Should you see a chiropractor or an osteopath for your migraines?

migraineI’ve previously written about the problems with chiropractors and osteopaths claiming to be able to treat all types of headaches. The Advertising Standards Authority (ASA) permits chiropractors and osteopaths to advertise their treatments for only two specific types of headache:

  • Headache arising from the neck (cervicogenic)
  • Migraine prevention

In this post I’m going to look more closely at chiropractic and osteopathy treatment for the prevention and treatment of migraines. How strong is the evidence behind these treatments?

Summary of conclusions:

1. Based on the currently available evidence there doesn’t seem to be any good reason to recommend osteopathy or chiropractic for the prevention or treatment of migraines.

2. The treatments recommended in the NICE guidelines for prevention and treatment of migraines are all available from a GP rather than a chiropractor or osteopath.

3. Further research in this area may be worthwhile as there is currently relatively little good research.

Evidence for chiropractic and osteopathy for migraine prevention

I don’t know the source of the ASA guideline permitting chiropractors and osteopaths to advertise their treatments for migraine prevention. However, it’s probable that at least part of the source is the Effectiveness of manual therapies: the UK evidence report (Bronfort report). Within this publication it states: “The impetus for this report stems from the media debate in the United Kingdom (UK) surrounding the scope of chiropractic care and claims regarding its effectiveness particularly for non-musculoskeletal conditions.” That’s not a very good reason for carrying out research. Regardless, let’s look at what it says about migraine prevention.

The Bronfort report states that there is “Moderate quality evidence that spinal manipulation has an effectiveness similar to a first-line prophylactic prescription medication (amitriptyline) for the prophylactic treatment of migraine”. This is based on 2 systematic reviews of manual therapy for migraine headache. The Bronfort report chooses to discard the results of 1 of the systematic reviews because it “evaluated study quality using a scale that is no longer recommended by the Cochrane Collaboration and did not apply evidence rules for their conclusions”. They chose instead to follow only the conclusions from the other systematic review. Who was the lead author for that systematic review? Gert Bronfort, the same person who is lead author for the Bronfort report. There is clearly a potential conflict of interest here so let’s have a look at the actual papers that formed the basis of both systematic reviews (there are only 3 of them and the same papers are in both reviews):

The first thing that surprises me here is that both systematic reviews found only 3 trials related to manual therapy and migraines. This suggests that it’s an area that is under-researched and makes drawing strong conclusions difficult. Furthermore, the conclusion drawn by the Bronfort report that “Moderate quality evidence that spinal manipulation has an effectiveness similar to a first-line prophylactic prescription medication (amitriptyline) for the prophylactic treatment of migraine” is rather strange. It is based on just a single trial. Drawing conclusions from a single trial is always problematic and we would usually like to see similar results independently replicated in another trial before making any significant recommendations. In fact, given the apparent success of SMT found in this trial, which was conducted over 20 years ago, it’s surprising that there isn’t further published research looking at the same thing in the 12 year period to 2010 (when the Bronfort report was published).

NICE Guidelines

For a more definitive and recent view it makes sense to look at the NICE guidelines. There are two key publications from NICE on this topic: NICE guidelines on Headaches in over 12s: diagnosis and management and the Clinical Knowledge Summary for Migraine. Neither of those publications makes any recommendation in favour of the use of the main treatments provided by chiropractors or osteopaths (manual therapy). If you look into the evidence behind the guidelines in more detail it’s easy to see why. This is what the NICE GDG (Guideline Development Group) had to say: “For migraine, there was one study showing some benefit. The GDG were concerned that the evidence reviewed was of low to very low quality with a lot of uncertainty in the effect estimates, and that rare adverse events may be severe when they do occur. It was agreed that better evidence was required to make a recommendation.”

The NICE guidelines recommend the use of medication-based treatments for the prevention and treatment of migraines. This should be in addition to use of a headache diary as well as providing appropriate information and support. All of these treatments and approaches are available from a GP.

