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.

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University College of Osteopathy: Training osteopaths to “treat” respiratory conditions in children

respiratory systemThe University College of Osteopathy (UCO) describes itself as “the leading provider of osteopathic education”. It is the only osteopathic institution in Europe that is allowed to award degrees. It would therefore be reasonable to expect that it provides high-quality, evidence-based education including continuing professional development (CPD) courses. Unfortunately, that is far from the truth. The UCO offers a range of CPD courses, many of which are not evidence-based. I will cover more of these in future blog posts but for now I’d like to focus specifically on their CPD course on The Paediatric Respiratory System. If the idea of an osteopath treating children with respiratory problems doesn’t immediately start ringing alarm bells, then it should do. Read on to understand more.

The UCO’s Paediatric Respiratory System course is a 2-day training session that covers the “osteopathic management” of a range of respiratory conditions including asthma, croup, bronchiolitis and allergic rhinitis. There are a number of serious issues with this training course:

  1. Osteopathy has not been shown to be effective for any respiratory conditions, in children or adults.
  2. Some of the conditions covered on the course are serious and need to be treated by a doctor with appropriate specialist knowledge, e.g. paediatrician. Some children do unfortunately die from asthma and it is totally inappropriate for an osteopath to be trying to treat this.
  3. This is a 2-day training course. Two days. After which the osteopaths who have been on the course will then go and try their treatments on unsuspecting members of the public. Training to be a paediatrician in the UK typically takes around 8 years after completion of a medical degree. Obviously, this is not all focused on respiratory conditions but it is clearly going to involve a LOT more than 2 days of training in the treatment of respiratory conditions.
  4. During the course the osteopaths do not actually see any paediatric patients. They get to see photographs (from which they are supposed to identify “what visible features are suggestive of pathology”) and work through some case studies. The learning outcomes from this course include “Learn how to examine the respiratory system in children of different ages”. How is it possible to do this without actually seeing patients? In reality, it isn’t. It’s nonsense to suggest that a medical professional can be trained to treat a particular group of conditions when they have never seen any patients with those conditions during their training.

Conclusion

This course provides a wholly inadequate grounding in treating respiratory problems in children and uses treatment approaches that have not been shown to be effective. Some of these conditions can, on occasions, be life threatening. This presents a danger to members of the public who may be misled into taking their children for treatment when they should instead be receiving care from a suitably qualified doctor. When the UCO, which claims to be “the leading provider of osteopathic education”, is providing completely unsuitable training like this it raises serious concerns about the osteopathic profession as a whole.

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

Many chiropractors and osteopaths advertise their treatments for headaches but are these treatments actually effective?

Summary of conclusions:

1. There are a large number of different types of headaches. Most of these CANNOT be treated effectively by osteopaths or chiropractors.

2. Osteopaths and chiropractors should be careful that their advertising makes it clear which types of headaches they are able to treat and should NOT give the impression that they can treat headaches in general. Osteopaths and chiropractors who fail to do this risk being reported to the Advertising Standards Authority and to their professional regulators.

3. If you suffer from headaches, The NHS website provides advice on how you can ease the headache yourself as well as situations when you should see your GP or visit A&E

The first thing to understand is that there are many different types of headache such as migraines, tension headaches and cluster headaches. The Advertising Standards Authority (ASA) permits chiropractors and osteopaths to advertise their treatments only for two very specific types of headache:

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

The ASA guidelines do not allow chiropractors or osteopaths to advertise for any other types of headaches because there is a lack of evidence that their treatments are beneficial. In spite of this guidance, many chiropractors and osteopaths continue to advertise their treatments for headaches in general without making it clear that they are unable to treat most types of headache.

More on types of headache

The International Classification of Headache Disorders (ICHD-3: https://www.ichd-3.org/  ) lists a very large number of different types of headaches. The different types of headache are split into two main categories: primary and secondary. Primary headaches are those that are not caused by an underlying disease or health condition. Secondary headaches are caused by an underlying disease or health condition such as an infection or head injury.

