Monthly Archives: November 2022
This study described osteopathic practise activity, scope of practice and the osteopathic patient profile in order to understand the role osteopathy plays within the United Kingdom’s (UK) health system a decade after the authors’ previous survey.
The researchers used a retrospective questionnaire survey design to ask about osteopathic practice and audit patient case notes. All UK-registered osteopaths were invited to participate in the survey. The survey was conducted using a web-based system. Each participating osteopath was asked about themselves, and their practice and asked to randomly select and extract data from up to 8 random new patient health records during 2018. All patient-related data were anonymized.
The survey response rate was 500 osteopaths (9.4% of the profession) who provided information about 395 patients and 2,215 consultations. Most osteopaths were:
- self-employed (81.1%; 344/424 responses),
- working alone either exclusively or often (63.9%; 237/371),
- able to offer 48.6% of patients an appointment within 3 days (184/379).
Patient ages ranged from 1 month to 96 years (mean 44.7 years, Std Dev. 21.5), of these 58.4% (227/389) were female. Infants <1 years old represented 4.8% (18/379) of patients. The majority of patients presented with musculoskeletal complaints (81.0%; 306/378) followed by pediatric conditions (5%). Persistent complaints (present for more than 12 weeks before the appointment) were the most common (67.9%; 256/377) and 41.7% (156/374) of patients had co-existing medical conditions.
The most common treatment approaches used at the first appointment were:
- soft-tissue techniques (73.9%; 292/395),
- articulatory techniques (69.4%; 274/395),
- high-velocity low-amplitude thrust (34.4%; 136/395),
- cranial techniques (23%).
The mean number of treatments per patient was 7 (mode 4). Osteopaths’ referral to other healthcare practitioners amounted to:
- GPs 29%
- Other complementary therapists 21%
- Other osteopaths 18%
The authors concluded that osteopaths predominantly provide care of musculoskeletal conditions, typically in private practice. To better understand the role of osteopathy in UK health service delivery, the profession needs to do more research with patients in order to understand their needs and their expected outcomes of care, and for this to inform osteopathic practice and education.
What can we conclude from a survey that has a 9% response rate?
Nothing!
If I ignore this fact, do I find anything of interest here?
Not a lot!
Perhaps just three points:
- Osteopaths use high-velocity low-amplitude thrusts, the type of manipulation that has most frequently been associated with serious complications, too frequently.
- They also employ cranial osteopathy, which is probably the least plausible technique in their repertoire, too often.
- They refer patients too frequently to other SCAM practitioners and too rarely to GPs.
To come back to the question asked in the title of this post: What do UK osteopaths do? My answer is
ALMOST NOTHING THAT MIGHT BE USEFUL.
Camilla spent ten days at the end of October in a sophisticated meditation and fitness center in southern India. Life has recently been hectic for the Queen Consort: at 75, she has been in a non-stop succession of various ceremonies for the funeral of Elizabeth II, always one step behind her husband, not to mention her new status as sovereign… Enough to block her chakras in no time.
She came to the resort with her bodyguards and a handful of friends and was able to take advantage of the tailor-made treatments concocted for her by the master of the house, Dr Issac Mathai, who created this high-end holistic centre on a dozen hectares of scented gardens near Bangalore. The program includes massages, herbal steam baths, yoga, naturopathy, homeopathy, meditation, and Ayurvedic treatments to “cleanse, de-stress, soothe and revitalize the mind, body and soul”, as the establishment’s website states.
Guests are required to follow an individualized, meat-free diet, with organic food from the resort’s vegetable gardens, based on lots of salads or soups – Camilla is said to be a fan of sweet corn soup with spinach. Cigarettes and mobile phones are not allowed, although it is assumed that Camilla must have some privileges due to her status… and the basic rate for the suites, which starts at $950 a night – the price of the rooms varies between $260 and $760, the rate including a consultation with the doctors.
Charles and Camilla have been fans of the Soukya Centre in India for a decade. The place corresponds in every way to their deep-rooted convictions about health. Like her husband, Camilla is a follower of organic food, she also practices yoga and treats her face with creams made from nettle and bee venom. For his part, Charles has long been an advocate of alternative medicine, homeopathy, acupuncture, aromatherapy, and also hypnosis… He even set up a foundation to support complementary medicine by lobbying the British health service to include it in complementary therapies for certain patients, which caused an uproar among the pundits of traditional medicine.
