Osteopaths undertake marketing dressed up as research

Many osteopaths (and chiropractors) use their treatments for babies even though there is no good evidence that these treatments benefit any infant condition. Osteopaths are desperate to find some evidence to support these treatments so that they can promote them more widely. They have therefore undertaken a study called CUTIES, which stands for Crying, Unsettled, disTressed Infants: Effectiveness Study. The first mention I found of this was in an edition of The Osteopath (magazine produced by the regulator, the General Osteopathic Council). There are a number of serious issues with this research that means the outcomes are unlikely to tell us anything about whether osteopathy is actually effective for unsettled babies. Let’s look at these issues in more detail.

Bias

When conducting research, it is inevitable that some level of bias will exist even in the best designed and conducted study. Good researchers work really hard to remove as much bias as possible in order to improve the accuracy of results from their study. However, that is not the case here. The introduction to the study states that the aim is “to build an evidence base for osteopathy in the care of infants”. The researchers are actually setting out to try and provide justification for osteopathic treatment of infants. Research should instead set out to find out IF a treatment works rather than to try and show that it does. This research was therefore deeply flawed before it even started.

Study design, lack of plausibility and “birth trauma” nonsense

This is described as an effectiveness study. This is putting the cart before the horse. Before undertaking an effectiveness study, it is normal to start with a feasibility study to ensure that the treatment is feasible and acceptable to patients. In the published protocol for this study, the authors claim that a pilot trial was conducted to assess feasibility. However, no reference was provided which suggests that it was unpublished. This is a serious concern. Moving to an effectiveness study without first publishing the pilot trial means that it’s not possible for anyone else to assess the basis for the approach used in the effectiveness study (e.g. sample size, recruitment, blinding, etc). This is not the way that good research should be conducted.   

In actual fact the main technique used by osteopaths on babies, cranial osteopathy, is based on a series of illogical unfounded ideas and therefore it is entirely infeasible. Even the protocol for this very trial states “There is little evidence to support the mechanism of action underpinning this approach with the rationale for treatment being theoretically driven”. The reason for the lack of evidence to support the mechanism of action is that it is biologically implausible and makes no sense in the context of a modern understanding of the human body.

Within this protocol paper we also see the same claimed justification for these treatments used by many osteopaths and chiropractors, i.e. “birth trauma”. This is something that isn’t recognised by conventional medicine. That’s because “birth trauma” is something that osteopaths and chiropractors have literally made up in order to try and justify their treatments. It’s not a real thing.

Study hypothesis

The study hypothesis is that “specific targeted osteopathic light touch usual care is superior to non-specific light touch”. The trouble is that is very hard to actually test. In practice, the osteopaths are likely to behave differently (whether intentionally or not) when they deliver the osteopathic intervention. It is this non-specific effect that is the most likely explanation for any difference between the intervention group and control group. In other words, any detected apparent benefit for the osteopathic intervention is very likely to be due to the behaviour of the osteopaths rather than the intervention itself. This doesn’t mean that osteopathy works, just that having the right approach when dealing with patients is important.  

Outcome measures

The outcome measures for this study are: effectiveness of osteopathic care on crying time, confidence in parenting, overall perceived change, and parental satisfaction and experience with osteopathic care. It’s noticeable that these are subjective self-reported measures that are very prone to bias. I’d also suggest that outcome measures such as “parental satisfaction and experience with osteopathic care” have no place in a trial that is intended to measure treatment effectiveness.

Popularity of osteopathic care for babies is very concerning

Although not related to the study itself, the lead for the study suggests that one in every eight / nine infants go to see an osteopath. Personally, I find this very concerning. There is no evidence that osteopathy provides any benefits for any infant condition and osteopaths lack the specialist expertise to treat babies. Any osteopath who is asked see a baby should instead refer them to a more qualified practitioner.

Conclusion

There are many serious issues with this study including an unpublished pilot trial, a treatment approach that lacks plausibility and a biased approach. I would therefore like to make a prediction in which I’m very confident. I predict that this study will produce positive results. How can I possibly know this before the study has been completed? That’s very simple. The study has been designed to generate a positive outcome. It is heavily biased throughout to the point that the person leading the study describes the aim as “to build an evidence base for osteopathy in the care of infants”. Will my prediction turn out to be correct? Let’s wait until the results are published and we’ll see. I’d be very pleased if I was proven wrong because that would indicate a rigorous approach to this research. Unfortunately, I think that’s very unlikely to happen.