Primary headaches are grouped into four categories: migraine, tension-type headache (TTH), trigeminal autonomic cephalagias (TACs) and other primary headache disorders. Migraine is the only one of these that osteopaths and chiropractors are allowed to advertise their treatments for and then only specifically for prevention of migraines and not for the treatment of an existing migraine.

There are eight different categories of secondary headache. Within each of these eight categories are a number of specific headaches, which results in a large number of specific types of secondary headache in total. Cervicogenic headache is just one of these specific types of secondary headache. This is the only type of headache that chiropractors and osteopaths can actually advertise to treat.

As you can see from the large number of different types of headaches, the vast majority of people who have headaches will not have the type of headache that can be treated by a chiropractor or osteopath.

What action can be taken to stop these misleading claims?

One example of an osteopathic practice that claims to be able to treat headaches in general is Moore Osteopathy. I complained to the ASA about the claims made by Moore Osteopathy (along with their misleading claims about treatment of babies ). The response from the ASA was to refer this to their compliance team. The ASA said “your complaint raises an issue which we know is a clear problem under the rules”. This makes it clear that an osteopath claiming to be able to treat headaches in general is a widespread recognised issue. (I have yet to complain about a chiropractor making these claims but will be doing so in future and it’s likely that the situation is similar).

Conclusion

The NHS website says that “Most headaches will go away on their own and aren’t a sign of something more serious.” The same page also provides advice on how you can ease the headache yourself as well as situations when you should see your GP or visit A&E. If you have frequent headaches, getting a diagnosis of the particular type of headaches you have is important. Your GP is best placed to help you with this diagnosis. As osteopaths and chiropractors are specialists in muscles and bones they are not well placed to diagnose or treat most types of headache because many of the wide variety of headache types and potential causes are outside their expertise.

UK osteopaths and chiropractors continue to treat babies in spite of a lack of evidence

babyThere is no good evidence that osteopathy or chiropractic provide any benefit for any infant condition. Treatments such as cranial osteopathy and craniosacral therapy that osteopaths and chiropractors often use on babies are based on concepts that directly conflict with a modern understanding of the way the human body works. In spite of this, a good number of osteopaths and chiropractors continue to treat babies. There has been significant work by the Advertising Standards Authority (ASA) and the Good Thinking Society to tackle this issue. Unfortunately, it remains a significant problem with a number of osteopaths and chiropractors continuing to mislead unsuspecting members of the public into taking their babies for treatment.

Summary of conclusions:

1. There is no good evidence that osteopathy or chiropractic provide any benefit for any infant condition.

2. Osteopaths and chiropractors who continue to treat babies in spite of the lack of evidence risk being reported to the advertising standards authority and to their professional regulators.

3. There is no situation in which it is appropriate to take your baby to a chiropractor or osteopath.

One example of an osteopathic practice that continues to treat babies and breaches ASA guidelines in doing so is Moore Osteopathy. There is a video on Moore Osteopathy’s website which includes a testimonial from parents who took their unsettled, crying baby for osteopathic treatment. The term “unsettled baby” implies colic and advertising osteopathic treatment for this breaches ASA guidelines. Furthermore, the video suggests that childbirth is harmful for babies and that osteopathy can “rectify” the problems that the birth has brought about. This is nonsense, constitutes an unsubstantiated claim and breaches ASA guidelines. The regulator of osteopaths, General Osteopathic Council (GOsC) , have made it clear that all claims must be substantiated and this includes when talking to patients as well as advertising. This therefore suggests that Moore Osteopathy, as well as other osteopaths who make similar claims, are not only in breach of advertising guidelines but may also be in breach of regulatory guidelines. This is not good. Not good for parents who are misled into wasting money on these unsuitable treatments. Not good for Moore Osteopathy, and others, who are at risk of sanctions. Also not good for the osteopathic profession as a whole as it risks undermining its credibility.

Why do osteopaths and chiropractors treat babies?

