A canna’ change the laws of physics

Scotty, The Naked Time, stardate 1704.3, Episode 7

Bowen Therapy and the ASA

Posted by apgaylard on February 18, 2012

I have, for a little while, been taking a careful look at the claims made for a decidedly second-division CAM called variously ‘Bowen Therapy’, ‘Bowen Technique’ or ‘Bowenwork’.  It involves a potentially relaxing, gentle manipulation of soft tissue using fingers and thumbs; moving them over muscle, ligament, tendon and fascia.

Aside from the potential benefits of a sympathetic consultation, the psychological impact of physical contact with someone who wants to help you and simple relaxation, it would appear to have little to offer.

It’s certainly not at all a plausible treatment for serious conditions like asthma.

I had a look at the research literature a little while ago, and it provides decidedly slim pickings.  As far as I could tell the sum total of the published evidence for Bowen listed in PubMed amounts to:

  • one or is it two (?) small uncontrolled trials for frozen shoulder from a single author (Carter 2001, 2002),
  • an uncontrolled intervention to try and reduce staff absence (Dicker, 2005a),
  • a small uncontrolled study on a range of issues with strong psychological components (Dicker, 2005b),
  • an RCT* showing improved hamstring flexibility in people with no hamstring problems (Marr et al 2011) and
  • a tiny case series that doesn’t show that Bowen technique helps stroke rehabilitation (Duncan et al, 2011).


A Bit of an Update

Since I last blogged about Bowen, Christine Hansen and Ruth E. Taylor-Piliae (2011) have published a systematic review.   Going by the abstract, as it is pay-walled and expensive, they found:

“15 articles met the inclusion criteria (randomized clinical trial, n=1; quasi-experimental, n=2; mixed methods, n=3; cross-sectional, n=2; case study, n=7).”

This is more articles than I found; but notice that they only found one randomized clinical trial and that most are case studies.  The extra trials they have unearthed appear not to be listed in PubMed.  Given that PubMed happily includes some very dodgy CAM journals (like The Australian Journal of Holistic Nursing, for example), I think that scraping beyond the bottom of the barrel is not helpful.  They did reach a positive conclusion:

“Over half of these studies (53%) reported that Bowenwork was effective for pain reduction and 33% reported improved mobility. In addition, several studies (n=5) reported the effectiveness of Bowenwork® on the relief of symptoms experienced by persons living with a chronic illness, such as multiple sclerosis.”  

So, the headline positive conclusions are for: pain reduction, improved mobility and symptomatic relief in chronic illness.  It’s worth noting, that this is a very modest list compared to the claims that Bowen therapists and trade bodies in the UK have been making; more on that shortly.

Anyway, it appears that in this review, that after dredging through the lower echelons of the CAM literature, the authors conducted an analysis that ignores any differences in methodological quality or design (such as the use of control groups and randomization) between the studies they identified.  It looks like they have lumped together the studies that they found, scoring the percentage of studies that gave positive outcomes in broad general categories (like “pain reduction” and “relief of symptoms”).   This approach gives a single case study the same weight as a large randomized controlled trial.

Commenting on this paper, Edzard Ernst tweeted “ever wondered how to draw positive conclusion out of [largely] negative or non-existant evidence? here is how”.

I wondered why the authors should use such a lax methodology in assessing Bowen.  Perhaps it had something to do with their personal sympathies?

A bit of googling suggests that Ruth E. Taylor-Piliae is a keen Tai Chi researcher.  Perhaps more interestingly, it looks like Christine Hansen is a Bowen practitioner of some standing, having received a Certificate of Recognition and Lifetime Membership, from American Association of Bowenwork Practitioners, “for her doctoral research project work regarding the use of Bowenwork for Breast Cancer Survivors with lymphedema.”

Now, just because someone is a CAM fan or Bowenist doesn’t mean that any research they do is tainted.  However, if their research is lax and overly positive it’s legitimate to question whether pre-existing commitments might be skewing their judgment.

So, unsurprisingly, they conclude that Bowen:

“… may provide a noninvasive and affordable complementary approach to improvements in health. This intervention may offer improvements in pain reduction for various conditions such as frozen shoulder and migraines. While Bowenwork is recognized internationally, scientific evidence is not well documented. Further research is needed to systematically test this modality, before widespread recommendations can be given.”

Even this overly positive review doesn’t claim that “widespread recommendations can be given.”  Although this stands in stark contrast to the very broad claims of Bowen practitioners, it’s safe to say that there is no evidence that Bowen technique can help with any specific medical condition.

Wild Claims

Perhaps inevitably, people who make their living from selling Bowen Therapy don’t seem to be influenced by the actual evidence.  This is seen in the wide ranging claims they make.  For example, the website Totallybowen.co.uk features this immodest list of conditions:

Copyright © 2007 Totallybowen.co.uk

The major Bowenist organizations in the UK are no less grandiose in the claims.  For example, the European College of Bowen Studies (ECBS) state that,

 “In short, almost everything can respond well to Bowen treatment”.

