AECC University College newborn feeding clinic continues to make misleading claims about treatment of babies by chiropractors

Rulings - ASA - CAP - www.asa.org.uk AECC take 2I have previously written about how inappropriate it is to have chiropractors working in a newborn feeding clinic. In order to address this, I complained to the Advertising Standards Authority (ASA) about the misleading advertising claims made by the AECC University College Newborn Feeding Clinic. In response to my complaint, the ASA got the AECC University College to make changes to their claims. However, it was quite clear that the changes made were merely superficial and did nothing to address the underlying issues with chiropractors “treating” infant feeding problems. I therefore complained to the ASA a second time and again AECC University College was found in breach of advertising guidelines.

The AECC University College made some further changes to their advertising in response to this second complaint. However, in reality, it is virtually impossible for the AECC University College to amend the information about its clinic to align with the available evidence because the entire clinic is based on chiropractors treating babies. There is no evidence base that supports chiropractors treating babies for feeding problems or any other health condition. The only way that the AECC Newborn Feeding Clinic could become evidence based is by removing chiropractors entirely. The AECC aren’t going to do that because they are a chiropractic college. Therefore, the AECC will keep tweaking the wording of their advertising until the ASA no longer finds issues with it. Will the AECC still be misleading the public when this point is reached? Absolutely! The entire basis of the clinic relies on deceiving the public into taking their babies to see a chiropractor for help with feeding problems.

Advertising guidelines do not prevent chiropractors from treating babies but it is clear that clinics like this are misleading the public. It is time that the chiropractic regulator, the General Chiropractic Council (GCC), stepped in to protect the public from these unsuitable treatments by applying a minimum age limit for chiropractic treatment.

The use of complementary medicine by cancer patients raises serious concerns

cancer awarenessI came across an article that looked at complementary medicine use in people receiving palliative cancer treatment in Lyon, France. It found that the vast majority (90%) of this patient group used complementary medicine. This raises a number of serious concerns that I’d like to explore further.

Effectiveness

To start with, let’s make something really clear: There are no alternative or complementary approaches that are effective for the treatment of cancer itself. None. What about when these alternative approaches are used as complementary to (along with) conventional treatments? Even in this situation, there is still very little evidence that they provide any benefit whether that be for the symptoms of cancer or to help manage side effects of conventional treatments. For instance, acupuncture is sometimes used to help with cancer-related pain but a recent review concluded that “there are insufficient high-quality RCTs to judge the efficacy of acupuncture for cancer-related pain”. Put more simply, acupuncture hasn’t been shown to be effective for cancer pain. There is a reason why these alternative or complementary treatments haven’t been accepted by mainstream medicine even though they have been tried for a long time: they don’t work.

Safety

Use of complementary treatments by people undergoing palliative cancer care raises a number of risks. Firstly, there is the risk from the treatments themselves. No treatment is without risk, in spite of what some practitioners may claim. Probably more importantly, there are also a number of indirect risks. For instance, the complementary treatment may interact with mainstream treatments reducing their effectiveness or increasing side effects. What’s particularly concerning is the number of people who use complementary treatments without telling their doctor. In this study half of respondents had not disclosed their use of complementary medicine to their oncologist. This is concerning as it doesn’t allow the doctor to have a complete picture all of the treatments being used. When someone is experiencing particular symptoms is this due to the cancer itself, the conventional treatment or side effects from the complementary treatment that the doctor doesn’t know about? It’s very important that if you use complementary treatments you tell your doctor, regardless of how “safe” or innocuous these treatments may appear.

Cost

Within this study, about a third of patients said that it was difficult to manage financially some of the time, all of the time or that it was impossible. Yet, 90% of the people studied are spending money on complementary treatments. Some people are therefore spending money on completely ineffective complementary treatments when they are facing financial hardship. If they realised how ineffective these treatments are, would they still spend the money or would they put the money towards the costs of daily living instead?

