base researchers to participate. I belive the minset to judge it needs to recognise the unique advantsges which it presents. However,some individuals will not take that view and thats perfectly ok.
Sina,
Let me say a big WOW… it sums up the discussion…..yes humans should be treated as humans and not…….!
All forms of medicine are equally good or bad for that matter.
I think the biggest problem with ‘alternative medicine’ is much of it is an art form, as is ‘osteopathy’, ‘acupuncture’ ‘homeopathy’, ‘aromatherapy’, ‘chinese medicine’, and so called ‘folk lore’. However, much of it exists because it stands the test of time and people use it because it just works for them. Medicine does not deny the mind body relationship, that the nerves involved in laughter do indeed innervate lymph nodes and stimulate them. So at the very least people feel better about themselves as opposed to do nothing about their maladies.
Medicine is wonderful because of the growth of science and application of mathematics to seed our understanding and continue to grow Medicine as an evidence based science and practice. The question we should really be asking is when will these ‘arts’ be welcomed into the field of science (and evidence based therapy) just as Medicine was.
The same is true about, Physics, Chemistry, and Biology each has it’s unifying theory, yet people scoff at evolution. Just because we haven’t discovered a causative relationship for something does it mean there isn’t one? We can only say ‘as far as the literature we’ve examine’, ‘as far as the literature we have published’…this is the case. Once Mendeleev produced the periodic table, or Newton identified the Laws of Motion. Even Einstein hates the very field he founded in Quantum Mechanics saying it was nonsense, but unfortunately [for Einstein] it works. It is what makes Medicine, Science and Mathematics so interesting to try to find out what the cause is.
To be fair I think that many contemporary osteopaths do strive for evidence-based practice, rather than relying on their traditional structural paradigm, which is heavily flawed.
Of course, there are limited literature in support of the management of many musculoskeletal disorders, which in part explains the fact that these conditions commonly result in chronic pain and disability. The multi-dimensional nature of CNSLBP has certainly not escaped the more clued-up osteopaths, of whom I know a few.
I completely agree that osteopathic treatment methods cannot plausibly be extended beyond the musculoskeletal system though (other than maybe in achieving general relaxation). To claim otherwise suggests either a lack of knowledge or a disrespect for it.
Opened this page and although at least Latvian osteopaths have to finish conventional med school and get registered, nothing prevents them from offering this nonsense. http://www.osteopats.lv/en/chto-lechit-osteopatiya
Regarding this part of your article “Osteopaths most commonly treat patients suffering from Chronic Non-Specific Low Back Pain (CNSLBP) using a set of non-drug interventions, particularly manual therapies such as spinal mobilisation and manipulation. The question is how well are these techniques supported by reliable evidence.”, we highly recommend that you take a look at our work ‘Osteopathic treatment of low back pain and sciatica caused by disc prolapse’ where you´ll find the results of 20 years treating disc prolapse.
Congrats on your article anyway, it´s really interesting.
Other than having a book to sell, can you point to any high quality trials that provide reliable evidence?
How can osteo provide any relief for a prolapsed disc, apart from short-term and placebo? What is the mechanism?
Just for interest there is a new big study by Licciardone et al on osteopathic manipulative treatement for CLBP available here; http://jaoa.org/article.aspx?articleid=2498824
@ Paul Barratt on Wednesday 16 March 2016 at 16:52,
Before I get to the study, let’s have a look at your interest; http://www.osteos.co.uk/team.aspx
At least you are honest enough to declare your interest; thank you. There are concerns, however, because you do include some considerable woo at your place;
“She once spent time in China studying acupuncture”
“His postgraduate studies have included paediatrics”
“Acupuncture is used to treat pain and many other different types of conditions and illnesses, both physical and emotional.”
“hot stone and aromatherapy. She gained her BSc degree in Complementary Therapies”
My concern with the study is differentiating “real” from “sham” osteopathy. The description is brief and not very elucidating. There is no discussion of whether any or all of the patients had received osteopathy beforehand. This leads to a significant problem with blinding; if a person knows what the treatment will be, a different treatment will be easily recognised. Equally, if the “sham” treatment is a bit of faffing about, this too will be easily spotted.
As far as I can discern, there are too many problems and the vested interests make it less than reliable.
My question is; why didn’t you critically examine the study before posting it here?
Dear Frank,
Thank you for your comments.
I do find them confusing though. What has my place got to do with the study in question?
Please don’t tell me you are really saying ‘undercut his personal credibility thereby discrediting the study he cited’ …are you?
I welcome any critique of the study itself. But again I’m confused; how do you arrive at the conclusion that I cannot have critically examined it before posting? All I did was post up the link for interest, like I said!
I agree; assuring blinding is an issue for studies of manual therapy and so no less with this one.
There is no discussion as to whether any/all patients had received osteopathy beforehand. Yes but at least, because of the randomisation, there should be no systematic difference between the treatment and sham groups regarding this, similarly for the previous and concurrent use of medications.
