Individual Enquiry Research Paper 2012 Title Author

Individual Enquiry
Research Paper 2012
Title: Oncologists and cancer specialists’ expert opinion
on the role of osteopathic treatment on patients with
Author: Dawn Hammond BSc (Hons)
Supervisor: Mr Chris Thomas MA (Med Ed) BSc (Hons)
The British School of Osteopathy
275, Borough High Street, London, SE1 1JE
Background: 1 in 3 people in the UK are affected by cancer according to Sasieni et
al (2010). Despite this Walters et al (2011) report improving cancer survivorship.
Mallik & Leonard, (2009) predict increasing numbers of these patients presenting to
manual therapists with musculoskeletal problems. Hann et al (2004) suggest little is
known about cancer specialists’ views on manual therapy.
Objectives: Explore cancer specialist’s opinions on the risks and benefits of
osteopathy on patients with cancer. Explore their experiences of patients having
manual therapy. Investigate their rationale for referral.
Methods: 12 semi-structured qualitative interviews were conducted with cancer
specialists’. The interviews were analysed using elements of grounded theory. Intrarelater reliability found 98% agreed. Inter-rater reliability found 89% was agreed after
discussion of errors and omissions.
Results: Benefits were associated with osteopathic treatment on patients with
cancer. Oncologists did not believe osteopathy increased metastatic spread risk but
were concerned about increased fracture risk. Few oncology consultants informally
recommended osteopathic treatment.
Conclusion: Participants agreed there could be a role for osteopathy in the care of
patients with cancer. Education, collaboration and research are required to facilitate
inclusion into oncology healthcare.
Key Search Words: Osteopathy, Chiropractic, Physiotherapy, Manipulation,
Massage, Manual therapy, Cancer, Oncologists
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Sasieni et al (2011) state, that 1 in 3 people are affected by cancer in the
United Kingdom (UK) and according to Cancer Research UK (CR UK) (2011) the
most common cancers diagnosed in the UK, in order of prevalence are: Breast,
Prostate, Lung, Bowel, Malignant Melanoma, Lymphoma, Bladder and Kidney
Cancer. Walters et al (2011) report UK cancer survival rates improved in 21 common
cancers. Mallik & Leonard, (2009) propose long survivorship of patients with cancer,
means an increased chance of developing other chronic conditions which may
initiate use of complementary and alternate medicine (CAM). Increasing cancer
prevalence and improving survival rates suggest osteopaths might be more likely to
come into contact with people who have a history of cancer. It is therefore beneficial
to gain opinions of cancer specialists’ with expertise in the most commonly
diagnosed cancers into treatment of this patient population.
Existing research on Oncologists opinions
Hyodo et al (2003) and Samano et al (2005) conducted questionnaire studies
on oncologists’ opinions of CAM of 751 and 119 participants respectively. They
found the majority had a lack of knowledge of CAM citing a lack of supportive
scientific evidence but despite this 92% and 68.8% respectively accepted the use of
CAM on patients with cancer. Hyodo et al (2003) and Hann et al (2004) found a large
proportion of oncologists support the use of massage on patients with cancer. Hann
et al (2004) found physicians commonly believed patients pursued CAM to take
control of their treatment. Samano et al (2005) identified a significant positive
correlation between oncologists with personal experience of CAM and their
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recommendation of CAM to patients. Hann et al (2004), Habermann et al (2009) and
Cox (2010) recommended research into cancer specialists’ opinions specifically on
manual treatment on patients with cancer, where as existing research investigated
opinions on CAM in general.
Existing referral recommendations
The G.Os.C (2006) and Schneider & Gilford (2008), report most patients self
refer. The G.Os.C (2006) found that only 1/5th of all patients presenting to an
osteopath were referred by a doctor, however Schneider & Gilford (2008) provided
no evidence to support this statement.
The Department of Health musculoskeletal services framework (2006)
recommend development of multidisciplinary teams to reduce waiting times and
better care for common musculoskeletal complaints. CR UK (2009) advocates the
use of osteopathic treatment, The National Institute for Health and Clinical
Excellence (NICE) (2009) suggest manual and manipulation treatment for non
specific low back pain, whilst The National Cancer Action Team (NCAT) (2009)
recommend physiotherapy for patients with cancer, guidelines include; teach
exercise, set purposeful activity, postural re-education, massage/mobilise soft tissue,
use of a TENS machine, use of heat and cold to ease pain and help with positioning.
Cancernet UK (2011) state osteopaths use similar treatment modalities to
physiotherapists with additional training in manipulative therapy.
Bengough (2010) proposed barriers to osteopathic treatment of life limiting
illnesses to be lack of knowledge, guidelines and the need to improve
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The Department of Health (2006), CR UK (2009), NCAT (2009) and NICE
(2009) recommendations all imply a potential role for osteopathy.
Concerns about Metastasis
Cox (2010) found osteopaths were concerned that improving fluid health in a
patient with cancer might accelerate the disease. Lerner (1994) and The
International Society of Lymphology (2003), theorise that massage increases blood
flow and mechanical compression could promote metastasis by tumour cell
mobilisation. Godette et al (2006) argued metastasis of cancer is a biologic process,
not the cell’s capacity to disseminate but ability to grow in a new location facilitated
by the microenvironment. Godette et al (2006) argue manual lymphatic drainage
does not contribute to the spread of cancer and should not be withheld from patients
with metastasis however evidence was not provided to support these claims.
Wu et al (2010), investigated 70 patients with osteosarcoma that had
manipulative therapy with massage to the site of an osteosarcoma tumour prior to
diagnosis of cancer, and found a significantly poorer five year survival rate and
significantly greater incidence of lung cancer metastasis compared to 68 with no
manipulative therapy. Wu et al (2010) theorise this may serve as a mechanism to
spread tumour cells recommending manipulative treatment should be avoided in
Shah & Salzman, (2011) conducted a review of imaging techniques and
appearance of spinal metastases, reporting spinal metastasis occur in 60-70% of
systemic cancer patients but only 10% were symptomatic. They believe the
mechanism to be haemodynamic with the venous route of Batson's plexus thought
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more important than the arterial route, rarely via the lymphatic system or direct
Risks of reduced bone mineral density
Howe (1993), Davis & Taylor, (2007), Roudier (2008) and Shah & Salzman,
(2011) believe bone metastases result in bone mineral density reduction.
Ernst (2007) identified three patients with pathological fractures following
manipulative therapy when a diagnosis of cancer had been missed in a systematic
review of manipulative therapy between 2001 and 2006. However, Breen (2006)
found his exclusion criteria neglected studies which tested the effectiveness of
Roudier (2008) found bone metastases from prostate cancer appearing with
increased bone density on x-ray, were under mineralised resulting in increased bone
fragility. The small sample of 12 cannot be generalised to all prostatic metastases.
CR UK (2009) caution against the strong manipulative techniques on patients
with: osteoporosis, bleeding disorders, broken bones, cancer of the bone, spinal cord
or marrow, during radiotherapy treatment and anticoagulant or steroid use.
Benefits of manual therapy on patients with cancer
According to the World Health Organisation (2010) osteopaths undergo
extensive training over a minimum of four year’s full time, which overlaps medical
training covering: anatomy, physiology, pathology, clinical methods and identification
of pathology where treatment is not appropriate and referral for further investigation
is required.
