Osteopathy:A Question of Evidence (Part 2)

Posted on February 3, 2011


Please see Part 1 of this series to get a view on what Cranial Osteopathy is and the reliability of the available evidence.

This post will cover:

* How common is Cranial Osteopathy
* Advertising advice & guidance!
* What answers has the GOsC given?
* And finally!

How common is Cranial Osteopathy?

It is worth looking to see how often Cranial Osteopathy it is used and who is most likely to be offered the treatment.  For this I will turn to information in the GOsC’s Standardised Data Collection (SDC) report released in June 2010. Available here in pdf format.  This covers the whole of the UK Osteopathic profession, Cranial Osteopathy is mentioned regularly throughout the document but for now I am only interested in the figures that show how common this treatment is.

Page 157 covers the ‘Profile of Osteopathic Care’.  This show that osteopaths predominantly treat musculoskeletal conditions, typically over 40% of patients will have symptoms relating to lower back problems.  Conditions where Cranial Osteopathy is more likely (but not exclusively) to be recommended are headaches (7%), conditions suffered by infants & children (8.5%) and ‘clinically diagnosed co-morbidity’ where more than one condition is present (13%).

Figure 2 on page 158 shows that regardless of symptoms or conditions presented, Cranial techniques are used as a treatment given during the first appointment in 25.8% of all cases and the sub-note to this figure states that:

‘The type of treatment given at second and subsequent appointments showed a similar distribution’

Page 175 of the report mentions a proposal that a version of the SDC tool, specifically for capturing data related to the treatment of children, is being considered :

“The development of a version of the SDC tool for infants and children is proposed, in collaboration with the osteopathic organisations specialising in this area of practice e.g. the Foundation for Paediatric Osteopathy, the Sutherland Cranial College, and representatives from the children’s clinics within Osteopathic Educational Institutions.”

This was also confirmed in a GOsC email from Dec 2010. So it is clear to see that although Cranial Osteopathy is some way from being the most popular treatment offered by Osteopaths and although not all osteopaths use cranial techniques, is certainly not uncommon – particularly for children and the elderly.  I do wonder if the reason it is so popular for infants and babies is that regular osteopathy may be unsuitable – so providing a ‘gentle’ treatment option adds another revenue stream!

Advertising advice & guidance!

The statutory regulator for Osteopathy within the UK is the General Osteopathic Council (GOsC).  The GOsC are talking to me via email (at least for the moment – but they’ve yet to read this!), so they are most certainly aware that there are questions surrounding the evidence for Cranial Osteopathy, but they were certainly aware of the issue well before I asked any questions.  The minutes of their committee meeting in July 2010 contains the following statement:

“9. Osteopaths’ advertising.  The GOsC was actively monitoring discussion of osteopaths’ advertising by members of the public in the blogosphere. There were claims by bloggers that osteopaths were making unverifiable claims for the treatments they offered and it appeared that cranial osteopaths’ websites were particularly under scrutiny.”

I should point out that it is ONLY Cranial Osteopaths that I have looked at!

“In addition to this monitoring, the GOsC continued to advise the provision in editions of the Osteopath and in the newly launched Fitness to Practise e-bulletin, that they should check their publicity for compliance with the Code of Practice and the Advertising Standards Authority Code. Osteopaths’ attention had also been drawn to up to date research published by the General Chiropractic Council – The Effectiveness of Manual Therapies – the UK evidence report , which could be used to check any claims being made in publicity. The help of the BOA in re-enforcing the advice to osteopaths on this issue was acknowledged.”

Rather than releasing evidence or a clear statement to counter the view that these claims are unverifiable, they choose to draw Osteopaths attention to their own Code of Practice, the ASA/CAP codes and the information in the UK Evidence Report.   Is it not perfectly reasonable to assume that if they held reliable evidence, they would release it when asked and in doing so counter any claims being made in the ‘blogosphere‘!  The UK Evidence Report was coverd in Part 1 of this topic.

The GOsC have certainly issued clear, unambiguous advice to their members and as the following examples show, they have been issuing this advice for well over a year.

The Osteopath Oct / Nov 09 edition (Page 9)

<-- Read this text then look at the image!

This is just the opening statement of a full page article called ‘Does Your Advertising Comply With The Rules‘. The article links advertising claims to their Code of Practice Clause 92, 122 and 123 and it goes a step further and asks their members to consider the following question:

“can you provide evidence that osteopathy in general,and the treatment you are offering in particular, is effective for the conditions you are claiming to treat?”

