Sundhedsudvalget 2022-23 (2. samling)
SUU Alm.del Bilag 211
Offentligt
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OSTEOPATHIC
HEALTHCARE
Global review
of osteopathic
medicine and
osteopathy 2020
Osteopathic International Alliance
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Foreword
This report on the status of the global osteopathic profession in 2020 was completed as a part of the
Osteopathic International Alliance’s 2018-2020 Collaborative Plan with the World Health Organization
(WHO). As a non-State actor in official relations with the WHO since February 2018, the OIA
continues to promote and document the commitment of the osteopathic profession to providing
quality healthcare to patients across the globe.
This survey provides a current view of the profession and its growth since the last global survey in
2013 and demonstrates greater acknowledgment and acceptance of both osteopathy and osteopathic
medicine throughout the world. Additionally, the evidence for effectiveness of manual therapies is
growing and becoming more robust.
The OIA Board appreciates and recognizes the integral contributions of OIA member organizations to
the data gathering process. The Chair is grateful to the OIA Board for its vision and diligent work in
editing the document. Special thanks also go out to the following:
Professor Dawn Carnes, Project Manager, United Kingdom
Dr Julie Ellwood, Project Researcher, Ireland
Mr Charles Hunt, Immediate Past Chair OIA Board
and Global Survey Task Force Chair, United Kingdom
Ms Ana Paula Ferreira, Chair-elect OIA Board, Brazil
Ms Amy Byerwalter, Interim CEO, OIA, United States
The OIA Board of Directors is proud to submit this report to the World Health Organization in
support of its strategic priorities, outcomes, and general program of work. We are also pleased to
share this document with our member organizations to advance the global osteopathic profession and
to advocate for high-quality osteopathic healthcare worldwide.
Dr William J. Burke
Chair, OIA Board of Directors
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Global Overview
Supporting material:
PART I:
The status of osteopathic healthcare
worldwide a survey of OIA members
PART II:
A profile of osteopathic healthcare
a review of literature
PART III:
Osteopathy evidence and
safety summary
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BACKGROUND
•
Osteopathic healthcare is a based on a perception of the body as an integrated whole. It is a
‘person-centered’ rather than ‘disease-centered’ approach to the prevention, diagnosis and treatment
of illness and injury.
•
Osteopathic professionals use a range of techniques including ‘hands-on’ manual techniques
for assessment and diagnosis to identify and then treat various health conditions, including
musculoskeletal structural problems that influence the body’s physiology, including the nervous
system, circulation, and internal organs.
•
There are two related professions providing osteopathic healthcare; there are osteopathic physicians
providing osteopathic medicine and osteopaths providing osteopathy.
PRESENCE AND STATUS WORLDWIDE
•
There are an estimated 196,861 clinicians delivering osteopathic care worldwide in 46 countries.
•
There are around 117,559 registered osteopathic physicians or physicians with additional training
in osteopathy.
•
There are 79,302 osteopaths. Of these 45,093 are statutorily regulated and registered osteopaths
and we estimate 34,207 osteopaths are not statutorily regulated and registered but may be registered
with voluntary registering organizations.
•
Osteopathic physicians are statutorily regulated and can obtain a license to practice medicine
in 57 countries
•
Osteopaths are statutorily recognized as healthcare professionals and regulated by law in
13 countries.
•
Osteopathy is either not recognized or regulated by governmental statute in 22 countries, where
registration is voluntary.
•
The number of osteopaths per 100,000 capita varies from <1 in Argentina, Brazil, Greece, Russia,
and the United Arab Emirates to 11 per 100,000 in Australia, 14 in Switzerland, 15 in New Zealand,
and 49 in France.