Deception

Cancer patients use complementary treatments for a variety of reasons. However, according to the paper, some people say that they are using these treatments for “assisting in stimulating the body’s ability to fight the cancer” and “trying to do everything that can help their treatment or recovery”. None of the complementary treatments being used can help with these things and this raises the question of why members of the public end up believing that they could. Whilst there will be a range of reasons it seems probable that the original source of this misinformation is the complementary medicine practitioners themselves. Indeed this particular paper, as well as several of those that it references, paints the benefits of complementary treatments in an unjustifiably positive light. For instance, it suggests that aromatherapy “is considered a popular form of alternative medicine to treat various conditions, both internally and externally”. Popular it may well be, effective it certainly isn’t. Unfortunately, the paper authors forgot to mention the latter. They further make the unsubstantiated claim that osteopathy is beneficial for a range of cancer-related complaints. The “evidence” they provide to support this? A study of just 16 patients where the patients were asked what they thought osteopathy had helped with. No actual objective evidence at all. Members of the public are therefore being deceived into using complementary treatments based on unsubstantiated claims.

Potential for rejection of conventional treatments

There are a number of issues with a cancer patient using alternative approaches as complementary to their mainstream treatment but what happens if they are persuaded to use an alternative approach instead of their mainstream treatment? That’s when things get really bad. A study from 2017 found that the death rate from cancer was significantly higher when cancer patients chose to use only alternative treatments.

Conclusions

Many people who are diagnosed with cancer use some form of alternative or complementary treatments. There are a number of serious issues with using these treatments including lack of effectiveness, safety concerns, cost and the potential for rejection of conventional treatments. If somebody with cancer wants to go for a complementary therapy because they find it relaxing and enjoyable then provided they are fully informed of any risks this doesn’t present any particular concerns. What does need to stop is the promotion of these therapies as any form of “treatment” with any specific health benefit. They don’t provide that and it is high time that measures were put in place to protect members of the public from being deceived into believing that they do.

Lessons from the Safer Care Victoria review of chiropractic spinal manipulation of children under 12

My take home points:

1. The evidence base for spinal manipulation in children is very poor with no good evidence that it benefits any health condition.

2. Chiropractic manipulations and other chiropractic treatments are offered for a wide range of conditions for which it is not reasonable to expect any benefit.

3. It is difficult to draw conclusions about the safety of chiropractic manipulation in children but it is clear that these treatments are not without risk.

4. A significant number of chiropractors who see children are attempting to treat serious conditions that should only fall under the remit of a doctor.

5. There is a need to protect vulnerable patients from being misled into undertaking unsuitable chiropractic treatments.

Overview & purpose

This was an independent review of chiropractic spinal manipulation on children under 12 years. It was not specifically intended to be a review of other aspects of chiropractic treatment. However, it provides an interesting insight into chiropractic treatment in general as some aspects of the review were not specific to spinal manipulation. The review was undertaken in Australia and was initiated by the Victorian Minister for Health. There were 4 components:

  • A search for evidence of harm
  • A review of evidence of effectiveness
  • An online public consultation
  • An online consultation with health practitioners

Key recommendations from the review

The review made a total of 10 recommendations. Here I would like to focus on 5 of them (recommendations in italics, my comments in normal font):

  • Recommendation 1 – “Spinal manipulation, as defined in Section 123 of National Law, should not be provided to children under 12 years of age, by any practitioner, for general wellness or for the management of the following conditions: developmental and behavioural disorders, hyperactivity disorders, autism spectrum disorders, asthma, infantile colic, bedwetting, ear infections, digestive problems, headache, cerebral palsy and torticollis.” This is a good recommendation. It will be interesting to see how this is enforced as it’s very clear that many practitioners are currently in breach of this new guideline.
  • Recommendation 3 – “Prior to treatment, practitioners offering spinal manipulation for children should provide parents or guardians with written information about the proposed benefits and possible risks of care.” (emphasis mine). This is an important change as it requires written information to be provided when previously only verbal consent was needed. It will be interesting to see what this written information contains. These treatments haven’t been shown to offer any benefits and it’s therefore hard to see how any parent given factually accurate information would choose to go ahead with the treatment.
  • Recommendation 5 – “Given the lack of Australian-based clinical trial evidence, the practitioner groups permitted to provide spinal manipulation (chiropractic, osteopathy, medical and physiotherapy) urgently undertake research to develop an evidence base for spinal manipulation on children, ceasing practice where the evidence shows no benefit.” This is a reasonable recommendation. However, before undertaking such research it’s important to ask whether there is a plausible biological mechanism of action for spinal manipulation for the particular condition. For some of the conditions listed, such as ear infections or asthma, there is no plausible mechanism by which spinal manipulation could have any effect and therefore it would be unethical to carry out such research. It would be more reasonable to undertake research in, for example, back pain.
  • Recommendation 7 – “In the longer term, the post registration training on offer to chiropractors with a special interest in paediatric care should be assessed against the evidence-based guidelines.” I have previously written about some of the inappropriate paediatric training provided to chiropractors and osteopaths in the UK. This is definitely something that needs to be addressed and in the UK at least I expect it will require changes to ALL of the paediatric training currently offered to chiropractors and osteopaths.
  • Recommendation 10 – “Health Ministers should consider increasing penalties for advertising offences under Section 133 of the National Law, where a registered practitioner claims benefits of spinal manipulation in children that have no evidence base“. Misleading advertising has been a widespread issue in the chiropractic and osteopathy professions for many years and it continues to be a significant problem that risks deceiving members of the public into taking inappropriate treatments. I have written about this many times on my blog. This is something that definitely needs to be tackled and it would be good to see more significant penalties being applied. As well as Australia, this should happen in the UK (and probably other countries) too.

