Osteopaths on the loose...

[davidrodway]

The jump from a specific condition or a single case to a general principle, and the idea that a single basic treatment can cure any condition, is fairly characteristic of "woo", for example:

• Cinchona bark treats malaria, and Hahnemann experienced fever-like symptoms after taking Cinchona bark, therefore any disease can be treated by something that produces its symptoms
• Spinal manipulation appeared to restore a man's hearing, therefore any disease can be treated by spinal manipulations
• Foot massages feel nice, so any condition can be treated by massaging the soles of the feet.

Similarly, the idea that all diseases have a single basic cause:

• Obstruction of nerve signals (e.g. chiropractic)
• Psora or Miasms (homoeopathy)
• obstruction of the flow of Qi along meridians (TCM)
• Imbalance of "humours" (Ayurveda, 18th century "allopathy")
• A slightly less sweeping example: all cancers are caused by liver flukes.

THe spinal manip to cure hearing claim is actusally chiropractic. Yes, AT Still thought he had found a panacea - a universal cure for all ills. He was wrong (see my previous post). That was back in 1875

[davidrodway]

Some Research:


Research
Research is vital to assess the efficacy of osteopathic treatment and further a knowledge base on which to enhance patient care and rational osteopathic practice.

Osteopathic research has grown in recent years, spurred on in part by the annual International Conference of Osteopathic Research that started ten years ago, and whose proceedings are printed in the International Journal of Osteopathic Medicine. A research ethos is encouraged in the undergraduates at the osteopathic colleges.

To help establish an evidence base the GOsC has helped to establish and part fund the National Council for Osteopathic Research (NCOR). This is an independent body, whose remit is to encourage and develop a research culture within the field of osteopathy.


The NCOR consists of representatives from GOsC, the osteopathic educational institutions, the British Osteopathic Association,(www.osteopathy.org) the NHS and private practitioners. It is chaired by Professor Ann Moore who is Director of the Clinical Research Centre forHealthProfessions (www.brighton.ac.uk/sohp/research/) at the University of Brighton. It has established research hubs throughout the UK where practicing osteopaths assemble to discuss and help implement research projects. For further information contact the Research Development Officer for NCOR or visit their website at www.ncor.org.uk.

EUROPEAN GUIDELINES FOR THE MANAGEMENT OF CHRONICNON-SPECIFIC LOW BACK PAIN

Summary of the concepts of treatment of chronic low back pain (CLBP)

• Conservative treatments:Cognitive behavioural therapy, exercise therapy, brief educational interventions,and multidisciplinary (bio-psycho-social) treatment can each be recommendedfor non-specific CLBP. Back schools, and short courses of manipulation canalso be considered. The use of physical therapy (TENS, heat/cold, traction,laser, ultrasound, short wave, interferential, massage, corsets) cannot be
recommended.

EUROPEAN GUIDELINES FOR THE MANAGEMENT OF ACUTE NONSPECIFIC LOW BACK PAIN IN PRIMARY CARESummary of recommendations for treatment of acute non-specific low back pain:
Consider (referral for) spinal manipulation for patients who are failing to return to normal activities

The musclulo-skeletal services framework. Published by the DOH in 2006 which suggests developing capacity in primary care including osteopathy.Welsh Back CampaignTaken from www.welshbacks.com Advice for health professionalsManagement of acute mechanical low back painIf failing to return to normal activities: Reassess to exclude serious pathology • Consider a short course of manipulation • Address beliefs/behaviours that may be delaying recovery Designed for People with Chronic Conditions Service Development and Commissioning Directives Chronic Non-Malignant Pain 4.4 Effective acute pain managementPossible solution:An example of how primary care could provide for early identification and management of red and yellow flags would be an acute back pain clinic. People with acute back pain could present for assessment, simple advice and treatment according to the evidence based guidelines. These centres could be run by appropriately trained nurses, physiotherapists, osteopaths and chiropractors. They could operate on a 6 treatment basis in liaison with the GP who could then seek other treatment avenues should ongoing treatment be required. 1. Systematic reviews and meta-analysis In 2005 a meta-analysis of osteopathic manipulative treatment for LBP was carried out.Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials BMC Musculoskeletal Disorders 2005, 6:43 doi:10.1186/1471-2474-6-43 Results: Overall, OMT significantly reduced low back pain (effect size, -0.30; 95% confidence interval, -0.47 – -0.13; P = .001). Stratified analyses demonstrated significant pain reductions in trials of OMT vs active treatment or placebo control and OMT vs no treatment control. There were significant pain reductions with OMT regardless of whether trials were performed in the United Kingdom or the United States. Significant pain reductions were also observed during short-, intermediate-, and long-term follow up.
Efficacy of spinal manipulation and mobilization for low back pain and neck pain: a systematic review and best evidence synthesis. Spine J. 2004 May-Jun;4(3):335-56.

cONCLUSIONS: Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP.Non pharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline. Ann Intern Med. 2007 Oct 2;147(7):492-504.CONCLUSIONS: Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation.
British School of Osteopathy

