No longer beyond the pale but residue of pseudoscience taints some therapies

“Okay, Doc, who should I see: a chiropractor, physio or an osteopath? What’s the difference?”

In bygone years, when orthopaedic surgery ruled the roost in musculoskeletal medicine, manipulation was verboten. Chiropractors and osteopaths were regarded by the medical profession as little more than hands-on crystal swingers.

In that era, before evidence-based medicine and academ­ic general practice, the hypocrisy of opinion-based medicine was conveniently ignored. A doctor’s opinion trumped all, and a specialist’s, more so. The fact that the manipulation professions had arisen at a time when their treatment modality was safer than apothecary or surgery was conveniently forgotten. To document in a 1970s’ orthopaedic referral that your patient had tried manipula­tion was neither brave nor smart.

Time changes all and, by the mid 1980s, the inroads musculoskeletal medicine was making into medicine brought with it manipulation and other manual therapy skills. Much of this was borrowed from osteopathy and physiotherapy. In the following decades, the differences between chiropractic, osteopathy, physiotherapy and medicine began to narrow. However, history has left a residue, a detritus, a smokescreen of professional rivalry that still confuses not only the public but also the professions themselves.

So, what are the differences? In a nutshell, chiropractors manipulate, physios stretch and osteopaths do a bit of both. Reality, however, is never simple, and each entity has its unique features, largely historical, that set it apart from the others and from medicine.

In this, physiotherapy, in Aotearoa New Zealand at least, is the closest to medicine in terms of philosophy, underly­ing scientific reasoning and professional relationships, while chiropractic remains separated, tainted with a residue of pseudoscience. Osteopathy is somewhat less so.

As far back in time as Hippocrates, there were recordings of massage, manual therapy and hydrotherapy usage.

But it was not until the late 19th century that the three professions were founded. It was a time when the medical doctor’s therapeutic arsenal included arsenic, opium, castor oil and whisky. Manual therapies offered treatments that were safer, holistic and probably more effective.

In 1913, physiotherapy entered the halls of academia with the founding at the University of Otago, of the School of Physiotherapy, an important step in cementing physiotherapy’s place in conventional healthcare alongside medicine.

Over the subsequent decades, the separation of osteopathy and chiropractic from medicine remained but, in the 1960s, chiropractors were regulated by an Act of Parliament. By 1978, osteopaths had been similarly regulated and, in the same year, an ACC review recom­mended chiropractic treatment be subsidised. This was subsequently implemented and osteopaths came under ACC coverage. Both professions are now covered by the Health Practitioners Competence Assurance Act 2003.

Founded in the US by D.D. Palmer, this profession’s philosophy emphasises “vitalism”, “innate intelligence” and a belief that vertebral “subluxations” are the cause of all disease.

These concepts are still held to be valid by “straight” chiropractors. By contrast, “mixer” chiropractors, appar­ently the majority in this country, appear to ignore the pseudoscientific gobbledegook. However, vertebral sublux­ation remains a central chiropractic concept, underlaid by some debatable concepts and therapeutic claims.

Thus “straights” may treat many diseases and conditions while “mixers” usually limit themselves to musculo-skeletal problems.

While chiropractic diagnostic techniques include history-taking and physical examination, they differ from physiotherapy and osteopathy in their focus on vertebral subluxation and the use of radiography to help diagnose these “spinal position” abnormalities.

Chiropractic treatment usually involves manipulation of joints using high-velocity, low-amplitude manipulation directly applied to the body segment of interest, plus a number of less physical techniques, including use of hammers, to correct subluxations.

There are two species of osteopaths: those trained in the US and those trained elsewhere, such as in New Zealand.

US osteopaths mostly train alongside medical doctors and can be described as doctors with manipulation skills; skills that usually form part of a treatment arsenal that otherwise is mainstream medicine. Their manipulation has been described as “extra training in pseudoscientific practices”.¹ A doctor of osteopathy can register as a doctor with the Medical Council here in New Zealand.