Why do osteopaths and chiropractors continue to “treat” babies for colic and other health conditions? That’s a complex issue and I’m sure there are many reasons. Here are a few:

  1. They genuinely believe that they are helping. Osteopaths and chiropractors are taught (at least a little bit) about treating babies during their education. When they try out these treatments on a baby and the baby gets better it’s an easy mistake for them to put the improvement down to their treatment. They therefore think that they are helping and continue to offer the treatments.
  2. It’s good for business. If you can get some babies on your patient list then maybe you can continue to treat them during childhood and on into adulthood giving you a long-term income. You could also potentially recruit their parents as patients too, increasing your income further.
  3. It’s easy work. A baby who has colic will get better regardless of what treatments they receive, or without treatment. They just outgrow it between 4 and 6 months of age. It’s therefore very easy for a chiropractor or osteopath to have “success” when treating a baby with colic.

Do chiropractic and osteopathy actually help with colic and other infant conditions?

Colic is an ideal condition for chiropractors and osteopaths to “treat” because it resolves of its own accord, typically between 4 and 6 months of age. If a baby is being “treated” for colic by an osteopath or chiropractor at the time that it resolves of its own accord then it is natural for the parents to assume that the treatment is the cause of the improvement. In reality, it is far more likely that the colic simply resolved. The best available scientific evidence indicates that osteopathy and chiropractic do not actually provide any benefit for colic. The situation is similar for other infant conditions: there is no evidence that osteopathy or chiropractic provide any benefit.

What action can be taken to stop these misleading treatments?

I reported Moore Osteopathy to the Advertising Standards Authority (ASA) for their misleading claims. The response from the ASA was to refer this to their compliance team. The ASA said “your complaint raises an issue which we know is a clear problem under the rules”. The fact that the ASA do not need to investigate my complaint any further indicates that this is a widespread issue rather than it being just one or two problematic osteopaths. Although the Compliance team will not report to me directly, it will be interesting to see what happens to the advertising of Moore Osteopathy on their website.

Conclusions

There is no evidence that osteopathy or chiropractic provide any benefit for any infant condition. In spite of this lack of evidence, misleading the public into taking their babies for treatment continues to be a significant problem in both the osteopathy and chiropractic professions. This is something that really ought to be tackled by the osteopathic and chiropractic regulators directly rather than leaving it just to the Advertising Standards Authority. The General Osteopathic Council (GOsC) and General Chiropractic Council (GCC) have been historically very poor at doing this and it is high time that they disciplined some of their registrants for this deception of the public. In the meantime I can only give this advice: There is no situation in which it is appropriate to take your baby to a chiropractor or osteopath.

Should you have acupuncture for your low back pain? A review of the Lancet series and 3 national guidelines

acupunctureIn March 2018 The Lancet published a series on low back pain consisting of three papers and a related podcast. This is an important topic due to the large number of people who suffer with back pain at some point during their lives and it’s good that the Lancet have given it particular focus. One thing that’s particularly interesting in this series is that acupuncture is recommended as a “second-line or adjunctive treatment option”. The UK NICE guidelines for low back pain and sciatica, published in November 2016, made it clear that acupuncture is no longer a recommended treatment in the UK for low back pain with or without sciatica. So why does this Lancet series recommend it as a second-line or adjunctive treatment option? This is an interesting question that is worthy of further investigation.

Summary of conclusions:

1. Based on the available evidence, there is no good reason to recommend acupuncture as a treatment for either acute or chronic low back pain with or without sciatica.

2. It is impossible to say whether acupuncture is safe or not.

3. It is hard to understand why the Lancet paper recommended acupuncture as a second-line or adjunctive treatment option as this is not consistent with the majority of national guidelines on which the Lancet paper is based.

The Lancet paper that covers this is effectively a systematic review of 3 national guidelines on low back pain from Denmark, the UK and the US. Of the 3 guidelines, the only one that recommends acupuncture is the one from the US. Those from the UK and Denmark do not recommend acupuncture. In their press release to accompany the latest version of the UK guidelines, NICE clearly states “Acupuncture for treating low back pain is not recommended because evidence shows it is not better than sham treatment”. Usually when developing guidelines, all relevant evidence is reviewed internationally. This leaves two key open questions:

  1. Why did the US guidelines reach a different conclusion to those from the UK and Denmark?
  2. Why did the Lancet series recommend acupuncture as a “second-line or adjunctive treatment option” when only 1 in 3 of the national guidelines they reviewed recommended it?

