Osteopathy Part 2 – a review of 100 Osteopathy websites

Last weekend I wrote a skeptical overview of osteopathy, how it was generally seen as a mainstream healthcare option but was actually born of pseudoscience, and how, even though modern evidence has pushed back many of its original wild claims, it is still rooted there and has at least one foot fully planted in the world of complimentary and alternative medicine (CAM). You can read part 1 here.

As part of my research I had started to survey a number of osteopaths’ websites within my own home county, and used that data to show the field’s continued connection to unevidenced CAM. As a result I received more than one criticism that I had cherry-picked osteopaths who were on the fringes of the field, and that mainstream osteopathy was scientific and well-researched medicine.

With that in mind I decided to continue my review and spend the rest of (coincidentally) International Osteopathic Healthcare Week (17-23 April 2016) surveying the websites of 100 randomly chosen osteopaths in the UK and Ireland, to see just how much pseudoscience remained within the profession. Is it fringe?

Selection procedure

Obviously, this is not a scientific study, I can only claim it is a careful review. I used only declarations published on the websites (as they appeared in April 2016) and took them at face value. The websites were selected using a random number generator and the General Osteopathic Council’s own online register of members.

The majority of osteopaths practice in the south, so the randomly selected websites come from four southern counties (ten each from West Sussex, Dorset, Surrey and Devon), two midland (not Midlands) counties (ten each from Staffordshire and Suffolk), two northern counties (ten each from Yorkshire and Lancashire), and then ten from Scotland, six from Wales, and four from Ireland. If a random number selected a GOC register entry with no website (or a dead link), I continued down the register until I hit the next entry with a working website.

Criteria

To check for pseudoscientific claims I picked four criteria:

i. the claim that osteopathy allows the body to ‘heal itself’;
ii. the practice of cranial osteopathy;
iii. the claim that osteopathy can treat specific conditions not related to the musculoskeletal system;
iv. whether an osteopath also personally uses another CAM therapy as part of his or her treatment system.

Let’s look at these in more detail …

i. Self-healing

The claim that a therapy aids the ‘self-healing’ process is a recognised red flag of pseudoscience and one that osteopathy shares with other CAM treatments such as chiropractic, naturopathy, homeopathy, reiki, therapeutic touch, energy healing, reflexology, acupuncture … and I could go on and on. It’s pretty much the central refrain of most quackery, and is perfectly placed to take credit for conditions that are temporary, that regress to the mean, or that appear to react to various placebo factors. The best evidence for this kind of self-healing is the least reliable: post-treatment anecdote.

The philosophy of Andrew T. Still, the founder of osteopathy, stated that the human body is perfect and contains within it everything needed to self-heal, and that the only impediment to this is if bones or nerves cause an obstruction to the free-flow of the body’s “fluids of life”. Osteopathic manipulation, he asserted, can be used to clear the obstruction and allow the body to return to its natural state of self-healing.

While it has been tempered slightly, this philosophy remains at the core of osteopathic medicine, often accompanied by a statement saying that no drugs or surgery are needed – it’s ‘natural healing’. Here’s how the World Health Organisation defines osteopathy:

“Osteopathy is grounded in the following principles for treatment and patient management:
i. the human being is a dynamic functional unit, whose state of health is influenced by the body, mind and spirit;
ii. the body possesses self-regulatory mechanisms and is naturally self-healing;
iii. structure and function are interrelated at all levels of the human body“

In my survey of 100 randomly selected osteopath websites, 57%, just over half, explicitly stated that osteopathic treatment aids the body’s own innate self-healing mechanism.

I did not count those that alluded to the idea but weren’t explicit, eg. “osteopathy is based on the principle that the body has the ability to heal”. No one can deny that, but the question is whether money is paid for a treatment that actually aids that process, whether it would have happened anyway, or even if it would have happened more quickly without treatment.

