Osteopathy

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 (D.O.s) are fully licensed medical physicians and surgeons, practicing in all clinical specialties along with their M.D. colleagues. Just like M.D.s, D.O.s practice the full scope of medicine. The practice rights of U.S.-trained Doctors of Osteopathic medicine varies.

In the United Kingdom, courses in Osteopathy have recently become integrated into the university system and instead of receiving a Diploma in Osteopathy (D.O.), with or without a Diploma in Naturopathy (N.D.), 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 Medicine^[3], 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.

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History

The practice of osteopathic medicine began in the United States in 1874. The term "osteopathy" was coined by Andrew Taylor Still, M.D., who was born in 1828 in Virginia. 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 was trained by apprenticeship, as were most physicians of the day, and was employed as an army doctor during the American Civil War in the U.S. Army. The horrors of battlefield injury and the subsequent death of his wife and several children from infectious diseases left him totally disillusioned with the traditional practice of medicine. Still perceived the medical practices of his day to be ineffective, even barbaric. Troubled by what he saw as problems in the medical profession, Still founded osteopathic practice. Using an alternative philosophical approach, he opposed the use of drugs and surgery as remedial agents, reserving their use for cases in which he considered them to be the cure for the condition, such as an antidote for a poison or amputation for gangrene. He saw the human body as being capable of curing itself, and the duty of the physician to remove any impediments to the healthy function of each person. He promoted healthy lifestyle, nutrition, abstinence from alcohol and drugs, and used manipulative techniques which he believed, improved physiological function.

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." The object of osteopathy was to "improve upon the present systems of surgery, midwifery, and the treatment of general diseases."^{[citation needed]} Its scientific foundation was the discipline of anatomy.^{[citation needed]} Its philosophy was based on the understanding of the integration between body, mind and spirit^{[citation needed]}, the interrelatedness of structure and function, and the posited ability of the body to heal itself when mechanically sound. Osteopathic treatment emphasises comprehensive patient care with a focus on the neuromusculoskeletal system as an integral part of health and disease processes. Over time Still and his students and faculty developed a complete medical school curriculum which included a series of specialized physical treatments, now called Osteopathic Manipulative Treatment (OMT). Still founded the American School of Osteopathy (now the Andrew Taylor Still University, Kirksville College of Osteopathic Medicine) in Kirksville, Missouri, for the teaching of osteopathic medicine 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 M.D. degree, he remained dissatisfied with the limitations of conventional medicine and instead chose to retain the distinction of the D.O. degree.

In the late 1800s Still taught that "dis-ease" was caused when bones were out of place and disrupted the flow of blood or the flow of nervous impulses; he therefore concluded that one could cure diseases by manipulating bones to restore the interrupted flow. Still stimulated his students to investigate these postulates. Research began in the 1890s at Kirksville and has continued there and at other osteopathic institutions ever since. The A.T. Still Research Institute was founded in 1913 and Louisa Burns, D.O. and others developed a rigorous series of scientific investigations of the relationships between musculoskeletal dysfunctions and health and disease. Still's critics point out that he never personally ran any controlled experiments to test his hypothesis; his supporters point out that many of Still's writings are philosophical rather than scientific in nature. He questioned the drug practices of his day and regarded surgery as a last resort.

By the 1960s, osteopathic medicine had become integrated into the American mainstream, and the reliance on manipulative therapies had fallen into less common usage. The osteopathic profession has evolved independently outside the US, where it has remained essentially a drug-free system based on manipulative techniques - a scope of practice similar to chiropractors. Chiropractic is a distinct manipulative profession that originated around 1895 in the US.

Osteopathic principles

These are the eight major principles of osteopathy and are widely believed throughout the osteopathic community. ^[5]

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 Manual Medicine

Main article: Osteopathic manipulative medicine

In the United States, physical or manual treatment carried out by D.O.s is referred to as Osteopathic Manual Medicine or Osteopathic Manipulative Medicine (both abbreviated OMM). In other countries, manual treatment by osteopathic physicians is simply referred to as osteopathic treatment.

