My last 2 posts on Cranial Osteopathy looked at what (Part 1) cranial osteopathy is, what was being claimed and the available evidence to support those claims. I also looked at (Part 2) what advertising advice had been provided. This all seemed quite appropriate as the ASA’s remit was about to change and these website claims would then come under their remit ……
….. Well the rules changed on 1 March, so it is worth a quick a look and see if anything has actually changed on the websites.
First though it is worth just clarifying something about the ASA remit and the CAP codes. The advertising regulations themselves have not really seen any dramatic changes, the only real difference is the fact that advertisers website content now comes under the remit of the ASA. If you can’t say it on your website now …… You shouldn’t have been saying it in your adversing before!
So back to Osteopathy….
In the past the GOsC had been issuing clear advertising guidance to its members, guidance that had largely been ignored by Cranial Osteopaths. The GOsC had also stated that it was their intention to start actively looking at the website content of its members and, where appropriate, advise the website owner on any potential breach of the ASA code and therefore the GOsC Code of Practice on advertising.
In Feb 2011 I was talking to the GOsC about a leaflet that was being supplied (via the internet) on one of its members websites. The leaflet carried the GOsC logo and made claims about the effectiveness of Osteopathic treatment for babies and children and includes a list of conditions ranging from colic to Cerebral Palsy and Downs syndrome.
I asked if this leaflet was ‘current‘ and if it was based on any robust evidence. The GOsC told me that this leaflet had in fact been withdrawn a number of years ago and that they had now contacted the clinic concerned to have the information removed and I can confirm that this has happened.
This was the osteopathic statutory regulator actually getting misleading information taken out of the public domain.
The GOsC email contained some interesting and very encouraging information.
They stated that they sought and achieved (in 2008) an amendment to the Osteopaths Act that removed their ‘promotional remit‘. This has to be a good thing as it removes any conflict of interest from an organisation that is tasked to both regulate and promote a profession. You only have to look at the GCC’s past Patient Information Leaflet to see what problems that can cause!
The GOsC also made an important statement regarding evidence.
As osteopathy matures into a mainstream regulated practice, the importance of empirical rather than anecdotal evidence is rapidly changing the culture of practice and steadily improving the quality of public information, including our own.
How the GOsC define ‘empirical‘ remains to be seen, but it acknowledges the limitations of anecdotal evidence if osteopathy is to be taken seriously ….. the ‘it worked for me‘ kind of testimonial just isn’t good enough … it never was!
They also confirmed something that they had alluded to in earlier emails. The fact that they are now looking at osteopaths website content and where appropriate, offering advice on how that content relates to current ASA guidelines …… and therefore the GOsC Code of Practice.
As you will already know, we are in the process of systematically reviewing all our registrants’ practice websites, so that we can advise osteopaths individually and more specifically on current good advertising practice. We hope the benefit of this action will be evident very soon.
This has to be seen as a very positive move from the GOsC. The osteopaths regulator actively regulating what their members say. It could be argued that this should have been done earlier, it could be argued that it shouldn’t NEED to be done at all (osteopaths are aware of the rules), but it is being done and it is to be hoped that the osteopaths take notice and make changes where needed.
On 1 March (the day the rules changed) the GOsC said:
Our review of registrants’ practice websites started late last year and we have used a variety of search terms and approaches. There are at this time 2,342 practice websites listed on the GOsC’s online Statutory Register of Osteopaths and, we estimate, a further several hundred osteopathy websites that are not linked to the Register.
Reviewing all of these has not been a simple exercise as website content tends to change fairly frequently and we know that many osteopaths have heeded the general advice that we and others have been giving to ensure their sites are compliant. We hope that we have identified the majority of those with content that might be confusing or misleading for patients, but we have not set ourselves a completion date for this process as we may well decide to undertake further similar exercises in future.
Notwithstanding that, we are encouraged that the focus on practice advertising is stimulating increased research awareness and interest amongst practitioners that can only be to the benefit of patients and the quality of osteopathic practice.
This has also been announced in the Feb/Mar 2011 edition of The Osteopath.
It would seem to be a clear statement that the GOsC are taking this seriously and that it remains an ongoing process. Importantly it acknowledges that this information may be confusing or misleading. If the GOsC believe that to be the case, then there is good reason to get these claims removed before they become the subject of complaints.
There are still quite a few websites making these claims, so I’m not sure if I agree with the statement that ‘many osteopaths‘ have heeded the advice, nor that they have ‘identified the majority‘ of those with misleading content.
Whilst there are osteopaths who have chosen to ignore the advice so far, there are certainly those who have acted upon it.
(Thanks to Zeno for sending me this info)
I am not clear if this is as a result of the GOsC’s actions or if the clinic acted independently. Either way, given the ASA’s new remit it is a sensible move.
