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ncor.uk Prof. Dr. Dawn Carnes Director : National Council for Osteopathic Research

www.ncor.org.uk Prof. Dr. Dawn Carnes Director : National Council for Osteopathic Research Research consultant HEdS -Fribourg To  advance, facilitate and disseminate osteopathic and osteopathic relevant research, in order to promote practice that optimises patient care. Presentation

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ncor.uk Prof. Dr. Dawn Carnes Director : National Council for Osteopathic Research

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  1. www.ncor.org.uk Prof. Dr. Dawn Carnes Director: National Council for OsteopathicResearch Researchconsultant HEdS-Fribourg To advance, facilitate and disseminate osteopathic and osteopathic relevant research, in order to promote practice that optimises patient care.

  2. Presentation I) Background: Whatisosteopathy ? II) Evidence relevant to osteopathic practice and care III) Other information and the future

  3. I) Background Frequentlyasked questions: • Whatisosteopathy? • Is osteopathyissafe? • Is osteopathy effective?

  4. I) Background Whatisosteopathy? Osteopathyis a form of manualtherapy, itis a multi-component complex intervention using a variety of techniques and methods to optimise patient function, health, self-management and well-being. It ismainlydelivered in the primary care healthsector. (otherdefinitionsexist but thereis no one accepteddefinition)

  5. I) Background Osteopathic International Alliance Global Report (2013) The profession: • 2 types: osteopathicphysicians (USA) and osteopathicpractitioners • Osteopathic healthcare is now provided in every continent except Antarctica and is practised in more than 50 countries. • 43,000 osteopathicpractitionersworldwide, the majority in France, Germany, Italy, UK, Australia, Belgium and Canada (38,000) • Osteopathsworkmainly in private practice in primary care

  6. I) Background Osteopathic International Alliance Global Report 2013 The patients: • 33% of patients were between 31 and 50 years old, 23.4% were aged 18 and younger (8.7% are below the age of 2 years) • Patients seek help for pain both acute and chronic conditions • Low back pain mostcommon complaint • Most patients self-refer and are self-funded

  7. I) Background Osteopathic International Alliance Global Report 2012 Education: • Osteopathic education programmes exist in more than 25 countries. • Most offer a Master’s level qualification over 4-5 years (Australia moving back to BSc). • EU standards exist for minimum levels of training (CEN 2015 Osteopathichealthcare provision)

  8. I) Background Corecurriculaeinclude: • Anatomy and physiology • Biochemistry and pharmacology • Biomechanics and exercise • Histology and embryology • Pathohysiology • Psychology, communication and self-managment • ClinicalResearch and Critical thinking and appraisal • Public health and epidemiology • Practicalskills: Case historytaking, Screening and Examination, Differentialdiagnosis, Treatment • 1000 hours of clinicalexperience (NHS and Health Education England - MSK corecapabilitiesframework 2018)

  9. I) Background Regulation: Regulatorsrole to: protect patients, uphold standards of practice, ensurequality of the education and training of osteopaths • Protectedtitle • Statutory recognition in many countries • Osteopathic Practice Standards existprimarily for regulation • Health care deliverygeneral standards apply • Fitness to Practice and Professional ConductCommittees • Key competencies to practice evaluated by osteopathiceducation institutions and awarding bodies

  10. II) EVIDENCE Frequentlyasked questions: • Whatisosteopathy? • Is osteopathyissafe? • Is osteopathy effective? Questions are sohuge, hard to answer. For example: Which part of osteopathic care is effective for whom, when and for what conditions ?

  11. II) EVIDENCE: Is itsafe? Systematicreview: Carnes D, Mars T, Mullinger B, Froud R, Underwood M. Adverse events and manual therapy: a systematic review. Manual Therapy Aug 2010; 15 (4): 355-363 • 8 prospective cohortstudiesshowingfairly consistent findings for manualtherapy and manipulation • RCT safety • Surveys • Concerns and complaints data

  12. Sources of information • Carnes D. Analysis of insurance and complaints data UK 2013-2018. https://www.osteopathy.org.uk/news-and-resources/document-library/research-and-surveys/types-of-concerns-raised-about-osteopaths-and-services/ • Carnes D, Mars T, Mullinger B, Froud R, Underwood M. Adverse events and manual therapy: a systematic review. Manual Therapy Aug 2010; 15 (4): 355-363 • S.Vogel, T.Mars, S.Keeping, T.Barton, N.Marlin, R.Froud, S.Eldridge, M.Underwood, T. Pincus. Clinical Risk Osteopathy and Management Scientific Report: The CROAM study (2013). https://www.osteopathy.org.uk/news-and-resources/document-library/research-and-surveys/the-croam-study-february-2013/

  13. II) EVIDENCE: Is itsafe ? • Minor adverse eventscommonafter the first treatment ~35-45% of patients, mostresolvewith 48, even more at 72 hours (over 90%) • Serious adverse eventsvery rare: • <1 per 100,000 manipulation • 1 per 50,000 – 100, 000 consultations • Adverse events more likelywith cervical and lumbar manœuvres, in females and first time patients • VBI patients are more likely to seekclinical care prior to an incident • Most concerns and complaints revolvearoundpoor communication

  14. II) Effectiveness Osteopathic relevant research for: • manual techniques • specific conditions (eg NSLBP, fibromyalgia) • patient practioner relations, shareddecisionmaking • orthopeadic / palpatory / diagnostic tests - reliability and validity • psychology of care and self-management • exerciseadvice and adherence • public / generalhealth messages and advice

