The Lancet has recently 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. Chiropractors and osteopaths have been quick to pick this up and comment on it, with their professional membership organisations (The Institute of Osteopathy and The British Chiropractic Association) making statements. There have also been statements from other organisations such as the McTimoney Chiropractic Association as well as lively discussion on twitter. Both chiropractors and osteopaths suggest that they are able to fulfil a key role in tackling this issue but are they actually as well placed as they make out?
Institute of Osteopathy
You can see the statement from The Institute of Osteopathy here. In their post they say:
“In the UK, low back pain is a burden on both the individual and our health care system which is why the National Institute for Health and Care Excellence (NICE) have produced extensive guidance. The guidance recommends manual therapy as part of an overall package of care for those with low back pain. They also recommend, exercise and self-management and psychological support which osteopaths routinely provide.”
There are a few interesting points here. The Institute of Osteopathy highlight manual therapy first in their statement and say that “They also recommend exercise …” (emphasis mine). That’s pretty misleading as NICE have made it really clear that exercise is THE first line treatment and manual therapy is only second-line. I have previously written about this here. The Institute of Osteopathy then go on to say that osteopaths routinely provide exercise, self-management and psychological support. This raises a number of important issues:
- There is a direct conflict between the types of treatments that osteopaths provide (manual therapy) and encouraging self-management. Manual therapy is a passive treatment that can result in an increased reliance on the practitioner which then reduces an individual’s ability to self-manage. Giving patients with back pain lots of hands-on osteopathic treatment is therefore not a good option.
- With regards to psychological therapies, this typically involves cognitive behaviour therapy (CBT) or something similar. CBT is a specialist area and is not something that osteopaths routinely receive training in. I imagine that those people who do actually specialise in this area would be pretty offended to see osteopaths suggesting that they can provide suitable psychological support with little or no training. If psychological support is to be included in a treatment package then this should be delivered by someone who specialises in this area rather than an osteopath who may have spent a few days on a training course. You can search for a more suitable psychological therapist on the NHS Choices website.
- As I’ve explained previously, Osteopaths are also NOT the right professionals to provide an exercise program.
At the end of that page, The Institute of Osteopathy says “Osteopathic practice is a safe and effective form of manual therapy aimed at preventing, diagnosing and treating a variety of health problems.” This is an untrue statement that cannot be substantiated. The safety of osteopathy cannot be established as there is no routine reporting of adverse events. It is clearly not that effective as even in the case of back pain it’s a second-line or adjunctive treatment only. For most other conditions there is little or no evidence that it provides any benefit at all and there is certainly no evidence that osteopathy is effective at preventing anything.
British Chiropractic Association (BCA)
The BCA start off by saying that “movement and physical activity is the best treatment for backpain”, which is accurate and aligns with the lancet paper and guidelines. However, they subsequently say “Chiropractors provide the safe and effective hands on care which has been suggested within the first steps for the treatment of low back pain.” There are a number of problems with this statement:
- There is a lack of evidence that chiropractic is safe with a number of serious adverse events having been reported and a lack of adequate monitoring of safety issues.
- Like osteopathy, chiropractic is also definitely not anywhere near as effective as chiropractors would like you to believe. If it was, it would be a first-line treatment but instead the NICE guidelines and lancet paper have it down as only a “second-line or adjunctive treatment option”.
- Nowhere in the NICE guidelines or lancet paper does it suggest that “hands on care” is a first step in treatment of low back pain. As highlighted above in the section on osteopathy, hands on care (such as the treatment provided by a chiropractor or osteopath) is a passive treatment that can result in an increased reliance on the practitioner which then reduces an individual’s ability to self-manage and therefore perpetuates the problems.
They then go on to say “chiropractors are able to provide non-pharmaceutical care options in the management of back pain, neck pain and other joint and muscle problems for which opioids are often prescribed”. This ignores the fact that chiropractic treatment is largely ineffective and has not been shown to be safe. The problem of over-prescription of opioids has been widely reported and does need to be tackled. However, replacing them with other ineffective treatments such as chiropractic that has risks of its own is definitely not the right solution!