Differences between UK and US guidelines

There are a number of differences between the approach taken by the UK and US guideline developers.

Firstly, the UK guidelines were quite focused on the need to show effects over and above contextual or placebo effects. This is what they say (highlighting mine):

“The GDG first discussed the necessity of a body of evidence to show specific intervention effects, that is, over and above any contextual or placebo effects. It was therefore agreed that if placebo-controlled evidence (or sham acupuncture) is available, this should inform decision making in preference to contextual effects, but that the effect sizes compared with usual care would be important to consider if effectiveness relative to placebo, or sham, has been demonstrated.”

This is different to the approach taken by the US guideline which has made recommendations based on the difference between acupuncture and no acupuncture without clear evidence of a specific effect over and above placebo. This is an important distinction because in order to show that a treatment is actually effective it’s important to show a benefit over and above the placebo effect.

When assessing the evidence for acupuncture compared with placebo / sham, this is what the UK GDG (Guideline Development Group) has to say:

“For the placebo/sham controlled evidence in the low back pain population, the GDG agreed that no clinical benefit was seen for pain or function.”

The other key difference between the UK and US guidelines is the approach to analysing the available evidence. The US guideline used systematic reviews directly without investigating the individual studies that made up the review. In contrast, the UK guideline used systematic reviews as a way to identify individual RCTs (Randomised Controlled Trials) but did not include the systematic reviews themselves. The UK approach is clearly significantly more work than the US approach. However, it is likely to result in a more accurate assessment of the evidence base for the following reasons:

  1. The systematic reviews may have set out to answer a slightly different question to the one that the guideline developers are seeking to answer.
  2. It enables the guideline developers to undertake a consistent assessment of all of the primary studies. (It’s unlikely that the assessment of studies will be consistent across multiple systematic reviews.)
  3. It removes the risk of a systematic review reaching inaccurate conclusions based on poor quality primary studies. (Unfortunately, some systematic reviews do report conclusions that are actually based on poor quality or highly biased primary RCTs.)

I’m not trying to suggest that the conclusions reached by the US guideline are wrong. In science it is not normal to talk in such strong terms as right and wrong but instead to talk about the probability of something being correct or what the best available evidence indicates. However, it is likely that the UK guideline is closer to an accurate answer than the US guideline for the reasons highlighted above. The UK guideline clearly states that acupuncture should not be recommended as a treatment for people with low back pain with or without sciatica.

Acupuncture recommendations in the US guidelines

Here are the 2 recommendations for the use of acupuncture in the US guidelines:

  • For acute or sub-acute low back pain, acupuncture is recommended as one of several treatments with the quality of evidence stated as low.
  • For chronic low back pain, acupuncture is recommended as one of several treatments with the quality of evidence stated as moderate.

Let’s take a closer look at the evidence that has informed these recommendations for acupuncture.

Acute or Subacute Low Back Pain

The following statement is made in the guideline:

“Low-quality evidence showed that acupuncture resulted in a small decrease in pain intensity compared with sham acupuncture with nonpenetrating needles, but there were no clear effects on function (76–78). Low-quality evidence showed that acupuncture slightly increased the likelihood of overall improvement compared with NSAIDs (76, 79–83).”

It is difficult to assess this in more detail as for several of the papers used only the abstract is readily available. However, low-quality evidence of a small decrease in pain intensity is hardly compelling evidence on which to base a recommendation for the use of acupuncture.

Chronic Low Back Pain

The following statement is made in the guideline:

“Low-quality evidence showed that acupuncture was associated with moderate improvement in pain relief immediately after treatment and up to 12 weeks later compared with sham acupuncture, but there was no improvement in function (125–130). Moderate-quality evidence showed that acupuncture was associated with moderately lower pain intensity and improved function compared with no acupuncture at the end of treatment (125). Low-quality evidence showed a small improvement in pain relief and function compared with medications (NSAIDs, muscle relaxants, or analgesics) (125).”

It’s interesting that the only item with moderate-quality evidence is a comparison between acupuncture and no acupuncture. In this situation there is no control for the placebo effect and the observed improvement may actually be entirely down to the placebo effect. What’s more important is the difference between acupuncture and sham acupuncture and there the evidence is low quality. It’s therefore surprising that the guideline authors have concluded in their summary recommendations that there is moderate-quality evidence for the use of acupuncture. The more detailed information that they present here clearly indicates that there is actually only low-quality evidence.