Conclusion

Overall, the lack of research in this area makes it difficult to draw any significant conclusions about the effectiveness of osteopathy or chiropractic for migraines. There is certainly not enough evidence in order to make a recommendation in favour of using these treatments. It makes sense to use the NICE guidelines as the most reliable source of evidence and they recommend treatments that are available from a GP rather than those from a chiropractor or osteopath.  I would summarise the current position as follows:

Based on the currently available evidence there doesn’t seem to be any good reason to recommend osteopathy or chiropractic for the treatment or prevention of migraines.

It would, however, make sense to conduct further research to see whether osteopathy or chiropractic could be of benefit. (The NICE guidelines make a similar recommendation for further research.)

In view of the lack of evidence, it’s surprising that the ASA guidelines allow chiropractors and osteopaths to advertise their treatments for migraines. The ASA guidelines would probably benefit from a review and update based on the evidence that’s available, in particular the NICE guidelines. In the meantime, if you have migraines it is best that you receive evidence-based treatments and these are all available from your GP.

A recent paper suggests Spinal Manipulation Therapy (SMT) is as effective as recommended treatments for low back pain. Chiropractors celebrate. Should they?

Introduction

Spinal Manipulation Therapy (SMT) is the primary treatment used by most chiropractors and osteopaths as well as being used by some physiotherapists. This study set out to compare Spinal Manipulation Therapy (SMT) with recommended therapies, non-recommended therapies, sham SMT and SMT as adjuvant therapy. It concluded that SMT showed similar benefits to “recommended interventions”. When it was published it was met with trumpet fanfares by a number of chiropractic organisations, as well as others, and claimed as providing strong justification for their treatments. In actual fact it does not do this so let’s explore further.

Summary of conclusions:

1. There are currently no really effective treatments for low back pain.

2. At best, SMT results in a modest average clinical effect. It has also not been shown to be more effective than sham SMT.

3. It’s not currently possible to know whether SMT is safe.

4. It is not currently clear whether SMT is cost effective or not.

5. Taking into account the limited clinical effectiveness and unclear position on safety and cost effectiveness it doesn’t seem to make sense to recommend SMT as a first-line treatment.

Background

Back pain is a widespread problem and SMT is currently listed as a second-line or adjunctive treatment in a number of national guidelines, such as the UK NICE Guidelines as well as the Lancet low back pain guidelines from last year. It’s not recommended as a first-line treatment because current evidence shows it is not sufficiently effective when used alone.

The study and its conclusions

The study was a systematic review and meta-analysis that compared SMT with recommended therapies, non-recommended therapies, sham SMT and SMT as adjuvant therapy. It identified recommended and non-recommended interventions based on guidelines from US, UK and The Netherlands. It’s not clear why these particular guidelines were picked. The Lancet series used a similar set but with Denmark in place of The Netherlands. Perhaps the inclusion of the guideline from The Netherlands is due to the lead author being based there? Whilst it’s understandable that someone will be more familiar and comfortable with guidelines from the country in which they live and work this does introduce a degree of bias into the results and it would be good to see that acknowledged in the paper.

The study concluded that SMT showed similar benefits to “recommended interventions”. It also concluded that SMT vs “non-recommended interventions” shows a statistically but not clinically significant benefit for pain but a statistically and clinically significant benefit for “back specific functional status”. There have been some criticisms, but more on that shortly.

The reaction

A number of chiropractic organisations, as well as others, latched onto this study and claimed it is strong justification for their treatments. Take for instance, this tweet from the British Chiropractic Association:

BCA on Twitter_ _As part of the package of care, chiropractors often _ - twitter.com

It suggests that SMT, the treatment most favoured by most chiropractors, should be considered a first-line treatment for chronic low back pain.

There is also this from the Chiropractic Research Council which includes the comment “supersedes other reviews and publications e.g The Lancet Series which only recommended SMT as a second line treatment option. Groundbreaking stuff!”

As I’ll explain shortly, this review is not particularly “groundbreaking” and the justification for SMT being a first-line treatment is nowhere near as strong as these comments would suggest.