Paediatric osteopaths continue to think they can treat a wide range of serious health conditions: This is a risk to the public

Much like paediatric chiropractic, there are many and serious issues with paediatric osteopathy including inappropriate treatment of babies as well as attempting to treat serious health conditions like asthma. The Osteopathic Centre for Children in London, UK, has recently announced a new course for osteopaths. Reading through this I was alarmed by many serious issues, not least of which is that these osteopaths appear to believe that they are doctors. UK osteopaths are not doctors and are instead musculoskeletal therapists very similar to chiropractors. They are not qualified to treat outside of musculoskeletal areas (e.g. back or neck pain) and certainly have no business handling prematurity, maternal mental health or (their words) “the seriously sick child”. The risk of an unqualified person addressing these sorts of serious health conditions cannot be understated. Let’s have a look at this course in more detail.

Course pre-requisites

The only pre-requisite for this course is “Osteopathy in the Cranial Field”. Cranial osteopathy is complete nonsense, conflicts with a modern understanding of the human body and there is no way it could possibly have any health benefit. I am honestly amazed that both osteopaths and the regulator allow cranial osteopathy to continue to be used as a treatment approach. Any course that builds on cranial osteopathy is, by definition, going to be mired in pseudoscience, misleading information and nonsense.

Obstetrics and paediatrics

In medicine, there is a good reason why there are separate specialists in obstetrics and paediatrics. They are very different things, each requiring specialist skills and knowledge. It isn’t reasonable for a single person to be a specialist in both of these areas of medicine. Osteopaths have a different view of this. They seem to think they can become skilled in both obstetrics and paediatrics as the course claims that it will enable osteopaths to develop their “obstetric and paediatric clinical skills”. This is the Dunning-Kruger effect at its finest. These osteopaths understand so little about these areas of medicine that they just don’t realise how little they actually know.

Birth trauma

Osteopaths and chiropractors who treat babies (almost?) always claim that they are treating “birth trauma”. We see this misconception repeated in the description of this course with training being included on “mechanical assisted birth interventions & strains”. In reality, this “birth trauma” is something that chiropractors and osteopaths have literally made up in order to try and justify their treatments. There is no such thing.

Conditions treated

The list of conditions that osteopaths will be learning about on this course is particularly alarming and includes:

• Plagiocephaly (flat head syndrome)
• Feeding issues
• Sleep
• Maternal mental health
• Prematurity
• Behavioural issues
• The seriously sick child (their wording)
• Enuresis (bed wetting)
• Immunity and vaccination
• Orthodontics

Osteopathy, including cranial osteopathy, is not effective for any of these conditions and UK osteopaths (like chiropractors) do not have the specialist expertise required to manage any of these things. In the case of things like immunity and vaccination, all an osteopath needs to know is that they should refer any questions or concerns about this to a qualified medical professional (e.g. GP).

If the idea of osteopaths treating these serious health issues doesn’t cause alarm, how about the idea of osteopaths treating newborn babies in a neonatal ward? Yes, apparently osteopaths on this course will get the opportunity to “treat babies in the Starlight neonatal ward in Barnet Hospital”! I do wonder if Barnet Hospital realise the level of pseudoscientific nonsense they are allowing to be used on newborn babies.

Conclusions

Like paediatric chiropractic, paediatric osteopathy is full of pseudoscience, false beliefs and misleading claims. In this course, UK osteopaths are learning to treat conditions that are far outside of their expertise. The idea of them treating prematurity, newborn babies and “the seriously sick child” is, quite frankly, frightening. The risk that this presents to unsuspecting members of the public cannot be understated. I think that the UK osteopathic and chiropractic regulators need to step in and set a minimum age limit for osteopathy and chiropractic treatment.

Yet another negative study of chiropractic care for infantile colic: It is time to stop these inappropriate treatments on babies

Of all of the different patient groups that chiropractors and osteopaths treat, the one that concerns me most is their treatment of babies. Chiropractors and osteopaths continue to offer their treatments for a range of conditions in babies in spite of no good evidence that they help with anything. They also continue to conduct research to try and show that these treatments “work” even though in many cases there is no plausible mechanism by which they could possibly do so. A recently published trial looked (again) at chiropractic care for infantile colic. This was yet another negative study. I would argue that it’s high time that research into chiropractic and osteopathy treatments for babies was stopped. In my view it’s unethical to continue to expose this vulnerable patient group to these treatments given a) the lack of a plausible mechanism of action for these treatments and b) the very limited training that chiropractors and osteopaths have in the treatment of babies, which are a unique patient group.

