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

spinal manipulation

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In one of my last posts, I was rather dismissive of veterinary chiropractic.

Was I too harsh?

I did ask readers who disagree with my judgment to send me their evidence.

Sadly, none arrived!

Therefore, I did several further literature searches and found a recent review of the topic. It included 14 studies; 13 were equine and one was a canine study. Seven of these were cohort studies and seven were randomized controlled clinical trials. . Study quality was low (n = 4), moderate (n = 7), and high (n = 3) and included a wide array of outcome parameters with varying levels of efficacy and duration of therapeutic effects, which prevented further meta-analysis. The authors concluded that it was difficult to draw firm conclusions despite all studies reporting positive effects. Optimal technique indications and dosages need to be determined to improve the standardization of these treatment options.

This, I think, can hardly be called good evidence. But I also found this more recent paper:

Chiropractic care is a common treatment modality used in equine practice to manage back pain and stiffness but has limited evidence for treating lameness. The objective of this blinded, controlled clinical trial was to evaluate the effect of chiropractic treatment on chronic lameness and concurrent axial skeleton pain and dysfunction. Two groups of horses with multiple limb lameness (polo) or isolated hind limb lameness (Quarter Horses) were enrolled. Outcome measures included subjective and objective measures of lameness, spinal pain and stiffness, epaxial muscle hypertonicity, and mechanical nociceptive thresholds collected on days 0, 14, and 28. Chiropractic treatment was applied on days 0, 7, 14, and 21. No treatment was applied to control horses. Data was analyzed by a mixed model fit separately for each response variable (p < 0.05) and was examined within each group of horses individually. Significant treatment effects were noted in subjective measures of hind limb and whole-body lameness scores and vertebral stiffness. Limited or inconsistent therapeutic effects were noted in objective lameness scores and other measures of axial skeleton pain and dysfunction. The lack of pathoanatomical diagnoses, multilimb lameness, and lack of validated outcome measures likely had negative impacts on the results.

Great! So, we finally have an RCT of chiropractic for horses. Unfortunately, the study is less than convincing:

  • It included just 20 polo horses plus 18 horses active in ridden or competitive work all suffering from lameness.
  • The authors state that ‘horses were numerically randomized to treatment and control groups’; yet I am not sure what this means.
  • Treatment consisted of high-velocity, low-amplitude, manually applied thrusts to sites of perceived pain or stiffness with the axial and appendicular articulations. Treatment was applied on days 0, 7, 14, and 21 by a single examiner. The control group received no treatment and was restrained quietly for 15 min to simulate the time required for chiropractic treatment. In other words, no placebo controls were used.
  • The validity of the many outcome measures is unknown.
  • The statistical analyses seem odd to me.
  • No correction for multiple statistical tests was done.
  • Most of the outcomes show no significant effect.
  • Overall, there were some small positive treatment effects based on subjective assessment of lameness, but no measurable treatment effects on objective measures of limb lameness.
  • The polo horses began their competition season at the beginning of the study which would have confounded the outcomes.

What does all this tell us about veterinary chiropractic?

Not a lot.

All we can safely say, I think, is that veterinary chiropractic is not evidence-based and that claims to the contrary are certainly ill-informed and most probably of a promotional nature.

This study examined the incidence and severity of adverse events (AEs) of patients receiving chiropractic spinal manipulative therapy (SMT), with the hypothesis that < 1 per 100,000 SMT sessions results in a grade ≥ 3 (severe) AE. A secondary objective was to examine independent predictors of grade ≥ 3 AEs.

The researchers retrospectively identified patients with SMT-related AEs from January 2017 through August 2022 across 30 chiropractic clinics in Hong Kong. AE data were extracted from a complaint log, including solicited patient surveys, complaints, and clinician reports, and corroborated by medical records. AEs were independently graded 1–5 based on severity (1-mild, 2-moderate, 3-severe, 4-life-threatening, 5-death).

Among 960,140 SMT sessions for 54,846 patients, 39 AEs were identified, two were grade 3, both of which were rib fractures occurring in women age > 60 with osteoporosis, while none were grade ≥ 4, yielding an incidence of grade ≥ 3 AEs of 0.21 per 100,000 SMT sessions (95% CI 0.00, 0.56 per 100,000). There were no AEs related to stroke or cauda equina syndrome. The sample size was insufficient to identify predictors of grade ≥ 3 AEs using multiple logistic regression.

