UK Health Centre: Misleading information about osteopathy – a second Advertising Standards Authority (ASA) complaint

Rulings - ASA I CAP_ UK Health Centre - https___www.asa.org.uk_codes-and-rI have previously highlighted the many misleading claims about complementary and alternative medicine on the UK Health Centre website. The website is owned by Core Health Ltd and they provide misleading information about osteopathy, chiropractic, acupuncture, homeopathy and herbal remedies. The information they provide is misleading the general public and has the potential to cause people to take unsuitable treatments. In the interest of public safety I therefore reported UK Health Centre to the Advertising Standards Authority (ASA) and focused on their claims relating to osteopathy in the first instance. That complaint was “informally resolved” but rather than addressing their misleading claims, Core Health Ltd actually added more conditions to the list of those that they claim osteopathy can treat. I therefore raised a second complaint to the ASA. This complaint was also “informally resolved” in January 2018. However, Core Health have still failed to address their misleading advertising.

The website has been changed in response to this second complaint with some claims being removed but also some new ones being added. The UK Health Centre website continues to make misleading claims about osteopathy as a treatment for a wide range of medical conditions including:

  • Whiplash
  • Asthma and chest problems
  • Long term illness
  • Stress
  • IBS
  • Infections and illness
  • Improving the immune system
  • Increasing the efficiency of nerve supply
  • Low energy
  • Dysmenorrhoea (period pains)
  • Recovery from childbirth
  • Common infant problems (including colic, sleep problems)
  • Monitoring baby’s growth and development
  • Improving cognitive function
  • Visual and hearing impairment

In this latest update they have removed the following:

  • Diabetes
  • Depression
  • Osteoporosis
  • Glue ear
  • Insomnia

However, this is not an improvement as they have added the following misleading claims in their place:

  • Improve blood flow
  • Reduce heart attack risk
  • Reduce risk of headaches
  • Increase bloody supply to the brain
  • Increase response time and feeling of “wellness”
  • Reduce side effects of drugs

Osteopathy hasn’t actually been shown to be effective for any of the above conditions.

As well as making misleading claims about specific health conditions the UK Health Centre website includes other inaccurate information. Of particular concern are things like this:

“Your GP may have suggested that you visit an osteopath. This is common for people who suffer from chronic symptoms including back pain, shoulder pain, migraines etc. Your GP may also refer you to an osteopath if you are pregnant or have just given birth (especially if your birth was particularly traumatic or your baby is experiencing problems sleeping or appears agitated).” I certainly hope that GPs are not suggesting that people visit an osteopath. There is little or no evidence that osteopathy provides benefit for any condition and GPs ought to be recommending evidence based treatments. There is absolutely no evidence that birth “trauma” causes any problems in babies. This is something that is claimed by some chiropractors and osteopaths but actually isn’t backed up by evidence and indicates the lack of even a basic understanding of paediatrics within these two professions. There is no reason to ever take a baby to an osteopath (or chiropractor). None.

Worryingly, osteopathy is not the only area where the UK Health Centre website makes misleading claims. For instance, they say that acupuncture can be beneficial for people with cancer including the nausea associated with chemotherapy and the anxiety and pain from the cancer itself. There is no evidence that acupuncture is effective for any of these things.

In spite of 2 complaints to the ASA, Core Health has failed to correct their misleading claims. As well as highlighting a problem with Core Health as an organisation, this also further highlights the ongoing problem with the osteopathy profession. It is now almost 3 years since the ASA issued clear guidance to osteopaths on the conditions they may advertise to treat. The General Osteopathic Council (GOsC) has also made it clear that osteopaths should be treating in an evidence based manner. It’s clear that some osteopaths are still willing to go against regulatory guidelines and continue to treat these conditions even though it isn’t in the patient’s interest to do so.

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Beware of osteopaths and chiropractors who offer a “package of care”

packageI have previously written about the NICE guidelines for low back pain and sciatica and the problems that these present for UK osteopaths and chiropractors. Their main treatments are no longer recognised as the first-line solution. How have these professions sought to address these challenges? Have they stepped back, considered what’s best for patients and accepted that they sometimes need to refer these patients elsewhere rather than treating themselves? No, what they have actually done is got out some sticking plasters and tried to cover up the issue.

You may have noticed that some osteopaths and chiropractors say that they offer a “package of care” to people with low back pain and sciatica. Although a few of them may have done this prior to the publication of NICE guidelines, in the majority of cases this is something “new” that they are offering. Why have they done this? Let’s remind ourselves what the NICE guidelines say about manual therapy (the main treatment offered by chiropractors and osteopaths):

“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.”

