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Osteopathy is an approach to healthcare that emphasizes the role of the musculoskeletal system in health and disease. In most countries osteopathy is a form of complementary medicine, emphasizing a holistic approach and the skilled use of a range of manual and physical treatment interventions (osteopathic manipulative medicine, or OMM in the United States) in the prevention and treatment of disease. In practice, this most commonly relates to musculoskeletal problems such as back and neck pain.

Many osteopaths see their role as facilitating the body's own recuperative powers by treating musculoskeletal or somatic dysfunction. According to the American Osteopathic Association, the difference between an osteopath and an osteopathic physician is often confused.¹ In the United States, Doctors of Osteopathic Medicine (DOs) are fully licensed medical physicians and surgeons, practicing in all clinical specialties along with their MD colleagues. Just like MDs, DOs practice the full scope of medicine.

In the United Kingdom, courses in Osteopathy have recently become integrated into the university system. Instead of receiving a Diploma in Osteopathy (DO), with or without a Diploma in Naturopathy (ND), graduates now become Bachelors of Osteopathy or Bachelors of Osteopathic Medicine, or Bachelors of Science in either Osteopathy or Osteopathic Medicine, according to the institution attended:² but these degrees do not lead to prescribing rights and in this case Osteopathy and Osteopathic Medicine are synonymous. There is one "cross-over" institution, the London College of Osteopathic Medicine³, which teaches osteopathy only to those already qualified in medicine. Before using the title of "osteopath," graduates have to register with the UK regulatory body by statute; the General Osteopathic Council.

History

See also: Andrew Taylor Still#Osteopathy

The practice of osteopathy began in the United States in 1874. The term "osteopathy" was coined by Andrew Taylor Still. Still was a free state leader who lived near Baldwin City, Kansas at the time of the American Civil War, and it was here he developed the practice of osteopathy.⁴

Still named his new school of medicine "osteopathy," reasoning that "the bone, osteon, was the starting point from which [he] was to ascertain the cause of pathological conditions."⁵ Still founded the American School of Osteopathy (now A.T. Still University) in Kirksville, Missouri, for the teaching of osteopathy on May 10, 1892. While the state of Missouri, recognizing the equivalency of the curriculum, was willing to grant him a charter for awarding the MD degree, he remained dissatisfied with the limitations of conventional medicine and instead chose to retain the distinction of the DO degree.⁶

Osteopathic principles

These are the eight major principles of osteopathy and are widely taught throughout the international osteopathic community. ⁷

1. The body is a unit.
2. Structure and function are reciprocally inter-related.
3. The body possesses self-regulatory mechanisms.
4. The body has the inherent capacity to defend and repair itself.
5. When the normal adaptability is disrupted, or when environmental changes overcome the body’s capacity for self maintenance, disease may ensue.
6. The movement of body fluids is essential to the maintenance of health.
7. The nerves play a crucial part in controlling the fluids of the body.
8. There are somatic components to disease that are not only manifestations of disease, but also are factors that contribute to maintenance of the disease state.

These principles are not held by osteopathic physicians to be empirical laws; they are thought to be the underpinnings of the osteopathic philosophy on health and disease.

Techniques of Osteopathic Treatment

Main article: Osteopathic manipulative medicine

The goal of OMM is the resolution of what many osteopaths call somatic dysfunction in an attempt to aid the body's own recuperative faculties. Osteopathic manual treatment of the musculoskeletal system employs a diverse array of techniques. These are normally employed together with dietary, postural, and occupational advice, as well as counseling in an attempt to help patients recover from illness and injury, in an attempt to minimise or manage pain and disease.

Scope of manual therapies

Osteopathy employs manual therapies for the treatment of many neuromusculoskeletal pain syndromes, such as lower back pain and tension headache, alongside exercise and other rehabilitative techniques. Many osteopaths also attempt to manage (or, more often, co-manage) organic or Type-O disorders conditions, such as asthma and middle ear infections in children,⁸ menstrual pain, and pulmonary infection.

Cranial osteopathy

It has been suggested that this section be split into a new article entitled Cranial osteopathy. ()

Main article: Craniosacral therapy

Cranial osteopathy is a term that is used to describe various subtle techniques that have developed from the observations of Dr William Sutherland DO ⁹ that the plates of the cranium. although fused, do permit microscopic movement or force dissipation and that there is a 'force' or rhythm that is operating in moving the plates of the skull.