Criticisms of the paper

A thorough and clear critique of the paper was submitted by Mary O’Keeffe and Neil O’Connell. This highlighted a number of issues, including:

  1. SMT was not shown to be better than sham SMT. As this is the only reliable way of assessing efficacy of SMT, it suggests that SMT is not effective as a treatment.
  2. The choice of “recommended” and “non-recommended” therapies was strange and does not align with guidelines. For instance, treatment with paracetamol (which is not recommended by clinical guidelines) was included as “recommended” therapy.
  3. The authors do not seem to interpret their results in line with their own thresholds for determining clinical effectiveness.

The authors submitted a response in which they stand by their original conclusions. They say that SMT cannot be adequately blinded and that therefore trials that compare with other treatments are more valuable than those comparing SMT to sham. In response to point 2 above about choice of “recommended” and “non-recommended” therapies, they say they have undertaken additional analysis taking account of this point and have still arrived at similar results. As far as I can tell, they haven’t responded to the point about thresholds for clinical effectiveness.

Neil O’Connell has sent some further replies on twitter about comparison with sham and the fact that we might see the same minimal benefit for an ineffective treatment:

Neil O'Connell on Twitter_ _Thanks for a considered and thoughtful re_ - twitter.com

It seems likely that this discussion will continue. Hopefully the authors will continue to engage as it’s good to have a healthy debate on complex issues like this. What’s clear is that SMT has not been shown to be particularly effective for low back pain and this new study doesn’t change that.

Safety of SMT

The paper says “About half of the studies examined adverse events (table 2). In most of these studies it was unclear how and whether adverse events were registered systematically; therefore, these data might be unreliable and not accurate for incidence.” In other words: due to a lack of systematic reporting of adverse events, it’s impossible to adequately assess the safety of SMT. The paper does go on to say “clinicians should ensure that patients are fully informed of potential risks before treatment”. This is good advice but I wonder how much this actually happens in practice? Do the main people who carry out SMT (osteopaths, chiropractors and some physiotherapists) ensure that their patients are fully informed of potential risks before they start treatment? Or do they just go ahead and start treatment without doing this?

Cost effectiveness

The paper states “it remains to be determined whether SMT is a cost effective option for the treatment of chronic low back pain.” As more research is needed to assess the cost effectiveness of SMT it would make sense to conduct this research before deciding whether to recommend it as a first-line treatment. If it turns out to be significantly more expensive than other similarly effective treatments then it would not make sense to recommend it as a first-line treatment.

Placing these results in the context of other research

In the section of the paper “Comparison with other studies” it is stated that our results are consistent with other recently published high quality systematic reviews and guidelines that recommend SMT”. I disagree that it is consistent with guidelines, e.g. from NICE, because they have SMT as a second-line treatment option whereas this paper suggests it is as good as currently recommended first-line treatments.

Future research

The paper says “Given the considerable data available, we can now calculate within reasonable certainty the effect of SMT in this setting as well as the impact of a future, methodologically well conducted trial (as determined by the prediction intervals).” In other words, don’t keep doing more similar research in this area because it isn’t going to add anything. This is good advice and is something that researchers should conclude much more often than currently happens. Far too often a study that doesn’t show effectiveness suggests that “more research is needed”. This is a waste of time and money as there is no point in continuing to carry out research when it isn’t going to add anything new.

Conclusions

Overall, this is a decent piece of research and shows fairly similar results to other previous research. It concludes “The evidence suggests that SMT results in a modest, average clinical effect at best”. What’s most strange is not the paper itself but the hype that has surrounded it. There were many “trumpet fanfares” from chiropractic organisations suggesting that this vindicates their treatments and should be used to promote them. It doesn’t actually do this. It shows that SMT isn’t a particularly effective treatment, that it’s not possible to adequately assess its safety and it is not known whether it’s cost effective or not. This is hardly a justification for shouting from the rooftops about how good it is.

