By Mal Vickers
I was recently asked, “Does osteopathy work? Is it scientific?” The short answer is: osteopathy is unlikely to be effective for most health conditions. It’s a form of alternative medicine. I wouldn’t put it in the category of a science–based medicine. Read on if you’re interested in why I would think such a thing.
It’s difficult to definitively answer questions like this for three reasons.
One – Science is all about probability.
Two – it’s hard to prove a negative.
Three – it’s not a very clear question.
If the idea is to sort the wheat from the chaff in medical treatments, there are better/tougher questions to ask.
Let’s try to explore it.
Whole health disciplines might contain just a handful of useful treatments for some ailments, yet the majority of things that can go wrong with one’s health aren’t successfully treated. This can even be the case for health disciplines that ARE based on Science and clinical evidence.
To illustrate my point about the appropriate use of treatments, you wouldn’t use speech therapy to threat nappy rash, nor would you use podiatry to treat an ear infection. For specific health conditions, speech therapy and podiatry are perfectly reasonable.
To investigate any health discipline requires dipping into the scientific-medical literature and reading lots of trials and reviews about particular health conditions. It takes time and it’s not easy.
It might be best if I make things simpler and narrow the question down to just one representative health condition, otherwise this blog would be ridiculously long. I’ve chosen asthma, with more details to follow. We also need to look specifically at osteopathy treatments rather than treatments that are evidence-based yet performed in exactly the same way as for example, physiotherapists would do. An osteopath might go through specific training that in some instances provides him or her with similar skills to other health professionals. Whilst that might give you more confidence in an osteopath, it’s not an argument that might help a consumer differentiate as to where someone’s health budget is spent, nor is it a good reason to ignore evidence.
To make matters even more difficult, there are some osteopaths who claim to only use evidence-based treatments and are ‘pro-Science’, while other osteopaths profess to be at the other end of the spectrum where they stick to established convention – nothing else will do.
What lumps all osteopaths together are the treatments they specifically offer and how those are represented in the medical research literature.
As this is a skeptical blog, I won’t consider shonky clinical trials and anecdotes.
By the way, I’m writing my own opinion here, based on my own reading of the evidence. Skeptics tend not to have communal fixed positions on things but encourage people to question, doubt, apply critical thinking, reason and to seek appropriate evidence.
Broadly, osteopathy is an alternative ‘medicine’ that encompasses treatments with an emphasis on manual manipulation. Joints and bones, muscles and other tissues, including the back and neck are pushed, pulled, thumped, moved slowly and rapidly, massaged etc – as the osteopath sees fit and as his/her training dictates. I’m sure osteopaths would be horrified by my description; the language used by osteopaths is gentler. They prefer terms like “soft tissue techniques”, “joint mobilisation” and “exercise rehabilitation”.
I know the above description is somewhat vague. That’s also the problem with many alternative medicines. As it happens, Edzard Ernst already has a blog post expressing the concern that osteopathy is vague.
The practice of osteopathy originated in the USA in 1874, thus it pre-dates chiropractic and indeed most modern scientific approaches to medicine. Osteopathy started with a physician named Andrew Taylor Still. Still had some experience of the American civil war and wasn’t happy with the medical practices of his day. Still was very taken with the ideas he developed; his statements are quite forthright. And it ‘still’ goes on today!
On the topic of anatomy, Still says:
‘Then go to the blood and nerve supply of all the parts of the body. If you find the plumbing perfect, say so, and don’t make an ass of yourself by saying that you “believe so”. If you only believe and don’t know, you should go back to your anatomy class and stay until you know that the blood and nerve supply are perfect and can again give God the credit for perfection’.
Still No Idea?
I don’t want to dwell too much on the history of osteopathy, because it doesn’t really matter what’s occurred in a historical sense. I’d rather look at the most up-to-date evidence. You can also read about the history of osteopathy elsewhere on the web, here and here for example. I think of osteopathy as a kind of smaller but slightly more sensible older brother to chiropractic. There are fewer osteopath businesses in Australian compared with chiropractic businesses. In the 2013/14 financial year, the Australian Health Practitioner Regulation Agency (AHPRA) had 1,865 registered osteopaths on the books, 979 of them from Victoria compared with only 529 from New South Wales. During the same period AHPRA had 4,845 registered chiropractors.