EVIDENCE that a treatment is EFFECTIVE – Is this not the same thing I’ve been asking the GOsC & NCOR!

The Osteopath Oct / Nov 10 edition (Page 16)

A year later another full page article called ‘Advertising Regulator To Look At Website Copy‘ said:

“All osteopaths must comply with the ASA’s requirements on healthcare advertising, as set out in the CAP Code, and you should therefore ensure that the claims made in your publicity material – both in print and online – can be verified by robust clinical evidence.”

And also …

“The change means that complaints regarding website content will now be considered by the ASA rather than trading standards officers, as is currently the case. Any complaints against an osteopath’s website could also be made directly to the GOsC, which we will be required to investigate.”

And more recently …..  The Osteopath Dec 09 / Jan 11 edition (page 22)

This is another full page article called ‘Advertising Guidelines Changed To Reflect Osteopathic Practice‘.  This is an interesting one, not only does it tell osteopaths that they need to conform to the ASA/CAP guidelines and where to obtain advice. It shows that the British Osteopathic Association have been talking to the ASA on this matter, also it actually tells osteopaths where to find a list of conditions that will require evidence to support them.

“The full list of conditions that osteopaths can refer to in their publicity material is contained in the Help Note on Health, Beauty and Slimming Marketing Communications that Refer to Medical Conditions.

This list applies to more than just Osteopaths.  Anybody making (or challenging) health, beauty or slimming claims should read it.   You need to register (free) to gain access to this list, but states that evidence may be required to support claims for colic, bed wetting and many, many more.  It also states that suitably qualified medical advice should be sought for conditions such as Asthma, Ear Disorders and Learning Difficulties …. ALL conditions that Cranial Osteopaths offer to treat!
The Osteopath also provides a good deal of coverage on The Effectiveness of Manual Therapies – the UK evidence report and have devoted a number of full page articles to the findings of this report.  These articles also contain references to ASA/CAP guidelines and advice on implementing the findings of the report.  As this report has been covered elsewhere I will simply provide links.

The Osteopath Jun / Jul 10 edition (page 14)  This gives an initial evaluation of the report by NCOR.

The Osteopath Aug / Sep 10 edition (pages 14-16)  This provides a more detailed breakdown of the conditions covered and the quality of the evidence reported.  Colic, Asthma and Ear Infections are all reported as Inconclusive.

What answers has the GOsC given?

Whilst it is true to say that the GOsC have not provided any research evidence to answer my questions and the only real action they have taken is to issue advertising guidance, they have made a number of statements on the subject and some of these are worth commenting on.  Back in May 2010 I asked the GOsC if they could point me in the direction of suitable evidence to support the use of Osteopathy as a treatment for a range of non-musculoskeletal conditions.

I have covered the majority of these comments in earlier posts:

18 Apr 2010: Osteopaths: Talking a good game..

23 May 2010:  Osteopathy: More words, Some actions, No evidence!

However since then I have had further contact with the GOsC and they have made a few interesting comments.

Dated 21/12/2010:
“You have asked us to provide details of current clinical evidence supporting osteopathic practice. The role of the GOsC – and indeed any healthcare profession regulator – is to regulate the professional conduct of individuals who are on its register; it is outside the scope of our role to collect evidence of the efficacy of particular treatments.”

They claim that collecting evidence is not a part of their role as a regulators, but they do have the services of NCOR to perform that task and that task has been done.
The GOsC are very aware of the claims being made and also of the poor quality of research evidence there is to support those claims.  They undoubtedly recognise that this could constitute a breach of their Code of Practice (item 122) otherwise there would be no reason to issue all the advertising guidance.  What they have said is:

“As you are probably aware, research development within UK Osteopathy is in its formative stages”

This may be a fact, but it is certainly not an excuse that would allow claims to be made without reliable evidence. The British School of Osteopathy was founded in 1917, the GOsC was established under the Osteopaths Act 1993. Osteopathic research should be well beyond its ‘formative stages’.

“Currently, as part of our work on improving the quality of information provided by registrants, we are focusing on the content of practice websites because of the growing public reliance on web-based information. Along with actively advising osteopaths to assess the accuracy of the information they provide in this way, we are also in the process of reviewing registrants’ practice websites, in order that we can advise them individually and more specifically on good advertising practice.”

Here is an acknowledgement that the content of a website is increasingly important to the public when seeking healthcare advice, therefore it is increasingly important that those claims are based on reliable evidence.