As we have seen, the actual evidence suggests the complete opposite.  The Bowen Therapy Practitioners Association (BTPA) state that:

“This remarkable technique can be quick and effective in helping the following:

  • Muscular and skeletal problems in neck, shoulder, hip, knees, ankle and back, including sciatica           
  • Frozen shoulder, tennis and golf elbow, R.S.I. and carpal tunnel
  • Whiplash and sports injuries
  • Problems with posture and body alignment
  • Migraine and recurring headaches
  • Bell’s Palsy, Multiple Sclerosis, Parkinson’s Disease and the difficulties suffered by stroke victims
  • Respiratory, bronchial and related conditions such as hayfever and asthma
  • Digestive problems such as IBS
  • Arthritis
  • Hormonal, pregnancy and fertility problems
  • Stress management, ME, fatigue and sleep problems”

Not to be outdone, the Bowen Association UK (BAUK) has their own list of implausible and unsubstantiated claims:

“Here is a list of just some of the conditions we have been able to assist with:

  • Allergies
  • Baby and childhood problems
  • Back problems
  • Bladder problems, bedwetting
  • Bowel problems
  • Digestive problems
  • Dizziness
  • Ear Problems
  • Fatigue
  • Fluid retention
  • Foot problems
  • Frozen shoulder
  • Headaches (migraine, sinus)
  • Bedwetting, incontinence
  • Jaw problems (grinding of teeth, misalignment etc)
  • Knee and hip restrictions, misalignments
  • Menstrual and other female problems
  • Pelvic tilt, leg length, hip imbalance
  • Poor mobility
  • Repetitive Strain Injury
  • Respiratory problems
  • Skeletal and muscular problems from lumbar to neck
  • Sports injuries
  • Stress”

The combination of grand claims, lack of decent evidence and mentions of serious conditions moved me to make a few complaints to the UK’s Advertising Standards Authority (ASA).  The organizations and practitioners that I complained about appear to have provided the ASA with what they consider to be ‘evidence’ which supports their position. 

The ASA has recently finished their assessment of the submissions made by promoters of Bowen Technique.  They sent me their conclusions, without the usual insistence on confidentiality (which I always respect).  So, in the spirit of letting potential consumers know how the ASA view these marketing claims, I’m providing a summary.

At this point I’d like to make it clear that I don’t mind at all if people want to use the services of a Bowenist.  It’s entirely up to them how they spend their hard-earned cash.  However, I do think that it’s important that consumers have access to honest and truthful information, so that they can make a properly informed choice.

On the other hand, I do take a very dim view of people who make unsubstantiated claims in order to sell their wares; especially when there is a chance that their marketing strategy could cause serious harm to their clients.

ASA and Evidence

The ASA have a very sensible policy on the sort of evidence that is required to substantiate the claims that advertisers of health products and services make.

“… the ASA’s established position is that claims that a therapy is effective in the treatment of a specific condition need to be substantiated with robust, appropriately controlled and blinded clinical trials conducted on people.”

As advertisers are trying to sell therapies to people who would like to have their ailments cured or at least managed, this is a fair standard. 

Given the extreme implausibility of some therapies, along with the variable nature of of illnesses in people and their perception of it, this is actually being more than fair.  It keeps the door open to whacky treatments that might score a few fluke ‘wins’ in the odd trial, enabling an advertiser to make claims that only appear to be true.

Advertisers sometimes structure their marketing messages in ways that seek to give potential clients the impression that they can treat or cure a condition, while avoiding explicitly saying so.  They use words like “help” rather than, say “treat” or “cure”.  They use testimonials or just list medical conditions without making explicit claims.

However, this does not wash with the ASA:

“… in the context of an ad or website for a specific treatment, we are likely to view any reference to a condition as a claim to be able to treat it. For example, references to having treated “with” a condition or a testimonial that references as a condition are, almost always going to need to be substantiated in the same way.”

Bowen Boosters Bite Back

It appears that the Bowen Association UK (BAUK), Bowen Therapy Practitioners Association (BTPA) and the European College of Bowen Studies (ECBS) all made submissions to the ASA.

These do not appear to have been at all persuasive.  For instance:

“The trial submitted by BAUK sought to evaluate Bowen Technique in the treatment of frozen shoulder. We noted however that the trial had not been controlled, for example by randomly allocating subjects to intervention and control groups; or blinded, for example by having the subjects independently assessed. We also noted that the study itself acknowledged that the results should be viewed with caution due to the comparative lack of rigour in its design. For those reasons, we considered that the study did not show that Bowen Technique was effective in the treatment of frozen shoulder.”

The ASA don’t identify the trial, but it looks to me like either Carter (2001) or Carter (2002); which may actually be the same trial.  In my first post on Bowen Therapy, I came to a similar view:

“(Carter 2001) used a case series of just twenty patients.  They were given up to five therapy sessions.  Improvements were claimed, but this is an uncontrolled study on a small number of patients” and “it’s a very small study with no control group.  Oddly it has exactly the same number of participants as the trial reported the year before.  I wonder why a second twenty-patient study was published by the same author within a year.  Could it be the same study?  If not, why do yet another methodologically weak small study?” (Carter, 2002)

Well, that’s not an auspicious start for the Bowen brigade.  According to the ASA, the BTPA also made submissions:

“… relating to the efficacy of Bowen in the treatment of cerebral palsy, asthma, migraine and Parkinson’s Disease.”

This is illustrates one of the main problems with the CAM community: they cannot be trusted to limit their ambitions to relatively minor self-limiting conditions where a bit of placebo is unlikely to do much harm.  Their healing fantasies even take them well beyond the shallow puddle of the CAM research literature.

