Should osteopaths provide an exercise program? (Part 2)

weight-trainingThis is a follow up to one of my previous posts: Should osteopaths provide an exercise program? This generated some interesting discussions on twitter with some osteopaths accepting that exercise programming isn’t something they are routinely taught and others claiming that osteopaths are well placed to offer an exercise program. One of the points made is that it’s the skill and experience of the individual therapist that really matters. That’s a valid point as, within any profession, some people are more skilled and experienced in a particular area than others. However, this presents something of a practical problem. It is difficult for many members of the general public to assess the training and qualifications of a professional offering an exercise program. It’s therefore important to have some guidance available so that members of the public are not misled into being given an exercise program by someone who lacks the qualifications and expertise to provide it. This post provides some clarification on whether osteopaths are well placed to provide an exercise program or not.

The National Council for Osteopathic Research (NCOR) produced a report that profiles day-to-day osteopathic practice. This report identifies the different types of treatments used by osteopaths in their first and subsequent appointments with patients. Less than 1 in 4 appointments involved exercise. In contrast, nearly 3 in 4 appointments involved articulation and a similar number involved soft tissue treatment. Approximately 1 in 3 appointments involved HVLA thrust. Osteopaths therefore used manual therapy (hands on) techniques much more than they used exercise. When someone practices a particular skill or technique frequently they usually become better at it. As most osteopaths use manual therapy more than exercise it is therefore very likely that they are also more skilled in manual therapy than exercise. It is also not clear what proportion of those appointments that did include exercise actually resulted in a suitable personalised exercise program.

Elsewhere in the report it is stated that “A high proportion of osteopaths have documented that they are recommending exercise to patients. Little work has been undertaken in this area which is not formally taught in all osteopathic educational institutions.” and “Investigation of the exercise regimes/advice being offered by osteopaths would be a helpful area of investigation. The inclusion of exercise in the management of patients is notably present in many clinical guidelines. It is important that the advice and recommendations by osteopaths are not only evidence based but appropriate and effective for patients.” The National Council for Osteopathic Research (NCOR) therefore recognises that there is a lack of evidence of the suitability and effectiveness of exercise advice provided by osteopaths.

You may be wondering why osteopaths are suddenly taking such an interest in exercise. That’s because osteopathy is no longer considered to be a first-line treatment for low back pain or sciatica. Treating “bad backs” is what osteopaths are known for and makes up a significant proportion of the patients seen by most osteopaths. The new NICE guidelines therefore put the businesses of many osteopaths, and potentially the profession as a whole, under threat. Osteopaths are therefore trying to tackle this issue by adding exercise programming to the services they offer. Most osteopaths don’t receive training in exercise nor do they use it routinely as part of their current practice. It therefore seems unrealistic to expect that they can suddenly become skilled in providing an exercise program to their patients. In the February / March edition of The Osteopath, the NCOR suggest that osteopaths could form a working relationship with a local exercise or movement specialist as a means of providing an exercise program to their patients. In that situation, wouldn’t the patient be better off just seeing the exercise specialist and not bothering with the osteopath at all?

Whilst it may be possible to find an individual osteopath who has taken specialist training in exercise programming and uses it regularly as part of their practice it is quite clear that these individuals are not commonly found within osteopathy. Osteopaths are primarily manual therapists and use mostly manual therapy techniques. The suggestion that osteopaths are well suited to help someone get started with an exercise program, teach the exercises correctly and progress the exercise program is therefore misleading. Most osteopaths lack the skills or experience to do this. If you need help with an exercise program please make sure you see someone who is suitably qualified in this field. As I made clear in my previous post on this subject it is physiotherapists who are more routinely trained in exercise programming rather than osteopaths.

30,000 People Visit an Osteopath Every Day, But Should They?

One figure that’s often quoted by osteopaths when promoting their services is that 30,000 people visit an osteopath in the UK every day. However, we know that misleading patients and the general public is widespread within the profession. This means that some of those 30,000 people will have been misled into having a treatment that was unsuitable for them.

