The density of osteopaths in France is a record (49 per 100,000 inhabitants) that even exceeds the USA, the country where the specialty was born. More notable divergence: American osteopaths are all doctors, having followed the same trunk of fundamental training. The French, on the other hand, are a minority of doctors, who have gone through additional training; the others do 5 years of private school after the high school diploma.
In France, osteopathy is thus more readily classified in alternative medicines. In the country of Claude Bernard, anything that has not provided experimental proof of its effectiveness is considered a “patamedicine” (from ‘patate’ dumb in french), a term dear to Marcel-Francis Kahn, a professor who had proposed in his time to homeopaths to come and evaluate their treatments in his department. Proposal declined. Homeopathy was already very popular and didn’t need a spotlight that risked equating it with a placebo.
A bit of medical schizophrenia
And is osteopathy a placebo or an authentic manual therapy with codified indications? Many in the medical world still give the first answer. In clear discordance with the popularity of the specialty, which even some skeptics resort to. A real schizophrenia that affects the highest spheres! My former boss in rheumatology taught his students that osteopathy is rubbish but was going discreetly to be handled when he suffered from back pain…
Sciences et Avenir echoed in 2021 a large study by Christelle Nguyen published in the Jama Internal Medicine, which concludes that osteopathy has a “barely superior to placebo” effect. Despite the undeniable statistical quality of the study, which involved 400 people, it is a real hankey-pankey in terms of science, for different reasons (methodology, choice of placebo and indication) that I will detail.
Previously, INSERM had issued a global report on osteopathy in 2012. Conclusion: “Osteopathy brings together a heterogeneous set of practices. It is aimed at frequent functional disorders, therefore of interest to a large number of people, but without proven superiority over conventional alternatives. Rare but serious accidents can occur during cervical manipulations.”
Trap for researchers
There is actually a substantial scientific literature on osteopathy, of which you have an overview here. INSERM consulted 64 studies, less important than for chiropractic (200) or acupuncture (more than 600). Understandable: these last two specialties are very codified, unlike osteopathy which brings together a multitude of different techniques, philosophies and personal practices.
An analogy would be that you are looking to study a new drug, but what you actually administer contains plenty of different additives from capsule to capsule, all of which can alter the effect of the product. How could you draw a general conclusion from the study? If one of the mixtures works, its good results will be drowned out by the failure of the others. Your study is useless. This is the caltrop in which Christelle Nguyen run.
Know osteopathy in detail
Here are the general characteristics of osteopathy, in the face of classical medical treatments:
-initially based on techniques with immediate effects,
-theorized in the wake without scientific method, drifting even in the mystical,
-secondarily backed by an excellent knowledge of neuro-anatomy,
-producing in the end a mixture of beliefs and physiological notions founded, variable from one therapist to another,
-operator-dependent medicine, according to manual skill, learning curve, and especially the ability to adapt one’s techniques to the case treated (lesional type and temperament of the patient),
-addressing various disorders and poorly codified by classical medicine.
I draw from this a subjective general observation, being a prescriber more often than a practitioner: Older osteopaths willingly have bizarre ideas but an experience that brings lasting results. Young people have a more homogeneous theoretical training, have stopped aggressive manipulations, bring less spectacular relief but also at lower risk.
In the quagmire
Let’s go back to Christelle Nguyen’s study from the beginning. She wants to analyze “the effectiveness of osteopathic manipulations versus false manipulations in low back pain”. Ouch! Manipulations are not codified as the administration of a capsule. They are operator-dependent. False manipulations are not an ineffective placebo, on the contrary: among the techniques, “energizing” does not require any contact. Placebo works very well in osteopathy (like saline in infiltrations, another trap for science).
Finally, “common” low back pain is a catch-all in which medicine is content to exclude proven biological disorders, infections, tumors, rheumatic inflammations etc. There are still mechanical malfunctions, as varied as the failures of an automobile engine. To say “Take care of this low back pain” is to ask the mechanic if he has a standard treatment to restart your car that refuses to move forward!
Blinders Based Medicine
Christelle Nguyen was therefore stuck in a deep quagmire as soon as her goal was declared. It is not likely to come out of it by using, as for a drug, the double-blind methodology. This is adapted to an isolated substance given in a specific indication. Not at all to multiple techniques, related to the operator, used in various subgroups. Galaxy of phenomena analyzed with a simple graduated rule!
To tell the truth, I am embarrassed about it for medicine because this kind of blindness casts a wider opprobrium on research based on the same methodology. Too often the isolation of the criterion studied is arbitrary, patients are assumed to be robots with a single symptom and indifferent to the context of the study. Evidence Based Medicine takes on the appearance of Blinders Based Medicine. Poor science! It is less Big Pharma that is a danger to it, than our own reductionism.
A real science for physical treatments
Which methodology is adapted to osteopathy? It is the opposite: make a protocol dependent on the operator, that is to say choose one, preferably experienced, let him customize his diagnosis and his treatment technique. He is asked to carry out either the interventions he thinks are effective, others that he thinks are ineffective, or no intervention at all. A neutral observer is present to verify that the management does not allow the patient to know what he is receiving. In addition, it is possible to ask the patient as soon as he leaves about the treatment he thinks he has received.
Another observer collects the results by later interviewing the patients of the 3 groups, true treatment, placebo, and non-treatment. A comprehensive survey will independently study the results of a number of operators sufficiently representative of the variety of schools and techniques. It is not 400 patients for a few osteopaths that must be expected, but rather 50 osteopaths each with their twenty patients to treat.
A good start
This is not a classic scientific assessment and common low back pain is not yet clearly dismembered as well. But it is an excellent method, for sure, to find the best trainers in osteopathy!
I deal in a complementary article: How does osteopathy work? What are the benefits and risks? How to choose your osteopath?