These are serious conditions for which there is not a whit of reliable evidence that Bowen Technique can provide any help.  So, it’s good to see the ASA come to the view that these:

“… conditions are designated by the ASA / CAP as being sufficiently serious that advice on them and their diagnosis and treatment should only be conducted under the supervision of a suitably qualified health professional. We therefore consider that, irrespective of any evidence which a Bowen therapist might hold, it is unlikely to be acceptable for Bowen Technique practitioners to refer to those conditions in their marketing communications.”

The Bowen ‘academics’ of the ECBS have apparently sent in a study on the effect of Bowen therapy on hamstring flexibility.  This is currently under review “by an independent expert to assess whether it is robust enough to support claims in advertising about Bowen’s efficacy in this area.”

While I await the outcome of that review with interest, my guess is that this is Marr et al (2010).  Previously I came to see that, “all this trial has demonstrated is improved hamstring flexibility in people without a hamstring problem, compared to other people with no hamstring problem who are just left to their own devices: unconvincing, to say the least.”

If a Bowen organization is relying on a trial on people without a medical problem to justify the use of Bowen on people who do have a medical problem, this would be a clear sign of desperation.

The Bottom Line

The ASA explained their current position to me as:

“… we are not aware of any evidence which shows that Bowen is efficacious in the treatment of any specific condition. With that in mind we are now advising Bowen practitioners with whom we are in dialogue, including totallybowen.co.uk, to remove any claims which relate to specific conditions. This may take some time and CAP may well have to conduct sector-wide compliance.”

Neither did the ASA see any merit in taking totally Totallybowen through a formal investigation, giving their reason as,

“totallybowen.co.uk are not in possession of any evidence and in light of the wider work we are doing, there seems little to be gained from proceeding with a formal investigation.”

This is a sad indictment of the advertiser.  I hope that they do the honest and decent thing by removing claims for which there is no good evidence from their website.

This saga also provides some background to a recent ASA adjudication against a Bowen Therapist called Howard Bult.  According to the ASA, he did not respond to them.  So they seem to have used the outcome of this investigation to assess the complaint.  Given the woeful inadequacy of the evidence relied on by the Bowen trade bodies, it’s no surprise that it was upheld.

It would be nice to think that dialogue with the Bowen peddlers and “sector-wide compliance” actions would protect the public from the wild, nonsensical and sometime dangerous claims made by Bowen practitioners and their trade organizations.  Looking at the grindingly slow progress that the ASA has been able to make getting homeopaths to advertise in a “legal, honest and decent” manner, I don’t expect substantial changes any time soon.

Disclaimer

I try to make sure that what I write is both accurate and fair.  If you think that I have got anything wrong please let me know.  If you are right I will happily change what I have written.

This is not medical advice.  If you need that see a properly qualified and registered doctor and not a Bowen Therapist, obviously.

Notes

* Commenter Kevin Minney pointed out that I’d not included a 2008 publication from The Journal of Bodywork and Movement Therapies. It’s not PubMed listed and appears to cover similar ground to the work published by Marr and colleagues in 2011 (Marr et al, 2011): hamstring flexibility. I’ve added the reference here for completeness (Marr, et al 2008) but there is too little information in the informal reproduced abstract from the ECBS to comment further.

References

Carter B. A pilot study to evaluate the effectiveness of Bowen technique in the management of clients with frozen shoulder. Complementary therapies in medicine. 2001 Dec;9(4):208–215. Available from: http://dx.doi.org/10.1054/ctim.2001.0481

Carter B. Clients’ experiences of frozen shoulder and its treatment with Bowen technique. Complementary therapies in nursing & midwifery. 2002 Nov;8(4):204–210. Available from: http://dx.doi.org/10.1054/ctnm.2002.0645.

Dicker A. Bowen technique–its use in work related injuries. The Australian journal of holistic nursing. 2005 Apr;12(1):31–34. Available from: http://view.ncbi.nlm.nih.gov/pubmed/19175268.

Dicker A. Using Bowen technique in a health service workplace to improve the physical and mental wellbeing of staff. The Australian journal of holistic nursing. 2005 Oct;12(2):35–42. Available from: http://view.ncbi.nlm.nih.gov/pubmed/19175262.

Duncan B, McHugh P, Houghton F, Wilson C. Improved motor function with Bowen therapy for rehabilitation in chronic stroke: a pilot study. Journal of primary health care. 2011 Mar;3(1):53–57. Available from: http://view.ncbi.nlm.nih.gov/pubmed/21359262.

Hansen C, Taylor-Piliae RE. What is Bowenwork®?  A systematic review. Journal of alternative and complementary medicine (New York, NY). 2011 Nov;17(11):1001–1006. Available from: http://dx.doi.org/10.1089/acm.2010.0023

Marr M, Lambon N, Baker J. Effects of The Bowen Technique on Flexibility Levels: Implications for Fascial Plasticity. Journal of Bodywork and Movement Therapies. 2008 Oct;12(4):388. Available from: http://dx.doi.org/10.1016/j.jbmt.2008.04.006

Marr M, Baker J, Lambon N, Perry J. The effects of the Bowen technique on hamstring flexibility over time: A randomised controlled trial. Journal of bodywork and movement therapies. 2011 Jul;15(3):281–290. Available from: http://dx.doi.org/10.1016/j.jbmt.2010.07.008

Edits

19/02/2012 A couple of links added to provide some context for the Edzard Ernst tweet, corrected to:

“ever wondered how to draw positive conclusion out of [largely] negative or non-existant evidence? here is how”.