journal PublicationsAbbey, H. (2008). ‘Assessing Clinical Competence in Osteopathic Education; analysis of outcomes of different assessment strategies at the British School of Osteopathy.’ International Journal of Osteopathic Medicine, 11 (4): 125-131.Brownhill, K. (2007). ‘Back pain and the homoeostatic requirements of the spinal system.’ International Journal of Osteopathic Medicine, 10 (1): 18-23.London, S. (2008). ‘The assessment of clinical practice in osteopathic education: Is there a need to define a gold standard?’ International Journal of Osteopathic Medicine 11 (4): 132-136.Parsons, S, Breen, A, Foster, N, Letley, L, Pincus, T, Vogel, S & Underwood, M. (2007). ‘Prevalence and comparative troublesomeness by age of musculoskeletal pain in different body locations.’ Family Practice 24 (4):308-16.Pincus, T, Santos, R et al. (2007). ‘Depressed cognitions in chronic pain patients are focused on health: evidence from a sentence completion task.’ Pain 130 (1-2): 84-92.Pincus, T, Ruso, A & Santos, R. (2008). “Responsiveness and construct validity of the Depression, Anxiety and Positive Outlook Scale (DAPOS)” Clinical Journal of Pain. 24 (5):431-7.Pincus, T, Santos, R, Breen, A, Burton, K & Underwood, M. (2007). “A review and proposal for a core set of factors for prospective cohorts in low back pain; the MMICS Statement.” Arthritis Care & Research, Arthritis and Rheumatism 28; 59 (1):14-24.Tyreman, S. (2007). ‘It's Illness, But Is It Mental Disorder?’
Philosophy, Psychiatry & Psychology – 14 (2): 103-106.Tyreman, S. (2008). ‘Valuing osteopathy: What are (our) professional values and how do we teach them?’ International Journal of Osteopathic Medicine 11 (3): 90-95.Tyreman, S. (2008). ‘Commentary on Is there a place for science in the definition of osteopathy?’ International Journal of Osteopathic Medicine 11 (3): 102-105.Zamani, J, Vogel, S, Moore, A & Lucas, K. (2007). ‘Analysis of exercise content in undergraduate osteopathic education - A content analysis of UK curricula.’ International Journal of Osteopathic Medicine 10 (4): 97-103.
Published journal paper reviews
Abbey, H. (2008). ‘Psychosocial predictors of chronicity in low back pain’ International Journal of Osteopathic Medicine, 11 (1): 34-38.Abbey, H. (2008). ‘Who uses CAM in Canada for back pain?’ International Journal of Osteopathic Medicine, 11 (3): 114-119.Abbey, H. (2008). ‘Psychosocial differences between acute and chronic low back pain patients’ International Journal of Osteopathic Medicine, 11 (3): 114-119.Abbey, H. (2008). ‘Do beliefs about back pain relate to pain experiences and contact with health professionals in Norway?’ International Journal of Osteopathic Medicine 12 (1): 1-5. (In press)Abbey, H. (2008). ‘Who gets what? A new screening tool to identify patient subgroups for back pain treatment allocation in primary care’ International Journal of Osteopathic Medicine 12 (1): 1-5. (In press)Blanchard, P. (2008). ‘Orthopaedic tests of the shoulder – are they accurate?’ International Journal of Osteopathic Medicine, 11 (2): 71-75. Blanchard, P. (2008). ‘Referred and nerve root pain arising from the low back – are they two distinct entities?’ International Journal of Osteopathic Medicine, 11 (2): 71-75. Blanchard, P. (2008). ‘Are there predictive rules for the development of adverse events following chiropractic care for patients with neck pain?’ International Journal of Osteopathic Medicine 12 (1): 1-5. (In press)Evans, D. (2008). ‘Persistent sciatica creates widespread sensitivity to further noxious stimuli’ International Journal of Osteopathic Medicine, 11 (1): 34-38.Evans, D. (2008). ‘Persistent neck pain – what hurts and where?’ International Journal of Osteopathic Medicine, 11 (3): 114-119.

Morrison, R. (2008). ‘Physiotherapy education: using simulated patients an evidence-based model’ International Journal of Osteopathic Medicine, 11 (3): 114-119.Parry, C. (2008). ‘The role of red flags in musculoskeletal pain presentations’ International Journal of Osteopathic Medicine, 11 (1): 34-38.

Parry, C. (2008). ‘Night pain in back pain triage: what is its significance?’ International Journal of Osteopathic Medicine, 11 (1): 34-38.Pincus, T. (2008). ‘Pain, ethnicity, race and culture: more research needed’ International Journal of Osteopathic Medicine 12 (1): 1-5. (In press)Tyreman, S. (2008). ‘Influence of a postgraduate clinical master’s qualification in manual therapy on the careers of physiotherapists in the United Kingdom’ International Journal of Osteopathic Medicine, 11 (1): 34-38.Vogel, S. (2008). ‘Adverse events round up’ International Journal of Osteopathic Medicine, 11 (2): 71-75. Zamani, J. (2008). ‘What influences physiotherapists to undertake Masters Level Study?’ International Journal of Osteopathic Medicine 12 (1): 1-5. (In press)