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If you suspected I was (yet again) sarcastic about the royal couple, you are mistaken. The text above is only my (slightly shortened) translation of an article published in the French magazine LE POINT (even the title is theirs). I found the article amusing and interesting; so, I looked up the Indian health center. Here are some of the things I found:
The 1st impression is that they are not shy about promotion calling themselves THE WORLD’S BEST AYURVEDA TREATMENT CENTER. The doctor in charge was once a ‘Consultant Physician’ at the Hale Clinic in London, where he treated a number of high-profile people. As his professional background, he offers this:
M.D. (Homeopathy); Hahnemann Post-Graduate Institute of Homeopathy, London M.R.C.H, London; Chinese Pulse Diagnosis and Acupuncture, WHO Institute of Traditional Chinese Medicine, Nanjing, China; Trained (Mind-Body Medicine Programme) at Harvard Medical School, USA
The approach of the center is described as follows:
The fundamental principle underlying Holistic Treatment is that the natural defense and immune system of an individual when strengthened, has the potential to heal and prevent diseases. In the age of super-specialisation where human beings are often viewed as a conglomeration of organs, it is crucial to understand ourselves as multi-dimensional beings with a body, mind and spirit. These interconnected dimensions need to be in perfect harmony to ensure real well-being.
And about homeopathy, they claim this:
Homeopathy originated in 1796 in Germany, and was discovered by Dr. Samuel Hahnemann, a German scientist. Homeopathy is popular today as a non-intrusive, holistic system of medicine. Instead of different medicines for different parts of the body, one single constitutional remedy is prescribed. As a system of medicine, Homeopathy is highly scientific, safe, logical and an extremely effective method of healing. For over 200 years people have used Homeopathy to maintain their good health, and also to treat and cure a wide range of illnesses like allergies, metabolic disorders, atopic dermatitis, Rheumatoid arthritis, Auto-immune disorders.
At this stage, I felt I had seen enough. Yes, you are right, we did not learn a lot from this little exploration. No, hold on! We did learn that homeopathy is highly scientific, safe, logical, and extremely effective!
The question, however, is should we believe it?
Shiatsu is a Japanese form of so-called alternative medicine (SCAM) derived from Traditional Chinese Medicine using deep pressure on the paths of the postulated acupuncture meridians. Clinical observations on this topic are said to be encouraging, especially for the treatment of sleep and conduct disorders, but there is a lack of empirical data.
The objective of this study was to examine the possible therapeutic effects of shiatsu in a clinical population of children treated in child and adolescent psychiatry. It was designed as a qualitative descriptive and non-interventional study, conducted on children treated in day-care hospital units and outpatient clinical settings. Shiatsu was administered, at least during 3 sessions, to children with an autism spectrum disorder or other disorders according to ICD-11 criteria (such as conduct disorders with impulsivity or attention deficit).
The evaluation was performed by two independent researchers (a child psychiatrist and a psychologist who were not the caregivers) based on direct observation of children during the shiatsu sessions, combined with semi-structured non-inductive interviews with their parents, and data collected from focus groups conducted with the children’s caregivers. A phenomenological interpretive analysis (IPA) approach with Nvivo coding software was used to analyze the data.
Based on semi-structured interviews with 13 parents cross-referenced with data from 2 focus groups and direct observations of 7 children during 2 full shiatsu sessions for each observation, the results show that shiatsu has positive effects on
- internal tension (a relief effect, notably on aggressive behaviors directed against others or self),
- sleep (including improvement of sleep quality),
- social interaction,
- attention,
- verbalization of affects and traumatic memories of early childhood,
- perception of bodily limits.
As these children had several other treatments as well, it cannot be proved that the positive effects observed in this study are related specifically to shiatsu practice. Shiatsu may participate and facilitate the effects of other treatments. It is noteworthy that most of the children came willingly to the shiatsu sessions, ask their parents to repeat the shiatsu sessions at home, and indicate to the practitioner, from one session to the next, their elective body points where they wish to receive the application of shiatsu.
The authors concluded that the findings suggest therapeutic benefits of shiatsu, especially on externalize violence with a relief of aggressive behavior directed against others or self (knowing, moreover, that internal tension, sleep disorders and non-verbalization of affects or traumatic memories, all improved by shiatsu, are also all risk factors for externalize violence). These results highlight, therefore, the need to develop a daily practice of shiatsu in child and adolescent psychiatry. Further research is required to clarify the effects of shiatsu and ascertain better its underlying mechanisms based on this exploratory pilot study.
I do appreciate that, with a treatment that has not been submitted to many controlled clinical trials, researchers feel that they have to start from scratch, e.g. simple observations. However, they also must realize that their observations do not lend themselves to firm conclusions about the effects of the treatment. In the present case, the researchers do seem to be aware of this caveat but nevertheless make statements that go way beyond of what is warranted:
- the results show that shiatsu has positive effects on …
- Shiatsu may participate and facilitate the effects of other treatments
- the findings suggest therapeutic benefits of shiatsu, especially on externalize violence
- These results highlight, therefore, the need to develop a daily practice of shiatsu in child and adolescent psychiatry
I fear that these statements are not merely exaggerated but suspect they are also untrue. Testing them in properly controlled clinical trials would show whether my suspicion is correct. Meanwhile, I would like to remind
- researchers,
- reviewers,
- and journal editors
of their duty to be truthful and not mislead the public.