The authors concluded that, in this study, severe SMT-related AEs were reassuringly very rare.

This is good news for all patients who consult chiropractors. However, there seem to be several problems with this study:

  • Data originated from 30 affiliated chiropractic clinics with 38 chiropractors (New York Chiropractic & Physiotherapy Center, EC Healthcare, Hong Kong). These clinics are integrated into a larger healthcare organization, including several medical specialties and imaging and laboratory testing centers that utilize a shared medical records system. The 38 chiropractors represent only a little more than 10% of all chiropractors working in Hanh Kong and are thus not representative of all chiropractors in that region. Is it possible that the participating chiropractors were better trained, more gentle, or more careful than the rest?
  • Data regarding AEs was obtained from a detailed complaint log that was routinely aggregated from several sources by a customer service department. One source of AEs in this log was a custom survey administered to patients after their 1st, 2nd, and 16th visits. Additional AEs derived from follow-up phone calls by a personal health manager. This means that not all AE might have been noted. Some patients might not have complained, others might have been too ill to do so. And, of course, dead patients cannot complain. The authors state that “the response to the SMS questionnaire was low. It is possible that severe AEs occurred but were not reported or recorded through these or other methods of ascertainment”.
  • The 39 AEs potentially related to chiropractic SMT included increased symptoms related to the patient’s chief complaint (n = 28), chest pain without a fracture on imaging (n = 4), jaw pain (n = 3), rib fracture confirmed by imaging (n = 2), headache and dizziness without evidence of stroke (n = 1), and new radicular symptoms (n = 1). Of the 39 AEs, grade 2 were most common (n = 32, 82%), followed by grade 1 (n = 5, 13%), and grade 3 (n = 2, 5%). There were no cases of stroke, transient ischemic attack (TIA), vertebral or carotid artery dissection, cauda equina syndrome, or spinal fracture. Yet, headache and dizziness could be signs of a TIA.
  • Calculating the rate of AEs per SMT session might be misleading and of questionable value. Are incidence rates of AEs not usually expressed as AE/patient? In this case, the % rate would be almost 20 times higher.

Altogether, this is a laudable effort to generate evidence for the risks of SMT. The findings seem reassuring but sadly they are not fully convincing.

 

The McTimoney College of Chiropractic just announced that it has established a new four-year program in veterinary chiropractic for college students:

It means that those without a prior degree can undertake the training and education necessary to enter this coveted career. To date, animal chiropractors were required to have a prior qualification in human chiropractic or a degree in the relevant sciences.

Applications for the new program are being accepted from September 2023. Students will attend Abingdon-based University, Oxford, and a variety of practical locations, enabling the development of academic knowledge and the application of practical skills together . Modules include anatomy and physiology, veterinary science, practice and professionalism, and clinical skills, with a research dissertation running over the four-year course.

University director Christina Cunliffe said the new program was an exciting step in the development of chiropractic care for animals.

“Building on our decades of experience graduating confident, competent, and highly-skilled animal chiropractors, now is the time to open up this exciting career opportunity to college students.”

For the past 50 years, McTimoney College of Chiropractic has been training and educating human chiropractors to the highest regulatory standards. Over the past 20 years, animal chiropractic has developed to meet the requirements for this gentle, holistic treatment in the veterinary world.

Prospective students are invited to a Open House at McTimoney College of Chiropractic in Abingdon on February 16.

McTimoney Chiropractic for Animals identifies areas of stiffness, asymmetry, and poor range of motion within the skeletal system, particularly the spine and pelvis. This affects the muscles that surround these structures, as well as the nerve impulses that pass from the central nervous system to the periphery of the body. The adjustments are very light and fast, stimulating an instant response in the affected soft tissues and joints, promoting relaxation of muscle spasms, improving nerve function, and helping the skeletal structure regain better symmetry and movement again.

In many cases, animals suffer from underlying conditions such as arthritic changes or degenerative diseases that force them to compensate in their posture and movement in an attempt to remain comfortable. However, these offsets become increasingly entrenched and can be painful or uncomfortable, requiring chiropractic care to provide some relief. In other cases, the animals are working hard or competing and as such accumulate tension and asymmetries due to the demands of their work. Once again, chiropractic care helps relieve pain and promote performance, whether it’s faster speeds over hurdles for racehorses and events, better jumping style in showjumpers, or more extravagant movements for dressage stars.