EUROPEAN GUIDELINESFOR THE MANAGEMENT OF CHRONICNON-SPECIFIC LOW BACK References1. Abenhaim L, Bergeron AM (1992) Twenty years of randomized clinical trials ofmanipulative therapy for back pain: a review. Clin Invest Med, 15(6): 527-35.2. Anderson R, Meeker WC, Wirick BE, Mootz RD, Kirk DH, Adams A (1992) A metaanalysisof clinical trials of spinal manipulation. J Manipulative Physiol Ther, 15(3):181-94.3. Andersson GB, Lucente T, Davis AM, Kappler RE, Lipton JA, Leurgans S (1999) Acomparison of osteopathic spinal manipulation with standard care for patients withlow back pain. N Engl J Med, 341(1426-1431).4. Assendelft WJ, Koes BW, van der Heijden GJ, Bouter LM (1992) The efficacy ofchiropractic manipulation for back pain: blinded review of relevant randomizedclinical trials. J Manipulative Physiol Ther, 15(8): 487-94.5. Assendelft WJ, Koes BW, van der Heijden GJ, Bouter LM (1996) Theeffectiveness of chiropractic for treatment of low back pain: an update and attempt atstatistical pooling. J Manipulative Physiol Ther, 19(8): 499-507.6. Assendelft WJ, Lankhorst GJ (1998) [Effectiveness of manipulative therapy in lowback pain: systematic literature reviews and guidelines are inconclusive]. NedTijdschr Geneeskd, 142(13): 684-7.7. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2003) Spinalmanipulative therapy for low back pain. A meta-analysis of effectiveness relative toother therapies. Ann Intern Med, 138(11): 871-81.8. Assendelft WJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2004) Spinalmanipulative therapy for low-back pain (Cochrane Review). In: The CochraneLibrary, Issue 3. John Wiley & Sons, Ltd.: Chichester, UK.9. Aure OF, Nilsen JH, Vasseljen O (2003) Manual therapy and exercise therapy inpatients with chronic low back pain: a randomized, controlled trial with 1-year followup.Spine, 28(6): 525-31; discussion 31-2.10. Bronfort G (1999) Spinal manipulation: current state of research and itsindications. Neurol Clin, 17(1): 91-111.11. Bronfort G, Goldsmith CH, Nelson CF, Boline PD, Anderson AV (1996) Trunkexercise combined with spinal manipulative or NSAID therapy for chronic low backpain: a randomized, observer-blinded clinical trial. J Manipulative Physiol Ther, 19(9):570-82.12. Brox JI, Hagen KB, Juel NG, Storheim K (1999) [Is exercise therapy andmanipulation effective in low back pain?]. Tidsskr Nor Laegeforen, 119(14): 2042-50.13. Cassidy JD, Thiel HW, Kirkaldy-Willis WH (1993) Side posture manipulation forlumbar intervertebral disk herniation. J Manipulative Physiol Ther, 16(2): 96-103.14. Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG (2003) A review of theevidence for the effectiveness, safety, and cost of acupuncture, massage therapy,and spinal manipulation for back pain. Ann Intern Med, 138(11): 898-906.15. Chiradejnant A, Maher CG, Latimer J, Stepkovitch N (2003) Efficacy of "therapistselected"versus "randomly selected" mobilisation techniques for the treatment of lowback pain: a randomised controlled trial. Aust J Physiother, 49(4): 233-41.16. CMAJ (Oct 2004). Cooperstein R, Perle SM, Gatterman MI, Lantz C, Schneider MJ (2001)Chiropractic technique procedures for specific low back conditions: characterizing theliterature. J Manipulative Physiol Ther, 24(6): 407-24.18. Ernst E (2001) Prospective investigations into the safety of spinal manipulation. JPain Symptom Manage, 21(3): 238-42.9919. Ernst E, Harkness E (2001) Spinal manipulation: a systematic review of shamcontrolled,double-blind, randomized clinical trials. J Pain Symptom Manage, 22(4):879-89.20. Evans DP, Burch MS, K.N. L, Roberts EE, Roberts GM (1978) Lumbar spinalmanipulation on trial. Part 1: Clinical assessment. Rheumatol Rehabil, 17: 46-53.21. Ferreira ML, Ferreira PH, Latimer J, Herbert R, Maher CG (2002) Does spinalmanipulative therapy help people with chronic low back pain? Aust J Physiother,48(4): 277-84.22. Gatterman MI, Cooperstein R, Lantz C, Perle SM, Schneider MJ (2001) Ratingspecific chiropractic technique procedures for common low back conditions. JManipulative Physiol Ther, 24(7): 449-56.23. Gibson T, Grahame R, Harkness J, Woo P, Blagrave P, Hills R (1985) Controlledcomparison of short-wave diathermy treatment with osteopathic treatment in nonspecificlow back pain. Lancet, 1(8440): 1258-61.24. Harvey E, Burton AK, Klaber Moffett J, Breen A (2003) Spinal manipulation forlow back pain: a treatment package agreed by the UK chiropractic, osteopathy andphysiotherapy professional associations. Manual Therapy, 8: 46-51.25. Hemmila HM, Keinanen-Kiukaanniemi SM, Levoska S, Puska P (1997) Does folkmedicine work? A randomized clinical trial on patients with prolonged back pain. ArchPhys Med Rehabil, 78(6): 571-7.26. Hemmila HM, Keinanen-Kiukaanniemi SM, Levoska S, Puska P (2002) Longtermeffectiveness of bone-setting, light exercise therapy, and physiotherapy forprolonged back pain: a randomized controlled trial. J Manipulative Physiol Ther,25(2): 99-104.27. Herzog W, Conway PJW, Wilcox BJ (1991) Effects of different treatmentmodalities on gait symmetry and clinical measures for sacroiliac joint patients. JManipulative Physiol Ther, 14: 104-9.28. Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Belin TR, Yu F, Adams AH(2002) A randomized trial of medical care with and without physical therapy andchiropractic care with and without physical modalities for patients with low back pain:6-month follow-up outcomes from the UCLA low back pain study. Spine, 27(20):2193-204.29. Koes B, Bouter L, H vM, Essers A, Verstegen G, Hofhuizen D, Houben J,Knipschild P (1992) The effectiveness of manual therapy, physiotherapy, andtreatment by the general practitioner for nonspecific back and neck complaints: Arandomized clinical tria. Spine, 17(1): 28-35.30. Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM (1996) Spinalmanipulation for low back pain. An updated systematic review of randomized clinicaltrials. Spine, 21(24): 2860-71; discussion 72-3.31. Koes BW, Assendelft WJ, van der Heijden GJ, Bouter LM, Knipschild PG (1991)Spinal manipulation and mobilisation for back and neck pain: a blinded review. Bmj,303(6813): 1298-303.32. Leboeuf-Yde C, Hennius B, Rudberg E, Leufvenmark P, Thunman M (1997) Sideeffects of chiropractic treatment: a prospective study. J Manipulative Physiol Ther,20(8): 511-5.33. Licciardone JC, Stoll ST, Fulda KG, Russo DP, Siu J, Winn W, Swift J, Jr. (2003)Osteopathic manipulative treatment for chronic low back pain: a randomizedcontrolled trial. Spine, 28(13): 1355-62.34. Niemisto L, Lahtinen-Suopanki T, Rissanen P, Lindgren K-A, Sarna S, Hurri H(2003) A randomized trial of combined manipulation, stabilising exercises, andphysician consultation compared to physician consultation alone for chronic low backpain. Spine, 28(19): 2185-91.35. Ongley MJ, Klein RG, Dorman TA, Eek BC, Hubert LJ (1987) A new approach tothe treatment of chronic low back pain. Lancet, 2(8551): 143-6.36. Ottenbacher K, DiFabio RP (1985) Efficacy of spinal manipulation/mobilizationtherapy. A meta-analysis. Spine, 10(9): 833-7.10037

[davidrodway]

And some more (Dont know why those smilies are there, sorry).



