UK osteopaths continue to operate far outside their expertise: they now think they can treat autism!

There are many and serious problems with the osteopathic profession in the UK. Even taking this into account, I was shocked and appalled to find that some of them now think they can treat autism. I recently came across the Paediatric sensory integration and GI dysfunction in autistic children course offered by the University College of Osteopathy (UCO). It’s important to remember that UK osteopaths are musculoskeletal therapists rather similar to chiropractors. They are not doctors and treatment of sensory integration, GI dysfunction and autism more generally is completely outside of their expertise. Let’s look a bit more closely at the course, and also the trainer.

The course

The aim of the course is to “give an overview of the signs and symptoms of Sensory Processing Disorders and Autism Spectrum Disorders as well as evidence for possible osteopathic interventions in both subjects”. Let’s be really clear straight away. There are NO osteopathic interventions that have been found effective for sensory processing or autism spectrum disorders (ASD).

The course goes on to suggest the use of “visceral osteopathic techniques on autistic children suffering from gastrointestinal symptoms”. Visceral osteopathy is based on the idea of relieving “imbalances and restrictions in the interconnections between the motions of all the organs and structures of the body”. If that sounds like nonsense, that’s because it is. Visceral osteopathy is implausible and has not been found effective for any health condition. As Edzard Ernst says in one of his posts on the subject: “Visceral osteopathy is not plausible and the best evidence available to date does not show it works. In my view, this means that we should declare it an obsolete aberration of medical history.”

I’m also concerned that the safety of visceral osteopathy has not been adequately assessed. At the very least, a non-medically qualified osteopath poking around in the abdomen of children with ASD has the potential to cause distress. I’m not aware of any research that addresses the potential harms of this treatment.

The trainer

The trainer for this course is an osteopath called Iona Bramati-Castellarin. She runs a private osteopathy clinic called IBC Care based in London. On her clinic website, as well as on Twitter, Facebook and Instagram, she makes a range of misleading health claims including osteopathy for autism, claims related to visceral osteopathy and referring to herself as “Dr”. I complained to the Advertising Standards Authority (ASA) about these misleading claims. They were very quick to respond and said they thought the advertising was likely to be in breach of the Advertising Codes. The ASA have contacted IBC Care and I can see that some changes have started to be made to their website. There is no longer an “autism clinic” on the site, which is good because no osteopath should ever run such a clinic.

Conclusions

This is not the first time that I have highlighted serious issues with the training offered by the University College of Osteopathy. I have written previously about their wholly inappropriate training to osteopaths in The Paediatric Respiratory System. Now they have run a course for osteopaths on the treatment of autism. There are many serious problems here, including:

1. Osteopathy has not been found effective for sensory integration, GI dysfunction or autism.
2. Osteopaths are not qualified to treat any of these conditions, which should instead be handled by a doctor.
3. The safety of some of the techniques being recommended has not been adequately assessed and raises concerns.
4. The trainer for this course was found in breach of advertising guidelines for misleading claims relating to the very subjects being taught.

I have long had serious concerns about the UK osteopathic profession but in attempting to treat autistic children they have stooped to a new low. I don’t doubt that there are some good osteopaths out there who focus on treating musculoskeletal problems in adults and try to be evidence based. Unfortunately, the very deep and serious systemic problems within the osteopathic profession lead me to believe that osteopaths like that are in a small minority. I think the safest option therefore is to not go to a UK osteopath at all and definitely not to take a child to see one! Instead, look for another professional who is better placed to help with your health needs.

Chiropractor in breach of chiropractic code of practice but found “not guilty”

The Professional Conduct Committee (PCC) of the General Chiropractic Council (GCC) have recently published their decision in the case of chiropractor Arleen Scholten. This was the very sad case of John Lawler who died after chiropractic treatment. The committee concluded that the allegation of “unacceptable professional conduct” was not well founded. Their primary rationale for this decision was that, although there had been breaches of “The Code: Standards of conduct, performance and ethics for chiropractors”, that these breaches were due to Mrs Scholten’s state of mind at the time rather than deliberate intent to be inaccurate or misleading.