Finally, the call here in this blog is (reasonably) for osteopaths to please carry out more research. How, then, can they escape the indictment of vested interests when they do actually do it?
@Paul Barratt
The study is not within my specific expertise, but it would have been nice if, at the end of the trial, the patients had been asked which treatment they thought they had received. This question has shown up, in many other trials, the blinding weakness Frank Collins has referred to in this one.
“… the call here in this blog is (reasonably) for osteopaths to please carry out more research. How, then, can they escape the indictment of vested interests when they do actually do it?” Your point is perfectly fair. However, most people doing clinical trials usually aim as high as they can for publication. Submission to, say, the New England Journal of Medicine will normally produce a pretty clear idea of what the serious objections to a study are going to be. There are other general medical journals with high impact factors Licciardone et al could have tried before falling back on the JAOA — presumed to be an osteopathy-sympathetic journal and which has a five-year impact factor of 0.0. That’s an astonishing low even by altmed journal standards.
@ Paul Barratt on Thursday 17 March 2016 at 14:11,
“What has my place got to do with the study in question?”
Having read the study, I didn’t find it very credible. Wondering why you thought it was, I looked at your website to see your mindset. That is why I pointed out the woo you seemingly believe.
“Please don’t tell me you are really saying ‘undercut his personal credibility thereby discrediting the study he cited’ …are you?”
It is called “Poisoning the Well” and wasn’t my intention. I only wanted to save others the time by listing some of your pseudo-scientific views shown on your public advertisement of your services.
“I welcome any critique of the study itself. But again I’m confused; how do you arrive at the conclusion that I cannot have critically examined it before posting? All I did was post up the link for interest, like I said!”
Incredulity abounds, it would seem. If all you did “was post up the link for interest”, what was the purpose of so doing, unless it was to advance the interests of osteopathy and, implicitly, your own? It is assumed, by the critically-minded (no True Scotsman intended), that you would only post a link if you understood its contents and, in this case, lends support to the views you hold.
“All I did was post up the link for interest, like I said!”
Whose interest? Interest, as in for interests sake or, as I believe, for your own interest? Please, a disingenuous response will be seen as such.
“I agree; assuring blinding is an issue for studies of manual therapy and so no less with this one.
Why then no critique on your part to address this significant aspect when you posted? Did you hope it would have an air of credibility that might escape critical examination?
“There is no discussion as to whether any/all patients had received osteopathy beforehand. Yes but at least, because of the randomisation, there should be no systematic difference between the treatment and sham groups regarding this, similarly for the previous and concurrent use of medications.”
Err, no. I shouldn’t need to point out the fallacy and hope you won’t even feel the need to ask. However, nothing surprises me anymore.
“Finally, the call here in this blog is (reasonably) for osteopaths to please carry out more research. How, then, can they escape the indictment of vested interests when they do actually do it?”
Yep, agreed, more research is always needed. All research, so far, points to osteo being as valid as chiro, so I wonder how much more is necessary to sink both down the big sewer of pseudo-science to the sewerage plant of nonsense?
If the research was properly conducted, addressed all of the problems, was undertaken by or involved non-osteo scientists, was reviewed by professionals who were competent, and published in a real medical journal, most of my criticisms would not be here. As it stands, the paper is of little use, except to flush after its only real useful purpose.
“Having read the study, I didn’t find it very credible”.
That’s your prerogative – so what?
“I only wanted to save others the time by listing some of your pseudo-scientific views shown on your public advertisement of your services”.
Yeh, aka poisoning the well then Frank; i.e. ‘nothing he says from here on in can possibly have any validity folks’.
“… that you would only post a link if you understood its contents and, in this case, lends support to the views you hold”.
But the blog is more-or-less about evidence (or lack thereof) for osteopathy incl. for chronic back pain in particular. The ink is practically not yet dry on the study I mentioned so, yes, just why not bung it in for interest’s sake?
“…Did you hope it would have an air of credibility that might escape critical examination?”
But I didn’t intend to (and didn’t) post up a ‘critique’ though Frank!
I think you would have preferred it had I said ‘here is a study relevant to this thread, – but ignore it as its crap’.
Why can’t I instead do people the courtesy of assuming they are capable of deciding for themselves one way or the other?
I didn’t say the study was flawless (no clinical study is of course) .
Yes. The aspect of blinding is unfortunately an issue with all randomised studies looking at physical interventions, – that is fairly self evident I would have thought. Does it render such studies completely worthless?
“Err, no. I shouldn’t need to point out the fallacy and hope you won’t even feel the need to ask. However, nothing surprises me anymore”.
I am not really afraid of the risk of appearing stupid! What was the logical fallacy there?
“Yep, agreed, more research is always needed. All research, so far, points to osteo being as valid as chiro, so…”
The paper I mentioned does not mention chiro,
“If the research was properly conducted, addressed all of the problems, was undertaken by or involved non-osteo scientists..”