What this study does do is add to the body of evidence that indicates that, unfortunately, there remains no good treatment for low back pain. This presents an issue for the many people who suffer with low back pain as there are no really effective treatments. When presented with a number of treatments that are not particularly effective, what is someone with back pain supposed to do? There is no easy answer. However, exercise is known to provide general health benefits and the NHS provides activity guidelines. The importance of these general health benefits should not be understated and is something that SMT cannot provide. In addition, the NICE guidelines recommend exercise as the first-line treatment as well as highlighting the importance of continuing with normal activities as far as possible (self-management). These approaches have the advantage of empowering the patient whereas SMT is a purely passive treatment that does not encourage self-management. I can understand the temptation for someone with back pain to want to go and “get fixed” by seeing a chiropractor, osteopath or physiotherapist who uses SMT. Unfortunately, the evidence indicates that it is not particularly effective and it’s not clear how safe it is. Bearing in mind that it doesn’t provide other general health benefits or empower the patient and is not currently considered a first-line treatment by national guidelines it should probably remain a second-line or adjunctive treatment.

It’s Chiropractic Awareness Week. Or should that be Chiropractic Marketing Week?

marketingChiropractic Awareness Week 2019 runs from 8th to 14th April and is being led by the British Chiropractic Association (BCA). In preparation for this week they have conducted a survey about how people manage their back health. They conducted a similar survey last year which looked at the incidence of back pain in different regions. Unfortunately, they don’t publish the raw details of their survey results but the highlights they have published do raise a number of issues with this “research”.

They conclude that “11% wouldn’t seek help from a health professional for back pain” and “31% would wait a month or longer”. They present this as if it’s a bad thing. However, the advice from the NHS is that back pain often improves within a few weeks or months and that “you may not need to see a doctor or other healthcare professional”. The treatments available for low back pain are currently not particularly effective, and that includes any treatments that a chiropractor may offer. Self-management is also seen as a key step in managing low back pain. It therefore seems entirely reasonable to wait for a little while before seeking professional advice. These statistics presented by the BCA seem to be more focused on marketing the services of chiropractors rather than giving rationale evidence-based advice. (Note: It’s important to be aware that there are situations where getting immediate medical advice is essential and the NHS website provides advice on this. This sort of immediate medical advice should come from a doctor rather than a chiropractor.)

They also say that “42% of people don’t take any steps to look after their back health” and “Only 58% have taken preventative steps to protect themselves from developing back or neck pain”. The more observant amongst you might have noticed that these numbers appear to add up to exactly 100%. That’s because they are exactly the same statistic, one simply being the reverse of the other. By reporting both separately, it looks like there is more “research” that can be reported on.

They report that “19% choose their mattresses bases on price, rather than comfort”. This is hardly surprising. If everyone had plenty of spare cash then they would ideally choose the mattress that is the most comfortable. However, in reality some people simply do not have enough money to be able to choose a mattress purely based on its comfort level and need to take into account the cost.

During Chiropractic Awareness Week, a number of other chiropractic organisations have reported on this research conducted by the BCA. They each seem to be reporting statistics based on their own region such as this and this. The research from the BCA seems to be suggesting that people from certain regions are better at taking steps to protect themselves from back pain than those from other regions. This is, quite frankly, ludicrous. Whenever you conduct a survey like this you will inevitably get a spread of results across the different groups (in this case, regions). This is what statisticians refer to as the normal distribution. This is a normal variation that is entirely to be expected and does not indicate that some regions manage back pain better than others! It should also not be used to derive specific advice such as tailoring recommended treatment approaches to particular regions.

Unfortunately, the British Chiropractic Association, as well as others who have promoted their research, don’t seem to have a good understanding of the basics of research and statistics. They seem to be more interested in producing marketing material that can be used to encourage people to seek out the care of a chiropractor rather than on conducting some actual useful research and providing evidence-based advice. Chiropractic Awareness Week seems to be used by chiropractors primarily as a means of marketing their services. I therefore think it could be more appropriately named Chiropractic Marketing Week.

Can a nutritionist help you treat autism or cancer with diet?

Diana Wright - Rulings - ASA - CAP - www.asa.org.ukI recently became aware of a nutritionist, Diana Wright Food Science and Nutrition, who was advertising treatment for autism with diet and supplementation. On closer investigation it became apparent that she also claimed to be able to treat a range of other health conditions including cancer, IBS, women’s hormonal health, arthritis, fibromyalgia, chronic fatigue and children with learning difficulties and genetic disorders. This is concerning because nutritionists are not permitted to provide diets for health conditions and it therefore warranted closer investigation.