Exponents of 'cranial osteopathy' believe that by holding the head and focusing their intention they can help with a range of health problems. No jurisdiction recognises the sub-specialty of cranial osteopathy. Both within the osteopathic profession and outside this is a contested phenomenon; also it is not known what proportion of osteopaths or osteopathic physicians believe in the basis of this treatment modality or are practitioners. Cranial osteopathy is said to be based on involuntary mechanisms or rhythm which some claim can be felt with a very finely developed sense of touch. There is a seemingly large esoteric component and practitioners may claim to be working with primordial energies and forces that are described using metaphysical language. This so-called involuntary mechanism is not acknowledged as existing in standard medical texts, and is frequently quoted as an examples of pseudoscience. The case for the existence of the involuntary mechanism is further weakened as no studies yet performed have demonstrated inter operator reliability in describing the phenomena which they claim to be able to manipulate through intention ¹⁰

The evidence for the existence of this mechanism is largely absent, thus its link with states of health and disease contested. Some osteopathic physicians believe that healing dysfunctional cranial rhythmic impulses enhances cerebral spinal fluid flow to peripheral nerves, thereby enhancing metabolic outflow and nutrition inflow. Others see cranial osteopathy as an example of non-specific therapeutic effect or placebo. It has gained particular popularity in the treatment of babies. Those within the osteopathic profession that reject cranial osteopathy as a legitimate modality would seek to explain perceived benefits of the treatment with a psychological explanation. To date the profession has resisted full schism over this issue, but particularly within academic tertiary institutions there is a drive for evidence and this may create difficulties in the future.

Craniosacral therapy is based on the same principles but the practitioners have not attended medical school and are therefore not osteopathic medical physicians. Chiropractor and osteopathic physician, M B Dejarnette further developed craniopathic techniques inside of a complete Chiropractic system known as Sacro-Occipital Technique or simply "SOT"¹¹¹²

Visceral osteopathy

Proponents of visceral osteopathy state that the visceral systems (the internal organs: digestive tract, respiratory system, etc.) rely on the interconnection synchronicity between the motion of all the organs and structures of the body, and that at optimal health this harmonious relationship remains stable despite the body's endless varieties of motion. The idea is that both somato-visceral and viscero-somatic connections exist, and manipulation of the somatic system can affect the visceral system (and vice-versa).

Practitioners contend that visceral osteopathy relieves imbalances and restrictions in the interconnections between the motion of all the organs and structures of the body--namely, nerves, blood vessels, and fascial compartments. During the 1940s, osteopaths like H V Hoover and M D Young built on the work of Andrew Taylor Still to create this method of assessment and manipulation. The efficacy and basis of this treatment remains controversial even within the osteopathic profession.

Osteopathy around the world

The osteopathic profession has evolved into two branches, practitioners in the United States and practitioners in European and Commonwealth countries. These groups have have grown so distinct that in practice they function as separate professions, though there have been attempts in the recent years to enhance exchange and dialogue between them.¹³

In Europe, commonwealth countries and elsewhere, osteopaths rely on non-surgical, non-pharmaceutical approaches, and see themselves as a complete school of manual medicine or NMS specialists, complementary to most mainstream medical practices. Commonwealth osteopathic students may spend up to ten times as many hours training in osteopathic diagnosis and technique as their American counterparts. Because of this specialization, they have traditionally remained as an alternative to mainstream healthcare alongside naturopaths and chiropractors. In commonwealth countries, osteopaths have also had to compete with physiotherapists, many of whom have integrated manipulative therapy into their practice. Nevertheless, osteopathy is growing in size in many countries of the Commonwealth and Europe.

United States

Main articles: Osteopathic medicine in the United States and Medical school in the United States

In the United States, osteopathic medicine (osteopathy) has continued to provide traditional comprehensive osteopathic health care inclusive of medicine and surgery as well as providing manual medicine using osteopathic manipulative techniques. U.S. "osteopathic physicians" (DOs) are licensed medical doctors who have completed comprehensive osteopathic medical education, and are licensed to practice medicine as physicians or surgeons.