But the other two authors were Gatchel, a professor of Psychology and Director of the Center for Excellence for the Study of Health & Chronic Illness at the University of Texas, and Ayral, Associate Professor Dept: Biostatistics and Epidemiology .
“was reviewed by professionals who were competent, and published in a real medical journal,”
Does publication in a real medical journal ensure that a study is good?
“Except where you might think posting a link may give the audience it has credibility? I was thinking about quoting Shakespeare about something smelling”.
Sorry, I don’t understand that one.
@ Paul Barratt on Friday 18 March 2016 at 15:34,
No response required. I’ll let your post speak for itself.
“ it would have been nice if, at the end of the trial, the patients had been asked which treatment they thought they had received”
I agree completely.
I don’t know if the authors tried submitting elsewhere or not.
The impact factor is undeniably dreadful but it’s a journal measure and shouldn’t be used to assess individual researchers.
“The impact factor is undeniably dreadful but it’s a journal measure and shouldn’t be used to assess individual researchers.”
Except where you might think posting a link may give the audience it has credibility? I was thinking about quoting Shakespeare about something smelling.
(Licciardone has also managed to publish in other journals in the past such as Annals of Family Medicine which apparently has a current impact factor of 5.43.
Licciardone et al Osteopathic Manual Treatment and Ultrasound Therapy for Chronic Low Back Pain: A Randomized Controlled Trial Ann Fam Med March/April 2013 vol. 11 no. 2 122-129)
I hightly recommend you a new approach about hoy to treat sciatica and low back pain with Osteapathy. Go and take a closer look here http://medoslibrosalud.com/en/osteopathy/114-osteopathic-treatment-of-the-low-back-pain-and-sciatica-caused-by-disc-prolapse.html
Best
Interesting that osteopath Nic Lucas who posted the first comments in defence of osteopathy in this thread has now left the profession and his new website does not mention his previous career in complementary medicine; http://niclucas.com/
1. Why is that interesting to you James? Please spell it out exactly for me.
2. In your opinion, does my current scope of work change or effect the validity of any of the comments I contributed on this thread? If so, how? If not, what’s your point? (See question 1 above)
And so that you don’t inadvertently lead people astray with your comment, I offered no ‘defence’ of Osteopathy in my comments above. If you were to read my comments, you’d know that I was providing feedback about the accuracy and influential nature of the title. When it came to research about the effectiveness of manipulation performed by osteopaths for back pain, I agreed with Ed about the research findings.
Also, from my perspective, I never had a career in ‘complementary medicine’. I don’t accept the term despite it’s popular usage, even amongst intelligent, educated people.
There is only medicine that is evidence-based, and that which is not evidence-based. In all I do, I seek and prefer evidence-based.
In my view, other descriptors such as ‘conventional’, ‘orthodox’, ‘alternative’ or ‘complementary’ are unnecessary distractions.
@ Nic on Tuesday 07 June 2016 at 17:02
“Also, from my perspective, I never had a career in ‘complementary medicine’. I don’t accept the term despite it’s popular usage, even amongst intelligent, educated people.”
Your acceptance, or otherwise, is irrelevant; you were, or are, an osteopath which is clearly alt-med. You didn’t do an internship in a hospital nor could you work in one, so the facts are clear.
“There is only medicine that is evidence-based, and that which is not evidence-based. In all I do, I seek and prefer evidence-based.”
So why become an osteopath?
“In my view, other descriptors such as ‘conventional’, ‘orthodox’, ‘alternative’ or ‘complementary’ are unnecessary distractions.”
Of course they are, they distract the gullible from what you are/were which, I suspect, you are/were quite happy with. If you regard those descriptors as “distractions”, you have little regard for what medicine entails.
From what I can ascertain from your new “career”, you are a business motivator. From your website, I also suspect you are as odious as that Robbins (of the large jaw) scammer who recently burnt the feet of several gullibles doing the stupid firewalk. You certainly give that impression here; your self-affection drips off the screen. So much sleaze, so little substance.
The author of this article is just another foolish person who is out there to build a name for himself over what he doesn’t even know. There are plenty of these idiots around. What he is doing is selfish, ignorant and foolish. Nic, don’t waste yr time trying to convince people like these about other possibilities. Go help people that needs yr help.
ROFL!
Please feel free to point out any errors he’s made, backed up with reasoned argument and good evidence, of course.
Too late, Mary, the Prof already has a “name” for himself; one of respect and admiration for his efforts in trying to dispel the witchcraft proffered by people like Nic.
Summary:
I am writing to you in the hopes that your wicked sense of humour is an indicator of an open mind and a greater desire to help.
That and the pain was so bad and so long lasting I became suicidal. The chiropractic ROM treatments were the most mpainful experience of my life next to wisdom teeth and TMJ pain (I had that too and the same chiropractor, god bless him cured that after 15 years of agony)
Now that I know the holy trinity, patient, chiro and osteo had results in less than a month, there needs to be a consensus on treating this awful condition.
