Chiropractors and Osteopaths continue to mislead about their role in the treatment of back pain

backpain

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:

  1. 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.
  2. 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.
  3. 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:

  1. 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.
  2. 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”.
  3. 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.

Twitter

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.

Misleading Information

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.

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Misleading the public into fundraising for evidence free osteopathic treatments

fundraisingMany members of the public give up their time to undertake fundraising activities for the benefit of others. Indeed many charities are heavily reliant on the generous work of their fundraisers in order to carry out their charitable activities. Sometimes individuals or organisations ask people to carry out fundraising in order that they can provide healthcare. For instance, the Alder Hey Children’s Charity raises funds to carry out research, innovation and education in medical care for children. A very worthwhile cause. What about when an individual or organisation raises funds for treatments that have not been shown to be effective? That seems rather less worthwhile and potentially involves misleading the fundraisers in order to persuade them to help the cause. That seems to be the case with CORE of Clapton and their osteopathic treatments.

On the face of it, the CORE of Clapton website gives the impression of trying to benefit the community. They state “We believe everybody has the right to a pain-free life and our aim is to make osteopathy accessible to all.” Wanting to make people more pain-free can only be a good thing. However, suggesting osteopathy as the solution seems to be misguided. Osteopathy is a treatment for which there is very little evidence of effectiveness. In the case of low back pain, the “home ground” of most osteopaths, osteopathy is no longer recommended as a first-line treatment. When it comes to treatment of other conditions, the evidence for osteopathy is even weaker or in many cases non-existent. Unfortunately, the treatments being offered at CORE of Clapton don’t even align with this weak evidence base but instead use approaches that are outdated and have been shown to be ineffective.

Treatments at CORE of Clapton

There has been coverage of the types of treatments being offered at CORE of Clapton in the news recently. The treatments described in that article are far from evidence based. For instance, the NICE guidelines for low back pain and sciatica make it clear that exercise is the first line treatment and that things like osteopathy should only be offered in addition to exercise. Is there any mention of exercise in this treatment program? No. It therefore doesn’t comply with the guidelines and is not evidence based. Things get far worse than this, however. In the sixth and final session, acupuncture is used as a treatment. Now, acupuncture has been removed entirely from the latest NICE guidelines due to lack of evidence of effectiveness. The treatment being offered by CORE of Clapton clearly does not follow relevant guidelines or recent research and this can’t be in the best interest of patients.

At this point you may be wondering whether fundraising for CORE of Clapton is such a good idea after all, but there is more. The treatment approach being used came in for stiff criticism from within the osteopathic profession on twitter. There were a large number of comments including “Focusing on fixing posture and mechanical dysfunction reinforces negative beliefs and from a pain science perspective clinically ineffective” and “In some case more than clinically ineffective, but potentially harmful”. So, here is an organisation that’s asking members of the public to donate or fundraise and yet the treatments they’re offering are “clinically ineffective” or even “potentially harmful”.

As an aside, it’s good to see that some osteopaths are trying to bring about change in a profession that is closely associated with quackery. They are few in number but it’s good that they are willing to challenge the many osteopaths who are using outdated, non-evidence based treatments and frequently misleading the public into taking these inappropriate treatments.

Research at CORE of Clapton

CORE of Clapton are keen to carry out research in osteopathy. When planning to carry out research it’s important to have a good understanding of all relevant existing research so that the new research is relevant and appropriate. Unfortunately, that doesn’t seem to be the case at CORE of Clapton. First of all, the treatments described above are clearly not based on a good understanding of the latest research. The “Research” section of the website makes this lack of understanding even more obvious. For instance, it says that “NICE recommends osteopathy for sub-acute and chronic low back pain” and provides a reference to the NICE guidelines from 2009. Now, these guidelines were superseded by the version published in November 2016 which downgraded the role of osteopathy in the treatment of low back pain. So, here is an organisation that is keen to carry out “research” yet still refers to NICE guidelines that were superseded nearly 6 months ago.

Another thing that’s absolutely key when carrying out research is to minimise the risk of bias. When research is carried out it should be to test IF something works rather than to deliberately try and search for evidence that it does. The latter would be a clear case of bias and is unfortunately what happens far too frequently in most research in complementary and alternative medicine, such as osteopathy. The Research page on their website lists a number of “further positive trials”. Unfortunately, this appears to be a cherry-picked list of studies that apparently show the benefits of osteopathy. There are no trials listed that showed a negative outcome for osteopathy and the list of trials presented are far from a complete list of all research in any of the areas mentioned. There is clearly a very strong bias here towards trying to show that osteopathy works rather than genuinely researching to see IF it works.

What’s worse is that the interpretation of the trials themselves is actually incorrect and clearly suffers from further bias. For instance, CORE of Clapton say that “In elderly patients hospitalised with pneumonia, treatment significantly reduced the duration of intravenous antibiotic use and length of hospital stay compared to a sham treatment.” The trial they reference doesn’t say that at all! It’s actually a negative trial and shows that osteopathy was NOT beneficial for this patient group. In the results section it clearly states “Intention-to-treat (ITT) analysis (n = 387) found no significant differences between groups”. In other words osteopathy was NOT effective. On the basis of this study, further research in this area is not warranted.