Ah, so now it’s all becoming clear. They can’t offer their treatments in isolation any more as that wouldn’t be in line with the guidelines so now they’re trying to offer a “package of care” instead. But wait, how are osteopaths and chiropractors suddenly gaining the knowledge and experience to deliver an exercise program and psychological therapy? Are they undertaking several years of further training and clinical practice before using these techniques on their patients? No. What they’re actually doing is attending a few 2-day training courses and then magically claiming that they are now in a place to offer these treatments as part of evidence-based care. Here is an example of a typical course: A yoga based approach to therapeutic movement & exercise. In the course description they refer to the NICE guidelines and state “Manual therapy is recommended but only as part of a treatment package which includes exercise”. It’s therefore pretty clear that they are trying to use this and other similar courses to provide a way to “align” their treatments with the guidelines. Is 2 days long enough to gain sufficient expertise in exercise or psychological therapy in order to use it on patients? Of course not! What will happen when an osteopath or chiropractor who has been on one of these courses starts applying it in their own practice? They will make mistakes. LOTS of mistakes. Who will they make those mistakes on? Unsuspecting members of the public who are misled into taking these treatments. At what point will the chiropractor or osteopath become sufficiently skilled that these mistakes become a rare event? If their only training is a 2-day course then I would actually suggest never. A course like that is nothing more than a “taster” session and is nowhere near enough to build even a basic grounding in exercise or psychological therapy. There is a very real risk of patients being harmed by someone providing a “treatment” when they have only received 2 days of training.

Most people go into healthcare because they wanted, at least at some point, to be able to help others rather than just as a way of making money. I’d therefore ask all osteopaths and chiropractors to think really carefully about whether it’s in the best interest of their patients for them to provide an exercise program or psychological therapy. Would it not be better for the patient to refer them to someone who is actually specialised in these areas?

If you are a patient reading this then beware of any osteopaths or chiropractors who offer a package of care including exercise and / or psychological therapy. It’s highly likely that they are going outside of their main expertise in doing so and you would probably be much better off looking elsewhere for treatment.

 

The Charity Commission consultation on complementary and alternative medicines reveals some “interesting” responses

charitycommissionBetween 13th March and 19th May 2017 The Charity Commission held a consultation about whether an organisation which uses or promotes CAM (Complementary and Alternative Medicine) therapies should be allowed to be a charity. This was prompted by the work of the Good Thinking Society. Although the consultation closed over 12 months ago, The Charity Commission have yet to publish the outcome and have stated that they will do so “in the first half of 2018”. A summary of the feedback received is available on this page and makes for “interesting” reading.

The first thing that’s apparent is that The Charity Commission is surprised by the number and type of responses they received. They say We received over 670 written responses, far in excess of the number usually received for a Commission consultation.” I’m struggling to understand why this was such a surprise. CAM covers a whole range of therapies such as homeopathy, chiropractic, osteopathy, acupuncture, reiki, reflexology, naturopathy and many others. There are a large number of organisations and individuals who have an interest in this area for a variety of reasons. Therefore it’s to be expected that there would be a large response. The Charity Commission also seem surprised by the number of individuals who responded. They say “The majority of responses received were from individuals apparently writing in a personal capacity”. Many individuals have relevant expertise in this area that enables them to usefully contribute to this sort of consultation even if they don’t work for an organisation that itself has an interest. Again, I’m not sure why The Charity Commission finds this surprising.

The Responses

The Charity Commission say “A broad range of opinions were expressed in response to the consultation, some of which clearly are strongly held.” Indeed they are. Some of those responses are reasonable and make logical sense and some, quite simply, don’t.  Reading through the responses gives an interesting insight to some of the highly illogical thinking of CAM providers.