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Osteopathy Guide (2010) proposes the benefits are: assist pain management,
reduce tension, help mental outlook and relieve debilitating side effects from
chemotherapy and radiotherapy. However, there was limited research identified on
the effects of osteopathy on patients with cancer therefore this study explores the
effects of the manual therapies of: massage, chiropractic and osteopathic treatment
on patients with cancer.
Effects on pain, mood and quality of life
Kutner, et al (2008) performed a multisite study of 380 participants with
advanced cancer examining massage effects on pain and mood compared to simple
touch demonstrating the benefit of massage over touch. This was well documented
and reproducible, performance bias was possible.
Jane et al (2009) found massage significantly reduced pain and fatigue in 30
patients with bone metastasis for up to 18 hours. The method was well documented
although weakened by variations in analgesia and small sample and therefore
difficult to extrapolate to the population with bone metastases. Performance bias was
Kutner et al (2008) and Jane et al (2009) reported improvement in pain levels
and mood in patients with cancer treated with manual therapy.
Effects on function
Schneider & Gilford (2008) and Hojan, et al (2011) report improved range of
movement in individual case studies. In a case of chiropractic treatment of a
terminally ill cancer patient with low back pain Schneider & Gilford (2008) reports
reduction of medication and improved quality of life. In a case of abdominal cancer
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Hojan et al (2011) describes physiotherapy and osteopathic techniques improving
pain and fatigue. Individual case studies cannot be generalised to the population of
patients with cancer but demonstrate treatment approach and effect.
Clemens et al (2010) found 94% of 90 patients had symptomatic relief with
lymphatic drainage reporting improvement. Variations in analgesia, small sample
and lack of control group weaken this study. Treatment was discontinued in four, as
manual therapy exacerbated their neuropathic pain which the authors dismissed as
oversensitivity to touch rather than an adverse response to treatment.
Stringer (2008) found one 20 minute light massage on 39 haematological
participants undergoing intensive chemotherapy, significantly reduced cortisol levels
temporarily and improved well-being. She suggests a potential effect on the immune
system, if reduction of high levels of cortisol were sustained. The sample was small
but the procedure was well explained and reproducible. Noll et al (2010) conducted a
multicentre study on 406 participants reporting a statistical significant improvement
with osteopathic treatment on patients with pneumonia resulting in reduced antibiotic
duration, reduced hospital stay and reduced respiratory failure suggesting an
influence on immune function. Noll et al (2010) did not investigate participants with
Study relevance
The aim of the study was to find out if oncologists refer patients with cancer to
osteopaths and what they refer patients for. Investigate oncologists’ views on the
risks and benefits of osteopathic treatment on patients with cancer and explore a
potential role of osteopathy in the treatment of musculoskeletal symptoms in patients
with cancer.
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Qualitative semi-structured interviews were used to obtain cancer specialists
opinions, views and experiences. Dawson (2009) recommends semi-structured
interviews to compare and contrast interview content, explore detailed participant
experiences and provide time and opportunity to discuss opinions and views.
160 oncologists were invited within 50 miles of the British School of Osteopathy
(BSO) taking every third name from the Dr Foster database and members of the
National Cancer Research Institute. Recruitment and interviews took place between
October and November 2011. Response rate was 8.75%.
A purposive sample of 12 currently practicing cancer professionals participated in
the study: nine Oncology consultants, two specialist cancer nurses and one palliative
care registrar. Sample size was determined by the BSO (2008) guideline for
interview studies of four hours of recorded interview material or 8-12 participants.
Participant criteria
Inclusion: A preliminary questionnaire (see appendix 3) identified participants
that either referred a patient or had personal experience of osteopathy,
chiropractic or massage.
Exclusion: One participant was excluded as they had no personal experience
and had not referred a patient with cancer for manual therapy.
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Materials sent to participants:
Letter of invitation (see appendix 8),
Participant information sheet (see appendix 1),
Two consent forms (see appendix 2)
Preliminary questionnaire (see appendix 3)
Other materials:
Researcher Interview Script (see appendix 7),
Digital Voice Recorder.
Weft QDA software (2006).
MindApp Premium (2011).
questionnaire, and invitation to participate were sent to participants.
Participants were given two weeks following receipt of a signed consent form
before arranging the interview to facilitate a period allowing participants to change
their mind about participation.
11 face-to-face Interviews were conducted in mutually convenient quiet
locations, two over the phone due to these participants current location. An
introducing question advocated by (Kvale, 1996 pp.133) was used to “break the ice”.
Open ended questions (see appendix 7) allowed participants to respond with
“richness and spontaneity” as recommended by (Oppenheim 1992 pg 81). Interviews
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were recorded using a digital voice recorder lasting between 5 and 32 minutes, four
hours in total were transcribed by the author.
Interview question content, validity and efficiency were discussed with the
supervisor and reviewed by a professor of oncology.
One pilot interview was conducted to trial the questions, identify bias, improve
interviewer skills and check interview timing. This identified confusion about the
therapies being discussed after discussing CAM therapies. Manual therapies were
specified as osteopathy, chiropractic and massage and CAM questions were
removed to prevent confusion.
Intra-rater reliability was assessed as 98%. Assessed with inter-rater reliability 89%
Data Analysis
Interview transcriptions were offered to participants to review the content prior
to inclusion in the study. No participants requested this option.
Interview data was analysed with content analysis and elements of grounded
theory. The interview transcripts read, reread and analysed for themes, meaning and
associations. Software package Weft QDA version 1.0.1 (2006) was used to collate
themes. Software package MindApp Premium version 7.0 (2011) was used to
graphically display the data.
Study ethics approval
The BSO research committee gave approval on May 14th 2011. The NHS
Ethics committee stated approval was not required providing the study commenced
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after September 1st 2011 as participants were professionals. The NHS Research and
Ethics Committee agreed with the NHS Ethics committee that approval was not
required see appendix 4 & 5.
Confidentiality & Anonymity
The participant information form asked participants to avoid names or details
that may lead to identification. Interviews were transcribed excluding names and
identifiable details to protect identity.
Participants were allocated a reference number so anonymous quotes by the
participants could be used in the study. Name, contact details and digital recordings
were securely stored by the author for the duration of the study then in a locked
cabinet at the BSO on completion of the study for a period of six years after which
they will be destroyed.
Selection bias is likely as participants chose to take part in the study. To
minimise misunderstanding questions which might lead to bias, questions were
checked with the research supervisor, a professor of oncology and piloted with an
Oncology consultant. Open questions were used to minimise question leading
question bias.
There may be researcher bias as the author was studying to become an
osteopath. To minimise reporting bias 16.7% of the interview data was transcribed
and analysed by another final year osteopathy student then discussed and
compared for inter-rater reliability.
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Data analysis identified five themes: understanding of osteopathy, referral route, time
constraints, manual therapy effects (see figure 2.0)
Participants details
Participant details
Occupation Oncology consultant
Oncology nurse
Palliative care registrar
Participant numbers (gender)
9 (5 males, 4 females)
2 (1 male, 1 female)
1 (1 female)
Fig 1.0 Areas of specialisation
In order of prevalence the areas of cancer specialism were: Haematology, Breast,
Kidney, Various, Lung, Prostate, Bowel, and Lymphoma.
