Edited and updated June 2016.
This has been one of the most popular blogs on osteofm.com. The most significant change is to the paragraph titled “Osteopathy needs different sort of research to standard scientific research”. I have altered this in the light of the work being done by CauseHealth.
It’s been many months since I spoke to Simon Singh on the subject of why there is not more research in osteopathy. He shot down many of my lazily held assumptions like fish in the proverbial barrel. At the time I was as confused and unsure as him about why we don’t have more studies to show to people like him. (Well, to be accurate, he‘s not confused because he’s come to a kind of Occam’s razor answer – there’s no research because it doesn’t work…doh!). I know that osteopaths see incontrovertible first hand results every day as people “get better” with our interventions – too many, and too evidently, to all be people who would have just got better anyway. Yes, amongst ourselves, we have anecdotes up to our eyeballs. Surely we just need to examine them, formally bunch them all together, subject them to analysis, and turn them into statistics. So why isn’t that happening? Or is it? For him it’s a matter of public protection, for me it’s about us getting our act together to prove something that many of us find to be self-evident, and to find ways of directing and targeting our treatments more effectively.
In response to our conversation, I tried to come up with as many reasons as I can think of why there isn’t more evidence, so we can examine them a bit more carefully.
Head in the sand
Yes that’s the first one. Research? That’s the boring bit of the osteopathy degree to many osteopaths. The dissertation in our final year? It was my favourite bit of the whole course; but I was in the minority. So we just don’t do it. Some osteopaths don’t see research as particularly important; lots of them are hands-on people who just want to get on with making people better, and being asked to scientifically justify what they do is a bit of a nuisance they ignore. Hard to understand for people with strong science-based belief systems, but true.
Fearful of a negative result
Well, I think this is what skeptics think. We won’t test our methods because we aren’t confident of a positive result and this will ruin our business. Well, speak for yourself. I believe we do good, but belief in that vague, undefined way isn’t really enough for me. I want something more to guide me. I know that skeptics don’t think indirect techniques in particular have a leg to stand on, and they also dispute that our hallmark technique, high velocity thrust, is what it’s cracked up to be (boom boom!). And they also believe that some of us are cynically marketing techniques we don’t really think work, or don’t want tested in case they don’t, because it would jeopardise our livelihood. (It is true that we do all need to pay our mortgages and feed our children.) The others, they think, are sincerely deluded, mistaking the placebo effect and regression to the mean (i.e. things that would have improved anyway) for efficacy. I obviously believe in what I do and with regard to testing it, all I can say is let’s bring it on so we can find out when and how to use osteopathy for maximum effect.
This is an interesting one, because I have long assumed this is basically the root of the problem. How many times have I explained to patients that because no drugs companies stand to gain, we don’t have millions of pounds to throw at RCTs? Well, he shot this fish straight out of the barrel. Down the phone line I heard him doing mental arithmetic out loud. Only afterwards I realised what a missed opportunity this was. A famous mathmo doing mental arithmetic OUT LOUD for my benefit. He was estimating an average osteopath’s salary as about £20,000, and then multiplying it by the number of osteopaths, ie 5,000, to make £100,000,000. Yes that’s an industry worth £100 million. I have never earnt much doing osteopathy, although I know it’s theoretically possible, but the extra money that I have earnt, I tend to have spent on courses. I love them. They are my ideal mini-break but they cost a lot. I must have spent over £10,000 on courses over my career, and that’s a conservative estimate. Osteopaths mostly don’t look like they have cash to splash, but courses costing from a few hundred pounds for a weekend to over a thousand for 4/5 days are often booked out months in advance. Yes, there is money there, but we don’t choose to spend it on research. NCOR have made over £9,000 from crowdfunding to fund a study exploring the efficacy of manual therapy for children. Most of that money was donated from abroad.
It’s a complex intervention and it’s individualized
Can you measure things easily when they’re a complex intervention? Lots of things go into a good treatment. Yes, many of the things that we find part of what makes osteopathy work (i.e. what you say to the patient, how therapeutic the environment is, how much you believe in what you do), are the very things that cause skeptics to dismiss the treatment as worthless. We both admit those things have a huge effect on the efficacy of the treatment, but that admission causes skeptics to think that there is no potency in specific treatment methods and techniques.
Osteopathy also depends very much on the individual, and what Stuart Korth calls the “alchemy” of the patient-practitioner relationship. Heard the phrase “The Doctor is the Drug”? Well I think there’s a lot in that. You need potency in some aspect of the treatment, but often patients who are extremely impressed with osteopathy have been through a few different practitioners before they find someone they like, or trust, or whose treatment works for them.
We have a guru culture, not a critical thinking culture
Yes we do have a guru culture in some aspects of osteopathy. Yes on courses we are often expected to take things on trust, because someone has been deemed by someone else before him to have attained a certain level of knowledge, in a chain stretching back to Still. And when I look up osteopathy on twitter, I see quite a bit of posting of archives from the early days of osteopathy. I tried to explain that osteopathy is so synonymous with Still, that there is a feeling that we need to preserve the purity of the direct line of transmission, individual to individual, so we don’t lose what he had. This held no water with Simon Singh. There have been great men in science – Louis Pasteur, he mentioned – but it doesn’t mean nobody subjects what he said to the test. Well, the guru culture is not totally endemic to osteopathy, and it has its problems, but I don’t think it is a wholly negative thing either. And Still is not such an authority as much of the literature would suggest. I remember in a first year lecture being clearly told that whereas Still believed that you could cure pathologies such as heart disease or hepatitis by improving function at specific spinal segments, we don’t now believe that. But skeptics still pick on it as if we do.