Pope MH, Phillips RB, Haugh LD, Hsieh CY, MacDonald L, Haldeman S (1994) Aprospective randomized three-week trial of spinal manipulation, transcutaneousmuscle stimulation, massage and corset in the treatment of subacute low back pain.Spine, 19(22): 2571-7.38. Postacchini F, Facchini M, Palieri P (1988) Efficacy of various forms ofconservative treatment in low back pain: a comparative study. Neurol Orthop, 6: 113-6.39. Pustaver MR (1994) Mechanical low back pain: etiology and conservativemanagement. J Manipulative Physiol Ther, 17(6): 376-84.40. Rasmussen-Barr E, Nilsson-Wikmar L, Arvidsson I (2003) Stabilizing trainingcompared with manual treatment in sub-acute and chronic low-back pain. Man Ther,8(4): 233-41.41. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Brook RH (1992) Spinalmanipulation for low-back pain. Ann Intern Med, 117(7): 590-8.42. Shekelle PG, Coulter I, Hurwitz EL, Genovese B, Adams AH, Mior SA, Brook RH(1998) Congruence between decisions to initiate chiropractic spinal manipulation forlow back pain and appropriateness criteria in North America. Ann Intern Med, 129(1):9-17.43. Skargren E, Oberg B, Carlsson P, Gade M (1997) Cost and EffectivenessAnalysis of Chiropractic and Physiotherapy Treatment for Low Back and Neck Pain.Six-Month Follow-Up. Spine, 22(18): 2167-77.44. Stevinson C, Ernst E (2002) Risks associated with spinal manipulation. Am JMed, 112(7): 566-71.45. Timm KE (1994) A randomized-control study of active and passive treatments forchronic low back pain following L5 laminectomy. J Orthop Sports Phys Ther, 20(6):276-86.46. Triano JJ, McGregor M, Hondras MA, Brennan PC (1995) Manipulative therapyversus education programs in chronic low back pain. Spine, 20(8): 948-55.47. UK BEAM Trial Team. Brealey S, Coulton S, Farrin A, Morton V, Torgerson D,Burton AK, Garratt A, Harvey E, Letley L, Martin J, Vickers M, Whyte K, Manca A,Klaber Moffett J, Russell I, Underwood M, Williams M (2004a) United Kingdom backpain exercise and manipulation (UK BEAM) randomised trial: Cost-effectiveness ofphysical treatments for back pain in primary care. British Medical Journal,329(7479):138148. UK BEAM Trial Team. Brealey S, Coulton S, Farrin A, Morton V, Torgerson D,Burton AK, Garratt A, Harvey E, Letley L, Martin J, Vickers M, Whyte K, Manca A,Klaber Moffett J, Russell I, Underwood M, Williams M (2004b) United Kingdom backpain exercise and manipulation (UK BEAM) randomised trial: effectiveness ofphysical treatments for back pain in primary care. British Medical Journal,329(7479):137749. van Tulder MW, Assendelft WJ, Koes BW, Bouter LM (1997) Method guidelinesfor systematic reviews in the Cochrane Collaboration Back Review Group for SpinalDisorders. Spine, 22(20): 2323-30.
50. Waagen GN, Haldeman S, Cook

[Blue Wode]

David Rodway wrote:

Nice point about “cranial” and the GOsC Code. I think that the response would be (But why not ask the GOsC directly?) that, if challenged, the “cranial” osteopath would say that they believe (and they really will) that what they are doing is in the patients best interests.

All of which fits in nicely with what Rose Shapiro writes on p.130 of her book, Suckers: Why alternative medicine makes fools of us all:

Osteopathy and chiropractic have both managed to gain huge respectability simply by being officially regulated, despite there being no official standards of efficacy for either practice. State regulation is equated with state approval, hence they go largely unquestioned and uncriticised.

David Rodway wrote:

Ernst says it is his reading of it [the BEAM trial]. So I assume there are others that vary. Interestingly he says (I think) that he thinks that touch enhances the benefits of exercise . Or is it exercise enhances the benefits of touch. Are we talking, all touch, any touch, touch by osteopaths, touch by physios? Is touch by osteopaths better than touch by physios.? A lot of the benefit of osteopathy is because of touch - that is the point. Doesn’t mean that just getting your husband/wife to toch you is going to be as beneficial for your health/pain as an osteopaths touch (although it might be)

Here’s Ernst on ‘touch’:

Some believe the power of touch is all down to the placebo effect. "If you touch your partner they feel relaxed, but if someone else touches they may not feel as relaxed," said Professor Edzard Ernst, a professor of complementary medicine at the University of Exeter. "That is very much mind over matter. It has nothing to with the sensations of being touched, it is the expectation and the context of the intervention, rather than the specific effect of that intervention."

http://www.independent.co.uk/life-style/health-and-wellbeing/health-news/how-the-power-of-touch-reduces-pain-and-even-fights-disease-419462.html

David Rodway wrote:

Neck treatment. Not sure of the source of your neck exercise is best quote. What neck exercises anyway?