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Uncertain of
osteopathic training
No manual therapy
Areas of the body
Joint manipulation
Colleagues’ views
Evidence based
of osteopathy
Personal experience
Concern about cost
& availability
No cost to patient
Ease of access &
Existing hospital
Barriers to
No formal guideline
Perception of the
effect on the body
Lack of supportive
evidence base
Patient experience
for manual
Risk of fracture
Limited time:
Prioritisation of
training needs
Oncology further
training time
NHS waiting lists for
physio and pain
Long wait
Risk of metastases
Reduction of pain
Feeling of control
Negative effects
Positive effects
Risk of discomfort
Manual therapy
effects & role
Risk of infection
Improvement of
Fig 2.0 Interview data themes and sub themes
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Improvement in
function, mobility
and movement
Theme one: Understanding and perception of osteopathy
This theme was divided into sub themes of training, treatment perception,
colleagues’ views and evidence base.
No oncology consultants had training on any manual therapies. One nurse
and one palliative care registrar had undertaken post graduate training explaining
risks and benefits associated with manual therapy. Eight participants (66.7%)
described their knowledge of osteopathy originating from personal or patient
experience with two participants (16.7%) claiming no knowledge at all.
I don't think there is enough knowledge about chiropractors and osteopaths. I
think that is something could be, we could all be more educated about that with
more education and more links between the two professions we would be able to
refer patients on.” (9)
Uncertainty was identified on the level of training of the osteopathic profession
and if identification of serious pathology was covered. One oncologist expressed
surprise at the length of time required to qualify as an osteopath.
“You know, I think I would hope that in manual therapists training they also train
to be aware of what the red flags would be with regarding cancer.” (1)
“I can remember at least two cases where the chiropractor or the osteopath told
the patient this is not right just go and see a specialist and then do something
about it. It just doesn't sound right which was very good, very perceptive.” (12)
Osteopathic treatment perception
Participants commonly described osteopathic treatment as: manipulation of
the joints and the bones in the limbs and in the back. One participant described
osteopathy as a holistic view of looking at patients.
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“Alignment of musculoskeletal systems.” (1)
“Osteopathy would be manipulation of the joints and the bones either in the limbs
or the back.” (10)
Participants described conditions helped by osteopathy as: mechanical,
chronic or degenerative back pain, muscle soreness, mobility, balance problems and
repetitive strain injuries.
“Alleviates um, um, pain and other problems people have with their back and
mobility” (2) “Mechanical back pain” (2). “Degenerative back problem.” (2)
“It is a useful thing to do because they get more suppor.t” (2)
“I think specifically the main benefit would be when a patient has muscle spasm
associated with muscular pain. Muscle spasm associated with joint pain because
of misalignment of joints as a result of muscle spasm. Which, could be caused by
a problem with another joint causing asymmetry, causing an isolated muscle
problem?” (9)
“I suspect you see muscle soreness and chronic back ache.” (12)
Confusion existed for participants on the difference between chiropractic and
osteopathic treatment.
“I get kind of confused between chiropractors and osteopathy.” (10)
“I had an idea that it is similar to chiropractors but that’s it really.” (12)
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Colleagues views on manual therapy
Six participants (50%) did not know what colleagues thought about manual
therapy on patients with cancer having not discussed this topic with colleagues.
“Um, and depending on how intelligently they realise they don't understand um so
will sort of say I don't know and some will say don't touch it with a barge pole.” (1)
“I guess not so many necessarily talk about it so much apart from the sort of
physio side.” (7)
“that is difficult as I've never really asked them.” (10)
complementary to standard medical treatment on patients with cancer and
encouraged it. Nurses and palliative care team colleagues were thought to have a
positive outlook on manual therapy on patients with cancer.
“I think physiotherapy and massage are viewed very positively by the palliative
care profession.” (9)
Two (16.7%) felt colleagues had a negative outlook suspecting some bias
against osteopathic and chiropractic practice as they are thought to be poorly trained
with a lack of supportive evidence.
“Chiropractors and Osteopaths would have a little bit more knowledge to dispel
the myths that we have about them and to practice more safely. So I think more
education is necessary in the two areas.” (9)
“I’m not sure if they are sceptical in a bad way, I just think they feel if there is not
enough evidence they wouldn't feel comfortable strongly recommending
complementary therapy.” (10)
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Osteopathic evidence base
Seven participants (58.3% or 77.8% of oncologists) felt there was the lack of
evidence based research to support the use of osteopathy on patients with cancer.
“Yes, evidence you need if you want to recommend things.” (2)
“I don't know enough about it and my mindset has always been that is there
evidence, are there trials, what's there experience of it.” (8)
“You know, in, in, um in our cancer. Very evidence based you know on trials and
things. Um, you know, I don't like commenting on anything unless I have actually
read about it properly.” (10)
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Theme two: Referral
This theme was divided into sub themes of protocol, convenience, confidence,
manual therapy referral, communication.
“It's all a question of priorities. In oncology you have to look into what the real
problem is for the patient what they are really suffering for and adjust your
treatment accordingly.” (2)
11 participants (91.7%) felt there was no set protocol for referral for
musculoskeletal symptoms. All participants described running appropriate tests or
scans were run to check if symptoms were related to cancer. If unrelated to cancer
then either prescription of analgesia and/or three participants (25%) described
referring for physiotherapy (despite 10 (83.3%) having referred for physiotherapy at
some point), two (16.7%) referred for massage (despite nine (75%) having
recommended massage at some point), one (8.3%) referred to a cancer nurse
specialist and one referred back to the GP.
“The first thing you do is try to work out if it is related to their cancer or not. That's
my job if you so like. So, you do scans, you know you take a history, you examine
the patient with scans, um, and then you know, if the problem isn't related to
cancer.” (2)
“We only refer our patients when they are safe enough to receive manual
therapy.” (5)
“If they have things that seem to be joint aches and pains we can prescribe
painkillers for that and again refer them for physiotherapy. If it seems to be a bony
problem for example bony pain from metastatic disease we don't tend to refer
them unless there is any associated muscle spasm.” (9)
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symptoms reported to
Related to cancer?
X-ray, MRI, Blood tests
Medical treatment e.g.
Referral to either:
Physiotherapy, GP,
Nurse Specialist,
Fig 3.0 Referral decision process
A common theme regarding referral pathway was the convenience of existing
hospital services. Participants described existing hospital services as the more likely
referral pathway and reasons given were: ease of access for patients, no cost to
patients and the ease of communication with hospital services.
“So unless they have the resources to get private physio we don't tend to refer.”
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Nine (75%) described massage as readily available in the hospitals visited
and widely accepted.
A lack of confidence in manual therapies was demonstrated by two
participants. A first-hand experience of two missed cervical spine fractures from road
traffic accidents and a second-hand report of two vertebral artery dissections
associated with manipulative treatment. None of the patients involved had cancer.
“Um, vertebral artery dissections, so um, it’s just when I was doing neurology we
had a few people that had some neck manipulation that went a bit wrong. So
that’s the only real experience I’ve had.” (7)
“I've heard about situations where medical issues like cervical spine fractures
have been missed by chiropractors and osteopaths leading to delay in diagnosis
after things like road traffic accidents probably on about 2 occasions.” (9)
Manual therapy referral
No cancer specialists referred patients for osteopathic treatment. Reasons
given included a lack of understanding of the profession, a lack of evidence base,
unsure of where available and concerns about patients’ financial situation. One felt
all patients should have access to osteopathy on the NHS and it would be beneficial
to patients with or without cancer. One described some cancer treatments as known
to cause musculoskeletal symptoms and these were normally self limiting.