The goal of OMM is the resolution of what osteopaths's believe to be somatic dysfunction in an attempt to reestablish the self-regulatory mechanisms of the body. There are various techniques applied to the musculoskeletal system as OMM. 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 minimize pain and disease. Most osteopathic physicians view manual therapies as a complement to physiotherapy, and use pharmaceuticals and surgery where they deem necessary.

Scope of manual therapies

Osteopathy employs manual therapies for the treatment of many neuromusculoskeletal pain syndromes, such as low back pain and tension headache, alongside exercise and other rehabilitative techniques. Osteopathy attempts to treat conditions such as asthma, middle ear infections in children,^[6] menstrual pain, and pulmonary infection.

Cranial osteopathy

Main article: Craniosacral therapy

Cranial osteopathy, although well-established,^[7] is a contested issue within the profession; it is not known what proportion of osteopathic physicians are practitioners. Cranial osteopathic physicians are trained to feel a very subtle, rhythmic shape change that they believe is present throughout the head and body. This is known as the involuntary mechanism or the cranial rhythm. The movement is said to be very subtle, and it takes practitioners with a very finely developed sense of touch (palpation) to feel it. This rhythm was first described in the early 1900s by Dr. William G. Sutherland.^[8]

The theory underlying cranial osteopathy is rejected by many physicians. It is believed by most modern osteopathic physicians working within the cranial field, that the spheno-basilar symphysis (a large joint in the skull base) ossifys (turn to bone). Cranial osteopathic teaching refers to movement remaining within the thin bone of the sutures, and that flexibility within living bone occurs, in contrast to dried specimen bones. Research suggests that examiners are unable to measure craniosacral motion reliably, as indicated by a lack of interrater agreement among examiners.^[9]The authors of this research suggest that this "measurement error may be sufficiently large to render many clinical decisions potentially erroneous".

No scientific links have been found between this mechanism and health/disease. 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.

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 "S.O.T."^[10][11]

Visceral osteopathy

Proponents of visceral osteopathy state that the visceral systems (the internal organs: digestive tract, respiratory system, etc.) rely on the interconnected synchronicity between the motion of all the organs and structures of the body, 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 believe 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

There are two main schools of thought within the osteopathic world. They are so different in practice as to be separate professions, but there have been attempts in the last few years to enhance exchange and dialogue between them.^[12]

Osteopathic physicians in the United States are licensed medical practitioners. In other countries, osteopaths continue to 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, osteopathic medicine is growing in size in many countries of the Commonwealth and Europe.

Osteopathy in the United States

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

In the United States, osteopathy is only practiced by doctors of osteopathy (D.O.'s), who are "osteopathic physicians" as opposed to medical doctors (M.D.'s), who have completed conventional medical training. Graduates of osteopathic medical schools are awarded the Doctor of Osteopathic Medicine degree, and can become licensed to practice medicine as a physician or surgeon.

Osteopathy in the United Kingdom

In the United Kingdom osteopathy developed as a distinct profession. 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. 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. There are currently eight approved training institutions in the UK. There are approximately 4000 registered osteopaths in the UK, a small but growing profession. For the sake of comparison there are approximately 36,000 physiotherapists. 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 of the cost-effectiveness and clinical effectiveness of manipulation in the management of low back pain, the latest being the UK Back pain Exercise And Manipulation (UK BEAM) trial.^{[13] [14]}

There is an increasing interest in osteopathic medicine amongst patients, but barriers remain to osteopathic provision within the state system, among them opposition from the medical profession and physiotherapists.^{[citation needed]} 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 D.O.s 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.

