Serendipitously, just after I had joined Twitter and was considering writing about osteopathy, a tweet appeared that Edzard Ernst would be giving a talk in Eastbourne to a local sceptics’ society. Now Ernst was the first ever Professor of Complementary Medicine, at Exeter University. He is pretty down on osteopathy, and I remember the day that his work was quoted all over the mainstream news. It was along the lines that osteopathy had been shown not only to be ineffective, but to be harmful. Needless to say, since then osteopathy has also been pretty down on him. But he has nevertheless always intrigued me. This was a chance to see the whites of the eyes of the man himself. Simon Singh urged CAM therapists to attend the talk, I guess in they hope that when faced with the incontrovertible evidence that the stats don’t support us, we will see sense and realise the error of our ways; another small step in their quest towards eliminating dangerous foolishness from the world. Whatever their motive, they are certainly full of confidence that they are right, and only want the chance to explain their rightness to open-minded CAM (complementary and alternative medical) therapists. I sincerely do appreciate their openness and welcoming attitude.
I duly turned up, on a quite beautiful Summer evening, to a civilized group of people drinking bottled beers, soft drinks and lattes on an upper floor in a contemporary art gallery. Despite the open invitation, I still felt in enemy camp, and slunk in fairly late so as to avoid engaging with anyone before the talk. A few people were taking photos of the stunning view from the balcony. I counted six or seven church spires, elegantly punctuating the balmy blue sky; slender vertical connections with the softly rolling downs. The talk was titled “A Scientist in Wonderland”, being also the title of Ernst’s autobiography. A great phrase that pretty much sums up the situation: two different worlds, one making no sense to the other. Could Edzard Ernst say anything in the next couple of hours to persuade me to see my job, or even those church spires, through a different lens?
In the event it was not the clash of world views that I anticipated. Ernst was a twinkly and avuncular man, dressed informally in a polo shirt and speaking in warm, low tones with a native German accent. He did not appear angry and bombastic, as I had expected. He began by disabusing us of the notion that he had ever set out to discredit alternative therapies. Indeed, as a young man he studied psychology before switching to medicine and after graduating, his first job was in a homeopathic hospital in Germany. Yes, you read that right. He was quite enthused about homeopathy, in fact. As his career progressed, he practised as a clinician in other hospitals, including stints in Vienna and London, but he found his true home in research. He then applied for this Professorship of Complementary Medicine due to his background in, and indeed his interest in, alternative medicine. In his mission statement he said that his intention was to “further analytical training in this area”. He says he did not consciously set out to be a debunker.
E Ernst has in fact recommended numerous alternative therapies to the NHS
He had a keen and productive research unit which included doctors, nurses, psychologists and pharmacologists. They looked at 38 different therapies. I didn’t see cranial in the list but osteopathy was there. They enthusiastically targeted the four that they thought looked the most promising, which were acupuncture, homeopathy, chiropractic and herbal medicine. He says it was a shock to him to find that of over 1000 papers and 300 systematic reviews that were produced, only about 5% turned out to have positive conclusions. He was sketched in a national newspaper, with the caption “Quackbuster”. He liked the drawing, but not the label. He says he was not anti-alternative, but rather pro-science. Maybe to counter the accusation, he recommended the NHS fund twenty different alternative treatments in a paper in the British Journal of General Medicine: Complementary and Alternative Medicine: What the NHS should be funding. If you want to cut to the chase, here is the table showing Treatments which demonstrably generate more good than harm. Quite a few are herbal remedies. He regards St John’s Wort as the “Emperor” of Alternative Treatments. He thinks it’s “wonderful” for mild to moderate depression. He also recommends melatonin for insomnia and hypnosis for labour pain, two things which have worked amazingly well for me. He approves massage for anxiety – well I use lots of massage in my treatments, and always have, it seems to have a multitude of benefits – physical and emotional. I’ve already made a mental note to look out for red clover when I go through the menopause. Nothing to disagree with so far.
But to my interest, and to be honest, mild discomfort, the focus of the talk then turned to chiropractic. (As far as EE is concerned, the debate about homeopathy is over. It’s a dead duck and he is presumably sick to the back teeth of talking about it). Osteopathy was referred to in passing as the lesser of two evils (“osteopaths practise a milder form of manipulation”). Well, I was just grateful that it was chiropractic getting it in the neck, and not osteopathy. And yes, that pun was totally intended. He sketched the early history of chiropractic, informing us that D.D. Palmer claimed that he cured a janitor of deafness by manipulation, and then cured someone’s heart problem with chiropractic, but that he did not even mention back pain during the first 20 years of the profession. He seemed to imply that D.D. Palmer’s son B.J. Palmer was so ambitious to take over the chiropractic enterprise that he either directly killed his father or hastened his death in some way. (Skeptics often imply that the love of money is at the root of all CAM therapies, but they clearly know a more affluent set of therapists than I do.). Ernst then got into the nitty-gritty of his issues with chiropractic as practised today. His unit looked at over 600 clinical trials testing the efficacy of spinal manipulation , and discovered that, for mechanical neck disorder,
Done alone, manipulation and/or mobilisation were not beneficial; when compared to one another, neither was superior.