Two (16.7% or 22.2% of oncology consultants) recommended patients
consider osteopathy or chiropractic treatment.
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“particularly for patients that don't have recurrence of cancer I do sometimes
suggest, have you thought about chiropractic or osteopathy?” (1)
“Well, um, I suggest to them that they consider it. I mention it if they have
mechanical back pain without any particular significant reasons behind it then I
suggest them to consider that.” (2).
These two participants would not refer to one practitioner over another. Both had
personal experience of osteopathy.
“No, I would never make a formal referral I suppose as I don't want to be seen as
recommending one particular practitioner over another.” (1)
“I try not to promote one practitioner in particular or I just suggest to them to have
consider it or what will work for them.” (2)
Seven participants (58.3%) thought personal experience an important factor in
their decision regarding referral/recommendation of manual therapy treatment to
their patients.
“I mean, yes for physical pain issues from my experience I've found chiropractic
and osteopathy helpful.” (1) “Your personal experience helps you with your
decision making process. Absolutely” (1)
“I've had personal experience in terms of having the common term is slipped discs
and having a course of osteopathy for that with acupuncture and it worked. I was
absolutely amazed by it. So I have a lot of faith in it.” (5)
Nine participants (75%) felt patients discussed their musculoskeletal
symptoms with them, Two (16.7%) felt only some patients did and One (8.3%)
suspected not all patients mentioned their musculoskeletal symptoms. Six
participants (50%) were aware their patients had self referred for a manual therapy.
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Five participants (41.7%) would like to be contacted regarding manual therapy
treatment on patients with cancer. One did not always see the same patients. One
felt it important to be fully informed what treatment was being undertaken by
patients, one felt it unnecessary.
Preferred communication methods were: telephone call, bleep, or
meeting. Concern was expressed about the use of emails due to passing patient
sensitive data using this unsecure method. Participants recommended getting to
know the local oncology consultants' preferred level of contact and method.
“I don't always see the same patients.” (1). “I am happy to be contacted about any
aspect of my patients care but I don't think that it is mandatory for me to know
what is going on as the patient will have made in most cases made that
independent decision themselves to go to that practitioner.” (1)
“The majority of healthcare professionals should be now on NHS.Net. So, should
be contactable. Because there's also the thing about patient confidentiality and
yeah, um, sending secure information over email, Secondly is calling, phoning.
So, you know like, our team don't mind being phoned by anyone outside this
particular organisation or being bleeped or paged.” (5)
“Um, it’s normally phone calls or MDT's”. “a meeting once a week where the
physios, the OT, the nurses and doctors sit down and discuss the progress of the
patients.” (7)
“I mean the best way would be that you just ring the secretary. The secretary is
always there. And then leave a message and then we would chat to you.” (10)
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Theme three: Time constraints
This theme includes sub themes of waiting lists, appointment times, and time
pressures on cancer specialists.
A common theme was time constraints within the NHS. Four participants
(33.3%) mentioned long waiting lists for physiotherapy and pain clinic appointments
which were a concern as sometimes patients with cancer did not have time due to
their disease.
“So, um, this is not related to his lymphoma so currently he's waiting from an
appointment with the experts at the back clinic which is a 4 month wait.” (2)
“Um, in general because there's, sort of restrictions on how much time the physios
have to see patients.” (3)
“There are a lot of patients that probably would benefit from things like
physiotherapy but the NHS we know that there is a very long waiting list.” (9)
One participant described their oncology appointments as short 15 minute
“If you see my clinics unfortunately they have 15 minute slots at which time I need
to see how they get on with their chemo or any new symptoms make them a
management plan so we will not have the time to discuss about all the other
things around their lifestyle.” (12)
One participant had a concern that should manual therapy training become
available time pressures would make this a low priority due to existing time
“We are all very busy and have a lot of pressure on our time. So, in the scheme of
things if we were to have a seminar on osteopathy and its benefits verses the
newest chemotherapies and its toxicities then I would have to say that the
osteopathy one would lose.” (1)
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Theme four: Manual therapy effects
This theme was divided into sub themes of positive and negative effects
Massage, spinal manipulation and lymphatic drainage were discussed.
100% of participants had something to contribute regarding the benefits
associated with manual therapy and 0% had come across negative effects
associated with manual therapy on patients with cancer.
Positive effects on pain, mood and lymphoedema
11 participants (91.7%) thought manual therapy could help reduce
lymphoedema (33.3% weakly), improve mood (50% weakly) and reduce pain (58.3%
weakly). The types of pain described were: degenerative, tension pain, muscle
spasm and misalignment of joints. Effects on mood were described as inducing
relaxation, a positive effect on mental state, endorphin release, therapeutic
interaction, distraction technique, placebo and reduction of anxiety.
“Well, regardless of whether there is any evidence for it there will always be a
placebo benefit to manual therapy because you are having a one to one
interaction with a patient.” (11)
Positive effects on function
10 participants (83.3%) felt that manual therapy might be able to help with
fatigue (75% weakly). Eight participants (66.7%) felt manual therapy could help joint
stiffness attributed to muscle spasm, reduction in function and immobility. Four
(33.3%) felt manual therapy might help improve immune function.
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” Improving the mobility of the joint or um, helping them to improve their
movement probably has a beneficial knock on effect, err, you know it may sort of
improve things that they may not require pharmaceutical intervention.” (3)
“So if you've had a breast cancer patient that's had a breast operation and then
they have got shoulder stiffness that is limiting your ability to give radiotherapy or
something then you might refer to a hospital physiotherapist to work on that so
that we can then give treatment.” (3)
Feeling of control
Three participants (25%) felt strongly that manual therapy helped patients
regain a sense of control in their treatment. The nature of the disease and hospital
treatment involves patients having things done to them and often results in feeling a
loss of control.
“It gives them a feeling of control. Because cancer, one of the main issues is that
you are not in control.” (2)
“Often patients feel something is being done and if it’s of benefit to them then yes
that can give them a sense of control because when they are in hospital so much
is taken out of their control. Having a lot of things done to them.” (5)
“Yeah I think it's not just passive. You are not just laying there waiting for the next
drip to come along.” (8)
Negative effects on bone density
Eight participants (66.7%) had concerns the presence of bony metastases
could weaken bones resulting in an increased risk of fracture. One (8.3%) felt
prostate metastases resulted in increased bone density.
“I suppose the cervical spine is a particular area to avoid. In terms of things to be
cautious about I think bony metastasis or a risk of osteoporosis whether it's
brought about by menopause or by medical treatments.” (9)
“I suppose there is the risk of some causing deterioration of bony disease if you
are manipulating bones and joints that have cancer in them. You could give them
a pathological fracture. Worst case, even, cord compression”. (11)
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Other possible negative effects described were: Increased bruising with low
platelet count, increased risk of infection spread to immune compromised patients,
sore skin from radiotherapy and the movement of blood clots with massage.
