This is a follow on to my earlier post Osteopaths: Talking a good game.. in which the General Osteopathic Council (GOsC) responded to my questions surrounding the quality of evidence to support certain non-musculoskeletal conditions.
From viewing various osteopathy websites and also from reading the comments on my earlier post, it is clear that the osteopathy profession within the UK seems to be split between those who take a more evidence based approach to treatments and those whose claims are more into the realms of quackery. It is the claims of the latter that I am concerned with.
One site offering cranial osteopathy links to a research paper (very loose description) on the osteopathic treatment of Down’s syndrome, the paper starts.
“This paper raises the hypothesis that postnatal hypoxia causes much of the handicap of Down’s syndrome and that osteopathic treatment may be used effectively to reduce it”.
Clearly a hypothesis may be the basis on which to conduct further research, but is not sufficient evidence on which to base a treatment! Yet there are sites where Down’s syndrome is listed as one of the condtions that can be treated, managed or benefit from ostoepathy!
I have stated in an earlier comment that my aim is not to start some campaign against the GOsC or NCOR, that is still the case! I am simply questioning the evidence for certain claims made by some sections of the profession, where these claims are clearly not supported by reliable evidence. Making those claims without holding the relevant research evidence is a clear breach of both the CAP and GOsC’s guidelines.
On 25 April, I contacted the GOsC again. In my email I asked if the GOsC (or NCOR) could provide any evidence for a range of non-musculoskeletal conditions that are available on a number UK osteopathy websites.
The GOsC’s was open and informative and covered a number or areas, however as my queries concern the evidence and not the finer detail of how the GOsC perform its regulatory duties, this post will only focus on those sections related to research and evidence
The main points of my email are as follows:
(I have not provided links to any particular osteopaths website (although they are available if needed) as these claims are not uncommon and it would be pointless to focus on a single website.)
From the other information supplied, it would appear that the GOsC has given its members some clear guidelines to follow on what is permitted or not for advertising.
However it would appear that a great many of your members are offering treatments for a range of conditions which seem to be lacking credible evidence to support those claims, indeed the websites themselves often provide nothing more than anecdotal evidence to support their clams. Whilst it could be argued that colic is a fairly minor, self limiting condition it can be distressing for both infant and parent and treatments should be backed up by robust, reliable evidence.
Of greater concern are a range of more serious conditions that appear regularly on osteopathy websites in the UK, these include asthma, allergies, cerebral palsy, downs syndrome, ADHD, epilepsy and autism, to name but a few. These certainly need to be justified by the evidence as they present a far greater risk to the patient.
And …
Could the GOsC or NCOR point me in the direction of any suitable evidence to support the use of osteopathy as a treatment for the following conditions:
Colic: Asthma: Allergies: ADHD: Cerebral Palsy: Autism: Epilepsy: Down’s syndromeMaking these claims without reliable evidence, or without the clinic holding a copy of the evidence, would seem to be a breach of both the CAP and GOsC guidelines. I realise that the GOsC have given its members clear guidelines, but it would seem that a significant number of osteopaths are choosing not to follow it.
On 12 May, I got a reply and was hopeful that it would refer to some research.
Below are some of the comments from the GOsC regarding evidence along with my comments. (Thanks to Zeno for his comments)
Anecdotal evidence in any healthcare field is not to be dismissed out of hand as it is often the precursor of controlled trials. In addition, lack of evidence is not in itself evidence of lack of efficacy.
Anecdotal evidence may be OK as a precursor to trials, but not as justification for treatments – and not if there is higher quality evidence that says otherwise !
“That said, the paucity of quality data relating to osteopathic practice is a deficit that must be addressed.”
A clear admission that there is a lack of quality evidence!
“One important, positive consequence of regulating osteopathic practice in the UK (introduced roughly ten years ago) is that steady, systematic collection of data about the practice of osteopathy is now underway. The aim is to provide answers to fundamental questions such as: what conditions are being treated with osteopathy and with what outcomes?”
Not really sure why, after 10 years of regulation this is ‘now underway’, surely to effectively regulate a profession you would need to know what the profession is claiming to treat! After all these are described as ‘fundamental questions’. It is important not to look on this as ‘new research’, it is an industry survey!
“The GOsC is funding through the National Council for Osteopathic Research (NCOR) the development of a Standardized Data Collection Tool (modelled on a similar recent development in Physiotherapy) to provide purchasers, providers and regulators of osteopathic practice with a clearer picture of developments in osteopathic care. We expect to have the results of the first national piloting of this systematic practice data collection exercise very shortly. Hard data is the essential foundation on which to construct clear standards for safety and quality improvement. The findings will be shared widely, with the public and the profession – I would be happy to alert you when we receive NCOR’s initial report.”