Responses to the first question “Question 1: What level and nature of evidence should the Commission require to establish the beneficial impact of CAM therapies?” include those that think patient testimony is more valuable than scientific evidence. This is, of course, nonsense. It is well known that most CAM practitioners promote their services largely or exclusively based on testimonials. The trouble is that testimonials actually tell you very little about the effectiveness of a treatment and they should therefore not be used as a basis for making treatment decisions. It’s clear that CAM practitioners either lack an understanding of the science behind measuring treatment effectiveness or conveniently choose to ignore it because it conflicts with the weird and wonderful therapy that they happen to provide. The most sensible responses to this question are the ones that align with this “Some responders expressed the view that the evidence to be considered in respect of CAM therapies should be the same in nature as that to be considered in respect of any other therapies. When assessing effectiveness of a therapy this should be done without bias. Therefore the level of evidence required should be the same regardless of the type of therapy. The suggestion by some respondents that “the breadth and/or history of use of a therapy should be used as a measure of evidence is laughable. Should we go back to using leeches as a treatment because it has a long history? Of course not. Science and medicine gradually improves by accepting new treatments that are shown to be effective and dropping those that are shown to be ineffective or where the risk / benefit ratio is not acceptable. Unfortunately, what we are seeing here is the opinion of CAM practitioners and organisations who have failed to reject the things that don’t work and keep misleading people into taking them as “treatments” for a whole range of conditions.

The second question in the consultation was “Question 2: Can the benefit of the use or promotion of CAM therapies be established by general acceptance or recognition, without the need for further evidence of beneficial impact? If so, what level of recognition, and by whom, should the Commission consider as evidence?” This is a really strange question to ask because the only rational answer is clearly “no”. The suggestion that a benefit of any therapy can be established merely because it is accepted or recognised is nonsense. It requires only a basic understanding of science to realise that this is not how treatment effectiveness should be assessed.

The responses to “Question 3: How should the Commission consider conflicting or inconsistent evidence of beneficial impact regarding CAM therapies?” show an astounding lack of science comprehension from some respondents. For instance, some responders urged the Commission to give applicants “the benefit of the doubt”, or to register CAM organisations unless and until their contentions are disproven.” Again, this is simply not how science works. The person or organisation making the claims needs to provide the evidence that they are valid rather than expecting that there should be proof that they are invalid first. This is really the only way that science can sensibly work and an example will help to make this completely clear. I could choose to make the claim that somebody on the planet is able to fly to the moon by flapping their arms. If we have to disprove my claim before it is seen as invalid then we would have to get every single person on the planet to try before we could do so. This is something that is clearly both impractical and very silly. Instead, we should assume that it’s not possible until someone proves otherwise. We can also use science to calculate the amount of force required to leave the earth’s atmosphere and conclude that even to try going to the moon by flapping your arms is an entirely pointless activity. No further research required. If only the same approach was used with CAM therapies, a lot of public money would be saved that is currently squandered on research into things that are completely implausible.

The next question was “Question 4: How, if at all, should the Commission’s approach be different in respect of CAM organisations which only use or promote therapies which are complementary, rather than alternative, to conventional treatments?” Some respondents “questioned whether there is a real distinction between the two categories referred to in this question, or whether it is possible to draw the distinction clearly.” If you study the way that CAM practitioners use their treatments it does indeed become difficult to separate these two things. Regardless of whether the particular type of CAM that a practitioner happens to use is homeopathy, acupuncture, chiropractic, osteopathy or anything else there is a need to believe in the treatment approach. In most cases this is in direct conflict with mainstream medical treatment and science. For instance, homeopaths believe that “like cures like” and that diluting a substance makes it stronger. Osteopaths and chiropractors believe that structure dictates function. Belief in any of these treatment approaches requires the practitioner to reject conventional approaches because it’s simply not possible to fully understand and accept science and medicine and to hold these beliefs. It’s therefore almost impossible for a CAM practitioner to apply their treatments in a complementary manner to conventional treatments. They will inevitably want to steer their patients away from conventional treatments that do not align with their belief system.

For “Question 5: Is it appropriate to require a lesser degree of evidence of beneficial impact for CAM therapies which are claimed to relieve symptoms rather than to cure or diagnose conditions” we have some further nonsense responses such as “Some responders thought that the Commission should assume that a benefit is provided by a particular therapy, unless it can be shown that it is harmful.” This is pretty ridiculous and again is clearly not how science and evidence actually works. Is it really okay to just use dubious unproven treatments on unsuspecting members of the public and continue to do so until harm is shown? Are we supposed to wait until people die or are suffer serious health consequences before putting a stop to a particular therapy? If conventional treatments were developed in the same way then lots of people would die. There is a reason why treatments are carefully developed and researched over a number of years before they start being used in routine care. Many initially promising treatments either turn out not to work that well or have harmful side effects. The same approach should be applied to CAM therapies. Why do CAM providers not want this? It’s very simple, most or all of them would not show sufficient benefit and have too many risks to recommend using them. CAM providers don’t want this research to be done because it would probably signal the end of their business.