The people who are misled into having an unsuitable osteopathic treatment include:

  1. Anyone with a condition that is not on the “allowed” list.
  2. Any pregnant woman, baby or child who is misled into taking treatment by information in conflict with the ASA guidelines
  3. A significant number of people with low back pain or sciatica as osteopathy is no longer a first-line treatment.
  4. Anyone who has a “preventative” or “maintenance” osteopathic treatment. There is no evidence that either of these is effective.

It’s impossible to quantify how many of the 30,000 people who visit an osteopath every day are misled into doing so. However, there are a large number of conditions that osteopaths CANNOT treat. Osteopaths also treat more people with back problems than any other condition and their treatments are no longer a first-line option for these people. It therefore seems likely that a significant proportion of the people who visit an osteopath every day have been misled into doing so.

The next time you are told that 30,000 people visit an osteopath every day, just remember that a significant number of them should not have done so.

Should osteopaths provide an exercise program?

weight-trainingSome osteopaths include exercises as part of their treatment approach. The Institute of Osteopathy has recently taken this up a notch suggesting that osteopaths are well suited to help someone get started with an exercise program, teach the exercises correctly and progress the exercise program. We know that misleading claims in osteopathy are widespread. Is this yet another attempt by the osteopathic profession to get people to pay for their treatments without considering what’s actually best for the patient? Or do osteopaths really have the expertise to provide an exercise program?

Osteopaths are primarily manual therapists and it’s actually physiotherapists who are the professionals most associated with using exercises as part of their treatment approach. We therefore compared the undergraduate training for osteopaths and physiotherapists to better understand which profession is best placed to provide an exercise program.

Osteopathy and Exercise

There are relatively few institutions that provide undergraduate programmes for osteopaths. A complete list is available here. We reviewed the syllabus for three of the organisations on the list:

None of the undergraduate programmes above provide any training on exercise. This immediately brings into question whether an osteopath should provide an exercise program. They haven’t been trained in exercise or exercise programming so it doesn’t seem like they are well placed to do this.

Physiotherapy and Exercise

There are a large number of Universities that provide undergraduate programmes for physiotherapists. As a comparison to the three organisations providing osteopathy training above, we reviewed the syllabus for three programmes for physiotherapists:

The Right Professional to Provide an Exercise Program

Of the undergraduate training programmes reviewed, none of those for osteopathy provide any specific training on exercise. This isn’t actually surprising as osteopaths are primarily manual therapists not exercise specialists. They therefore receive most of their training in manual therapy rather than exercise. In contrast to osteopathy, all of the undergraduate training programmes for physiotherapy reviewed above included specific modules on exercise. This suggests that physiotherapists receive more direct training in exercise programming and are therefore better placed than osteopaths to provide an exercise program for their patients.

It’s actually quite concerning that the Institute of Osteopathy have suggested that its members can provide exercise programming and technique advice when osteopaths do not receive training in this area. An osteopath providing an exercise program is rather like an electrical engineer designing a bridge. They might have more idea of the general engineering principles involved than a member of the public but there’s a very real risk that the bridge might fall down! In the same way that bridge building should be left to civil engineers, exercise programming and technique should be left to professionals who specialise in this area and that is physiotherapists. 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.

Regular exercise is, in general, a very good idea. If you need help with an exercise program please make sure you see someone who is suitably qualified in this field. That would be a physiotherapist and NOT an osteopath!

Tackling misleading information about osteopathy

A lot of the information available online about osteopathy is misleading and includes claims to treat conditions for which there is no good evidence of effectiveness. This makes it easy for a patient or member of the public to be misled into having (and paying for) a treatment that is completely inappropriate for them.

The Good Thinking Society has done a lot of work over the past year or so to highlight misleading claims in advertising about osteopathy. This resulted in further guidance being provided to all osteopaths by the General Osteopathic Council (regulatory body for osteopathy in the UK), the Advertising Standards Authority and the Committee of Advertising Practice. See this link for the guidance they provided to osteopaths: http://www.osteopathy.org.uk/news-and-resources/document-library/practice-guidance/gosc-asa-cap-letter-to-osteopaths/ In December 2016, the General Osteopathic Council and Advertising Standards Authority issued further guidance to osteopaths about the claims they can and cannot make about treatments for pregnant women, babies and children. More background to this can be found here. Although some osteopaths have improved the accuracy of their advertising, others continue to mislead with inappropriate claims.