Lastly, I figured out that frozen shoulder is the body’s defense mechanism to prevent further permanent damange due to the individual components being out of alignment and no longer working in a dynamic functional way.
The summary is after 3-5 years of physiotherapy, two consulatations with orthopedic surgeons, I lived through about 30 plus years of chronic pain ending in a frozen shoulder.
Only by combining an osteopath with a chiropractor was I able to finally start living a pain reduced life.
The chiropractor excelled at stripping scar tissue from the muscles in a far more effective way than the osteopath. While the osteopath was able to begin a cycle of myofascial releases. Please see the link below which I sincerely believe someone needs to correct or create/document clinical evidence to the contrary.
https://en.wikipedia.org/wiki/Myofascial_release
Ironically the osteopath was the ONLY individual to solve the problem by explaining that the pectoralis major was in contraction and screwing up the normal clearances for full ROM in the complex shoulder joint and coracoids process which was also impinged. I say ironically because he never really treated the pec muscles so I tried myself but lacked the strength or knowledge to know how hard to push so I got the chiropractor to do accupunture and muscle stripping. After one treatment my shoulder was 50% improved.
All prior physio had focused on strengthening the pectoralis musles and the 2 cm are of the actual coracoids process which only HURT because the dam muscle was PULLING On it. NOT ROCKET SCIENCE people! (sorry it was over three decades and two dam surgeons looked at it as well as three or four physiotherapists)
I have an overactive brain so I m stopping typing unless you have questions and are genuinely interested in this
Oh one last thing, Chiropractic is correct in that the spine and cranium alignment MUST be established prior to working on the shoulder. In my case, I did a release of the neck muscles and my shoulder bone/s litteraly dropped about 1-3? Cm at which point a chronic pain in my mid back between my shoulder blades went poof for good. (Rocket science here…..if you are curious I can explain this but briefly the head/neck/spine is the most crucial system in a human the most fragile so everythning is intercoonected to spread stress to as much as the physical structure as possible to limit damage to the immediate overloaded zone. (that’s how boxers produce 800-900 PSI at the tip of their fist with an arm that weighs 2-5% of the total mass of the force produced) I know I need a hobby
HISTORY
By combining CBDs (cannibinoids) with cyclobenzaprine I was able to increase the ROM (range of motion) but there were a lot of clicking sounds.
The original chipopractor said off the record, he was okay with me being on pain medicine for an adjustment but I recall by father saying “pain is purely protective in nature”.
Having lived in chronic pain for the last 30 years I was very annoyed by that quote but felt better safe than sorry.
Following the lead of the osteopath, I would very gently palpate the painful area and could feel the point of origin of the musle or point of insertion releasing after a very long time but with no actual sharp pains.
The chiropractor was abel to explain how the muscle fascia is basically linked from the tip of your toes to the tip of your fingers and so on and by very careful stretching I could feel a release in an area (pelvis/abdomen) by palpating the deltoids or points of insertion/origin of the muscles under the armpit.
The deltoids were the most difficult to release and it was often easier to palpate the funny bone or under armpit area and follow the release as far as possible until it completely let go.
In some cases, it was impossible to get a release and the tendon? Would feel like a steel cable so in the spirit of caution I would give up and change areas only to occasionally feel/hear a click in a completely unrelated area.
Knowing the funny bone is really a laymans term for a nerve ending? Made me realize most tendons must have a safety nerve to let the body know when the point of insertion/origin is at risk of a complete catastrophic failure (just good engineering) so I started to target those agonizing trigger points only to realize that very/extremely gentle palpation caused a virtually pain free release.
The pain is the worst I have experienced in my life not for the intensity but for the shear duration…..you literally cannot sleep, move or work or even watch TV and never mind readinga book unless someone can hold it for you. Made TMJ pain look fairly benign. (Ya it s terrible but only last a day or so :P) It literally caused severe depression bordering on suicidal tendencies.
The reason I am writing is because I treated this like the most important problem in my life and researched it extensively.
I first went and saw a physiotherapist who was also a chiropractor with a speciality and in sports medicine and rehab.
After 4 weeks of treatement it was much worse.
On to a chiropractor for about 4 weeks who also made it worse. About two weeks or three I had figured out it was two problems. Impingement of the coracoids process and the more common impingement of the acromium? (sorry I can visualize a model of the shoulder but sometimes forget the names for things but I fully understood the biomechanics from a physics point of view…..absolute amazing feat of engineering with respect to range of motion and relative strength)
Now comes the interesting part.
When my shoulder was first injured THIRTY (30) years ago!!!!!! I immediately went to a doctor then physio for 2-5 years, yes YEARS.
Someone pranked me at work at my desk. I was sitting facing my cubicle wall and stretched with my hands behind my head when someone snuck up behind me and pulled me back slightly. The problem is I felt myself falling backwards and jerked forward to prevent an injury to the back of my skull. I reacted faster than the prankster which caused a pull in the the muscle or ligaments or tendons going to the coracoids process.