See here:

…neck pain is not a life-threatening condition, it is often a self-limiting complaint, and treatments exist that are devoid of risk.
-snip-
There is general agreement (supported by data) that Cochrane reviews are of the highest quality and thus contribute the most definitive evidence. The Cochrane review on the present topic had very broad inclusion criteria (e.g. including trials with multi-modal interventions),2 thus we have to be very careful when citing it specifically in relation to spinal manipulation. In its results section, the reviewers dedicate several paragraphs to the heading ‘manipulation alone’. These make very clear statements: ‘Four RCTs assessed the effect of a single session of manipulation. When compared to a control there was moderate evidence that single sessions did not result in short-term pain relief … Five trials assessed the effect of 6–20 sessions of manipulation … against various comparisons … In every case, the results were negative … Three trials found no difference in short- and intermediate-term pain relief when manipulation was compared to mobilisation …’ This important piece of evidence is often misquoted. It yields positive results for ‘multimodal therapy’, e.g. manipulation plus mobilisation or exercise or physical therapies such as heart application. Proponents of spinal manipulation therefore tend to represent this as positive evidence for their therapy. This is not correct!

Proponents of spinal manipulation will rightly point out that the absence of evidence is not the same as evidence of absence of an effect. On the other hand, critical thinkers would argue that, even if an effect can one day be demonstrated, it could be due to a placebo response.3 Spinal manipulation has several of the characteristics that make a ‘powerful placebo’. But who cares? Does it really matter whether a patient gets better because of a specific or a non-specific response? Perhaps not from a practical, clinical point of view – provided the placebo is safe!

The references are listed here:
http://www.medicinescomplete.com/journals/fact/current/fact0902a06d01.htm

David Rodway wrote:

I should also add that before an LAHVT we will test eg auscultate for carotid bruit. Also the history may point against LAHVT – eg drop attacks, clotting disorders – in which case no LAHVT is done.

That’s still not very reassuring considering the following:

Some therapists have started advocating screening patients for risk factors before treatment.55-57 Based on cadaver studies of human vertebral arteries, Cagnie et al.58 have suggested that, in the presence of arteriosclerotic changes, the stretching and compression effects of rotational manipulation may constitute a risk factor for vascular accidents. These authors concluded that ‘therapists should avoid manipulative techniques at all levels of the cervical spine in the presence of any indirect sign of arteriosclerotic disease or in the presence of calcified arterial walls or tortuosities of the vessel.’58 Others have suggested that high homocystein levels constitute a risk factor for arterial dissection.59 Spinal manipulation might therefore be contraindicated in such individuals. The effectiveness of screening has, however, not been convincingly demonstrated.

Adverse effects of spinal manipulation: a systematic review
http://jrsm.rsmjournals.com/cgi/content/full/100/7/330

In the absence of neurologic symptoms, there is no reliable way to predict which patients are at risk of stroke.

-snip-

…what about the patients who present for care with no symptoms of CAD and without even complaining of head or neck pain? Stroke victims are clearly NOT just patients who went to a chiropractor with head or neck pain. Some were being treated for things like low back pain or shoulder pain. Some patients like Sandra Nette had no pain at all: she had a catastrophic stroke after neck manipulation done simply for health maintenance purposes. Laurie Jean Mathiason, a 20 year old woman, received 186 manipulations of her neck over a 6 month period when her original complaint was lower back pain. The 186th one killed her.

http://www.sciencebasedmedicine.org/?p=362

David Rodway wrote:

Ernst – not decrying him completely, just saying he is not the sole authority. For example (without looking it up again ) I think there was something in that advice he gave in the Daily Mail about making sure that the osteopath would not use vigorous treatment if the patient told them they had cancer, bone infection, clotting disorders and some others. This implies he does not realise that an osteopath will know not to use certain techniques if these conditions are present.

He’s probably erring on the side of caution since it's apparent that some osteopaths are deluded enough to use quackery such as craniosacral therapy/cranial osteopathy on their patients.

David Rodway wrote:

Point is, why doesn’t Ernst know that is what is what we do? Should he not visit a few osteopathic colleges?. He can come to my practice if he likes and watch me work.

One has to assume that Ernst is very familiar with what you do when you consider that he was the Head of the Department of Physical and Rehabilitation Medicine in the University of Vienna’s Medical Faculty,
http://www.newscientist.com/article/mg19826531.400-interview-the-complementary-medicine-detective.html?page=2
and that he has also been trained in spinal manipulation and has applied it clinically. See the end of his Systematic review of case reports of serious adverse events following manipulation of the cervical spine (1995–2001) here:
http://www.mja.com.au/public/issues/176_08_150402/ern10520_fm.html

David Rodway wrote:

Ernst impartial – trouble is he doesn’t do research of his own as far as I know. And he has overlooked some that has been done (references to folllow as I said before}

Who should do research –If osteopaths do it the results are “biased”, if we do not do it we are criticised for not doing our own research If we use other peoples results we are “piggy backing”. Cant win .l I think osteopaths and non-osteopaths should do the research and then the studies stand on their own merits.

It’s not up to Ernst to do the research; rather it is the responsibility of the proponents who make the claims. Ernst’s job is to evaluate the emerging evidence for CAM from a scientific point of view. What could be fairer than that?

BTW, re the cost-effectiveness of osteopathy. The following review from 2006 might be of interest to you,

Prospective, controlled, cost-effectiveness studies of complementary therapies have been carried out in the UK only for spinal manipulation (four studies) and acupuncture (two studies). The limited data available indicate that the use of these therapies usually represents an additional cost to conventional treatment.

Cost-Effectiveness of Complementary Therapies in the United Kingdom—A Systematic Review
http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17173105

And this as well:

One controlled study of a medical osteopathy service found that service users did not decrease their use of NHS resources.

