OK it’s a long one, so you might want to grab a coffee before you sit down to read it.
For the information of the uninitiated, everyone I know pronounces NCOR like N-Core, making it sound like a rap star, or a sciencey-term for a nuclear reactor or particle. I just entered NCOR as a search term to check whether it’s the National Council for Osteopathic Research or the National Council of Osteopathic Research (attention to detail! – it’s the former), and discovered that there is in fact a gene called NCOR1 (which encodes the protein known as the nuclear receptor co-repressor 1.) This gene occupies most of the first page of Google, but the NCOR we know and love is half way down the second. There we find it is the National Council FOR Osteopathic Research and is described as “a research centre focussing on evidence based osteopathic practice.”
I have been attending an NCOR research hub at Haywards Heath for at least ten years now. Our initial, ambitious enthusiasm to conduct randomized controlled trials in local cardiac surgery units soon gave way to a more realistic programme of learning and improving our critical thinking, and acquainting ourselves with research relevant to clinical practice. We do this by reviewing and presenting recent papers. It’s also a good gossip opportunity – there are usually 6 or 7 of us there, from a pool of maybe 10 or 12 , and while we’re not going through the papers, we chat about what’s going on in the world of osteopathy, and swap notes on patients, while we drink tea and eat chocolate biscuits. There are a few of these NCOR satellites around the country. Ours meets for a couple of hours on a Wednesday evening every three months, and Carol Fawkes, who has been a main player in NCOR from the start, is our facilitator. She is the one who finds and assigns each of us papers on whatever topic we choose as a group. (Currently we’re on fibromyalgia.) She used to travel a long distance to the group, but now establishes her placid, informed presence via a telephone receiver which sits like a beacon of rationality in our midst. The hub has been a great way to learn a bit about research, and to discover just how to read a paper, and also how patchy the evidence is for much of what manual therapists have been doing for years.
But this time, I was to travel to London to witness the actual meeting of NCOR proper. I had no idea what to expect. Austin Plunkett, an energetic and prolific poster on osteopathic social media, had invited me, but would not be there. Thank goodness I knew Carol at least. Apparently the meetings are normally held at Osteopathy House (GOsC) but this time it was at my old stomping ground, BCOM. It was called the BCNO back then, but that was about the only thing that looked obviously different. Maybe the rubber plant in reception had gone, but I’m not sure. I even had a mildly Proustian moment when I saw Manoj silhouetted in the corridor.
In a handsome upstairs meeting room I came across a few people unpacking trays of sandwiches and wraps. As more attendees blew in one by one off the Finchley Rd, I got an idea of the make up of the Council. There were about 16 people there. Dawn is the chatty and friendly director of NCOR who chairs the meeting. Carol, as I’ve mentioned, was also there. Austin would have been there if his plans to attend had not been unfortunately dashed by an urgent skiing holiday. I was surprised to see Tim and Bridgit from the GOsC turn up. I hadn’t anticipated that. Then there was Maurice Cheng of iO, and also there were representatives of most of the colleges, or “Educational Institutions” as they seem to be called in these circles. Even OEIs if you want to get really acronymic. I was personally delighted to see a representative from the SCC research committee present, apparently for the first time. Gosh, might osteopathy finally be moving from a “diverse” to an “inclusive” profession, to use two of today’s most oft-used descriptors. If we keep going this way, who knows, we might arrive at a neutral some time soon.
News from the Various Schools and Colleges
The meeting kicked off with a discussion about setting up a database of abstracts from the different OEIs (colleges, remember?). The rep for each organisation then gave an update on what was happening in their world. There was lots of detail and my notes are sketchy, so this will just give you an idea of what they talked about.
The BSO gives the impression of having a busy department. Amongst mentions of the upcoming IFOMPT conference, Britspine and the International Group on Somatic Dysfunction, Steve Vogel is also involved with the Society of Back Pain Research and their Pathfinder Project, which is a pathway for spinal pain. This is in the process of being updated. The BSO’s first professional doctorate has now gone through the Viva stage, and two more are due this Summer. I think four are due to finish in total. The doctorates are awarded by the University of Bedfordshire. It sounds like more people start the doctorate than finish. (It’s quite a big undertaking). The BSO are also using an NHS version of PROMS (patient reported outcome measures) in their clinic. This is called MSK-HQ. They are looking at a collaboration with “Liverpool” on the role of “gentle touch” in the perinatal period. Excuse all these quotation marks. It denotes only my lack of certainty about what is being referred to. Possibly this study into gentle touch is part of the reframing/rebranding/renaming of “cranial” by the pain science types who are hugely into the potential power and efficacy of touch, but who are not at all into the traditional osteopathic models espoused by people like the SCC. I think. To them the question about “gentle touch” boils down to either 1) it feels nice and might do something, or 2) it feels nice and might not do something. (That last bit was a direct quote). They are looking at a trial in Italy. (Sorry I know these details are a bit vague, but hope it gives you some sort of impression of the meeting – they talk fast about things I know nothing about and my notes are not that detailed, and my handwriting is not what it was before the computer age). There is also some talk of some organisation looking for biomarkers of somatic dysfunction (good luck with that), however there seems to be more talk than ready cash associated with this plan.