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Table 1. Number and status of osteopathic physicians and osteopathic practitioners worldwide
Osteopathic physicians and/or medical
physicians with osteopathic training
(Statutory regulated)
Belgium 4
Burundi 1
Canada 37
Caribbean 0
Denmark 1
Ethiopia 1
Finland 3
France 2500
Germany 2547
Greece 1
Italy 250
Kenya Unknown
Malawi 2
Nigeria Unknown
Papua New Guinea 1
Russia 1500
Singapore Unknown
Slovenia 3
Spain 4
United Arab Emirates 2
United States of America 110,700
Zambia 2
Statutory regulated and registered
osteopaths
Australia 2741
Denmark 165
Finland 485
France 33,000
Iceland 6
Lichtenstein Unknown
Malta 11
New Zealand 735
Portugal 1352
South Africa 38
Switzerland 1086
United Arab Emirates 35
United Kingdom 5,439
Voluntary registered osteopaths
and non-registered osteopaths
Argentina 139
Austria 1000
Belgium 866*
Brazil 139
Canada 2900
Croatia Unknown
Cyprus 15
Egypt 8
Fed. States of Micronesia 0
Germany 4065
Greece 35
Israel 90
Italy 13,600
Japan 96
Netherlands 700
Norway 372
Republic of Korea 101
Republic of Ireland 157
Seychelles Unknown
Singapore 50
Spain 9420
Sweden 456
*Self-reported Belgian number updated to 1800 at the time of publication. All numbers included in this report are self-reported.
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OSTEOPATHIC EDUCATION AND TRAINING
•
Osteopathic physicians have a minimum of a medical degree qualification and post-doctoral training that
enables them to practice as licensed medical physician plus additional training in osteopathic principles and
osteopathic manipulative treatment.
•
Osteopathic physician education institutions are found in at least 6 countries.
•
Osteopath qualifications ranged from diplomas to Masters degrees.
•
The minimum education requirement to practice for new osteopaths is a Bachelor degree in most countries.
•
Osteopathic training and education institutions are found in at least 20 countries.
•
Where osteopathy is regulated there is an obligatory requirement for continuing professional development, in
countries where osteopathy has voluntary registration there are informal requirements.
•
Continuing Professional Development is stipulated by hours spent learning (range 11 to 40 hours).
OSTEOPATHIC PRACTICE
•
The majority of osteopathic practitioners are aged between 30 and 59 years, with more than 8 years of work
experience as an osteopath or osteopathic physician.
•
Osteopaths generally work in practices on their own.
•
Osteopaths across UK and central Europe are generally able to provide their patients with an osteopathic
consultation within one week.
•
The most common forms of manual treatment modality are soft tissue manipulation, joint mobilization and
manipulation, but may also include other approaches such as facilitating self-management, giving wellbeing and
lifestyle advice and support as part of a package of care.
•
The reported range and diversity of techniques used by osteopaths and osteopathic physicians is large. In
central Europe there is a preference for more gentle techniques such as osteopathy in the cranial field,
visceral, functional, and bio-dynamic techniques compared with the UK and Australia where the preference
is more towards structural techniques such as soft tissue manipulation, articulation/mobilization, and spinal
manipulation technique.
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OSTEOPATHIC PATIENTS
•
People seeking osteopathy for care are typically between 40 and 50 years old, although children make up
around 10-25% of patients and of these around three quarters are under 2 years old.
•
More females than males (60:40) visit an osteopath.
•
Osteopathic patients typically seek care for low back, mid back, and neck pain although in some countries
care for non-musculoskeletal conditions such as digestive complaints, headaches, respiratory conditions and
specifically for women’s health is common.
•
Patients who attend osteopathic consultations are likely to be employed/self-employed adults.
EVIDENCE AND SAFETY OF OSTEOPATHIC CARE
•
Practitioners from different manual therapy disciplines share many of the same techniques, such as
mobilization, manipulation, muscle energy and soft tissue techniques.
•
The evidence for effectiveness of manual therapies is growing and becoming more robust. There is
moderate and strong evidence for pain relief and improving function for low back, neck, shoulder disorders
and headaches.
•
There is a growing positive evidence base of beneficial effects for hip and knee osteoarthritis, heel pain,
pulled elbow in children, length-of-hospital-stay in pre-term infants, irritable bowel syndrome, lymphatic
drainage as part of breast cancer care and infantile colic.
•
The risk of serious harm with manual treatments including with manipulation and mobilization techniques
is very low.