The greatest danger with the CAM definition of ‘self-healing’ comes when it is applied to the many serious and semi-serious afflictions that do not normally obey this supposed universal rule of ‘natural healing’.

ii. Cranial osteopathy

I discussed cranial osteopathy (also known as craniosacral therapy) in part 1, but, briefly, it’s based on the belief that tiny pulsations can be felt with the fingertips and can be gently manipulated to ‘release restrictions’ and promote health.

There is no strong evidence behind this claim, and it remains scientifically implausible. In the words of Dr. Stephen Barrett – “cranial therapy is silly”.

In my survey of 100 randomly selected osteopath websites, 70% said they offered cranial osteopathy as part of their treatment services.

It was especially pushed as being beneficial for babies and children, with many setting no lower limit on age – often explicitly stating “from birth” or “from a few days old”. One website said “osteopaths believe all babies should be routinely checked after birth”. (Out of interest, only 2% of osteopathic practitioners reviewed stated they would not see babies).

And whereas general structural osteopathic manipulation focussed predominantly on conditions related to the musculoskeletal system, cranial therapy had much fuzzier claims made for it, often relating to general health and unsettled babies (eg. 19% said it could help with colic).

iii. Treatment of conditions unrelated to the musculoskeletal system

The NHS website proclaims that there’s …

“good evidence that osteopathy is effective in treating persistent lower back pain* … there’s currently no good evidence that osteopathy is effective as a treatment for health conditions unrelated to the musculoskeletal system (bones and muscle).”

(*Many osteopathy websites cite NICE’s 2009 guidance that suggested this positive outcome for early lower back pain, but in March 2016 this advice was updated to say that manual therapy should not be used on its own due to a lack of evidence.)

About this time last year, the Good Thinking Society investigated a number of websites that claimed osteopathy could treat a variety of non-musculoskeletal conditions, including colic, asthma, dyslexia, and many more. After a number of complaints made to the Advertising Standards Authority (ASA) this eventually resulted in a directive from the General Osteopathic Council suggesting that their members check their claims were in line with those advised by the Committee of Advertising Practice (CAP).

While the profession has reigned in many of the wilder claims on their marketing, osteopathy still sees itself as a ‘holistic’ treatment that can tackle a plethora of human disabilities and illnesses.

In my survey of 100 randomly selected osteopath websites, 61% claimed to be able to help with specific conditions that were unrelated to the musculoskeletal system. These included various digestive problems, asthma, colic, ME and Chronic Fatigue Syndrome, eye and ear infections, haemorrhoids, post-natal depression, boosting the immune system, menstrual problems, insomnia and more.

In the light of the CAP guidelines, there were some interesting statements. The majority of websites included a list of CAP-approved conditions, rounded off with “plus many more” (such generalisations were not counted in my survey). Some were more brazen …

“Osteopathy can help with many other conditions. If your symptoms are not listed, please telephone to enquire whether osteopathy might be effective for you.”

Another alluded to the ASA directly …

“The Advertising Standards Agency will only allow osteopaths to mention conditions where the efficacy has been proven by large-scale clinical trials. This data is not available for many conditions that patients report improvement in, so they may not be mentioned here.”

While another said …

“There is no statistical evidence it [osteopathy] can treat conditions such as asthma, colic, IBS, painful periods. However, there is plenty of clinical and anecdotal evidence suggesting it can.”

One even stretched his hand into the world of conspiracy theories …

“Most clinical trials are funded by drug & pharmaceutical companies, and osteopaths do not have prescribing rights for drugs. As a result data is not currently available for a lot of the conditions that our patients report to have improved, and so we cannot mention them here.”

Although I only looked at four osteopathic clinics in Ireland, these made some of the most far-fetched claims and were out of the jurisdiction of the ASA, including some bold statements about the treatment of autism, cerebral palsy, dyslexia, Down’s Syndrome, fertility and immune difficulties due to ‘post vaccination’, to name a few.

Concerning vaccines (excuse this short detour into another personal interest), while it is by no means a mainstream osteopathic view, the founding philosophy of osteopathy was anti-vaccine. On his website, one UK osteopath states …

“not only does immunisation directly oppose our [osteopaths] principles, it is a key point on how our principles supersede others. Immunisation is a slow poison.”