Although this was a review in Australia, many of the recommendations made are generally applicable and it would be good to see them being implemented in other countries too.

Effectiveness

The review about the effectiveness of spinal manipulation for children concluded that the evidence base is very poor. The review found that chiropractic manipulations are widely offered for colic, enuresis, back/neck pain, headache, asthma, otitis media, cerebral palsy, hyperactivity and torticollis in children in spite of a lack of evidence in most of these conditions. In reality it is not surprising that the effectiveness review failed to find evidence to support treatment of these conditions as, in most cases, there is no plausible biological mechanism by which these treatments could provide any benefit. I find it particularly concerning that chiropractors are treating serious health conditions such as asthma and cerebral palsy. In view of recommendation 1 (above) it’s important that regulatory bodies take action to stop these unsuitable treatments.

Many members of the public mistakenly believe that chiropractic treatment is effective as they reported improvement in the condition after the treatment. This highlights how members of the public have very little awareness of how often health conditions improve of their own accord. E.g. Behavioural issues, bedwetting, constipation, colic, reflux, etc cannot plausibly be helped by chiropractic care but do often improve on their own. Therefore the “improvement” that the members of the public reported are very likely to be down to just the natural course of the condition rather than any direct benefit from the chiropractic treatment.

Chiropractors also clearly believe that their treatments are beneficial even when there is no plausible mechanism by which they could be so. For instance, 34% believed their treatments helped babies feed / latch better, 20% thought they improved bowel movements and 16% said treatments resulted in better behaviour. There is simply no mechanism by which treatment from a chiropractor could help with any of these things. This raises serious concerns about some chiropractors understanding of the human body and health. Worryingly, a significant number of chiropractors reported providing treatment for conditions that should only be treated by a doctor. For instance, 2/3 provided treatment for gastrointestinal issues, over 40% for respiratory problems (including asthma and apnoea) and 1/3 for a variety of special needs (including autism, cerebral palsy and prematurity). Some chiropractors also try to give the impression that they are doctors. Let’s be really clear, chiropractors aren’t doctors and their training is in no way comparable to that of a medical doctor.

A concerning 17.4% of people took their child to a chiropractor for “general health and wellbeing / preventative care / alignment”. Some also report using chiropractic as a routine e.g. “As they grow, I consider regular chiropractic checks to be part of our family health regime -just like regular medical and dental checks, I consider it setting a strong foundation for their future health.” There is no evidence that chiropractic treatments provide any general health benefits or prevent any health condition. There is no good reason for anyone to have “regular” chiropractic treatments and these are in no way equivalent to regular medical or dental checks. Also, the treatments that chiropractors provide do not “align” anything, in spite of what some chiropractors may claim. The fact that members of the public hold these erroneous beliefs raises concerns about what they are being told by some chiropractors.

