Is there a place for science in the definition of osteopathy?
Article Outline
Manipulation. What is it? Why do we do it? What does it do? What role does it play in osteopathy today? As defined by the American Association of Colleges of Osteopathic Medicine (AACOM) in their Glossary of Osteopathic Terminology,1 manipulation is simply “…the therapeutic application of manual force…” and when provided by an osteopath its definition is expanded to include the aim of manipulation, which is “…to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction.”
The definition goes further to state that manipulation includes ‘direct’ and ‘indirect’ approaches, listing a variety of over 40 different techniques described under the heading of osteopathic manipulative treatment. Phillip Greenman illustrates this view in a foreword written for a textbook on manipulation, in which he writes, “The authors focus upon high-velocity low-amplitude (HVLA) thrust technique. It continues to be one of the most widely used forms of manipulation by many health care professions” [emphasis added].2
Despite the AACOM definition of manipulation including a range of different types of technique, it is plain that some authors currently use the term ‘manipulation’ to refer to high-velocity low-amplitude (HVLA) thrust techniques.3, 4, 5, 6 Authors of systematic reviews and meta-analyses have also combined ‘mobilisation’ and ‘manipulation’ together under the umbrella term “manipulation” which has lead to inappropriate pooling of different interventions (ie comparing ‘apples with oranges’) and subsequent dilution of treatment effects that may be specific to manipulation but not mobilisation (and vice versa).7
Given the wide range of apparent uses it is no wonder that the term manipulation provides the potential for misunderstanding and misrepresentation; vigorous debates and begrudged compromises; professional identity and professional identity crisis. To some, manipulation refers to a technique in which a joint goes ‘pop’; to others it refers to the entire collection of techniques that they have built their professional careers upon. To some, osteopathy may well be synonymous with manipulation – whatever your definition – whereas to others manipulation is a tool that an osteopath may choose to use. Without some informed consensus about how the term manipulation is to be used then confusion and opportunities for ongoing misunderstanding will continue.
The key issue to resolve internationally and inter-professionally is this: does manipulation refer to a range of manual forces applied to the patient, or does it refer only to high-velocity, low-amplitude thrust technique, with or without an associated ‘pop’. A move toward a multidisciplinary consensus definition of manipulation has been undertaken and utilised in research,8 and it is important that this process is ongoing and informed by research regarding the basic mechanisms and effects of osteopathic techniques.
In this edition of the journal, Bolton and colleagues report an interesting study from New Zealand in which they investigated the laterality of the sound emanating from the cervical spine during “cervical spine manipulation” (their wording). They applied two different HVLA thrust techniques to the cervical spine and using microphones were able to record which side ‘popped’. In a thoughtful addition to this study, they also compared the subjects' perception of the location (left or right) of the ‘pop’ with the results obtained from the microphone recordings. Clearly, this research falls into what Patterson describes as an evaluation of “a manipulative technique” and not “osteopathic manipulative treatment” or “osteopathic health care.”9 The importance of this study is dependent on the relative importance we might place on the ‘pop’, and the meaning we, and our patients, attribute to that ‘pop’.
Also in this issue, and in contrast to research on HVLA thrust techniques, McCarthy and colleagues present an experimental prospective case study from Australia on the use of ideomotor concepts in a patient with chronic cervicobrachial pain; which could be described as evaluating a “manipulative treatment” in a single patient.9 While clinical trials present information about average outcomes in a sample of patients, they do not provide information about the outcomes occurring in individuals. Only prospective case studies, or N
=1 randomised controlled trials can document individual outcomes.10, 11 To date, ideomotion has been overlooked in osteopathy as a phenomenon that may explain the practitioner's perception of subtle movement in patients. This prospective case report of ideomotor therapy by McCarthy et al. is the first of its kind in the peer-reviewed literature, and while not generalisable to other patients and settings, is an important bridge between clinical practice and research.
Also in this issue is a paper from the UK by Zamani and colleagues, who present the findings of an analysis of UK osteopathic education providers' curricula regarding exercise content. This work provides the first published evidence within the profession to anchor opinions about the content of exercise related coursework in osteopathic programmes, and will contribute to an informed evaluation of existing and future curricula. Their research provides an obvious example of the breadth of osteopathic practice, and supports our personal view that osteopathy should not be defined as a ‘manual therapy’, but that manual therapy and exercise are among the range of tools that osteopaths may use.
We began this editorial by raising questions about the definition of manipulation and continue with questions about the definition of osteopathy and osteopathic treatment. Various definitions of osteopathy provide a basis for discussion. In the Glossary of Osteopathic Terminology,1 osteopathy is defined as:
“A complete system of medical care with a philosophy that combines the needs of the patient with current practice of medicine, surgery and obstetrics. Emphasizes the interrelationship between structure and function, and has an appreciation of the body's ability to heal itself.”
The Australian Osteopathic Association offers the following description of osteopathy12:
“Osteopathy is a “whole body” system of manual therapy, based on unique biomechanical principles, which uses a wide range of techniques to treat musculo-skeletal problems and other functional disorders of the body.”
