FAQs www.ncor.org.uk

Questions What is osteopathy? Does osteopathy work? Is it safe? Is it better than other ‘treatments’?

What is osteopathy?

What is osteopathy? Osteopathic International Alliance take two pages in the WHO report to describe osteopathy and osteopaths 2 types: Osteopathic Physicians Osteopaths

What is osteopathy? Osteopathy means different things to different people If osteopaths can’t define osteopathy they should at least be able to describe what they do

What is osteopathy? Standardised data collection survey and clinical audit (2009) In the UK there are just over 5,000 registered osteopaths, 9% responded. ref: www.ncor.org.uk/audit

Survey results Osteopathic patients are: ~56% female most are treated for low back pain 36% 51% have acute pain, 15% sub-acute and 31% chronic

Survey results - Soft tissue manipulation (78%), - Articulation (73%), Most commonly used treatments are: - Soft tissue manipulation (78%), - Articulation (73%), - HVT (38%), - Cranial osteopathic techniques (26%), - MET (18%) - Functional (14%)

What is osteopathy? It is a multi-component complex intervention delivered by health care practitioners in primary care The components of osteopathy are combined and delivered as a package of care in a consultation and can include:

What is osteopathy? A case history Examination Discussion of findings Discussion of treatment and care plan Consent Manual therapy Health care advice Self-management support Listening and talking (psychosocial care) We need to decide on the generalisability of research. Just because it may not be ‘osteopathy’ it does not mean that the research is not relevant. Of course different people may have different views and answers to these questions. Osteopathy is a small profession in the big wide world of health care. In reality there is not much research done by osteopaths for osteopaths Osteopathy from a research perspective Osteopathy is a complex intervention which includes many components, we need to be able to appraise how relevant other research is to our profession and practice and the treatment we provide for treating certain conditions such as neck or lower back pain services Lets consider the largest RCT done in the UK, the UK BEAM trial.

Questions What is osteopathy? Does osteopathy work? Is it safe? Is it better than other ‘treatments’? In the second part of the presentation we will review the research that over the last few years NCOR (with the GOSC) has facilitated. NCOR has gathered and produced some really important research, about evidence and risk. I will present a quick round up of this to illustrate how research can be applied to everyday practice Finally I shall talk a little about the future.

Does osteopathy work? Question a bit like asking: Is BREXIT a good idea? Does surgery work? Questions are too big: Work for whom work, for what condition, when and for how long ?

‘Osteopathic’ research ? Osteopathic research done by osteopaths for osteopaths? Any research done by other musculoskeletal health professionals? Shared techniques, shared research? We need to decide on the generalisability of research. Just because it may not be ‘osteopathy’ it does not mean that the research is not relevant. Of course different people may have different views and answers to these questions. Osteopathy is a small profession in the big wide world of health care. In reality there is not much research done by osteopaths for osteopaths Osteopathy is a complex intervention which includes many components, we need to be able to appraise how relevant other research is to our profession and practice and the treatment we provide for treating certain conditions such as neck or lower back pain services Lets consider the largest RCT done in the UK, the UK BEAM trial.

Does osteopathy work? We can only answer this when we can define osteopathy but in reality we focus on: Techniques e.g. HVT Conditions e.g. Low back pain We need to decide on the generalisability of research. Just because it may not be ‘osteopathy’ it does not mean that the research is not relevant. Of course different people may have different views and answers to these questions. Osteopathy is a small profession in the big wide world of health care. In reality there is not much research done by osteopaths for osteopaths Osteopathy is a complex intervention which includes many components, we need to be able to appraise how relevant other research is to our profession and practice and the treatment we provide for treating certain conditions such as neck or lower back pain services Lets consider the largest RCT done in the UK, the UK BEAM trial.

Evidence

Evidence Effectiveness of ‘osteopathy’ (for what)? Effectiveness of techniques used by osteopaths Effectiveness of techniques for conditions? What benefits are important to patients? We still have some questions before we start searching for evidence

Effectiveness data Systematic reviews Randomised controlled trials Prospective cohort studies Guidelines compiled for managing musculoskeletal conditions Particularly relevant are these types of studies and these inform the development of guidelines which consider all forms of research for managing musculoskeeltal conditions

Guidelines UK NICE Guidelines for Low back pain and sciatica (2016) Recommend the use of manual therapy (including osteopathy) as part of a package of care.

Rationale for recommendation of manual / physical therapy for: Low back pain Examples of evidence (http://www.ncor.org.uk/research/evidence-for-osteopathy/)

Date Authors Type of study Evidence for: 2012 Rubinstein et al SR 26 RCTs 6070 people SMT is as effective as other common therapies for chronic low back pain and safe 20 RCTs 2674 people Evidence was low quality showed little effect for those with acute low back pain but it is safe Furlan et al 10 RCTS SMT and mobilisation were superior to no treatment and placebos for low back pain 2013 Licciardone et al RCT 455 people OMT patients significantly better outcomes than sham OMT and ultrasound for chronic low back pain Von Heymann et al 100 people SMT treatment effects greater than placebo and diclofenac for acute low back pain 2004 UK BEAM trial team 1334 people Manipulation package showed sustained beneficial outcomes at after 3 and 12 months