This informal list shows just a few sites that continue to make these claims and may help to highlight the level of claims still being made. Even this small list shows the range of conditions being claimed. Colic, Asthma, Allergies, Learning Difficulties, Autism, Infections (ear & recurrent), Cerebral Palsy & Brain damage (or symptoms associated with) and even ‘Threatened Miscarriage’. Not a single one of these sites provide any robust evidence to support these claims!
http://www.cambridgeosteopaths.com/osteopathy.php
http://www.coachhouseclinic.com/motherandbabyclinic.htm
http://www.osteopath-bristol.co.uk/baby-childhood-ailments.asp
http://www.bridgendosteopath.co.uk/paediatric_cranial_osteopathy.html
http://www.ealingosteopathyforchildren.co.uk/
http://www.busheyosteopathy.co.uk/cranial-osteopathy.html
http://www.leomeyerosteopath.co.uk/whatosteocanhelp.htm
There are lots more sites just like this ……
Note: Simply saying ‘may benefit‘ rather than ‘cure‘ doesn’t matter. Anything that implies a particular condition can be treated would require evidence. The ASA/CAP website provides some clear guidance and there is Osteopathy specific advice available if needed (requires login – free)
(At present) I am not aware of any complaints having actually been sent to either the ASA or GOsC on this matter yet, however those making claims for Cranial Osteopathy would do well to heed the GOsC advice and also to familiarise themselves with how the ASA viewed similar claims for Craniosacral Therapy. http://www.asa.org.uk/Asa-Action/Adjudications/2010/9/Craniosacral-Therapy-Association/TF_ADJ_49005.aspx
We have already seen how research ‘evidence’ for the two therapies is virtually interchangeable and the claims being made are almost identical.
On the subject of evidence. NCOR are still conducting their literature/evidence review and have said they hope to release the results sometime around the end of March.
The results of an RCT into Cranial Osteopathy for Cerebral Palsy has recently been published and an abstract can be found here: http://adc.bmj.com/content/early/2011/02/23/adc.2010.199877.abstract
The conclusions of the trial say:
Conclusions: This trial found no statistically significant evidence that cranial osteopathy leads to sustained improvement in motor function, pain, sleep or quality of life in children aged 5–12 years with cerebral palsy nor in quality of life of their carers.
There is an interesting comment in the results that says carers of those in the intervention group were almost twice as likely to report that ‘global health’ had improved, rather than decreased.
I have contacted one of the researchers on this, although I suspect that any perceived improvement could be down to the fact that they were actually getting some form of treatment, compared to the control group that were simply on a waiting list. It remains to be seen if this comment will be ‘cherry picked’ as evidence, the overall conclusions however show no benefits for carer or patient.
I’m sure this will be included in NCOR’s review.
Alan Henness
March 14, 2011
Excellent! A regulator that actually seems to be regulating and taking their role to protect the public seriously.
skepticbarista
March 14, 2011
Agreed!
Of course the real test will be to see if the Cranial Osteopaths choose to make the required changes. If not then they have made a deliberate decision to ignore both the ASA and GOsC guidance ……….. and that would be silly!
http://www.nightingale-collaboration.org/
skepticbarista
March 14, 2011
And Richard Lanigan becomes the first to cherry pick the cranial osteo for cerebral palsy ‘global health improvement’ comment.
Via Twitter:
Then when it is pointed out states that it was reported to him second hand!
….Best to read the report before getting too excited!
I knew somebody would jump to conclusions (or rather ignore them), but I thought it would take a little longer and would come from somebody who had at least read the abstract report results!
Richard Lanigan
March 14, 2011
Hi SB,
I have not read the entire study, just the abstract. I know nothing about Cranial Osteopathy, as you know I have questions myself about claims they make about feeling “suture movement” so it makes no difference to me whether the study is positive or negative and I have no reason to cherry pick.
Presumably Professor Ernst has read the entire article and obviously coming from different sides of the argument, I was making the same observation about him as you are now making about me, I had only 140 characters to do so.
From a clinical point of view, I would argue that making a reductionist analysis of specific conditions was secondary to an overall perceptions of well being, and I asked Ernst to “explain” these observations in the Tweet.
Ernst presented study as no effect at all. Now if the carers of the CP children report positive anecdotal observations simply because someone is trying to help them, is that not important to the general wellbeing of people with CB. If some touchy feely persons comes with crystals and puts them under the bed and it makes people with severe difficulties in their life a little bit happier, so what?
I for one would not deny them that. I would go as far as saying it was cruel to deny them because of a dogmatic attachment to statistical analysis of ” scientific evidence”. I may have mentioned a guy I started seeing 2 years ago with Parkinson’s. He came in a wheel chair with back pain. He still gets back pain but his life has been transformed and I dont spend ten seconds wondering about whats happened to him or whether I had anything to do with it.
A friend of mine died last week from pneumonia, he was given months to live 8 years ago, yet he lived another 6 years and wrote about 10 acclaimed academic books in that time. Nothing wrong with seeking explanations however the fact remains there is not always an explanation and I can live with that. It was Theo who thought me that http://www.henryreevebrigade.org/?p=202 . He was a qualified medical doctor and an epidemiologist consultant for the World Health Organisation.