26/02/2012 Bibliographic data updated for Marr et al (2011) and a note added referencing an earlier abstract published by the same authors (Marr, et al 2008).

22 Responses to “Bowen Therapy and the ASA”

  1. Excellent and measured review of available information. Thank you.

    You say that research performed by a CAM believer isn’t necessarily tainted, but the vast majority certainly is. This makes ploughing through the garbage particularly painful and having people like yourself prepared to do the job is very valuable,.

    • apgaylard said

      @Acleron: Thank you for the kind comment. I’ve certainly been expereincing a bit of CAM lit fatigue recently.

    • Does that mean that research carried out on surgical procedures by a surgeon is tainted? What about research on a pharmaceutical product carried out or commissioned by the pharmaceutical company that will be marketing it?

      Peer review is there for a reason. Literature reviews as part of any published material and good referencing using established methodology, together with statistics that can clearly eliminate bias. These are all relatively easy to check on. However it’s worth remembering that a lot of CAM stuff is going to be difficult to measure within the scope of current scientific thinking.

      You may be very fond of your dog, cat, Mum, and have no doubt about that. But you can’t measure it. Yet!

  2. Does the Journal of Bodywork and Movement Therapy, a peer-reviewed journal published by Elsevier count? October 2008 and July 2011 have an abstract and an article on Bowen, respectively.
    There will be a large-scale study coming out soon on Lymphedema reduction using Bowenwork after mastectomy. Keep your eyes open.

    I did observe a 65 year old asthmatic increase her tidal volume by 50% after a Bowenwork session. Love to have the chance to test it on a large cohort.
    Kevin Minney

    • apgaylard said

      Kevin: Thank you for your comment. Of course I’m happy to consider the Journal of Bodywork and Movement Therapy. I tend to keep to PubMed listed articles as a basic quality control measure. The July 2011 article your refer to is, I think, included in my piece. Assuming you are refering to the article by Marr et al: It’s cited under the bibliographic data for the e-pub; as that was the form it was available in when I wrote about Bowen last. I’ll update the citation for clarity. The October 2008 abstract isn’t available on the Journal site and isn’t on PubMed, which is probably why I missed it. May add a footnote though.

      I’ll be interested to see the Lymphedema reduction study. Please feel free to send me a copy when it comes out.

      I think the elephant in the room for me is basic plausibility. Is there any physiological reason why gentle superficial manipulation should improve a condition of the airways? In the absence of high quality evidence should Bowen practitions be selling this treatment for a potentially life-threatening condition?

      • Couple of points. Firstly as I’ve said, the research article is on PubMed and has been for some time. A full PDF is available on Wikipedia.

        Secondly I think the problem is that you might have a plausibility issue, but you are expressing personal opinion rather than any degree of understanding based on latest scientific understanding.

        I teach Phd students connective tissue theory and run human dissection workshops explaining how and why physiology and bio-mechanical elements are key in the management of issues such as asthma and other pathological presentations.

        Anatomy has traditionally been taught around the separation of tissues, muscles, bones and so forth. Unfortunately this is not how the body moves or behaves. Simply dropping the shoulders forward will inhibit the ability to breathe functionally. Changes in the neck or upper back will similarly affect respiratory function.

        Connective tissue is as the name suggests, connecting structures that by themselves are separate and distinct. Thus the traditional view of a hamstring will be a beginning and end at certain points. Dissective evidence extends this structure into the lower back and creates implication for functional stability and movement patterns.

        It’s why we have the diaphragm and then a whole list of ‘accessory muscles of respiration’. So yes there are lots of reasons why the most gentle of movements, not just Bowen will have significant impacts on respiratory function and this is a big element of respiratory work carried out by physiotherapists with the elderly or children.

        I love what this kind of thread represents. Enquiry and debate and discussion where we can air view or doubts. But condemning things that appear unusual simply because they haven’t been proven to our own satisfaction restricts and inhibits enquiry and progressive thought.

        Absence of proof is not the same as proof of absence!

    • apgaylard said

      @Julianmarkbaker
      I think you’ve misconstrued my comments on the research articles. The PubMed listed 2011 article by Marr et al is referenced (and linked to) in my post (It’s just that the bibliographic data is not up to date). It’s the 2008 publication Kevin mentions that does not, as it appears to be an abstract only, is not cited on PubMed, nor is it linked to in wikipedia.

      Of course this blog represents my opinion. It’s my attempt as a potential consumer of various services to see if I think the evidence stacks up.

      I’m happy to accept that you know more about anatomy than I do. I’ll accept for the moment, that what you outlined provides a plausible hypothesis for asthma treatment. As an asthmatic, what I need to see before spending my hard-earned cash (and trusting my health to a therapy) is the hypothesis tested and confirmed to a reasonable degree. For me, “a reasonable degree” would be a large (preferably multi-centre) controlled trial as an addition to conventional treatment (given the safety issue) with blinding to the degree possible in ‘touch therapies’ (patients unaware of the identity of the treatment, independent assessment of patients’ response, use of convincing control(s)). Ideally I’d like to see replication as well.

      In the absence of this sort of evidence I struggle to see that bold marketing claims are ethical. What I have noticed from looking at Bowen websites is that claims are not limited even to the limited trial evidence that exists. What that means is that very confident sounding claims are being made based on hypotheses and anecdotes. I don’t think that this properly informs choice.