The results should be worth looking at, but what would be interesting would be to see some details of the design of this study and how it rules out any bias.
“..the treatment of non-musculoskeletal conditions has yet to be properly explored in terms of efficacy and safety, and in terms of what both the patient and the clinician believe to be the purpose of the osteopathic intervention.”
Another admission that there is insufficient evidence, more worrying is the fact that its ‘safety‘ has not been properly explored! WHY SHOULD THAT BE ACCEPTABLE!
“To take the examples of colic and asthma – it is likely that neither expects a cure from the osteopath, but both parties are hoping to enhance the management (rather than the treatment) of the condition”
Actually, I think it is highly likely that anybody paying for osteopathy for a given condition would expect some form of cure. Particularly if the website lists colic or asthma in a list of ‘conditions treated’. Of course I may be wrong and the patient gets told “I’m going to charge you to treat this condition, but don’t expect a cure”
Even if we accept the term ‘manage’ the condition ….. this needs to be supported by evidence!
“You may also be interested in the publication later this year of another study we have recently conducted exploring patients’ expectations of osteopathic care, and the degree to which these expectations are met. We expect that the findings of this research – which involved 1,700 patients selected randomly across the UK – to inform revisions to the Osteopathic Code of Practice”.
Again this is not ‘new research’, it is a customer satisfaction survey. Does this survey even take into account the different type of condition being treated. Will the results differentiate between the satisfaction levels for musculoskeletal and non-musculoskeletal conditions ?
You have made some points specific to NCOR’s research strategy – I have suggested to that organisation that it may be more appropriate for NCOR to respond directly to you on this.
The GOsC’s reply was dated 12 May, at present there has been no response from NCOR.
“In addition to the right to be informed where there is no evidence of positive effect the GOsC considers it essential that patients are also alerted to any identified risks associated with osteopathic care”
There’s that ‘no evidence’ statement again! As for the associated risks, the GOsC are currently spending almost £203,000 to fund a study, the aim of which is “To address the paucity of available information/knowledge concerning risks associated with osteopathic treatment;“(pdf)
That’s a lot of money to spend on assessing the safety of a profession that has been regulated for the past 10 years and is freely available on the highstreet.
To ensure that I’ve not cherry picked comments or taken anything out of context, full versions of my email and the GOsC’s response are available at the bottom of this post,
Some positive points:
In addition to the earlier comment about addressing the paucity of quality data, the GOsC have also listed two other areas where they agree there is more they can do. This is obviously a positive and very welcome step. I would be interested to see the guidance they publish, more interesting will be to see the effect it has (if any) on those websites making these claims.
“Notwithstanding the points above, your observations regarding osteopathic websites indicate that the GOsC must be more targeted in our guidance to practitioners.”
“Your additional queries relating to “cranial osteopathy” highlight another area where information could be fuller in the public interest.”
These comments alone justify the questions being asked in the first place, however they are not a substitute for providing the evidence, or if no evidence exists, a clear statement to that effect.
Summary:
The GOsC have provided some interesting information and agreed that there are areas where they as regulators can provide more targetted guidance and public information (That alone makes it worth asking the questions!).
What they have not been able to do is answer the main points of my email – that of the evidence to support the claims surrounding non-musculoskeletal conditions, comments have been made about the ‘paucity of quality data’ and ‘anecdotal evidence’ and also attempts to divert away from the meaning of ‘treatment’ (towards ‘management’) of a particular condition, however not a single piece of evidence has been supplied to support any of the conditions listed.
I don’t think it is unreasonable to assume that if any reliable evidence was available it would have been mentioned by now. After all … that’s all I really asked for!
My earlier post on this subject has resulted in regular, daily blog hits from closed osteopathy websites (Sacralmusings & British School of Osteopathy), although few have chosen to make any public comment. For their benefit I will point out that I realise not all osteopaths make these claims.
The majority of those who do seem to be from the Cranial Ostopathy side of the profession. However, cranial osteopaths are fully qualified and regulated osteopaths and they also offer to treat conditions such as lower back pain – how does the public tell the difference ?
(pdf) Link to full Emails:
Perhaps it’s time to make a list of UK osteopathy websites offering to treat these conditions!
skepticbarista
May 23, 2010
And the hits from the Sacralmusings website keep coming.
( http://www.sacralmusings.com/ )
Two threads continue to provide blog hits: I don’t have access to that site and I doubt they’d allow me in to join the discussion, so here’s a couple of points to consider.
( Quotes taken from Sacralmusings 21:00 Sunday 23 May )
I don’t know of any skeptic who is ‘coming for you next’. I have made it clear that I’m only interested in seeing the evidence that support ‘certain’ treatment claims. These claims are not made by the majority of osteopaths. Whilst I would agree that osteopaths should ensure their advertising material complies with current guidelines, this is mostly scaremongering by a chiropractor.
and…
This is a point I feel more strongly about.
