osteopathy, practice of therapy based on manipulation of bones and muscles. This school of medicine, founded by A. T. Still in 1874, maintains that the normal body produces forces necessary to fight disease and that most ailments are due to "structural derangement" of the body. Frequent slight strains are held to be capable of causing misalignment of bones and various other conditions of the muscle tissue and cartilage, and treatment is directed toward correction of these conditions.

The first school of osteopathy was founded at Kirksville, Mo., in 1892. A growing number of other colleges in the United States are accredited by the American Osteopathic Association to give the required four-year course of training and to grant the degree of D.O. (Doctor of Osteopathy). These colleges give a complete course of instruction in conventional medicine as well as in osteopathic theory and practice. Osteopaths are licensed to practice medicine, including surgery and the prescription of drugs, throughout the United States. Many specialize in treating bone and muscle conditions, but about half are primary-care physicians in general medical practice.

Health-care profession founded by the U.S. physician Andrew Taylor Still (1828–1917) as a reform movement against the rather primitive 19th-century drugs and surgical techniques. It emphasizes the relationship between musculoskeletal structure and organ function. Osteopathic physicians learn to recognize and correct structural problems through manipulative and other therapies. Osteopathic hospitals provide general or specialized health care, including maternity and emergency care.

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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. 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: 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, 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

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. 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." 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 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 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.

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. 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 taught throughout the international 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; they are thought to be the underpinnings of the osteopathic philosophy on health and disease.

Techniques of Osteopathic Treatment

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, menstrual pain, and pulmonary infection.

Cranial osteopathy

Cranial osteopathy is a well-established branch of CAM therapy based on working with what is known as the cranial rhythm. Cranial osteopaths/osteopathic physicians are trained to feel a very subtle, rhythmic pattern of movement or shape changes while holding a patient's head. Outside the profession this is a contested phenomenon; also it is not known what proportion of osteopaths or osteopathic physicians are practitioners nor is it known what portion of practitioners have formal osteopathic training. Cranial osteopathy is based on the subtle involuntary mechanisms or rhythms which can be felt with a very finely developed sense of touch and, generally, through the use of an elaborate adjustable "lift" massage table which allows the practitioner to position his or her hands, arms and shoulders at the sufficiently relaxed angle (attitude) which allows energy connectedness, enabling conductivity and from which the cranial rhythm can be felt following sufficient treatment. From the experienced cranial osteopath, pulses in hydrostatic pressure can be initiated by pulsing the pressure of the practitioner's palms and fingers on the head and neck of the patient. Over time this allows the patient's cranial plates to release and their cranial rhythm to come through. The practitioner's own neurotransmitters are said by many practitioners to be somehow "activated" as the practitioner's fingers and palms find and settle in on locations on the patient's head which have an electrostatic presence. Treatments are generally weekly and continue until cranial osteopathy has re-established the rhythmic movement of the plates which together form the skull. Generally the patient begins with the plates locked into a single unit by calcification. This rhythm was first described in the early 1900s by Dr. William G. Sutherland.

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) ossifies (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.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 "SOT

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.

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.

Osteopathy in the United States

In the United States, osteopathic medicine has diverged significantly from traditional osteopathy. U.S. "osteopathic physicians" (DOs) are licensed medical doctors who have completed conventional medical training, and are licensed to practice medicine as physicians or surgeons.

Osteopathy in the 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. 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.

Osteopathy in Australia & New Zealand

In Australia the profession has developed along the same lines as in Britain, and Osteopathy celebrated 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 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 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.

Osteopathy in Canada

In Canada osteopaths are trained along similar lines to those in Britain and other Commonwealth countries. This provides a traditional approach to Canadian Osteopaths education, focusing on the treatment of the whole patient, not simply medicating the symptoms. Education includes focus on the musculoskeletal system, cranial sacral, visceral manipulation, pediatrics, obstetrics and gynecological work and pathology.

There are currently 550 in the country, all practicing under provincial associations. Canadian osteopaths with the DOMP title do not have prescribing rights.

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

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 treatment or for pain after knee/hip surgery.

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.

Another study, which aimed to identify cellular mechanisms at work during OMM, was published in the Journal of American Osteopathic Association in December 2007. 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.

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 estimate. 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