Two recent graduates of the school’s Master of Animal Handling (Chiropractic) program did not hesitate to recommend the university. Natalie McQuiggan said that she had wanted to do McTimoney Chiropractic from a very young age, “but the process of doing it always seemed really daunting.

“But from the start, the staff and teachers were lovely and welcoming, and queries were answered promptly. I have really enjoyed my two years in the Master of Animal Handling (Chiropractic) program and would recommend anyone thinking of doing it to just do it.”

Pollyanna Fitzgerald said the university offered a supportive and welcoming learning environment, allowing her to grow and develop as a student and future professional. “There is always someone to talk to and offer encouragement when needed. As a student I have learned a lot and have been encouraged to believe in myself and it has been a wonderful place to learn.”

A free webinar, McTimoney’s Animal Chiropractic as a Careeron January 24 at 7:30 p.m. (GMT), is open to those who wish to learn more about the McTimoney technique and its application, and the training paths available to those interested in becoming a McTimoney Animal Chiropractor.

________________________

I think this announcement is puzzling on several levels:

  1. I was unable to find an ‘Abingdon-based University, Oxford’; could it be this institution that is a college and not a university?
  2. Christina Cunliffe seems to be (or has been?) affiliated with the McTimoney College of Chiropractic which is a bit odd, in my opinion.
  3. The college does not have ‘decades of experience’; it was founded only in 2001.
  4. Most importantly, I am unable to find a jot of good evidence that veterinary chiropractic is effective for any condition (see also here, here, and here). In case anyone is aware of any, please let me know. I’d be delighted to revise my judgment.

If I am right, the new course could be a fine example of quackademia where students are ripped off and taught to later rip off the owners of animals after the academically trained quacks have mistreated them.

The purpose of this review was to

  • identify and map the available evidence regarding the effectiveness and harms of spinal manipulation and mobilisation for infants, children and adolescents with a broad range of conditions;
  • identify and synthesise policies, regulations, position statements and practice guidelines informing their clinical use.

Two reviewers independently screened and selected the studies, extracted key findings and assessed the methodological quality of included papers. A descriptive synthesis of reported findings was undertaken using a level-of-evidence approach.

Eighty-seven articles were included. Their methodological quality varied. Spinal manipulation and mobilisation are being utilised clinically by a variety of health professionals to manage paediatric populations with

  • adolescent idiopathic scoliosis (AIS),
  • asthma,
  • attention deficit hyperactivity disorder (ADHD),
  • autism spectrum disorder (ASD),
  • back/neck pain,
  • breastfeeding difficulties,
  • cerebral palsy (CP),
  • dysfunctional voiding,
  • excessive crying,
  • headaches,
  • infantile colic,
  • kinetic imbalances due to suboccipital strain (KISS),
  • nocturnal enuresis,
  • otitis media,
  • torticollis,
  • plagiocephaly.

The descriptive synthesis revealed: no evidence to explicitly support the effectiveness of spinal manipulation or mobilisation for any condition in paediatric populations. Mild transient symptoms were commonly described in randomised controlled trials and on occasion, moderate-to-severe adverse events were reported in systematic reviews of randomised controlled trials and other lower-quality studies. There was strong to very strong evidence for ‘no significant effect’ of spinal manipulation for managing

  • asthma (pulmonary function),
  • headache,
  • nocturnal enuresis.

There was inconclusive or insufficient evidence for all other conditions explored. There is insufficient evidence to draw conclusions regarding spinal mobilisation to treat paediatric populations with any condition.

The authors concluded that, whilst some individual high-quality studies demonstrate positive results for some conditions, our descriptive synthesis of the collective findings does not provide support for spinal manipulation or mobilisation in paediatric populations for any condition. Increased reporting of adverse events is required to determine true risks. Randomised controlled trials examining effectiveness of spinal manipulation and mobilisation in paediatric populations are warranted.

Perhaps the most important findings of this review relate to safety. They confirm (yet again) that there is only limited reporting of adverse events in this body of research. Six reviews, eight RCTs and five other studies made no mention of adverse events or harms associated with spinal manipulation. This, in my view, amounts to scientific misconduct. Four systematic reviews focused specifically on adverse events and harms. They revealed that adverse events ranged from mild to severe and even death.