The study

The study sought to assess the effectiveness of chiropractic care for infantile colic with parents blinded to treatment allocation. Both groups attended clinic twice a week for two weeks. The intervention group received chiropractic care and the control group was not treated. To maintain parent blinding, parents were not present in the treatment room. 185 babies completed the trial (96 in the treatment group, 89 in the control). Duration of crying was reduced by 1.5 hours in the treatment group and 1 hour in the control. The difference was not statistically significant. Let’s be clear, such a small difference in crying time means that the treatment didn’t show any effect and this is a negative trial. (The reduction in both groups is probably due to the tendency for colic to just improve of its own accord over time). However, the authors go on to suggest that further research should be undertaken “to investigate if subgroups of children, e.g. those with musculoskeletal problems, benefit more than others from chiropractic care”. I disagree with this on a number of points:

1. There is no indication that colic has a musculoskeletal origin so there isn’t a good rationale for the suggestion that these treatments might benefit crying time in babies with musculoskeletal problems.
2. These treatments carry risks.
3. Chiropractors have very limited training in the treatment of babies and lack the specialist knowledge required for this unique patient group

Risks associated with these treatments

An extensive review in Australia looked at chiropractic treatment of children. It stated that “it is difficult to draw conclusions about the safety and effectiveness of spinal manipulation in children” and went on to say “Nonetheless, it is clear that spinal manipulation in children is not wholly without risk.”

Conclusions

This is yet another negative study of chiropractic care for infant colic. The evidence is really pretty clear: these treatments aren’t effective. The situation is the same for chiropractic and osteopathy treatments of other infant problems: there is no good evidence that these treatments benefit any condition. Given the potential risks associated with some of these treatments and the lack of expertise of the practitioners with the treatment of babies, there is no good reason to carry out any further research on these treatments in this vulnerable patient group.

UK osteopaths continue to operate outside a reasonable scope of practice: They now think they can treat long COVID

For a number of years I have been concerned that UK osteopaths and chiropractors believe that they are able to treat conditions for which they lack expertise. For instance, a significant number of osteopaths and chiropractors claim that their treatments “boost the immune system”. They also think that they can treat respiratory conditions in children, such as asthma or bronchiolitis, when their treatments are totally inappropriate for these conditions. It was only a matter of time before these practitioners turned their attentions to COVID-19. The University College of Osteopathy has recently offered a course in treatment of “thoracic restrictions” which they claim can be used for patients “who are experiencing shortness of breath”, which could be related to a COVID-19 infection or long COVID. It should be immediately obvious that treating these conditions is far outside the remit of UK osteopaths. UK osteopaths are not doctors and have no medical training.

Summary of conclusions:

1. UK osteopaths are not doctors and lack the necessary medical training to treat a complex condition like long COVID.

2. By operating so far outside of their expertise, osteopaths are putting the health and safety of members of the public at risk.

3. If an osteopath suspects one of their patients may have Long COVID, the best thing that they can do is to immediately cease treatment and refer the patient directly to a doctor.

What is Long COVID?

The NHS website says:

“For some people, coronavirus (COVID-19) can cause symptoms that last weeks or months after the infection has gone. This is sometimes called post-COVID-19 syndrome or “long COVID”.”

There are many and varied symptoms that can be experienced by people with long COVID including:

• extreme tiredness (fatigue)
• shortness of breath
• chest pain or tightness
• problems with memory and concentration (“brain fog”)
• difficulty sleeping (insomnia)
• heart palpitations
• dizziness
• pins and needles
• joint pain
• depression and anxiety
• tinnitus, earaches
• feeling sick, diarrhoea, stomach aches, loss of appetite
• a high temperature, cough, headaches, sore throat, changes to sense of smell or taste
• rashes

Research suggests that most people with long COVID have symptoms affecting three or more organ systems.

Management of long COVID

In October 2020, the NHS announced a 5-point plan including specialist clinics, an online platform and the development of guidelines by NICE. NICE has since produced a guideline on managing the long-term effects of COVID-19, which provides advice on identifying, assessing and managing long COVID. These guidelines make no mention of osteopaths treating patients who have difficulties with their breathing. In addition, these guidelines include urgent onward referral in the case of acute or life-threatening complications and a set of specific blood tests. An osteopath can’t offer blood tests and may be less likely to spot serious complications than a qualified doctor.

The course

In the course description it says “Over the course of the pandemic Valeria Ferreira has seen increasing numbers of patients presenting with a range of thoracic restrictions as a result of changes in working practices or as a result of long covid”.

This appears to be an osteopathic interpretation of what happens in Long COVID rather than an accepted medical approach. Nowhere in conventional medical advice, such as the NICE guidelines, does it make any mention of treating “thoracic restrictions”. It is concerning when a group of health professionals, in this case osteopaths, are taking their own approach that does not align with conventional treatment.