      As for proof and it’s absence; I’m not arguing here that proof cannot be adduced in principle, but rather that it has not been. Personally, I’m OK with this therapy being researched (it’s not homeopathy after all). If some strong evidence emerges, then I’ll be delighted. However, it’s not OK to say that as proof could possibly emerge in the future, then it’s OK to make the claims now. It is also possible that the lack of proof is an indication of its absence; perhaps no good evidence will emerge from the search and hypotheses like the one you proposed will be falsified.

      What’s at the core of this for me is that heathcare (CAM or conventional) interventions should have been convincingly demonstrated to be effective before they are marketed to the public. If I’m condemning anything here, it’s not the search for understanding; rather, it’s the assumption inherent in these claims that understanding has been attained.

      I’d be interested to hear if you think that any of the claims for Bowen identified in this post are unwarranted (allergies, MS, Hormonal, pregnancy and fertility problems), or do you share the ECBS’s view that, ”In short, almost everything can respond well to Bowen treatment”?

      • Good response! You raise some valid and salient points. Asthma by itself is a condition which kind of doesn’t exist in real terms. A collection of symptoms which brought together and with often some reasonable markers, which point towards a respiratory condition triggered by many variants, lumped together and managed pharmaceutically, called for convenience ‘asthma’.

        Incorrect diagnosis, lack of functional understanding of the diaphragmatic relationships and their impact on respiratory health and lack of foresight all mean that current medical thinking states that there is no cure for asthma.

        There is no first aid for an asthma attack. If you get one in the middle of nowhere and there is no Bowen therapist there, you’re probably going to die. 500 people a year do in the UK!

        Yet to be honest your asthma doesn’t interest me as it’s a condition which you may or may not have according to current medical thinking. What interests me is how it affects you, what your functional position is, how you deal with your condition and what it means to you personally.

        I’m not going to treat your asthma I’m going to treat you. If you read all these ‘claims’ you will see that they should and I say SHOULD make this clear. The ASA (who incidentally are not a legal body and have no standing or ability to take any sort of action at all against anyone) is happy with the statement that Bowen and other therapies help people who are living with x.y or z. The difference is huge.

        As far as marketing is concerned, well you can’t make a rule for one and not the other. We take on board a whole range of treatment and drugs which have been mixed together to extend a patent, without there being any research done. Prozac, Ritalin, and half the antibiotics on the market are not being prescribed for the way they were designed. Back surgery has a success rate of around 24% and under that banner, success is defined by your pain not being any worse than before surgery in six months time!

        I do agree that some people make too many claims and I feel that these should be addressed and changed when it happens. Do I work with people with MS yes and their lives are hugely different as a result. Do they still have MS? Of course they do!! I didn’t set out to stop their condition just to help them get to the toilet without soiling themselves or to allow their husband to stay at work a bit longer.

        Want to talk about hormones? Press a fatty bit anywhere on your body. You’ve just pressed the biggest endocrine organ in the system, the adipose layer. Full of hormones. Pregnancy? I don’t have rubber gloves. Yet a woman with back pain or neck pain who presents, will find that I have a wide understanding of why. I’m not going to see if she’s dilated!

        And so we go on. Conditions don’t interest me, people do. The four rules we teach all our therapists are that 1) We don’t diagnose, 2) We don’t treat specific conditions 3) We don’t prescribe or alter medication 4) We don’t make claims as to efficacy of treatment.

        Researching asthma is something I would LOVE to do, and I have no issues with any of the guidelines you lay out. Problems? Well it’s a vicious circle and a little bit like being homeless. Because there is no research on the use of Bowen and asthma, it’s difficult to find someone to give you permission to do research. Mental eh? It makes me smile when people assume that all you have to do is rock up and say you want to research something and then the doors open.

        Sadly it doesn’t work like that. Ethics committees, statistics, box plots, pilots, etc etc etc. And then you have to have someone write it in a language that fits where it will be published, get it accepted, get it through peer review and then sit back and watch while every smart arse with half a brain cell tells you how crap it is!

        So again back at ya! Find me the facility and let’s draw up a protocol and put it to the local ethics committee. Actually statistically you would need to show some degree of change in relatively few people for asthma and wouldn’t need to blind the patient or have a control group. A mean improvement of peak flow (a crap way of measuring asthma IMHO) of say 20% over a group of 30 or so, maintained over 6 weeks would rock the world and would be early replicated.

        It’s been done lots anyway, but just not published.

  3. Interesting stuff. Well written, thoughtful and as sceptical as it’s possible to be. Actually you praise with faint damning and I’m relatively happy with what you talk about given the perspective you come from.

    Let’s remember that absence of proof is not the same as proof of absence and if all medical treatments were required to demonstrate the same level of proof that you seem to think all CAM treatments should, then the whole health system the world over would shut down.

    The VAST majority of practice within the field of modern medicine is unproven and untested according any standardised criteria and physiotherapy is pretty much anecdotal in it’s theory and approach.

    All medicine is, to some degree placebo as once you place a pill in the hands of the human GP, the degree of subjectivity becomes hard to measure.

    The ASA have dismissed themselves by recently suggesting that trials should be double blind, randomised controlled trials. So in other words the practitioner wouldn’t know if they were giving a sham treatment or not.