Osteopaths do not market their profession as aggressively as chiropractors, nor do they subscribe to chiropractic theories about mythical ‘subluxations’. Osteopaths tend to subject patients to fewer X-rays. For these reasons, osteopathy tends to fly under the radar somewhat. Chiropractors and osteopaths don’t always get along, (although sometimes it’s hard to tell one from the other in the language they use and the treatments they offer, and there is a professional representative body in Australia for both chiropractic and osteopathy, COCA – the Chiropractic and Osteopathic College of Australia).
If you read up on the history of osteopathy, you’ll find very few allusions to chiropractic, although osteopaths like to mention that AT Still taught Daniel David Palmer. DD Palmer was the founder of chiropractic.
What Can You Effectively Treat?
If a health treatment practice of any kind can’t actually successfully treat any health condition – there isn’t much point to it.
First – what health conditions do osteopaths say they can treat, i.e. what are the claims being made?
The most prevalent claims I’ve found on the websites of Australian osteopathic businesses are about treating back pain and neck pain. As many of you may know, trying to remove the placebo effect from trials related to any question of ‘pain’ is difficult. Measurement of pain is based on a patient’s perception of pain. Typically patients taking part in trials to measure pain are asked to mark on a line from one to ten the intensity of pain they are experiencing – it’s quite subjective. The claim to successfully treat back pain and neck pain is similar for both osteopathy and chiropractic. However the results aren’t clear at all and could be argued at length.
Both chiropractors and osteopaths perform the treatment called ‘spinal manipulative therapy’ (SMT). The conclusion of this systematic review is not very favourable for SMT:
‘High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain.’
There is also this review:
‘SMT is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention’.
However it’s hard to separate chiropractic from osteopathy in the light of the above focus on SMT and ‘pain’ related health conditions.
Other Health Conditions
Surprisingly, advertisements for osteopathy mention heath conditions that appear to be unrelated to your joints and your bones – the claimed area of osteopathic expertise. On many websites I’ve found claims that osteopathy can successfully threat asthma, colic, help with pregnancy, bedwetting, period pain, tinnitus and many more.
A Google Advanced search gives a rough idea of the prevalence of the following health conditions on osteopathy business websites. The search was restricted to Australian websites only. I refined the hits to pages that contain the word “osteopath” and a number of the health conditions as listed below. Shown below are the totals of the Google “hits”.
“Asthma AND osteopath” – 32,000 [search again]
“Colic” AND osteopath” – 453,000 [search again]
“Bedwetting AND osteopath” – 537,000 [search again]
“Tinnitus AND osteopath” – 44,900 [search again]
I’ve reviewed the above search results and the ‘hits’ aren’t strictly from the advertising websites of osteopathic businesses. Feel free to click on the links and skim through the results. You should have no trouble finding a significant number of claims by Australian osteopathic businesses suggesting they successfully treat these health conditions.
Time for Science
Let’s now delve into the scientific medical literature to look for the evidence. For the sake of brevity I’ll highlight one particular health condition; asthma. Asthma can be a serious and life-threatening condition. Anyone offering treatment should act responsibly and ethically, at the risk of diverting sufferers away from effective treatments. It is possible to obtain an objective measurement of asthma by measuring peak air flow in and out of the lungs.
The critical question is:
Does the scientific evidence support osteopathic treatment as being effective for asthma?
I’ve searched for relevant systematic reviews of the medical literature. Such reviews are written by independent professionals. Good reviewers know the difference between studies which are scientifically rigorous and those which are not. They evaluate the scientific medical literature and publish their findings. This assists doctors and others to make good, evidenced based decisions about health treatments.
Let’s start with this systematic review, titled:
Osteopathic Manipulative Treatment for Paediatric Conditions: A Systematic Review (P. Posadzki, et al, 2013)
The review is only two years old, thus it includes up-to-date research. It appears to be particularly thorough. The reviewers looked at many paediatric health conditions (including asthma) against osteopathic manipulative treatment (OMT). They concluded:
“The evidence of the effectiveness of OMT for paediatric conditions remains unproven due to the paucity and low methodological quality of the primary studies.”
Note that the reviewers complain about the paucity of relevant studies.
Here’s another systematic review; this time by reviewers from the Cochrane Collaboration, titled:
Manual Therapy for Asthma (Review) (Hondras et al, 2011)
The nice thing about this review is that it only looked specifically at treatments for asthma. The term “Manual Therapy” in the title means it included osteopathy amongst other manual therapies, such as chiropractic and massage.
This very large and thorough study concluded:
“The review found there is not enough evidence from trials to show whether any of these therapies can improve asthma symptoms, and more research is needed.”
If the studies that they’ve found are of poor quality, then it’s reasonable they would say “… more research is needed”; it’s still a negative result. The evidence in favour of osteopathy in the treatment of asthma isn’t there or wasn’t found.