The osteopath I subsequently visited was able to explain the pectoralis major was in serious spasm and pulling the entire shoulder complex forward thereby causing impingement of both the coracoids and acromium.
https://youtu.be/xKzACBoKLhg?t=15m32s
The only interest I get out of this is astonishment at the level of unhinged ramblings of some loon who has no introspection or self-awareness.
let’s cut out the ramblings
orthodox medicine looks over its shoulder at chiro and osteopaths worryingly
orthodox medicine has no answer to back pain
period
tens of thousands of people swear by manipulation and readily pay their hard earned money for it , because of the relief it gives
my GP would pump my body full of drugs and tell me to lie down ???
my osteopath would manipulate my spine and I would walk out the clinic pain free
there are thousands of us who use manipulation because it gives us the results we need
are we all wrong I think not
“there are thousands of us who use manipulation because it gives us the results we need
are we all wrong I think not”
you might want to read up about logical fallacies – start with ‘argumentum ad populum’ [appeal to popularity]
@ Darren Small on Saturday 29 October 2016 at 09:27
“let’s cut out the ramblings”
That’s all you did.
What a load of bull, trying to defame a profession because of a few idiots who pretend to be qualified to practice.
Osteopathy, or at least my Osteopath had treated my back pain for 4 years when it flared up, but after revisits to keep the pain at bay and to sort out the problems I had, the pain went and I was able to function normally again. Yes, sometimes the pain returned but I knew what exercises I needed to do to alleviate and reverse the trend. I returned once more a few times to make sure the problem was gone but it was not just the therapy I was getting, it was the advice and examples given of what to do before exertion and what to do if you feel a twinge coming on. All have served me to live a better life at work and at home.
There was one point where I couldnt walk down the corridor at home, managed to get a booking that day, drove down barely able to get out of the car, 3/4 hr later i was walking out that surgery with just a dull pain left where there was a slight soreness. Kept careful for two days and it was gone. Went back a week later for secondary massage treatment and I can say with hand on heart I was fine for over a year until I lifted a case badly and i was back in his surgery two days later.
Thing is, this is not wishful thinking, this is not anecdotal evidence if you take in all the other cases where Osteopaths have cured people of back pain. He even cured me of tennis elbow which I had had for over ten days and it was getting so agonising doing simple things. 1/2 an hour with him and again, it was a little sore and there was some dull pain but the arm was feeling so much better and the agony had gone. Next day I was able to drink tea out of a mug again. That is not wishful thinking, so however you want to paint it, all professions have charlatans and Osteopathy is no exception, but get real please and do not tar everyone with the same brush or experience you had.
PS, painkillers are the worst thing for back pain, you are just prolonging and making the base problem worse by using the muscles when the body says dont with pain.
Lets just say that osteopathy is based on little more than wishful thinking and the vast majority of the results it gets is placebo (I know it’s not and I know it has massive benefits to many people).
What is so massively wrong with this? Sports performance coaching and life coaching I’m sure we can all agree benefit many people in big ways. There is no better research proving these to be ‘real’ than there is osteopathy.
If someone is getting massive benefits from a certain treatment or therapy then let them do it and let the public benefit.
it is cheating patients out of important specific therapeutic effects – you don’t need placebos to generate placebo-effects!
“it is cheating patients out of important specific therapeutic effects”
The tough thing with massage, physical therapy, occupational therapy, or any other type of physical modality, is that so much is based on patient feedback, and since pain is felt in different ways by different people that’s always going to challenge the repeatability of success of a given treatment. Then you throw psychosomatic issues into the mix and it’s a whole different ballgame. This all makes it a challenge for both the practitioner trying to find methods that can be applied with reliable results, and the researcher trying to make sense of it all.
“you don’t need placebos to generate placebo-effects!”
True, though it seems like it would be much easier to judge the effectiveness of a treatment versus a control.
@James White on Wednesday 14 December 2016 at 09:30
James has declared his interest by including a link, however, I do wish the interest were disclosed more openly and forthrightly; he is an osteopath who founded this clinic; http://www.taunton-chiropractic-osteopathy.com/
What is not disclosed, on initial viewing of the website, is that the chiro part is premised on treatment on that aspect of chiro which has eluded chiro, and everyone else, for nearly 122 years – the mystical and mythical subluxation. Scrolling down the page, there is a video which links to; http://haavikresearch.com/
and this, about the principal;
“Dr Heidi Haavik is a chiropractor and a neurophysiologist who has worked in the area of human neurophysiology for over 15 years. Heidi has a PhD in human neurophysiology from the University of Auckland. Her work has been instrumental in building the base of scientific evidence demonstrating the efficacy of chiropractic care in improving people’s health and wellbeing.”
