anyway, I'm out, arguing on the internet never changed anyone's mind
What you have missed ned is that ALL spinal manipulation as practised by osteopaths and chiropractors is bad. the data is quite clear. No evidence of good, plenty evidence of harm
a physio who is doing spinal manipulation that exceeds normal movement is putting their registration at risk by using a known harmful technique. I guess the confusion is that physios will use spinal manipulation withing the normal limits of movement to stretch ligaments and muscles. An osteopath will exceed the normal limits of movements to "correct dislocations / subluxations" which apart from being baloney is harmful
So the difference between what an osteopath and a physio will do is about the normal limits of movement. An osteopath will exceed this and that is where the danger lies, a physio will not exceed the normal limits of movement thus causes no harm
Evidence based practice!
The reason I have such strong views on this is I understand the basics of medicine and I hate charlatans who prey on the credulous. Its not so bad when its crystals or homeopathy but osteopathy with is potential for serious harm needs to be countered.
How, given the above, do you arrive at such a strongly held opinion that a) there is a special type of Osteo SMT, b) that this type is universally bad, and c) the type of SMT that Physios do can be recommended without hesitation?
I expect the difference is that physios do spinal treatments for spinal issues rather than because you've got a cold.
In any case, there's increasing pressure* within the profession for them to stop doing it, because of the risks and because it encourages and validates things like chiropractic.
(* - sorry)
you seem to be lumping all spinal manipulation together
Not me. TJ's trying to make a distinction based on "the evidence", and "the evidence" he links to makes no such distinction. There's no basis for his position in there. The studies lump them all together. Where distinctions are made, there are certainly no osteo bad/ physio/good.
I've just been responding to TJ being a dick about the side he's picked, trying and failing to back it up with selective reading, sloppy thinking and sloppy arguments. And whatt some guy said 130 years ago.
Anyhoo, til the next time!
As someone who cracks his neck a lot (it feels a relief when I do it plus I think it may be a ‘stim’ for me) this thread has made me realise the stroke risk. It’s going to be a hard habit to break 😣
Where distinctions are made, there are certainly no osteo bad/ physio/good.
SMT bad, whether it's done by an osteopath, a chiropractor, a physiotherapist or a used car salesman. It's efficacy is at best debatable, certainly when compared to other treatments, and the risk vs potential reward is too high.
I found this, from March:
https://www.bmj.com/content/364/bmj.l689
which concludes (emphasis mine), "SMT produces similar effects to recommended therapies for chronic low back pain, whereas SMT seems to be better than non-recommended interventions for improvement in function in the short term. Clinicians should inform their patients of the potential risks of adverse events associated with SMT."
... and a 'rapid response' to this study here:
"In conclusion, these results demonstrate no convincing evidence for the superiority of SMT over sham SMT, and a lack of clinically important benefit of SMT when compared with any other treatment. The lack of a benefit of SMT over sham therapy indicates that SMT is unlikely to have any direct benefits and observed improvements are the result of contextual and other effects. It is likely that the apparent equivalence with both ‘recommended’ and ‘non-recommended’ therapies tells us more about the disappointing effectiveness of those approaches than it does about the benefit of SMT."
TL;DR - spines are delicate things, leave them alone.
Flippin' heck. Go on then.
What you have missed ned is that ALL spinal manipulation as practised by osteopaths and chiropractors is bad
Can you please show me the parts I've missed that show this?
I've taken great pains to read and analyse what you've linked to, I've quoted, summarised what I've felt are the salient points (all of which you seem to ignored). And believe me, I've looked hard for evidence of the conclusion you've reached above, because I'd have been quite happy to hold my hands up and accept that evidence if it was there.
But I've not found it.
Have you?
Where is it?
The reason I have such strong views on this is I understand the basics of medicine and I hate charlatans who prey on the credulous.
Not because you love a good argument then! 😀
Ned - I gave the explanation. the differnce is physio techniques do not eceed the normal limits of movement, osteopathic does. One is safe, one is not.
A physio using osteopathic treatments is not practicing physiotherapy and is putting their registration as a physio in danger by doing so. They would have no defense in a professional misconduct hearing as they are acting outside of their training
I linked to that piece to show the evidence of harm and the lack of evidence of benefit of this technique
Evidence based practice. the evidence is clear. Osteopathic spinal manipulation techniques do no good and do harm.
Now go on seeing as you believe that osteopaths can do good - find some evidence to back you up
I found this, from March:
keep up, we've been arguing about that one since tj linked to it on page 1!
Ned - its states it clearly You even quoted it
“The body of evidence, which includes data from large, prospective observational studies of SMT[again – no distinction for type or practitioner] , suggests that benign adverse events are common and serious adverse events are rare.
What you fail to understand is the difference - physio treatments do not exceed the normal limits of movement, osteopathic does.
A "physio" who uses osteopathic techniques by going beyond the normal limits of movement is not practicing physiotherapy as they are trained to do
I saw a shamster at a show the other day offering this:
www.eurotherapy.org.uk/
He even looked like the spiv out of Dad's army which ought to be a clue. Old ladies loved it though, they were queuing up to hand their cash over.