It has always made me laugh when I get criticised for coming under the influence of quackery when by far Theo is person who has influenced my thinking the most and why I dont cherry pick, I evaluate all the evidence as best I can. I will be reviewing Theos books in the coming weeks, if you want to start reading the works of a man who truly wanted to make a difference to peoples lives.
WOsteopath
March 14, 2011
shall I start the countdown to another interesting blog-post about Osteopathy turning into a debate about chiropractic?
Richard Lanigan
March 15, 2011
Its not about osteopathy or chiropractic is about the use of evidence?
Bruce
March 15, 2011
@WOsteopath
Ok why don’t you answer this simple Osteopathy question. How many disorders listed on the ASA list for Osteopathy are actually covered by robust evidence for that treatment.
I have no ax to grind with osteopaths as much as I dont have with chiropractors. But as the post above says it is all about evidence and strong evidence at that which is what the ASA suggests it requires. (high positive RCT’s)
If it’s any consolation I’m with you, let’s keep this on subject this time, it is an interesting debate.
skepticbarista
March 15, 2011
Bruce & Richard.
You are both wrong. This thread is not specifically about the evidence, it is about the claims of cranial osteopaths, the impact of the ASA’s new remit and the actions being taken by the GOsC to regulate those claims in accordance with the ASA/CAP guidelines and GOsC Code of Practice.
If you have any issues with the ASA’s stance or use of evidence, then take it up with them. The rules are in place and until they change then (ALL) advertisers need to comply with them.
CAM is not a special case!
The question of evidence was covered here:
http://skepticbarista.wordpress.com/2011/02/01/osteopathya-question-of-evidence-part-1/
http://skepticbarista.wordpress.com/2011/02/03/osteopathya-question-of-evidence-part-2/
And it you want to talk about it that’s the best place to post.
This is about the advertising a nd regulation of (cranial) osteopathy and IT WILL NOT become another thread where pro-chiros can deflect from their own lack of evidence by moaning that others don’t have it either.
WOsteopath
March 15, 2011
Arthritic pain
- no good RCTs as far as I am aware
Muscle spasms
- no good RCTs as far as I am aware
Neck ache
a few reasonable RCTs
Fibromyalgia
- bizarre that this is in there
Rheumatic pain
- a strange nonsensical term not even sure what it refers too
Backache
- several good RCTs
Circulatory problems
- no good RCTs as far as I am aware
Digestion problems
- no good RCTs as far as I am aware
Joint pains including hip and knee pains
- a few reasonable RCTs but not conclusive
Lumbago
- assuming that this refers to LBP several good RCTs
Neuralgia
- a strange nonsensical term not even sure what it refers too
Sciatica
- not too sure about this one would say the evidence is mixed
Inability to relax and tension
- a strange nonsensical term not even sure what it refers too
Minor sports injuries
a mixed bag of evidence
Generalised Aches and pains
- a strange nonsensical term not even sure what it refers too
Back pain, general acute and chronic
-see above
Cramps
-not sure about the evidence for this
Muscle spasms
- a strange nonsensical term not even sure what it refers too
Headaches
- again not a very well defined thing mixed evidence at best
Frozen shoulder /tennis elbow
- why are these together as they are separate clinical entities (and not much in the way of evidence here either)
as you can see there is very little evidence for much in Osteopathy.
I am fairly relaxed about this, gradually we can work on increasing this through research.
Skeptics and anti-CAM activists may not be happy about this and make the point “why should Osteopaths be allowed to practice as if they had evidence for what they do…”
an interesting point but until all medical interventions are backed by that level of evidence and legislation requires robust evidence for all medical interventions a redundant one.
The ASAs list is slightly bizarre I don’t really understand how they have arrived at it but thems the rules and Osteos would do well to stick by them.
With regards to Cranial Ost. I don’t believe that the Cranialists model of what is going on under their hands is correct. As they propose a left field model that does not conform with a conventional understanding of anatomy and physiology and they need a little more in terms of evidence to back that up.
This is not to say that there is not therapeutic benefits from Cranial treatment, but as it is at the moment experimental and not understood properly I don’t think it is right to start advertising
Bruce
March 15, 2011
@WOsteopathy
A fair representation of the facts. I believe both osteopathy and chiropractic have been shaken and need to work on better evidence. I think it will come though either individually or as a joint venture where appropriate.
With regards cranial osteopathy, the same applies, more evidence is required.
Richard Lanigan
March 15, 2011
No one would dispute that there could be more evidence for all clinical interventions. The biggest study of this kind was done by the Kings Fund on claims being made by GPs in 1998.
All clinicians need to clean up there act with regard to advertising claims as to “treatment” for specific “conditions” and I am not an apologist for chiropractors or osteopaths producing shoddy websites. However claiming to “treat” a condition is not the same as providing “health care” for someone with a certain condition and skeptics don’t seem able to grasp the difference.
The guy with Parkinsons who I mentioned above, now does two hours of intensive exercise every day, drinks more water, better diet and maintains spinal joint function. To me common sense, not things his consultant attached much importance to and a life has been transformed.