Safety

The report found little evidence of direct harm to children from spinal manipulation in children but this was more due to a lack of adequate studies rather than because there isn’t risk: “consistent with the findings of other systematic reviews, due to the paucity of studies and the lack of reported information on the specific treatment techniques employed, it is difficult to draw conclusions about the safety and effectiveness of spinal manipulation in children.” The report noted that “Nonetheless, it is clear that spinal manipulation in children is not wholly without risk. Any risk associated with care, no matter how uncommon or minor, must be considered in light of any potential or likely benefits”. This is important as when assessing suitability of a treatment it’s the risk / benefit analysis that matters. A treatment such as spinal manipulation in children that has no evidence of benefits should not be recommended even if risks are low. The submissions from bodies representing medical or physiotherapy professions are particularly relevant here: “Submissions made by bodies representative of the medical or physiotherapy professions raised concerns related to the potential harm of chiropractic spinal manipulation on children under 12 years. In particular, there was specific concern about potential risks of harm associated with spinal manipulation of very young children, i.e. those under 2 years of age. However, no specific or confirmed instances of proven harm were presented in any submission. Nonetheless, it was the professional view of those groups that in the absence of evidence of benefit, the risks of harm were sufficient to recommend banning chiropractic spinal manipulation of children.”

It’s disappointing that the report didn’t really discuss the potential for indirect risks, in particular the risks of delaying more appropriate care. This is important, and perhaps the biggest risk associated with these treatments, particularly when some chiropractors treat serious conditions like asthma or cerebral palsy.

Medical practitioners clearly have concerns about the suitability of chiropractic care for children under 12. Of the 37 medical practitioners who provided care to a child that had previously received spinal care almost 90% expressed a sentiment that is unsupportive of chiropractic spinal care for children under 12. Concerns were raised about “Delayed / reduced access to appropriate care and non-evidence based / misleading / unethical / inappropriate recommendations”. One example statement from a practitioner was “Fortunately, I am yet to personally have to manage direct physical adverse effects of this treatment. What I have experienced, however, is the infants involved, have generally had unnecessary and unhelpful treatment which has delayed their parents seeking appropriate treatment. Furthermore, this treatment generally feeds the anxiety of their parents.” These are serious issues and it’s important to consider risks like this rather than just direct risks of chiropractic care.

Negative experiences reported by the general public were focused on cost of treatment with no resultant improvement in the condition being treated, excessive use of X-rays, or practitioner pressure to avoid medications or advice previously provided by other health practitioners. The latter points are particularly important and raise concerns about chiropractors advising against proven medical treatments.

The review also raises concerns about the need to protect vulnerable patients from being targeted by chiropractic care. Comments raised included “I feel that vulnerable families are paying large amounts of money to chiropractors/osteopaths who are performing treatments which are not evidence based and may actually harm their child.” and “I also feel that it is morally unconscionable to be purporting to provide “treatment” that is costly and ineffective to vulnerable, worried parents who can be easily taken advantage of.”

Informed consent

It is a legal requirement for any health professional to take informed consent before commencing treatments. This should include a discussion of the benefits and risks associated with the treatment as well as possible alternative treatments. Chiropractors are clearly NOT openly sharing evidence of effectiveness and risks of their treatments otherwise they would be turning away many of these patients e.g. for colic, headache, walking / crawling problems, breastfeeding, bedwetting, asthma, etc. as there is no evidence of benefit and some level of risk. This discussion ought to happen as part of the informed consent process but it is clearly not taking place as chiropractors would otherwise not be continuing to treat these conditions.

Age of children

From this review it is very apparent that most of the children being treated by chiropractors are very young (under 2). Over half (54.5%) of respondents who had accessed care in the past 10 years reported that the care was provided to a child of 0-3 months and nearly three quarters (73.1%) for a child aged 2 years and younger. Of those chiropractors who treat children under 12, the vast majority treat babies under 2 (88.5%). This is a serious concern as there are no infant conditions for which chiropractic or osteopathy treatments have been shown to provide any benefits. This is also the age group for which medical and physiotherapy professions raised the most concerns about these treatments.

Conclusions

This is a very important review of spinal manipulation for children under 12 and also provides a broader insight into chiropractic treatment of babies and children. There is no good evidence that chiropractic treatments provide any benefit for any infant or childhood condition. In many cases there is also no plausible mechanism by which these treatments could provide a benefit and due to a lack of suitable studies, it is not clear whether these treatments are safe. There are undoubtedly some indirect risks such as delaying more suitable treatments and there is also a need to protect vulnerable patients from being targeted for these treatments. The review makes several important recommendations that, if fully implemented, would help to protect members of the public from being misled into undertaking these unsuitable treatments. It will be interesting to see how these recommendations are implemented in practice not just in Australia but also how they are applied around the World.