Another UK osteopath uses the shield of ‘I’m not anti-vaccine, I’m pro-choice’, before stating “often, it is the family that has vaccinated and has lived through the horror of vaccine damage unfolding within their family, that precipitates a change in their choices”.

The British Institute of Osteopathy also has an ‘interesting’ view on vaccines, strongly suggesting you have a choice whether to vaccinate or not and then spending some time adding weight to the ‘not’, in particular by linking to the website of ‘vaccine-concerned’ homeopath, Jayne Donegan, not the only osteopath I found to do so.

Thankfully, these are outliers, and the vast majority of UK osteopaths accept the science, the safety, and the benefit of vaccination.

iv. Osteopaths who use other CAM therapies

While this category does not address the field of osteopathy directly, it does, I believe, say something quite strongly about the mindset and philosophy of the practitioner in question. It is an interesting marker of how much store they set in science-based medicine, and perhaps how much they are happy to wallow in pseudoscience.

In my survey of 100 randomly selected osteopath websites, 48%, almost half, had practitioners who personally practiced and offered another CAM therapy. The majority of these were acupuncture, but they also included naturopathy, homeopathy, reiki, ear candling and even magnified healing and Bach flower remedies.

While just 29% of websites surveyed seemed to show they practiced osteopathy alone with no other CAM available in their clinic, 71% practiced in clinics where other CAM was available, either from themselves or from fellow clinic tenants. Many presented this as having the advantage of quick referral to one of the other CAM therapies as part of an ‘holistic treatment’.

In relation to children, one osteopath said “I may suggest using homeopathic remedies. These are harmless, have no side effects and can be extremely helpful.”

Another had a different source of healing power … “God’s values and principles will underpin your treatment session”.

To sum up

57% of websites in the survey published the ‘self-healing’ claim;
70% publicised the fact they offered cranial therapy;
61% made a claim to treat one or more specific ailments not related to the musculoskeletal system;
48% of practitioners also personally offered another CAM therapy – with 71% of all sites surveyed located in a setting where other CAM was immediately available.

All in all, 93% of the randomly selected websites in my survey checked at least one, often more, of these criteria for pseudoscientific claims, concluding that they are far from existing only on the fringe of osteopathic practice.

The average price for treatments seemed to be around the £40 mark, with hour-long initial consultations being more expensive than the subsequent half-hour regular treatments.

And while the FAQs often indicated a finite number of sessions were required to bring the patient back to a ‘state of balance’, there was also a strong suggestion that clients should continue with regular treatments, or ‘MOTs’, to prevent old conditions from resurfacing, and to forestall new ones from emerging. As one website put it …

“Who needs an Osteopath? Potentially everybody, of any age!”

See part 1 here.

Notes: A good follow-up by Professor Edzard Ernst can be read here.

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Osteopathy part 1 – pseudoscience in disguise?

It’s happened many times – you may have seen it yourself. There’s a Facebook thread on the effectiveness of ‘alternative medicine’, the skeptical parties are deflecting pseudoscience left, right and centre, citing evidence, throwing facts, and then someone mentions osteopathy (or even chiropractic), and suddenly the skeptics are arguing with each other … “no, this one is science! It works!”

Many people do not think of osteopathy or chiropractic as alternative medicine, perhaps largely because you see them on the High Street in almost every town, because they are often recommended by GPs, because they seem sciencey, because they have governing bodies and training programmes, because they’re manual therapies, and because so many people use them.

Anecdotes about successful treatments are everywhere. If someone has a bad back, they’re quite likely to think of a chiropractor or an osteopath before they think of a GP or a physiotherapist. I’ve seen both a chiropractor and an osteopath myself, and I came out of each feeling more ‘balanced’ and generally … good!