I was fascinated to find a chiropractor who proudly listed ‘the most common conditions chiropractors help kids with‘:
- Vision problems
- Skin conditions
- Bedwetting
- Sinus problems
- ADD/ADHD
- Stomachaches
- Asthma
- Allergies
- Loss of hearing
- Ear Infections
- Hip, leg, or foot pain
- Constipation
- Poor coordination
- Breastfeeding difficulties
- Arm, hand, or shoulder pain
- Anxiety and nervousness
- Colic
- Scoliosis
The birth process, even under normal conditions, is frequently the first cause of spinal stress. After the head of the child appears, the physician grabs the baby’s head and twists it around in a figure eight motion, lifting it up to receive the lower shoulder and then down to receive the upper shoulder. This creates significant stress on the spine of the baby.
“Spinal cord and brain stem traumas often occur during the process of birth but frequently escape diagnosis. Infants often experience lasting neurological defects. Spinal trauma at birth is essentially attributed to longitudinal traction, especially when this force is combined with flexion and torsion of the spinal axis during delivery.” ~Abraham Towbin, MD
Growth patterns suggest the potential for neurological disorders is most critical from birth to two years of age, as this time is the most dynamic and important phase of postnatal brain development. Over sixty percent of all neurological development occurs after birth in the child’s first year of life. This is why it is so important to bring your child to a local pediatric chiropractor to have them checked and for your child to get a chiropractic adjustment during the first year of their life. Lee Hadley MD states “Subluxation alone is a rational reason for Pediatric Chiropractic care throughout a lifetime from birth.”
As our children continue to grow, the daily stresses can have a negative impact on an ever growing body. During the first few years of life, an infant often falls while learning to walk or can fall while tumbling off a bed or other piece of furniture. Even the seemingly innocent act of playfully tossing babies up in the air and catching them often results in a whiplash-like trauma to the spine, making it essential to get your baby checked by a pediatric chiropractor every stage of his/her development as minor injuries can present as major health concerns down the road if gone uncorrected.
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On the Internet, similar texts can be found by the hundreds. I am sure that many new parents are sufficiently impressed by them to take their kids to a chiropractor. I have yet to hear of a single case where the chiropractor then checked out the child and concluded: “there is nothing wrong; your baby does not need any therapy.” Chiropractors always find something – not something truly pathological, but something to mislead the parent and to earn some money.
Often the treatment that follows turns out to be a prolonged and thus expensive series of sessions that almost invariably involve manipulating the infant’s fragile and developing spine. There is no compelling evidence that this approach is effective for anything. In addition, there is evidence that it can do harm, sometimes even serious harm.
And that’s the reason why I have mentioned this topic before and intend to continue doing so in the future:
- There is hardly a good reason for adults to consult a chiropractor.
- There is no reason to take a child to a chiropractor.
- There are good reasons for chiropractors to stop treating children.
But let’s be a bit more specific. Let’s deal with the above list of indications on the basis of the reliable evidence:
- Vision problems – no sound evidence that chiropractic manipulations are effective.
- Skin conditions – no sound evidence that chiropractic manipulations are effective.
- Bedwetting – some evidence that chiropractic manipulations are ineffective.
- Sinus problems – no sound evidence that chiropractic manipulations are effective.
- ADD/ADHD – some evidence that chiropractic manipulations are ineffective.
- Stomachaches – no sound evidence that chiropractic manipulations are effective.
- Asthma – some evidence that chiropractic manipulations are ineffective.
- Allergies – no sound evidence that chiropractic manipulations are effective.
- Loss of hearing – no sound evidence that chiropractic manipulations are effective.
- Ear Infections – some evidence that chiropractic manipulations are ineffective.
- Hip, leg, or foot pain – no sound evidence that chiropractic manipulations are effective.
- Constipation – no sound evidence that chiropractic manipulations are effective.
- Poor coordination – no sound evidence that chiropractic manipulations are effective.
- Breastfeeding difficulties – no good evidence that chiropractic manipulations are effective.
- Arm, hand, or shoulder pain – no sound evidence that chiropractic manipulations are effective.
- Anxiety and nervousness – no sound evidence that chiropractic manipulations are effective.
- Colic – some evidence that chiropractic manipulations are ineffective.
- Scoliosis – no sound evidence that chiropractic manipulations are effective.
I rest my case.
