MD, PhD, MAE, FMedSci, FRSB, FRCP, FRCPEd.

Osteopathy is a form of manual therapy invented by the American Andrew Taylor Still (1828-1917). Today, US osteopaths (doctors of osteopathy or DOs) practise no or little manual therapy; they are fully recognised as medical doctors who can specialise in any medical field after their training which is almost identical with that of MDs. Outside the US, osteopaths practice almost exclusively manual treatments and are considered alternative practitioners. This post deals with the latter category of osteopaths.

Still defined his original osteopathy as a science which consists of such exact, exhaustive, and verifiable knowledge of the structure and function of the human mechanism, anatomical, physiological and psychological, including the chemistry and physics of its known elements, as has made discoverable certain organic laws and remedial resources, within the body itself, by which nature under the scientific treatment peculiar to osteopathic practice, apart from all ordinary methods of extraneous, artificial, or medicinal stimulation, and in harmonious accord with its own mechanical principles, molecular activities, and metabolic processes, may recover from displacements, disorganizations, derangements, and consequent disease, and regained its normal equilibrium of form and function in health and strength.

Based on such vague and largely nonsensical statements, traditional osteopaths feel entitled to offer treatments for most human diseases, conditions and symptoms. The studies they produce to back up their claims tend to be as poor as Still’s original assumptions were fantastic.

Here is an apt example:

The aim of this new study was to study the effect of osteopathic manipulation on pain relief and quality of life improvement in hospitalized oncology geriatric patients.

The researchers conducted a non-randomized controlled clinical trial with 23 cancer patients. They were allocated to two groups: the study group (OMT [osteopathic manipulative therapy] group, N = 12) underwent OMT in addition to physiotherapy (PT), while the control group (PT group, N = 12) underwent only PT. Included were postsurgical cancer patients, male and female, age ⩾65 years, with an oncology prognosis of 6 to 24 months and chronic pain for at least 3 months with an intensity score higher than 3, measured with the Numeric Rating Scale. Exclusion criteria were patients receiving chemotherapy or radiotherapy treatment at the time of the study, with mental disorders (Mini-Mental State Examination [MMSE] = 10-20), with infection, anticoagulation therapy, cardiopulmonary disease, or clinical instability post-surgery. Oncology patients were admitted for rehabilitation after cancer surgery. The main cancers were colorectal cancer, osteosarcoma, spinal metastasis from breast and prostatic cancer, and kidney cancer.

The OMT, based on osteopathic principles of body unit, structure-function relationship, and homeostasis, was designed for each patient on the basis of the results of the osteopathic examination. Diagnosis and treatment were founded on 5 models: biomechanics, neurologic, metabolic, respiratory-circulatory, and behaviour. The OMT protocol was administered by an osteopath with clinical experience of 10 years in one-on-one individual sessions. The techniques used were: dorsal and lumbar soft tissue, rib raising, back and abdominal myofascial release, cervical spine soft tissue, sub-occipital decompression, and sacroiliac myofascial release. Back and abdominal myofascial release techniques are used to improve back movement and internal abdominal pressure. Sub-occipital decompression involves traction at the base of the skull, which is considered to release restrictions around the vagus nerve, theoretically improving nerve function. Sacroiliac myofascial release is used to improve sacroiliac joint movement and to reduce ligament tension. Strain-counter-strain and muscle energy technique are used to diminish the presence of trigger points and their pain intensity. OMT was repeated once every week during 4 weeks for each group, for a total of 4 treatments. Each treatment lasted 45 minutes.

At enrolment (T0), the patients were evaluated for pain intensity and quality of life by an external examiner. All patients were re-evaluated every week (T1, T2, T3, and T4) for pain intensity, and at the end of the study treatment (T4) for quality of life.

The OMT added to physiotherapy produced a significant reduction in pain both at T2 and T4. The difference in quality of life improvements between T0 and T4 was not statistically significant. Pain improved in the PT group at T4. Between-group analysis of pain and quality of life did not show any significant difference between the two treatments.