Question 6 was “Do you have any other comments about the Commission’s approach to registering CAM organisations as charities?” Like the earlier questions, there are some responses that really make no logical sense. For instance, “CAM therapies are not susceptible to assessment in the same way as conventional treatments.” This is something that a large number of CAM providers claim. They say they don’t have evidence for their treatments because they can’t be assessed in the normal way or because they treat the individual not the condition. This is a complete cop out. With some thought it should be possible to test pretty much any treatment in a scientific and objective manner to see if it is effective. Again, CAM providers are making excuses because they know that when their treatments have actually been assessed they have been shown to be ineffective. This is the case with many CAM approaches that have been around for a long time such as homeopathy, acupuncture, osteopathy and chiropractic. They have actually had significant research carried out on them and the results are spectacularly uninspiring as they show that they have little or no benefit.

One of the answers to this question raises a classic argument from many CAM providers: “A decision which might result in the removal of CAM organisations from the charity register would compromise patient choice.” There are two key points here. Firstly, this consultation is about whether CAM organisations can be eligible as charities. Even if the decision is that they can’t that doesn’t stop CAM providers from existing, just that they can’t be registered as a charity and receive the associated benefits. Secondly, and more importantly, providing patients with a “choice” that includes treatments that don’t work is misleading and unethical. Imagine if you went to a doctor and they said “Would you like to try treatment A that has been shown to be effective or treatment B that hasn’t?” This kind of “choice” is a false balance argument that is absolutely not in the interest of patients.

At the end of the document is a list of organisations that responded to the consultation.  It’s quite the collection of CAM organisations promoting a whole range of weird, wonderful and unproven therapies from homeopathy to reiki to osteopathy to meridian energy to acupuncture. There are also a small number of organisations that provide a more rational view such as the Good Thinking Society and The Nightingale Collaboration.

Conclusion

Charities are required to provide a “public benefit”. The benefit part states “a purpose must be beneficial – this must be in a way that is identifiable and capable of being proved by evidence where necessary and which is not based on personal views” (https://www.gov.uk/guidance/public-benefit-rules-for-charities). Many CAM charities fail this test as they actually promote treatments that have either been shown not to work or that have not been shown to work. I have written about a couple of examples previously: The Sunflower Trust and CORE of Clapton. An excellent article from Michael Marshall of the Good Thinking Society highlights several others. However, this really only scratches the surface and there are a whole range of charities offering unproven “treatments” from the whole spectrum of CAM. When The Charity Commission finally get around to reaching a conclusion from this consultation it is hoped that they will act in the interest of the health and safety of the general public and remove all CAM charities from the charity register.

Osteopathy can be used to treat mental health issues related to back pain … or can it?

I came across this article which makes the bold claim in the title that “Osteopathy can be used to treat mental health issues related to back pain” and later in the article that it is “effective for reducing anxiety and psychological distress, as well as improving patient self-care”. If accurate, this could present a significant step forward in treating mental health issues but do the claims stand up to closer scrutiny?

The Article

Firstly, let’s assess the article before moving on to the study itself. The article makes a number of claims that are not substantiated by evidence. Here I will highlight just a few of the most serious issues:

  • “OMT* has already been found to be effective for several types of muscoskeletal pain, such as chronic neck pain”. Really? I think I must have missed the research that was published to show that it’s effective for several types of musculoskeletal pain. The link they provide to back this up is a Cochrane Review of manipulation and mobilization for mechanical neck disorders, available here. It doesn’t take much reading to realise that this does NOT demonstrate that osteopathy is effective for neck pain. It’s right there in the conclusion section in black and white “Done alone, manipulation and/or mobilization were not beneficial”. The claim about effectiveness of OMT is misleading and does not have evidence to back it up. (*OMT is short for Osteopathic Manipulative Therapy, the main treatment approach used by most osteopaths)
  • “Spinal mobilisation and manipulation alone have been found to be effective for acute, subacute and chronic low back pain.” This is simply not true when all of the available evidence is considered. I have previously written about the NICE guidelines for low back pain and sciatica which make it clear that the treatments provided by osteopaths and chiropractors (mobilisation and manipulation) are NOT first-line treatments because they have not been shown to be effective when used in isolation.
  • When discussing the current study, the article states that “This data has shown that OMT is effective for reducing anxiety and psychological distress, as well as improving patient self-care”. I will address this in more detail below when I assess the study itself but suffice it to say that the study definitely did not show this.
  • “Our results also suggested that the positive psychological effects of OMT could be further optimised by combining it with therapy approaches like acceptance and commitment therapy (ACT).” Again, the results don’t show anything of the sort. Also, adding something else to a therapy that hasn’t been shown to be effective is not “optimising”, it’s an attempt to hide the fact that the therapy doesn’t actually work.