It would be wrong of me to advertise a “treatment” for Parkinsons however I dont have a problem with saying I provide spinal care to a man suffering from Parkinsons and believe others should try it just to see if there are benefits. Or do Skeptics believe I should keep this information to myself, as no RCT’s have been done and people with Parkinsons shopuld do as there consultant advises and not over do it.
If a patient presents because they have been led to believe by advertising that a condition can be treated by an intervention there should be robust scientific evidence to support these claims.
If someone wished to try an intervention on the basis of “anecdotal evidence” that is their choice. Skeptics might argue that people are “delusional” and are being misled by claims being made by CAM practitioners and need skeptics to look after them, fine but I cant see the point. There is tiny amount of evidence of people being misled by CAM.
The “evidence” shows that the GCC has spent near on £3,000,000 to pacify agitated skeptics to make chiropractors write better websites that comply with ASA guidelines. I can think of better ways to spend £3,000,000, perhaps the skeptics think this is money well spent, I suspect not or they would have done more crowing over the admonishments that have been given out by the GCC. You think the GOC is unaware of what has been going on with chiropractors, however they have more leeway and will only send cases to the PCC
Compare this to the fact not one complaint was brought against a GP after the Kings Fund study for what included claims about some life threatening conditions. The GMC made GPs aware of their deficiencies after the study and GPs acted on them as presumably will CAM practitioners in the future, it is a criminal offence to commit fraud in the UK and rightly so.
Insurance premiums will increase, lawyers and committee members will have earned from all of this, unfortunately none of the money has been spent on research and is less likely in the future, where the emphasis will be on how to play the game and write a good website.
I have contacted the ASA asking how they arrive at their conclusions about “evidence” as to efficacy of “Beauty products & health care interventions” . They refuse to divulge who their experts are, which I would have though affects the credibility of their decisions.
Andrew Gilbey
March 15, 2011
@Richard Lanigan
Why do you think that you have helped the guy with Parkinsons? Also, given that I suspect he could be identifiable in the town where you trade, do you think he would mind being discussed by you on this blog?
More generally, is it me, or do CAM advocates seem to assume that when [more] research is conducted the results will be positive? My guess is that due to being severely underpowered, most actually would not provide postive evidence.
Richard Lanigan
March 20, 2011
Because I pushed harder than his consultant.
We are going to write up his case as a case study so he does not mind.
Its you, there is a big difference in the skill level of different practitioners.
Bruce
March 17, 2011
@Andrew Gilbey
I actually agree with you Andrew, for once. The results, as in any healthcare profession, would be mixed. Regarding dealing with functional biomechanical evidence, if it was easy or straightforward to prove, physiotherapy would have done it years ago and they have access to far more research grants than CAM at any level.
But once again, the necessity and difficulty of proving something works, depending on methodology, variables etc. is the same for all healthcare, including allopaths.
One thing I do agree with, is we are entering an age where evidence is required and good evidence at that. CAM as well as allopathy must rise to the challenge. As said before that is why I am sure that a more sensible guide to evidence eg College if Medicine, will be beneficial to healthcare and the public in general.
The concept of presuming something would pass the test to become ‘evidence based’, I suppose would be based on the experience of the clinician and the patient.
Interestingly, a friend of a friend has been seeing a homeopath for many years for a stomach problem. She stopped going because of the bad publicity. She now suggests to them her complaint is back. For the last three to four months I understand she has been undergoing tests through her GP which must be costing a few pounds, and as yet to no avail. The medication prescribed has not helped. My only advice, although I am not a great advocate of homeopathy was, if it works for you, it’s finacially viable and it’s safe, use it. Forget what the media and sKeptics say, they are not suffering she is.. Never an easy call but I think the advice I gave was based on common sense. Not sure what direction she took?
I am not sure we are not going off topic though but responding to a question from a sKeptic must be allowed? Sorry about the homeopathy anecdote, it was interesting in the fact that if something is taken away and allopathy or EBM cannot help, is there not a danger of stopping people getting the treatment ‘they’ find beneficial. This must include osteopathy or in fact cranial osteopathy?
Bruce
March 17, 2011
Sorry to answer the last paragraph i made: Yes I know it’s the claims being made, but as WOsteopathy has rightly said, the ASA guidance on osteopathy does not stand up to scrutiny. Where is protecting the public in that. This is a fascinating thread and shows holes in both sides of the argument, as it should. CAM I am sure will rise to the challenge, will the sKeptics?
Blue Wode
March 17, 2011
Bruce wrote: “Interestingly, a friend of a friend has been seeing a homeopath for many years for a stomach problem. She stopped going because of the bad publicity. She now suggests to them her complaint is back. For the last three to four months I understand she has been undergoing tests through her GP which must be costing a few pounds, and as yet to no avail. The medication prescribed has not helped. My only advice, although I am not a great advocate of homeopathy was, if it works for you, it’s finacially viable and it’s safe, use it. Forget what the media and sKeptics say, they are not suffering she is…Sorry about the homeopathy anecdote, it was interesting in the fact that if something is taken away and allopathy or EBM cannot help, is there not a danger of stopping people getting the treatment ‘they’ find beneficial. This must include osteopathy or in fact cranial osteopathy?”
