Join Date: Jan 2011
Location: Hamilton, Ontario
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Conversations with an Osteopath
I have been in some discussions with a local Osteopath. He is an interesting fellow and I get confused about where he is coming from quite frequently. He seems to discourse quite a bit about scientific credibility. But I get the sense that he actually doesn't really believe in science. He hasn't said so directly.
A recent conversation I have had with him has left me a bit confused. I don't know whether it is me who isn't explaining things clearly or him who is changing the conversation.
Maybe some of you here can help me correct my language or understanding or point out if he is misdirecting.
Byron: In regards to our discussion about what can be felt in the body with the hands;
Have a read through this article here: http://www.somasimple.com/forums/showthread.php?t=3886.
Jason Silvernail is a pretty darn good writer on these types of topics.
While he doesn't specifically go into detail about hands, I think his points on inter and intra -rater reliability are cogent.
I find the fact that he is challenging his own profession for which he has devoted many hours and dollars to become credentialed in gives his points some extra power.
I have to do more digging to find some points on the exact point I was making.
Osteo: That was a good post by Jason. I think he is absolutely right about interrater reliability. There seem to be studies around regarding chiropractic evaluation of the spine, showing poor interrater reliability. But I haven't had a chence to read the studies so I can't comment on the methodology.
There is a need for osteopathic palpation studies. Actually I am planning for my thesis - considering an interrater reliability study with regards to diagnosing lesions within a bone.
Honestly I don't know what the study will show. Maybe that no one agrees what a bony lesion feels like in osteopathy. That would be a kick in the pants. Or maybe it would show that they identify them reliably. We'll see in a couple of years if I can get the study approved.
Either way it will be good to know.
Byron: You are so right that it is good to know.
The sooner we can focus on the things that are effective and reliable the better.
The really painful thing I have noticed, I'm sure you have to, is how long some groups or organizations hold on to expired ideas, just can't let them go.
I try to look at Yoga the hardest because it is where I am the most likely to deceive myself.
Osteo: Food for thought, if you want to go all the way in the direction of effective and reliable, why not stay away from therapy altogether and just stick with pain medications?
Medications are easy to study, provide a list of effects and side effects that can be measured, and are capable of eliminating pain and inflammation more quickly than any type of therapy.
What's the point of debating about the most effective and reliable therapy when prescription medications are the most effective and reliable of all?
The drug companies beat you to this argument decades ago, they have a lock on it!
Here's how I see it. You can either have a recipe treatment, the same for everyone (drugs) and have lots of research behind it. OR you can have treatments tailored to each patient's physiology and individual case (manual therapy) that does not stand up to randomized double-blind placebo controlled studies, because as soon as you turn manual therapy into standardized treatments, they don't seem to work.
But you can't have both! I don't yet know of a recipe book therapy that is applied the same way to everyone, stops pain and proves statistically significant in randomized double-blind placebo controlled studies (p less than or equal to 0.05).
If you want reliable, take a pill!
Hmmm. Wouldn't you say that exercise is effective and reliable? That everyone gains benefit from it's application?
I think that would challenge your statement of "If you want reliable, take a pill!". Of course it may not resolve issues but it does improve outcomes.
To be sure, medication is mostly short term, reliable and effective treatment in many cases, but I would also say that it has to be tailored as well. Being tailored does not mean that you can't evaluate effectiveness and reliability. With manual therapy, the question is who is going to benefit from this? At this point there is not a great deal of screening available so it does seem like a bit of poking around in the dark. But does that mean we should not consider it possible even? I also like to remember that medication has afforded a great increase in lifespan, despite the villianizing it regularly gets. But lots of drawbacks and risks as well. Like you put so well in your comments on vaccinations.
You are right that RCT's don't evaluate manual therapy very well.
I think we know by now that pain is a complex, many faceted thing. Complicated by biopsychosocial factors. This you also covered well when you mentioned evaluating the whole person emotional, spiritual etc. This is also very relevant in the application of Yoga as a therapy.
But we do still learn about ineffective and unreliable treatments. As you mentioned also below about chiropractic adjustments, or more specifically High Velocity Low Amplitude (HVLA) manipulations have been problematic. There is some research starting to point to certain populations (which are identified through a screening process) that benefit from this. The rest just don't fair well. If the screening were not developed it would seem like hit or miss with each person as to whether it was effective or not.
"What's the point of debating about the most effective and reliable therapy when prescription medications are the most effective and reliable of all? "
I wouldn't say that they have resolved the source of the problem, so I guess our definitions of effective are not in alignment.
"I don't yet know of a recipe book therapy that is applied the same way to everyone, stops pain and proves statistically significant in randomized double-blind placebo controlled studies (p less than or equal to 0.05)."
Can't argue with you there. Maybe we never will. But ineffective therapy can be identified and eliminated.
Good food for thought. Thank you!
Osteo: From your previous email:
>>There is some research starting to point to certain populations (which are identified through a screening process) that benefit from this. The rest just don't fair well. If the screening were not developed it would seem like hit or miss with each person as to whether it was effective or not.
I think you absolutely nailed it with this statement. If the population is properly screened, results are statistically significant. With this statement, you are actually making my argument for me.
You have just captured the essence of manual therapy. Find the people who actually need the techniques you do, and do them. If their physiology is sufficiently deviated from "normal" you have a chance at a measurable outcome.
I mentioned that I thought you put too much faith in statistical significance supporting your choice of therapy, I actually believe that more than ever at the moment, for the following reason: in order to have statistical significance you need one of two conditions, either a very large sample size to demonstrate a small treatment effect, or a very large treatment effect with a small population.
Of course to increase the power, you would have a large treatment effect on a large population, but then one of the two factors will be overkill.
Then all you need is the statistician to apply the right statistical algorithm to show significance when applied to your data.
The advantage drug companies have is they can more easily achieve a large sample size due to a standardized application of the medication and a deep pool of financial resources. So they only need to demonstrate a relatively small effect to have supporting research published in the literature.
Therapists doing research bend over backwards to identify a sample size of 24 subjects. Then they spend 1 to 3 years of their lives (at least at the CCO) working on these subjects at no charge, with whatever valid measuring tool they could afford.
So a required element of any RCT therapy study is a very large, consistent treatment effect across a small pool of subjects, since a large sample size is simply not realistic for such a clinical trial.
So where does that leave us? The general public has to try different therapies on their own, and see if they work for them specifically. Then they make an informed decision to continue or discontinue.
The proof is in the pudding Byron! If a therapist is not helping anyone, they will not be a therapist for very long. If a therapist is gainfully employed as a chiropractor, or osteopath or physiotherapist or athletic therapist (for example), they must be doing something right.
I like to ask people the question, do you think millions of people are all crazy and you're the only sane one, or the other way around?
There are probably occasions when it's the former. But I am always wary of people who think they know some secret that the whole world is ignorant about. Most of the time the collective wisdom of the population is more valuable that one person's opinion. At least I think so.
Any thoughts would be appreciated.
Byron Selorme - Science Based Yoga Educator
Shavasana Yoga Center
"The first principle is that you must not fool yourself - and you are the easiest person to fool" Richard Feynman
Last edited by byronselorme; 21-03-2012 at 02:07 AM.
Reason: bad grammar