This is vastly different from osteopaths trained here, whose therapeutic regime is largely limited to physical therapies. New Zealand osteopaths diagnose using a variety of clinical examination skills and history-taking. They use a wide range of manual techniques, in particular, the same high-velocity, low-amplitude manipulations chiropractors use. The difference is that they tend to use limbs and body-positioning to apply the forces, rather than direct thrust to the segment of interest.

Like physios, they also use soft-tissue stretching, resisted isometric stretching and myofascial release techniques, plus some contentious therapies such as craniosacral treatment, visceral (body organ) and neural (nerve) manipulations. While their treatments tend to be focused on central skeletal problems (segmental dysfunc­tions), osteopaths may also provide diagnosis and care for pathophysiological clinical problems such as glue ear, an issue that, under the Health Practitioners Competence Assurance Act, appears to result in some dissonance within the profession.

This is the profession with which most Kiwi doctors are familiar. Of the three, it is most aligned with medical scientific thinking. Some historical physiotherapy treatment modalities have pushed the boundaries of medical science but so, too, have some historical medical therapies.

Some physios may use manipulation, but it is not central to the discipline. Exercise, massage, stretching and rehabilitation programmes form the mainstay of physio­therapy. These allow treatment of a more diverse range of musculoskeletal problems, both central and appendicular and over a longer time frame.

If one limits the research outcomes to acute lower back pain, there is some evidence that manipulation, when compared with “usual” therapy including other manual therapies, may have a short-term (under six-weeks) benefit.² Long term, there appears to be no difference.

For other central spinal musculoskeletal problems, the evidence for the effectiveness of manipulation is either absent, low quality or shows no benefit, a similar problem to its use in the appendicular skeleton.

As for visceral manipulation, a BMJ review found two reasonable-quality studies showing no benefit.³

As to which profession is the most effective in manipulation, comparative studies are lacking.

In terms of harms from these practices, the literature has a number of anecdotes and case studies implicating neck manipulation in the development of vertebral artery thrombosis, but more in-depth studies have failed to establish whether the rate of this and other harms (headache, stroke, increased pain, muscle stiffness) is clinically significant.^4,5

The lack of a consistent comprehensive reporting system for manipulation harm is a significant confounder in this regard.

In the 1980s, as a young GP, I ventured into the realms of acupuncture and manipulation, undertaking week-long courses in both and then practising them enthusiastically as part of my early general practice career.

Experiential reflection on these therapies and their enthusiasts led me to realise that sceptical or critical thinking was of no use if one was to become an expert at either of these modalities. However, the musculo­skeletal training proved invaluable for diagnosis, patient care, and ability to assist patients in understanding their musculoskeletal problems and likely outcomes.

In looking ahead, and appraising the New Zealand literature here on osteopathic training and some of the discussions in chiropractic, it seems the incorporation of these two professions under the act has been accompanied by an increase in critical thinking among them, as well as an attenuation of some of their more way-out ideas.

This suggests time and application of scientific evidence will help close the professional gaps, for our patients’ benefit at least.

How you choose to answer the question posed by my patient at the beginning of this article depends, as do most issues in general practice, upon the time available for explanation.

An explanation of the underlying philosophies, scientific thinking and comparative therapeutic tech­niques is likely to go straight over your patient’s head.

My response that “chiropractors manipulate, physios stretch and osteopaths do a bit of both” may be simplistic, but is a concept easily grasped.

Your diagnosis is, however, critical. When considering manipulation as a therapeutic option, your patient’s problem needs to be a central musculoskeletal problem.

You also need to consider the longer-term outcomes, particularly whether rehabilitation is important – swing­ing your referral towards physiotherapy. Conversely, patient choice might well be for the short, sharp fix of a spinal crunch.

Similarly, safety is important, contraindicating manipu­lation in the frail elderly, those with central skeletal arthritis, or a condition or injury that weakens bones or joints. Cerebral vascular disease, particularly vertebrovas­cular, is another contraindication.

As for the end result, it is my experience that patient belief, therapist communication skill, hands-on ability, the placebo response and chance will have a far greater impact on the outcome than any particular professional tech­nique.

For those times when your patient throws back at you, “What would you choose, Doc?”, tossing a coin might not be a bad option.

Jim Vause is a retired GP living in Nelson