    Your hamstring comment is inaccurate and demonstrates a lack of understanding of the literature review. By treating a group of Asymptomatic patients, it demonstrates that the technique increases flexibility better than anything else that has ever been tried, so the comment is unfair and reflects on you poorly.

    The implication for this in relation to muscular skeletal issues is wide ranging, as the literature has demonstrated. It’s a good piece of work undertaken by Coventry University and has a lot of implications and potential. It is indeed on PubMed and Science Direct.com and is easily found with any referenced search.

    Do we need more study? Certainly. The quality needs upping and the rate increasing.

    A lot of the studies are relatively poor, but research is very expensive and time consuming. However it is evident that something is working and that Bowen is more than prepared to put itself under the microscope and be tested with rigorous protocols, outside of the remit of the technique and practice environment. It’s also worth remembering that Bowen has been in the UK only since 1992.

    I am however flattered buy your excessive attention. I would also challenge you personally to set any kind of test that you would like to see. Write the protocol, define whatever you would like and I will undertake to be supervised by you and or anyone you nominate, in testing any of the claims you object to. I don’t expect you to fund it as it is eye waveringly expensive. What I ask is that you put your objectivity where your blog is!

    The ASA have singularly failed to be a reasonable and legal moderator given the nonsense in their vocabulary.

    There comes a point when scepticism steps into the realms of which the sceptics themselves abhor, that of adherence to a rigid view in spite of evidence to the contrary.

    When someone, no matter how much evidence is produced countering the existence of something, continues in their belief of the illogical. I am feeling a little of this from your otherwise interesting blog.

    Julian Baker

  4. Julianmarkbaker said:

    “The VAST majority of practice within the field of modern medicine is unproven and untested according any standardised criteria and physiotherapy is pretty much anecdotal in it’s theory and approach.”

    That’s interesting – where did you find that?

    • “According to Clinical Evidence.com, only 15 % of the thousands of treatments they have reviewed have been proven to be beneficial. A further 23% are likely to be beneficial, 7% are a trade-off between benefit and harm, 5 % are unlikely to be beneficial, 4% are likely to be ineffective or harmful and a whopping 46% are of “unknown effectiveness.” Clearly, much more research needs to be funded before the NHS can claim to be evidence based.”

      MD aka Phil Hammond Column; Private Eye 2006,

    • apgaylard said

      Just read on interesting review that’s relevant here. It would appear that, on average around 3/4 of clinical practice is based on some form of compelling evidence (see page 4).

      Of course it’s important to distinguish between the percentage of possible treatments based on evidence, and the percentage of treatments used that are.

  5. Julianmarkbaker

    I’m probably just not seeing it, but I can’t find these figures on http://clinicalevidence.com – even a search for “unknown effectiveness” gives one page, but it doesn’t have the figures you’ve quoted. Do you have a link to the right page?

    Ta!

  6. Julianmarkbaker

    What I have been able to find are numerous claims that only 15% to 20% of treatments are based on good evidence – does that sound right to you? Have you come across this?

  7. apgaylard said

    @julianmarkbarker
    Sorry for the delay in responding – it’s been a busy few days. Still, I’ve been mulling over your very thought provoking reply, and I think I can see some common ground as well as substantial points of difference.
    First, I can’t say that I entirely buy into your view that “Asthma by itself is a condition which kind of doesn’t exist in real terms.” I can see where you are coming from, as the diagnosis is usually based on symptoms and response to interventions. However, that doesn’t mean that the symptoms are not caused by a real underlying disease in most people. In fact, as you must be aware, there is a lot that is understood about this disease; as well as much still to be discovered.

    I do wonder where you get your special knowledge from though. Stating that,

    “Incorrect diagnosis, lack of functional understanding of the diaphragmatic relationships and their impact on respiratory health and lack of foresight all mean that current medical thinking states that there is no cure for asthma”

    implies that you know something that doctors, consultants and medical researchers working in this field do not; that, somehow, you have not made the mistakes that blind them. You’ll have to excuse me, but I think that the state of affairs that you claim prevails is astonishingly unlikely.
    Your claim that, “There is no first aid for an asthma attack” is not really true. Yes, medical intervention is required, but there are important things individuals can do, like getting prompt help and using a inhaler. The implication that a Bowen Therapist could intervene and save a life using Bowen Therapy is a very rash claim given the evidence (you seem to be transgressing your ‘fourth rule’ here).

    “Find me the facility and let’s draw up a protocol and put it to the local ethics committee …”

    I understand that designing and running clinical trials must be hard; but it’s not my job, it’s yours:-) I’m just a careful consumer trying to weigh up marketing claims. If you want to sell me a therapy (or anything else) it’s your job to show that it works as advertised. In other words, the burden of proof lies with you.

    I must admit to being astonished to hear that, “It’s been done lots anyway, but just not published.” I have heard of negative results not being published (a problem that blights medical research of all stripes), but what’s the motivation for not publishing positive results? Given the standard of some CAM papers I’ve read, I’d be surprised if the researchers couldn’t get a journal interested. It makes me wonder if the work is just not credible. In any case, it’s a bit “the dog ate my homework” don’t you think?

    The other main strand of your argument is basically CAM holism: you are really interested in is helping people to live with whatever ails them. Have I got that right?

    If this is the case, why the claims for curing ‘asthma’? Why the interest in defining a trial? Why comment on hormones in the context of fertility?