Ned – I gave the explanation. the difference is physio techniques do not exceed the normal limits of movement, osteopathic does.
Can you show me the evidence for this difference existing in any of the studies you linked to?
The different types of SMT referred to are HVLA and LVLA. All "Low amplitude". If there was a difference in how far the movements were pushed, there would be High Amplitude, surely? But no. No mention of any difference worth categorising in the amplitude of movements in different types of SMT used by differrent practitioners.
I'm quite happy to hold my hands up and admit if I've missed something, but you've got to help me find it!
its not in those studies. Its just basic stuff. What that study includes is people who are physiotherapists who are using techniques that are not physiotherapy. Neither HVLA and LVLA.are physiotherapy! NO spinal manipulation of that type is physiotherapy. Anything that takes it outside of normal movement is not physiotherapy.
its not in those studies. Its just basic stuff.
Righto. If that's all you've got, then I'm definitely out.
There's a good reply on that Guardian link, above:
"This piece does not, perhaps, convey adequately the fact that there is a wide range of beliefs among osteopaths. The best of them are indistinguishable form physiotherapists (indeed they may be better than that subgroup of physiotherapists who think that sticking pins into patients is a good idea). At the other extreme, there is utterly barmy "cranial ostepathy", an entirely bogus form of treatment for which there is not a jot of evidence."
... neatly dispelling all the anecdotal "evidence" in favour of one over another.
Ned - its in some of the stuff linked to. Thats the difference. Osteopaths can use physio techniques and some physios may use osteopathic techniques. Its the technique that matters not the label of the practitioner. Spinal manipulation that goes outside of normal range of movements is not physio.
So the study you were looking at which includes physios is physios using techniques that actually are osteopathic hence no difference found in outcomes
Osteopaths are gentler than Chiropractors
Thanks Cougar, that's pretty much exactly what I said on page 1. And what our contributing osteopath said too.
What yo have missed again is that anecdote is not evidence! hence cougars inverted commas.
Now - the evidence of osteopathy doing good? found any yet?
It doesn't matter who is doing the spinal manipulation - its wrong, has no evidence base and can be harmful.
Spinal manipulation as described and as the term is used in these studies is not a physiotherapy technique even tho some "physiotherapists" may use spinal manipulation.
I am a nurse. I could do a one year course in spinal manipulation and perform it on the public. However I would not be acting as a nurse if I did so!
and I suppose it is so easy to run a trial with actual spinal manipulation versus placebo spinal manipulation - how would you do the latter ?
they did sham spinal manipulation but of course you cannot do a double blind study - using a sham technique would only be single blind
so how do you obtain meaningful trial data ?
TJ where is the evidence that your evidence based information is in fact based on evidence that is evident and fulfills the evidential requirements of evidence based practice that eventually evidences to this evidence dependent forum that the specific submitted evidence fulfills the requirements of such evidence upon which we will peer review your expected evidence in the context of your non verified evidence based information around evidence based practice.
With great difficulty Turnerguy. all yo can do is look at the data you obtain, use single blind or cohort studies / longitudinal and accept the limitations of the data - like the metastudy I linked to. However whenj yo have enough data points adn the data is heavily weighted in one direct what the evidence indicates is obvious. As it is.
D Faff - my head just exploded!
Tell us all about the time you got the arm issue sorted Tj
Which evidence based practitioner did that for you again ?
The osteo I use was, up until not that long ago, employed as an osteo by the NHS at a London hospital. Confusing isn't it!
TJ the evidence did suggest that such an outcome was likely 😉
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using a sham technique would only be single blind
And one would assume, inherently risky?
Osteopaths can use physio techniques and some physios may use osteopathic techniques. Its the technique that matters not the label of the practitioner. Spinal manipulation that goes outside of normal range of movements is not physio.
And this possibly explains some of the (mis)interpretation on the thread. Saying "Osteopaths are charlatans" (label of the practitioner) instead of "certain osteopathic techniques have no evidence base and can cause harm" (it's the technique that matters).
I've seen a osteopath a few times, and they've helped greatly. They didn't do anything a physio wouldn't have done - all just massage and gentle movements, combined with some good questioning and advice that help identify the causes of the issues and ways of fixing them.
I also doubt whether the clicking and thrusting and cranial has any measurable benefit, and I've always thought it potentially dangerous.
And this possibly explains some of the (mis)interpretation on the thread. Saying “Osteopaths are charlatans” (label of the practitioner) instead of “certain osteopathic techniques have no evidence base and can cause harm” (it’s the technique that matters).
Thats probably air enough. they are not really practicing as osteopaths then are they? Can't claim to be a physio without the training and registration.
But yes - its the technique not the label that counts
but physiotherapists do spinal manipulation, and 'cracking' too...
https://www.physio-pedia.com/Spinal_Manipulation
...I’ve seen a osteopath a few times, and they’ve helped greatly. They didn’t do anything a physio wouldn’t have done – ...
Osteopathy as a field that tries to associate itself with healthcare is a sham, and thus those who choose to practice under its banner are open to scorn.
If they want to practise 'physio techniques' then they should become physios.
