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. 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, but with an emphasis on the role of the neuromusculoskeletal system. D.O.s practicing in primary care, pediatrics, family, or internal medicine, are trained to have a more empathetic approach to patient care which has awarded them some level of distinction from M.D.s Outside the United States. The practice rights of U.S.-trained Doctors of Osteopathic medicine varies.

History
The practice of osteopathic medicine began in the United States in 1874. The term "osteopathy" was coined by Andrew Taylor Still, M.D., an allopathically-trained physician 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. 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 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 manipulative techniques to improve 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." 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 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 allopathic 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. As medical science developed, osteopathic medicine gradually incorporated all its proven theories and practices.

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. The ancient Greek "father of medicine," Hippocrates, is said to have spoken highly of manual and manipulative therapies for a range of conditions.

Osteopathic principles
These are the eight major principles of osteopathy and are widely accepted throughout the osteopathic community.


 * 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, nor contradictions to medical principles; they are thought to be the underpinnings of the osteopathic philosophy on health and disease.

Techniques of Osteopathic Manual 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 somatic dysfunction 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 to help patients recover from illness and injury, and to minimize pain and disease. Most osteopathic physicians view manual therapies as a complement to physiotherapy, and use more invasive therapies (pharmaceuticals and surgery) where necessary.

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, mainstream medicine 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, although well-established, 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 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. The theory underlying cranial osteopathy is rejected by many physicians 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 adjacent bones forming the sutural margins, and it is known that these specialized fibers form only at areas where tissue movement is allowed. It is, of course, accepted by most modern osteopathic physicians 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. The same study looked at inter-operator reliability of palpating the 'cranial rhythm' and found there to be little agreement, 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 has not been scientifically established. 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. Many without direct experience of the benefits of treatment dismiss cranial osteopathy as merely theoretical. However, patients of cranial osteopathic physicians have reported emotional releases, lightness and buoyancy, and visualizations. This technique 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.

Craniosacral therapy is based on the same principles but the practitioners have not attended medical school and are therefore not osteopathic medical physicians. Chiropractor & 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."

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--namely, nerves, blood vessels, and fascial compartments. During the 1940s, osteopaths like H.V. Hoover and M.D. Young built on the pioneering work of Andrew Taylor Still 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 medical 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.

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.

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 and mainstream acceptance in many countries of the Commonwealth and Europe. Osteopathic and allopathic physicians now work side by side in academic, hospital, and clinical settings, and osteopathic medical departments are now well-established in many public universities.

Osteopathy in the United States
In the United States, osteopathy is only practiced by medical doctors. 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 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.

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 allopathic 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 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, and Osteopathy celebrates 100 years in Australia in 2007. The peak body representing Osteopaths in Australia is the Australian Osteopathic Association (#REDIRECT 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 insurancers all recognise 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 recognises 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.

Note: with the exception of the Provice of Quebec, D.O.M.P. is no longer recognized by the Insurance industry as a covered practitioner, only a fully-fledged D.O.

In some countries, osteopathic medicine straddles the boundary between Allopathic 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. 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. .

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. 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. 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 - but the NHS will not usually pay for any treatment. 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.

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 experiment based. Placebo-controlled trials show that osteopathy is no better than sham treatment for lower back pain or for pain after knee/hip surgery.

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, but - in general - the risk is small when performed by skilled practitioners. The skill of the practitioner also determines the relative safety of the technique. '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. However, the causal relationship between stroke and neck manipulation has never been established sufficiently to resolve the debate, with osteopaths and other manipulative therapists contending that the risk of injury is very small in any case.

Associations and regulatory bodies

 * International
 * International Osteopathic Alliance
 * World Osteopathic Health Organization
 * Osteopathy and Chiropractic


 * 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 medicine and back pain - spine-health.com
 * 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

Osteopathie (Diagnose- und Behandlungskonzept) Osteopatía Ostéopathie אוסטאופתיה Osteopatia Osteopathie オステオパシー Osteopati Osteopatia Osteopatia