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Osteopathy and osteopathic medicine are often used interchangeably[1] for the philosophy and system of alternative medical practice first proposed by A. T. Still MD in 1874. Its practitioners are knowns as osteopaths. It emphasizes the interrelationship between structure and function of the body and recognizes the body's ability to heal itself; it is the role of the osteopathic practitioner to facilitate that process.[2] The American Osteopathic Association recommends using osteopathic physician and osteopathic medicine to describe "American Osteopathy", practiced by full scope of practice physicians, and using osteopath and osteopathy to describe the restricted-scope form of practice in many other jurisdictions.[3][4][5] Despite this, many osteopathic physicians in the US still use the term osteopath.[6]
There is an international organization for individuals, the World Osteopathic Health Organization (WOHO),[7] which permits membership by both "restricted scope manual therapist" osteopaths and "full scope of medical practice" osteopathic physicians. Similarly, there is also an international organization of organizations for national osteopathic and osteopathic medical associations, statutory regulators, and universities/medical schools offering osteopathic and osteopathic medical education, known as the Osteopathic International Alliance (OIA).[8]
Osteopathy and osteopaths should not be confused with the study of bones, osteology, and its practitioners, osteologists.
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The practice of osteopathy began in the United States in 1874. The term "osteopathy" was coined by Andrew Taylor Still, MD, DO. Still was a physician and surgeon,[9][10] Kansas state and territorial legislator,[11] a free state leader,[12] and one of the founders of Baker University,[13] who lived near Baldwin City, Kansas at the time of the American Civil War. In Baldwin, he developed the practice of osteopathy.[14]
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."[15] Still founded the American School of Osteopathy (now A.T. Still University of the Health Sciences) in Kirksville, Missouri, for the teaching of osteopathy on 10 May 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.[16]
The osteopathic medical philosophy is defined as the concept of health care that embraces the concept of the unity of the living organism's structure (anatomy) and function (physiology). These are the four major principles of osteopathy:[17]
These principles are not held by osteopathic physicians to be empirical laws; they serve, rather, as the underpinnings of the osteopathic philosophy on health and disease.
Osteopathic manipulative treatment (OMT) is the therapeutic application of manually guided forces by an osteopathic physician (U.S. usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction.[19] Somatic dysfunction is defined as impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures and their related vascular, lymphatic and neural elements. Acute somatic dysfunction is an immediate or short-term impairment or altered function of related components of the somatic(body) framework. It is characterized in early stages by vasodilation, edema, tenderness, pain and tissue contraction. It is diagnosed by history and palpatory assessment of tenderness, asymmetry of motion and relative position, restriction of motion and tissue texture change.[20] Chronic somatic dysfunction is the impairment or altered function of related components of the somatic (body framework) system. It may be characterized by tenderness, itching, fibrosis, paresthesias and tissue contraction.[20]
While there are many treatment techniques, OMT methods utilized may broadly be classified as active or passive and direct or indirect in nature.
Many osteopaths also manage and/or co-manage organic or Type-O disorders and conditions, such as asthma and middle ear infections in children,[23] menstrual pain,[24] and pulmonary infection. A small subdivision of UK Osteopathic practitioners, following the teachings of John Martin Littlejohn and John Wernham, are known as "Classical Osteopaths". They practice a style of whole or "total" body adjustment which contends that structural strains and patterns, through effects on circulation, reflexes and sensory feedback, precede pathological tissue states. This is said to be due to the downrating, for example, of arterial microcirculation or lymphatic drainage. Treatment is said to lead to successful patient outcomes in a great number of functional and pathological disorders, including infections and degenerative conditions. Great emphasis is made of clearance of the products of metabolism, which place a load on metabolic toxin clearance mechanisms and are said to be irritative. The approach is contentious even within Osteopathy, in a similar way to Cranial Osteopathy. It is no longer taught at undergraduate level in the UK following the loss of GOSc accreditation by the Maidstone school, and is taught as a post graduate specialty.