The impact of NHS based complementary therapy services on health outcomes and NHS costs: A review of service audits and evaluations
http://7thspace.com/headlines/304871/the_impact_of_nhs_based_complementary_therapy_serv ices_on_health_outcomes_and_nhs_costs_a_review_of_ service_audits_and_evaluations.html

[Blue Wode]

David Rodway wrote:

sceptic has a c in it not a bloody k

It’s deliberate. John Jackson, the founder of UK Skeptics, has previously explained the reasons for the use of a ‘k’ instead of ‘c’. A search of the forum should unearth the relevant post.

Pebble wrote:

Woo:

http://www.osteopathy.ie/history.htm

He believed that the human body was self-healing (Hippocrates thought this somewhat earlier), and that uninterrupted nerve and blood supply to all the tissues of the body was indispensable to their normal function (even Galen thought this though for the wrong reasons). If any structural problem, e.g. muscle spasm, curvature of the spine, etc. interfered with the nerve and blood flow (blood flow and minor spinal abnormalities?), the self healing power was interfered with, and disease would result. With this in mind, he worked out a system of manipulation/adjustment intended to re-align any structural deviations and abnormalities.

So individuals with kyphoscoliosis must have very poor healing abilities! Clearly recovery from colds and sinus disorders must be very delayed in such individuals

Some more on the woo origins of osteopathy from Rose Shapiro on p.134 of her book:

Famously, at ten in the morning on June 22, 1874, Andrew Taylor Still had a ‘prophetic vision’ where he was shot, as he described in his autobiography, ‘not in the heart, but in the dome of reason’ where ‘like a burst of sunshine the whole truth dawned upon my mind’. This truth was that ‘ there was no such disease as fever, flux diphtheria, typhus, typhoid, lung-fever, or any other fever classed und the common head of fever of rheumatism, sciatica gout, colic, liver disease, nettle-rash, or croup, on to the end of the list, they do not exist as diseases’. Instead ‘all diseases are mere effects, the cause being a partial or complete failure of the nerves’, brought about by misalignments of the vertebrae.

As for the current evidence on osteopathy, it includes the following which, once again, I have lifted from Rose Shapiro’s book (p.132):

Osteopathy and chiropractic may be popular with patients the world over, but make enquiries beyond reports of customer satisfaction and there is minimal evidence to show that spinal manipulation is any better at alleviating back pain than gentle exercise. In a review of current research that enraged osteopaths and chiropractors, leading sceptic Professor Edzard Ernst concluded that there was no evidence to suggest that spinal manipulation was an effective intervention for any condition. This finding applies to both osteopathy and chiropractic.

A systematic review of systematic reviews of spinal manipulation (2006)
http://www.jrsm.org/cgi/content/full/99/4/192

Similar conclusions were reached by Dr Scott Kinkade of the University of Texas in another research review. He concluded that manipulative therapy might provide short-term benefits compared with sham therapy, but not when it was compared with conventional treatments including painkillers, anti-inflammatories, heat treatments and advice to stay active.

Evaluation and Treatment of Acute Low Back Pain, American Family Physician (2007)
http://www.aafp.org/afp/20070415/1181.html

And from p.135:

In the years since Still’s death osteopathy may have attained the highest status of all fringe medical practices, but the most recent review of the evidence for spinal manipulative therapy as a treatment for lower-back pain found ‘it was no more or less effective than medication for pain, physical therapy, exercises, back school or the care given by a general practitioner’.

http://www.cochrane.org/reviews/en/ab000447.html

David Rodway wrote:

EUROPEAN GUIDELINES FOR THE MANAGEMENT OF CHRONICNON-SPECIFIC LOW BACK PAIN

Summary of the concepts of treatment of chronic low back pain (CLBP)

• Conservative treatments:Cognitive behavioural therapy, exercise therapy, brief educational interventions,and multidisciplinary (bio-psycho-social) treatment can each be recommendedfor non-specific CLBP. Back schools, and short courses of manipulation canalso be considered. The use of physical therapy (TENS, heat/cold, traction,laser, ultrasound, short wave, interferential, massage, corsets) cannot be
recommended.

EUROPEAN GUIDELINES FOR THE MANAGEMENT OF ACUTE NONSPECIFIC LOW BACK PAIN IN PRIMARY CARESummary of recommendations for treatment of acute non-specific low back pain:
Consider (referral for) spinal manipulation for patients who are failing to return to normal activities.

Bearing in mind what the most up-to-date Cochrane review has to say about spinal manipulation for back pain (see above), here’s Ernst’s thoughts on guidelines…

…guidelines are well known to be influenced by the people who serve on the panel that develops them. Cochrane reviews, on the other hand, are generally considered to be objective and rigorous. Writing about the importance of systematic reviews for health care in the Lancet, Sir Ian Chalmers stated, ‘I challenge decision makers within those spheres who continue to frustrate efforts to promote this form of research to come out from behind their closed doors and defend their attitudes and policies in public. There is now plenty of evidence to show how patients are suffering unnecessarily as a result of their persuasive influence.’ 10

http://www.medicinescomplete.com/journals/fact/current/fact1002a02t01.htm

[Pebble]

The summary on placebo effect contains many facts, assumptions and ends with unjustifiable conclusions.

In placebo controlled trials the patient is not duped into believing that they are being administered active therapies. They are specifically informed that they have a 50/50 or occasionally 25/75 chance of receiving inactive therapy.

Thus to properly study the placebo effect one must also analyse the response of people who are not necessarily of the opinion that the pill is active.

Second the regression to the mean phenomenon cannot be catered for by studying 'normal' controls. For example people admitted with heart failure though having a high mortality and high likelihood of readmission over the next 6 months tend to spontaneously improve whatever one does. Thus on average most will be somewhat better in a few hours however inactive the treatment. Studying normal controls can tell you nothing of this.

Third, even if one could understand the placebo effect completely it clearly varies from person to person, thus precisely negating its effects in each individual would be impossible. Counter-active therapies (even if this were possible) would actually simply induce more errors into the trial.

