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Osteopathy

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The research and literature reviews collated by our TAB Research Team are not to be shared external to the Branch. These are for internal TAB use only and are intended to assist our advisors with their reasonable and necessary decision-making. Delegates have access to a wide variety of comprehensive guidance material. If Delegates require further information on access or planning matters, they are to call the TAPS line for advice. The Research Team are unable to ensure that the information listed below provides an accurate & up-to-date snapshot of these matters

Research question: Is osteopathy effective in improving functional outcomes for people with physical disability compared with physiotherapy?

Date: 31/10/2023 Requestor: Natasha s22(1)(a)(ii) - irrelevant material Endorsed by: Katrin s22(1)(a)(ii) - irreleva Researcher: Aaron s22(1)(a)(ii) - irrelevant ma Cleared by: Stephanie s22(1)(a)(ii) - irrelevant mat

Contents

Osteopathy ………………………………………………………………………………………………………………… 1

  • Contents ……………………………………………………………………………………………………….. 1
  • Summary ………………………………………………………………………………………………………. 2
  • Osteopathy Scope of Practice ………………………………………………………………………….. 2
    • Osteopathy and evidence-based practice ………………………………………………………… 4
    • Doctors of Osteopathy ………………………………………………………………………………….. 4
  • Efficacy …………………………………………………………………………………………………………. 5
    • Quality of evidence ………………………………………………………………………………………. 5
    • Osteopathy for children …………………………………………………………………………………. 5
    • Pain related conditions …………………………………………………………………………………. 6
  • References ……………………………………………………………………………………………………. 7

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Summary

Osteopathy is an allied health profession focussing on treatment of pain and dysfunction caused by musculoskeletal conditions. It is classed as a traditional or complimentary therapy by the World Health Organisation. There is low or very low quality evidence that osteopathic techniques are more effective in reducing pain and improving function for people with pain-related conditions compared to standard treatment such as physiotherapy, exercise or medication. Evidence is inconsistent regarding treatment of children and non-pain related conditions. Assessments of the quality of the literature vary. Some reviews suggest moderate quality evidence exists for the effectiveness of osteopathic manipulative treatment in reducing pain and improving function. However, the methodological quality of these reviews is low.

Osteopathy Scope of Practice

Osteopathy is an area of traditional or complementary medicine that uses manual techniques to diagnose and treat mostly neuro-musculoskeletal and pain-related complaints (Osteopathy Australia, 2023; WHO, 2019). Osteopathy is said to take a holistic approach to diagnosis and treatment:

Osteopathy is holistic in the sense that health, disease, and functional impairment are multi-factorial, and an osteopath considers a client’s needs and goals in the relevant biopsychosocial context. This applies equally for prevention, diagnosis or therapeutic management (Osteopathy Australia, 2023, p.2).

Osteopathy is a discipline rather than a single technique and so practitioners can employ a variety of manual techniques, some of which overlap with the practices of physiotherapists and chiropractors (Steel, 2018). They may use common manual therapy techniques such as soft tissue techniques, manipulation or mobilisation. Osteopaths may also prescribe exercise, complete referrals or provide advice about lifestyle changes and available services (Osteopathy Australia, 2023). Table 1 details techniques and treatment strategies in use by Australian osteopaths. Previous TAPIB research, RES 322 Manual therapy to address neuromusculoskeletal function, contains further consideration of manual techniques.

Osteopathic practice in Australia focusses on musculoskeletal conditions, especially related to treatment of pain conditions (Osteopathy Australia, 2023; Adams et al, 2018; Steel, 2018). Practitioners frequently treat people with sports injuries, people with work-related injuries and pregnant women. Around 12% of Australian osteopaths treat non-musculoskeletal conditions (Adams et al, 2018).

In Australia, osteopaths are university-trained allied health professionals. Osteopathy is a regulated health professional regulated by the Australian Health Practitioner Regulation Agency (AHPRA). Osteopaths must be registered with the Osteopathy Board of Australia and

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accredited by the Australian Osteopathic Accreditation Council (AOAC). Osteopathy Australia is Australia’s peak body representing and advocating on behalf of the profession.