Well prof, there it is; (pretend doctor) Heidi has evidence, not only of the efficacy of chiro, but of the existence of the SUBLUXATION. After all this time and you still haven’t found one tiny skerrick of its existence.
“Lets just say that osteopathy is based on little more than wishful thinking and the vast majority of the results it gets is placebo (I know it’s not and I know it has massive benefits to many people).”
James falls into the classic error and doesn’t realise his word is of not weight at all. From the website, he doesn’t confidence and self-assuredness, so he must be right?
“What is so massively wrong with this? Sports performance coaching and life coaching I’m sure we can all agree benefit many people in big ways. There is no better research proving these to be ‘real’ than there is osteopathy.”
More logical fallacies, but James forges ahead with his misplaced self-confidence.
“If someone is getting massive benefits from a certain treatment or therapy then let them do it and let the public benefit.”
What, more fallacies? Yet another fallacy.
The common thread through posts from chiros and osteos is a lack of understanding of what constitutes evidence and that logical fallacies do not constitute anything. Sorry James, it is no wonder you couldn’t get into a real medical course; you just aren’t very bright.
@ James White….”Lets just say that osteopathy is based on little more than wishful thinking and the vast majority of the results it gets is placebo”
I think you are talking about homeopathy not osteopathy, and I concur having done a course of Homeopathy for a swollen knee.
@ Paul Kerry on Tuesday 10 January 2017 at 17:43
No, he was talking about osteopathy.
@ Frank Collins “No, he was talking about osteopathy”
I know, that’s why i opened with the word “Osteopathy”.
Frank….can you explain to me why the British NHS is now slowly adopting Osteopathy as part of complimentary and alternative treatments and Doctors surgeries around the country are now able to recommend Osteopaths instead of banning them from all conversations and some doctors are able to refer patients to an osteopath for treatment funded by the NHS.
Is this a step backward for western medicine or part of a national recognition of a science that has evidence to prove its worth and effect on muscular and skeletal pain ?
Would the NHS really fund a practice that you view as a placebo or unscientific ? as for having no scientific basis then maybe you should see what is involved in becoming an Osteopath, how different in terms of basis in the practical sciences it is to becoming, say, a forensic pathologist…..used to help prove guilt or innocence in a court of law ?
“Courses generally lead to a bachelor’s degree in Osteopathy (a BSc Hons, BOst or BOstMed) or a masters degree (MOst). Courses usually consist of four years of full-time training, five years part-time or a mixture of full or part-time. There are also courses with accelerated pathways for doctors and physiotherapists.
A degree course includes anatomy, physiology, pathology, pharmacology, nutrition and biomechanics, plus at least 1,000 hours of clinical training. Then there follows a 4 year program to complete Osteopathic Medical School, during which there a 3 levels of licensure to complete. Residency for Internship follows which can take 3 – 5 years by speciality. Once board certification is awarded, Osteopathic doctors are required to meet various certification renewal mandates”.
We can all generalise about a practice and then pick holes in it, there is nothing in science that is finite and one analogy towards this is that no scientist can describe how electricity is formed, only that we know it works and we can use it to our own advantage and usefulness, but do not know its origin.
The only problems that I see with this post are that it takes no account of heterogeneity of osteopaths and it lacks a comparison with the only alternative, physiotherapists (I don’t count chiropractors as an alternative). I’d choose a physiotherapisy over an osteopath in general. But if I found the physiotherapist pushed acupuncture (as too many so), I’d certainly prefer a good osteopath, as long, of course, as they weren’t the sort of osteopath who sells the utterly barmy craniosacral nonsense.
Both physiotherapy and osteopathy have weak evidence bases. Both jobs are divided into good practitioners who recognise that, and bad practitioners who clutch at straws like acupuncture (for physios) or craniosacral (osteopaths). I suspect that it makes little difference whether you go to a physiotherapist or to an osteopath as long as they are the sort who do their best to take notice of what evidence there is. The treatment is likely to be essentially the same (whether it works or not is a different question).
@David Colquhoun on Friday 13 January 2017 at 19:37
The substantial difference is that one is aligned to science and medicine, while the other is not.
I can’t agree entirely with that. For example, many physios offer acupuncture -certainly not aligned with science or medicine. And some osteopaths stick quite closely to what little evidence exists. I suggest that the big variability is between practice, not between job labels.
Keep it simple folks and look to see what the info arising from the neurosciences, epigenetics, genetics and social sciences are telling us.
Consider, unless I am mistaken, the absence of reference to clinical disciplinary names in the latest issue from NICE for back pain and sciatica. Yes, in reality a sub-group, but a large one!
Then there is the problem of personal comfort zones and the reluctance of too many clinicians and academics to look beyond them for the benefit of the patient.
My regards to all.
@Greg Sharp on Sunday 05 March 2017 at 16:17
“Keep it simple folks and look to see what the info arising from the neurosciences, epigenetics, genetics and social sciences are telling us.”