Concerns about spreading cancer
No participants had concerns the technique modalities of joint manipulation,
articulation and lymphatic techniques would spread cancer further in the body.
Concerns were that treatment might cause further discomfort.
“I'm not worried about spread of cancer. Basically once the cancer has got to the
spine it is incurable anyway.” (1)
“I don't think spread really it's more about underlying fragility” “No, I'm assuming
that is a myth. What I worry about is that they might hurt from the treatment itself
not that the cancer might spread.” (8)
“No, no. More as to how the patient will feel afterwards and of course with regards
as we said to the bone mets is risk of fractures, sprains, things that may make the
patient feel more unwell.” (9)
Two participants (16.7%) were concerned massage directly onto a tumour site
might cause the tumour to spread. These participants refer for massage stating that
they trust the massage therapists to avoid tumour sites.
“If somebody had a big tumour in their abdominal wall that was obviously
palpable, Um, I think if somebody vigorously massaged that and pushed it about
then it is possible that some cells might fly off. But, I think that most sensible
human beings wouldn't undertake that.” (1)
“If there is a malignancy in the leg in the muscle and there is massage to that part
of the leg then of course there is a risk of spreading it.” (Participant 7)
No participants felt the movement of lymph contributed to the spread of
cancer throughout the body. One (8.3%) felt that massage avoided lymph nodes and
that manual therapy did not influence lymphatic flow around the body.
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“Not really, lymph glands are in the armpit, or in the groin or in the neck. You don't
really massage those.” (5)
“What about the influence of manual therapy on the lymphatic system influencing
lymphatic flow? No it shouldn't.” (5)
One (8.3%) felt manual therapy techniques would not spread the progression
of lymphoma (cancer of the lymphatic system) throughout the body although
ultrasound and electro therapy might.
“They say that you should avoid ultrasound and electro therapy as this may
advance the cancer progression.” (2)
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Study aim
The study explored the experiences and opinions of these cancer specialists
on the use and effects of manual therapies on patients with cancer. The study
consisted of semi-structured interviews of nine oncology consultants, two cancer
nurse specialists and one palliative care registrar with experience either referring a
patient for manual therapy or personal experience. The participant sample had
expertise in the seven most commonly diagnosed cancers in the UK with the
exception of malignant melanoma with reference to CR UK (2011).
10 participants (83.3%) felt their patients discussed their musculoskeletal
aches and pains with them, however, no evidence was found supporting the
Department of Health (2006) referral to multidisciplinary teams dealing with
musculoskeletal symptoms. 10 participants (83.3%) had referred for physiotherapy
as recommended by NCAT (2009), however, there did not appear to be a protocol or
guideline for referral of musculoskeletal symptoms for patients with cancer. Each
specialist described a clinical decision to first rule out cancer as the underlying cause
then recommended either analgesia or referral to one of the following:
physiotherapist, a cancer nurse specialist, massage therapist or back to the GP.
Factors described influencing referrals were: the existence of bony metastases,
patient ability to cope with further treatment, long waiting lists and patient finance.
Existing research found a small percentage of cancer specialists refer or
recommend therapies such as osteopathy or chiropractic care to their patients with a
larger percentage in favour of massage therapy. Hann et al (2004) reported 40% of
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oncologists recommended chiropractic treatment and 84% recommended massage.
The study findings seem to support this with 16.7% recommending patients consider
osteopathy and 75% recommending massage, further research is required to
investigate this finding.
Two oncology consultants (22.2%) that recommended patients consider
osteopathy or chiropractic treatment had positive personal experiences. A correlation
between personal experience and referral recommendation was identified by
Samano et al (2005) where 22% of oncologists questioned had personal experience
and recommended osteopathy or chiropractic treatment. This could suggest the
study findings support research by Samano et al (2005). Future research could
explore this potential relationship.
Understanding of manual therapy
A lack of awareness of the level of training covered in the osteopathic
profession was identified and specifically if identification of pathologies were
“You know, I think I would hope that in manual therapists training they also train
to be aware of what the red flags would be with regarding cancer.” (1)
Eight participants (66.7%) that had a limited understanding of osteopathy or
chiropractic treatment attributed it to personal or patient experience with no formal
training. One nurse and one palliative care registrar had undertaken training on
manual therapy.
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The main condition participants described helped with osteopathy was back
pain which is recognised by the NICE (2009). Other conditions described included
muscle soreness, balance problems and repetitive strain injuries.
Seven oncologists (77.8%) commented on the lack of evidence base for
osteopathy as a factor in their ability to recommend it to patients. This suggests
support for the findings of Hyodo et al (2003) and Samano et al (2005) where
oncologists were unable to advise patients on complementary therapies due to a
lack of supportive evidence base.
“a lot of our treatments are based around evidence based medicine and as you
know a lot of complementary medicine is not evidence based.” “I understand that
it is very difficult to do a randomised blind trial of some complementary therapies.
It's also about numbers.”(10)
Implications for patient care
Despite the lack of training and evidence base 100% of participants perceived
benefits from the application of manual therapy on patients with cancer.
“Well, regardless of whether there is any evidence for it there will always be a
placebo benefit to manual therapy because you are having a one to one
interaction with a patient. You are just physically giving them attention. That
makes people feel better.” (11)
“My feeling is that If that helps a patient get through their treatment and helps
them cope with their cancer diagnoses and in itself doesn't do harm or effect the
cancer treatment and they are fully informed and aware and I must admit they are
financially able to do it then I have no problem with it.” (10)
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11 (91.7%) felt manual therapy could reduce pain levels and improve mood.
Research by Kutner et al (2008), Schneider & Gilford (2008) and Jane et al (2009)
support these views. Larger participant samples, and control groups would improve
future studies. Schneider & Gilford (2008) and Hojan et al (2011) demonstrated
manual therapies improving mobility and range of movement in individual case
studies and eight participants (66.7%) agreed. Clemens et al (2010) demonstrated
symptomatic relief from lymphatic drainage which can also improve pain and range
of movement.
Participants were uncertain of a benefit to the immune system with four
(33.3%) suspecting some benefit. Stringer (2008) identified a temporary reduction of
cortisol levels and Noll et al (2010) found reduced antibiotic duration and hospital
stay. 10 participants (83.3%) suspected that manual therapy may reduce levels of
Participants agreed with Hann et al (2004) that patients pursued manual
therapies like osteopathy to regain a sense of control over their situation and
restoration of agency is an important concept in patient care.
“If the patient feels that they have instigated the treatment it helps them regain a
sense of control over their condition. Um, a lot of the time people having stuff like
radiotherapy or chemotherapy, there is this perception that it is something that is
done to them. “(1)
Massage was identified by nine participants (75%) to be an established
treatment modality that is integrated into standard medical treatment because of its
inclusion in the hospitals today.
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Eight (66.7%) were concerned about an increased risk of fracture in patients
with bone metastases. Existing research by Howe (1993), Davis & Taylor, (2007),
Roudier (2008) and Shah & Salzman, (2011) support this view describing a reduction
of bone mineral density in bone metastases increasing the risk of fracture. One
participant stated that bone density increased in prostate cancer however, a small
study of 12 cadavers by Roudier (2008) found although the radiographic appearance
appears to show increased bone density this is still associated with an increased risk
of fracture due to the additional bone material being weak.
