Before starting to review specific pieces of research here are a few thoughts about evidence in relation to osteopathic practice.
Evidence based practice has been defined as “the process of systematically finding, appraising and using contemporaneous research findings as the basis for clinical decisions” (Rosenberg & Donald 1995, p.1122). There are, however, difficulties inherent in basing osteopathic clinical decisions on high quality research. For the most part, osteopathy has developed independently of rigorously researched studies and much of its teaching relies heavily on tradition, policy and clinical experience. The profession of osteopathy is starting to tentatively embrace the need for evidence based research despite mistrust within the profession of the methods used to acquire this evidence. Accurately or not, some of this mistrust is due to the belief “that a reductionist research paradigm cannot investigate a holistic patient centred approach” (Lucas & Moran 2006 p.76). This philosophical difference may complicate clinical decision making.
For example there are a few trials which seek to compare the efficacy of non-steroidal anti-inflammatories (NSAID) and spinal manipulation for low back pain. Osteopathic philosophy does not see manipulation as a valid treatment intervention in isolation from the complete osteopathic consultation. As Kuchera & Kuchera (1994 p.2) say, “manipulation is not osteopathic philosophy and technically it is not osteopathy”. To remove manipulation from the context of osteopathic, or for that matter chiropractic, consultation and assess the technique in isolation is therapeutically inappropriate. However, the use of NSAIDs for pain relief is viewed by allopathic medicine as being a valid and complete treatment method in and of itself, within or without professional consultation.
Using RCTs to compare these groups compounds this difference. Double blinding is not possible in trials assessing manipulation (Andersson et al 1999). Therefore, when trial quality is assessed using scales such as Jadad (1996) or PEDro (1999), which both see blinding as integral to high quality RCTs, NSAID trials will always have an advantage over manipulation trials in quality rating. This raises questions of whether these types of trial and rating systems are appropriate for studies of manipulation and whether more emphasis should be placed on qualitative and not quantitative research. Qualitative methods may be better suited to analysing the subjective nature of pain, its complex bio-psychosocial and behavioural elements, and the relationships between the variables (Faltermaier 1997).
Designing suitable studies for manipulation/osteopathy is vital if osteopathic practice is to become evidence based. Until good quality studies are provided, little evidence can be shown to those influencing healthcare policy and funding, that osteopathic treatment including spinal manipulation is a viable alternative to treatments such as NSAID use for back pain.
References:
Andersson, G; Lucente, T; Davis, A; Kappler, R; Lipton, J; Leurgans, S. (1999). A comparison of osteopathic spinal manipulation with standard care for patients with low back pain. The New England Journal of Medicine, Volume 341(19), pp 1426-1431
Faltermaier, T. (1997) Why public health research needs qualitative approaches: Subjects and methods in change. The European Journal of Public Health 7 (4):357-363;.Jadad A.R, Moore R.A, Carroll D. et al. (1996). Assessing the quality of reports of randomized clinical trials: Is blinding necessary?. Control Clinical Trials 17 pp. 1–12
Lucas N, Moran R. (2006). Is Osteopathy Research Relevant? A Challenge Has Been Made. International Journal of Osteopathic Medicine. Volume 9 number 3 pp 75-76.
PEDro (Physiotherapy Evidence Database (1999) [Online] Available from http://www.pedro.fhs.usyd.edu.au/ [Accessed November 25 2006].
Rosenberg W, Donald A. (1995) Evidence-based medicine: an approach to clinical problem-solving. BMJ 310:1122-1126.