United Kingdom

The first osteopathic college was established in the UK in 1917 by Littlejohn, a Scot who had studied under Dr Andrew Taylor Still. Littlejohn altered the osteopathic curriculum to include the study of physiology. The UK school he founded, the British School of Osteopathy, was the first osteopathic education institution outside the USA, and it still exists today, now located in Borough High Street, Southwark. British osteopaths use manipulative techniques based on the philosophy of Dr Andrew Taylor Still, but are not medical doctors. Some medical doctors do undertake osteopathic training as a postgraduate interest. The profession is subject to statutory regulation following the passing of the Osteopathy Act in 1993. The General Osteopathic Council (GOsC) was established by the act to regulate the profession. Most medical services in the UK are delivered through the state funded National Health Service, osteopathy is largely excluded from this with most osteopaths working in private practice. Several large studies in the UK have produced evidence that demonstrates positive clinical and cost effectiveness of manipulation in the management of lower back pain, the latest being the UK Back pain Exercise And Manipulation (UK BEAM) trial.^{14 15} The physical manipulation condition of the UK BEAM trial involved "... a package of techniques representative of those used by the UK chiropractic, osteopathic, and physiotherapy professions."

Many UK osteopaths are also naturopaths, with one osteopathic college offering a dual training in osteopathy & naturopathy (the British College of Osteopathic Medicine) and another offering a post-graduate programme (the College of Osteopaths).

In 2005 the General Medical Council of Great Britain announced that U.S.-trained DOs would be accepted for full medical practice rights in the United Kingdom. This decision was an important departure from the United Kingdom's long-standing tradition of exclusively manual, or "traditional" osteopathy.

Australia & New Zealand

This article or section may contain original research or unverified claims. Please improve the article by adding references. See the talk page for details. (December 2007)

In Australia the profession has developed along the same lines as in Britain, and Osteopathy celebrated 100 years in Australia in 2007. The professional body representing Osteopaths in Australia is the Australian Osteopathic Association (AOA), and in New Zealand the Osteopathic Society of New Zealand (OSNZ). Since the 1970s Australia has formally trained practitioners although many were trained less formally prior to that time. Both Australia and New Zealand require registration, and thus disallow osteopathic practice except by government registered practitioners. Workers' compensation, the various motor accident authorities, Medicare and private health insurers, and the Accident Compensation Corporation (ACC), all recognize and reimburse osteopathic treatment. Four publicly-funded Universities now offer osteopathic medical courses in Australia - RMIT, VU, SCU and UWS. It is offered at UNITEC in New Zealand. Australasian courses consist of a bachelor's degree in clinical science (Osteopathy) followed by a Master's degree. Integration into the university system has given Australasian osteopathic educators the opportunity to access public research funding.^{citation needed}

Canada

Doctor of Osteopathy (Osteopathic Medicine) in Canada

In Canada, as in the United States, only osteopathic graduates of American colleges of osteopathic medicine, accredited by the American Osteopathic Association (AOA) are eligible for licensure, which gives them all the rights and responsibilities of a conventionally trained MD.^161718192021 While there are non-physician practitioners using osteopathic terminology in Canada, they are not recognized by any government regulatory or licensing authority. Eligibility for the practice of osteopathy in Canada requires a degree from an AOA accredited college of osteopathic medicine and registration with a provincial College of Physicians and Surgeons ²². The Canadian osteopathic medical profession, which typifies traditional comprehensive osteopathy inclusive of medicine, and surgery, as well as osteopathic manipulative treatment, was established over 100 years ago, and continues to be represented by the Canadian Osteopathic Association. Accurate details regarding the legal status of osteopathy in Canada and registration requirements to practice can be viewed on the website for the Canadian Osteopathic Association [17].

Licensed osteopathic practitioners in Canada are fully trained physicians.²³ As well as being skilled in the use of osteopathic manipulative treatment, they are also able to prescribe medicine, perform surgery, and have access to all diagnostic facilities including laboratory and imaging facilities (e.g. X-ray, CT scan, MRI, Bone scan, Ultrasound, etc). All medical services are covered by provincial health insurance plans. Osteopaths in Canada with AOA accredited training and appropriate post-graduate medical education in a specialty, are eligible for specialty certification with the College of Family Physicians of Canada,²⁴ and the Royal College of Physicians and Surgeons of Canada.²⁵

Non-physician Osteopaths in Canada

In Canada non-physician practitioners take part-time manual therapy training with a scope of practice similar to those in Britain and other Commonwealth countries. This approach to education focuses on the musculoskeletal system, cranial sacral, and visceral manipulation. Canadian and International non-physician osteopaths are not eligible for licensure in Canada.²⁶

European Union

Within the EU there is no standardized training or regulatory framework for osteopaths but attempts are being made to coordinate the profession within the union. There is a conflict between the principle of free movement of labour - a cornerstone of the EU - and the right to practice osteopathy in different member states as there is cross-border equivalence in training and regulation of the profession. The UK's General Osteopathic Council, a regulatory body set up under the country's 1993 Osteopaths Act has issued a position paper on European regulation of osteopathy.²⁷ The teaching of osteopathy in the UK, France and (European Economic Area member) Switzerland is well established - but not all European nations have yet embraced this form of medicine.