How to design a study to give the false impression that your favourite treatment “works” in three easy steps: a worked example using craniosacral therapy

craniumCraniosacral therapy, along with the similar cranial osteopathy, is a nonsensical “treatment” based on a set of entirely false beliefs about the way the human body works. Not much competes with homeopathy for sheer ridiculous rejection of modern science but craniosacral therapy has a pretty good go. I was therefore surprised to find a recent study that claimed to show that craniosacral therapy is effective for colic. On closer inspection it became apparent that this study was so full of flaws that it was really impossible to draw any meaningful conclusions from the results. Using this trial as an example I’d like to show how to design a study that will give the false impression that even the most implausible treatment is effective.

The three easy steps

This study demonstrates 3 really important ways to ensure that you get a false positive result for your favourite nonsensical therapy:

  1. Make sure that the control condition involves no treatment at all. When doing something is compared with doing nothing it will usually show a better outcome due to the placebo effect, even if the something isn’t actually an effective treatment. That’s exactly what was done in this study. The treatment arm received between 1 and 3 craniosacral therapy treatments and the control arm received no treatment. This study didn’t control for the placebo effect and it’s therefore impossible to know whether the treatment was actually effective.
  2. Use only subjective measures of treatment effectiveness. After all, if we have objective measures they are likely to provide a more valid measure of treatment effectiveness (or in this case ineffectiveness). Subjective measures are much more prone to bias and inaccurate reporting which means they are more likely to give a positive result. In this study the primary outcome measure was the total number of hours crying per day reported by the parents, an entirely subjective measure.
  3. Ensure that the participants (or in this case their parents) are definitely not blind to whether treatment has been provided or not. When someone knows that they are receiving a treatment they are more likely to report a positive result due to an expectation that the treatment will be beneficial. This is part of the placebo response and is something that should be controlled for (i.e. the effect should be minimised) in any well controlled trial. This did not happen in this study and is very likely to have resulted in a more positive result. Incredibly, the rationale the authors gave for not blinding the parents was that they did not want to prevent parents from being present during the treatment. That’s a ridiculous excuse and shows a lack of thought about appropriate trial design and choice of control condition. They should instead have used an appropriate sham treatment for the control arm. This way the parents could be present at all times but it would not have been obvious to them whether their baby was receiving the real treatment or the sham.

By combining a no treatment control, subjective outcome measures and unblinded participants you maximise the chances of even a completely fake treatment providing a positive result. That is exactly what we see with this study which, entirely erroneously, claimed that craniosacral therapy is an effective treatment for colic. With a study designed like this one it’s impossible to know whether the observed benefits are due to the treatment or non-specific treatment effects (placebo, biased reporting etc). No meaningful conclusions can be drawn about treatment effectiveness. Trials with as many serious flaws as this really shouldn’t be approved for publication. As we know that craniosacral therapy is biologically implausible it’s very likely that the effect observed here was due to poor trial design rather than the treatment actually being effective.

Further steps to really make sure you get an incorrect result

I’d consider the above 3 items to be the most important to ensure that your study provides a false positive result. However, if you’d like to go further (and gain bonus points) this particular trial of craniosacral therapy highlights some other approaches that can be used to really make sure of a false positive result:

  1. If participants drop out, just ignore them! In a well-designed trial it’s important to appropriately control for drop outs when analysing the results as it’s often the case that more people drop out from the control arm than the treatment arm. That’s what was observed in this trial with 4 dropouts from the control arm and 0 from the treatment arm. This will influence the results and should have been appropriately handled in the analysis rather than simply ignored.
  2. Make sure that you don’t prospectively register your trial with any central registry. Do it retrospectively instead, that way you can change the protocol part way through to ensure you get the result you want. In this case the trial was registered nearly 2 years after it had been completed!

Conclusions

When a trial reports a positive treatment effect it’s important to not take this at face value but to first look in more detail at the design of the trial. In this article I’ve highlighted some of the ways that studies can appear to show a positive effect but actually it’s a false positive and due to poor trial design rather than treatment effectiveness. Poorly designed trials like the example here don’t tell us anything about whether a treatment is effective or not and are really a waste of time and money (although they are sometimes used to market unsuitable treatments). They shouldn’t be approved for publication.

Poorly designed trials that are used to try to claim evidence of effectiveness are very common in complementary and alternative medicine (CAM). However, these issues also occur in some trials involving mainstream medical treatments too. It’s therefore important to critically appraise all trials before using them as a basis for treatment  recommendations.