The GOsC are focusing on the content of their members websites and actively advising osteopaths to check their accuracy …  The GOsC have a statutory duty to protect the public, yet these websites and claims are still common place – Why!
And if the GOsC are looking at their members websites, shouldn’t they at least have a view on the evidence ….. something they claim is outside of their remit!

To summarise what I’ve been told when asking for evidence – these comments are taken from a series of emails – sadly none contained any evidence!

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.

Anecdotes do not count as evidence!

That said, the paucity of quality data relating to osteopathic practice is a deficit that must be addressed”.

I appreciate the acknowledgement that the is a lack of quality evidence – but this has so far not been addressed

“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.”

If the efficacy and safety have not been explored – Osteopaths should not be treating anybody ….. let alone babies! Why is this even remotely acceptable. Websites regularly say how safe and gentle the treatment is.

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”

I totally disagree – When Osteopaths advertise a treatment for colic, I would believe paying customers are expecting something more positive.  I think it is unlikely‘  this is based on actually asking  patients or parents,  just personal opinion.

“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”

Patients have a right to be informed  …….. I agree, but nobody is doing it!

“Notwithstanding the points above, your observations regarding osteopathic websites indicate that the GOsC must be more targeted in our guidance to practitioners.”

I will accept that a reasonable amount of clear guidance has been issued ……. but it is being ignored.  So GOsC need to take further action.

“Your additional queries relating to “cranial osteopathy” highlight another area where information could be fuller in the public interest.”

What information has been made public.  There certainly doesn’t seem to be anything on the GOsC website to inform the public.

It is difficult to avoid the similarities between this and the General Chiropractic Councils regulation of chiropractic!

And finally!

I firmly believe that there is insufficient evidence to support the claims being publicly made by Cranial Osteopaths.   I believe that making these claims constitutes a breach of the Osteopaths Code of Practice and also of the ASA/CAP advertising guidelines.  What is more the Osteopaths regulator within the UK is aware of this and seems content to simply issue advertising guidance – something that is clearly being ignored!

I am absolutely certain that there are people out there who will strongly disagree with what I have said.  The majority of the comments on the quality of the evidence have been drawn from sources within the Osteopathic profession.  If they disagree with that assessment, then they need to be able to provide robust evidence to show otherwise.

My own views on Cranial Osteopathy have been formed by looking at the information that is available and given what I have found, I believe I can justify those views.

What is more, I am not alone in thinking this and the criticisms come not just from Skeptics but from UK Osteopaths.

This division is recognised by the GOsC and the NCOR evidence summary contains the following message:

Dissenting voices
Cranial osteopathy is not without its critics who question its scientific plausibility, its place within osteopathic medicine, and its lack of evidence of effectiveness. The growth of good quality clinic trials and scientific investigation will attempt to act as a rebuttal to such critics.

I would point out here that it is equally valid (and more likely) that good quality evidence will support the views of critics!

Since my last post on the subject, I have had comments from UK Osteopaths some wishing me ‘good luck’ and others going somewhat further:

“Unfortunately cranial osteopathy is becoming increasingly popular, I think the celebrity woo endorsement has a lot to answer for… Believe it or not your campaign will have tacit support amongst many osteopaths.”

If true then that would be good.  And also …

“I would say from personal experience that while the “philosophy” underpinning cranial practice is wrong and much of belief systems that have grown up around it are flawed, there is much to be said for simple touch and a friendly face. I have had cranial treatment done on me by colleagues And I felt it to be a pleasant and relaxing experience. This however does not justify the grand claims being made by some practitioners.”

I have no problem with the notion that a friendly face and time spent with a patient is of benefit and agree that this can be lacking in many doctors surgeries, although doctors may spend more time with you if you pay them £30-£40 per session (typically 30 mins & 1 hour).  I can also understand how it may be pleasant and relaxing (even if only temporarily) and I agree with the comment that this is not a license to practice nonsense!

“However there is a large epistemological variance between what I claim to be able to do and some of my colleagues are claiming. I find this extremely worrying and to be honest feel that this needs to be addressed..”

I can understand many Osteopaths being reluctant to be openly critical of their peers, but they need to recognise that to the public  ………  you are all Osteopaths!

Criticism of Cranial Osteopathy is nothing new, as this (2004) article  from Ben Goldacre shows.  Bad Science – Cranial Osteopathy

I will do an update once the results of the NCOR literature review have been published and am interested in seeing if it comes to a difference conclusion and on  what research it is based upon. (I’ll try to make it shorter!)

Until then, it is very clear that the evidence for Cranial Osteopathy is extremely weak and has been openly criticised by many with the Osteopathic profession.

Posted in: Osteopathy