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Table 1. Evidence summary of beneficial effects with manual therapy
The orange boxes indicate moderate to high level evidence of benefit. Techniques tested varied between manipulation,
mobilization, soft tissue manipulation, muscle energy techniques and combinations. The blue boxes indicate moderate to
low level evidence.
Condition (with positive,
moderate, or high-level
evidence)
Adult low back pain
Pediatric low back pain
Pregnancy related low
back, pelvic pain
Post-partum low back
and pelvic pain
Neck Pain
Headaches
Shoulder dysfunctions
Elbow pain
Hip osteoarthritis
Knee osteoarthritis
Heel pain (plantar fasciitis)
Infantile colic
Infant pulled elbow
Preterm infants
Breast cancer care
(upper extremity
lymphatic drainage)
Irritable bowel syndrome
Pain reduction
Function/
ROM/disability
Return to work
Quality of life
Satisfaction
with care
Other
Co-ordination
Reduction in
crying time
Length of
hospital stay
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COMPARISON BETWEEN 2013 AND 2020
•
The global osteopathic profession is rapidly growing. Since 2013 the number of osteopathic physicians has
increased by 34%; osteopaths by 84%.
•
The number of countries where osteopaths are recognized formally as healthcare professionals contributing
to the healthcare delivery of their nations has grown, indicating greater acknowledgment and acceptance
of the profession globally.
•
The availability of data is more consistent across nations, although it is still difficult to accurately define in
some countries the number of practicing osteopaths and osteopathic physicians where registration
is voluntary.
•
The patient demographic has changed, osteopaths see more children (0-2 years old: 8.7% in 2013 to 16.7%)
and older adults (>65 years: 9% in 2013 to 15.1%) and working age adults decreased from 69% to 49.5%.
•
The reasons for seeking care have not changed, low back and neck pain are the most common complaints
and around one third are acute presenting complaints.
•
Osteopaths deliver multiple interventions as a part of a package of care, which was less obvious in 2013.
•
The evidence base is stronger with additional emerging evidence of benefit for osteoarthritic conditions,
chronic pelvic pain in women, irritable bowel syndrome, lymphatic drainage, infantile colic, pulled elbow and
for preterm infants.
•
The evidence about safety of manual therapy is more conclusive and established.
CONCLUSIONS
•
Osteopathic care makes a substantial contribution to healthcare across the globe. If we use a modest
assumption that osteopaths deliver around 25 consultations per week for 46 weeks in every year, we can
estimate that the total number of osteopaths and osteopathic physicians (n = 196,851) provide around
226,378,650 healthcare consultations per year.
•
If we take the mean number of consultations per patient as 6, we can estimate that around 37,729,775 people
receive osteopathic care per year across the world in a year.
•
Osteopaths generally deliver a multi-component complex intervention as a package of care which is bespoke.
This type of healthcare fits with a growing demand from international health agendas to improve overall
patient wellbeing and consider the biological, sociological, psychological, and spiritual needs of people as part
of global health.
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PART I.
The status of osteopathic
healthcare worldwide:
A SURVEY OF OIA MEMBERS.
SUMMARY
•
Osteopathy is practiced in around 46 countries worldwide.
•
There were around 117,559 registered osteopathic physicians and around 79,302 osteopaths.
•
There was statutory regulation for osteopathic physicians and medically trained physicians
with osteopathic training practicing in 22 countries in addition to a further 35 countries where
US trained osteopathic physicians who are licensed to practice as medical physicians.
•
Osteopaths practice in 35 countries, of which there was statutory regulation in 13 countries,
and recognition of the profession as a healthcare practice in a further 6 countries.
•
There was almost an equal gender representation internationally for both osteopathic
physicians and osteopaths with the exception of Argentina where 70% of osteopaths were
female and Portugal where 70% were male.
•
A considerable proportion (50-70%) of osteopaths and osteopathic physicians worldwide are
between 30 to 49-years-old.
•
In all countries, with the exception of Republic of Korea, Slovenia, and Malawi where certain
conditions apply, self-referral for consultation is permissible and commonplace.
