Article: Osteopathy

Osteopathy is a system of healthcare that applies a unique philosophy to diagnosis and treatment. With a strong emphasis on the inter-relationship of the body's nerves, muscles, bones and organs, osteopaths apply the philosophy of treating the whole person (holistic approach) to the prevention, diagnosis and treatment of illness, disease and injury using manual and physical therapies (OMM).

Osteopathic medicine is practised by osteopathic physicians in the United States. Osteopaths educated in countries outside the U.S. are referred to by American osteopathic physicians as "non-physician osteopaths". Their scope of practice is limited largely to musculoskeletal conditions and treatment of some other conditions using manual treatment (OMM), not unlike chiropractors (although the distinction between the two professions remains important to both). For a description of osteopathy in the US, see Osteopathic medicine.

History

Osteopathic practice began approximately 120 years ago in the Midwest of the United States. Early in the twentieth century, the American osteopathic profession adopted the use of medicine and surgery, whereas chiropractors continue to use strictly manipulative techniques. Outside of the US, particularly in the United Kingdom, osteopaths tended to stay closer to the traditional approach.

Osteopathy was founded by Andrew Taylor Still, M.D., D.O., who was born in 1828 in Virginia. Still was trained by apprenticeship 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 such cases as being 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 primarily manipulation techniques to improve physiologic 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." Its scientific foundation was the discipline of anatomy. Its philosophy was based on the understanding of the integration between body, mind and spirit, the interrelatedness of structure and function, and the ability of the body to heal itself when mechanically sound. Osteopathic treatment must be a rational application of these principles in comprehensive patient care with a focus on the neuromusculoskeletal system as an integral part of health and disease processes. Over time he 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 osteopathy on May 10, 1892. Kirksville was one of few places where he was not figuratively "chased out of town" by other doctors. While the state of Missouri was willing to grant him a charter for awarding the M.D. degree, he remained unhappy with the practices of his peers and chose instead to grant his own 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, DO 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 -- a point critics would likely not contest. He questioned the drug practices of his day and regarded surgery as a last resort. As medical science developed, osteopathy gradually incorporated all its proven theories and practices. Internationally, all osteopathic training currently incorporates at least the basic biomedical sciences and differential diagnosis, while emphasising non-surgical, non-pharmaceutical care of the musculoskeletal system and its related neural, vascular and lymphatic components.

Osteopathic principles

These are the eight major principles of osteopathy and are widely accepted throughout the osteopathic community. They are taken from the curriculum of the Kirksville College of Osteopathic Medicine.

(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 osteopaths to be empirical laws, nor contradictions to orthodox medical principles; they are thought to be the underpinnings of the osteopathic perspective on health and disease.

Techniques of Osteopathic Manual Medicine (OMM)

It has been suggested that this article or section be merged with Osteopathic Manipulative Medicine. (Discuss)

The goal of OMM is the resolution of somatic dysfunction. There are different techniques applied to the musculoskeletal system as OMM. These techniques can be applied to:

(1) The joints (using articulatory, High Velocity Low Amplitude Technique, mobilization, etc.)

(2) Their surrounding soft tissues (using functional and soft tissue techniques, etc.)

(3) The muscles

(4) The fascia.

When combined, these forms of treatment allow the therapist to restore the normal contact within the joint and with other structures. This eliminates muscular spasms and tensions in the ligaments thereby restoring complete mobility to the joint.

Osteopaths have at their disposal a wide range of manual techniques including:

• High Velocity Low Amplitude Thrust
• Myofascial Release
• Muscle Energy Technique
• Soft Tissue Technique
• Counterstrain
• Cranial Osteopathy
• Balanced Ligamentous Tension
• Lymphatic Pump
• Visceral Manipulation
• Joint Mobilization - Articulatory techniques
• Trigger (or Myodysneuric) Point Therapy

These are normally employed together with dietary, postural, and occupational advice, as well as counseling to help patients recover from illness and injury, and to minimize pain and disease. Most osteopaths view manual therapies as a complement to physiotherapy, and the judicious use of invasive therapies (pharmaceuticals and surgery) where necessary.

It is probably OMM's comprehensive and eclectic style that distinguishes it most from that employed by most other manual therapists.