When it comes to evidence-based medicine … YES you should WANT to go there and YES some sections of your profession do NEED to go there!
Without evidence your treatments are unproven and fall into the realms of Quackery! Those who offer to treat, without reliable evidence to support that treatment, are no different to homeopaths, reiki practicioners or faith healers!
You can’t claim to be a part of an ‘evidence based’ profession and choose to ignore the requirement for evidence. I would suggest that there are some osteopaths who need to take a step back and take an honest look at the validity of the treaments they offer. So far the osteopaths who have commented on this blog (see earlier post) all seem to support evidence based practice!
Andrew Gilbey
May 23, 2010
@SkepticBArista
Good article, although I personally feel you do not need to explain your motives.
Anyway, I had a very quick browse of 5 osteopath websites chosen at random suign google.co.nz, and felt they are considerably more conservative than those of their chiropractic counterparts. That said, I did find claims regarding infertility, which to me seems to be a biologically implausible claim.
I also found this link, which did cause me to have a little chuckle:
http://www.aucklandosteopaths.co.nz/equine_osteopathy.html
One thing I’m personally very pleased to see is that osteopaths in New Zealand don’t generally call themselves Doctor (6%) – the rate for Chiropractors was 73%. (See Gilbey, A. (2008) in the New Zealand Medical Journal).
skepticbarista
May 24, 2010
Hi,
Thanks for the comment. The only reason I offer some explaination for my actions is that there are some osteopaths I talk to (usually on twitter) who have a peffectly sensible approach to the treatments they offer. It’s not this type of practicioner that I have a problem with.
Have you tried a google search for ‘cranial osteopathy’, that’s where the quackery element are most prevalent (within the UK at least).
vongollum
July 23, 2010
Dr Gilbey PhD (?), a marketeer, banging on endlessly in a personal bucket about the title ‘dr’, probably sponsored by the NZMA and desperate to maintain his PBRF (performance-based research fund) score. Suggest he undertakes a study to see whether the general public in NZ have the intellectual ability to read and understand the Yellow and White pages. The null hypothesis for this proposed study might be: The NZ general public do not have a reading age high enough to read and understand the telephone directory. To credit the general public with inadequate intelligence capable of discerning between a tree-surgeon and and orthopaedic surgeon, a general practitioner and a dr chiropractic is very very ‘old school’. Given that Yellow Pages has headings like ‘chiropractor’ or ‘medical practitioner’ or the white pages provides a discreet listing for medical practitioners and separate alphabetical listings for dentists (dr), vets (dr), chiropractors (dr), tree (dr), plumber (dr) and so on, the general public do not suffer from confusion in this regard. They are well able to discern between ‘dr’; and ‘doctor’ and certainly between a quack ‘dr’ practicing cranial osteopathy or fixing ‘subluxations’ to treat disease.
Further reading: the Hansard report from the Australian Northern Territory debate on the subject makes a good study. Incidentally, the medical practitioner ‘dr’ title is an honorific, unless the individual has an MD (or PhD). A PhD is definitely a ‘Dr’ but not a ‘doctor’. No confusion here. But what or who is Dr Who exactly? And Doctor Harold Shipman, of course, the quintessential example of the consummate ‘doctor’ not a real ‘dr’! Titles denote relatively little these days!
davidp
May 24, 2010
To see the evidence,
1. Find a cranial osteopath who advertises (beyond their own web site)
2. Ask them for the evidence supporting a claim in the advertisment.
The GoC code states
“All advertising must be legal, decent, honest and truthful and must conform to the current guidance, such as the British Code of Advertising Practice.”
The Code of Advertising Practice requires advertisers to _hold_ evidence for all claims. If the specific osteopath does not respond or responds inadequately, then
3. Complain to the ASA – The ASA will then demand the evidence. You won’t see the evidence, but you will see an ASA summary and assesment of it.
skepticbarista
May 24, 2010
Hi,
I agree the ASA are an effective way to tackle any suspect claims and to get the question of evidence addressed. Won’t do any harm if any ASA complaint can be backed up with a statement that the profession regulator has been asked for the evindence and could not provided any
I’ve already visited the 2 closest osteopaths to where I live and both seem to be OK.
I currently have an ASA complaint under investigation for Cranio Sacral Therapy (CST), which is very similar to Cranial Osteopathy, but in the case of CST the practicioners are not qualified osteopaths and are not regulated.