Summary of conclusions:

1. Nutritionists are not qualified to provide specific diets for people with health conditions. Only dietitians are permitted to do that.

2. Beware of nutritionists who claim that they can treat serious health conditions such as autism or cancer with diet. These claims are not substantiated by evidence.

What is a nutritionist?

A nutritionist is a professional who advises on diet and nutrition. However, unlike dietitian, nutritionist is not a protected term. Therefore, anyone can call themselves a nutritionist regardless of whether they hold relevant qualifications and skills or not. In addition, only dietitians are actually qualified to provide advice on specific diets for health conditions. Nutritionists may provide information about food and healthy eating but not special diets for health conditions.

All of this does not mean that all nutritionists are bad. Nutritionists that are registered with a trustworthy professional body and don’t claim to be able to treat medical conditions don’t raise any particular cause for concern. This situation is different, however. Here we had a nutritionist who claimed to be able to treat a whole range of health conditions. She was clearly going beyond her professional expertise and scope of practice, which puts unsuspecting members of the public at potential risk of harm.

Nutritional and biomedical protocols for autism

Diana Wright claimed that there are nutritional and biomedical protocols that are effective for treating autism. She listed a range of different protocols including “Eliminating heavy metals”, “Improving detoxification pathways” and “Supporting the immune system”. Is there any science or evidence behind these treatment approaches? Short answer: no. Longer answer:

  • “Eliminating heavy metals” is covered in some detail on Science Based Medicine (a site that I thoroughly recommend if you aren’t aware of it already).
  • As to “improving detoxification pathways”, your body is perfectly capable of detoxing on its own and you cannot improve this through diet and supplementation.
  • With regards to “supporting the immune system”, this is covered in detail in this excellent article by Dr Dave Stukus (spoiler: there is no basis to this claim of supporting the immune system).

Cancer

Diana Wright also made unsubstantiated claims related to the treatment of cancer. She said that you can keep “your liver clean with dandelion tea and fresh juices of beetroot and kale with carrot and apple” to “fight cancer”. She also suggests that green tea can “inhibit tumour growth as well as help them self destruct”. These claims are nonsensical and there is no evidence to back them up. Although a healthy diet is important for people with cancer, you cannot treat cancer with diet. More information is available on the Cancer Research UK website.

What action can be taken to stop these misleading treatments?

I reported Diana Wright Food Science and Nutrition to the Advertising Standards Authority (ASA) for their misleading claims. My complaint focused on two main issues:

  1. The lack of evidence to back up these claims.
  2. The fact that these conditions are those for which appropriate medical supervision should be sought. Diana Wright is not a doctor or a registered dietitian.

The ASA investigated my complaint and contacted Diana Wright. She said that the site is out of date and would soon be taken down and on this basis the ASA closed my complaint. Given the seriousness of the misleading claims on this site, I would have preferred the ASA to insist on this happening before closing the complaint. Fortunately, the site has since been taken down and there is now a message to say that a new version is being worked on. Let’s hope that the new site doesn’t include such misleading and nonsensical claims.

In response to my complaint, the ASA picked up on the misleading claims related to cancer and suggested that I should contact Trading Standards about this because it is a legal issue. If the claims relating to cancer appear on the new site I will follow up with Trading Standards directly.

Conclusions

When looking for dietary advice, it’s important to be aware of the credentials of the professional that you are going to see. This is particularly important if you want to use diet as treatment for a medical condition. Only registered dietitians are qualified to provide advice on specific diets for health conditions. Nutritionists are not permitted to do this and may only provide more general information about food and healthy eating. If you are thinking of using diet as a treatment for a medical condition, it would make sense to take the advice of your own doctor first.

World Federation of Chiropractic Biennial Congress – EPIC2019: Evidence based or not?

The World Federation for Chiropractic Biennial Conference will take place in Berlin from 20th to 23rd March 2019. The theme of this congress is “EPIC2019: Global Opportunities in Spine Care” with EPIC standing for Evidence-based, Patient-centred, Interprofessional and Collaborative. The claim of being “evidence-based” is particularly interesting as the evidence behind the main treatment provided by chiropractors (Spinal Manipulative Therapy) is less than compelling. There are also widespread issues within the chiropractic profession with misleading advertising claims. Some chiropractors claim that they can help a whole range of conditions such as cancer, autism or mental health problems through their treatments. I have written more about the problems with the chiropractic profession in the UK here. It’s therefore worth looking more closely at the details of this congress to see whether it is truly evidence-based. The full programme for the conference is available here and in this post I’ll discuss four of the areas being covered.

