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being offered at CORE of Clapton don’t even align with this weak evidence base but instead use approaches that are outdated and have been shown to be ineffective.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.

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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.