The Study

Now let’s take a closer look at the study that prompted this article. It’s published in Health Psychology Open and can be found here. In the conclusion of this paper there is the statement “this study has demonstrated that OMT was effective at reducing pain, anxiety and psychiatric disorders”. It doesn’t actually show that at all. There are MANY issues with this study and here are just a few of the most serious:

  • This was not a randomised controlled trial and had no control condition. This means that there is no way to control for non-specific treatment effects such as regression to the mean or placebo. It’s therefore impossible to say whether this treatment actually provided any benefit or not.
  • The time period over which benefits were assessed is just two weeks. TWO WEEKS! Using such a short time period to try and measure effectiveness of a treatment for mental health conditions is ridiculous. To suggest that this treatment is “effective” when using such a short treatment period demonstrates a lack of understanding of both mental health conditions and also how to conduct research.
  • There is no mention within the paper about whether participants in the study were receiving any other interventions at the same time. Obviously if participants receive another treatment at the same time then this will influence outcomes and again it becomes impossible to tell whether osteopathy provides any benefit or not.

In summary this study is not a randomised controlled trial, uses a ridiculously short assessment period and does not control whether participants receive other treatments. As such, it is totally unsuitable for assessing treatment effectiveness. The authors are, quite simply, wrong in their claim that this demonstrates effectiveness of osteopathy for mental health conditions. It’s extremely disappointing that such serious flaws were not picked up in peer review and the article blocked from publication.

Conclusion

Others have written previously about osteopaths producing “research” that is really more about marketing and promotion than actual research. This article and paper are full of serious issues including misleading claims and erroneous conclusions. The Conversation, where the article was published, has as its strapline “Academic rigour, journalistic flair”. This article seems to be entirely the latter with none of the former. Professor Edzard Ernst has also written about this and reached similar conclusions to my own.

Let me finish with a clear, evidence-based statement about osteopathy for mental health conditions: There is currently no evidence that osteopathy provides any benefit for any mental health condition. None. At. All.

 

Children’s Charity “The Sunflower Trust” in breach of advertising guidelines due to misleading treatment claims

Rulings - ASA I CAP_ Sunflower Trust - https___www.asa.org.uk_codes-and-rI have previously written about the children’s charity The Sunflower Trust. This is a charity that claims to treat a whole range of health conditions in children and has as its president an osteopath who was removed from the register of practicing osteopaths for unacceptable professional conduct. I complained to the Advertising Standards Authority (ASA) about the misleading treatment claims and the ASA also challenged whether the adverts discouraged essential treatment for conditions for which medical supervision should be sought. The Sunflower Trust responded by saying that they would remove the misleading claims and the complaint was therefore “informally resolved”. Rather than complying with the guidelines as they claimed they were going to do, The Sunflower Trust has actually created more new content that is in breach of the guidelines.

Here is an example where the Sunflower Trust claims that their treatment helped with dyspraxia and dyslexia. In this story, Justin’s mother says “I soon realised that I needed outside help if I was going to help him with his education. He has dyspraxia and suspected dyslexia, so he finds everything twice as hard as other children.” For some reason that isn’t explained in the story, rather than following the normal routes of talking to the SENCO (Special educational needs co-ordinator) at her son’s school or taking him to the GP she decided to go to The Sunflower Trust instead. He was given a pre-programme assessment which “showed his musculoskeletal to be of particular concern as his body appeared to be completely out of alignment”. Now, there is no such thing as someone’s body being “out of alignment”. This is an imaginary concept used by some chiropractors and osteopaths to justify the treatments they provide but in reality it doesn’t actually exist at all. There is also no evidence whatsoever that “re-aligning” someone’s body or any other aspect of the “treatment” included in the Sunflower Programme can provide any benefit for someone with dyspraxia or dyslexia.