The President of the BCA, Catherine Quinn, was also invited to speak on Channel 5 News. Rather than discussing what the guidelines actually say about the right approach to treatment of low back pain she used the opportunity to “sell” chiropractic as a profession. She said “The Lancet definitely highlights the fact that the package of care that’s offered by chiropractors and many other healthcare professionals is really the best way to go”. Unfortunately, members of the public watching this could be easily misled into thinking that a chiropractor is the best option for treating their back pain. That’s simply not correct. The guidelines recommend self-management, keeping active and exercise as the first-line treatments. As highlighted above, the treatments offered by most chiropractors are only a second-line treatment and can actually reduce self-management. Channel 5 made a serious error here in inviting a leader from a profession that is mired with pseudoscientific beliefs, and has a history of misleading the public, to act as an “expert” in this news piece. Experts should not be “selling” something (as the BCA president is with chiropractic) as this inevitably leads to bias in the advice given and they should instead be independent. I just hope that the views she shared have not done too much harm to the many people who suffer with low back pain and that Channel 5 have learned their lesson and will choose their experts much more carefully in future. To be completely clear, when looking for an expert it’s important to remember that chiropractors and osteopaths are NOT experts in ANY health condition.
McTimoney Chiropractic Association
The McTimoney Chiropractic Association also made a statement here. They start off by saying “According to the research, education and activity can be of more benefit to patients than automatically reaching for the painkillers or drugs” which is accurate. However, they then go on to say “Chiropractic is effective for issues such as low back pain and may be an appropriate way to both get out of pain and help you to feel better enough to get moving more.” I didn’t read anything in the lancet paper about using chiropractic as a way to feel better so that you could then move more. What it actually says is that the best way to start feeling better is to move more. That doesn’t require chiropractic treatment and, as highlighted above, chiropractic is not nearly as effective as chiropractors would like you to believe.
There has been a lively discussion on twitter since the Lancet series was published with a range of different views and interpretations of the papers becoming apparent. One example of a particularly strong view that is relevant to this discussion was the statement:
“evidence from multiple guidelines and recent world experts in @TheLancet says manipulation for low back pain is an effective and safe option. Period”.
This is a bold statement and it is worth assessing this in more detail with careful consideration of the NICE guidelines and the Lancet low back pain series. Manipulation / manual therapy is identified as a second-line or adjunctive treatment in both sources. That’s because evidence shows it is not sufficiently effective when used alone. It’s also quite clear that NICE found it difficult to decide whether to recommend manual therapy at all due to lack of evidence of effectiveness. For instance, they say “Where these benefits were observed in the short term follow up they were somewhat inconsistent, and were not maintained in the longer term. Evidence compared to usual care was conflicting and did not consistently show benefit when manual therapy was offered as a single treatment.” Is it therefore appropriate to describe its effectiveness in such strong terms as the statement above? Definitely not. In terms of safety, the Lancet paper makes no statement in this regard. This paper is effectively a meta-analysis of 3 national guidelines and does not assess individual treatments in any depth or make statements about safety. NICE also do not make a clear statement about the safety or otherwise of manipulation / manual therapy for low back pain. However, they do recognise that there are some potential risks as within the guidelines it says “The GDG were aware of possible serious but very rare adverse events that may be related to spinal manipulation”. I’m not sure where the author of the above tweet was looking but it’s quite clear that the NICE guidelines and Lancet paper don’t actually say that manipulation is “an effective and safe option”.
Should manual therapy ever be used for low-back pain?
I’d like to be clear that I’m not suggesting that manual therapy should never be used. The NICE guidelines and the Lancet paper list manual therapy as a second-line or adjunctive therapy, although they recognise that the evidence of effectiveness is limited. There are therefore likely to be a minority of cases where it would be appropriate to try manual therapy provided that fully informed consent is taken including a discussion of the limited evidence of effectiveness and potential risks. However, any practitioner who is using manual therapy for the majority of their patients and / or using it before FIRST using the preferred treatments of self-management and exercise is definitely NOT complying with the guidelines. It would be totally inappropriate for such a therapist to describe themselves as providing “evidence-based treatments”. This is likely to be a significant issue for the vast majority of chiropractors and osteopaths (as well as a subset of physiotherapists) who frequently use manual therapy as the primary treatment for most of their patients with low back pain.
Yet again, we have examples of osteopaths and chiropractors providing misleading information to members of the public in an attempt to get more patients. Osteopaths and chiropractors are trained in manual therapy and they need focus on this and stop pretending that they have the skills to deliver things like an exercise program or psychological support. They should also stop claiming that their treatments are “safe and effective” until they provide evidence to substantiate that claim. There is, however, one thing that both professions are really skilled in and that’s marketing. Whatever the evidence or guidance says, they will find a way to spin it to give the impression that they can deliver the treatment needed. This isn’t in the best interest of members of the public trying to find the right treatment for their own health problems.