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

Today, several UK dailies report about a review of osteopathy just published in BMJ-online. The aim of this paper was to summarise the available clinical evidence on the efficacy and safety of osteopathic manipulative treatment (OMT) for different conditions. The authors conducted an overview of systematic reviews (SRs) and meta-analyses (MAs). SRs and MAs of randomised controlled trials evaluating the efficacy and safety of OMT for any condition were included.

The literature searches revealed nine SRs or MAs conducted between 2013 and 2020 with 55 primary trials involving 3740 participants. The SRs covered a wide range of conditions including

  • acute and chronic non-specific low back pain (NSLBP, four SRs),
  • chronic non-specific neck pain (CNSNP, one SR),
  • chronic non-cancer pain (CNCP, one SR),
  • paediatric (one SR),
  • neurological (primary headache, one SR),
  • irritable bowel syndrome (IBS, one SR).

Although with different effect sizes and quality of evidence, MAs reported that OMT is more effective than comparators in reducing pain and improving the functional status in acute/chronic NSLBP, CNSNP and CNCP. Due
to the small sample size, presence of conflicting results and high heterogeneity, questionable evidence existed on OMT efficacy for paediatric conditions, primary headaches and IBS. No adverse events were reported in most SRs. The methodological quality of the included SRs was rated low or critically low.

The authors concluded that based on the currently available SRs and MAs, promising evidence suggests the possible effectiveness of OMT for musculoskeletal disorders. Limited and inconclusive evidence occurs for paediatric conditions, primary headache and IBS. Further well-conducted SRs and MAs are needed to confirm and extend the efficacy and safety of OMT.

This paper raises several questions. Here a just the two that bothered me most:

  1. If the authors had truly wanted to evaluate the SAFETY of OMT (as they state in the abstract), they would have needed to look beyond SRs, MAs or RCTs. We know – and the authors of the overview confirm this – that clinical trials of so-called alternative medicine (SCAM) often fail to mention adverse effects. This means that, in order to obtain a more realistic picture, we need to look at case reports, case series and other observational studies. It also means that the positive message about safety generated here is most likely misleading.
  2. The authors (the lead author is an osteopath) might have noticed that most – if not all – of the positive SRs were published by osteopaths. Their assessments might thus have been less than objective. The authors did not include one of our SRs (because it fell outside their inclusion period). Yet, I do believe that it is one of the few reviews of OMT for musculoskeletal problems that was not done by osteopaths. Therefore, it is worth showing you its abstract here:

The objective of this systematic review was to assess the effectiveness of osteopathy as a treatment option for musculoskeletal pain. Six databases were searched from their inception to August 2010. Only randomized clinical trials (RCTs) were considered if they tested osteopathic manipulation/mobilization against any control intervention or no therapy in human with any musculoskeletal pain in any anatomical location, and if they assessed pain as an outcome measure. The selection of studies, data extraction, and validation were performed independently by two reviewers. Studies of chiropractic manipulations were excluded. Sixteen RCTs met the inclusion criteria. Their methodological quality ranged between 1 and 4 on the Jadad scale (max = 5). Five RCTs suggested that osteopathy compared to various control interventions leads to a significantly stronger reduction of musculoskeletal pain. Eleven RCTs indicated that osteopathy compared to controls generates no change in musculoskeletal pain. Collectively, these data fail to produce compelling evidence for the effectiveness of osteopathy as a treatment of musculoskeletal pain.

It was published 11 years ago. But I have so far not seen compelling evidence that would make me change our conclusion. As I state in the newspapers:

OSTEOPATHY SHOULD BE TAKEN WITH A SIZABLE PINCH OF SALT.

 

 

6 Responses to Osteopathic manipulative treatment: an overview of the evidence

  • I noted a Dail Mail review of this BMJ-online piece – and it referred to a DM article some years back which I had not seen before. (November 2019.)
    It covered the arrest of an osteopath whose patient Mr John Lawler had sadly died.
    He was known to have ankylosing spondylitis, had already had stabilisation surgery and yet the chiropractor used a ‘drop table’ on his cervical spine.

    The ‘Dr’ was subsequently exonerated by the GCC who accepted the ‘expert’ evidence of a chiropractor who had no experience of spinal surgery.

    Prof Ernst’s opinions were referred to in that article, but DM also persistently referred to the chiropractor as being “Dr Arleen Scholten”. And that’s the problem with ‘ostepathy’, it lacks integrity: scientific, professional, ethical.

    Osteopathy was founded by a A. T. Still, a US Army medical orderly who had not received any medical school training (unlike his father). Still had an idea that pathology could be obviated by improving the blood flow to parts, which in turn could be improved by spinal manipulations – as he had been taught by alternative healer Paul Caster.
    Osteopathy is now largely absorbed into mainstram US medical practice – in the UK we expect all practitioners claiming to be ‘doctors’ (in healthcare) to have qualifications registerable by the GMC. Osteopaths do not. (Simone Biles and the US gymnastic team’s ‘doctor’ was a DO, not MD.)

    I have never had an answer from an osteopath as to why they took up with osteopathy and not chiropractic, physiotherapy, or medicine – but this is why ‘ostepathy’ is an ‘alternative medicine’ – it is practised by alternative practitioners who have alternative concepts of pathology and physiology – and of professional practice.

  • Given that Osteopathy is so prevalent and readily accessible in the Uk, a result of “ promising evidence suggests the possible effectiveness of OMT for musculoskeletal disorders.” is somewhat disturbing.

  • in order to obtain a more realistic picture, we need to look at case reports, case series and other observational studies.

    What adverse effects from OMT have been reported in those sources?

  • As you said there are many issues here. One that stands out for me is that osteopaths continue to think that their approach (OMT) is somehow special or different when compared with manual therapy performed by e.g. a chiropractor or physiotherapist. With the exception of cranial osteopathy and visceral osteopathy, both of which are complete nonsense, I don’t believe there is anything “special” about the manual therapy performed by osteopaths. They use manipulations, mobilisations, etc in a similar way to other professions. It therefore makes no sense that they only searched for trials where the manual therapy was performend by osteopaths because this is not materially different to those trials where the manual therapy was carried out by another type of professional.

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