Here is another example where they claim they can treat autism. According to this story, Helen’s parents were told by an Educational Psychologist to “put her in a special school and forget about her and concentrate on her older sister.” If the parents were really told this then that is truly awful and should be dealt with via a formal complaint about the Educational Psychologist. I’m somewhat sceptical that this is actually what was said, however. In recent years, the range of services and support available for children with special needs have improved significantly and there are some really excellent special schools. Sending a child to a special needs school is therefore (when appropriate) giving them the opportunity to achieve their maximum potential rather than somewhere to “forget” about them. During the assessment provided by The Sunflower Trust the parents were told that things were “in the wrong place”. This is frightening thing to tell parents about their child and what parent given that message wouldn’t be scared into continuing with “treatment” in a desperate attempt to correct these problems? No professional should ever use fear to encourage someone to undertake their treatments. The treatment provided apparently consisted of manipulation of the “head, neck, spine and pelvis”. Presumably the therapist (Clive) told the parents that he was re-aligning these things through this treatment. This is completely false and shows a startling lack of understanding of the way the human body works. Manipulation does not “re-align” anything regardless of what some osteopaths and chiropractors claim. There is no evidence that any treatment provided by an osteopath or chiropractor or any other aspect of the Sunflower Programme provides any benefit for autism.

Charities like this one are preying on desperate people by misleading them into taking completely unsuitable “treatments” when they should instead be following the advice of their own doctor. This charity clearly fails the “public benefit” test as rather than being in the public interest it’s actually harmful to members of the public. It’s high time that the Charity Commission put a stop to charities like this and I hope that the consultation prompted by the Good Thinking Society will result in removal of charity status for this and similar charities. That would certainly be the right thing to do in the interest of protecting the public.

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.

Charity that “treats” children run by osteopath who was struck off

On 16th January 2018 the osteopath Mark Mathews was removed from the register of practicing osteopaths for unacceptable professional conduct. That same osteopath is the founder and president of The Sunflower Trust, a charity that claims to be able to treat a whole range of health conditions in children. In this post I look more closely at this charity and the claims that it makes.

The list of conditions that the charity claims its programme can treat is mind boggling and appears to be a list of all of the common childhood conditions that they could think of. Here is a list of just some of the things they claim to treat:

  • ADHD (Attention Deficit Hyperactivity Disorder)
  • ODD (Oppositional Defiant Disorder)
  • Allergies
  • Asthma
  • Anxiety
  • Asperger syndrome
  • Autism
  • Auditory processing problems
  • Behavioural difficulties
  • Depression
  • Learning difficulties
  • Dyslexia
  • Dyspraxia
  • Emotional problems
  • Fatigue / CFS
  • Global developmental delay
  • Headaches
  • Memory problems
  • Skin problems
  • Social skills
  • Speech and language problems
  • Stomach aches
  • Stress

They’re basically suggesting that if you have a child then they can do something to help them. What evidence is there that the Sunflower Programme can do any of these things? As far as I can tell there is none whatsoever. Their claims appear to be entirely unsubstantiated.

This is a good opportunity to highlight a useful “rule of thumb” for spotting misleading treatment claims. Any treatment that claims to be effective for a wide range of unrelated conditions probably isn’t effective for any of them. Why is that? The human body is very complex and the medical conditions that we experience are also often complex and have a whole range of different causes. For instance, asthma is completely different to anxiety. Both of these have totally different causes and symptoms and the treatment is therefore also completely different. It’s simply not reasonable to expect a single treatment to be effective for a wide range of conditions. When you see a treatment, like the Sunflower Programme, that makes these sorts of claims it’s highly likely that there simply isn’t evidence to back them up.

When you look at the practitioners who work at the charity it makes for interesting reading. This is what the charity website says “Each Sunflower Practitioner is a practising Osteopath, registered with the iO, as well as being a qualified Master of Applied Kinesiology, Master of Neurolinguistic Programming (or an equivalent qualification such as a teacher) and fully trained in the Sunflower Programme.” So they’re combining osteopathy, applied kinesiology and neurolinguistic programming (NLP) together in this programme. All of these specialities are based on pseudoscientific beliefs and have little or no evidence of effectiveness for any health condition. It therefore looks as though the Sunflower Programme is built on shaky foundations with no evidence to back up any of the claims being made. When you take into account that the founder and president of the charity has been removed from the register of osteopaths for unprofessional conduct (something that happens only in extreme circumstances) then it raises concerns for the health and safety of the children undertaking the Sunflower Programme. In order to try and protect members of the public from being taken in by the unsubstantiated claims being made, I have raised a complaint with the Advertising Standards Authority.

Yet again this highlights the misleading claims that are so widespread within the osteopathy profession. Some osteopaths seem to believe that they can “treat anything” when actually this simply isn’t true. Whilst the General Osteopathic Council (GOsC) has taken action against this particular osteopath, in response to a complaint from a patient, they have failed to tackle the widespread issue of misleading claims by many of their registrants. Unfortunately, the public are therefore not being adequately protected and this places them at risk of undertaking unsuitable and, in some cases, harmful treatments.