According to Shah & Salzman, (2011) spinal metastasis occurs in 60-70% of
systemic cancer patients but only 10% of spinal metastases were symptomatic which
implies extreme caution should be used as patients with spinal metastases are
unlikely to be aware of their presence. Manual therapists should consider this
possibility in their treatment approach.
Cox (2010) found osteopaths were concerned about the use of lymphatic
pumping techniques on patients with cancer in case this spreads cancer throughout
the body. Wu et al (2010) theorise manipulation may serve as a mechanism to
spread tumour cells in osteosarcoma as patients had a significantly poorer 5 year
survival rate. In contrast, participants interviewed had no concern manual therapy
techniques of joint manipulation, articulation or lymphatic techniques might spread
cancer. This highlights a discrepancy between manual therapy perceived effects on
the body between cancer specialists and osteopaths.
“I don't think spread really it's more about underlying fragility” “No, I'm assuming
that is a myth. What I worry about is that they might hurt from the treatment itself
not that the cancer might spread.” (8)
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One participant stated that manual therapy did not affected lymph at all.
Whether lymph is moved or not highlights a further discrepancy between the
osteopathic perception of treatment effects on the body and that of the oncologists.
Collaboration and discussion of perceived treatment modality effects is required to
research this further.
Two oncologists (22.2%) interviewed shared the views of Lerner (1994) and
The International Society of Lymphology (2003) that direct mechanical compression
could promote tumour cell mobilisation. However, these oncologists were confident
that the hospital massage therapists would avoid the tumour sites. Existing research
into this area appears limited and inconclusive.
Implications for osteopathy
11 participants (91.7%) thought there could be a role for osteopathy in the
care of patients with cancer. The most popular reasons given were the symptomatic
relief of musculoskeletal pain, improved mood, improved function, regain a sense of
control, and to avoid long waiting lists of existing hospital services. Osteopathy
Guide (2010) agreed and suggested patients with cancer might use osteopathy to
help cope with the side effects from chemotherapy and radiotherapy. Negative
personal or second-hand experience did not result in participants excluding a role for
osteopathy in the care of patients with cancer.
Participants felt long NHS waiting lists for physiotherapy or pain clinics can
deter referral and can delay treatment implying a role for osteopathy.
Barriers to osteopathy identified in the study agreed with Bengough (2010) as:
a lack of referral guidelines, a lack of knowledge of osteopathy and understanding of
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the level of osteopathic training. In addition further barriers identified were: poor
evidence base to support osteopathy, concern about an increased fracture risk,
concern about cost, and uncertainty of availability versus the convenience of existing
hospital services.
Participants recommended contacting oncology consultants to check if
treatment is considered safe on a patient with cancer. The preferred contact method
was via telephone.
Study Limitations
The small study sample means the findings are unlikely to be applicable to the
UK professional oncology community and it is inappropriate to make any conclusions
from such a small qualitative study. A larger study sample would be beneficial.
An element of bias is expected due to self selection however, it is important to
note two participants had negative stories associated with manipulation treatment,
one from a first-hand experience with a patient and the other from a second-hand
The competence of the interviewer may have affected the validity of data
collected. Two telephone interviews were conducted due to difficulty obtaining
participants and their location. These interviews may have missed important data
due to the absence of non verbal cues. Seven participants experienced interruptions
during the interview process and participants had time constraints which was a result
of responsibility of care to patients. The interviewer inexperience, interruptions and
time constraints resulted in inconsistencies between questioning depth.
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No prior knowledge of the interview questions meant it was difficult to be
confident in participants recall ability. A future design would benefit from advance
notification of the interview questions.
The response rate of 8.75% was lower than the anticipated conservative
estimate of 10% when compared to previous research by Samano et al (2005) who
achieved an 18.2% response rate.
Further research
Further research is required to support osteopathic treatment on patients with
cancer such as case studies or survey the opinions of patients with cancer that have
undertaken osteopathy. Other possible studies could interview GPs, cancer nurse
specialists, physiotherapists and the massage therapists that work on oncology
wards. It might be beneficial to give talks on osteopathy at oncology conferences to
inform cancer specialists on the level of training of osteopaths and the potential risks
and benefits of treatment.
Participants recommended:
Attending oncology conferences to describe patient case studies,
Circulate a questionnaire survey of cancer specialists working in hospices on
their opinions and experiences of manual therapy on patients with cancer as
they were described as more likely to come across complementary therapies.
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The study demonstrated a potential role for osteopathy in the treatment of
patients with cancer to fill a gap in the care of musculoskeletal symptoms in patients
with cancer.
Barriers to referral or recommendation for osteopathy were identified as: no
existing referral guide or protocol for musculoskeletal symptoms in patients with
cancer, lack of understanding of treatment, lack of understanding of the level of
osteopathy training, lack of supportive evidence base and uncertainty of availability
and cost.
Benefits associated with osteopathy on patients with cancer were described
as improved pain levels, mood, mobility, range of movement and regaining a sense
of control in treatment. No negative effects of manual therapy on patients with cancer
were identified in the study. Perceived risks associated with osteopathic treatment on
patients with cancer were seen as: an increased risk of fracture due to a reduction in
bone mineral density with bone metastases and concern that massage directly onto
a tumour might promote metastatic spread. Other concerns were a risk infection
spread to immune compromised individuals and bruising.
An important finding was a discrepancy between perception of the effects of
manual therapy on the body and between osteopaths and oncologists. Future
interdisciplinary collaboration would be beneficial to explore this.
Interdisciplinary dialogue between cancer professionals about manual therapy
on patients with cancer would be beneficial as most participants had not discussed
manual therapy with colleagues.
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Future research would be beneficial into individual case studies on the effects
of osteopathic treatment on patients with cancer. A presence at oncology
conferences would be beneficial to increase awareness, understanding and referral
to osteopathy. The osteopathic profession would benefit from publicizing the level of
training involved in becoming an osteopath, specifically the training to recognise
pathology and identify red flags.
Word count: 5,460
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In no particular order I would like to thank:
The consultants and cancer specialists who gave up their valuable time to participate
in this study making this research project possible.
My supervisor Mr Chris Thomas for encouraging me to pursue an area of interest
and being 100% supportive despite knowing that I had to go through the marathon
NHS Ethics application process. Thank you for your patience and diligence
Mrs Elliann Fairbairn from the National Cancer Research Institute, Mrs Hilary Abbey,
Mr Danny Church, Mrs Hannah Kirshaw, Professor Johnson, Miss Aimee Cox for
their support and advice.
Thank you to my family for their love and support throughout my studies.
Page 38 of 61
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Principle research questions:
 Could Osteopathy provide complementary assistance in cancer care?
 What are the benefits and risks associated with the different treatment
techniques on symptoms of patients with cancer?
Secondary research questions:
 What symptoms cause Oncologists to refer cancer patients to a manual
 What type of manual therapist do Oncologists refer cancer patients to?
 Do Oncologists have a regular dialogue with manual therapists?
 Do Oncologists believe that manual therapy may increase the risk of
metastatic spread?
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Appendix 1 Participant Information Sheet
Study Title:
An interview into Oncologists experience and opinion of osteopathic treatment
of patients with cancer
You are invited to take part in a research study to explore the role of manual therapies in the
treatment of symptoms related to cancer or other concerns of cancer patients but not the
treatment of cancer itself. Manual therapies for the purpose of this study include: osteopathy,
chiropractic care and massage.