I have been contacting independent websites (i.e. not those associated with a particular osteopathic practice) that carry misleading information about osteopathy. In most cases, the authors of these sites are not experts in osteopathy, have been given the information for their articles by others (mostly osteopaths) and are therefore unaware that they are providing misleading information. Several sites that I’ve contacted have either amended their content to make it more accurate or removed the misleading pages altogether. These include:

  • MadeForMums – They had an article that suggested cranial osteopathy could help with learning difficulties, toddler tantrums, behavioural disorders and repeated infections as well as common infant problems such as colic, excessive crying, feeding difficulties, sleep problems and glue ear, and the general statement that it is “effective in young children”. None of those claims have evidence to support them and making these kinds of claims in advertising would be in breach of the above guidelines. MadeForMums opted to update their article and, whilst the article is not perfect (particularly with regards to some of the comments from osteopaths), it is much improved from the original version. You can see the updated article here: http://www.madeformums.com/baby/cranial-osteopathy-could-it-help-you-and-your-baby/10768.html
  • Mumfidential – Their article had an entire section listing unsubstantiated claims about osteopathy for treating babies and also older children. The claims included crying all the time, not crying at all, sleeping problems, constipation and wind, developmental delay, cerebral palsy, ADD / ADHD and many others. Initially Mumfidential said they would update their article. However, nearly three weeks later it remained unchanged so I contacted them again. At that point they opted to remove the article. Interestingly, the osteopath who contributed to the original article is Rosie Scott from Black Swan Osteopathy. Their website is still not fully compliant with the CAP code including claiming to be able to help with whiplash (specifically excluded in the CAP) and irritable bowel (IBS) and suggesting that stresses and strains from birth can lead to health problems.
  • West Bridgford Wire – They had several articles relating to osteopathy that were essentially adverts written by Moore Osteopathy. Unsubstantiated claims included those relating to wind and colic, feeding difficulties and plagiocephaly (flat head syndrome). West Bridgford Wire responded very positively, removing all of the misleading articles within one working day and writing back to inform me that they had done so. This was a very professional response.
  • Mother&Baby – I covered their excellent response in another article here

The accuracy of the information available about osteopathy is improving. However, there is still much more to be done to ensure that patients and members of the public are not misled into taking unsuitable treatments.

Misleading claims in osteopathy: A systemic problem

Some osteopaths claim that they are able to treat a wide range of health conditions ranging from infantile colic to asthma to cerebral palsy and many others. However, there is a lack of evidence for the effectiveness of osteopathy for many of these conditions. There is clear guidance on the conditions that osteopaths may advertise to treat on the CAP website. However, many osteopaths breach these guidelines and continue to offer treatments for conditions outside the “allowed” list. Osteopaths who do this are misleading prospective patients and the general public. This could result in someone being misled into having osteopathic treatment when it was not suitable for them. In the best case this would simply be a waste of money but in some situations could put a patient’s health at serious risk.

In September 2015, further guidance was provided to all osteopaths by the General Osteopathic Council (regulatory body for osteopathy in the UK), the Advertising Standards Authority and the Committee of Advertising Practice. See this link for the guidance they provided to osteopaths: http://www.osteopathy.org.uk/news-and-resources/document-library/practice-guidance/gosc-asa-cap-letter-to-osteopaths/ In December 2016, the General Osteopathic Council and Advertising Standards Authority issued further guidance to osteopaths about the claims they can and cannot make about treatments for pregnant women, babies and children. More background to this can be found here.

The General Osteopathic Council took an important step forward in their Dec 16 / Jan 17 edition of “The Osteopath” by making it clear that all claims must be substantiated and this includes when talking to patients as well as advertising:

“Remember, you must be able to substantiate any claims that you make in your advertising – and you should adopt the same approach when discussing treatment options with patients.”

This statement from the General Osteopathic Council should help to protect patients from being misled by osteopaths not just in their advertising but also during appointments.

