Every year, I’m an invited lecturer at the University of Ottawa to talk to future science communicators about pseudoscience. I use a number of increasingly muddied examples to show these students that there is no clear demarcation between science and pseudoscience; rather, it’s a spectrum, and figuring out where something lies can be tricky.
Osteopathy is one of these muddy examples that are hard to position on that spectrum, in my opinion. Is it a fake science? Is it a science in the making? Is it, by now, an “unpromising project,” a label philosopher of science Paul Thagard said could have been attached to astrology before it became clear it was pseudoscientific?
Like the alien creature in John Carpenter’s The Thing, osteopathy is a shape-shifting animal that can look outrageous in some contexts but perfectly respectable in others. Questioning the validity of osteopathy pulls us into the debate over which healthcare professions borne out of simplistic ideas deserve to be salvaged, especially given our poor track record of addressing a serious problem: chronic pain.
Plumbing the depths of the human body
Osteopathy can be traced back to 1873. It was devised by Dr. Andrew Taylor Still in Missouri, and the first college of osteopathy was opened in that state 17 years later by Still and Dr. William Smith.
To try to define what osteopathy is is akin to grabbing a wet fish. Definitions tend to be vague, even those coming out of official bodies. Like so many alternatives to medicine, osteopathy focuses on an imagined boogeyman. Diseases and their symptoms are thought to originate from the impaired movement of muscles, bones, tendons, or ligaments. These blockages can allegedly be felt by the osteopath by touching their client’s body and treated by manipulating muscles, limbs, joints, and especially the fascia, the web of connective tissue that envelops our muscles and organs. This manual intervention is said to “help the body heal itself,” a phrase often used by those who market unproven health interventions as a way to get around making the illegal claim that they can treat or cure diseases.
If osteopathy so far sounds like chiropractic, there’s a good reason. D.D. Palmer, the spiritual magnetic healer who came up with chiropractic, was a contemporary of Andrew Still’s and he trained in osteopathy. The osteopathic lesion, blamed for all ills, became the chiropractic subluxation, which also echoes the blockage of qi in acupuncture. Before biology informed us of the complexities of the human body, many gurus imagined that all diseases were due to blockages that could be resolved using a single intervention. The body was tubing, and healers were plumbers. This turned out to be very wrong.
1873, however, was a long time ago. Medicine’s own growing pains were accompanied by a belief in humours and an overreliance on leeches. Osteopathy has changed over the decades and many of its claims have been tested. But the scientific literature on osteopathic interventions reveals many rotten branches and a core that has been poorly studied.
A gut feeling about skullduggery
Just like acupuncture eventually spawned ear acupuncture, osteopathy has strange children of its own. In the 1980s, French osteopaths came up with the concept of visceral osteopathy. The organs of our abdomen—like the stomach, liver, and small and large intestines—naturally move about a little, for example when we breathe. If their mobility were impaired, might this not trigger gastrointestinal or even musculoskeletal problems? These French osteopaths thought so. But a group of researchers combed the scientific literature in 2018 to see what happens when the accuracy of visceral osteopathy’s diagnoses and treatments was put to the test, and the results were abysmal. “Well-conducted and sound evidence,” the authors concluded, “on the reliability and the efficacy of techniques of visceral osteopathy is absent.”
Then there is craniosacral osteopathy. This one-hundred-year-old spin-off (first as cranial osteopathy, then mutated into craniosacral osteopathy) is predicated on the belief that the colourless liquid that surrounds our brain and spine, the cerebrospinal fluid, pulses; that this pulse can be felt by touching the head; that it is indicative of health or illness; and that, incredibly enough, osteopaths can fix it by moving about the plates of the skull with their fingers. If such light touch could cure diseases, I can only imagine what dancing, jumping, or even simply walking might do the plates of our skull, which actually require tremendous force to cause tiny movements. The reality is that craniosacral osteopathy is nonsensical. Therapists can’t agree on this pulse, for the existence of which there is no evidence, and the same group that surveyed the literature on visceral osteopathy concluded about its craniosacral counterpart that its diagnostic procedures were unreliable and that good evidence for it working was “almost non-existent.”
You would think this absence of good evidence would keep osteopaths humble, but their websites often show them boasting about tackling all sorts of health problems. An examination of 100 random websites of UK-based osteopaths in 2016 revealed that nearly three quarters of them listed craniosacral osteopathy as a service (especially recommended for babies and children), and nearly two thirds offered to help treat non-musculoskeletal problems, like asthma, ear infections, and dyslexia. A year earlier, UK osteopaths had been warned against advertising these exact services, following an investigation by the Good Thinking Society. Here in Quebec, science communicator Olivier Bernard contracted a science firm to perform a similar exercise on 50 websites of local osteopaths selected at random. Visceral or craniosacral osteopathy was offered by nearly three quarters of them, and almost all of these osteopaths claimed to treat non-musculoskeletal issues.
This is a worrying trend. Interventions that were once thought to be efficacious but have since been debunked should be weeded out of a discipline, but their momentum carries them forward, especially since so many osteopaths are working in private practice and a large scope of practice means more potential clients.
When we trim the obvious nonsense off the osteopathy tree, we are left with a plausible assumption: that moving limbs around and massaging certain spots of the body might alleviate musculoskeletal pain. Even there, however, osteopathy flounders.
A salvage operation
Despite its long existence, osteopathy has only been looked at through the empirical lens of science fairly recently and quite infrequently. A scan of the literature spanning the years 1966 to 2018 managed to unearth a measly 389 papers, more than a third of which were mere case reports and of very limited value.