On 2–4 February 1975, a research symposium organized and conducted by the National Institute of Neurological Disorders and Stroke was held at the National Institutes of Health on The Research Status of Spinal Manipulative Therapy. Papers were presented and discussed by the 116 participants. Basic scientists reviewed information about the status of research and research findings on the pathological spinal cord "nidus" fundamental to the clinical concepts on which manipulative therapy is based (i.e. chiropractic subluxation; osteopathic lesion; patho-physiological zone of neural hyper-excitability). Although focusing on the biology and therapy of back pain, there was discussion of other neuromuscular disorders and of visceral disorders in which manipulative therapy is used. The basic science studies presented were in anatomy, biochemistry, biomechanics, and neuroscience. Clinical investigators with chiropracatic, osteopathic and medical backgrounds presented papers on research findings from pathology, radiology and clinical evaluations; the latter primarily observational studies. Following this in-depth analysis of what was known at that time about spinal manipulative therapy and the principles on which it was founded, there was group discussion of what was not known and what needed to be known. Recommendations were made about research questions requiring targeted additional attention and the priority need for the establishment of research training opportunities in chiropractic and osteopathic professional schools. Basic and clinical investigators in medical schools commented that their laboratories were available for collaborative research training and research project endeavors for colleagues with chiropractic or osteopathic backgrounds.[25]
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."[26]
In a 2005 meta-analysis and systematic review of six randomized controlled trials of osteopathic manipulative treatment (OMT) that involved blinded assessments of lower back pain in ambulatory settings, it was concluded that OMT significantly reduces lower back pain, and that the level of pain reduction is greater than expected from placebo effects alone and persists for at least three months.[27]
The NIH's National Center for Complementary and Alternative Medicine states[28] that overall, studies have shown that spinal manipulation can provide mild to moderate relief from low-back pain and appears to be as effective as conventional medical treatments. In 2007 guidelines, the American College of Physicians and the American Pain Society include spinal manipulation as one of several treatment options for practitioners to consider using when pain does not improve with self-care.[29][30] Recent research into spinal manipulation for low-back pain has begun to look at the effects of different forms of manipulation, as well as treatment duration and frequency. Studies have found that spinal manipulation provides relief from low-back pain at least over the short term (i.e., up to 3 months), and that pain-relieving effects may continue for up to 1 year. Spinal manipulation is generally a safe treatment for low-back pain. Serious complications are very rare.[28]
The osteopathic profession has evolved into two branches, non-physician manual medicine osteopaths and full scope of medical practice osteopathic physicians. These groups are so distinct that in practice they function as separate professions. In recent years, the profession has actively attempted to enhance exchange and dialogue between them. Manual osteopaths who have graduated from a recognized college and are members of International Osteopathic Association may practice in all countries. In certain countries such as Canada and the USA they may not provide joint manipulation and diagnosis as these are regulated acts.[31]
The following sections describe the legal status of Osteopathy and Osteopathic Medicine in each country listed:
Osteopaths are primary contact health professionals who, in their own practice, make independent judgments in the examination, diagnosis, treatment, prevention and care of conditions of the human body to the extent of their individual competence. Osteopaths work in private practice, and the majority of private health insurance providers cover treatment performed by osteopaths.[32]
Three publicly funded Australian universities now offer degrees in osteopathy: RMIT University (formerly The Royal Melbourne Institute of Technology),[33] Victoria University of Technology,[34][35] and Southern Cross University.[36]
The Osteopathy Board of Australia[37] is part of the Australian Health Practitioner Regulation Agency.[38]
The first self-identified college of Osteopathy in Canada opened in 1981. There are 7 osteopathy colleges in Canada teaching in Montreal, Quebec City, Toronto, Hamilton, Vancouver, Ottawa, London, Winnipeg, Calgary and Edmonton. Currently there is no a testing centre for manual osteopathic practitioners in Canada. The purpose of the Canadian Manual Osteopathy Examining Board (CMOEB) is to establish and maintain uniform high standards of excellence in the manual osteopathy profession and education, primarily but not exclusively by preparing and administering to qualified applicants examinations of superior quality, whereby those legal agencies which govern the manual osteopathic practice within each province and other countries may accept, at their discretion, those individuals who have successfully completed any part of the examinations of CMOEB, and by providing test and measurement services to the manual osteopathy profession in all areas of demonstrated need, and to advance the manual osteopathy profession when in the best interests of manual osteopathy testing. Manual osteopaths who pass exams administered by Canadian Manual Osteopathy Examining Board are permitted to join International Osteopathic Association (IOA) and receive certificate of registration. No osteopathic associations in Ontario are recognized or accredited by any regulatory authority as osteopathy is not regulated yet.[39]
The authority for licensing of US-trained osteopathic physicians lies with the provincial Colleges of Physicians and Surgeons.[40][41][42][43][44][45] The Ontario Medicine Act 1991 states that "No person other than a member (registered with the College of Physicians & Surgeons) shall use the titles "physician" or "surgeon", a variation or abbreviation or an equivalent in another language. 1991, c. 30, s. 9 (1)." and "No person other than a member shall hold himself or herself out as a person who is qualified to practise in Ontario as a physician or surgeon or in a specialty of medicine. 1991, c. 30, s. 9 (3)." Membership in the College of Physicians and Surgeons requires that members are physicians trained in the full scope of medical practice.[46] Similar title protection laws have been enacted in Alberta[45] and British Columbia.[47] The Canadian Osteopathic Association[48] has been representing osteopathic physicians in Canada for more than 80 years and has enabled near uniform licensing across Canada for US-trained osteopathic medical graduates.