Table 1 % of Australian osteopaths who use specific osteopathic techniques and treatment strategies (Source: Adams et al, 2018)

Manual technique %
Strain/Counterstain 42.4
Muscle energy techniques 79.5
High velocity low amplitude/Spinal manipulation 63.8
Peripheral joint manipulation 39.7
Soft tissue 85.7
Myofascial release 61.8
Cranial techniques 23.5
Facilitated positional release 16.8
Needling techniques/acupuncture 23.6
Visceral techniques 9.9
Lymphatic pump 8.5
Autonomic balancing 15.9
Biodynamic techniques 15.6
Functional techniques 27.3
Balanced ligamentous tension/Ligamentous articular strain 35.2
Exercise prescription 74
Chapmans reflexes 2.4
Shockwave therapy 1.8

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Manual technique %
Ultrasound therapy 2.7
TENS or other electrotherapy 1.9
Instrument-assisted manipulative techniques 0.2
Instrument-assisted soft tissue mobilisation 1.2
Trigger point therapy 26.1
Sports taping 12.3

3.1 Osteopathy and evidence-based practice

Osteopathy is based on the following principles:

  • The body is one unit of function
  • The body has self-regulating mechanisms
  • The body’s structure and function are reciprocally inter-related (Osteopathy Australia, 2023).

Osteopathy Australia states that these principles are used together with current medical knowledge and that “scientific plausibility and evidence-informed reasoning are fundamental to diagnosis, treatment and case management” (Osteopathy Australia, 2023, p.2). Contemporary researchers have questioned whether these principles are scientifically justifiable and whether osteopathy has sufficiently incorporated evidence-based practice (Thomson & MacMillan, 2023; Skinner et al, 2022; Steel, 2018).

A 2018 survey of 992 Australian osteopaths found 75% of respondents agree that research has a moderate to high impact on their clinical practice (Adams et al, 2018). A 2019 survey of 332 Australian osteopaths found that most respondents considered evidence-based practice to be beneficial for patients, useful for clinicians and necessary for the discipline (Leach et al, 2019). In contrast, the same survey also found that most practitioners either do not engage in evidence-based practice or do so only infrequently. This is supported by a 2022 survey of 116 Australian osteopaths, which found 71% never, rarely or only sometimes considered the evidence-base for a particular technique (Clifford et al, 2022).

3.2 Doctors of Osteopathy

In most regions internationally, osteopathy is an allied health profession. In the United States, osteopathy is taught in some medical schools as part of a complete medical degree. Graduates of osteopathic schools of medicine are Doctors of Osteopathy (DO). Their

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education includes training in osteopathic manual techniques and may include an emphasis on preventive care (American Osteopathic Association, n.d.). DOs are fully qualified medical doctors and practice in all medical specialties. A recent survey showed less than half of DOs employ osteopathic techniques in their practice. Of those that do, 44% employ osteopathic techniques infrequently (Healy et al, 2021).

Efficacy

Quality of evidence

The literature considering osteopathic techniques is generally of low quality (Bagagiolo et al, 2022), though there is some evidence that quality is improving in recent studies (Psadzki et al, 2022). Most studies investigate pain-related conditions, reflecting current osteopathic practice. In a bibliometric study of osteopathic research, Morin and Gaboury (2021) found that most studies are published in osteopathy-focussed journals rather than general medical or allied health journals.

Osteopathy for children

Bagagiolo et al (2022) found limited or inconclusive evidence that OMT could be beneficial in the treatment of paediatric conditions. Psadzki et al (2022) reviewed 13 studies and found that OMT has little or no effect on reducing the length of hospital stay of preterm infants or improving breastfeeding. Results were inconsistent for other conditions such as asthma, ADHD, otitis media, colic and headache.

Osteopathy Australia released a position statement on the use of osteopathy for children. They state:

Osteopathy Australia recommends that spinal manipulative techniques not be used on babies, infants or children aged under 12 years, given limited systematic evidence of clinical benefit for these patient groups. Further considerable public and regulatory concern has been raised in relation to the practice…

A range of other clinical management approaches can be used to encourage range of movement, physical mobility and age-appropriate skill growth while managing potential clinical risk. Where relevant to a differential diagnosis, management options could include soft tissue manual therapy approaches, positional or postural advice, aids, toy or appliance prescription, play activity prescription and/or exercise programming (Osteopathy Australia, 2022).

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There is evidence that manual therapy techniques can be effective at managing pain and discomfort and improving physical functioning for people with musculoskeletal-related pain conditions, especially low back pain and neck pain. Minimal evidence exists related to improvements in function for people with non-pain related conditions. Refer to RES 322 Manual therapy to address neuromusculoskeletal function for more information around the efficacy of manual therapy in general. This section will consider the efficacy of specific osteopathic manual techniques or manual therapy performed by an osteopath.

A recent narrative review (Licciardone et al, 2021) argues there is sufficient evidence for the effectiveness of osteopathic manipulative treatment (OMT) for lower back pain, citing large effect sizes comparable to some pain medications. However, the authors do not report the quality of these studies. They also note insufficient evidence for the effectiveness of OMT for any other condition.

Rehman et al (2020) reviewed 16 randomly controlled trials into the effectiveness of OMT in patients with non-specific cancer pain. They found moderate quality in favour of OMT in reducing pain, disability and improving quality of life compared to control treatments including exercise, physiotherapy and medication.