In terms of therapeutic benefit, the review confirms the findings from the previous research, e.g.:

  • Green et al (Green S, McDonald S, Murano M, Miyoung C, Brennan S. Systematic review of spinal manipulation in children: review prepared by Cochrane Australia for Safer Care Victoria. Melbourne, Victoria: Victorian Government 2019. p. 1–67.) explored the effectiveness and safety of spinal manipulation and showed that spinal manipulation should – due to a lack of evidence and potential risk of harm – be recommended as a treatment of headache, asthma, otitis media, cerebral palsy, hyperactivity disorders or torticollis.
  • Cote et al showed that evidence is lacking to support the use of spinal manipulation to treat non-musculoskeletal disorders.

In terms of risk/benefit balance, the conclusion could thus not be clearer: no matter whether chiropractors, osteopaths, physiotherapists, or any other healthcare professionals propose to manipulate the spine of your child, DON’T LET THEM DO IT!

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:

  1. Osteopaths use high-velocity low-amplitude thrusts, the type of manipulation that has most frequently been associated with serious complications, too frequently.
  2. They also employ cranial osteopathy, which is probably the least plausible technique in their repertoire, too often.
  3. 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.

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 list is so impressive that I felt compelled to read on:

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.

______________________________

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:

I rest my case.

 

Yesterday, L’EXPRESS published an interview with me. It was introduced with these words (my translation):

Professor emeritus at the University of Exeter in the United Kingdom, Edzard Ernst is certainly the best connoisseur of unconventional healing practices. For 25 years, he has been sifting through the scientific evaluation of these so-called “alternative” medicines. With a single goal: to provide an objective view, based on solid evidence, of the reality of the benefits and risks of these therapies. While this former homeopathic doctor initially thought he was bringing them a certain legitimacy, he has become one of their most enlightened critics. It is notable as a result of his work that the British health system, the NHS, gave up covering homeopathy. Since then, he has never ceased to alert us to the abuses and lies associated with these practices. For L’Express, he looks back at the challenges of regulating this vast sector and deciphers the main concepts put forward by “wellness” professionals – holism, detox, prevention, strengthening the immune system, etc.

The interview itself is quite extraordinary, in my view. While UK, US, and German journalists usually are at pains to tone down my often outspoken answers, the French journalists (there were two doing the interview with me) did nothing of the sort. This starts with the title of the piece: “Homeopathy is implausible but energy healing takes the biscuit”.

The overall result is one of the most outspoken interviews of my entire career. Let me offer you a few examples (again my translation):

Why are you so critical of celebrities like Gwyneth Paltrow who promote these wellness methods?

Sadly, we have gone from evidence-based medicine to celebrity-based medicine. A celebrity without any medical background becomes infatuated with a certain method. They popularize this form of treatment, very often making money from it. The best example of this is Prince Charles, sorry Charles III, who spent forty years of his life promoting very strange things under the guise of defending alternative medicine. He even tried to market a “detox” tincture, based on artichoke and dandelion, which was quickly withdrawn from the market.

How to regulate this sector of wellness and alternative medicines? Today, anyone can present himself as a naturopath or yoga teacher…

Each country has its own regulation, or rather its own lack of regulation. In Germany, for instance, we have the “Heilpraktikter”. Anyone can get this paramedical status, you just have to pass an exam showing that you are not a danger to the public. You can retake this exam as often as you want. Even the dumbest will eventually pass. But these practitioners have an incredible amount of freedom, they even may give infusions and injections. So there is a two-tier health care system, with university-trained doctors and these practitioners.

In France, you have non-medical practitioners who are fighting for recognition. Osteopaths are a good example. They are not officially recognized as a health profession. Many schools have popped up to train them, promising a good income to their students, but today there are too many osteopaths compared to the demand of the patients (knowing that nobody really needs an osteopath to begin with…). Naturopaths are in the same situation.

In Great Britain, osteopaths and chiropractors are regulated by statute. There is even a Royal College dedicated to chiropractic. It’s a bit like having a Royal College for hairdressers! It’s stupid, but we have that. We also have professionals like naturopaths, acupuncturists, or herbalists who have an intermediate status. So it’s a very complex area, depending on the state. It is high time to have more uniform regulations in Europe.

But what would adequate regulation look like?

From my point of view, if you really regulate a profession like homeopaths, it means that these professionals may only practice according to the best scientific evidence available. Which, in practice, means that a homeopath cannot practice homeopathy. This is why these practitioners have a schizophrenic attitude toward regulation. On the one hand, they would like to be recognized to gain credibility. But on the other hand, they know very well that a real regulation would mean that they would have to close shop…

What about the side effects of these practices?