Many osteopaths also don’t have such a strong belief system in science. I love science, and think it’s an essential tool and it helps us understand and act in the world. And I think osteopathy needs more of it. But the Big Bang is not my creation myth, Darwin is not my prophet, and I don’t think evolution is the purpose of life. Science is not the Truth and the Light. And we find evangelical scientists can be quite difficult to communicate with as they look at the world through a scientific lens and demand that the rest of us do too. (Yes, look at Simon Singh’s profile picture on his website – he is literally looking through a lens. I won’t mention motes and beams as that could be too controversial on many fronts). Fed up with being regarded by this small but vociferous minority as dangerous liars and idiots, we can become disenchanted with the medical and scientific establishment in general. Many of us turned to osteopathy because we had personally experienced harm or lack of efficacy from orthodox medicine based on the scientific method, which made us distrust it. We found help and effective treatment in osteopathy.
Would research actually make any difference? My husband was once an Alexander Technique teacher. One of his cohort was married to a medical professor. This man, so impressed by what he saw, ran a study at Southampton University which ended up in the BMJ. It showed unequivocally that 6 sessions of Alexander Technique were effective for low back pain. Did this lead to a flood of referrals from GPs, and a stampede out of the pain clinics into the rooms of Alexander teachers? No. It didn’t. Do you recommend it to patients? Probably not as much as you recommend Pilates. Fashion has dictated that Pilates is all the rage now, regardless of the fact that recent research has shown it to be no more effective in the treatment of back pain than any other exercise. Alexander Technique trundles on the same as before, although if challenged I suppose at least they have at least a few solid stats to fend off critics.
Research is weaker than personal bias in decision making
You only have to look at the example of David Nutt, former drugs tsar, who was actually sacked for presenting evidence (which he’d been employed to provide) which conflicted with the government’s drugs policy. In Nutt’s eyes, politicians like to use research to justify decisions already made. “Any evidence that goes against that policy is quietly, or less quietly, ignored.”
I once treated an intimate relative of a minor politician, who at the time appeared only occasionally on Newsnight. Through our conversations I was very aware of the family’s medical and personal history, and their attitude towards various medical issues; everything from diet to alcoholism to vaccination. Over fifteen years I watched this politician’s steady rise to a position of huge political influence. Whenever there is a public debate on alternative medicine, I feel very reassured to know that at least some of his family are favourable towards osteopathy. Sure, scientific evidence might be one factor in decision making, but powerful lobbying from special interest groups, the need to win votes, plus one’s own personal experience and bias, will probably count mightily strongly.
Not true. There’s plenty of brain power in osteopathy.
Osteopathy is too new for research to have happened yet
I was brought down to earth with a bump by Singh’s comment “but modern medicine’s less than a hundred years old”. Ahhh…yes. You have a point. Yes osteopathy might only be recently regulated, giving it fairly new “professional” status, but it’s been around a long time. Let’s face it, it’s Victorian. What feels to us to be new and emerging and cutting edge, particularly with fields like biodynamics and pain science, looks to them like some antiquated charlatanism that is well past its sell-by date and needs chucking in the bin. No, we have had time to do research, we just haven’t had the culture.
Osteopathy needs a different type of research from the standard type of research
This is an argument that I had never truly got my head around. Standard kinds of research don’t work for osteopathy. Don’t they? If not, why not? I posed this question in the blog, not expecting to find an answer so soon. Well, I’m happy to say I have recently come across CauseHealth, who held a conference in Nottingham looking at Causation, Complexity and Evidence in Healthcare. Rani Lili Anjum, who is a philosopher, is leading the way in looking at the way the received notion of causation underpins science, and how that affects scientific research. Perhaps by examining that notion of causation, we can figure out why RCTs don’t seem to work very well for unexplained medical symptoms, including pain, fatigue and depression. Maybe instead of RCTs being at the top of the hierarchy of evidence, these symptoms need a different hierarchy of evidence. If we could put anecdotes at the top of the pyramid, why, you wouldn’t be able to move for the vast amount of evidence supporting osteopathy. If you want to understand this better, look at their website, or read my accounts of their conference here and here, so rich in ideas and information that I had to write it in two parts.
We use research from other disciplines and don’t really need special osteopathic research
Yes the boundaries between the manual therapy professions are becoming blurred, and really, if you have a problem with lots of what osteopaths do, you might as well look at physios as well because they’re doing the same kinds of techniques you don’t like us doing. And physios have faced the same demands and difficulties around EBM as we have, only they maybe got going earlier than us at meeting those challenges, and now are in a position of greater strength. But we are all striving to be more effective and safe, and thanks to Tim Berners-Lee, we are all finding it easier and easier to network and use each others’ research on the same techniques we all use.
We still don’t actually know how manual therapy , including indirect techniques (what we used to call things like cranial and functional), actually work
I tried to say to Simon Singh that we are only at the start of understanding the mechanisms of manual therapy, and that exploration is even branching into things like attention and consciousness which are “hard problems” in neuroscience. So what chance do we have of figuring out the mechanism of action? Well, another fish blown away. You don’t have to understand how it works. Skeptics don’t need to know how it works – just show it works. Look on the bright side; this might be easier to do than explain the mechanism of action.
What are we talking about? There IS evidence, and there IS a research culture developing. We were just late starters
Yes, we have people in reseach posts in educational institutions, we have NCOR, we have ongoing studies, PhDs, research hubs, outcome measuring apps to give patients, anonymous online feedback in the form of PREOS, and anonymous adverse event reporting systems. We are getting our act together, but that’s still fairly new. The infrastructure is still being developed as I write. But we are working on it. And I am amazed at the number of really bright and informed people there are in what is a relatively small profession as ours. And helpfully NCOR, at a WHO conference last year, summed the state of play up by identifying the difficulties of osteopathic research as
- complex interventions
- standardisation vs individualism
- raising research quality
So there we are. We honestly are trying.