There is also this systematic review:
Effectiveness of Manual Therapies: the UK Evidence Report (Bronfort et al, 2010 – otherwise known as the ‘Bronfort Report’)
This systematic review included both chiropractic and osteopathy. When it was published, this review was heavily criticised for being biased in favour of chiropractic and osteopathy. Yet this review was strongly negative in relation to asthma, the conclusion stating:
“Spinal manipulation is not effective for asthma…”
“…it [spinal manipulation] is not effective for infantile colic and asthma when compared to sham manipulation.”
So far that’s nil support for osteopathy from three systematic reviews.
Let’s See for Ourselves
What about finding the original trials? Is it possible to search the medical literature for oneself? Let’s look in detail at the trials they found in the above reviews and try to find any others they might have missed.
PubMed is a good place to start. PubMed has some 24 million records of scientific research as at May 2015. If osteopathy really is a good treatment for asthma, many confirmatory trials should be found on PubMed. The very best kind of studies are randomised, placebo controlled, double blind clinical trials. I’ve searched for this type of trial on PubMed in relation to asthma and osteopathy. There are NONE at all to be found.
Below are just two clinical trials worth noting; however they don’t fit the criteria of rigorously conducted clinical trials.
Effects of Osteopathic Manipulative Treatment on Paediatric Patients with Asthma: a Randomized Controlled Trial (Guiney et al, 2005)
The full text of this trial can be handily found on-line.
This trial is the best evidence put forward in the Bronfort Report, and at first glance shows positive results.
“Our current study, however, demonstrates a statistically significant improvement of pulmonary function in paediatric patients, as measured in PEFs, after OMT.”
If you look more closely at the details, it starts to go sour. It was published in an osteopathic journal; the authors are osteopaths and they give a quite glowing appraisal of osteopathy in relation to asthma – before they present the details of the trial.
“A fully effective respiratory cycle can be achieved by increasing the mobility of the thoracic cage and the thoracic spine to allow for full excursion of the ventilatory mechanism.”
No reference is given as to why the authors might think this.
Significantly concerning was the way the trial wasn’t “blinded”. A blind or blinded experiment is an experiment in which information about the test is kept from the participant until after the test. If both tester and subject are blinded, the trial is a double-blind experiment. Blinding is done to remove bias from the procedure, whether intentional or unconscious.
The authors stated:
“Patients who entered this randomized controlled trial were subject to single-blind assignment within one of the two study groups.”
In simpler terms, the caregivers for the placebo group knew they were giving ‘light touch’ as the placebo.
Whilst it’s very difficult to do double blinding trials with osteopathy, it is possible to take strong measures with single blinding then try to find out how well it was done. The usual way is to survey patients after the trial ended. You simply ask:
Do you think you got the real osteopathy treatment or the placebo one? However this wasn’t done – so we don’t know.
It’s also important to “blind” the people who do the measuring, but this wasn’t done either.
“The physicians who were responsible for measuring and recording patient PEFs were not blinded as to the study group to which patients were assigned (i.e. OMT or sham procedure). Thus, physicians might have unconsciously affected patient PEFs with subtle acts of encouragement or discouragement.”
Nor has this trial been replicated. Accepting a conclusion based on one trial isn’t a good idea –consider Andrew Wakefield and MMR.
In a more real-world setting, people with asthma might ask “can I throw away my puffer and use osteopathy instead?” However, this trial didn’t try to answer that question; it measured osteopathy against “light touch”. A more useful comparison might be osteopathy against best medical practice.
The next trial to consider:
Efficacy of a Standardized Osteopathic Manipulative Therapy Protocol on Pulmonary Function and Symptomatology in Moderate Persistent Asthmatic Children (Brady, 2010)
I can’t find this one on PubMed. The Posadzki Review makes note of it. The details are very sketchy – for example, how many subjects participated in the trial?
“…an unknown number of children with moderately severe asthma.”
Blinding? Type of placebo? I can’t tell. In any case the result was negative.
“…concluded that OMT did not improve pulmonary function or subjective asthma symptoms in paediatric patients.”
Looking at these two trials in some detail has used up quite a lot of blog space. It’s important, however. If you can’t trust the quality of the trials you can’t be sure about drawing conclusions from them.
“The problem is, without knowing whether a trial followed sound scientific principals and procedures, we can’t tell if it was credible or not.” – Brian Schmidt
Does the scientific evidence say yes, no, or maybe to the question – is osteopathic treatment effective for asthma?