In the case of craniosacral therapy / cranial osteopathy, it’s a biologically implausible treatment that conflicts with a modern understanding of the human body. The very few good quality trials that exist for this treatment show no benefits. It should therefore not be offered as a treatment for colic or any other health condition and there is no value in continuing to undertake further research on this implausible treatment.

UK osteopath promotes conspiracy theories, anti-vaccination beliefs and uses unproven health screening techniques on unsuspecting patients

I have written previously about some of the unsuitable treatment approaches used by some osteopaths, such as cranial osteopathy. I recently became aware of an osteopathic practice that also uses a number of unproven health screening techniques. The practice in question is the Atman Clinic. The osteopaths at the Atman Clinic use cranial osteopathy and treat babies, both of which are nonsense and worryingly common within the osteopathic profession. The Atman Clinic additionally uses sound therapy, electroacupuncture and regulation thermometry to screen patients. These are not recommended screening techniques and have not been shown to be valid for diagnosing or assessing any health problems. In addition, the principle osteopath at the Atman Clinic, Geoffrey Montague-Smith, promotes a number of other unproven treatments, conspiracy theories and anti-vaccination beliefs via his Facebook account. All of this presents clear risks to members of the public.

Summary of conclusions:

1. Here is an osteopath who promotes a wide range of conspiracy theories, anti-vaccination beliefs and unproven health treatments to unsuspecting members of the public.

2. Health screening should be carried out by a doctor who has access to all relevant tests rather than an osteopath providing unproven and unscientific diagnostic techniques.

3. There is no good evidence that osteopathy or chiropractic provide any benefit for any infant condition or that these treatments can help with birth preparation.

Unproven health screening

The Atman Clinic offers a range of unproven health screening techniques including:

  • Sound therapy – as well as being used for diagnosis it claims that this can be beneficial to reduce the recovery time, support healing and clear residual effects of trauma. It states “For the modern day practitioner the use of musical tuning forks on and off the body offers a diagnostic and therapeutic modality which is safe, reliable and effective”. If that sounds like nonsense, that’s because it is. There is no possible way that using musical tuning forks could provide any information about someone’s health.
  • Electroacupuncture (EAV) / Vega Test – The Atman Clinic claims to be able detect inflammation, fatigue and tissue degeneration using this technique. They state “Elecrodermal screening uses an electronic probe to measure the electrical resistance at numerous points on the body (primarily the hands and feet). This technology is not an instrument used to diagnose disease. It does however measure the electrical current moving through the acupuncture meridians and as such gives information about the bioenergetics of the body.” There is no such thing as an acupuncture meridian so attempting to measure the electrical current moving through them isn’t going to be possible. In reality, the description provided by the Atman Clinic is a word salad of pseudoscience and there is no way that EAV could possibly provide any useful diagnostic information. The National Institute for Health and Clinical Excellence (NICE) has also warned against the use of these tests. The page goes on to say that based on the outcome of the EAV test, the osteopath may then recommend nutritional, herbal or homeopathic supplements. How often do we see this? A CAM practitioner that makes use of other completely unproven CAM treatments as part of their overall approach. From what I’ve seen, quite often. I imagine that rejecting conventional medical approaches to believe in one type of pseudoscience makes it more likely that you will be taken in by others.
  • Regulation thermometry – The Atman Clinic claims that this is suitable for diagnosing ongoing health problems, investigating undiagnosed symptoms and that it will allow the assessment of various systems within the body. They state “Information is collected from over 100 points on the body. Various body tissues and organs are analysed by measuring skin temperature using the infrared sensor. This gathering of information is performed during and after a brief cooling period which acts as a mild stimulus to the body.” Again, this is pseudoscience of the highest order. It’s interesting that one of the main claims they make is for investigating undiagnosed symptoms. Very good though it is, modern medicine doesn’t always have the answers and sometimes it not possible to make a diagnosis. CAM practitioners, including osteopaths, know that people often visit them when they can’t get an answer to their symptoms from a doctor. It’s therefore common to see them offer to investigate undiagnosed / untreatable problems even though most of the treatments they offer have little or no evidence of effectiveness for any health condition.