There is no universal regulatory authority for the practice of osteopathy or osteopathic medicine within the European Union; it is on a country by country basis. The UK's General Osteopathic Council, a regulatory body set up under the country's Osteopaths Act 1993 has issued a position paper on European regulation of osteopathy.[49]
In Austria and Switzerland, osteopathic practitioners are MDs or Physiotherapists who take additional courses in osteopathy after completing their medical training or Physical Therapy Training.
Osteopathy is a governmentally recognized profession and has title protection, autorisation d'utiliser le titre d'ostéopathe.[50] The most recent decree regarding osteopathy was enacted in 2007, Décret n° 2007-435 du 25 mars 2007 relatif aux actes et aux conditions d'exercice de l'ostéopathie.
Germany has both osteopathy and osteopathic medicine. There is a difference in the osteopathic education between non-physician osteopaths, physiotherapists, and medical physicians.
Physiotherapists are a recognized health profession and can achieve a degree of “Diploma in Osteopathic Therapy (D.O.T.).” Non-physician osteopaths are not medically licensed. They have an average total of 1200 hours of training, roughly half being in manual therapy and osteopathy, with no medical specialization before they attain their degree. Non-physician osteopaths in Germany officially work under the “Heilpraktiker” law. Heilpraktiker is a separate profession within the health care system. There are many schools of Osteopathy in Germany; most are moving toward national recognition although such recognition does not currently exist.[51] In Germany there are rules (at the country level) under which persons (non-physicians) may call themselves Osteopath.[52]
Osteopathic physicians in Germany achieve a degree of “D.O.- DAAO” or “D.O.M.”, from the DAAO and DGOM respectively. Osteopathic physicians in Germany are fully licensed with at least 6,500 hours in medical school 6 years, at least 7,000 hours in specialty training, which is 3 to 6 years, plus at least 680 hours of training in manual medicine and osteopathy before attaining their degree. German physicians who have obtained the degree designation Dr. med., and who have completed their medical education and specialty training in areas such as general practise, orthopaedics, neurology, internal medicine, etc. can earn a Diploma in Osteopathic Medicine, either a DO-DAAO from the DAAO (German-American Academy for Osteopathy), a DOM™ from the DGOM (German Society of Osteopathic Medicine), or an MDO (Medical Doctor of Osteopathy) from the DGCO (German Society for Chirotherapy and Osteopathy) if additional educational requirements are met. The additional education includes a 320-hour program in manual medicine and an additional minimum of 380 hours in osteopathic medicine, which together makes a minimum of 700 hours. The osteopathic medicine course is limited to physicians only.[53]
The scope of practise for a US-trained osteopathic physician in Germany is unlimited. A foreign physician may apply for licensure with the regional medical authorities, the Health Ministry, which represents the state in which the applicant intends to work. The regional state health ministry has information regarding the types of medical providers needed in that area and therefore grants work permits to licensed physicians depending on the specialty of the foreign physician.[53]
The practice of osteopathy is regulated by law, under the terms of the Health Practitioners Competence Assurance Act 2003[54] which came into effect on 18 September 2004. Under the Act, it is a legal requirement to be registered with the Osteopathic Council of New Zealand [OCNZ],[55] and to hold an annual practicing certificate issued by them, in order to practice as an osteopath. Each of the thirteen healthcare professions regulated by the HPCA Act works within the "Scope of Practise" determined and published by its professional Council. Osteopaths in New Zealand are not fully licensed physicians. In New Zealand, in addition to the general scope of practice, osteopaths may also hold the Scope of Practice for Osteopaths using Western Medical Acupuncture and Related Needling Techniques.[56]
In New Zealand a course is offered at Unitec.[57] Australasian courses consist of a bachelor's degree in clinical science (Osteopathy) followed by a master's degree. The Unitec New Zealand double degree programme is the OCNZ prescribed qualification for registration in the scope of practice: Osteopath, Australian qualifications accredited by the Australian and New Zealand Osteopathic Council are also prescribed qualifications.