If you ask an alternative practitioner about the risks involved, he or she will take exception. The problem is that there is no system in alternative medicine to monitor side effects and risks. However, there have been cases where chiropractors or acupuncturists have killed people. These cases end up in court, but not in the medical literature. The acupuncturists have no problem saying that a hundred deaths due to acupuncture – a figure that can be found in the scientific literature – is negligible compared to the millions of treatments performed every day in this discipline. But this is only the tip of the iceberg. There are many cases that are not published and therefore not included in the data, because there is no real surveillance system for these disciplines.

Do you see a connection between the wellness sector and conspiracy theories? In the US, we saw that Qanon was thriving in the yoga sector, for example…

Several studies have confirmed these links: people who adhere to conspiracy theories also tend to turn to alternative medicine. If you think about it, alternative medicine is itself a conspiracy theory. It is the idea that conventional medicine, in the name of pharmaceutical interests, in particular, wants to suppress certain treatments, which can therefore only exist in an alternative world. But in reality, the pharmaceutical industry is only too eager to take advantage of this craze for alternative products and well-being. Similarly, universities, hospitals, and other health organizations are all too willing to open their doors to these disciplines, despite the lack of evidence of their effectiveness.

 

Osteopathy is becoming under increasing criticism – not just in the UK but also in other countries. Here are the summary points from a very good overview from Canada:

– Osteopathy is based on the belief that illness comes from the impaired movement of muscles, bones, and their connecting structures, and that an osteopath can restore proper movement using their hands
– Offshoots of osteopathy include visceral osteopathy and craniosacral osteopathy, which make extraordinary claims that are not backed up by good evidence
– There is an absence of good quality evidence to support the use of osteopathy to address musculoskeletal issues
– Osteopathy has been reformed in the United States, with osteopathic physicians receiving training comparable to medical doctors and few of them regularly using osteopathic manual manipulations

An article from Germany is equally skeptical. Here is my translation of an excerpt from a recent article:

When asked which studies prove the effectiveness, the VOD kindly and convincingly handed the author of this article a list of about 20 studies. And emphasized that these were listed in Medline, i.e. a recognized medical database. But a close examination of the studies reveals: Almost without exception, all of them qualify their results and point to uncertainties.
The treatment is “possibly helpful,” for example, they say, the study quality is “very low,” “low” to “moderate,” there are too few studies, they are small, the “evidence is preliminary” and “insufficient to draw definitive conclusions. Again and again it is emphasized that further, methodically better, more sustainable studies are needed, which also record more precisely what happened in osteopathic treatment in the first place.

Another article was published by myself in ‘L’Express’. As it is in French, I translated the conclusion for you:

… would I recommend consulting an osteopath? My answer is a carefully considered NO! For patients with back pain, the evidence is as good (or bad, depending on your point of view) as for many other proposed therapies. So if a patient insists on osteopathy, I might support it, but I would still prefer physical therapy. For all other musculoskeletal conditions, there is not enough evidence to make positive recommendations. For patients with conditions other than musculoskeletal, I would advise against osteopathy.

All this comes after it has been shown that worldwide research into osteopathy is scarce and has hardly any impact at all. The question we should therefore ask is this:

why do we need osteopaths?

PS

Osteopaths in the US have studied medicine, rarely practice manual treatments, and are almost indistinguishable from MDs. Everywhere else, osteopaths are practitioners of so-called alternative medicine.

One of my recent posts prompted the following comment from a chiropractor: “… please don’t let me stop you…while we actually treat patients“. It was given in the context of a debate about the evidence for or against chiropractic spinal manipulations as a treatment of whiplash injuries. My position was that there is no convincing evidence, while the chiropractor argued that he has been using manipulations for this indication with good results. Here I do not want to re-visit the pros and cons of that particular debate. Since similar objections have been put to me so many times, I want rather to raise several more principal points.

Before I do this, I need to quickly get the personal stuff out of the way: the comment implies that I  don’t really know what I am talking about because I don’t see patients and thus don’t understand their needs. The truth is that I started my professional life as a clinician, then I went into basic science, then I went back into clinical medicine (while also doing research), and eventually, I became a full-time clinical researcher. I have thus seen plenty of patients, certainly enough to empathize with both the needs of patients and the reasoning of clinicians. In fact, these provided the motives for my clinical research during the last decades of my professional career (more details here).