In their scoping review, Jara Silva et al (2022) found all included studies showed benefit of OMT in at least one measure. However, the authors did not consider risk of bias or others measures of the quality of included studies.

Dal Farra et al (2021) reviewed 10 studies of osteopathic techniques for the treatment of chronic non-specific low back pain, including osteopathic manipulative treatment (OMT), myofascial release, craniosacral treatment and osteopathic visceral manipulation. The authors found moderate-quality evidence in favour of myofascial release compared to control treatment in the reduction in pain, but very low-quality evidence for its effectiveness in improving functional status. They also found low quality evidence in favour of OMT for pain reduction and improvement in functional status.

Bagagiolo et al (2022) assessed Rehman et al (2020) and Dal Farra et al (2020) as providing low quality evidence. All primary studies included in Rehman et al (2020) and Dal Farra et al (2020) were rated at high risk of bias. Bagagiolo et al reviewed nine systematic reviews investigating the effectiveness of OMT. They found evidence of possible reduction in pain and improvement in functional status for people with lower back and neck pain and in chronic non-specific cancer pain after OMT. They found limited or inconclusive evidence that OMT could be beneficial in the treatment of migraine or tension headache. However, Bagagiolo et al also noted that all included systematic reviews were low or critically low quality.

Bagagiolo et al (2022) found limited or inconclusive evidence that OMT could be beneficial in the treatment of irritable bowel syndrome. A more recent review presents similar results. Buffone et al (2023) found low or very low-quality evidence that OMT could improve pain and constipation associated with irritable bowel syndrome.

References

Adams, J., Sibbritt, D., Steel, A., & Peng, W. (2018). A workforce survey of Australian osteopathy: analysis of a nationally representative sample of osteopaths from the Osteopathy Research and Innovation Network (ORION) project. BMC health services research, 18(1), 352. https://doi.org/10.1186/s12913-018-3158-y American Osteopathic Association. (n.d.). What is a DO? https://osteopathic.org/what-is-osteopathic-medicine/what-is-a-do/ Bagagiolo, D., Rosa, D., & Borrelli, F. (2022). Efficacy and safety of osteopathic manipulative treatment: an overview of systematic reviews. BMJ open, 12(4), e053468. https://doi.org/10.1136/bmjopen-2021-053468 Buffone, F., Tarantino, A. G., Belloni, F., Spadafora, A., Bolzoni, G., Bruini, I., Bergna, A., & Vismara, L. (2023). Effectiveness of Osteopathic Manipulative Treatment in Adults with Irritable Bowel Syndrome: A Systematic Review and Meta-Analysis. Healthcare (Basel, Switzerland), 11(17), 2442. https://doi.org/10.3390/healthcare11172442 Clifford, A., Segal, A., Guterres, A., & Orrock, P. J. (2022). An exploration of the clinical reasoning used by registered osteopaths in their choice of therapeutic approach. International Journal of Osteopathic Medicine, 46, 19-28. https://doi.org/10.1016/j.ijosm.2022.10.003 Dal Farra, F., Risio, R. G., Vismara, L., & Bergna, A. (2021). Effectiveness of osteopathic interventions in chronic non-specific low back pain: A systematic review and meta-analysis. Complementary therapies in medicine, 56, 102616. https://doi.org/10.1016/j.ctim.2020.102616 Healy, C. J., Brockway, M. D., & Wilde, B. B. (2021). Osteopathic manipulative treatment (OMT) use among osteopathic physicians in the United States. Journal of osteopathic medicine, 121(1), 57–61. https://doi.org/10.1515/jom-2020-0013 Jara Silva, C. E., Joseph, A. M., Khatib, M., Knafo, J., Karas, M., Krupa, K., Rivera, B., Macia, A., Madhu, B., McMillan, M., Burtch, J., Quinonez, J., Albert, T., & Khanna, D. (2022). Osteopathic Manipulative Treatment and the Management of Headaches: A Scoping Review. Cureus, 14(8), e27830. https://doi.org/10.7759/cureus.27830 Leach, M. J., Sundberg, T., Fryer, G., Austin, P., Thomson, O. P., & Adams, J. (2019). An investigation of Australian osteopaths’ attitudes, skills and utilisation of evidence-based practice: a national cross-sectional survey. BMC health services research, 19(1), 498. https://doi.org/10.1186/s12913-019-4329-1 Licciardone, J. C., Schultz, M. J., & Amen, B. (2020). Osteopathic Manipulation in the Management of Chronic Pain: Current Perspectives. Journal of pain research, 13, 1839–1847. https://doi.org/10.2147/JPR.S183170

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