Risk of Harm

The US guideline states that “Low-quality evidence showed no reported harms or serious adverse events associated with … acupuncture”. However, adverse event reporting is unfortunately omitted from many trials of complementary and alternative medicine including acupuncture. This is a serious ethical issue that makes it difficult to objectively assess the risk associated with acupuncture and other CAM therapies. Edzard Ernst frequently highlights this on his blog, with an example relating to acupuncture here. All of this leads us to this conclusion: It is impossible to say whether acupuncture is safe as adverse events are not adequately reported or investigated.

Recommendations from the Lancet paper

The Lancet paper is effectively a systematic review of 3 national guidelines. Only the US guidelines recommend acupuncture as a treatment for low back pain. The guidelines from the UK and Denmark say that it isn’t recommended. Why then does the Lancet paper make a recommendation for the use of acupuncture as a second-line or adjunctive treatment? I was unable to find a reasonable explanation within the Lancet paper itself. Perhaps the authors made a mistake because this is otherwise a very strange way of interpreting the recommendations from the 3 national guidelines. When the majority of the national guidelines assessed recommend against acupuncture then it would make much more sense for the Lancet paper to recommend against it also.

Conclusion

Based on the available evidence, there is no good reason to recommend acupuncture as a treatment for either acute or chronic low back pain with or without sciatica. It’s hard to understand why the Lancet paper has recommended otherwise. Whilst there are unfortunately no treatments that have been shown to be highly effective there are other interventions, such as exercise and self-management, that have a stronger indication of effectiveness than acupuncture. Patients should therefore be guided towards these treatments. In addition, future research should focus on improving and optimising interventions such as exercise and self-management rather than continuing to study something like acupuncture that shows little evidence of benefit.

Tui Na: What is it? Is it effective for autism?

I recently became aware of a form of treatment known as “Tui Na” when it was advertised for children with autism. Having not come across this before, I decided to investigate further to find out what Tui Na is and whether or not it is a suitable treatment for autism and other conditions.

Summary of conclusions:

1.       Tui Na is a type of traditional Chinese medicine based on Qi and meridians. Qi and meridians don’t actually exist and Tui Na is therefore not consistent with a modern understanding of the way the human body works.

2.       There is no good evidence that Tui Na provides any benefit for autism or any other health condition

3.       The safety of Tui Na has not been established

4.       Based on the currently available evidence, there is no health condition for which Tui Na should be recommended

5.       Charities should carefully assess the suitability of treatments before giving a platform to treatments like this that could actually do more harm than good.

What is Autism?

The National Autistic Society says:

“Autism is a lifelong developmental disability that affects how people perceive the world and interact with others.

Autistic people see, hear and feel the world differently to other people. If you are autistic, you are autistic for life; autism is not an illness or disease and cannot be ‘cured‘. Often people feel being autistic is a fundamental aspect of their identity.

Autism is a spectrum condition. All autistic people share certain difficulties, but being autistic will affect them in different ways.”

What is Tui Na?

Tui Na is a type of traditional Chinese medicine focused on massage and manipulation. Like acupuncture, it has its basis in the “flow of internal energy” called Qi through the meridians. In reality, there is no such thing as Qi or meridians. Tui Na is therefore based on an outdated view of the human body and there is no scientific basis behind these treatments.

Does Tui Na work?

There are a number of research studies on the use of Tui Na for a range of different conditions. Whilst I did not undertake a detailed review of all of the studies, most of them seem to be of low quality with a high risk of bias which makes drawing any meaningful conclusions difficult. I have not been able to find any studies about the use of Tui Na for autism, which suggests that it has never been properly researched. Overall, there is no good evidence that Tui Na is effective for autism or any other health condition.

Is Tui Na a suitable treatment for autism?

For the following reasons, Tui Na is not a suitable treatment for autism:

  1. There is no good evidence that Tui Na provides any benefits for the treatment of autism.
  2. The rationale behind Tui Na is based on outdated principles and is not consistent with a modern understanding of the way that the human body works.
  3. The safety of Tui Na has not been established.