Before you decide if you would like to take part in this research study we would like you to
understand why the research is being done and what it will involve for you.
Who is organising this research?
My name is Dawn Hammond, and as a 4th year undergraduate Masters of Osteopathy
student at the British School of Osteopathy, I am undertaking this research study as part of
my final year dissertation. If required I will be more than happy to go through the information
sheet with you and answer any questions you may have. Please read the following
information carefully and feel free to discuss it with others.
My supervisor is Mr Chris Thomas a qualified practicing osteopath and clinic tutor at the
British School of Osteopathy.
What is the purpose of the study?
This study aims to gather Oncologists opinions of the use of manual therapy on patients with
cancer, to identify the perceived benefits and risks, investigate inter-practitioner
communication between cancer specialists and manual therapists, to exploring Oncologists’
experiences of treating cancer patients who utilised manual therapies. The study aims to
investigate the role for Osteopathic care of patients with cancer.
There is little research into Oncologists opinions of manual therapy, it is anticipated that the
interview will enable exploration of Oncologists personal views and experiences which may
contribute to inform manual therapists working in this field
Why have I been invited?
You have been identified as a practicing Oncologist from an online consultant database Dr
Foster (2010) recommended by the Royal College of Physicians or by the National Cancer
Research Network.
A preliminary questionnaire has been sent to 100 Oncologists within 50 miles of the British
School of Osteopathy and a 50 mile radius of my home postcode. This preliminary
questionnaire aims to identify practicing Oncologists having referred a patient for manual
therapy whilst under their care. If you choose to take part you will be participating in a group
of no less than 8 interviewees.
Do I have to take part?
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It is up to you if you decide to join the study. Participation is not required and not
participating will not affect your standing as a professional. You are free to withdraw at any
time without giving any reason and withdrawal is without penalty or detriment.
What will the interview involve?
The interview will last approximately 30 minutes and will be recorded on a digital voice
recorder. A series of questions will be asked which aim to investigate your experience and
opinion of the use of manual therapy on patients with cancer. You can ask questions to the
interviewer at any time during the interview.
You can decline to answer any question without giving a reason. You are advised to contact
the research supervisor in the unlikely event that you should you feel any distress as a result
of the interview. You can withdraw from the study at any time without giving a reason.
Withdrawal is without penalty or detriment.
What do I have to do?
If you agree to take part you will need to complete and sign one consent form and the
preliminary questionnaire, seal and returned in the SAE provided within 2 weeks of receiving
them or by the 1st of November 2011.
Early September 2011 you will be contacted on the day/time you indicate on your consent
form to arrange the interview. The interview will be arranged for a mutually convenient time
and location in a quiet room as the interview will be digitally voice recorded or over the
You have the option to amend and confirm the content of the interview transcription. If you
choose to do this the transcription will be sent to you and you will need to complete your
preferred changes and send it back in the SAE by the 01st December 2011 otherwise the
original transcription will be used.
What are the possible disadvantages and risks of taking part?
You need to be comfortable that you are giving up at least 30 minutes of your valuable time
in order to complete the interview.
What are the possible benefits of taking part?
By contributing your personal opinion and experience you will be helping inform manual
therapists and students reading this research study on their care of patients with cancer.
Patients or relatives of patients with cancer may read this research study and it may inform
them of Oncologists thoughts on the risks and benefits of manual therapy. There will be no
direct benefits received from participating in the study
What if there is a problem?
If you have any concerns, anxieties, complaints, or feel harmed in any way as a result of this
study please contact myself or my supervisor using the details at the end of this document.
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You can withdraw from the study at any time without giving a reason and withdrawal is
without penalty or detriment. If you decide to withdraw from the study please contact myself
or my research supervisor.
Will my taking part in the study remain confidential?
Your name, signature and contact method will be required on the consent form. This will be
kept strictly confidential and stored securely with the interview recordings at the British
School of Osteopathy by the research department accessible by myself, my supervisor and
the research team. After a period of 6 years the consent form, interview recording and
preliminary questionnaire will be destroyed.
You will be allocated a unique participant identification number against which your interview
will be transcribed and the data described so that your participation remains anonymous.
You will be reminded at the start of the interview that no patient or practitioner names should
be used or details that may lead to identification to protect anonymity and data
confidentiality. If this happens by mistake it will not be included in the document transcription
of the voice recording or in the study.
The interview recordings will be stored in an encrypted file on my password protected laptop
which is and backed up on the British School of Osteopathy secure server until the data has
been transcribed when it will be copied onto a CD and deleted from my laptop and the
secure server. The CD will be stored securely with the consent forms by the research
department to be destroyed after 6 years following completion of the study.
My supervisor, the research team at the British School of Osteopathy and I will have access
to the interview recordings which will be stored securely at all times.
The interview recording will be transcribed onto a word document by myself and one other
4th year masters student of Osteopathy to check to check reliability of the interview
transcription. This student will not have access to consent forms or participant identities. This
process is to check reliability of the data transcription.
What will happen to the results from my study?
The results will be used to write my 4th year dissertation. The interview data will be
transcribed and analysed in order to identify themes and to generate conclusions.
A copy of this dissertation will be held in the library at the British School of Osteopathy after
July 2012. If you would like a copy please indicate on the consent form whether you would
like a summary or full version of the study and where to send the copy, a copy will be sent to
you in July 2012.
The results may be disseminated to a wider audience through publication. Brief anonymous
extracts may be used in the dissertation. You will not be identified in any report or
Please keep this sheet for your information.
Thank you for taking the time to read the information sheet. Our contact details are given
below should you have any questions or want any further information.
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Researcher details:
Name: Miss Dawn Hammond
Address: The British School of Osteopathy, 275 Borough High Street, London, SE1 1JE
Email Address: [email protected]
Supervisor details:
Name: Mr Chris Thomas MA (Med Ed), BSc (Hons) Ost,
Address: The British School of Osteopathy, 275 Borough High Street, London, SE1 1JE
Email Address: [email protected]
Telephone Number: 0207 089 5341
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Appendix 2 Consent form
Participant Identification Number:
Title of Project:
An investigation into oncologists experience and opinion of
osteopathic treatment of patients with cancer
Name of Researcher:
Miss Dawn Hammond
Name of Supervisor:
Mr Chris Thomas
Please tick where appropriate:
I confirm that I have read the information sheet for the above study and
have had the opportunity to ask questions.
I understand that my participation is voluntary and that I am free to withdraw
at any time, without giving any reason and without penalty or detriment.
I understand that the interview will be voice recorded and typed up in full.
I understand that the recording will be stored and transported securely at all
I understand that the recordings will be used solely for this study.
I understand that the data collected will be retained securely by the research
department for six years before it is erased.
I understand that no personal details, patient names or practitioner names
will be used during the interview in order to protect anonymity and
I understand that brief anonymous extracts from the interview may be
reproduced in academic presentations, academic and non-academic
I agree to take part in the above study.
I would like a copy of the transcribed interview to check accuracy and to
have the opportunity to include additional comments, amend or delete my
comments prior to data analysis. Send the transcription to:
I would like to receive a full copy / summary of the results (circle as
Please send the results to:
Please indicate when it would be best to contact you in order to arrange the interview
and the best method to contact you:
Contact method:
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Name of Participant
Miss Dawn Hammond
Mr Chris Thomas MA (Med Ed) BSc (Hons) Ost
C/o British School of Osteopathy
275 Borough High Street
SE1 1JE.