The ESO also seem to have a pretty thoughtful research department. I gather that in collaboration with the SCC they are doing a study into infant colic. They want 30 subjects and at the time of the meeting had 23. I think it’s happening in Maidstone so if you’ve got a friend or relative with a screaming baby over in Kent, give them a shout. The trial will be blinded; the parents seem happy to sit behind a screen.
The SCC then gave an update. They are due to hold a second research conference in June/July 2018. I was at the first, back in 2013, entitled “Hidden Treasures”, and it was evident that while there hasn’t been that much of a research mill in Sutherland world, there are certainly some very clever people there. I thought that Jane Stark’s keynote speech on palpatory validity was worth the ticket price alone.
The SCC deliberately gave everyone a few years after the last conference to make sure people had time to develop something.
The BCOM have had a research conference going for a while (ICOR), and next year (2017) will have one in Milan. They are sorting out keynote speakers our at the moment.
NESCOTT – have a new validating partnership with Kingston.
GOsC and iO News
The GOsC representatives now had a bit of a say. They have a study looking for common factors among people who’ve had a complaint investigated over the last 5 years, and will present this in June. They are going to look at factors such as age, gender and time since graduation. Initial concerns are analysed by NCOR. The results will be discussed with schools and published in the osteopathy magazine(s). There is apparently a very good relationship between the regulator and insurers which is good to know. Bridgit drew our attention to the fact that after treatment 37% of people are going to temporarily feel worse. Please inform patients of this BEFORE the treatment. Interestingly there is NO ASSOCIATION between manipulation and soreness. This bears out my personal experience. I have had more adverse reactions from soft tissue and strain counterstrain than from HVTs. There was also a suggestion that we collectively look at the kinds of conditions or tissues for which transient soreness is a positive step in the healing process.
There is a group which Tim is involved with having a look at the issue of prescribing rights for 10 different professions including osteopaths and chiropractors, but don’t hold your breath. This will take a while. Tim thought it could be years until implementation.
There was a mention of the leadership programme (sorry, applications closed but if you feel aspirational I think there might be another chance in the future) and also the Regional Societies Meeting. Everyone who mentionned this Regional Societies meeting seems to have found it a really positive and uplifting event, and what I gather is that basically anyone who runs any sort of osteopathic group can apply to come along and meet with other similar people running groups. Our recently formed Brighton and Hove Pain Science Group (not sure if that’s our official name) might even be eligible. Not all the groups around the country are listed and registered, but if it sounds interesting to you phone someone at GOsC or iO to get your name on their list.
iO announced that they are promoting PROMS, updating their website, and holding talks with all the final years from the OEIs (colleges, in case you’ve already forgotten).
Well, this issue isn’t going away, but it is being seen as a fairly positive opportunity for clarification. The current guidance is not very clear, there have been many anomalies and inconsistencies in the CAP copy advice (with some people being told that certain research is acceptable, and others being told that the exact same research is deemed to fall below the acceptable threshold for evidence) and collectively we need to find out what we can say that isn’t “implied efficacy”. I used to write on my website that people brought children for treatment; commonly I saw children with conditions such as asthma, colic, discomfort following injuries, headaches etc. I thought that in a court of law this would not be claiming efficacy for treating those named “conditions”, but I was wrong. What I was doing was “implying efficacy”, and is not allowed with the current threshold of evidence stipulated. How can we put the words osteopathic treatment, children and ADHD, or excessive crying, or headaches, in the same sentence without being accused of claiming that we are treating the condition? That is the question. So much depends on context and shifting thresholds, and osteopathy is such a complex health profession, that it seems that the ASA might be coming to realise that this is not as black and white as they prevously assumed. I also discovered that I am clearly not familiar with the nuances of research becase apparently effectiveness and efficacy are different things, and we have many trials showing effectiveness but not so many showing efficacy.