Out of the two, chiropractic and osteopathy, it’s osteopathy that has the better reputation. This may be partly to do with the status of each in the United States, where chiropractors are campaigning (and failing) to achieve the status of primary care-givers, and osteopaths are already recognised as such – being just about on a par with medical doctors, and often rarely using any actual osteopathic manipulative treatment but relying on the more conventional and scientific medical practices in which they’ve also been trained.

There is a greater awareness (though still not great enough) that chiropractors were born out of non-evidenced pseudoscience and that they retain those shackles even now, in the 21st century. Most hold on to the fantasy of the ‘subluxation theory’, and quite often also hold views that promote anti-vaccination, reject the germ theory of disease, and align with various ‘Big Pharma’ conspiracy theories. It is not true of all, but generally they are more Natural News than BMJ.

Many people may be surprised to know that, in the UK, some osteopaths are not far off this mark themselves. Like chiropractic, osteopathy was born of blatant pseudoscience, and while the field has had to make some advances due to public awareness of scientific principles and stricter standards of practice, it keeps at least one foot firmly in the world of ‘complimentary and alternative medicine’ (CAM), and the actual scientific evidence for osteopathy is scant.

The originator of osteopathy was Andrew Taylor Still (1828-1917). A read of his autobiography reveals that he hated “allopathic” medicine (doctors could not save three of his family from spinal meningitis) but he was a physician of a sort. He admits he learned anatomy by desecrating the graves of dead Native Americans (“[they] never objected … their relatives knew nothing about it …”) and eventually came to the conclusion that “all the remedies necessary to health exist in the human body”, all you had to do was ‘adjust’ that body and it would heal itself – nothing else should be used.

Still believed that there was no such thing as disease, and that what we call disease is actually just the effects of a “partial or complete failure of the nerves to properly conduct the fluids of life”. He goes on to detail how his osteopathy cured colds, croup, diphtheria, pneumonia, flux, ulcerated eyes, erysipelas, asthma, and how he delivered twenty babies painlessly, stopped scarlet fever with the “shake of a child”, and whooping cough with a “wring of its neck”.

If you search Google for the websites of osteopaths (see my survey in part 2 here) you’ll see that, while the Advertising Standards Authority (ASA) has made sure many of the field’s wilder claims are no longer openly promoted, the central beliefs of A. T. Still remain at the core of the profession’s philosophy and four-year training course. Here’s a few statements from the websites of osteopaths, from around my own locality in the south-east of England, all certified members of the regulating General Osteopathic Council

“We believe in the body’s inherent ability to heal itself, and the techniques used aim to set the best conditions for recovery.”

“Osteopaths work to restore your body to a state of balance, where possible without the use of drugs or surgery … to enhance the blood and nerve supply and to help your body’s own healing mechanisms.”

“An osteopath spends many years training to develop a very fine sense of palpation to enable them to feel and effectively listen via their hands to what is going on in the body.”

“Treatment can improve the circulation, immune and nervous system functioning along with improved digestion, breathing and energy levels … treatment has significantly improved conditions such as acid reflux, constipation, menstrual pain, sleeping problems and fatigue …”

“The entire connective tissue matrix, the largest organ of the body, is controlled by the unifying influence of water … treatment encourages tissues to release, promoting blood flow and cellular communication.”

“We work with the philosophy espoused by the founding fathers of osteopathy who understood the relationship between the physical body, the rhythmic forces within the body and the bio-energetic flow systems in and around the body.”

Again and again it is emphasised that osteopathic techniques restore the body to its ‘natural balance’ allowing it to ‘heal itself’ – this is the essence of osteopathy (also, by the way, of naturopathy), and the theory is not backed up by science. Alongside such phrases as ‘holistic’ and ‘individual’ treatment, there’s enough vagueness in the language that a fairly sizeable cartload of pseudoscientific claims can be ushered in through the door.

In addition, while a few practices offer osteopathy alone, the majority also provide some other form of unproven alternative therapy, such as acupuncture, homeopathy, naturopathy, reflexology, reiki and applied kinesiology, to name a few, giving you some idea of an osteopath’s general mindset. Babies and animals are often singled out as specialisms of the osteopath, and the more brazen practitioners will blithely claim that their musculoskeletal manipulations can treat ailments such as eczema, asthma, colic and irritable bowel syndrome.