With regards to safety, The Tui Na Centre has this video showing their treatment of a child with autism. From viewing the video it looks as though there is at least some potential to cause psychological distress to a child receiving the treatment as they appear to be being physically restrained in order to carry out the treatment. In my view, this treatment should therefore not be offered until its safety has been thoroughly assessed, probably under the guidance of a suitable research ethics committee.

Tui Na should not be offered as a treatment for autism or any other condition until evidence of effectiveness and safety has been established.

What action can be taken to stop people being misled into taking this treatment?

I became aware of this treatment when it was being promoted by a charity called Thinking Autism. They planned to invite the main therapist from the Tui Na Centre to give a talk at one of their parent awareness roadshows. Thanks to a major awareness campaign on twitter led by Autistic Inclusive Meets, the talk was cancelled. This was a small success in reducing the exposure of parents to misleading claims about this unsuitable treatment.

Unfortunately, the Tui Na Centre itself continues to make misleading claims about the effectiveness of Tui Na for autism as well as a number of other health conditions. I therefore reported them to the Advertising Standards Authority (ASA). My complaint covered the claims made by the Tui Na centre for physical problems, chronic pain, sports injuries, headaches, migraines, constipation, IBS, sleep problems, anxiety, digestion, liver and kidney function, stress. In particular, I highlighted concerns about the claimed therapeutic benefits for autism and cerebral palsy. My complaint centred on two main issues:

  1. I don’t believe there is any evidence that substantiates any of these claims.
  2. Most of these conditions are those for which appropriate medical supervision should be sought. The therapist providing these treatments is not a doctor.

The ASA were very quick to pick this up and responded in under a week. They decided to refer my complaint directly to their Compliance team to take action. The Compliance team work proactively to ensure compliance with the ASA standards. They pick up cases that don’t require further investigation by the ASA and take more direct action. Although the Compliance team will not report to me directly, it will be interesting to see what happens to the advertising of the Tui Na centre on their website, YouTube, Facebook and Twitter accounts (all of which were included in my complaint).

Update 21/01/19: The ASA compliance team are starting to have some effect. Whilst the claims on the Tui Na Centre website are still misleading they are less egregious than previously. There is less focus on Tui Na as a treatment for autism and cerebral palsy and a new statement has appeared about the need for “suitably qualified medical treatment”. The video on their website has now been removed, although it still exists on YouTube. This is a step in the right direction although there is clearly a lot more change needed. I will be monitoring what happens and if there are no further improvements will raise with the ASA again.

The Thinking Autism charity made a serious error of judgement here in planning to give a platform to the Tui Na centre. Fortunately, the potential for parents and patients to be misled was stopped by the work of Autistic Inclusive Meets. I understand that it can be difficult for a small charity to carry out an in-depth assessment of potential treatments. However, if Thinking Autism wants to ensure that they are helping people with autism they should undertake a more careful assessment of any speakers they plan to use at their events in future. Otherwise, they risk giving a platform to organisations promoting unsuitable treatments which may ultimately result in harm to those very people they are trying to help.

Is chiropractic care a suitable treatment for children?

On twitter, I often highlight the highly dubious practice of chiropractors and osteopaths treating babies and children. On one such occasion I received a response to one of my tweets that said “Read the best practice guidelines.” with a link to a journal article titled Best Practices for Chiropractic Care of Children: A Consensus Update. I was shocked that such a thing existed because there is a lack of evidence of chiropractic (and osteopathy) for children. Safety has also not been established. I therefore decided to evaluate this in more detail and present my review of this below along with conclusions about the suitability of chiropractic care for children.

Summary of conclusions:

1. There is currently no good evidence that chiropractic care provides any benefit for any infant or childhood condition.

2. It is impossible to know whether chiropractic treatment for children is safe or not.

3. Based on the currently available evidence, there is no situation when chiropractic care should be recommended for children.