I’ve had loads of problems over the years. I’ve regularly seen two physios, an Osteo and currently a sports masseuse. They all have used very similar techniques. Only people to have tried manipulation have been the physios.
Turnerguy - if they do they are not practicing physiotherapy and could lose their registration for doing so given the proof it does not work and that its dangerous.
However see Beejs comments above - it doesn't matter what they call themselves its the techniques that count. spinal manipulation and cracking are inneffective and dangerous - this is a fact well proven.
From the body that maintains the registration of physiotherapists
Registrant physiotherapists must:
1. be able to practise safely and effectively within their scope of practice
So if they are doing spinal manipulation and bone cracking osteopathic type they have breached this
http://www.hcpc-uk.co.uk/standards/standards-of-proficiency/physiotherapists/
The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the UK's 58,000 chartered physiotherapists, physiotherapy students and support workers.
Here's a course they offer in Spinal Manipulation.
https://www.csp.org.uk/event/complete-manipulation-course-2-days
tj, you've put things in very firm boxes which don't reflect reality: that if an osteopath isn't doing SMT, they're not being an osteopath, and that if a physiotherapist is using SMT, they're either using the good type which isn't SMT, or they're not being a physiotherapist and risk being struck off.
You've made up a distinction between what a physio calls Spinal Manipulation and "osteo" SM which doesn't exist in reality. There's a broad range of SMT techniques and none of the descriptions in the literature talk about this "normal range of movement" you've decided upon. What would normal mean anyway? It's passive or physiological.
The evidence suggests that SMT is of marginal benefit, but then so are the alternatives (drugs, exercise...). So it remains in the toolbox for many professionals, including physios, with caveats about when and when not to use it, given the possiblity of harm and probability of success.
If you go and see a physio or an osteopath with a spinal problem, there's a good chance they'll use some SMT techniques in their treatment, depending on their personal preference and feelings based on their background, personality and professional development.
Whoever you're seeing, ask them about their personal approach to SMT, and if you're not 100% sure, decide between you what's "out of bounds" for treatment, or find someone else.
And it's a good idea to go on recommendation, even though all recommendations are worthless because they're just anecdotes.
Generally, if you adopt a binary, black and white position with no room for grey, you're going to be wrong.
Dr Andrew Leaver, Senior Lecturer in Physiotherapy at the University of Sydney, points out, evidence-based practice is "not a black and white proposition".
"True evidence-based practice is using the best available evidence that you have, and the best available evidence for any intervention is sometimes not that good," Dr Leaver said.
"We don't have robust clinical trials that prove the efficacy of every single thing that we do, but neither does any profession — a lot of medicine is not backed up by robust randomised controlled trials."
I had osteo - maybe the final one - yesterday and here’s what he did for a knotted trap/neck situation
a) cracked my neck vertically, and spine between my shoulder blades
b) manipulated and massaged the knots around my trapezius
c) cracked my neck whilst lying, in a R/H direction (my issue is on the left side)
d) more massage.
I was a year at the physio prior with sports massage and dry needling and I’ve been 8 months with the osteo Both have said it’s a chronic issue and I need to stop cycling for 6months to a year to resolve it, or face continual remedial efforts at undoing the damage from riding and races
The both seem “right”, the results are slightly not as good with the Osteo in terms of short term pain relief. Who to stick with - no idea...
People are getting aerated about this aren’t they!
A few points:
Risk - my annual professional indemnity insurance is circa £270, this means that the chance of me needing it is low. There are risks associated with all interventions, ask a surgeon or anaesthetist what there premiums are.
Treatment - when I trained the definition of osteopathic treatment was ‘treatment provided by an osteopath’. You need to be competent in using your chosen technique, but it is not limited to HVLA manipulation. I use various techniques, including (occasionally) HVLA thrusts, probably the most useful element of what I do in the longer term is offer advice about how to help recovery and reduce the chance of recurrence in the future. Different patients get different treatment, dependent on the nature of their problem and what is appropriate and safe for that individual.
Manipulation - there were pictures in the library where I trained of a chap called Cyriax (a physio IIRC) doing the kind of manipulation described by tj, it was universally felt to be unacceptable then. We were taught that the correct way to manipulate was to create tension using a variety of levers and apply pressure within the physiological range of the joint. Not just ‘take it as far as it can go & then force it further’.
@Kryton53 you are asking the symptomatic area to do more than it can manage, you need to alter what you are asking it to do &/or make it more able to cope with the demands placed on it. Looking at a combination of your strength, flexibility and movement patterns should help.
Guys - there is NO evidence base for spinal manipulation - none at all.
Go on - two osteos have poked their heads above the parapet. I thank you for that.
Your quote about evidence practice is irrelevant - the evidence for spinal manipulation is very clear.
So let me see the evidence for it working because all the evidence I have seen works one way only - its does no good and its dangerous. and given conditions of registration for spinal manipulation then any registerd physiotherapist using it does indeed risk being struck off - as I would if I used nursing treatments from 100 years ago which are proven to have no use and to be harmful
I linked to a major meta study earlier that shows spinal manipulation does no significant good and can do significant harm. given that is the best evidence we have then how can anyone no matter their label perform this?