    If you make specific, measurable claims about specific conditions, then you will be scrutinised on this basis.
    If all various therapists and their representative bodies claimed was that they were helping people with chronic conditions feel better, I wouldn’t bother blogging about them or contacting the ASA. My interest is in the link between specific claims and evidence, as well as the nature of evidence.

    It also makes me wonder why you were unhappy with the ASA? In one of your earlier replies you say,

    “The ASA have singularly failed to be a reasonable and legal moderator given the nonsense in their vocabulary.”

    If they are happy with your claims about helping people feel better, as you say, and this is what you are really interested in offering, then the conflict melts away.

    Now, the common ground: You say that, “I do agree that some people make too many claims and I feel that these should be addressed and changed when it happens.” I’m glad that you said that and I agree; which is what this post is about.

    I wonder, are you a member of Bowen Association UK (BAUK) or the Bowen Therapy Practitioners Association (BTPA)? Do you have any links with the European College of Bowen Studies (ECBS)? If so, would you be happy to help them moderate their claims?

    “The four rules we teach all our therapists are that 1) We don’t diagnose, 2) We don’t treat specific conditions 3) We don’t prescribe or alter medication 4) We don’t make claims as to efficacy of treatment.”

    If all CAM teachers and therapists followed your advice, then we wouldn’t be having this interesting debate (but I do think you’ve flirted with rule 4). I certainly think you have something to teach BAUK, BTPA and ECBS. I hope they listen.

    • “However, that doesn’t mean that the symptoms are not caused by a real underlying disease in most people” I can’t let you get away with broad unreferenced statements. Asthma by itself is not a disease. Symptoms caused by a disease doesn’t make a disease.

      “you know something that doctors, consultants and medical researchers working in this field do not” Yes I do. That traditional anatomy is fundamentally flawed when examining functional relationships. The position and function of the diaphragm is completely unchallenged in conventional terms. Yet it is firmly connected to the transverse abdominus and as a result subject to the transverse forces applied to it. It connects inferiorly to the pubis and the pelvic floor. If you look up these in an anatomy book you will not find them anywhere, but this doesn’t make them non-existent.

      My work teaches connective tissue dissection and in this I dissect the human form very differently to the way that it has been worked on for a long time. Anatomy means to cut up and the reductionist approach to the human form misses the relationships that make us able to function. Traditional explanations for the function of the diaphragm miss most of what is important.

      ” there are important things individuals can do, like getting prompt help and using a inhaler’ This advise is laughable and 500 dead people every year are testament to it. If you want to be able to save your life in an asthma attack I can show you how to do it. Or you can get help (if it’s around) and use an inhaler (golly who would have thought of that). If neither of these are available, you will die.

      It’s not a rash claim. I have quite literally saved the lives of several people using a simple move to create a change in the diaphragm. Status asthmaticus is very serious and I advise you not to be so naive in the idea that just because you haven’t heard of it, it’s not helpful. Similarly is the silly idea that if it works it will be used by everyone. Medicine is littered with brilliant ideas and useful techniques that will never be used and methods of working that are unproven and questionable, yet still widely used. Diabetes is littered with inadequacies as far as treatment is concerned for instance.

      The trouble is that politics in the tri-fector of first aid teaching means that it will take a few years before this will be universally taught. A paramedic has however quite categorically stated that this move is a life saver and has been used in emergencies on many occasions.

      “The burden of proof lies with you” Actually no it doesn’t and there is no law or rule that says it does. CAM in this country is governed by common law. Caveat Emptor. Buyer beware. It’s up to you to decide what choices you make for your health and no-one can stop you from deciding what is best for you.

      The ASA are a pointless organisation who regulate advertising. They have been very inconsistent with their requests and the line they take and have libelled several organisations in the process. However the thing to remember is that they have no power or legal standing in any way whatsoever. Criticism of anything by them is akin to being stung by a butterfly. I have responded to them and I advise most people to be responsible and then ignore them.

      The point is that we have to be able to say something. I have not mentioned a cure for asthma and never will. I have treated many people who have been diagnosed as having asthma. Most of them end up not having any more asthma type symptoms. As far as I’m concerned they still have asthma, just no symptoms. I’m not really interested in the name of a condition anyway, it’s the you and the rest of the world that hold on to that.

      The good thing is that we now have the debate about what we can or should say. I think that saying we can treat people who have asthma and thereby help with some of the symptoms they experience, is a reasonable claim. Anyone coming to me with any condition can benefit. Does that mean that they will not have symptoms of their disease? I don’t know. In any case the concept of benefit is many fold.

      Better sleep? Relaxation? More ability to stay at work due to less pain? etc etc. People want to know how people have benefitted and we want to be able to tell them about how we have helped. Research needs to be more accessible to this group. You sneer at the ‘quality’ of the research, without being a researcher. Yet the language that has to be used to get published is, quite frankly nonsense and beyond the capacity of most non academic people.

      Hence there are studies that will never be published, simply because they are to of acceptable quality, meaning that they have not been Harvard referenced or have a literature review.

      Remember that most medicine is unproven. Science is a blunt tool with which to dissect reality and has never addressed the major issues that we experience as humans. Absence of proof is NOT the same as proof of absence.

      • apgaylard said

        Hey, @Julianmarkbaker, where’s all the holism gone? What about your ‘rule 4’? I hope I’m wrong, but you are starting to sound like you really really want to make specific claims about specific conditions without proper evidence?