FOR EXAMPLE: BEAM 4 arm trial, ~330 people each arm total recruited 1334 GP care, exercise, manipulation and exercise (private and NHS), manipulation (private and NHS). This trial involved osteopaths, physios and chiropractors. The results were hugely important to each profession it was the biggest trial at the time provided robust statistical evidence that manipulation had a positive beneficial effect for those with sub acute and chronic low back pain. UK BEAM trial helped inform UK NICE Guidelines (National Institute for Clinical Excellence) that recommended the use of manipulative treatment for persisting low back pain. ‘Consider offering a course of manual therapy including spinal manipulation, comprising up to a maximum of nine sessions over a period of up to 12 weeks.’ These guidelines have helped osteopathy achieve better recognition in the wider health care community. Good collaborative bit of research usefull for all musculoskeletal professions

Rationale for recommendation of manual / physical therapy for: Neck pain Examples of evidence

Date Authors Type of study Evidence for: 2012 Posadzki & Ernst SR 5 RCTs 348 people SMT more effective than drug therapy, placebo, usual care and no treatment for tension type headache Vincent et al 27 RCTs MT contributes to improved pain and function in adults with non-specific neck pain. 2010 Gross et al 17 RCTs Positive evidence for SMT and mobilisation and exercise for improving neck pain 2009 Hurwitz et al 30 SRs Manual therapy and exercise are more effective than alternative strategies for patients with neck pain 2004 Bronfort et al 22 RCTs SM may be an effective treatment option with a short term effect similar to amytryptiline for migraine. For cervicogenic headache neck exercise and SMT effective in short and long term

Summary of evidence Growing body of evidence Evidence base is positive Quality of evidence is getting better NCOR website for up to date information http://www.ncor.org.uk/wp-content/uploads/2013/06/Table-of-evidence-for-manual-therapy.pdf What NCOR / GOSC did was instigate 4 projects from 2007 onwards: A systematic review of adverse events in manual therapy Communicating risk and obtaining consent in osteopathic practice Insurance claim trends and patient complaints to the osteopathic regulator 4) Prospective cohort study to investigate osteopaths' attitudes to managing and assessing risk in clinical settings and patients' experiences and responses to osteopathic treatment.

Questions What is osteopathy? Does osteopathy work? Is osteopathy safe? Is it better than other ‘treatments’? In the second part of the presentation we will review the research that over the last few years NCOR (with the GOSC) has facilitated. NCOR has gathered and produced some really important research, about evidence and risk. I will present a quick round up of this to illustrate how research can be applied to everyday practice Finally I shall talk a little about the future.

Evidence about risk

Evidence of risk Adverse events and patient incidences in manual therapy Why research this? Read and go to next slide which considers why

Why research this? Understanding risk and types of risk Clinical decision making Comparison with other health care providers Patient informed consent What NCOR / GOSC did was instigate 4 projects from 2007 onwards: A systematic review of adverse events in manual therapy Communicating risk and obtaining consent in osteopathic practice Insurance claim trends and patient complaints to the osteopathic regulator 4) Prospective cohort study to investigate osteopaths' attitudes to managing and assessing risk in clinical settings and patients' experiences and responses to osteopathic treatment.

Clinical Risk in osteopathy and management S. Vogel et al. July 2012 http://www.ncor.org.uk/wp-content/uploads/2012/10/croam Here I will just report the findings from the systemic review that was conducted into adverse events in manual therapy. This was the first of the series of adverse events projects commissioned by the GOSC and facilitated via NCOR This review was conducted in 2008/9 and published in 2010, and even now some of this data can be updated as you will see later in conference

Here I will just report the findings from the systemic review that was conducted into adverse events in manual therapy. This was the first of the series of adverse events projects commissioned by the GOSC and facilitated via NCOR This review was conducted in 2008/9 and published in 2010, and even now some of this data can be updated as you will see later in conference

Our initial searches yielded nearly 20,000 potentially relevant articles. Fortunately after sifting and scrutiny using our exclusion and inclusion criteria we selected 60 papers containing original research about manual therapies and adverse events, we found 36 trials of manual therapy that reported data on adverse events and we analysed data from 9 prospective cohort studies.

Adverse events in manual therapy: findings Major/serious adverse events are rare We estimate 1 vascular insult per 50,000 patients or per100,000 cervical manipulations (Carnes et al 2009) Those likely to have a CVA are likely to seek treatment prior to the accident due to the nature of the symptoms (Cassidy et al 2008) Serious adverse events are: Death Unresolving Requiring further care

Adverse events in manual therapy: findings Minor adverse events are common ~46% of all patients after MT treatment Most minor and moderate adverse events resolve within 48 hours Adverse events are most likely to be reported after the first treatment

Summary There is good evidence of beneficial effects for techniques used by osteopaths particularly manipulation The techniques used by osteopaths have low risk of serious incidents associated with them. We need to do more large scale research Perhaps this should be a research priority

Questions What is osteopathy? Does osteopathy work? Is osteopathy safe? Is osteopathy better than other ‘treatments’? In the second part of the presentation we will review the research that over the last few years NCOR (with the GOSC) has facilitated. NCOR has gathered and produced some really important research, about evidence and risk. I will present a quick round up of this to illustrate how research can be applied to everyday practice Finally I shall talk a little about the future.

Is osteopathy better than other treatments? For what ? For whom? And when?

Acknowledging limitations of practice Seeking informed consent Advising patients about alternatives Patient choice Different communities e.g. Osteopaths, special interest groups, the public

Acknowledging limitations of practice Acknowledging lack of knowledge There are many unknowns in the medical profession Communicating effectively and eloquently is part of being an osteopath Different communities e.g. Osteopaths, special interest groups, the public

Making research accessible and relevant so it can be easily used www.ncor.org.uk