C/o British School of Osteopathy
275 Borough High Street
SE1 1JE.
1 copy for the researcher: 1 copy for the participant
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Appendix 3 Preliminary Questionnaire
Thank you for your time to complete this questionnaire.
Participant reference number:
Title of Project:
Name of Researcher:
Name of Supervisor:
An interview into Oncologists experience and opinions of
osteopathic treatment of patients with cancer
Miss Dawn Hammond
Mr Chris Thomas
Please tick as appropriate:
Has a patient of yours undertaken osteopathic or
manual therapy whilst in your care?
Have you referred/recommended a patient with cancer
for any of the following: osteopathic, chiropractic or
physiotherapy whilst in your care?
Would you be willing to take part in a 20 minute
interview to discuss the use of manual therapy on
patients with cancer?
I would not like to take part in this study, please do not
send me any further correspondence
What is your current position?
Grade or role?
How long have you been in this position?
Do you have any personal experience with any of the following therapies:
Others (please specify)
What is your area or areas of specialisation?
How old are you?
Are you:
Please return this questionnaire in the SAE provided by 1st of November 2011.
Researcher: Dawn Hammond
Post: C/o BSO, 275 Borough High Street, London, SE1 1JE
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Appendix 4 BSO REC Committee response
Student Number: 803723
Name: Dawn Hammond
Supervisor: Chris Thomas
Title: An investigation into oncologists experience and opinion of osteopathic treatment of
patients with cancer
14 May 2011
Dear Dawn
Outcome: Approved
Thank you for your application to the BSO REC. I’m happy to say that your application has
now been approved and you’re free to begin your project.
If you encounter future issues and wish to make any changes to the protocol then please do
not hesitate to contact REC Secretary Sam Keeping on either [email protected] or 0207
089 5330 who will advise you on how to proceed.
Let me take this opportunity to wish you the best of luck with your study.
Yours sincerely,
Dr Jo Zamani
The British School of Osteopathy Research Ethics Committee
Research Centre, Room 2.02, 275 Borough High St, London SE1 1JE. Tel: 0207 089 5330
Please direct all queries to BSO REC secretary Sam Keeping ([email protected]).
Registered in England No. 146343
Registered Charity No. 312873 Registered Office: As
The British School of Osteopathy is a registered charity which educates student osteopaths,
treats patients and promotes research.
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Appendix 5 NHS REC Committee response
10th August 2011
Hi Dawn
Following our telephone conversation this morning, this is just to advise that, as requested
your application has been withdrawn from the County Durham & Tees Valley REC
Proportionate Review Meeting scheduled for 19 August. This is because you confirmed that
you will not be starting your research before 1 September, and as your project involves NHS
staff only, who will be participating in their professional role, this will not legally require NHS
ethics review. From 1 September the revised Governance Arrangements for Research
Ethics Committees (Harmonised Edition) comes into effect. Excerpt from Governance
Arrangements for Research Ethics Committees - A Harmonised Edition as follows:
Other Exclusions
2.3.12 - Employers owe a duty of care to their employees. It is different from the duty of
care that care providers owe to users of their services. RECs are not expected to assume
employers' responsbilities or liabilities, or to act as a substitute for employers' proper
management of health and safety in the workplace. It is for employers to ensure that they
are fulfilling their duties as employers when their employees take part in research. Research
involving staff of the services listed in paragraph 2.3.1 who are recruited by virtue of their
professional role, does not therefore require REC review except where it would otherwise
require REC review under this document (for example, because there is a legal requirement
for REC review, or because the research also involves patients or service users as research
For more detailed guidance you should refer to the full document
There is a link from the NRES website at
If you have any further queries please do not hesitate to contact me.
Many thanks
Leigh Pollard
Acting Manager - North East REC Centre
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Appendix 6 Research and Development Department response:
18th April 2011
Dear Dawn
Further to our telephone conversation, I can confirm that the study does not constitute
research and you don’t need to register it with the R&D office.
Should you have further queries – please feel free to contact me.
Kind regards
Salma Kibaida
R&D Governance Specialist
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Appendix 7 Interview schedule
Thank you for agreeing to take part in this study and for giving up your valuable time. I would
like to remind you this interview will be recorded. Are you happy to continue?
Please refrain from using patient or practitioner names or identifiable details so all the data
remains anonymous. You can stop the interview at anytime without giving a reason.
Interview Questions
1. To begin, could you please tell me what your understanding of osteopathy is?
2. In your training to date can you tell me about any training on manual therapies such
as physiotherapy, massage, chiropractic or osteopathic treatment?
3. Do your patients discuss musculoskeletal symptoms with you?
4. Do you refer or recommend patients with musculoskeletal symptoms for manual
What therapy?
Is there a guideline to follow?
Do many of your patients self refer for manual therapy?
Do patients discuss other treatments they pursue?
5. Can you tell me about a patient that undertook Osteopathic/Manual therapy
treatment while in your care?
What type of cancer?
Did you refer this patient?
Why that therapy?
Did you specify the treatment?
Did you have a regular dialogue with the manual therapist?
What were the outcomes of the manual therapy treatment?
Did you have any concerns about the treatment given?
Do you know of any adverse effects?
What do you think were the positive effects?
6. What do you think about the use of the following treatment on a patient with cancer?
Joint Manipulation HVLA
7. In a patient with cancer are there any areas of the body that should be avoided by
manual therapists?
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8. What do you think might be the positive effects of manual therapy on a patient with
9. What do you think might be the negative effects of manual therapy on a patient with
10. Would you recommend or consider manual therapy to help patients with cancer with
any of the following symptoms?
Joint stiffness?
Immune function?
Depression or stress?
11. How do you believe other Oncologists view manual therapy treatment on cancer
12. How do you feel about interdisciplinary communication with manual therapists?
13. Do you think there could be the role of Osteopathy in the care of patients with
Have you any questions for me?
Thank you very much for you time.
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Appendix 8 Letter of Invitation
Version: 1.0
Date: 28th July 2011
The British School of Osteopathy
Borough High Street
DATE 05th October 2011
Dear Sir/Madam,
I am a 4 year undergraduate student at the British School of Osteopathy preparing my final year
research project.
My aim is to interview oncologists on their experience and opinion regarding osteopathic treatment
and manual therapy on patients with cancer. I am interested specifically in the use of massage, joint
manipulation and lymphatic drainage.
Would you be willing to be interviewed? I estimate the interview to take approximately 30 minutes,
and to be conducted in October/November 2011. No names (interviewees, practitioners or patients)
will be used to respect confidentiality.
A copy of the research project will be made available to you should you be interested in the findings
on completion. Please specify your preference on the consent form.
Please read the patient information sheet if you would like to take part in this study please complete
the preliminary questionnaire and consent form and return both forms in the SAE envelope provided.
If you would not like to take part in this study please complete and return our preliminary
questionnaire in the SAE provided.
Thank you for your time taken to read this.
Yours faithfully,
Dawn Hammond
B.S.O. Undergraduate student
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Appendix 9 Interview data schematic diagram
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