What NCOR itself has been up to
NCOR was present at the Royal College of Chiropractors AGM where over 200 people were present. I think NCOR even gave a well-received presentation.
Then we have the alliterative delight of PROMS, PREOS and PILARs (which they seem to pronounce Pillars).
“Evey osteopath should be promming” said Maurice Cheng. PROMS in osteopathy have got going recently, coordinated by Carol, I believe. PROMS are everywhere now in healthcare, and the letters stand for Patient Reported Outcome Measures. It is a way of generating data directly from the reports of patients. And ideally every single osteopath would do it. About 42 people have already volunteered, and this has so far generated five sets of complete data. It is not time consuming for the practitioner, the questions are short for the patient to fill in, it is a response to our critics who complain we lack good research and statistical evidence, it gives NCOR useful feedback, and could be a really easy way to get CPD points, especially when the reflective/self audit aspect kicks in, which is not long now. The patient doesn’t show their report to you, so that removes a few layers of awkwardness, fear of judgement, and bias. Click here to sign up. I don’t think they’ve got one up and running yet for paediatric patients as the design is more of a challenge.
Not many reports have gone into this system yet , which stands for Patient Reported Experiences of Osteopathic Treatment, but watch this space. Or even click on this link.
This is our profession’s attempt to have a system for reporting adverse events, and at the same time reduce feelings of isolation. (Two things that our profession has been surprisingly poor on, but both things should help our confidence and self-awareness immeasurably). Any osteopath can log onto PILARS and report any incident, realized or potential, and you will probably then get advice and supportive comments from fellow osteopaths. You can also just go there to see what other osteopaths are reporting and make helpful comments. I had need of it a few years ago, before it existed. It is private and anonymous, and even though incidents don’t happen very often in practice, we are invited to record even historical incidents for the benefit of the profession. There has been some international interest about PILARS.
Social Media – The NCOR website gets between 20 and 70 visitors a day. Not bad figures: I still have the occasional day in single figures on osteofm. 29% of views are from mobile phones. People like to look at the practitioner and research pages. The NCOR Facebook page gets a couple of new followers a day. The most popular updates get between 1000 – 3000 views. These tend to be research papers, and updates which include photos (most of which are photos of the members of NCOR!). The NCOR twitter account gains about 1 twitter follower a day.
The tweet about the job for systematic reviewer (for a systematic review of manual therapies for paediatric patients) reached 1600 people which is pretty good. There were nearly 40 applicants, and some osteopaths with no experience were considered, but in the end, as it is only part time, and for a limited period, it was thought an experienced reviewer was needed. Clare Miles, who has experience writing Cochrane Reviews, got the job. The review will be registered on PROSPERO and she has just begun. (“Prospero” seems sadly to be nothing to do with stranded dukes doing magic on stormy islands, but is more an acronym associated with a register of PROSPEctive REview PROtocols.)
There was also mention of the Centre for Reviews. A number of voluteers, including me, have offered to write some “snapshot summaries” of current research, for the benefit of osteopaths, for us all to refer to. It is a learning curve and is quite a lot of work and I need to get on with it now.
VOX POP Videos – now this sounds new and exciting, especially if you like the idea of being on screen. You can do your own 2 minute presentation about using research in clinical practice, produced for you by NCOR.
There is a donate £2 a month campaign. NCOR always needs more funds. Give less than the price of a latte a month here.
The MOCAM Study
This is the study happening at Southampon looking at non-specific effects of treatment (the bits that happen that aren’t the actual techniques/hands on treatment) by osteos, acupuncturists and physios. Slow to start signing up, the osteopaths have had a late surge and there are now more osteopaths than acupuncturists or physios being represented.
NCOR Conference – early next year
This is going to be at the start of 2017 – January or February. It should be affordable, (in the region of £100 or less for a whole day of research CPD), they are looking for speakers now (time to get in touch if you feel you have something to offer), and it might be in 2 centres, to cover the North and South of the country. Steve Vogel might be one of the speakers, talking about NICE Guidelines and Consent. The four postdoctoral students from the BSO might also be presenting on their interesting sounding subjects which include OSTEOMAP, unsettled babies and a project on e-learning and assessment of the biopsychosocial model. (The excellent course by Jerry Draper-Rodi).
There you are, I know it was long, and it is neither official nor exhaustive, but I hope you can see that there is plenty of life in research in osteopathy, with a particular focus on paediatrics right now, plus the creation of an infrastructure for feedback and support which can only raise the self-awareness of our great profession.