The immediate goal of musculoskeletal manipulation is to restore maximal, pain-free movement of the musculoskeletal system in postural balance.

Scope of manual therapies

There is now a well-established body of scientific literature that makes a strong case for the use of manual therapies in the treatment of many neuromusculoskeletal pain syndromes, such as low back pain and tension headache, alongside exercise and other rehabilitative techniques. In recent years, the mainstream medical profession has begun to accept the use of manual therapies to treat spinal pain of mechanical origin.

More controversial is the use of manual therapies in the treatment of seemingly organic conditions, such as asthma, middle ear infections in children, menstrual pain, and pulmonary infection. While research is beginning to shed some light in this area, exploration of the relationship between the NMS system and organic disease and the scope of manual therapies are in their infancy. Nevertheless, the sum of research and clinical experience to date suggests that osteopathic treatment can be a safe and cost-effective means of managing (or co-managing) certain diseases.

Cranial osteopathy

Cranial osteopathy [2] is a contested issue within the profession; it is not known what proportion of osteopaths are practitioners. Some medical insurance companies may not reimburse for 'cranial' treatment due to the lack of awareness of research in the field.

Cranial osteopaths are trained to feel a very subtle, rhythmic shape change that 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. [3] The theory underlying cranial osteopathy is rejected by many osteopaths and orthodox medical doctors because it was previously understood that cranial bones fuse by the end of adolescence. However, histological studies have demonstrated the presence of 'Sharpey's fibres' between the adjecent bones forming the sutural margins, and it is known that these specialised fibres form only at areas where tissue movement is allowed. It is, of course, accepted by most modern osteopaths working within the cranial field, that the spheno-basilar symphysis (a large joint in the skull base) does indeed ossify (turn to bone) and the original principles of cranial osteopathy have thus evolved alongside increasing knowledge. 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. The brain does pulsate, but some research suggests this is related to the cardiovascular system. [4] Several studies have looked at inter-operator reliability of palpating the 'cranial rhythm' and found there to be little agreement, [5] although modern understandings in the cranial field describe a number of simultaneous rhythms with differing rates, relating to different aspects of function.

How this mechanism is related to health/disease is not established. Many without direct experience of the benefits of treatment dismiss cranial osteopathy as pseudo-science. However, cranial osteopathy is increasingly being recognised as especially suitable for newborn babies and young children, with particularly good results in the treatment of colic and crying. It is claimed that as their bones have not fully fused and hardened, they are more susceptible to the treatment. All in all, this practice appears to be popular with patients with an increasing demand for experienced practitioners. Cranio-sacral therapy is based on the same principles but the practitioners are not qualified osteopaths, and do not have the same depth of training in the clinical sciences and differential diagnosis. Chiropractors are developing similar techniques known as sacro-occipital therapy (SOT) or craniopathy.

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 theory is that both somato-visceral and viscero-somatic connections exist, and manipulation of the somatic system can affect the visceral system (and vice-versa).

Visceral osteopathy is said to relieve imbalances and restrictions in the interconnections between the motion of all the organs and structures of the body. During the 1940s, osteopaths like H.V. Hoover or M.D. Young built on the pioneering work of Andrew Taylor Still D.O. to create this method of detailed assessment and highly specific manipulation. The efficacy and basis of this treatment remains controversial even within the osteopathic profession. Visceral manipulation was further promoted within osteopathic treatment by Jean-Pierre Barral in his recent series of books on the subject.

While neither cranial osteopathy nor visceral manipulation are the mainstay of most osteopathic practices, there is increasing interest in both of these areas from patients and practitioners alike. Training in Cranial osteopathy in the UK has now reached validated MSc. Level, which aims to improve standards and contribute to the body of evidence with research-based studies carried out from within the profession.

Osteopathic medicine 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.

1. Osteopathic physicians in the United States are medical practitioners, see Osteopathic medicine for further details.
2. The international model of osteopathic medicine is significantly different to that in the U.S. 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 relegated to the fringe of healthcare alongside naturopaths, chiropractors and others. 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 and mainstream acceptance in many countries of the Commonwealth and Europe. More and more osteopaths are now working alongside the mainstream in interdisciplinary settings, and osteopathic departments are now well-established in many public universities.