Sounds to me like the lady was benefiting from the highly focused, compassionate, attention that she would no doubt have received at each visit to her homeopath. It makes one wonder if there isn’t a place for “tea and sympathy” cafes where those in need of an understanding ear could enjoy a cuppa and a cake, and even a hug, without being deceived, and without unwittingly helping to create double standards in healthcare.
See the last paragraph here:
http://www.arthritisresearchuk.org/arthritis_information/arthritis_today_magazine/winter_2006/mind_over_matter.aspx
skepticbarista
March 17, 2011
There are some interesting comments showing up in this thread, some I agree with and some I don’t. As soon as I get a little spare time I’ll respond to some of them.
Briefly ….
@Richard Lanigan:
You talk of the cost of skeptics actions and say “unfortunately none of the money has been spent on research and is less likely in the future”
Whilst the Bronfort Report was not ‘new’ research, (it was just a review) it did only happen because of the impact of the complaints.
How much did they spend on research BEFORE this happened?
@WOsteopath:
Nice to have the views of an osteopath on osteopathy. Some good points.
@Bruce:
“CAM I am sure will rise to the challenge, will the sKeptics?”
I have to disagree with your assumption that CAM will rise to the challenge. Particularly if you are talking CAM as a whole. There are some deeply ingrained belief systems at play here.
Most CAM practitioners will happily reject any evidence unless it supports their cause.
Your comment touches on an area that @Andrew has already mentioned.
CAM supporters automatically assume that evidence will support their view.
The have an expectation that future results will justify their current claims!
Many forms of CAM have been around for many years (and usually use this as some form of justification) yet they continue to operate without any consideration for evidence.
The fact remains that many continue to offer to treat medical conditions (some serious) without any evidence to support the treatments.
If good quality evidence were to be published and the results could be independently verified to support a particular CAM treatment, I think most skeptics would accept this …. at least all the ones I know would!
@Blue Wode:
Tea and sympathy is no cure for any condition, but it goes some way to putting the patient at ease, but to give that attention takes time …. the vast majority of GP’s don’t have that time.
CAM therapists can provide this (at a cost ££) and exploit it as best they can ……. for the vast majority of them it is all they have!
I wonder how many NHS patients would take up the offer of a 30min-1hour appointment if they had to pay £30 or £40 extra for it …. I guess not a lot and many would complain about having to pay for it, they then happily run off, wallet in hand, to a CAM therapist!
When talking about chiro the W.H.O. acknowledge that the majority of any perceived benefit comes from the attention given and the ‘laying on of hands’ rather than any benefit from the treatment.
I think this is probably true for most CAM.
Blue Wode
March 17, 2011
Skeptic Barista wrote: “Tea and sympathy is no cure for any condition…”
…that’s assuming a patient has a condition that requires curing. Many CAM patients are the ‘worried well’.
Sketpic Barista wrote: “…it goes some way to putting the patient at ease, but to give that attention takes time …. the vast majority of GP’s don’t have that time.
I agree. It seems to be more of a social problem.
Skeptic Barista wrote: “CAM therapists can provide this (at a cost ££) and exploit it as best they can ……. for the vast majority of them it is all they have!”
Totally agree.
Skeptic Barista wrote: “I wonder how many NHS patients would take up the offer of a 30min-1hour appointment if they had to pay £30 or £40 extra for it …. I guess not a lot and many would complain about having to pay for it, they then happily run off, wallet in hand, to a CAM therapist!”
…but they might pay £5-10 for tea and sympathy!
Skeptic Barista wrote: “When talking about chiro the W.H.O. acknowledge that the majority of any perceived benefit comes from the attention given and the ‘laying on of hands’ rather than any benefit from the treatment. I think this is probably true for most CAM.”
Then perhaps ‘free hugs’ are the answer:
Bruce
March 17, 2011
@ blue woad
I am not advocating homeopathy, and I am aware of Lewiths research. What I am advocating is a persons right to choose, given all the facts. I mean this whether in CAM or allopathy. You can’t have one rule for one and another for another.
@skeptic barista
Yip, my only experience with CAM is with chiropractic and osteopathy and I believe that both those professions can and will rise to the challenge. I am also certain that the time and care given to the patient goes some way in helping them get better. But isn’t that basic stuff, and is the ‘care’ part in ‘healthcare’. However, in both profession I allude to, I feel that it is not the whole answer and at least when dealing with biomechanics and functional problems, evidence will progressively appear positive. I cannot speak for the traditionalists in both camps, but I get the impression they actually stand up for themselves.
Only time and reserarch will tell.
Interestingly, the statement with regards GP’s and time is accurate. My own, and I am certain others will share my feelings and experience, is that the service and caring, in some cases, has been lost and making money has taken precedence.