The course leader

The biography of the course leader also raises a number of concerns. She apparently leads the “4th year visceral osteopathic module”. Visceral osteopathy is implausible nonsense and it is appalling that osteopathic education institutions continue to teach it. She also apparently applies another ridiculous osteopathic technique: cranial osteopathy. I would suggest that someone who teaches and applies such unsuitable treatment approaches is not the right person to be providing a training course on a complex medical condition like Long COVID.

Conclusions

UK osteopaths are not doctors but yet some of them continue to believe that they are or that they are somehow equivalent to doctors. This belief causes them to try and treat conditions for which they lack the necessary specialist expertise. Long COVID is an obvious example of a condition that is clearly outside the expertise of an osteopath. The expertise of osteopaths is in treating musculoskeletal problems, e.g. low back pain, whereas Long COVID is a complex condition that affects multiple organ systems such as gastrointestinal, cardiopulmonary and neurological. An osteopath does not have the medical training required to treat these sorts of problems.

For the health and safety of the public, treatment of a complex condition like long COVID should be handled by doctors in the NHS working in accordance with the NICE guidelines. Members of the public are being placed at risk because they may mistakenly go to an osteopath for treatment when they should instead be seeing a doctor.

If an osteopath suspects one of their patients may have Long COVID, the best thing that they can do is to immediately cease treatment and refer the patient directly to a doctor.

Which involves more “quackery”: physiotherapy, chiropractic or osteopathy?

Summary of conclusions:

In the UK, I would say that chiropractic involves the most quackery with osteopathy a close second. Physiotherapy is significantly better than either of the others but there is still room for improvement.

This is an interesting question that was raised on Twitter. Answering this question may help members of the public decide whether to see a physiotherapist, chiropractor or osteopath.

What is “quackery”?

According to Wikipedia: “Quackery, often synonymous with health fraud, is the promotion of fraudulent or ignorant medical practices. A quack is a “fraudulent or ignorant pretender to medical skill” or “a person who pretends, professionally or publicly, to have skill, knowledge, qualification or credentials they do not possess; a charlatan or snake oil salesman”.”

It is often difficult to differentiate between those practices that are merely ignorant, where the practitioner believes they are helping, and fraudulent, where the practitioner knows they are deceiving their patients. Both definitely exist but it seems likely that more cases fit into the former category than the latter. In this situation, the practitioner has been so indoctrinated into the particular treatment approach that they believe they are helping even though the treatment they are using is unproven. This happens even in the most ridiculous treatment approaches such as homeopathy or reiki. It is important to understand that although the motivation of an ignorant practitioner is different to a fraudulent one; both present a risk to members of the public.

Quackery in the physiotherapy, chiropractic and osteopathy professions

As a starting point, I have previously highlighted some of the many issues with chiropractic and osteopathy professions in the UK: Now, this page could do with some updates as I have found even more issues with these professions since writing that. For instance, during the Covid-19 pandemic a number of UK chiropractors and osteopaths have made misleading claims about their treatments “boosting the immune system”.

As to physiotherapy, it is not free from the use of quackery. For instance, acupuncture is quite widely used within the physiotherapy profession (including on the NHS). Acupuncture lacks a plausible mechanism of action and has minimal evidence of effectiveness. However, is this really quackery at the same level as cranial osteopathy / craniosacral, treating “birth trauma”, treatment of asthma or autism and frequent breaches of advertising guidelines? I would suggest that it is not. The National Institute for Health and Care Excellence (NICE) included acupuncture in their draft guidelines for chronic pain. I have explained why I think this is wrong, but it is hard to blame an individual physio for using acupuncture when it is recommended by NICE. Chiropractors and osteopaths do use acupuncture too.

Treatment of babies

Treatment of babies is worryingly widespread within the chiropractic and osteopathy professions even though there is no evidence that these treatments provide any benefit for any infant health condition. See here, here, here and here for a few examples of misleading claims from chiropractors and osteopaths. This is just the tip of the iceberg as there are many other such claims that I have not yet had time to fully investigate.

I have previously tried to look for misleading claims from physios who treat babies and such claims are hard to find. Even though I was searching for physios, I found mostly osteopaths being returned from my searches.

Misleading advertising

Misleading advertising claims within the osteopathic and chiropractic professions has been a serious problem for many years. Although regulatory action, led by the Advertising Standards Authority, has resulted in some improvement it remains a significant issue. There are misleading claims from some physiotherapists too, although it appears to be a much less widespread issue. For instance, The Good Thinking Society have previously assessed the proportion of misleading advertising claims from physiotherapists, osteopaths and chiropractors. They found the chiropractors are the most likely to make misleading claims with osteopaths next and physios much less likely.

Conclusion

In the UK, I would say that chiropractic involves the most quackery with osteopathy a close second. Physiotherapy is significantly better than either of the others but there is still room for improvement.