This study aimed to evaluate the number of craniosacral therapy sessions that can be helpful to obtain a resolution of the symptoms of infantile colic and to observe if there are any differences in the evolution obtained by the groups that received a different number of Craniosacral Therapy sessions at 24 days of treatment, compared with the control group which did not received any treatment.
Fifty-eight infants with colic were randomized into two groups:
- 29 babies in the control group received no treatment;
- babies in the experimental group received 1-3 sessions of craniosacral therapy (CST) until symptoms were resolved.
Evaluations were performed until day 24 of the study. Crying hours served as the primary outcome measure. The secondary outcome measures were the hours of sleep and the severity, measured by an Infantile Colic Severity Questionnaire (ICSQ).
Statistically significant differences were observed in favor of the experimental group compared to the control group on day 24 in all outcome measures:
- crying hours (mean difference = 2.94, at 95 %CI = 2.30-3.58; p < 0.001);
- hours of sleep (mean difference = 2.80; at 95 %CI = – 3.85 to – 1.73; p < 0.001);
- colic severity (mean difference = 17.24; at 95 %CI = 14.42-20.05; p < 0.001).
Also, the differences between the groups ≤ 2 CST sessions (n = 19), 3 CST sessions (n = 10), and control (n = 25) were statistically significant on day 24 of the treatment for crying, sleep and colic severity outcomes (p < 0.001).
The authors concluded that babies with infantile colic may obtain a complete resolution of symptoms on day 24 by receiving 2 or 3 CST sessions compared to the control group, which did not receive any treatment.
Why do SCAM researchers so often have no problem leaving the control group of patients in clinical trials without any treatment at all, while shying away from administering a placebo? Is it because they enjoy being the laughingstock of the science community? Probably not.
I suspect the reason might be that often they know that their treatments are placebos and that their trials would otherwise generate negative findings. Whatever the reasons, this new study demonstrates three things many of us already knew:
- Colic in babies always resolves on its own but can be helped by a placebo response (e.g. via the non-blinded parents), by holding the infant, and by paying attention to the child.
- Flawed trials lend themselves to drawing the wrong conclusions.
- Craniosacral therapy is not biologically plausible and most likely not effective beyond placebo.
One of the numerous conditions chiropractors, osteopaths, and other manual therapists claim to treat effectively is tension-type headache (TTH). For this purpose, they (in particular, chiropractors) often use high-velocity, low-amplitude manipulations of the neck. They do so despite the fact that the evidence for these techniques is less than convincing.
This systematic review evaluated the evidence about the effectiveness of manual therapy (MT) on pain intensity, frequency, and impact of pain in individuals with tension-type headache (TTH).
Medline, Embase, Scopus, Web of Science, CENTRAL, and PEDro were searched in June 2020. Randomized clinical trials that applied MT not associated with other interventions for TTH were selected. The level of evidence was synthesized using GRADE, and Standardized Mean Differences (SMD) were calculated for meta-analysis.
Fifteen studies were included with a total sample of 1131 individuals. The analyses show that high-velocity, low-amplitude techniques were not superior to no treatment in reducing pain intensity (SMD = 0.01, low evidence) and frequency (SMD = -0.27, moderate evidence). Soft tissue interventions were superior to no treatment in reducing pain intensity (SMD = -0.86, low evidence) and frequency of pain (SMD = -1.45, low evidence). Dry needling was superior to no treatment in reducing pain intensity (SMD = -5.16, moderate evidence) and frequency (SMD = -2.14, moderate evidence). Soft tissue interventions were not superior to no treatment and other treatments on the impact of headache.
The authors concluded that manual therapy may have positive effects on pain intensity and frequency, but more studies are necessary to strengthen the evidence of the effects of manual therapy on subjects with tension-type headache. Implications for rehabilitation soft tissue interventions and dry needling can be used to improve pain intensity and frequency in patients with tension type headache. High velocity and low amplitude thrust manipulations were not effective for improving pain intensity and frequency in patients with tension type headache. Manual therapy was not effective for improving the impact of headache in patients with tension type headache.
So, this review shows that:
- soft tissue interventions are better than no treatment,
- dry needling is better than no treatment.
These two results fail to impress me. Due to a placebo effect, almost any treatment should be better than no therapy at all.
ALMOST, because high-velocity, low-amplitude techniques were not superior to no treatment in reducing the intensity and frequency of pain. This, I feel, is an important finding that needs an explanation.
As it is only logical that high-velocity, low-amplitude techniques must also produce a positive placebo effect, the finding can only mean that these manipulations also generate a negative effect that is strong enough to cancel the positive response to placebo. (In addition, they can also cause severe complications via arterial dissections, as discussed often on this blog.)
Too complicated?
Perhaps; let me, therefore, put it simply and use the blunt words of a neurologist who once was quoted saying this:
DON’T LET THE BUGGARS TOUCH YOUR NECK!