•
The minimum requirement to practice as an osteopath is a Bachelor degree in most countries
with educational institutions for osteopathic training found in at least 20 countries.
•
Training as an osteopathic physician is underpinned by a medical degree and there are
educational institutions found in at least 6 countries.
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CONTENTS
1
INTRODUCTION
2
THE SURVEY
3
FINDINGS
3.1
Number of osteopathic physicians and osteopaths
3.2
Recognition and regulation of osteopathic physicians and osteopaths
3.3
Numbers of regulated registered, non-regulated and or voluntary
registered osteopathic physicians and osteopaths
3.4
Number of osteopathic physicians and osteopaths compared with 2013
3.5
Gender and age profile of osteopathic physicians and osteopaths
3.6
Cost and consultation information
3.7
Training, education and continuing professional development
4
CONCLUSIONS
APPENDIX
QUESTIONNAIRE SURVEY
14
15
16
16
18
20
22
24
26
28
36
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1. INTRODUCTION
The Osteopathic International Alliance (OIA) was established to advance and unify the global osteopathic
profession by connecting schools, regulatory bodies, and regional, national, and multi-country groups. The global
osteopathic profession comprises two related professions: osteopathic physicians and osteopaths. The OIA is
an organization of organizations which launched in 2003 when 34 individuals representing ten countries and
seventeen organizations came to together to support the global profession.
Today the OIA represents 73 organizations from 20 countries on five continents. It is the primary international
organization advocating for high-quality osteopathic healthcare and a leading representative of osteopathic
physicians and osteopaths worldwide. Part of the OIA remit is to collect and disseminate accurate targeted
information about the global osteopathic profession. This objective was prioritized in response to a call from
the World Health Organization’s Traditional and Complementary Medicine Unit and their strategy objectives
(2014-2023) to understand more about global traditional healthcare.
In 2013 the OIA put together a report and published: Osteopathy and Osteopathic Medicine: A Global View
of Practice, Patients, Education and the Contribution to Healthcare Delivery (https://oialliance.org/resources/
oia-status-report/). This report detailed information about the status of the osteopathic healthcare provision
worldwide and the contribution it made to worldwide healthcare. The report content was targeted at national
and international policy makers, health ministers, government departments, non-governmental organizations,
educators, students, health media and interested members of the public. It has also been extensively used by
members of the global osteopathic profession to help describe and explain the role of osteopathic physicians
and osteopaths in osteopathic healthcare provision. The report described osteopathic healthcare, its history
and evolution. A survey conducted by the OIA in 2012 enabled them to provide data about the nature of the
osteopathic healthcare: its scale, the practitioner profile, its regulation and registration, the patient profile, its
education and training systems and the evidence about effectiveness and safety.
The aim of this report is to update the 2013 report and provide information about the current status of the
global osteopathic profession. It covers the size, structure, and nature of the professions worldwide.
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2. THE SURVEY
The Osteopathic International Alliance (OIA) conducted a survey in 2020 designed to update the information
collected and published in the OIA 2013 Global Report (https://oialliance.org/resources/oia-status-report/).
The 2020 survey was divided into 5 sections about: the country/region, the state of recognition and regulation,
practitioner and practice demographics, education and continuing professional development (CPD). OIA
member organizations and peer networks were contacted to provide information for this report. There
are two related professions providing osteopathic healthcare, there are osteopathic physicians providing
osteopathic medicine and osteopaths providing osteopathy. Both osteopathic physicians and osteopaths
contributed data to this survey. All OIA members were invited to contribute data.
The survey questionnaire attracted 55 responses from 29 countries. Missing data, where available online
or through personal communication, allowed the inclusion of a further 17 countries resulting in a total of
46 countries represented in this report. In some circumstances multiple responses were received for one
country resulting in differing data. Some of the discrepant data was due to live databases that can change daily
and others because respondents represented one of several country organizations. In these cases, clarification
was sought from respondents, the OIA and other online sources and the best estimate was made from all
the information collated. All data for both osteopaths and osteopathic physicians was analyzed and organized
by country into four main themes which are presented here. The first theme presents the global osteopathic
profession at the organizational level and examines recognition, regulation, and numbers on the register. The
second theme presents information on practitioner demographics by country. The third theme describes
details on practice management and the final theme presents education within the professions including
continuing professional development (CPD) conditions.