Apart from bad English, what is being told? As it seems to have eluded the prof, I’d suggest not much. By-the-way, why didn’t you declare upfront that you are an osteo?
There is no such this as bad “English”, it’s bad grammar- numpty!
lol I suggest if you wish criticise another’s gramnar, don’t do it with bad grammar.
Is that trite reply because you support ostenonsense but have norhing in the form of evidence?
“Numpty”.
It was for someone else’s attention and not yours in particular. Sorry to take up your time.
Dear all and especially the original author ,
I apologise if this has already been covered – there are many posts here and i havnt the time to read them all.
I live in London in the UK , Im 32 yrs old and I am a graphic designer and claim no knowledge in the areas you discuss.
Before any one forms any opinions In my message below i am not about to attack OR defend osteopathy or traditional medicine or any field. I have had positive and negative experiences in solving my pain problems from various parties. i am asking questions and i am interested in the responses of both sides of this argument.
I am someone with a couple of regular what i understand to be ‘muscular-skeleto’ issues (forgive me if I am using wrong term – I should say in lay terms – painful muscular injuries, most commonly only painful during and after physical activity ) some more painful than others and others just more restricting. Most Notably an ongoing issue with my knees that appears to be interconnected with lower back pain and pain in my ‘girdle’ area around hips etc – and also more recently a shoulder/’rotator cuff’ area issue, now recurring for the second time with some slight variation in the issue.
I have also had numerous other non recurring injuries.
I’ve had these because I do a variety of sports – often changing my sporting practice because an injury has prevented me from continuing the previous any further. These have included kung fu, swimming, rock climbing, basketball, cycling and squash and yoga. Sometimes little forays into other things but mainly these.
I seem to be very prone to injury – not traumatic accidents , bumps and bruises etc but pain in the knees after running, stiff shoulders, jammed up muscles etc… The kind of stuff osteopaths, Physios etc claim to treat.
Out of desperation i discovered osteopathy about 7 years ago having received some ineffective NHS physiotherapy for a knee problem i developed studying kung-fu in china about 4 years prior.
I have had numerous treatments. Some successful , some less so, some seemingly temporarily resolving the issue.
Primarily I have visited osteopaths. And I have seen a number of different osteopaths – sometimes changing because i felt their work ineffective , other times raving to my friends about how effective the treatment has been.
In that time i have come to observe that each can have his/her own approach which i have tried to understand from a laymans perspective, asking questions and so forth. It is wroth noting one of my osteopaths is in fact a GP, that i have seen extremely expensive practitioners and some much cheaper, some with big reputations, others less well known.
In this time i found i was tempted towards different practitioners for different types of issues i felt them better equipped to deal with. As i mentioned – there have been times I’ve been unsatisfied and times i have been treated well.
As you have probably guessed, i have spent a vast amount of money on this now, and frankly, i cannot afford it.
My knee problem has prevented me from running now for about 7 years, conversely i seem to be able to play basketball with almost complete impunity from the same knee pain – it has been suggested it the repeat action of running is what agitates it so much, so i altered my running practice to short sprints and slow jogs in constantly changing directions, interspersed with various jumps. Yes i looked like a complete nutcase doing this in the park and no it didn’t make a difference. My personal belief here is that its a psychological issue and that i am hyper aware of my problem and constantly consider it whilst running , whereas in basketball my mind is fully occupied on the game and my knees do their thing more naturally.
Also worth noting – I am a naturally very flexible person in most areas , though the lower back/hip/girdle issue I discussed (the other major ongoing issues – again seemingly interconnected with my knees – costs me flexibility in some areas.I also have a good practice of warming up and stretching etc before practice. I say this because im aware that lots of injuries are cause my badly warmed up muscles and low flexibility.
I know this all quite boring so far – again please bear with me.
My shoulder injury was initially caused rock climbing, i was at my topmost level, in great shape and pushing my personal boundaries – i spent a session trying to complete a certain route, 3 hours going back to the same bit, getting to the ‘crux’ of the route and attempting to complete the required move to get to the next point in my route. I failed, felt fine, I had a good sessions and went home. In the following week the injury appeared, pain, bunching up, horrible restrictive clicks on rotation and became extreme if i tried anything stressful and i was unable to practice. I rested my arms for about two months and did very light stretching . Nothing. No progress. So i started seeing osteopaths again (including people i had found very good previously), spending lots of time and money on expensive treatments with weeks in between each .Eventually i found one guy ( A student actually) whose treatment seemed most effective. 5 months it took to rehabilitate the shoulder from that point with some clicks and adjustments and lots of very intense massage type treatment to my pectoral muscles and my biceps and around various points on the shoulder and most importantly some theraband work and light exercises he gave me. It has never been quite perfect again but i have been able to do sports.
In this time , as my knees will only allow to do very limited activities (basketball and swimming being the only cardio-beneficial sports i can safely practice now) and all of which required my arms… i was unable to any sport or keep fit as i cant run – the only thing that doesnt require arms . Sport is what keeps me sane and positive and away from anxiety and depression – needless to say this year was no fun.