Treatment of babies

One of the sessions at the conference is called “Tiny Tune-Ups” and is focused on the treatment of neonates, i.e. babies less than four weeks old. Some chiropractors (and osteopaths) claim that babies suffer birth trauma and need to have this “corrected” by their treatments. In reality this “birth trauma” doesn’t actually exist and there is no evidence that any chiropractic treatment provides benefits for any infant condition. A baby who has health problems needs specialist care from a doctor not a chiropractor. (It’s important to remember that chiropractors are not doctors and shouldn’t be claiming to be). I personally find the idea of a parent taking their newborn baby to a chiropractor frightening. Given the lack of evidence behind chiropractic treatments for newborns it seems to be completely inappropriate to have this kind of session at a congress that claims to be “evidence-based”.

Functional Neurology

Functional Neurology seems to be a new field / profession and so far I have seen mostly chiropractors claiming to have this expertise. There is a good article on the Science Based Medicine website about it which describes chiropractic neurology as “the very definition of pseudoscience”. At EPIC 2019, there is a talk about functional neurology in which new material on “Transcranial Low Level Light Therapy” will be presented. Whilst there has been some research on the medical use of this technique the evidence of benefit is not strong. If this treatment is going to be used this really ought to be under the specialist care of a qualified doctor rather than a chiropractor and certainly not one that claims to be a specialist in “functional neurology”.

Sales and marketing in chiropractic

One of the talks at EPIC 2019 is by Jeffrey Langmaid who runs a website called “The Evidence Based Chiropractor”. Is this a website with lot of research articles and links to evidence based guidelines? Sadly not. It’s actually focused on helping chiropractors to boost their referral rates from doctors. This is a rather strange and disappointing definition of “evidence-based”. Patients should be receiving care because it is in their best interests not because it makes the practitioner money. A congress that is focused on evidence-based patient-centred care shouldn’t include talks on this sort of aggressive marketing.

Activator treatments

The premier sponsor for EPIC2019 is Activator Methods International Ltd. As well as being the premier sponsor, they have two talks at the conference. A number of papers have been published about The Activator Method but there isn’t any good evidence to show that it’s effective as a treatment. Many of the trials conducted have a small number of participants as well as other methodological issues such as lack of control or sham treatment groups. There is some more info on the Activator Method on the excellent Science-Based Medicine website. Based on all of the available evidence it isn’t appropriate to describe The Activator Method as evidence-based.

Conclusions

The EPIC2019 congress claims to be “evidence-based”. It is good that the chiropractic profession is trying to become more evidence-based but doing so requires much more than a few statements. The EPIC2019 congress unfortunately fails to live up to its billing because it involves presentations on a range of different topics that are definitely not evidence-based. This includes chiropractic treatment of newborn babies, blatant pseudoscience such as functional neurology and mechanical “Activator” treatments. As well as this there are aggressive marketing strategies being taught that are clearly not “patient-centred”. There may well be some aspects of EPIC2019 that are “evidence-based” but whilst these sorts of topics are included in the conference it is completely inappropriate to describe the congress as evidence-based. If the chiropractic profession wants to be taken seriously in its attempt to become more evidence-based then it needs to completely remove all of these inappropriate treatments and approaches from its repertoire.

 

Should you see a chiropractor or an osteopath for sports injuries or to improve sports performance?

Many chiropractors and osteopaths advertise their treatments for the prevention and treatment of sports injuries. Some also claim to be able to improve sports performance. Do these claims stand up to scientific scrutiny? Should chiropractors and osteopaths be advertising these treatments?

Summary of conclusions:

1. The most common types of sports injuries have not been shown to benefit from chiropractic or osteopathy treatment.

2. There are some specific types of sports injury where treatment from a chiropractor or osteopath may provide some benefit. It would make sense to try and get an accurate diagnosis first before considering going to an osteopath or chiropractor to make sure that the injury you have may benefit from these treatments.