Prescribing and taking a cut out of what they prescribe springs instantly to mind. A bit of an ethical problem there I think eh? But that’s for another debate.
Where has the vocational aspect gone, thankfully it still seems to survive in all, not just a few, of the osteopaths and chiropractors I have met.?
Just an opinion based on personal experience over time, but not in all cases,the last statement us for clarification and just to reduce the potential teeth gnashing
Blue Wode
March 17, 2011
Bruce wrote: “What I am advocating is a persons right to choose, given all the facts.”
Isn’t that the main crux of the argument – i.e. “given all the facts”? I, too, am for the right to choose, but I care that it should always be an *informed* choice, and you can’t do that without a good explanation of the evidence. There’s a good article about the problem here:
Freedom of Informed Choice
http://www.skepticreport.com/sr/?p=80
skepticbarista
March 17, 2011
@Blue Wode:
“Many CAM patients are the ‘worried well’.” – Very true and tea & sympathy would work very well there.
@Bruce:
There are a few things the chiro & osteo’s need to accept if there is any genuine desire to rise to the challenge of becoming an evidence based profession.
The evidence we have NOW is what they need to use to justify current claims. Future evidence may change that ……. but making claims now in the hope that something will eventually back them up, is not the way it should work!
They need to accept the findings of well designed, well conducted trials BEFORE the results are published. Not reject good research that doesn’t say what they want it too and blindly carry on until something comes along that they might agree with.
skepticbarista
March 17, 2011
On the subject of this thread.
At least one site linked to in the blog post has made some changes.
Conditions like colic, ear infections and cerebral palsy have gone, however ‘feeding difficulties’ and Asthma remains. The CAP guidance is very clear on Asthma !
Asthma was one of the first condition I asked the GOsC about almost a year ago. Perhaps NCOR have some new evidence to support this and it will come to light in a couple of weeks when they publish the results of their latest literature review.
…. but it’s a start!
Bruce
March 17, 2011
@ bluewoad
My goodness, it seems like I have reached an agreement in principle, with you.lol
@skeptic barista
I also agree with not advertising things where there is no evidence, based on ASA guidelines and within the confines of common sense e.g. bronfort states that tennis elbow can be treated but not golfers elbow, yet basically they are the same biomechanical and pathological process?
I think, as long as the rules for CAM remain the same for ‘mainstream’ medicine to include physiotherapy, then no one would have a problem. Currently that seems not to be the case.
So let’s see if the NC can get it’s act together and work on a level playing field. Personally, based on the people involved and their history, I cannot see it. I wait with hope and bated breath though lol
WOsteopath
March 17, 2011
I am in agreement with much of what is being said here.
I totally agree that where an effective treatment is available that should be what patients are offered first. I would agree that where asthma allergies learning difficulties etc etc are concerned without better evidence than what is on the table already there is a serious ethical and legal (obviously) issue about making claims.
One thing to bear in mind however is the general paucity of evidence across the gamut of musculo-skeletal medicine. Should everyone suffering chronic hamstring strains be told: sorry there is no good evidence for any approach (because there ain’t) just give up playing football. should knee surgery be banned for lack of evidence? Clearly that is nonsensical.
At present musculo-skeletal practioners are all muddling through attempting to deal with the massive variability of response to treatment due to the complexity of the neuromusculoskeletal system. This is still not even vaguely understood. Many long held pet theories are being swept away by advances in the understanding of Neuroscience.
This is in the process of changing rapidly in the next 5-10 years we will see huge shifts in the understanding of the way the musculo-skeletal system actually works through basic scientific research. and this should help to inform further research by other disciplines. Whether those disciplines are prepared to give up long held pet theories is another story however. This applies equally to chiros osteos and physios.
My personal view is that you will see much more of different professions crossing over in training MSK medicine is moving very much toward the Multi Disciplinary Team model. There is huge overlap between the way physios and osteos are trained. On my MSc there is an even split between physios, osteos and medics (mostly GPs and docs that have just finished their F2 training). And although the osteos are out of the NHS loop the osteos on the course have no trouble keeping up with any of the other professions, and ‘shock horror’ are able to make sensible comments and dont just start waving crystals and offering sugar pills at the sight of a meniscus tear.
However it appears to me that some professions are more tightly bound to their belief systems than others. And Cranialism seems to be one of those areas within osteopathy. I can only agree with SkepticBarista that belief plays a huge role in refusal to accept negative evidence and I have seen this with many of my cranial colleagues.
While I dont believe in the mechanism proposed by cranialists, people do get a benefit from the treatment of some sort, whether this is medically relevant to any conditions is a debatable matter (i dont think so and the evidence certainly doesnt point that way), potentially it is just a placebo response being elicited.
I personally feel that there is an element of what could be described as social grooming (after all we are still primates) creating a sense of well-being through the act of simple touch, and this could account for the perception of health improvement and the undoubted popularity of cranial treatment. However I come down on the side of the skeptics when I see people claiming to treat medical conditions with cranialism.