Let’s now summarise and review evidence – skeptically. The scientific medical literature shows three negative reviews based on two poorly conducted clinical trials. I’ve tried as hard as I possibly can to be fair to osteopathy and find good quality evidence that supports the view that osteopathy is effective for asthma. If osteopathic treatment was truly effective the evidence shouldn’t be so hard to find. In my humble opinion, this is not acceptable science on which to base the promotion of a treatment for asthma to the Australian public.
The Posadzki review also suggests that there are other paediatric health conditions where there is a similar paucity of scientific evidence.
What Did A. T. Still Say about Osteopathy and the Treatment of Asthma?
If you search the writings of AT Still he was quite definite about it, asthma could be effectively treated with osteopathy. He claimed many times to have done what he called “experiments” that proved his claims. I’ve searched his writings and I’m not sure what he’s talking about. AT Still’s era was well after the occurrence of the first clinical trial conducted by James Lind in 1747. Theoretically, Still could have conducted clinical trials, however I don’t see any evidence of him doing so.
Getting Ready for the Blowback
To finish off, I anticipate that some people might not like my assessment of osteopathy. If you really like your local osteopath and want to continue to see him/her for treatment of your favourite health condition, feel free to do so. To me it appears to be the equivalent of undergoing medical experimentation without any controls or plausibility, although I agree; the risk of harm is probably small.
You might like to read these cases before you try it however.
I’ve invited people to write in the comments section. However I’d like to cover a few more points in anticipation of comments this post might attract.
“I went to an osteopath. He/she gave me great advice about health and diet and my (insert any health condition) has never been better.”
Personal experience is very compelling but it’s not science. Step outside your personal experience for a moment and look at your experience a little more objectively – as an experiment. The number of participants in the experiment is one and there was no placebo control. There can be many confounding factors in an uncontrolled health experiment;
– the placebo effect,
– regression to the mean,
– many health conditions will resolve without any intervention
– there is a possibility that other treatments were tried at the same time
– you can’t do much statistically with the number ‘1’.
I’ve previously written about this topic here.
Anyone can fall into the trap of believing something that isn’t true. Magicians manage to convince people of things that aren’t true all the time; we just don’t like to admit that we’ve been fooled.
Other health professionals can also offer advice about preventative health I.e. exercise and diet, an osteopath is not unique in that regard.
“But universities teach osteopathy”
Yes they do. Here in Australia, in my home state of Victoria, RMIT University and Victoria University offer osteopathy up to and including degree level. Just because a subject is taught at a University, it doesn’t mean that it’s “scientific”. For many years some Australian Universities have been teaching woo medicine. RMIT in particular teaches courses in chiropractic, Chinese herbal medicine and ‘wellness’. The government body that regulates degree courses at universities is TEQSA. They require that:
“The content of the course of study is drawn from a substantial, coherent and current body of knowledge and scholarship in one or more academic disciplines and includes the study of relevant theoretical frameworks and research findings.”
So far, TEQSA have interpreted the words “research findings” somewhat broadly and not necessarily in a strict scientific sense.
“But you can’t do a Double Blind clinical trial with osteopathy”
As mentioned in the post above, it is possible to test a placebo treatment to find out how well it mimics the treatment under test. If you must compromise on the blinding of your trial – how about surveying your subjects to establish if blinding was achieved?
Point two: It’s not logical to argue that your favourite treatment is more effective than other treatments simply because it’s difficult to perform a placebo controlled trial on that treatment.
“But quality researchers and universities are researching osteopathy”
I’m not suggesting research into osteopathy should stop, quite the contrary. However I am concerned that research money is not wasted. Osteopathy research dollars should go towards high quality, rigorously conducted trials that would qualify for use in systematic reviews. We don’t need more surveys and shonky trials.
The most ethical approach to any new treatment – do the research first. Once a treatment is well tested and shown to be effective, the risks can be weighed up – then it can be marketed to the public.
“But aren’t osteopaths the same as real medical doctors?”
The US and Australian systems for training and regulating osteopaths are very different. It’s my understanding that the level of training in the US varies greatly. A highly trained registered osteopath in the US can write a prescription for medicine and perform minor surgery, more like a regular medical doctor in Australia. However other US osteopathic colleges don’t train to that level (people from the US, please comment on this below). In Australia, osteopaths can’t write a prescription for medicine and perform surgery. The level of training of osteopaths in Australia is similar to chiropractors; they are not part of mainstream science based medicine and they tend to have their own clinics separate from medical doctors. Regardless, osteopaths can use the term ‘doctor’.