Background to the “best practice guidelines”

The purpose of the best practice guidelines article was to undertake a formal consensus process on chiropractic care for children. Part of the work undertaken was a systematic review with the primary search question “What is the effectiveness of chiropractic care, including spinal manipulation, for conditions experienced by children (< 18 years of age)?” To start with, this is a rather strange thing to try and answer via a systematic review. The purpose of a systematic review is to provide a complete, exhaustive summary of evidence relevant to a particular research question. However, the question needs to be sufficiently specific to enable a complete and exhaustive assessment to be carried out and reasonable conclusions and recommendations to be made. In this case the question covers “conditions experienced by children (< 18 years of age)”. This is far too broad for a systematic review and the review will end up finding lots of primary research studies that are not sufficiently related to each other to enable meaningful conclusions to be drawn. In fact, this is exactly what has happened with this review as it tries to draw conclusions for conditions ranging from cancer to headache to autism to infantile colic. How can a review of such a wide range of conditions expect to reach sensible conclusions and recommendations? Quite simply, it can’t. The systematic review just makes no sense. There are more issues, however, so let’s explore further.

The evidence for chiropractic care for children

Within the systematic review, a total of 21 studies were identified. Yes, that’s really only 21 studies of sufficient quality that assessed the effectiveness of chiropractic care or manipulation for children across all conditions. The results reported in the systematic review suggest that there is “limited support” for asthma, infantile colic, nocturnal enuresis and respiratory disease. The definitions used by the authors for different levels of evidence were as follows:

  • No support – insufficient evidence
  • Limited support – a small number of studies of mixed quality with positive findings
  • Effective – a number of studies with at least some of high quality with positive findings

Infantile colic is the condition with the most relevant papers identified so let’s look at the evidence for effectiveness of chiropractic care for that as an example. The authors identified 5 relevant articles:

  • Efficacy of chiropractic manual therapy on infant colic: a pragmatic single-blind, randomized controlled trial – The authors reported this as a high quality study which was “effective”. I was unable to access the full paper but parts of it are reproduced at the link above. Unfortunately, the method and results are not reproduced which makes a full assessment problematic. Based on the limited amount of information available, I can see that there are some potential issues with the conclusions reached due to significant numbers of dropouts (all from the no-treatment group) and patients who “recovered” being discharged early in the trial. It’s not possible to assess this further without access to the full paper. However, for the purposes of this assessment, let’s be really generous and assume that the study was indeed of high quality and did show effectiveness of chiropractic.
  • The chiropractic care of infants with colic: a systematic review of the literature – The authors considered this to be a review of low quality and to show limited supported for the use of chiropractic for infantile colic. I was unable to access the full paper but the abstract includes a wide range of different study types including case reports and commentaries. That isn’t an appropriate way to establish evidence of effectiveness as case reports and commentaries are not measures of effectiveness. This review should therefore be marked as “no support” as it is unable to provide sufficient evidence of treatment effectiveness.
  • Chiropractic spinal manipulation for infant colic: a systematic review of randomised clinical trials – This review found no support for the use of chiropractic for infantile colic.
  • Manipulative therapies for infantile colic – The conclusion in that paper clearly states “The studies included in this meta-analysis were generally small and methodologically prone to bias, which makes it impossible to arrive at a definitive conclusion about the effectiveness of manipulative therapies for infantile colic”. This clearly fits the definition above of “no support” as there is insufficient evidence to reach conclusions. For some reason, the authors of the practice guideline have rated this as “limited support” which I don’t believe to be correct.
  • The use of spinal manipulative therapy for paediatric health conditions: a systematic review of the literature – The authors note that this provides “limited support” for asthma. It did not provide support for any of the other conditions assessed including infantile colic.

Of the 5 articles that the authors identified for infantile colic we therefore have:

  • 1 RCT that shows chiropractic to be effective
  • 4 systematic reviews that show no evidence of effectiveness

I’m therefore confused why the authors concluded that there was overall “limited support” for infantile colic. A single RCT that has not been independently reproduced definitely does NOT trump 4 systematic reviews that have not found evidence of effectiveness. The reality is: based on the currently available evidence there is no evidence to suggest that chiropractic care is an effective treatment for infantile colic.