In the UK, since the Osteopaths Act, osteopathy has been a recognised profession. Some doctors within the country's National Health Service recognise osteopathy as a therapy and refer patients to its practitioners when other forms of treatment are not successful or are considered inappropriate[18] - but the NHS will not usually pay for any treatment.²⁸

Criticism

Osteopathy is not currently well researched. A major criticism is that claims for the efficacy of the treatment are testimonial-based and not evidence-based. One placebo-controlled trial showed that osteopathy is no better than sham treatment for chronic nonspecific lower back pain, although the authors acknowledged the difficulty of providing a non-therapeutic sham treatment²⁹ or for pain after knee/hip surgery³⁰.

However, a meta-analysis of six randomized controlled trials of OMT that involved blinded assessments of lower back pain in ambulatory settings found from computerized bibliographic searches of MEDLINE, EMBASE, MANTIS, OSTMED, and the Cochrane Central Register of Controlled Trials, found that OMT significantly reduces lower back pain. It also concluded that the level of pain reduction is greater than expected from placebo effects alone and persists for at least three months. ³¹

Another study, which aimed to identify cellular mechanisms at work during OMM, was published in the Journal of American Osteopathic Association in December 2007. ³² Data from the present study suggest that fibroblast proliferation and expression/secretion of proinflammatory and anti-inflammatory interleukins may contribute to the clinical efficacy of indirect osteopathic manipulative techniques.

The practice of osteopathy in the cranial field is considered even by some within the field as lacking scientific evidence. One meta-analysis from the British Columbia Office of Health Technology Assessment (BCOHTA) concluded that although some of the central tenets of craniosacral therapy are supported by convincing evidence, "this systematic review found there is insufficient scientific evidence to recommend craniosacral therapy to patients, practitioners or third party payers for any clinical condition."

The literature suggests that the adult cranium does not obliterate, fuse or ossify its sutures until well into late life. There is also some evidence (albeit of variable research quality) that there is potential movement at these suture sites in earlier life. Questions remain as to whether such “movement” is detectable by human palpation or whether mobility has any influence on health or disease.

The authors of this review also note that, in accord with a basic tenet of craniosacral therapy, there is evidence for a craniosacral rhythm, impulse or “primary respiration” independent of other measurable body rhythms (heart rate, or respiration). Avezaat & Eijndhoven ’86 (40) and Feinberg & Mark ’87 (46) used sophisticated technology to gain an understanding of the phenomenon. However, these and other studies do not provide any valid evidence that such a craniosacral “rhythm” or “pulse” can be reliably perceived by an examiner. Our review does not suggest any reasonable data that would allow such a conclusion. The influence of this craniosacral rhythm on health or disease states is completely unknown. ³³

As with all medical treatments, manipulative and manual therapies carry inherent risks of injury. Direct, forceful techniques are more likely than indirect techniques to cause injury. 'Neck cracking', i.e. cervical high-velocity low-amplitude thrusting, has received particular attention in the popular media because of a risk of arterial occlusion and consequently of stroke. Although the existing data cannot provide a conclusive estimate of the cervical artery dissection risk researchers have stated that a stroke risk of about 1.3 per 100 000 chiropractic visits for individuals aged under 45 years, with a 95% confidence interval of 0.5–16.7 per 100 000 is a theoretically unbiased estimate³⁴. Although this data primarily concerns chiropractic visits, both osteopaths and chiropractors may practice cervical manipulations.

See also

• Doctor of Osteopathic Medicine
• List of osteopathic colleges
• List of medical schools in the United States
• Naturopathic medicine

References

Further reading

• Science in the Art of Osteopathy: Osteopathic Principles and Models, Caroline Stone, Nelson Thornes, 1999, paperback, 384 pages, ISBN 0-7487-3328-0
• An Osteopathic Approach to Diagnosis and Treatment , Eileen DiGiovanna, Lippincott Williams and Wilkins, 2004, hardback, 600 pages, ISBN 0-7817-4293-5

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• This page was last modified on 22 November 2008, at 23:59.

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