In reaching their decision, the committee seem to have given great weight to:

1. An acute stress reaction being the source of the numerous inaccuracies in Mrs Scholten’s reporting of the events and records.
2. Testimonials from patients and colleagues.

They seem to have not considered, or inadequately considered, that:

1. She lacked even basic first aid knowledge and as such provided totally inappropriate care during the medical emergency that occurred.
2. She changed her position multiple times with regards to what she claimed to have said to the ambulance crew.
3. She had previously (probably for many years) been deceiving the public by referring to herself as “Dr”.

Let’s look at each of those items in a little more detail.

Acute Stress Reaction

The committee received advice from two expert psychiatric witnesses and on the basis of this advice concluded that Mrs Scholten had been suffering from an “Acute Stress Reaction”. The committee considered that this provided an explanation for Mrs Scholten’s inaccurate reporting of the treatment provided to the 999 call handler, the ambulance crew and inaccurate records in her own clinic notes about the treatment provided. However, there are a number of things that don’t seem to stack up here particularly with regards to the sequence of events:

1. When the ambulance crew arrived, they both described Mrs Scholten as being calm with one of the crew stating that she “handed over the patient and what she had found in a calm manner” and the other saying that she “was reasonably calm”.
2. Immediately after the ambulance had left, the clinic receptionist said that “Mrs Scholten was crying and shaking, she was in a state of shock.”
3. Mrs Scholten then went on to treat other patients. According to her receptionist “I asked Mrs Scholten if she wanted to see a couple of patients who had arrived. After about five or six minutes she went to see them”.

Now, does somebody go from a state of being unable to accurately explain the treatment she has provided to an ambulance crew, to crying and shaking, to then treating further patients in what appears to be (according to the accounts) a relatively short amount of time? If Mrs Scholten was so stressed, how could she contemplate treating further patients? Wouldn’t it be a duty of care to cancel those patients, recognising that she was unable to provide suitable treatment?

Testimonials from patients and colleagues

The committee seem to have given great weight to testimonials from patients and colleagues and they state “Indeed, the Committee had never before encountered such an impressive collection of character evidence, which it considered particularly noteworthy”. Now, even the very worst healthcare professionals can usually find people who are willing to provide positive testimonials. For instance, I know someone who was once a patient of the notorious Harold Shipman who said that they had often had a good experience seeing him as a GP! It is a serious mistake for any conduct committee give much weight to a set of self-selected testimonials from someone they are investigating.

Interestingly, several of the testimonials are from patients who went to Mrs Scholten for regular treatments over many years. This is in itself a concern, and would suggest inappropriate care, as there is no benefit to regular or routine chiropractic treatment.

First Aid Training

At the time of this tragic incident there was no specific guidance provided to chiropractors on the need for them to have first aid training. You might reasonably expect that a healthcare professional who is allowed to treat patients fully independently would be trained to handle any emergencies resulting from such treatments. There was, however, no such requirement. In fact, the General Chiropractic Council brought in new guidance in March 2020 relating to First Aid presumably in response to the very basic errors made by Mrs Scholten in this case. Interestingly, the GCC largely absolves themselves of any responsibility for deciding what First Aid training is appropriate and instead push that decision onto the individual chiropractors. This seems likely to result in very different approaches and a lack of consistency across the profession. This is a potential risk to the public, the very thing the GCC are there to protect against. As Edzard Ernst reports in one of his posts on this case, Mr Lawler would probably have survived if Mrs Scholten had not provided the entirely wrong first aid care.

Changing her statement

In a statement to police several days after the incident, Mrs Scholten claimed that she told the ambulance crew: “I explained that following the use of the drop table [Patient A] had reported loss of sensation in his arms and I confirmed the sequence of events.” However, she later changed her position on this and the GCC report states “It was subsequently no longer Mrs Scholten’s case that she informed the paramedics of the use of the drop technique”. In later written observations to the GCC, she then claimed that the did not classify the Thompson Drop technique as a manual adjustment and she did not “therefore accept that I misled the paramedics by stating that I did not carry out any manual adjustments”. With all of these changes of statements I think it is reasonable to question the reliability of Mrs Scholten’s testimony.