Osteopaths registered and in good standing with the Australian Health Practitioner Regulation Agency – Osteopathy Board of Australian are eligible to register in New Zealand under the mutual recognition system operating between the two countries. Graduates from programs in every other country are required to complete an assessment procedure.[58]
The scope of practice for US-trained osteopathic physicians is unlimited on an exceptions basis. Full licensure to practice medicine is awarded on an exceptions basis following a hearing before the licensing authorities in New Zealand. Both the Medical Council of New Zealand[59] and the Osteopathic Council of New Zealand [OCNZ][60] regulate osteopathic physicians in New Zealand. Currently, the country has no recognized osteopathic medical schools.[61]
The practice of osteopathy has a long history in the UK. The first school of osteopathy was established in London in 1917 by John Martin Littlejohn, PhD, MD, DO, a pupil of A.T. Still, who had been Dean of The Chicago College of Osteopathic Medicine. After many years of existing outside the mainstream of health care provision, the osteopathic profession in the UK was finally accorded formal recognition by Parliament in 1993 by the Osteopaths Act.[62] This legislation now provides the profession of osteopathy the same legal framework of statutory self-regulation as other healthcare professions such as medicine and dentistry.
The General Osteopathic Council (GOsC) regulates the practice of osteopathy under the terms of the Osteopaths Act 1993. A person cannot practise unless they register with the GOsC. The General Osteopathic Council has a statutory duty to promote, develop and regulate the profession of osteopathy in the UK. It fulfils its duty to protect the interests of the public by ensuring that all osteopaths maintain high standards of safety, competence and professional conduct throughout their professional lives. In order to be registered with the General Osteopathic Council an osteopath must hold a recognized qualification that meets the standards as set out by law in the GOsC's Standard of Practice.[63] This Act provides for “protection of title” A person who, whether expressly or implication describes himself as an osteopath, osteopathic practitioner, osteopathic physician, osteopathist, osteotherapist, or any kind of osteopath is guilty of an offence unless he is registered as an osteopath. There are currently approximately four thousand osteopaths registered in the UK.[64]
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 Masters or Bachelors of Osteopathy, or Osteopathic Medicine, (BOst or MOst) or else Bachelors of Science (BSc) in Osteopathy or Osteopathic Medicine, according to the institution attended:[65] in this case osteopathy and osteopathic medicine are synonymous, but these degrees do not lead to prescribing rights.
The recognition of osteopathy also means that doctors can now refer patients to osteopaths for treatment with the transfer of clinical responsibility rather than simply delegating the responsibility for care, as is the case with other healthcare professionals. It may or may not be a covered benefit under the National Health Service depending on where in the UK you may live.[66]
Osteopathic medicine is regulated by the General Osteopathic Council (GOsC) under the terms of the Osteopaths Act 1993 and statement from the GMC. The London College of Osteopathic Medicine,[67] teaches osteopathy only to those who are already physicians.
Foreign-trained osteopathic physicians, who are registered with the GMC and GOsC, hold both a full medical practise and osteopathic license. Each applicant will have to pass the Professional and Linguistic Assessment Board test (PLAB) and work for one supervised year in the National Health Service (NHS). Following that year, the applicants will be able to apply for full registration (unsupervised practice or private practice). If the physician is already a specialist, postgraduate training will need to be separately recognized by the Postgraduate Medical Education and Training Board (PMETB).[68]
Licensure or registration of non-physician osteopaths is not permitted anywhere in the United States. European style osteopaths are prohibited to call themselves osteopaths. They are referred to as osteopathic manual practitioners. A.T. Still's American School of Osteopathy, now known as A.T. Still University of the Health Sciences, was chartered by the state of Missouri to award the MD degree.[69]
Osteopathic medicine in the United States has always meant a physician trained in and entitled to the full scope of medical practice. Osteopathy or osteopath as written in some US state and federal laws refers only to osteopathic medicine or osteopathic physicians, respectively.[70] With the increased internationalization of the profession, these older terms have fallen out of favor as generally accepted use due to the confusion they may cause.[71][72]