The authors concluded that our study showed a significant improvement in pain relief and a nonsignificant improvement in quality of life in hospitalized geriatric oncology patients during osteopathic manipulative treatment.

GOOD GRIEF!

Where to begin?

Even if there had been a difference in outcome between the two groups, such a finding would not have shown an effect of OMT per se. More likely, it would have been due to the extra attention and the expectation in the OMT group (or caused by the lack of randomisation). The A+B vs B design used for this study  does not control for non-specific effects. Therefore it is incapable of establishing a causal relationship between the therapy and the outcome.

As it turns out, there were no inter-group differences. How can this be? I have often stated that A+B is always more than B alone. And this is surely true!

So, how can I explain this?

As far as I can see, there are two possibilities:

  1. The study was underpowered, and thus an existing difference was not picked up.
  2. The OMT had a detrimental effect on the outcome measures thus neutralising the positive effects of the extra attention and expectation.

And which possibility does apply in this case?

Nobody can know from these data.

Integrative Cancer Therapies, the journal that published this paper, states that it focuses on a new and growing movement in cancer treatment. The journal emphasizes scientific understanding of alternative and traditional medicine therapies, and the responsible integration of both with conventional health care. Integrative care includes therapeutic interventions in diet, lifestyle, exercise, stress care, and nutritional supplements, as well as experimental vaccines, chrono-chemotherapy, and other advanced treatments. I feel that the editors should rather focus more on the quality of the science they publish.

My conclusion from all this is the one I draw so depressingly often: fatally flawed science is not just useless, it is unethical, gives clinical research a bad name, hinders progress, and can be harmful to patients.

10 Responses to A new osteopathy trial – I think, it might the worst bit of research in 2018 so far

  • Still was a hospital servant during the Civil War. Later he did a course in millery and was listed in tve census as a “mechanic”. Later in 1874 he advertised as “magnetic healer” and later as “lightning bone-setter”. He called himself a doctor of drugless healing. He was the first to develop a public teaching system for bone-setting which was a family tradition before. Therefore he mixed up this old tradition with vitalisric and istromechanistic explanations. Two days after his father died he became a member of the local lodge of free masonry with a one vote majority only. All his explanations are based on the theories of drugless healing which spread all over the western societies with the first industrial revolution. There is still a huge movement amongst US osteopathic physician’s profession which doesn’t accept any critical comments or research in osteopathic history. It would be a catastrophy for the profession to publish the truth about its founder as they just renamed and upgradet the leading osteopathic medical college into A.T. Still University.

  • How the blazes did they get that passed an ethics committee? An N = 21 study alone should have disqualified it.

  • Osteopath or not- it is your knowledge and understanding of anatomy, physiology and how to put it all together to help promote health in a patient that we should stayed focused on. Osteopathy has helped countless amounts of people where other therapies have fallen short. Take what you will with a grain of salt however Osteopathy is a beautiful art that takes many years of experience and clinical application to understand it’s true grace and finesse to practice the way it was intended to. Jealously of those without the gift of sight through their hands, heart and spirit will always make noise to disregard something they can not comprehend. Alas, may all beings be blessed and find happiness in this wonderfilled life!

  • Our study didn’t show any benefit of osteopathy but we wanted a positive conclusion so we just wrote one anyway.

  • I think that you (and others in the skeptic community) overcredit American DO’s. Their ranks are as rife with quacks who heartily embrace the woo parts that remain in the newer DO training as the MD’s. My clinic, a large regional academic medical center in the heartland, has little brochures in the office of the DO I once saw when my own internist was on leave which go on and on with lots of alt-med rubbish about “treating the whole person” and “hands on manipulation”. Many DO’s advertise in media associated with alt-med (such as the health food stores newsletters) in which they tout their special manipulative skills and various other typical woo modalities.They also have a presence on YouTube where, again, they lean heavily to alt med. I don’t know the percentage of them that indulge in this, or if it is higher than with MD’s, but I think it’s important to not give them a pass just the same.

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