Use of “Dr”

I have previously written about how, at the time that Mr Lawler went for treatment, Mrs Scholten marketed herself as “Dr”. This is a widespread issue within the chiropractic profession. However, a chiropractor who misleads the public about their professional status doesn’t suggest someone who is honest and trustworthy.

Conclusions

Of all of the professions that offer “alternative” treatments in the UK, there are two that have statutory regulation. Those are chiropractors (regulated by the General Chiropractic Council) and osteopaths (regulated by the General Osteopathic Council). The purpose of this statutory regulation is supposed to be to provide independence from the professions and therefore more effectively protect the public. Here we have a chiropractor who deceived the public by referring to herself as “Dr”, repeatedly changed her statement on key facts within the case and provided totally inappropriate first aid care after her patient suffered a severe reaction to her chiropractic treatment. The regulator has decided that this is all okay, does not amount to unacceptable professional conduct and that she can continue to practice without any sanctions. Whilst decisions in cases like this are clearly very complex, it is hard to see how the GCC is fulfilling its primary regulatory duty of protecting the public by reaching this decision. I would suggest that this decision undermines any remaining trust that the public could have had in the chiropractic profession.

Are osteopathy and chiropractic treatments really as safe as they are claimed to be?

I have seen many chiropractors and osteopaths claim that their treatments are “very safe” but is that really accurate? This is a complex question without a straightforward answer. A survey of UK osteopaths helps to shed some light on this important question. Whilst that survey focuses specifically on osteopaths, the situation with chiropractors is likely to be similar as many of the same treatments are used by both groups of practitioners.

Treatment effectiveness and risk / benefit analysis

When assessing the suitability of treatments, it’s important not to assess safety in isolation but to consider it in the context of the potential benefits of a treatment. A treatment that has high risks might still be the right option if the benefits it provides are also very significant. Similarly, a treatment that has limited benefit might not be suitable even if it carries low risks. What matters is the risk / benefit analysis. The primary treatments used by chiropractors and osteopaths (manual therapy) have zero or very small beneficial effects. So, when assessing risk / benefit even a low level of risk should probably result in a recommendation against these treatments.

Serious adverse events

In the above survey, there are some important findings related to serious adverse events:

• 4% of patients reported experiencing “temporary incapacity or disability that they attributed to their osteopathic treatment”. 10 of these patients were interviewed, 2 of whom described “experiences that were characteristic of a serious adverse event”.
• “Serious adverse events including severe new symptoms, the worsening of existing symptoms leading to hospital referral and/or permanent disability or incapacity or death were reported by 12% of osteopaths” over their career. 4% of osteopaths reported a serious adverse event in the past year.

Taken together the above statistics suggest that serious adverse events from osteopathy (and probably chiropractic, physios using manual therapy, etc) treatments are not frequent but they do happen to a reasonable number of patients. This is not good and it would not be appropriate to describe such treatments as “very safe”.

Consent

Consent is an important part of any treatment by a healthcare professional and falls under the Health and Social Care Act 2008. In the above survey, patient reports of receiving consent was lower than that claimed by osteopaths. Only 36% reported receiving information about risks and 38% about alternative or no treatment options. This is awful and is a serious ethical issue.

The report provides some insight into why informed consent may be so lacking, such as “Some osteopaths expressed concern that giving information about serious risks may cause stress and prevent patients from gaining the best outcomes”. What seems to be underlying these concerns from osteopaths is a fear that patients will decline treatments if informed about the risks. That is the whole point of the informed consent process!

Conclusions

The safety of treatments provided by chiropractors and osteopaths is an often debated topic. Many practitioners claim that their treatments are “very safe” without providing any data or evidence to support these claims. It isn’t appropriate to use a single survey of UK osteopaths to try and reach definitive conclusions about the safety of these treatments. However, this survey does provide some useful insights. We already know that the treatments from chiropractors and osteopaths are of limited therapeutic benefit. Based on the information from this survey, as well as numerous published case reports, these treatments do appear to carry risks of severe adverse events. Importantly, patients often appear not to be informed of these risks or the potential of alternative options before treatment is undertaken.

If a drug had such limited benefits and carried risks of severe adverse events it is unlikely that it would ever be licensed. Applying the same approach to chiropractic and osteopathy treatments, I would suggest that you think twice before visiting one of these practitioners.

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.