What is the chance of the “research” that’s going to be carried out at CORE of Clapton resulting in an accurate unbiased assessment of the effectiveness of osteopathy? Based on the extremely biased view presented on their website I would say “zero”. Whatever “research” does get carried out is therefore unlikely to add anything at all to our understanding of what osteopathy can and cannot treat. Any public money spent on such “research” is being wasted and could be spent better elsewhere.

Conclusions

A Community Interest Company (CIC) like CORE is supposed to be of benefit to the community. CORE are asking the general public to donate to them or fundraise for them because they want to improve access to osteopathy for the public and to carry out research into osteopathy. These are goals that, on the face of it, appear to be in the public interest. However, once you look more closely it’s very clear that this is not the case. The treatments offered are not evidence based and in some cases potentially harmful. The “research” that they plan to carry out is likely to be so biased as to provide no useful information on the effectiveness of osteopathy. It’s hard to imagine how this venture can benefit the community at all given the types of treatments and research being offered. Misleading the public to fundraise for something that isn’t actually going to benefit the community is unethical. Public time and money should instead be given to other organisations that provide a genuine benefit.

NICE guidelines for low back pain and sciatica: a clarification

The recently published NICE guidelines for low back pain and sciatica are clear and unambiguous. However, they seem to have been misinterpreted by some people. One area where this has happened is the part about manual therapy. Here is what the guideline says:

“Consider manual therapy (spinal manipulation, mobilisation or soft tissue techniques such as massage) for managing low back pain with or without sciatica, but only as part of a treatment package including exercise, with or without psychological therapy.”

I have seen this misinterpreted as:

  • “Select just the bits you like”
  • “Manual therapy with exercise or psychological therapy”
  • “Exercise and manual therapy is the choice for low back pain”
  • “Osteopathy or manual therapy continues to be the treatment of choice for low back pain with the proviso that it is provided with exercise”

It’s important to understand that the wording from the guideline above makes it clear that exercise is a mandatory part of a treatment package. Manual therapy and psychological therapy are optional add-ons but exercise is compulsory. That means that the treatment options are: exercise alone, exercise plus manual therapy, exercise plus psychological therapy, exercise plus manual therapy and psychological therapy. Using a treatment package that consists of manual therapy alone, psychological therapy alone or manual therapy plus psychological therapy does not comply with the guidance. It’s also important to understand that there is no requirement to provide a multimodal treatment package and in some cases exercise alone will be the most appropriate treatment. You certainly can’t “select just the bits you like” as exercise is not an optional component.

Now let’s look at what the NICE guidelines say about exercise:

“Consider a group exercise programme (biomechanical, aerobic, mind–body or a combination of approaches) within the NHS for people with a specific episode or flare-up of low back pain with or without sciatica. Take people’s specific needs, preferences and capabilities into account when choosing the type of exercise.”

One important point from this guidance is that NICE recommends a “group exercise programme”. This presents something of a problem for pure manual therapists such as osteopaths and chiropractors as they don’t normally have access to a group exercise programme for their patients. I have already highlighted the fact that osteopathy and chiropractic are no longer first line treatment choices for low back pain and sciatica. NICE have made it clear in their own press release that exercise is the “first step in managing the condition”. The right person to deliver an exercise programme is of course a physiotherapist.

Ultimately, the purpose behind these guidelines is to bring about improvement in care for patients. Views such as “Osteopathy or manual therapy continues to be the treatment of choice for low back pain with the proviso that it is provided with exercise” give an interesting insight into the goals of the osteopathic profession. This statement is far too obviously in conflict with the guidelines to be a mere “misunderstanding”. These kinds of statements appear to be more focused on promoting the businesses of the osteopaths. In so doing, osteopaths seem to have forgotten the most important thing of all: looking after the best interest of their patients.

The new NICE guidelines are something of a problem for osteopaths and chiropractors as their treatments are no longer first line choices and they are not well placed to offer a suitable exercise programme. Some of them may opt to continue treating patients the way the always have and not take the NICE guidelines into account. However, that is a potentially risky strategy for two reasons:

  1. It doesn’t seem to be in the best interest of their patients
  2. They risk being found in breach of their “Practice Standards” which could result in formal complaints to either the GOsC or GCC.

Osteopathy and Chiropractic no longer recommended as a first line treatment for low back pain or sciatica

If you ask a member of the public what osteopaths and chiropractors treat you will probably get the answer “bad backs”. It is true that most people who go to an osteopath or a chiropractor do so because of back pain. However, the treatments offered by osteopaths and chiropractors are no longer considered to be first-line treatments for low back pain or sciatica. The recently published NICE guidelines for low back pain and sciatica emphasize exercise as being central to the treatment approach.

Manual therapy, such as that provided by osteopaths and chiropractors, can only be considered in addition to an exercise programme. Manual therapy should not be offered in isolation. This is a “downgrading” of the role of osteopathy and chiropractic in the treatment of low back pain as those treatments were previously considered as a valid alternative to exercise. What has brought about this change? Quite simply, evidence. Recent research has shown that osteopathy and chiropractic (manual therapy) are not an effective treatment in isolation for low back pain and sciatica. Any osteopath or chiropractor who recommends their treatments to a patient who is not already following an exercise programme is not following the NICE guidelines. This brings into question whether they are acting in the best interest of the patient.

The right person to deliver an exercise programme is of course a physiotherapist. Physiotherapy is available on the NHS via a referral from a GP. Alternatively, private physiotherapy is available and it’s easy to search for a suitable physio on the Chartered Society of Physiotherapy website.