I haven’t assessed the evidence raised by the authors for the other health conditions (asthma, nocturnal enuresis and respiratory disease) in detail. However, given the questionable conclusion that the authors reached with regards to infantile colic it would make sense to not follow their advice for the other health conditions without first undertaking a rigorous review of the evidence presented.

Safety and Adverse Events

This section of the paper is quite strange. The authors looked for articles that specifically focused on the safety of chiropractic treatment in children. That makes sense at one level but the authors have failed to address the point that adverse event reporting should be the norm in any good quality trial. Therefore, they should have been looking at adverse event reporting in ALL of the studies they identified including those that they used to assess effectiveness. I can understand why this would present a problem for the authors because trials of alternative medicine, including chiropractic, are notoriously poor at reporting adverse events. Edzard Ernst has talked about this on numerous occasions, such as here. It’s disappointing that the authors failed to comment on this at all, however. Until adverse event reporting becomes the norm in all of these sorts of trials there is only one thing we can say with any confidence about the safety of chiropractic treatment for children: It is impossible to know whether chiropractic treatment for children is safe or not.

Recommendations for chiropractic management of pediatric patients

The article has a section of recommendations for chiropractic management of pediatric patients. This includes the recommendation that “A therapeutic trial of chiropractic care can be a reasonable approach to management of the pediatric patient in the absence of conclusive research evidence when clinical experience and patient/parent preferences are aligned”. Really? For any clinical presentation even if the symptoms are potentially very serious it’s okay to have a trial of chiropractic care provided the chiropractor and patient / parent agree? I have previously explained why this is not an evidence-based approach, not in the best interest of patients and the potential problems that it presents. A more suitable recommendation would be: In the absence of conclusive research evidence the chiropractor should cease treating the patient and should instead refer them to their primary care doctor (GP in the UK).

The article also recommends “Comanagement with other appropriate health care providers” in a range of different circumstances including:

  1. “The child patient is not showing clinically significant improvement after an initial trial of chiropractic care.” If chiropractic care has not provided a benefit, why would you continue to provide it under a comanagement approach? There is no logic behind this recommendation and it would be much more appropriate to cease chiropractic care and refer the patient to a doctor.
  2. “Management of many nonmusculoskeletal conditions may benefit from comanagement with the child’s primary care physician and/or other providers, depending on the condition.” This is simply not true. There is no evidence that chiropractic provides any benefit for any non-musculoskeletal condition and therefore no chiropractor should be seeing a patient (child or adult) for these conditions.

The article also lists a set of “signs / symptoms of potentially serious illness for which appropriate referral and/or co-management are indicated”. Included in this list are suicidal ideation, loss of developmental milestones, unexplained weight loss and many others. If a child presents with any of these serious signs or symptoms, co-management would be totally inappropriate as chiropractic has nothing to offer. Instead, chiropractors should only be recommended to refer on to an appropriate specialist and take no further part in the child’s care.

It is concerning that a “best practice guidelines” has been produced with these sorts of recommendations. They are not evidence-based, logical or in the best interest of patients.

Vaccinations

With regards to vaccinations, the article states “Although immunization is a well-established medical approach to disease prevention, DCs may be asked for information about immunizations by a child’s parents. Doctors of chiropractic should provide balanced, evidence-based information from credible resources and/or refer the parents to such resources.” Actually, they shouldn’t do that. Instead, chiropractors should state that advising on immunization is outside of their expertise and scope of practice and instead refer patients to their primary care doctor (GP in the UK).

Conclusions

The focus of this systematic review was too broad to be able to draw meaningful conclusions. The review falsely reports that chiropractic provides some benefit to some health conditions in children when the evidence does not back this up. Some of the recommendations provided for the chiropractic care of children are inappropriate. Overall, this “best practice guideline” is not suitable to use as a basis for chiropractic care in children.

What evidence and recommendations should be made regarding chiropractic care for children? Here is a summary:

  1. There is currently no good evidence that chiropractic care provides any benefit for any infant or childhood condition.
  2. It is impossible to know whether chiropractic treatment for children is safe or not.
  3. Based on the currently available evidence, there is no situation when chiropractic care should be recommended for children.

The final conclusion from all of this is simple: Don’t take your child to a chiropractor.