        On the asthma thing, the point is I’m not going to take something on the say-so of someone I know nothing about, making un-evidenced assertions on the internet. Particularly someone who claims special knowledge that contradicts the overwhelming scientific consensus. If I want to know about asthma I’ll consult asthma UK or the NHS. Your extraordinary claims come with less than ordinary evidence.

        As for me ‘sneering at the quality of the research’, no, that’s just the weary experience of carefully reading lots of papers and assessing them against very straightforward quality criteria. Is it only researchers in a field who can make assessments and form opinions? This sounds rather restrictive; a little like an elite reserving privilege for themselves.

        Of course, as a lay person, I may well make mistakes and welcome them being pointed out.

        As for your thin excuse for unpublished positive studies: I just don’t buy it. Language and formatting issues are not insurmountable. I’d have thought it not impossible to get some mentoring from a friendly academic. Peer reviews are actually sorted out for an author by the journal (but you know that).

        And now you return to the ‘most medicine is unproven’ line, that you were asked about by @Alan Henness earlier. Perhaps you’d care to provide a reference for these claims?

        The ‘science not addressing human experience’ thing is a bit of a red herring. What I’m disputing with you are specific claims made for specific, scientifically defined and measurable conditions; not love or well-being. And I’ve addressed the “Absence of proof is NOT the same as proof of absence” already, so won’t go around that again.

      • Hi again. Check out @alan henness and what he has found, namely that only 15-20 of all medical practices are based on good evidence.

        Things take a while to change. The word consensus is interesting and I’m very happy to present my evidence in the new book on Bowen and fascial continuity which comes out this year. Medicine and science changes its view regularly as well it needs to and if you keep up in certain fields you will see the changes. Maddeningly enough there is no medical specialty that addresses connective tissue or indeed the whole body. Mental isnt it? We move, breath and function as a whole unit, yet no-one is given the responsibility to address it!

        Overwhelming evidence on fascial continuity is well documented and in the public domain. Check out Robt Schleip, Andre Vleeming, Tom Myers, Gil Hedley, Thomas Findley ad nauseum and there is mountains of peer reviewed research addressing it.

        However I’m not that interested in convincing you, honest! As I’m sure you will know, respiratory function is inextricably linked to postural and bio-mechanical function. If you doubt this, then we can move no further and you need to take up your books and study!

        Pharmacology as a sole intervention misses an important element and that’s a choice people take. I think we’re going round in circles though.

        At the end of the day, if I had a serious condition, I would a) continue to take my medication and b) explore as many non invasive approaches as possible, keeping an open mind until I had tried them.

        Open mind eh? Now there’s a thought! :-)

      • Zeno said

        Julianmarkbaker said:

        “Check out @alan henness and what he has found, namely that only 15-20 of all medical practices are based on good evidence.”

        I didn’t find that only 15-20% of all medical practices are based on good evidence. I said I had found lots of claims that that was true – it is a very common claim made by proponents of alternative therapies, but that claim, like many of the therapies themselves, is entirely bogus because it does not represent what they think it does.

        You said earlier:

        The four rules we teach all our therapists are that 1) We don’t diagnose, 2) We don’t treat specific conditions 3) We don’t prescribe or alter medication 4) We don’t make claims as to efficacy of treatment.

        One of my local Bowen therapists claims:

        Some of the symptoms the Bowen technique may help you with are listed below. The list is not exhaustive!

        muscular or skeletal pain e.g. sciatica, coccyx pain, hip and knee problems, frozen shoulder, carpal tunnel syndrome, tennis/golfer elbow, bunions, hammer toes,
        poor mobility e.g. caused by stroke, surgery,
        digestive and bowel problems e.g. bloating, acid reflux,
        respiratory problems e.g. hay fever,
        earache, tinnitus and tension in the jaw,
        migraines and other types of headaches,
        infertility and menstrual problems,
        discomforts experienced during and after pregnancy e.g. swelling of ankles, backache, tiredness, and
        problems experienced with newborn babies e.g. colic, feeding difficulties.

        (Source, CNHC member)

        Another:

        Benefits
        Bowen technique is very effective for sports injuries, back pain, Sciatica, RSI, Tennis Elbow, neck and shoulder and knee and ankle problems, migraines, headaches, stress, chronic fatigue, ME and menstrual irregularities.

        (Source, BAUK member)

        And again:

        What can it safely treat:

        Back pain, neck pain, headaches, restricted shoulder,
        Frozen shoulder, tennis/golfers elbow,
        carpal tunnel syndrome, knee problems,sports injury. RSI, conditions such as chronic fatigue, respiratory problems, hayfever, kidney problems, high blood pressure, arthritis, hay fever and headaches.
        Bowen Therapy can also be used for stress management, fatigue and sleep problems. And wonderful for health maintenance.
        The last Bowen Back Pain project suggested that almost 90% of Bowen treatments could result in either a complete or partial recovery –

        Bowen Technique is currently being used at Children’s Clinics around the Country, helping young children to overcome difficulties with dyspraxia, learning difficulties and ADHD, amongst other conditions

        (Source, BTPA member)

        I suspect I could find many, many more making similar claims to treat/help a wide variety of medical conditions.

      • Zeno said

        Just so there is no confusion, I logged in to WordPress to reply this time and it used my alias, Zeno, rather than my full name, which I had used in my previous comments.

        Alan Henness

  8. [...] A Canna’ Change the Laws of Physics Bowen Therapy and the ASA [...]

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