The subtext (not always very sub) is clear – many osteopaths see themselves as natural healers, travelling a different road to that of the General Practitioner, Physiotherapist and mainstream medicine, getting to the real cause of illness rather than just applying drugs to the symptom. The red flags of pseudoscience are definitely aflutter within the profession’s territory.

I’ve no doubt that a good bone and tissue massage, plus a great deal of personal attention, can do wonders for any patient (indeed I’ve experienced this myself, and it has its place), and there’s some (not strong) evidence that manual therapy may have some benefit in the case of lower back pain. But that’s as much as the NHS will admit to (“osteopathy is a complimentary or alternative medicine … [and] isn’t always based on scientific evidence”) and the National Institute for Health and Care Excellence (NICE) no longer recommends massage and manipulation as a first step in treating back pain due to the poor quality of supporting evidence.

Of course the anecdotes of many will say different – even my own experience was somewhat positive in the short term (longer term, the best thing for my back has been an increase in exercise, just what NICE does now recommend, and a lot cheaper too). But the trouble with anecdote in relation to osteopathy is that it’s prone to so many obscuring factors: confusing correlation with causation, regression to the mean, the self-limitation or natural remission of the condition, placebo effect, short-term relief of symptoms but not cure, misdiagnosis by an osteo-biased practitioner, and even, sometimes, a bit of self-delusion due to the financial and emotional investment of the patient.

There are a couple of more controversial aspects of treatment given by the majority of mainstream osteopaths that are worth looking at in a little more detail: spinal manipulation and cranial osteopathy.

Spinal manipulation at the neck involves the practitioner giving a sudden twist of the patient’s head to one side. I’ve had this done, and it was not a pleasant experience. The question is, however, does its supposed benefit far outweigh any risk? There’s no clear-cut answer, but there is a growing chorus of scientific voices who think the technique may increase the risk of vertebrobasilar stroke, and a number of cases have been highlighted. Part of the problem is that some of these strokes may not happen until some time after the manipulation, a matter of weeks even, and so the correlation, if present, may not be obvious.

Cranial osteopathy is a technique whereby the practitioner uses their hands to feel the skull for ‘rhythmic pulsations’ where they can then detect and release ‘restrictions’ using very light pressure. The alleged danger comes not in the physicality of the technique itself, but in the ailments it claims to be able to treat, and the lack of plausible science to back the theory and its outcomes (not to mention the taking of money for such a thing). It is especially controversial as it is often highlighted as a technique that can (and in some cases, should) be used on very young babies.

There is no doubt that osteopathy exists at the shallow end of the pseudoscientific spectrum, at its best inhabiting much of the same arena as its more practical cousin, physiotherapy, at its worst still clinging onto the full philosophy of its quack founder, A. T. Still, while also giving credence to a whole host of non-effective alternative medicine systems that accompany many practices, legitimised by the seemingly scientific glow of a Masters Osteopathy certificate on the clinic wall.

I’ll end with a quote from a GP I once saw, who was telling me about his new baby daughter’s problem with colic: “My wife and I took her to see an osteopath. Complete quackery, but we were desperate!”. Well, he said it, not me.

Part 2 – a survey of 100 osteopath websites – can be read here.

Notes: please see the links in the article above for sources and extra information. See also:

Edzard Ernst on Osteopathy
Skeptic Barista: Osteopaths: Talking a good game
Vic Skeptics: Does Osteopathy work? Is it Scientific?
Good Thinking Investigates: Osteopathy
Quackwatch: Dubious aspects of Osteopathy
RationalWiki: Osteopathy
David Colquhoun: Cranial Osteopathy at the Royal London Hospital for Integrated Medicine

Note 2: this article was posted at the beginning of International Osteopathic Healthcare Week (17-23 April 2016).