Promotion of conspiracy theories, anti-vaccination beliefs and other unsuitable health treatments

The principle osteopath at Atman Clinic, Geoffrey Montague-Smith, promotes a number of other unproven treatments, conspiracy theories and anti-vaccination beliefs via his Facebook account. Here are just a few examples:

It is totally inappropriate for any health professional to be promoting such misleading health advice. This has the potential to do significant harm to unsuspecting members of the public.

Cranial osteopathy, preparation for birth and treatment of babies

The use of cranial osteopathy and treatment of babies is worryingly widespread within the osteopathy profession. I have written about that previously on several occasions, such as The Perrymount Clinic and Moore Osteopathy. Cranial osteopathy is complete nonsense and there is no evidence that any osteopathic treatment provides any benefit for babies. It’s clearly a systemic problem within the profession as even the Institute of Osteopathy (professional membership organisation for osteopaths) was found in breach of advertising guidelines.

The Atman Clinic promotes cranial osteopathy suggesting that osteopaths can feel the involuntary motion within the body. That is, of course, impossible because such motion doesn’t actually exist. They further suggest that babies experience soft tissue tension, tight muscles and cramping and that osteopaths can examine babies for asymmetry, misalignment of cranial bones and muscular tension at the base of the skull and in the rest of the body. There is no evidence to back up these claims and no good reason to take any baby to an osteopath.

The Atman Clinic offers a “Birth Prep program” that claims to “help mothers achieve their ideal birthing experience”. In addition it claims that osteopathy can help with conditions that are specific to pregnancy including SPD, indigestion and nausea. There is no evidence to substantiate these claims and they are clearly in breach of Advertising Standards Authority (ASA) guidelines.

What action can be taken to tackle these issues?

I reported The Atman Clinic to the Advertising Standards Authority (ASA) for their misleading advertising claims. The ASA said “We have previously investigated and ruled upon advertising like this and we are concerned to see that it continues to appear”. The ASA have therefore referred my complaint to their Compliance Team who will work to address the misleading advertising.

The promotion of conspiracy theories and other unsuitable health treatments by Geoffrey Montague-Smith on his Facebook page is an issue that really ought to be tackled by the osteopathic regulator, the General Osteopathic Council (GOsC). Protecting the public is their primary function and here one of their osteopaths presents a clear risk to the public. They therefore ought to take immediate action to protect the public and fulfil their regulatory duty.

Conclusions

Osteopaths are health professionals and as such ought to provide rational, evidence-based advice to members of the public. Unfortunately, there are many problems within the osteopathic profession. Here is an osteopathic practice that uses completely unproven diagnostic techniques and the principle osteopath promotes conspiracy theories, unproven health treatments and anti-vaccination beliefs. This presents a clear risk to members of the public. It is important that the GOsC fulfils its duties as the regulator and takes immediate action to tackle this in order to protect members of the public from harm.

Chiropractic and osteopathic regulators should use doctors as experts in fitness to practice cases

I’m sure that many of you will have come across the tragic case of John Lawler who died as a result of chiropractic treatment. The chiropractic regulator, the General Chiropractic Council (GCC), had previously investigated this case in 2017 and concluded that it was safe to allow the chiropractor in question to continue to practice without any sanctions applied. According to a statement from the family, when investigating this case the GCC heard evidence “from an expert chiropractor that it would be “physically impossible” for the treatment provided to cause the injury which followed.” In the inquest that is currently taking place it has become clear that the advice provide by this expert chiropractor was factually incorrect. The coroner in the inquest stated that “Mr Lawler had died from the fracture to his neck and resulting spinal cord injury, while undergoing chiropractic treatment, which led to respiratory depression.” This highlights a serious issue with fitness to practice cases undertaken by the GCC and also those by the General Osteopathic Council (GOsC). They normally use members of their own profession as expert witnesses. That isn’t appropriate, particularly in cases involving potential patient harm, as chiropractors and osteopaths are not doctors and are therefore not well placed to fully assess the potential for harm from treatments used.

