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.
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 syndrome
Making 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.
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!