3. Treatment from a chiropractor or osteopath has not been shown to provide any benefit for injury prevention.

4. There is no good evidence that chiropractic or osteopathy treatments provide any benefit for sports performance.

Injury prevention

The first thing to clear up is the suitability of chiropractic and osteopathy treatments as a prevention of injuries. This can be stated very simply:

Chiropractic and osteopathy treatments have not been shown to provide any benefit for the prevention of injuries.

Whilst we are on the topic of prevention, it’s worth pointing out that chiropractic and osteopathy treatments have not been shown to provide any benefits for the prevention of any other health condition either. There is no good reason why anyone should visit a chiropractor or osteopath on a regular or long-term basis.

Treatment of sports injuries

In November 2017 the Advertising Standards Authority (ASA) published new guidance for chiropractors on the treatment of sciatica, sports injuries, whiplash as well the treatment of babies, children & pregnant women. Within this document it states “The ASA considers consumers will understand broad claims made by chiropractors for the treatment of “sports injuries” to mean that chiropractic is effective for the treatment of all, or most, problems which may arise from sports injury. Given the evidence for efficacy is limited to certain, usually minor conditions which could be caused by injuries sustained during sporting activities, the ASA considers that consumers are likely to be misled by such broad claims”. The ASA provides a list of specific sports injuries that chiropractors may claim to treat including some specific shoulder injuries, short term management of ankle sprains and plantar fasciitis. The ASA guidelines for osteopaths are less detailed in this area but do state that osteopaths may only claim to treat “minor sports injuries”. What’s very clear is that an osteopath or chiropractor who claims to treat a wide range of sports injuries is not going to be compliant with the ASA guidelines due to a lack of evidence to support these treatments.

The most common injuries are sprains and strains (definitions from NHS website):

  • A sprain is a torn or twisted ligament (tissue that connects the joints)
  • A strain is an overstretched or torn muscle (also known as a pulled muscle)

A useful source of clear guidance on suitability of treatments can be found in the relevant NICE guidelines. The NICE guidelines for sprains and strains don’t suggest chiropractic or osteopathy as a suitable treatment. In fact, the NHS website states that for these common injuries “Most can be treated at home without seeing a GP”.

Sports performance

Some chiropractors and osteopaths claim that by having treatments with them you will improve your sports performance. In some cases they claim that this is achieved by improving the “alignment” of your body through their treatments therefore enabling you to perform better. The concept of “alignment” as promoted by some chiropractors and osteopaths is nonsensical. The human body does not become “misaligned” and treatments from a chiropractor or osteopath will not “correct” these misalignments.

As to whether treatment from a chiropractor or osteopath improves sports performance, there is no good evidence to suggest that it does. Like any treatment, chiropractic and osteopathy carry risks. It therefore doesn’t make sense to undertake a treatment that hasn’t been shown to provide any benefit for sports performance when there is the potential for harm from the treatment.

What action can be taken to stop these misleading claims?

One example of a chiropractic practice that claims to be able to prevent and treat a wide range of injuries as well as help with sports performance is Putney Chiropractic Clinic. I complained to the ASA about the claims made by this clinic including their suggestion that chiropractic could result in “more energy”, “maximise performance” and prevent and treat a wide range of injuries. The response from the ASA was to refer this to their compliance team. The ASA do this when what you have complained about is a clear issue that they have already taken a stance on. The claims made by Putney Chiropractic Clinic breach the ASA guidelines as they are not substantiated by evidence. This is not an isolated incident and I will be making complaints about other chiropractors and osteopaths in future.

Conclusions

The term “sports injury” covers a wide range of different potential problems such as sprains, strains, back injury and concussion. Chiropractic and osteopathy have only been shown to provide benefit for a small number of these. Maybe you have already been given a diagnosis of the particular type of injury you have and it is one of those for which chiropractic or osteopathy have been shown to provide some benefit. In this situation then you may benefit from seeing a chiropractor or osteopath, although you should compare the suitability of this against other treatment options that are available. In all other situations these treatments are not recommended.