However, the General Osteopathic Council seem to be sending a somewhat mixed message to their registrants about the importance of complying with these guidelines. Within the very same magazine they have several adverts that offer training to osteopaths in the very things that the guidelines say they shouldn’t be treating. Here are just a couple of examples:

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And:

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When you follow the link for more details about this course it takes you here. Many of the items in the course content are in conflict with the guidance such as “Infant digestive disorders including infantile colic”, “Asthma”, “Otitis media” and “The adaptation of the infant to labour”.

The Institute of Osteopathy (the UK’s professional membership organisation for registered Osteopaths) is also not setting a good example of the need to comply with the guidelines. I have written about this previously here.

It’s going to be difficult for the osteopathic profession to clean up its act when:

  1. The regulator is continuing to allow adverts for training that breaches the guidelines in its own magazine.
  2. Their professional membership organisation is offering training in the conditions that osteopaths should not be treating.

Over the last 18 months the problems with osteopaths misleading patients and the public with their advertising has been repeatedly highlighted. The General Osteopathic Council has now made it clear that these guidelines also apply to actual treatments given to patients. This is an important step forward but the osteopathic profession has a long way to go to clean up its act. Misleading patients and the general public actually appears to be a systemic problem in the profession. The problem seems to be not just with osteopaths themselves but also with their professional organisation and even the regulator is not leading by example. By continuing to treat people with conditions for which there is no good quality evidence, osteopaths are putting their own businesses ahead of the needs of their patients.

In order to bring about a real improvement in the osteopathic profession a lot of changes need to be made, such as:

  1. Educational establishments should stop training osteopaths to treat conditions for which there is no good evidence. This includes, undergraduate and postgraduate training courses as well as specific CPD courses
  2. Osteopaths should stop advertising and treating people with conditions for which there isn’t strong evidence of treatment effectiveness
  3. The General Osteopathic Council should police all of this strongly and proactively to ensure that all training, advertising and treatments are compliant with the regulations.

Osteopathy and chiropractic are holistic … or are they?

Many osteopaths and chiropractors claim that their treatment approach is more holistic than conventional medical treatment and that this therefore makes it “better”. Firstly, this makes the assumption that conventional medicine is not holistic. That’s actually an invalid assumption and more on that later. But are osteopathy and chiropractic really holistic? Holistic is defined as “dealing with or treating the whole of something or someone and not just a part” (source: Cambridge English Dictionary). Osteopaths and chiropractors treat the musculoskeletal system and only the musculoskeletal system. They cannot do anything about the other systems in the human body, such as the respiratory system, lymphatic system and cardiovascular system. How can a treatment that focuses on only one of the body’s systems ever be considered “holistic”? The short answer is that it can’t. Whilst osteopaths and chiropractors may look at different parts of the musculoskeletal system, it is impossible for an osteopath or chiropractor to treat holistically as there is so much of the body that they cannot treat.

Now let’s return to the question of whether conventional medicine is holistic. The NHS has some doctors who are “generalists” and some who are “specialists”. The generalists have a reasonable knowledge of a wide range of health conditions but don’t have deep expertise in any particular area. They then refer on to an appropriate specialist when more detailed knowledge of a particular condition is needed. This is an entirely natural and sensible way of setting up a healthcare system. After all, would you want your GP to treat you if you have cancer or someone with more specialist knowledge like an oncologist? In this case the GP might carry out initial investigations and tests but would always refer on to the right specialist. The “generalists” in the NHS are GPs (General Practitioners), paediatricians and geriatricians. They look after a patient’s holistic care, leaving the specialists (of which there are many different types) to focus on the areas where they have particular expertise. These generalists can, unlike osteopaths and chiropractors, be truly holistic as they are able to assess and treat all systems in the human body.

Now we are in a good position to answer the question “Is osteopathy or chiropractic holistic?” The answer is clearly “no” and it’s actually impossible for an osteopath or chiropractor to treat holistically. Any osteopath or chiropractor who claims that they treat holistically is misleading their patients and the general public. Conventional medicine on the other hand is very much holistic. If you want to be treated holistically, stay away from osteopathy and chiropractic and stick with the NHS instead.

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.