Bruce
March 18, 2011
@WOsteopathy
you said
‘One thing to bear in mind however is the general paucity of evidence across the gamut of musculo-skeletal medicine’
Look the problem I have is these guys hide under the banner of patient safety and informed choice, yet they ignore the same problems in mainstream medicine. They make accusations that we go off thread, they ban or censor posters and all for asking for fairness across the board.
It is not only musculoskeletal medicine that has little evidence, with I believe physiotherapy coming way down the pile, but it is the same in dentistry, podiatry, medicine, psychotherapy etc.
Surely patient informed choice and risk must come into that as well. Some of the replies have been silly at best and on occasions dangerously bigoted and intolerant. But I am grateful for these subjects being brought up eg CAM, evidence, regulation and that it will only make those who rise to the challenge stronger especially osteopathy and chiropractic.
I read this on a CAM website, I’m guessing the information is accurate otherwise it wouldn’t be posted on YouTube.
With regards chiropractors prescribing in the same vein as nurses, dentists, podiatrists and Physiotherapists, it will be interesting to see how this plays out, if at all.
The piece states at 1.50 that a representative of the American Medical Association, who was against chiropractors prescribing, seems to have use as part of her argument that medicine is the 5th largest cause of death.
I think a search for EBM in CAM is worthwhile. I think the denounciatiom of any profession out for serious finicial gain from sick patients is itself sick. I believe in patient choice but agree with informed choice. I worry about the current state of the NHS, the concept of GPs being paid 300k and being in charge of the purse strings, of making money out of the drugs they themselves prescribe as much as I worry about unethical CAM practitioners offering bogus treatments for large sums of money. What I don’t agree with is global accusations and generalised attacks even though there is large proportion of both allopathy and CAM that are ethical and professional.
As always a difficult call to post or not to post in order to keep within the confines of the thread.
WOsteopath
March 18, 2011
guessing that info is accurate because its on YouTube? hmm not sure about that.
I feel there should be a new addition to goodwins law
http://encyclopedia2.thefreedictionary.com/Goodwins+law
(perhaps the first amendment)
stating:
As an internet discussion about CAM grows longer, the probability of ending up discussing chiropractic approaches one.
Bruce
March 18, 2011
@WOsteopathy
That’s a little unfair, the statement was in relation to the general attack on CAM but was intended to highlight that allopathy is in the same boat. It just happens to be on a YouTube clip of chiropractic.
I am surmising that the statement has some credibility based on the fact it describes meetings between a committee made up of US senators, some of whom were named, and representatives of other groups. The comment allegedly made by the AMA rep would probably hold up based simply on research and would surely be able to be verified. If the statement was untrue, the US is hardly known for it’s lack of litigation.
I also believe that it is rather naive to think that both the chiropractic and osteopathic professions are not in this together to a certain degree. Talking to friends in both professions, I also understand that they see themselves as distinct and separate, especially the traditionalists. But surely those following EBM and musculoskeletal medicine are actually to outsiders, possibly two spokes of the same wheel albeit with slightly differing treatment approaches. ( before a sKeptic pops in, it needs to be clarified that I believe both groups to be beneficial, ethical and professional in their approach to patients).
Or maybe you are right WOsteopathy and actually it is easier if both professions stand alone in all this. Who knows? Lol
To clarify, there was no intent to turn the conversation around to chiropractic as, based on experience, I support osteopathy equally as well.
I am sure the sKeptics, who will be giggling in the corner, will see your response as some form of divide and conquer. Not really anything on my part to either divide or in fact conquer:-)
Enjoy the weekend
skepticbarista
March 18, 2011
Speaking generally, I think one of the main differences I’ve seen between chiro and osteo is the fact that many osteos do not offer to treat colic, asthma, allergies etc, those that do are almost exclusively ‘cranialists’. This is a different divide that that we see in chiropractic. The differences or similarities between the two may make for an interesting discussion …. but that would be on another post. (it gives me an idea though!)
I would also point out that the osteo & chiro evidence problems I look at tend to focus on the non-musculoskeletal conditions, even if I think there are other areas in both professions where the evidence is by no means conclusive.
What tends to happen most of the time is people (usually the pro-chiro group) will come along and start talking about evidence for back pain or tennis elbow etc. That, or some comparison with GP’s or Edzard Ernst. Even Higgs Boson particles ….. Anything but the question in hand
Just to be clear …… what I’m talking about here is people like osteos, chiros and physios (if they advertise it) offering to treat conditions like colic, asthma, allergies, learning difficulties, threatened miscarriage and brain damage etc – Not a stiff shoulder or aching back.
It’s also about the regulation of these claims. Not only do they breach the CAP codes, but they often breach the various regulators code of ethics/practice.
Each time I’ve looked at this, I have started by talking to those who should know the answers, GOsC, NCOR & GCC for chiros and even the Craniosacral Association, when they fail to provide any sound evidence, I think it is perfectly acceptable to question it more openly.