In terms of injury prevention, there is no good reason to see a chiropractor or osteopath. The same advice applies for sports performance.

Problems in the UK osteopathy and chiropractic professions and the need for reform

In the past few weeks I’ve had a number of comments on my blog and direct messages from osteopaths and chiropractors unhappy with some of my blog content. Some valid points were raised and I’m in the process of amending blog posts accordingly. I also plan to review all of my old blog posts over the coming months and refresh them where needed. I’m always open to discussion about the contents of my blog and happy to make amendments if what I’ve written is shown to be incorrect. However, some commenters felt that significant proportions of my blog were unreasonable and that this was intended as some sort of “attack” on the two professions and that I am “scaremongering”. I’d like to explore that further here.

There have, for many years, been a number of serious issues in the chiropractic and osteopathy professions in the UK. This includes things like misleading advertising, treating conditions for which there is no evidence of effectiveness, claiming that childbirth is “traumatic” and many others. I’d like to make it clear that this does not mean that all chiropractors and osteopaths are “bad” and a danger to the public. I’m aware that there are some members of these professions who work very hard to ensure their knowledge is up-to-date, that their treatments are in-line with relevant guidelines and that they do not mislead the public. I would not seek to criticise these individuals. However, there are serious deep-seated problems within these two professions that do need to be addressed.

Here is a selection of some of the most serious issues. This is not intended to be an exhaustive list and is not in any particular order:

  1. Using cranial osteopathy and craniosacral therapy treatments. These are nonsensical treatments based on something that doesn’t actually exist.
  2. Treating babies for “birth trauma” and other infant conditions such as colic, tongue tie and feeding problems. There is no evidence that babies experience “birth trauma” and osteopathy and chiropractic have not been shown to be effective for any infant condition.
  3. Treatment of non-musculoskeletal conditions such as asthma, autism, ADHD or mental health problems. Osteopathy and chiropractic have not been shown to be effective for any of these conditions.
  4. Ongoing significant issues with misleading advertising in spite of many years of work and the issuing of clear guidance by the Advertising Standards Authority (with support from the General Osteopathic Council and the General Chiropractic Council)
  5. Offering unscientific and unproven treatments such as homeopathy, reflexology, reiki and naturopathy either delivered by a chiropractor / osteopath directly or within the same clinic.
  6. The leading osteopathic training institution, The University College of Osteopathy, offering osteopaths training in treatment of respiratory conditions in children. There is no evidence that osteopathy is effective for these conditions, some of which are serious and can be life-threatening.
  7. The leading professional membership organisation for osteopaths, The Institute of Osteopathy, found in breach of advertising guidelines.
  8. The leading professional membership organisation for chiropractors, the British Chiropractic Association, making unsubstantiated and misleading claims such as the “harm” of wearing high heels and skinny jeans (as well as many other issues). There is no evidence that these things are harmful and trying to scare members of the public into not wearing skinny jeans just undermines the reputation of the chiropractic profession.
  9. The osteopathic regulator, the General Osteopathic Council (GOsC), allowing advertising of training for osteopaths in conditions that they are not allowed to advertise to treat.

Even before looking at the effectiveness of the treatments offered by chiropractors and osteopaths (which is far from compelling but I won’t be covering in this post) it’s clear that there are serious issues within these two professions. I would therefore argue that rather than “scaremongering” or “attacking” these professions I’m actually protecting the public from unsuitable treatments and approaches. This is particularly important as the problems are clearly deeply embedded within these professions as they exist within the leading professional membership organisations, a leading educational institution and even the regulator. This is clearly not just a problem with a few fringe osteopaths and chiropractors.

The need for reform

Maybe there are some osteopaths or chiropractors reading this and thinking: “Actually I agree with this, I’d like to see this nonsense out of my profession” (or words to that effect). If that’s the case then you need to do something to tackle the issues. The level of reform that’s needed can only be achieved from within the professions themselves rather than from outside. It won’t be easy because the issues are so deeply embedded but it is necessary if osteopaths and chiropractors want to be taken more seriously as healthcare professionals.

Thanks for reading. Any comments / questions / discussion points always welcome – please use the comment box below.