When osteopathy’s musculoskeletal interventions have been investigated in systematic reviews and meta-analyses, the conclusions are almost always the same. The benefits are either non-existent, inconclusive, or very carefully enunciated as being preliminary, while the studies that are examined in these reviews are diagnosed as being of low or very low quality and at high risk of bias.
This is often because blinding in these clinical trials, meaning the inability of a participant to figure out if they are getting the real treatment or a sham, is absent or not reported. Shams typically used include light touch or the use of ultrasound instead of manual manipulations, which look and feel different from the real deal. In a particularly robust trial of osteopathy for fibromyalgia, however, the sham treatment used was all of the usual osteopathic manipulations, in the same order and accompanied by the same comments by the practitioners, but the maneuvers were stopped at their halfway point to prevent joint mobilization. The result? No decrease in pain when comparing fibromyalgia patients receiving osteopathy versus the sham, but interestingly enough, their expectations going in could predict the level of pain after the intervention. Pain, after all, is in the brain of the beholder and can be swayed by expectations.
Even back pain, which sounds like it might be the remit of osteopathy, does not emerge as a clear indication for osteopathic manipulations. Last year, a systematic review and meta-analysis of the evidence rendered its uncertain conclusion: no clinically relevant effect when compared to sham interventions, but the quality of the trials was so bad that the authors were unsure of their findings. As Professor Edzard Ernst, who has spent his career looking at so-called alternative medicine through the lens of science, has pointed out, the benefits of osteopathy for low back pain seem to rely heavily on a single researcher who works at “the flag-ship of research into osteopathy.” When the same researcher keeps reporting positive findings that the rest of the world can’t replicate, we have reasons to be skeptical.
It would be hypocritical of me to dismiss all of osteopathy in light of the fact that receiving osteopathic manipulations did help me greatly. I was in a lot of pain from a musculoskeletal condition that kept worsening. But seeing an osteopath regularly, painful as it was in the beginning, really loosened up my body, increased my mobility, and allowed me to engage in physical activity that could keep this pain at bay. Her interventions were not asinine; they involved deep tissue massage (the painful part), orthotics, and a progressive training program of yoga and Pilates.
But something interesting happened one day. She had just returned from a special training session and wanted to try a different osteopathic intervention. It involved light touch and pinching and had “pseudoscience” written all over it. She never went back to it with me. Another osteopath, however, might make this their bread and butter. You simply don’t know what you are going to get.
This is all the more frustrating given how poorly we do at treating painful musculoskeletal conditions. Part of the problem is that many of the healthcare disciplines devoted to tackling these issues are kicking and screaming when dragged into the evidence-based era. There was a time when a man could simply create a diagnostic and treatment system and start teaching it. Practitioners would be swayed by the renown of their peers, leading to the valuing of eminence over evidence. Medicine, while still falling short of having every one of its interventions backed up by solid evidence, has embraced the idea of basing its practice on rigorous data and not anecdotes, but other disciplines have only put a hesitant toe down this path.
Massage therapy is based on so many misconceptions that any objective benefit it claims to offer should be questioned. Even physical therapy (also known as physiotherapy) has been criticized for being ill-equipped to relieve the problems it claims to focus on (see, for example, here, here, and here). Dismissing these disciplines—including the core part of osteopathy dedicated to the musculoskeletal system—because they don’t seem to work is to miss the point. It’s not that they do not work; it’s that we often do not know if they work and there is, especially in osteopathy, a lack of uniformity in practice.
Can osteopathy be salvaged and reformed in some way? The United States offer an example of this. Osteopathic physicians in America are of a very different breed than the osteopaths that practice in much of the rest of the world. They receive a training that is comparable to medical doctors and is complemented by a few hundreds of hours of osteopathic manual therapy training. Interestingly, more than half of American osteopathic physicians say they do not use these manual interventions on their patients. They prescribe pills, order medical imagery, and do the things that physicians do. But practicing actual osteopathy? It’s rare and has gotten rarer over the years. It’s not mainly because they believe these manipulations do not work; rather, three quarters say it’s because they lack time, often due to “administrative burden.” Essentially, the increase in paperwork is preventing them from engaging in an intervention that lacks evidence. We could see this as a silver lining.
In Quebec last spring, the governmental body in charge of overseeing professions gave the green light for osteopaths to form a professional order. Professional orders allow regulation, but they also confer legitimacy to practices that may not deserve it. And when they are run by fellow practitioners who believe in the pseudoscience behind their profession, the public is justified in wondering if the regulation is too weak and the legitimizing too great.
Our governmental body, in its report, seems to imply that a good reason for giving osteopaths a professional order is because of how popular osteopathy has become: two million therapy sessions a year; 3,000 osteopaths in the province; the reimbursement of services by insurers; and a recognition of osteopathy as an essential service during the pandemic. But popularity is no gauge of effectiveness.
On the topic of craniosacral and visceral osteopathy, the report says that more data is needed to adjudicate. Ditto for the official recognition of the need by osteopaths to insert an instrument or a finger into a bodily orifice for the purpose of treatment.
Given the body of evidence on osteopathy, I think these questions should be settled by now. As for the rest, and as so many meta-analyses of osteopathy conclude, much better studies are needed to see what can be salvaged.
Take-home message:
- Osteopathy is based on the belief that illness comes from the impaired movement of muscles, bones, and their connecting structures, and that an osteopath can restore proper movement using their hands
- Offshoots of osteopathy include visceral osteopathy and craniosacral osteopathy, which make extraordinary claims that are not backed up by good evidence
- There is an absence of good quality evidence to support the use of osteopathy to address musculoskeletal issues
- Osteopathy has been reformed in the United States, with osteopathic physicians receiving training comparable to medical doctors and few of them regularly using osteopathic manual manipulations