Within the inquest itself a “World expert” from the field of chiropractic was asked to give his verdict on the treatment provided. The expert was Richard Brown, secretary-general of the World Federation of Chiropractic. Mr Brown apparently said that a chiropractic activator is “used to maximise mobility and wellbeing and its use was appropriate”. As far as I’m aware, there is no good evidence to demonstrate that a chiropractic activator provides any health benefit and certainly not that it maximises “wellbeing”. I would question whether using a tool that lacks evidence of effectiveness is “appropriate”. Other aspects of the testimony from Mr Brown were more reasonable such as saying that “he would not personally have used the drop table with a patient whom he suspected of having osteoarthritis”. Mr Brown may well be an expert in the field of chiropractic but does that mean he is sufficiently qualified to give expert evidence in a case of patient harm? Based on his views of the use of a chiropractic activator I would suggest not. These views don’t appear to be objective and don’t align with the evidence. Whilst a chiropractic activator may present a low risk of harm, that doesn’t mean that it is “appropriate” to use something that lacks evidence of effectiveness. When a “World expert” is invited to give evidence in a case it is to be hoped that all of their advice would align with the available science and evidence. In this case it did not.

In future fitness to practice cases I believe it would be much more appropriate for the GCC and GOsC to use a doctor as the expert witness particularly where the potential for patient harm is being investigated. That should lower the risk of these cases reaching the wrong verdict because of inaccurate “expert” advice. This should help to ensure that the public are better protected from the risk of harm, which is after all the main purpose of these regulators in the first place.

UK Chiropractors and osteopaths are not doctors yet many give the impression that they are

I’m sure that many of you will have come across the tragic case of John Lawler who died as a result of chiropractic treatment. The case has received much media attention during the inquest that took place in November 2019. In this post I’d like to focus on one particular point: Mr Lawler thought that he was receiving treatment from a doctor. Chiropractors are not doctors.

The chiropractor in question was Arleen Scholten. According to the article linked above, “The chiropractor, who earned a Doctor of Chiropractic degree at Northwestern College of Chiropractic in Canada, conceded that, under British rules, she should not be styled as ‘Dr’ but as ‘Mrs’.” In the UK, chiropractors and osteopaths are not doctors (unless they also happen to have a medical degree – the vast majority don’t) and should not give the impression that they are. How did Mr Lawler end up thinking that he was being treated by a doctor? Because that’s exactly how she marketed herself! Here is her website from September 2017 which clearly states “Dr. Arleen Scholten welcomes you”. The website was subsequently changed in October 2017 to read “Arleen Scholten D.C. (Doctor of Chiropractic) Welcomes You.” It’s not clear why this change was made but it may have happened in response to the investigation of this case that was undertaken by the General Chiropractic Council during 2017.

Unfortunately, this is not an isolated case and it is not unusual for UK chiropractors and osteopaths to give the impression either that they are doctors or are equivalent to doctors. In some cases this is done by directly referring to themselves as “Dr” as Arleen Scholten did. In other cases they draw parallels between their own training and that of a medical doctor. See this osteopathy practice website as an example where they say (emphasis mine) “To qualify an osteopath must study for four to five years for an undergraduate degree. This is similar to a medical degree, with more emphasis on anatomy and musculoskeletal medicine”. A detailed comparison will have to wait for a future blog post but suffice it to say that the training that osteopaths and chiropractors receive is in no way comparable to that undertaken by doctors. I also don’t think that most members of the public would realise that a chiropractor who refers to themselves as “Dr” but then qualifies it with “Doctor of Chiropractic” means that they aren’t actually a medical doctor. There are many examples of this such as is done on this large chiropractic clinic website. It is not reasonable to expect members of the public to unpick these sorts of subtle indications and to be fully confident they know the type of practitioner they are seeing. There is a need for much greater clarity and explicit statements to make it clear that chiropractors and osteopaths are not doctors.

In the interest of the health and safety of the general public, I believe that the chiropractic and osteopathy regulators (General Chiropractic Council (GCC) and General Osteopathic Council (GOsC)) need to take steps to put a stop to these misleading claims and to ensure that the public are completely clear that chiropractors and osteopaths are not doctors. I’d suggest the following actions:

  1. Provide clear guidance to all chiropractors and osteopaths that they should not in any way suggest that they are a doctor or that their training is equivalent to that of a doctor. This should cover all advertising materials and also what is said to patients before, during and after appointments.
  2. Apply sanctions to any chiropractor or osteopath who fails to comply with the above guidance.
  3. Undertake a media campaign targeted at the general public to ensure that they understand that chiropractors and osteopaths are not doctors.

If these actions had been undertaken before now then Mr Lawler may have gone to his GP instead of a chiropractor and his tragic death may not have occurred. I only hope that lessons will be learned here and the regulators will take actions to reduce the risk of similar incidents in future.