Now I was extremely pleased to see this. Not a great fan of manipulation, I find it of pretty limited value in practice. It has a place, for sure, but there’s no way I could get most people out of pain if I relied on HVT alone. So with those two little words at the start – “Done alone”- I felt validated. I even appreciated the equal ranking given to mobilization and manipulation, albeit in a negative context.
For chronic low back pain,
spinal manipulation achieved a small, significant but not clinically relevant short-term effect.
In chronic pain patients, I do sometimes use HVT, but yes I agree I often find it a very short-term solution, and aside from the odd exceptional case, useless on its own. I often use it just to give some immediate symptomatic relief, but I don’t expect it to sort out persistent pain for long. If the patient requires several treatments I end up phasing it out in favour of things that work better and last longer. So this resonated with me entirely.
For acute low back pain
spinal manipulative therapy was not more effective than either sham spinal manipulative therapy or inert interventions.
I’ve personally never found HVT my treatment of choice in acute situations, even though it is what many patients want (and ask for). My experience was validated by the research yet again!
I found myself agreeing with every word Ernst said, with something of a sigh of relief. No longer do I have to feel inferior to those alpha manipulators who can click any joint of the body with ease. There’s a lot more to it than that, and these studies prove it. I can’t remember the last time I actually clicked a neck. I used to do it a lot when I entered practice, because it was easy – so much easier than thoracic and lumbar thrusts. (Don’t even get me started on sacro-iliacs and ribs). But I took fright when I began to hear occasional stories about strokes, and once I gave it up I found that I could easily get the same results without it. Ernst went on to give us more trial results: chiropractic is ineffective for dysmenorrhea, colic, asthma, otitis media, fibromyalgia or hypertension. Now I have always found that there is a lack of clarity and consistency in the terminology in this field which has somewhat muddied any research results. Ernst seemed to be using chiropractic and manipulation as virtually synonymous terms. Does chiropractic treatment always mean manipulation? Come to that, does “manipulation” in these studies always mean HVT? Surely no one was treating colicky babies with HVTs? And surely nobody really would expect or claim to treat hypertension with spinal clicks on their own?
Ernst explains the risks of CAM therapies, as he sees it
Whilst Ernst thinks that many alternative treatments and remedies are ineffective, he acknowledges that they are often harmless in themselves and can be pleasant experiences. His concern with this category is the indirect risk that people with serious conditions might be dissuaded from using effective treatments in favour of new age nonsense e.g. treating cancer with Carol Vorderman’s detox diet. However HVT has direct risks. He said that 50% of treatments give mild to moderate side effects: not a problem if the treatment is effective, but pointless if it is not. He also had a figure that there have been 700 adverse events, including 100 deaths, from spinal manipulation. Mostly this is due to vertebral artery dissection causing strokes. I’m not sure if this is a global figure across all time from all therapies, but in any case he thinks that there is “monstrous” under reporting of these incidents. This is probably true. Hopefully osteopaths will soon start to use PILARS more often, to routinely record any adverse event. Because we need to know this stuff. We have an obligation to inform our patients of risks. We can’t do that until we know by informing ourselves, as a body. Ernst believes that chiropractors are disingenuous about the risks. He says they are fond of using the statistic that there is less than a one in a million chance of a major adverse event from chiropractic compared to 53 in a million from opiod use, 153 in a million from NSAIDS and aspirin, and 1800 per million from surgery. While this one in a million statistic (which is speculative anyway) would seem to be putting the risk into perspective, it is the lack of research showing a clear and obvious benefit from manipulation that drives Ernst to campaign against it. In the risk-benefit analysis, he says, there must be a benefit to justify the risk. And he doesn’t believe there is one.
In the end, I found this a fascinating talk. Edzard was really engaging. I applaud his determination to stand up for the truth as he sees it, regardless of the consequences. But I didn’t come away totally disillusioned with my day job, rather my suspicions that HVT was hugely overrated and not really what ostoepathy should be about were confirmed. I had already become disillusioned with HVT as a panacea for all ills before I even graduated from my osteopathy college. And I am not alone. Osteopathy does not = spinal manipulation to many osteopaths. It is just a technique, not even in everyone’s repertoire. But here we come up against the perennial problem of the definition and identity of osteopathy, and how we are perceived by the public. Even after 20 years as an osteopath I found myself embarrassingly struck dumb the other day when my dental hygienist asked, what do osteopaths do? If manipulation does not define us and distinguish us from any other manual therapist (many of whom manipulate too), what does? Is it our skill level, our palpation, our values, our ability to treat patients on many levels, our different way of viewing the patient, or interacting with the patient? A period of self-scrutiny seems called for, along with up-skilling and a level-headed look at the safety and efficacy of HVT.