So my current situation is this.. my shoulder injury has returned,its a little different than previously but def related.
No specific incident seems to have caused this (though perhaps inactivity as i stopped most exercise for a few months – i wont go into the reasons). The shoulder injury is so bad i cannot swim, play basketball, rock climb – i cannot even play table tennis with sudden extreme pain on certain movements and as above i cannot run.
I immediately started seeing an osteopath (the same guy not available as hes moved to another city). Ive been to four treatments, the massage feels great, i feel slightly better for a few days and then im back to normal and stiffness with no notable improvement. Ive spent £260 now and im no better. Im broke as it is and cant continue like this and i cant bear another year like the one described. I have an expensive surf and yoga holiday booked happening in less than two months. And Id like to be able to do it!
Now – like previously I am starting to question osteopathy – yes it has worked for me, other times it hasnt.
Often i have spent vast amounts of cash across a bunch of people trying different things, sticking with them for a while to give them a chance and moving on. I imagine through time and the right person and the right exercises being given and treatments being made and restraint on behalf from agitating it with the sports i enjoy that it will eventually be fixed again. But I might be a year older by then, out of shape (again due to injury) and taking up the next step down in terms of a sport than my body can handle instead of enjoying improving in doing what i love.
Previously Ive seen a very nice osteopath who stated very clearly on hearing my story , before i have mentioned anything about cash – that she wanted to avoid me spending lots, that its not necessary – she even dropped her price without me asking – very generous of her. I had seen her previously about one problem (for which she was incredibly effective – almost magician like.) but for that treatment and for all her generosity it amounted to nothing and i moved on.
Needless to say i have spoken to my GP numerous times over the years – his contributions are next to useless.
My position is this :
I get injuries, they make my life hard and i try to resolve them. Im happy to spend good money on good treatment . I don’t care if its from an osteopath a Chiro, a GP, a physio or a wizard – as long as it works – im also aware that rehab can take time and im willing to put the work in.
I believe in scientific approaches and i do my best to understand them, and i naively convince myself that it do.
As a lay person the jargon of osteopathy convinced me to try it.
Various positive treatments from various people have convinced me of its potential to be effective – pseudoscience or not i have had good experiences. However I have also have many, many ineffective expensive treatments for varying issues from the SAME people. Ive rooted out some good ones , honest people i believe genuinely not after my money (some even free) and and a few with very strong reputations – these are people who treat olympians (including usain bolt).
My questions:
Mr Author (edzard) –
a. What do you say to my positive experiences ? Please dont say luck
b. What is your suggestion as a non believer ? Who do i turn to if not these practitiners – my GP seems to be able to do little. Please give me some options! I Welcome your input
C. Thoughts on cortisone steroid injection as a part solution now?
d. Thoughts on my money spent on the ineffective treatments?
To the osteopaths here
A. is it fair i spend this money on ineffective treatments – if my builder did not build my wall i would not pay him and it would stand in a court of law. Yes the body is more complex than a wall and my recurring issues are clearly complex ones – even for these top osteopaths have said so themselves. But surely there should be some option for me to decline payment. I like these guys, i don’t want to take liberties and i’m not an “ill sue you!” kinda guy.
I’m reasonable and i don’t want to deny anyone their income for their hard efforts – but surely there is a line i can draw.
I am in some debt and to be honest what i have spent on treatment in 7 years amounts to about exactly the amount i’m in debt. I blame no-one but myself for this but its frustrating to know that money could have gone onto my credit cards.
B. Thoughts on a cortisone treatment ?
C. Suggested next steps?
D. Any London based osteopaths willing to put their money where their mouth is and offer a money back guarantee?
As i’ve said – i do believe in the potential effectiveness of osteopathy – especially for simpler problems but it seems
inconsistent and i think people spending money should have protections.
Thankyou for reading this lengthy message!
I hope it promotes some positive discussion
William
William, I can only advise you to treat Osteopathy (Acupuncture, Chiropractic, Homeopathy etc) a complimentary procedure in tandem with normal medical practices and treatment. You may find benefit from using two or three different approaches as both precautionary and immediate treatment to ease your problems.
Paul is right, as Osteopathy will help to overcome the cause of the pain and will give long lasting relief… i myself works a long time of compauter and had back pain, after getting obsessed with medicines, i turned towards an osteopath which was proved quite beneficial for me…
https://edzardernst.com/2012/11/what-is-and-what-isnt-clinical-evidence-and-why-is-the-distinction-important/
In the Most forms of therapy for CNSLBP have problems. Consider for example Lederman’s paper on the Myth of Core Stability an approach which is used extensively by most professions including osteopaths and physiotherapists. But I love this forest row osteopath from clinic at bordehill’s Osteopathy service’s because they are really helpful and friendly also love your awesome guidance about Osteopath.