@Bruce: You say “I am sure the sKeptics, who will be giggling in the corner, will see your response as some form of divide and conquer.”
I don’t see WOsteopath’s comment as any form of divide & conquer, what I see is an osteopath who agrees that there are issues with certain areas within his profession (the cranial side) and is willing to discuss it. I think there is an honesty in that approach that gets some respect from me.
Also WOsteopath isn’t alone, I’ve seen other osteos who feel the same. Show me a chiro who is openly critical of those in his/her profession who claim to treat allergies or asthma and all other similar conditions!
P.S.
@Bruce: You shouldn’t be surprised if a skeptic does pop along ….. it’s a skeptical sort of blog!
Richard Lanigan
March 20, 2011
“Show me a chiro who is openly critical of those in his/her profession who claim to treat allergies or asthma and all other similar conditions”!
I am critical or all chiropractors who claim to “treat” medical conditions. http://www.chiropracticlive.com/if-you-are-going-to-treat-symptoms-this-is-the-british-chiropractic-associations-advice-on-complying-with-asa-code-if-you-correct-vertebral-subluxations-its-irrelevant/ You will have never heard me claim to treat anything. Thats why many chiropractors are opposed to chiropractors prescribing because it implies treatment for conditions. It is wrong for a practitioner of any intervention to claim a treatment unless there is overwhelming evidence to support it.
Chiropractors should stick to providing spinal care for dysfunctional joints and I am happy for scientists to examine how the relationship, between spinal joints and nerves affects the systems our body requires for health and wellbeing.
Bruce
March 18, 2011
@skeptic barista
Actually I agree with the general thrust of your attacks.
If either chiros or osteos advertise things such as colic, asthma (mechanical function rather than the pathology excluded, however that would not allow for an ad to ‘treat’ asthma), allergies etc. then they must have evidence. It is that simple. However, the level of evidence required by the ASA has been strengthened and therefore I think all healthcare must abide by those same rules.
As for chiros who wouldn’t criticise those who advertise those disorders, I am sure they are quite a few. I do however believe that the skeptic attack has made people more responsible in their advertising. Which is a good thing.
With regards WOsteopathy being right, possibly and although I can see his point in part, I must stand by my statement
With regards sKeptics popping in, I know, that’s why I am here
skepticbarista
March 19, 2011
@Bruce:
I agree that healthcare in general should be required to meet the rules and I think the ASA’s required standard for evidence is fine.
What needs to be remembered is that the ASA only deal with ‘advertising’ and the rules apply right across the board …….. CAM or otherwise, there are no exceptions.
GP’s don’t tend to make such outrageous claims ….. if they do then they SHOULD be challenged.
The ASA are not able to prevent a therapist or GP actually offering these things in the clinics/surgeries.
Also whilst general medicine may not be perfect (I don’t know of any skeptic who claims it is), there are far stricter controls and regulations in place to cover it. CAM is largely unregulated and where it is, they are ‘usually’ self appointed or bodies who are more concerned with promoting a therapy than regulating it.
Bruce
March 19, 2011
@skeptic barista
This is getting scary, I agree totally with your last post. I appreciate the statement re CAM. I understand the concept of controls in medicine and appreciate they have on the face of things ‘tighter controls’.
My beef has always been, attacking CAM for it’s laxity in advertising, and I have said before my only experience is with osteopathy and chiropractic, is not necessarily a bad thing. But I think the standards of critiquing are ridiculously high as these standards are not reflected across the board and most certainly not enforced in ‘mainstream’. This is why the College of Medicine, populated by many esteemed and respectable scientists, will review and set guidance for evaluating evidence. Surely, if fair and reasonable, it must also be acceptable?
Therefore if the current critiquing mechanism were used ‘fairly’ across the board, and patients were informed about the evidence and made fully aware of the risks involved in procedures and treatments, than a large percentage would possibly not happen and psychotherapy and physiotherapy at the very least would have very little to do. Does that mean I do not believe they offer a benefit, for physiotherapy my own experience is it is a waste if time, but I am sure others gain some benefit. This of course is even without any robust evidence existing. However I am also aware, as is the ASA I understand, that they have been used in a politically motivated attack rather than that of ethics. This is borne out by comments made on sKeptic websites who openly admit it was in response to the BCA-Singh case.
We are where we are, with some positive outcomes and some negative ones at present. What intrigues me, although I am happy that it hasn’t happened, is why the ASA listing for osteopathy has not been challenged on behalf of the patient, if as you guys now claim, evidence/ informed choice/safety is the real reason for the current attack. You even have an osteopath stating openly that the ASA listing has no real basis and I commend him for that.
Interesting as always, and talking to my friends in CAM they don’t have a problem following EBM ( the chiros I know are members of the British group). I get the impression that a very large percentage of those being pulled up, just went along with the leaflets published by their organisations and got caught out.
To round the circle, I agree with you, you seem to follow a clear and reasoned approach, and based on that I hope we can agree on some things but as this is a debate, chose to amicably disagree on others.