Zeno
May 26, 2010
Cranio Sacral Therapist
Cranial Osteopath
Osteomylogist
Neurosteomyologist
Orthopractor
Chiropractor
Osteopath
Physiotherapist
Spinal manipulation therapist
Spine specialist
etc
How is the average person expected to be able to separate the wheat from the chaff?
vongollum
July 27, 2010
Craniosacral treatment or any synonym denoting the same, undertaken by any practitioner of any discipline, persuasion, religion or cult is unmitigated ‘woo’. Several peer reviewed articles highlight this well. The absence of evidence at any level (anatomical, clinical, biological) remains a persisting and glaring omission. Alternative explanations, placebo, relaxation, regression to the mean and so on are well described by Hartman SE in his paper ‘Why do ineffective treatments seem helpful? A brief review’ Chiropractic and Osteopathy 2009, 17:10. doi: 10.1186/1746-1340-17-10.
A review of the physiology of cranial osteopathy: viewpoint. McGrath, MC. Journal of Osteopathic Medicine 2003, 6(2):84-86.
Interexaminer reliability and cranial osteopathy. Hartman SE, Norton JM. Scientific Review Alternative Medicine 2002;6:23-34.
A review of King HH and Lay EM, “Osteopathy in the cranial field,” in Foundations for Osteopathic Medicine 2nd ed. Hartman SE, Norton JM. Scientific Review Alternative Medicine 2004 – 2005;8:24-8.
Cranial osteopathy: its fate seems clear. Hartman SE. Chiropractic and Osteopathy 2006, 14:10. doi: 10.1186/1746-1240-14-10
On the other hand, the ‘Effectiveness of manual therapies: the UK evidence report’ Brontfort et al. Chiropractic and Osteopathy 2010, 18:3 doi: 10.1186/1746-1340-18-3
make it explicitly clear where the evidence lies, based on 49 recent systematic reviews, 16 evidence-based clinical guidelines and an additional 46 RCT’s not yet included in systematic reviews and guidelines.
Those that hold to evidence based practice in manual therapies (including educational establishments in the UK, USA and Australasia are unable to desist from ‘teaching’ the arcane practices of ‘woo’ -craniosacral therapy- citing public (and student) demand. This is a travesty of science and education. Students would very often prefer to learn something more relevant with evidence but cannot. If they fail the ‘woo’ component they don’t get the degree and they can’t practice. This is utterly deplorable. Tertiary institution funding derives from the public purse as does the student course fees in many instances. Surely, some accountability exists here?
On the grounds of ‘best practice’ and ethics, the various groups that utilise manual therapeutics should be held to evidence based practice. Needless to say, this ‘benchmark’ is one that requires equal application to surgery, the practice of medicine and CAM treatments in general, which it is clearly not. A lot of what passes for contemporary medicine does not meet EBP criteria. Neither does it actively enact or engage in EBP processes of ‘in time learning’.
Patients are always free to choose faith based, unregulated care, but such choices should never be informed or made on the basis of spurious claims or advertising.
Paul Barratt
December 8, 2010
Dear SkepticBArista,
Thank you for your comments regarding the paucity of evidence to support osteopathic treatment of non-musculoskeletal conditions.
I like to think of myself as an ‘evidence based’ osteopath, and, I do agree with you.
There is a danger that my profession may become split along the lines of scientific versus non scientific and this worries me.
There is a pretty good (though not yet excellent) evidence base for the treatment of musculoskeletal conditions (NCOR 2010) but I am optimistic that this will consolidate and broaden out.
Lay people put themselves in to the care of the profession and they should be able to expect a duty of care that is based in scientific reasoning not metaphysical or pseudo-scientific philosophy (ie quackery).
The osteopathic profession is well placed to state what it knows it does well, get on with it, and forget the other stuff. This will only benefit us in the end by gaining the respect of the public (who we MUST care for and inform properly), and of the wider scientific community.
P
Sonia
June 21, 2012
Dear SkepticBarista,
I recently underwent 11 treatments with an osteopath to relieve occasional knee pain. As a result of the treatments I am now experiencing pain in almost every corner of my body; nerve pain in the arms and hands, all over the legs, neck and back pain. Osteopathy is definitely a dangerous practice and I hope more is done to alert the public to this fact. Do you know of any resources for those who have been injured by osteopaths?
Thanks!
S.
skepticbarista
June 21, 2012
Hi,
Sorry to hear you are having problems following your osteopathy treatment.
If you had the treatment in the UK by a UK registered osteopath, then I would suggest you contact the General Osteopathic Council who have a complaints procedure. They will take your complaint seriously!
http://www.osteopathy.org.uk/information/complaints/
I would avoid posting online any specific details of the ‘who, what, where & when’ relating to your treatment as this may prejudice any future hearing.
skepticbarista@googlemail.com