As someone who couldn’t even work Facebook nine months ago, it came as something of a shock to find I was involved in a Twitter spat with Simon Singh, one of osteopathy’s fiercest critics. What next? A public fracas with Richard Dawkins? However several emails and a long phone call later, feathers were unruffled, a personal goodwill of sorts was expressed on both sides, the “ad hominem” bit was taken out of the equation and I had plenty of material and inspiration for more blogging along with permission to use our conversation as I wished. There were no great surprises in what Simon Singh said, and I agree with him about many, many things. Part of my reason for starting my blog was to reduce confusion and promote research in osteopathy. I just love research. However we differ in that his starting point is assuming that osteopathy, and what we call cranial osteopathy, doesn’t “work”, and I come from a position that it does. He wants to make sure we are not conning the general public into thinking we can do something we can’t (an admirable and reasonable motivation). I want to find out how osteopathy works, how well it works, for which patients, and which conditions, and how we can best teach practitioners the skills and assess them for competence before they are let loose on the general public. The conversation stimulated me to think a little more clearly about the reasons WHY there isn’t more research in osteopathy, and a post will follow. But like many conversations where you feel on the back foot, I also began to reflect more on all the things I hadn’t said, and could have said, than the things I had.
There were a couple of jokes
“Well I’m guessing by the way you say that that you’re a Taurus”; and “I suppose we’ll just have to wait till the next life to find out who was right”. But I quickly realised that I always approach skeptics on the wrong level. They are not immediately interested in a grand debate on the existence of life after death, the existence of extrasensory dimensions, or the nature of personal experience, they are interested in more pressing and everyday questions such as:
If this treatment you’re offering really does help kids with asthma/colic/dyslexia/ADHD, why don’t you do a study and show the evidence? (“It would be easy”, according to him)
And how can you do it if you have no evidence for it?
Then were were the questions I wished I’d asked:
Do you think your campaign is actually successful in protecting patients?
Do you want all treatment which is not EBM or allopathic to be eliminated (including the 20% of treatments used in the orthodox medical world which have no evidence base)?
What do you think would be the attitude of patients if they were not allowed to access the non-evidence based treatments which they feel help them?
Do you think the NHS could cope with the influx of pain patients if osteopaths, chiropractors, acupuncturists and massage therapists were not able to practise, and if physios were prevented from using all the techniques (including acupunture, craniosacral, ultrasound, taping, HVT etc etc?) that are not indisputably evidence-based.
(These excellent questions were provided by a colleague, who probably would have done a better job than I did of debating the case. I forgot about them completely and largely resorted to repeating “I don’t know” and “Could we really do a study on that?”)
Then there were the explanations:
What do osteopaths treat?
Pain, Pain and tension. That’s really what it comes down to. I did say that. But I could have expanded. Pain and tension and related discomfort. The strains that cause pain and tension. The stiffness, the torsions, the increased tone, the areas that feel awkwardly held.
I will personally go to get a treatment for just feeling a bit wobbly, tired or “out of sorts”, but tension is normally involved in that too. Then there are symptoms that are the result of tension: trapped nerves, dizziness, insomnia, IBS. There is the odd person with a diagnosed condition, for example, facial hemiplegia, or trigeminal neuralgia, or Menieres disease, who is willing to try anything that might help, and I treat them in the same way by looking to reduce tension and strain and optimize the physical state in the hope that it helps the condition, or helps the patient to cope better with the condition. And that’s just the manual therapy side, which is not the entire osteopathic toolkit. There are also the personal issues and lifestyle that contribute to that pain and tension. We can affect that with advice, exercises and the clinician-patient interaction.
We treat the person not the condition.
If I treat a child with cerebral palsy, I am not treating the cerebral palsy; I am looking at the feel and state of the child’s body regardless of what is wrong with them, and trying to make them feel more comfortable, and make their body and ultimately their life function better as a result. To what extent this actually reduces the child’s suffering or alters the course of the actual condition, I would like to know with more certainty, and this is why I want more research.
I feel the lack of evidence is limiting the good we can do.
I also agree we have to be clear that patients understand that we treat the body not the condition. I issue so many disclaimers now that patients often don’t book in with me. Someone called a couple of weeks ago asking if I could treat plagiocephaly. The reality is that I felt that I would help and would do her baby good, but I must have pushed her away with my honesty about lack of evidence and no guarantee of results, and my effort to limit her expectations. She didn’t book in. I now feel that that child is missing out on something which would have benefited them, but until I can have more hard evidence to go on I feel I have to be honest about the lack of it to maintain my integrity.
How can I justify treating adults with cranial when there’s no evidence?
It is easy to see the moral dilemma in, say, advertising that you can treat autism or dyslexia, but treating an adult with a tension headache, or a stiff low back, using cranial osteopathy? This is not a moral dilemma to me at all, and I was slightly surprised to hear that it could be regarded as such. Here’s why. This might look like sidestepping, and is only a snapshot in an incomplete thinking process, but it’s how it seems to me right now. I see all manual therapy techniques as essentially the same thing. There is my body, applying some kind of force to the patient’s body, in the hope that it changes. I want that change to be in the direction of ease and relaxation and ideal tone, and I want it to last longer than a few days. I really want to somehow effect a change in the central nervous system.
Cranial is at the gentle end of the manual therapy spectrum
You can try to do that by using all sorts of techniques, and believe me, getting a lasting change is often not that easy. There are dozens of techniques. Let’s see: manipulation, traction, functional, cranial, effleurage, inhibitions, trigger points, stretching, and let’s not forget techniques like lymph drainage, muscle energy, and even strain counterstrain, and that’s just a small selection. To me, cranial is just another technique which sits at the opposite end of the spectrum from strong techniques like HVT or Rolfing. There is a gradation from coarse and strong at one end, to fine and gentle at the other. At the extremely fine and gentle end of the spectrum the force is of such a subtle quality that it is barely more than a light contact and the force of your attention. It’s still my body trying to make a difference to your body using pressure of some sort in some direction, not always direct. (And yes I can totally see why it is hard to believe it could work – another reason why we need hard scientific evidence). So to think stronger techniques are of a different type or order to cranial techniques is, I think, a bit of a problem which pervades and divides osteopathy and causes confusion to the outside world. It is partly a result of a complex hypothesis which arose decades ago to try to explain observed phenomena, and which still seems to be the public (if not private) explanation for how cranial works, (flawed though it evidently is to most people who examine it). But I digress – another future post! If manual therapy is OK, and massage is OK, then as far as I am concerned cranial is just a very refined form of that and I don’t need special permission to use it, because it’s all part of the same continuum to me. It doesn’t mean we don’t need to test its efficacy in the same way that we test the efficacy of other techniques.
And at the more mundane level, gentle techniques and massage are really the only things that seems to work for me. When I’m doing it right, cranial brings the quickest and most profound change to the patient, with the least chance of adverse events. If I don’t use “cranial” I find it harder to get some people feeling very much better, very quickly, for very long. I feel a responsibility to offer them what I think will work best, and I look forward to the day that the research proves me right.
Could you help me to design a trial please?