  15. II) Effectiveness Low back pain I Bernstein et al. Low back pain and sciatica: summary of NICE guidance BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.i6748 Manualtherapyrecommended as part of a package of care thatincludesexercise and psychological support (Manualtherapists= osteopaths, chiropractors and physiotherapists)

  16. II) Effectiveness General Evidence reviews: A. Steel et al. Osteopathic manipulative treatment: A systematic review and critical appraisal of comparative effectiveness and health economics research. Musculoskeletal Science and Practice (2017) 27: 165-175. • 16 studies included for comparative effectiveness (n = 9) and economic evaluation (n = 7) • Some positive findings for low back and neck pain and preterm neonate recovery (length of hospital stay) • Studies need to be replicated in different settings and jurisdictions to verify current findings • Insufficient quantity and quality of comparative effectiveness and cost effectiveness research for policy decision making.

  17. II) Effectiveness General Evidence reviews: C. Clar et al. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Chiropractic & Manual Therapies 2014, 22:12 Moderate positive/favourableevidence of effectiveness for: • Spinal and or thoracic manipulation and mobilisation for acute, sub-acute and chronic low back pain and neck pain • Manipulation and exercise for rotator cuff disorder; • Spinal manipulation and or mobilisation for cervicogenicheadache, migraine and miscellaneous headache • Manipulation/mobilisation for several extremity joint conditions (carpal tunnel ankle sprains, plantar fasciitis) • Massage including myofascial release/strain/counterstrainfor cancer care

  18. II) Effectiveness Clar et al 2014 continued: Inconclusiveevidence of effectiveness for: • Osteopathic manual therapy for asthma • Spinal manipulation for paediatric nocturnal enuresis • Spinal manipulation for premenstrual syndrome • Cervical spinal manipulation for Stage 1 hypertension • Osteopathic manual therapy for Otitis media • Osteopathic manual therapy for pneumonia in elderly adults • Manipulation and mobilisation dysmenorrhoea, fibromyalgia, myofascial pain syndrome • Manipulation and mobilisation for mid back pain, sciatica, coccydynia, temporomandibular joint disorders, knee osteoarthritis

  19. II) Effectiveness: Projects PROMS – online national data collection projectasking patients about the outcomes of theirtreatment Provision of an evidence for the profession (only as good as the input, need lots of data, lots of engagement): - Weask about the patient (for profilingour client base) - Weask how they do aftertreatment and how satisfiedthey are

  20. National PROMS Database (Unpublished data, studyongoing. N=~2000 patient datasets) • Reported global change after 1 week 8% reported being completely recovered, 55% reported being much improved, 26% reported being slightly improved, and 11% reported no change. • Reported global change after 6 weeks 78% of patients reported being completely recovered or reported being much improved, 15% reported being slightly improved, and 7% reported no change.

  21. National PROMS Database (Unpublished data, studyongoing. N=~2000 patient datasets) • Reported levels of satisfaction 91% reported their care as being very good, 8% as being fairly good, 1% as being neither good nor poor, and 1% as being fairly poor.

  22. II) Effectiveness- Paediatric care Evidence base - Paediatric care underscrutiny: Carnes D, Plunkett A, Ellwood J, Miles C. Effectiveness of manual therapy for distressed, unsettled and excessively crying infants: a systematic review and meta-analyses. BMJ Open: 2017: 8(1) http://dx.doi.org/10.1136/bmjopen-2017-019040 Showedbenefit of manualtherapy for reducedcrying time (of 1.27 hours per 24 hours) of for distressedunsettled and excessivelycryinginfants • VERY limitedevidence for effectiveness of osteopathic care for paediatric conditions (except for pre-term infants in hospital care setting)

  23. III) Other info Sparecapacity room for growth • UK ~8 osteopaths per 100’000 residents • France: ~30 osteopaths per 100’000 residents • Switzerland overall: ~16 osteopaths per 100’000 residents

  24. III) Other info Shortage of osteopaths in the future consideringage profile • Should the profession wish to maintain its ‘market’ presence it may need to consider training more osteopaths • Attrition rates: osteopaths will be retiring over the next 5 years, plus others will leave the profession and or take career breaks and work part-time • Gender shift towards more female osteopaths (data indicates that women see 30% less patients than men) • Population growth

  25. III) Other info Potentialeducation and training gaps ? • Population aging profile but little training in the care of older people given • 1 in 4 infants are taken to see an osteopath but thereislittleadvanced practice training in this area • Increasingevidence for psychological, behaviour change and self-management interventions for long-term conditions, osteoapths are wellplaced to givethis care but little training available • Increasingevidence for exercise interventions, osteopathsare wellplaced to givethis care but little training available

  26. III) Other info Multidisciplinary care, multi-skilledpractitioners and integrated care pathways • Osteopathstreat a range of conditions (not all musculoskeletal) using multiple types of interventions • Patient profile varied but nearly all treatmentgiven in primary care, Can thisrolebeexpanded, for exampleincludewithprimary care physicianassociaterolewith a musculoskeletal orientation ?

  27. III) Future Role of osteopaths in the future health care arena: • Aging population • Increase in long term conditions • Reduction in GPs • 10-20% of GP consultations are musculo-skeletalrelated Plugging the gap in primary care health service provision a societalpriority

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