Now about the real issue that is at stake here. When offered by a clinician to a scientist, the comment “… please don’t let me stop you…while we actually treat patients” is an expression of an arrogant feeling of superiority that clinicians often harbor vis a vis professionals who are not at the ‘coal face’ of healthcare. Stripped down to its core, the argument implies that science is fairly useless because the only knowledge worth having stems from dealing with patients. In other words, it is about the tension that so often exists between clinical experience and scientific evidence.

Many clinicians feel that experience is the best guide to correct decision-making.

Many scientists feel that experience is fraught with errors, and only science can lead us towards optimal decisions.

Such arguments emerge regularly on this blog and are constant company to almost any type of healthcare. The question is, who is right and who is wrong?

As I indicated, I can empathize with both positions. I can see that, in the context of making therapeutic decisions in a busy clinic, for instance, the clinician’s argument weighs heavily and can make sense, particularly in areas where the evidence is mixed, weak, or uncertain.

However, in the context of this blog and other discussions focused on critical evaluation of the science, I am strongly on the side of the scientist. In fact, in this context, the argument “… please don’t let me stop you…while we actually treat patients” seems ridiculous and resembles an embarrassing admission of having no rational argument left for defending one’s own position.

To put my view of this in a nutshell: it is not a question of either or; for optimal healthcare, we obviously need both clinical experience AND scientific evidence (an insight that is not in the slightest original, since it is even part of Sackett’s definition of EBM).

If you go on Twitter you will find that chiropractors are keen like mustard to promote the idea that, after a car accident, you should consult a chiropractor. Here is just one Tweet that might stand for hundreds, perhaps even thousands:

Recovering from a car accident? If you have accident-related injuries such as whiplash, chiropractic care may provide relief. Treatments like spinal manipulation and soft tissue therapy can aid in your recovery.

In case you don’t like Twitter, you could also go on the Internet where you find hundreds of websites that promote the same idea. Here are just two examples:

A frequent injury arising from an automobile accident … is whiplash. After an accident, a chiropractor can help treat resulting issues and pain from the whiplash… Proceeding reduction in swelling and pain, treatment will then focus on manipulation of the spine and other areas.

The primary whiplash treatment for joint dysfunction, spinal manipulation involves the chiropractor gently moving the involved joint into the direction in which it is restricted.

There is no question, chiropractors earn much of their living by treating patients suffering from whiplash (neck injury caused by sudden back and forth movement of the neck often causing neck pain and stiffness, shoulder pain, and headache) after a car accident with spinal manipulation.

Why?

There are two not mutually exclusive possibilities:

  1. They think it is effective.
  2. It brings in good money.

I have no doubt about the latter notion, yet I think we should question the first. Is there really good evidence that chiropractic manipulations are effective for whiplash?

When I was head of the PMR department at the University of Vienna, treating whiplash was my team’s daily bread. At the time, our strategy was to treat each patient according to the whiplash stage and to his/her individual signs and symptoms. Manipulations were generally considered to be contra-indicated. But that was about 30 years ago. Perhaps the evidence has now changed. Perhaps manipulation therapy has been shown to be effective for certain types of whiplash injuries?

To find out, I did a few Medline searches. These did, however, not locate compelling evidence for spinal manipulation as a treatment of any stage of whiplash injuries. Here is an example of the evidence I found:

In 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) found limited evidence on the effectiveness of manual therapies, passive physical modalities, or acupuncture for the management of whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD). This review aimed to update the findings of the Neck Pain Task Force, which examined the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD or NAD. Its findings show the following: Evidence from 15 evaluation studies suggests that for recent neck pain and associated disorders grades I-II, cervical and thoracic manipulation provides no additional benefit to high-dose supervised exercises.

But this is most puzzling!

Why do chiropractors promote their manipulations for whiplash, if there is no compelling evidence that it does more good than harm? Again, there are two possibilities:

  1. They erroneously believe it to be effective.
  2. They don’t care but are in it purely for the money.

Whatever it is – and obviously not all chiropractors would have the same reason – I must point out that, in both cases, they behave unethically. Not being informed about the evidence related to the interventions used clearly violates healthcare ethics, and so does financially not informing and exploiting patients.

 

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