Finally even apparently objective measures have inherent inaccuracies - e.g. 11% variation between hemoglobin measured in the same sample using the same machinery and personnel.

In summary the current structure of placebo controlled randomised trials is designed to cater for many known and unknown potential sources of bias, including individual variation in response to therapies, variable causes of symptom complexes, variable disease stage and natural history - attempts made in advance to 'homogenise' these, to be sure, but in the certain knowledge that this can be achieved only partially. The placebo aspect is but one, and will remain incompletely understood for a long time to come.

[Pebble]

Dear Pebble (Alan?)

Nope, try again

years osteopaths , in UK at least , were , as far as I know the only ones doing any sort of serious, educated hands on manipulation.

In more recent years physios have started doing some, following the teachings of Maitland, who, I understand, got his technqiues from watching osteopaths work (I think its called plagiarism).

Obviously physiotherapists have a different view of their history:

http://thephysiosite.com/

In Ancient Greece circa 460 BC, Hector practiced a physiotherapy technique called "hydrotherapy" - which is Greek for water treatment. Physiotherapists today still employ hydrotherapy, now evolved and adapted specifically to various patient conditions.

In 1894, the UK recognized physiotherapy as a specialized branch of nursing regulated by a Chartered Society. In the succeeding two decades, formal physiotherapy programs were established in other countries including New Zealand (1913) and the USA (1914).

The first record of American physiotherapy was at Walter Reed College and Hospital of Portland, Oregon where nurses with physical education experience worked as "reconstruction aides". These "reconstruction aides" contributed vitally to the recovery and rehabilitation of many WWI vets.

doctors too manipulation was popularised by Dr James Cyriax who used very forceful manipluations to "Replace discal fragments". They are still there in the form of BIMM (Used to be called BAMM)

Never heard of him, from what I can see on the web I get the impression he is a charlatan. Is this worth pursuing? Some practices deserve to be shut down, problem is they do tend toward countries with poor regulation if discredited.

Still probably would not like the osteopathy of today. We do not think that the spine is the source of all disease. Where we might disagree with some of the medical profession is that, in some patients, the musculo-skeletal system can have an influence on other body systems (the severe kypho-scoliosis you mentioned for example may have reduced rib expansion on breathing - is that WOO?)

The fact that severe kyphoscoliosis can lead to chest wall restriction and respiratory problems is not the issue. If spinal mal-alignment is to have any real meaning, then such patients should suffer intractably from all the conditions that osteopaths claim to be able to treat on this basis. While we are on the subject on nonsense claims, manipulation of the cranium in children with Down's Syndrome - really! If there is anything guaranteed to get you labeled a woo-monger allowing charlatans that abuse the desperation of vulnerable parents like these to remain members of your organisation is a prime example.

comment on my previous posts about the patient with the high blood pressure ?

170/120 is just about high enough to be symptomatic, so as an anecdote it is plausible.

[Pebble]

Cyriax update:

Have found him - not a charlatan - though some of the clinics advertising use of his techniques cause concern:

http://www.bimm.org.uk/uploads/docs/...ge_booklet.pdf

It is unclear from this article whether the approach owes anything (other than superficial similarity) to osteopathy.

[Pebble]

Interesting chap Maitland:

http://www.imta.ch/gmaitland.htm

Geoffrey Douglas Maitland was born in Adelaide Australia in 1924. He trained as a physiotherapist from 1946 to 1949 after serving in the RAAF (Royal Australian Airforce) during the second World War.

His first job was at the Royal Adelaide Hospital and the Adelaide Children's Hospital, with a main interest in the treatment of orthopedic and neurological disorders. Later he continued working part time in the hospital and part time in his own private clinic. After a few years he became a part time private practitioner and part time clinical tutor at the School of Physiotherapy in the Southern Australian Institute of Technology, now the University of South Australia. He continuously studied and spent half a day each week in the Barr-Smith Library and the excellent Library at the Medical School of the University of Adelaide.

As a lecturer, he emphasized clinical examination and assessment. He stimulated his students to write treatment records from the very beginning, as he felt that “one needed to commit ones self to paper to analyze what one was doing”. In 1954 he started with manipulative therapy teaching sessions.

In 1961 he received an award from a special studies fund, which enabled him and his wife Anne to go overseas for a study tour. They visited osteopaths, chiropractors, medical doctors and physiotherapy colleagues whom they had heard and read about and corresponded with in the previous years. In London, Geoff had interesting lunchtime clinical sessions with James Cyriax and his staff. During this tour Geoff Maitland established a friendship with Gregory P. Grieve from the UK. They had extensive correspondence about their clinical experiences and this continued for many years.

In 1962 Geoff Maitland delivered a paper to the Physiotherapy Society of Australia entitled “The Problems of Teaching Vertebral Manipulation” in which he presented a clear differentiation between manipulation and mobilization and became a strong advocate of the use of gentle passive movement in the treatment of pain, in addition to the more forceful techniques used to increase range of motion.

The charge of plagirism seems overblown, prepared to learn from a variety of sources seems closer to the mark!

[davidrodway]

Cyriax update:

Have found him - not a charlatan - though some of the clinics advertising use of his techniques cause concern:

http://www.bimm.org.uk/uploads/docs/...ge_booklet.pdf

It is unclear from this article whether the approach owes anything (other than superficial similarity) to osteopathy.

Dear Pebble

You beat me to it.

Why not a charlatan all of a sudden?

Do not know where Cyriax learned his manipulation, but a glance through his books will show you they were very vigorous _ eg nurse holding on to the supine patient as Cyriax, holding the chin leaned back with all his weight before performing a forceful neck rotation. He beleived he was "replacing fragments of disc".

Not sure how the present day BIMM members treat - i hope not so roughly. I know that they also like using sclerosants ("Prolotherapy). Dont know how much research has been done into their results.