Definitions and the survey questionnaire
We asked about recognition, registration and regulation of osteopathic physicians and osteopaths. We defined
recognition as a situation where: osteopathy is a recognized and legitimate profession, meaning osteopaths
can practice legally. This normally means that the title is protected by law, and that osteopathic physicians
and osteopaths can only use these titles if they meet certain statutory conditions in terms of competencies
and training.
We defined regulation as statutory or voluntary. Statutory or legal regulation normally requires statutory
registration as the health professional must comply with set standards of practice that protect the patients
they treat; statutory regulation is set out in government or state law. Regulation and registration can be
voluntary, that is, it is not required by law.Voluntary regulation is where practitioners normally have to
voluntarily comply with a code of good practice.Voluntary registration also exists but it does not necessarily
always mean it is associated with voluntary regulation.
The questionnaire is shown in the appendix.
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3. FINDINGS
3.1 Number of osteopathic physicians and osteopaths
We found data from 46 countries in total, indicating some form of osteopathic practice. We estimated that
there are around 196,861 osteopathic physicians and osteopaths practicing globally. Table 1 provides a snapshot
of the current scale of osteopathic practice around the world. In addition to the countries listed in Table 1
the Caribbean countries, Croatia, Federated States of Micronesia, Kenya, Nigeria, and the Seychelles provided
information about osteopathic care in their countries but reported no practicing osteopathic physicians
or osteopaths.
Osteopathic physicians
Globally, osteopathic physicians outnumber osteopaths. However, the vast majority of osteopathic physicians
practice in the United States of America (USA) with a small proportion practicing throughout the rest of
the world, mostly in Germany. As registered doctors, the data for osteopathic physicians was more complete
than for osteopaths. The current survey identified 117,559 registered osteopathic physicians worldwide, with
approximately 110,700 of these registered in the USA. Access to osteopathic physician care in the USA is
estimated at 34 osteopathic physicians per 100,000 people. In the rest of the world, it is much lower ranging
from 4 and 3 per 100,000 in France and Germany respectively and even lower in the rest of the world (Table 1).
Osteopaths
Assessing the total number of osteopaths globally was more difficult as many countries do not regulate or
register the profession, so the aggregated data included a number of estimates. Overall, the current OIA 2020
survey identified 79,302 osteopaths worldwide. Access to osteopaths ranged from < 1 per 100,000 people
in many countries to 23 in Italy and 49 in France and 20 in Spain. Countries that have between 10 and 15
osteopaths per 100,000 were Australia, Austria, New Zealand, Portugal, and Switzerland (Table 1).