• Status of Osteopathy Around the World

Osteopathic medicine in the UK, Australia, Canada and NZ

In the United Kingdom osteopathy developed as a distinct profession. The first osteopathic college was established in the UK in 1917 by a Scot, Littlejohn, 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 [6]. 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) [7]was established by the act to regulate the profession, to protect the public by maintaining a register of practitioners, to investigate allegations of professional misconduct, and to ensure the quality of training. Since 2001, there has been graduate only entry to the register. There are currently seven approved training institutions in the UK. There are approximately 5000 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, [8], [9]. There is an increasing interest in osteopathy amongst patients, but barriers remain to osteopathic provision within the state system; not the least being hostility from the orthodox medical profession and physiotherapists. 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 program (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. [10]

In Australia and New Zealand the profession has developed along the same lines, and until recently neither country trained its own practitioners and relied on UK graduates. Likewise, each country maintains a government-approved list of practitioners and private health insurance reimbursement is available for osteopathic treatment. Three publicly-funded Universities now offer osteopathic medical courses in Australia. 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, raised the credibility of the profession, and focused attention on refining the scope of practice through clinical trials and basic research.

In Canada osteopaths 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, they have an unlimited scope of medical practice.

In all four countries osteopathy straddles the boundary between orthodox and complementary/alternative medicine, with a variety of approaches and philosophies being brought to the practice. The model of osteopathy employed is essentially a drug-free system of manual therapy. Osteopaths are trained in standard medical differential diagnosis and have diagnostic competencies similar to primary care physicians, but with a scope of practice focussed mainly on musculoskeletal conditions and treatment of some other conditions by manual means. Osteopaths in all four countries do not have prescribing rights, although the British Government has included osteopathy in the list of professions allied to medicine that may be granted prescribing rights in the future. Unless separately qualified as a medical doctor or holder of a doctorate degree, osteopaths in New Zealand or the UK do not use the honorific title of Doctor. Contested by some osteopaths, there is a campaign to use the title Doctor anyway. Australian osteopaths routinely call themselves Doctor. There is a debate on what differentiates an osteopath from a chiropractor from a physiotherapist in these countries, rather than the D.O./M.D. debate in the USA.

Osteopathic medicine in the European Union

Within the European Union there is no standardised training or regulatory framework for the profession, although attempts are being made to coordinate the profession within the EU. At present there is a conflict between the principle of free movement of labour and right to practice osteopathy in different member states as there is little equivalency in training and regulation of the profession. Previously the practice of spinal manipulation by non-medically qualified practitioners was outlawed in many European countries. This led to the arrest and imprisonment of the osteopathic faculty in France in the 1960s, who on their release then sought refuge in the UK and established the European School of Osteopathy.

The General Osteopathic Council, the UK osteopathic regulatory body, has issued a position paper on pan-European regulation of the profession.[11] However, formation in osteopathy is built up in very few states : UK, France and Switzerland are the only countries to already have a solid, well-shaped conception of the osteopathy they wish to defend. In the other states, osteopathy is studied in rare schools.

Future challenges

In countries where osteopathy does not encompass conventional medical practices, it is subject to the same criticisms levelled at many alternative medicine modalities. In spite of the many claims of success by osteopaths who practise osteopathy in the cranial field, this modality is often attacked, even from within the osteopathic profession, for lacking scientific evidence.

Manipulation, especially of the cervical spine, has caused injury, and like most medical procedures osteopathic manipulative treatment is not entirely without risk. The comprehensive training, and competence of osteopaths to carry out patient screening has reduced the dangers to a minimum.

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See also

• Osteopathic medicine
• Allopathic medicine
• Medicine
• Chiropractic
• Naturopathy
• Complementary and alternative medicine

Further reading

• Science in the Art of Osteopathy: Osteopathic Principles and Models, Caroline Stone, Nelson Thornes, 1999, paperback, 384 pages, ISBN 0748733280
• An Osteopathic Approach to Diagnosis and Treatment , Eileen DiGiovanna, Lippincott Williams and Wilkins, 2004, hardback, 600 pages, ISBN 0781742935