Osteopathy in Australia & New Zealand

In Australia the profession has developed along the same lines as in Britain, and Osteopathy celebrates 100 years in Australia in 2007. The peak body representing Osteopaths in Australia is the Australian Osteopathic Association (AOA), and in New Zealand the Osteopathic Society of New Zealand (OSNZ). Since the 1970's 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 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. Australian courses consist of a bachelor's degree in clinical science (Osteopathy) followed by a Master's degree. Integration into the university system has given Australian osteopaths the opportunity to access public research funding, has raised the credibility of the profession, and focused attention on refining the scope of practice through clinical trials and basic research. Australia now recognizes the USA D.O. degree for full medical practice rights within Australia. Australia and the UK now recognise the USA medical educational model as the equivalent to its own.

Osteopathy in Canada

In Canada osteopathic physicians are trained along similar lines to those in Britain and other Commonwealth countries. However, when US-trained osteopathic physicians visit or relocate to Canada or Great Britain, their parity with allopathic physicians is recognized and they have an unlimited scope of medical practice.

There are currently over 1100 practicing manual Osteopaths (DOMP) in the country, all practicing under provincial associations and the Canadian Federation of Osteopaths.

In some countries, osteopathic medicine straddles the boundary between Conventional medicine and alternative medicine, with a variety of approaches and philosophies being brought to the practice. Osteopathic physicians are trained in standard medical differential diagnosis and have diagnostic competences similar to primary care physicians, but with a scope of practice focused mainly on musculoskeletal conditions and treatment of some other conditions by manual means^{[citation needed]}. Osteopathic physicians in these countries, except Canada, do not have prescribing rights, although the British Government has included osteopathic medicine in the list of Allied health professions that may be granted prescribing rights in the future.^[15]

Osteopathy in the 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 osteopathic medicine 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.^[16] 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[6] - but the NHS will not usually pay for any treatment.^[17] Final year students following the B. Ost. degree course offered by the British School of Osteopathy gain hands-on experience under the supervision of tutors, who are practicing osteopaths, in the school's Borough, south London, building in Europe's largest osteopathic clinic. The fees that patients, who do not need a doctor's referral, at the school's clinics are greatly subsidised - and people who qualify for pensions or some benefits get a 50 percent discount on them. Some people qualify for free treatment. The school, founded in 1917, also offers postgraduate qualifications, an M.Sc. postgraduate degree in pediatric osteopathy and a professional diploma in cranial osteopathy.^[18]

Criticism

Osteopathic medicine is subject to criticisms from those outside of the field, similar to those levelled at other types of alternative medicine, namely that evidence for the efficacy of the treatment is 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 treatment^[19] or for pain after knee/hip surgery^[20].

The practice of osteopathy in the cranial field is considered even by some within the field as lacking scientific evidence.

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 confidence interval of 0.5–16.7 per 100 000 is a relatively unbiased estimate^[21]. Although this data primarily concerns chiropractic visits, both osteopaths and chiropractors may practice cervical manipulations.

See also

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

Associations and regulatory bodies

International

• International Osteopathic Alliance
• World Osteopathic Health Organization
• Osteopathy and Chiropractic Society

Individual countries

• American Osteopathic Association
• Australian Osteopathic Association
• British Osteopathic Association website
• Irish Osteopathic Society
• Israeli Osteopathic Association
• NZ Osteopathic Council website
• Osteopathic Society of NZ website
• The Sutherland Society for Cranial Osteopathy UK
• UK General Osteopathic Council website
• Singapore Osteopathic Society website
• Swiss Federation of Osteopaths
• Verband der Osteopathen Deutschland e.V.

Journals

• Chiropractic & Osteopathy - Online journal published by BioMed Central
• International Journal of Osteopathic Medicine
• Journal of the American Osteopathic Association
• Osteopathic Medicine and Primary Care

Other links

• Osteopathic research information and database - Vienna School of Osteopathy
• British School of Osteopathy clinics
• The College of Osteopaths

Criticism

• The Paradox of Osteopathy - New England Journal of Medicine
• Dubious Aspects of Osteopathy - Quackwatch