Some doctors have also trained as osteopaths. There is the LCOM which is purely for training doctors in osteopathy. Why some choose to do that route and not the BIMM route I dont know. There are also a few osteopaths who then trained as doctors - eg Peter Gibbons, head of an osteopathic training college in Australia.
London College of Osteopathic MedicineHome
About LCOM
About osteopathy
Clinic
Training
Links
Contact us
About the College

The London College of Osteopathic Medicine (LCOM) was founded in 1946 to provide training in osteopathic principles and methods for people who were already qualified medical doctors.

Those in training spend over 80% of that time is treating patients in the Clinic under the close supervision of tutors who are qualified osteopaths, registered with the General Osteopathic Council, most of whom are graduates of the College themselves and are therefore also medically qualified.

The College is recognised by the General Osteopathic Council and so its graduates are eligible to be fully registered osteopaths.

[davidrodway]

All of which fits in nicely with what Rose Shapiro writes on p.130 of her book, Suckers: Why alternative medicine makes fools of us all:

I didnt say it was a good thing - i was pointing out the problems of getting some people off the GOsC register


That’s still not very reassuring considering the following:

Adverse effects of spinal manipulation: a systematic review

I thoiught I had made the point that if there were anything in the history that contra-indicated cervical LAHVT , then an LAHVT is not performed. The value of pre screening is , as pointed out, not proved, but if i hear a carotid bruit or for example see silver wiring or vessel tortuosity with an opthalmoscope the i am NOT going to LAHVT whatever the research says


He’s probably erring on the side of caution since it's apparent that some osteopaths are deluded enough to use quackery such as craniosacral therapy/cranial osteopathy on their patients.

Maybe, may be not.



One has to assume that Ernst is very familiar with what you do when you consider that he was the Head of the Department of Physical and Rehabilitation Medicine in the University of Vienna’s Medical Faculty,
and that he has also been trained in spinal manipulation and has applied it clinically.

I thought it just said trained in acupuncture and homeopathy. I dont know that Austrianosteopaths do what we do in Britain anyway. Assume nothing.





]It’s not up to Ernst to do the research; rather it is the responsibility of the proponents who make the claims. Ernst’s job is to evaluate the emerging evidence for CAM from a scientific point of view. What could be fairer than that?

Good point, but i still think he could get more aquainted with what osteopaths actually do.

BTW, re the cost-effectiveness of osteopathy. The following review from 2006 might be of interest to you,

Will look up these references. I beleive there is some interesting news on cost effectiveness coming out in May 2009.

[Pebble]

Why not a charlatan all of a sudden?

Holding that manipulative and physical therapies have a role in neuromuscular conditions is hardly off beam. Would need more in-depth study to determine if there were aspects of what he believed that were inconsistent with the prevailing level of knowledge at the time, but from the paper found all seems within the realms of plausibility given the limited understanding of the time.

Some doctors are skeptics, and use techniques learned through scepticism in their daily practice - does that legitimise skepticism?

[davidrodway]

DearPebble

The charge of plagirism seems overblown, prepared to learn from a variety of sources seems closer to the mark![/quote]

It would be interesting to know what he drew from which sources, what he left out and why. And how much did he learn. Osteopathy even then was a four year course, and I assume the other course swere rigorous. I dont think a few weeks studying physiotherapy would equip me to launch a school of Rodway Manipulation.

i understand Maitland manipulation is graded 1 to 4, 1 being gentle, 4 being what we would call an LAHVT (although we do it better of course). My problem with this is that
1 it impies an LAHVT has to be forceful
2 It implies that Grade 4 is a difference of quantity, wheras I would say that it is a fundmantally different manipulation from grades 1 to 3 (those grades are also called mobilsation by physos and articulation by osteopaths)

Most hands on i UK is done by osteopaths. When I trained I was interested in the biomechanics of the body and hands-on ttt - that is why I chose osteopathy (i had , perhaps luckily, never heard of chiropractors.)Apart from obvious "tribal" reasons it doesnt really bother me if we eventually have an amalgamation of the best of osteopathy, hands on physio, orthopaedic medicine and even chiro. Perhaps thats the way its going. We'll end up with a profession of primary care practitioners with good knowledge, diagnostic skill and the range of manipulative skills in their therapeutic toolbox. Only thing is, we have already got them - they are called osteopaths

[davidrodway]

Pebble wrote:

Some more on the woo origins of osteopathy from Rose Shapiro on p.134 of her book:

I have already commented on that. WOO origins maybe, but we are in 2009 now not 1875




]

[davidrodway]

Holding that manipulative and physical therapies have a role in neuromuscular conditions is hardly off beam. Would need more in-depth study to determine if there were aspects of what he believed that were inconsistent with the prevailing level of knowledge at the time, but from the paper found all seems within the realms of plausibility given the limited understanding of the time.

Some doctors are skeptics, and use techniques learned through scepticism in their daily practice - does that legitimise skepticism?

Given that I trained in the 1970s, I can tell you that yes his ideas were inconsistent with knowledge. Or, put it another way, his claims of replacing discal fragments were derided by the osteopathic profession.

We were also by the way, advising against bed rest, the routine use of x-rays and the use of baby strollers. The "proper doctors" have now comme round to our position (no thanks to us). In fact, they have gone completely the other way.

"Consistent with the kowledge of the time (Or lack of it)" - my point about A T Stills ideas, I think

Your first sentence - very telling. Those ideas were considered "off beam" then .Its perhaps a measure of how far we have come that you think that manipulation has a role to play in neuromuscular conditions. Back in the 1960s and 70s even that was not accepted. Cyriax had almost as much struggle with his medical colleagues as osteopaths did.

Holding that manipulative and physical therapies have a role in neuromuscular conditions is hardly off beam. That sounds to me perilously close to an osteopathic viewpoint. Careful!

Sorry, do not understand your last sentence.Please explain