The British Osteopathic Association provides this description13:
“Osteopathy is an established system of clinical diagnosis and manual treatment in which a caring approach to the patient and attention to individual needs are of primary importance. In particular, it is concerned with the inter-relationship between the structure of the body and the way in which it functions and is therefore an appropriate form of therapy for many problems affecting the neuro-musculo-skeletal systems”
The glossary1 defines an ‘osteopath’ as:
“1. A person who has achieved the nationally recognized academic and professional standards within her or his country to independently practice diagnosis and treatment based upon the principles of osteopathic philosophy. Individual countries establish the national academic and professional standards for osteopaths practicing within their countries (International usage). 2. Considered by the American Osteopathic Association to be an archaic term when applied to graduates of U.S. schools.”
The distinction between International usage and North American usage is continued with the definitions of osteopathic manipulative therapy and osteopathic manipulative treatment. Osteopathic manipulative therapy (OMTh) is defined as:
“The therapeutic application of manually guided forces by an osteopath (non-physician) to improve physiological function and homeostasis that has been altered by somatic dysfunction”
Whereas, osteopathic manipulative treatment is defined as:
“The therapeutic application of manually guided forces by an osteopathic physician (US Usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction.”
While the intentional use of the synonyms treatment and therapy to describe the same thing provided by osteopaths of different training is politically intriguing, the message is clear that the application of manually guided forces is something that osteopaths do rather than something that defines osteopathy, osteopathic medicine, or what an osteopath is. The definition of Osteopathy is intended to specify that it is not the diagnosis or treatment that defines Osteopathy but a guiding philosophy and set of principles.
On the basis of the AACOM Glossary definitions, osteopathy and manipulation are clearly not synonymous. Nor are osteopathy and manual therapy. To define osteopathy as a manual therapy is short sighted and incomplete, as it unnecessarily restricts osteopathy to just one of its many components. However, articles and research reports often include statements such as “Osteopathy and other manual therapies”, “the professions of manual therapy, such as osteopathy…” and “osteopaths and other manual therapists”; yet none of these portray osteopathy, or osteopaths, accurately.
Do osteopaths take patient histories and perform a physical examination for diagnostic classification? Do osteopaths refer for diagnostic imaging? Do osteopaths use exercise for rehabilitation, or recommend over the counter medications, or educate patients about general health or specific health conditions? Do osteopaths develop a management plan and develop a reasoned prognosis for the patient? Are any of these adequately described as ‘manual therapy’?
Clearly the definition of osteopathy is intended to specify that it is not the diagnosis or treatment that defines osteopathy but a guiding philosophy and set of principles. This brings us to the crux of the issue, for it follows from this definition that any diagnostic or treatment strategy can be osteopathic, so long as it is based on osteopathic principles and philosophy.
We are, however, somewhat uncomfortable with this conclusion. As it stands, anything seems allowable, so long as it theoretically conforms to the osteopathic principles and philosophy. Surgery, counselling, exercise for rehabilitation, cranial techniques, medication, HVLA and ideomotor therapy can all be justified as osteopathic treatments. But where does it end… is prayer acceptable?
We suggest that defining something as ‘osteopathic’ on the basis of osteopathic principles and philosophy alone lacks the caveat that what is included in osteopathy should be based on science. This requirement is hardly controversial, either by current, or historical standards. For many osteopaths, A.T. Still holds substantial relevance to the modern practice of osteopathy, and it is appropriate to refer to his views on this subject. The following quotations are from Still's Osteopathy: Research and Practice14:
“Osteopathy is a science” p. 6
“[An osteopath] has no use for theories unless they are demonstrated” p. 6
“I will accept nothing from any man's pen as a truthful presentation of this science unless he courts investigation and proves by demonstration that every statement is a truth.” p. 6
“…this book is far from perfection, and it is my hope and wish that every osteopath will go on and on in search for scientific facts as they relate to the human mechanism and health….” p. 2
Acceptance of these statements leads naturally to the conclusion that diagnostic, treatment and prognostic strategies have no place in osteopathy if they are not demonstrable or are inconsistent with scientific facts. Still appears to have been a positivist; and post-modernists will cringe at words like “truth” and “scientific facts”. Many readers may also be uncomfortable with such definitive and uncompromising terms, as science is more closely aligned with probability, likelihoods, variability and uncertainty; than with ‘truth’. However, given Still's emphasis on the combination of “science”, “principles” and “osteopathic philosophy” it is surprising that current definitions of osteopathy make no reference to science. A discussion paper that proposed revisions and updates to the osteopathic tenets and principles includes reference to the importance of evidence based guidelines in patient care.15 We hope that evidence and science might be featured as a central tenet and defining feature of contemporary osteopathy, and in so doing, acknowledge osteopathy's origins while also aligning with modern health care.
References
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- . Viewpoint: effectiveness of cervical spine manipulation and prescribed exercise in reduction of cervicogenic headache pain and frequency: a single case study experimental design. Int J Osteopathic Med. 2005;8:114–116
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- Proposed tenets of osteopathic medicine and principles for patient care. J Am Osteopath Assoc. 2002;102:63–65
PII: S1746-0689(07)00070-3
doi:10.1016/j.ijosm.2007.10.001
© 2007 Elsevier Ltd. All rights reserved.
