An Osteopath Looks at Ernst' Flawed Study
Researchers get my back up
(Originally from the Guardian, by Nicola Sturzaker a practicising osteopath)
Now, we hear from experts at the Peninsula Medical School in Exeter, and writing in the Journal of the Royal Society of Medicine, that that I and my colleagues in the osteopathy profession (and chiropractors too) have got it wrong - a review from a report released yesterday looked at 16 academic papers on spinal manipulation (one of a number of techniques osteopaths and chiropractors use) where it was practised for conditions such as back pain, neck pain, period pains, asthma and allergy.
They concluded that spinal manipulation was only effective for back pain where it is superior to "sham" manipulation but not better than conventional treatments and, "considering the possibility of adverse effects", they said suggested that manipulation was to be avoided.
Well, how kind of them to suggest that its better than "sham treatment" - osteopaths and chiropractors are one up from snake-oil salesmen after all. One of the study's authors, Professor Edzard Ernst, is the UK's only professor of complementary medicine - so we might have hoped for a more constructive approach.
The report is based on academic reports of clinical trials. Not on cases, not on treatments, but on a limited area of past research - from which the authors make sweeping generalisations. I have yet to see the provenance of 16 academic papers pulled together from between 2000 and 2005 to make the argument but, as with all data, the selection is important. Choose academic research from the mainstream medical profession and you'll get the answers you might expect. A surgeon will always recommend surgery for a back problem, just as a butcher will always try to sell you meat.
Furthermore, a substantial amount of research has been carried out in the last few years, most notably a Medical Research Council-funded trial on spinal manipulation and exercise therapy for back pain in 2004 which provided strong evidence to support spinal manipulation for low back pain, particularly when combined with exercise guidance - which is typical osteopathic management. The report looks out of date and while the academic papers may date from as late as 2005, the data which underpins them already looks much older than that.
It's partly our own fault. Osteopathy, as a relatively young profession, is only just starting to get its act together with research and with making papers available to the academic world. As a subject it isn't taught in a vast number of universities and the research that is done is done for a rather closed world of other practitioners, not for a wider audience. And it certainly won't make the select list of 16 selected by the researchers at Exeter.
The point of spinal manipulation in osteopathy is that the treatment doesn't stop there. As a technique it is the therapeutic application of manually guided forces (usually hands, let's face it) in order to restore normal functions and improve physiological function. For example, we may manipulate the lower back with the aim of improving the function of that joint, but this is almost always followed up with exercise to maintain the changes improvements gained during treatments. Spinal manipulation does help - but it is rarely done in isolation. Back pain is never a simple thing (remember when someone gives you the precise definition of their pain as "lumbago", it's Latin for "bad back"), and it's rarely the relatively simple treatment of injury. It is usually a combination of physical, psychological and social issues that produce back pain and you can't effectively treat one without treating the others.
In his report, Professor Ernst claimed that "the findings are of concern because chiropractors and osteopaths are regulated by statute in the UK. Patients and the public at large perceive regulation as proof of the usefulness of treatment."
The implication of quackery is clear and the idea that the regulation of these professions is less than rigorous is not-so-subtly planted.
But both osteopaths and chiropractors train for between four and five years, learning anatomy to the same degree as doctors as well as studying physiology, the respiratory system, cardiovascular system, pharmacology and pathology among others, which all help in our diagnostic triage as we are becoming all the more often the first port of call for many patients.
All patients undergo a detailed documented case history when they present to an osteopath where we screen for any medical conditions and assess for their suitability for osteopathic treatment. The insinuation that the professions are peopled with fly-by-nights with no real medical knowledge is untrue, insulting - and unworthy of a man who professes to understand complementary medicine.
There may well be cases where spinal manipulation has not been successful and a patient condition has worsened. Patients have also died on operating tables, GPs have made errors in diagnosis and overworked nurses have left patients on trolleys for longer than necessary. It happens, but we don't question the validity of the profession or the skills of the practitioners. Although it's tempting when professors of complementary medicine come out with such erroneous generalisations on the back of such limited research.
Nicola Sturzaker is a practicising osteopath and teaches at the British School of Osteopathy
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