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Table 1 Access to osteopaths and osteopathic physicians
Country
Population
Number of osteopaths
(per 100,000)
139 (<1)
2,741 (11)
1,000 (11)
866* (8)
139 (<1)
Number of
osteopathic physicians
(per 100,000)
0
Information Source
(number of responses)
Survey (x1)
Survey (x1) AHPRA
EFFO
Argentina
Australia
Austria
Belgium
Brazil
Burundi
Canada
Cyprus
Denmark
Egypt
Ethiopia
Finland
France
Germany
Greece
Iceland
Israel
Italy
Japan
Malawi
Malta
Netherlands
New Zealand
Norway
Papua New Guinea
Portugal
Republic of Ireland
Republic of Korea
Russia
Singapore
Slovenia
South Africa
Spain
Sweden
Switzerland
United Arab Emirates
United Kingdom
Unites States of America
Zambia
Total
44.5M
25M
8.86M
11M
210M
11.9M
37.6M
1.2M
5.8M
102.3M
115M
5.5M
67M
83M
10.7M
364K
8.66M
60M
125M
17M
441.5K
17.1M
5M
5.5M
8.95M
10.28M
4.9M
45M
144.5M
5.8M
2M
59.3M
46.8M
10M
8M
9M
67M
330M
18.4M
4 (<1)
1 (<1)
Survey (x1)
Survey (x3)
OIA
Survey (x9) & OIA
EFFO
Survey (x1)
OIA
OIA
Survey (x1)
Survey (x1)
Survey (x4)
Survey (x1)
EFFO
EFFO
c2,900 (8)
15 (1)
165 (3)
8 (<1)
37 (<1)
1 (<1)
1(<1)
485 (9)
33,000 (49)
4,065 (5)
35 (<1)
6 (2)
90 (1)
13,600 (23)
96 (<1)
3 (<1)
2,500 (4)
2,547 (3)
1(<1)
250 (<1)
2 (<1)
Survey (x1)
Survey (x1)
Survey (x1)
EFFO
EFFO
Survey (x3)
Survey (x1)
11 (2.5)
700 (4)
735 (15)
372 (7)
1 (<1)
1,352 (13)
157 (3)
101(<1)
c1500 (1)
50 (<1)
3 (<1)
38 (<1)
9,420 (20)
456 (5)
1,086 (14)
35 (<1)
5,439 (8)
110,700 (34)
2 (<1)
79,302
(Range <1 – 56 per
100,000)
117,559
(Range <1– 34
per 100,000)
2 (<1)
4 (<1)
OIA
Survey (x2)
Survey (x1)
Survey (x1)
Survey (x4)
Survey (x3)
Survey (x1)
OIA
EFFO
Survey (x1)
EFFO
Survey (x1)
Survey (x1)
Survey (x5)
OIA
*Self-reported Belgian number updated to 1800 at the time of publication. All numbers included in this report are self-reported.
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3.2 Recognition and regulation of osteopathic physicians and osteopaths
Of the 46 countries included in this report, osteopathy is recognized as an independent profession in
25 countries. Twenty-two countries had registers for osteopathic physicians, or medical doctors with additional
osteopathic training. Two countries (Russia and United States) recognize medically trained osteopathic
physicians specifically (Table 2). Thirteen countries were identified with statutory regulation for osteopaths and
22 countries with voluntary regulation for osteopaths (Table 3).
Osteopathic physicians
The medical physicians who undertake further training in the practice of osteopathy, generally hold a license
under their medical organization to practice medicine but the requirement for osteopathic regulation is usually
voluntary and therefore were not captured in our survey data unless they had voluntarily registered with an
osteopathic organization.
USA trained osteopathic physicians can obtain a license to practice as medical physicians in 57 countries. In
addition to the countries listed in Table 2 they can practice in the following 35 countries: Australia, Botswana,
China, Costa Rica, Dominican Republic, Ethiopia, Eswatini, Ghana, Grenada, Guam, Haiti, Iran, Ireland, Israel,
Jamaica, Kenya, Lesotho, Liberia, Macedonia, Malta, Mauritius, Namibia, Nigeria, New Zealand, Puerto Rico,
Rwanda, Seychelles, Sierra Leone, South Africa, South Sudan, Tanzania, Uganda, United Kingdom, US Virgin
Islands, Zimbabwe. We do not have any data from these countries about the number of osteopathic physicians
that may be practicing in them.
Osteopaths
The status of regulation for osteopaths varies between countries, and sometimes within countries (e.g.,
Canada) regardless of recognition and depending on qualification as an osteopath or osteopathic physician.
Some countries have achieved statutory regulation which is enforced by law, while others are working towards
it (e.g., Italy and Republic of Ireland). Many countries without statutory regulation have specific national or
regional agreements for voluntary regulation which allow for recognition as primary healthcare practitioners.
In Germany, osteopaths with training in heilpraktiker as well as medically trained osteopathic physicians are
recognized, voluntary regulation in Germany for osteopaths stipulates prior training as medical doctor or
heilpraktiker. (Table 2). Individual stipulations for professional practice vary between countries particularly
in those with voluntary arrangements. For example, in Belgium* regulation to practice as an osteopath is
voluntary, legislation on non-conventional medical practices has existed since 1999 (which is known as the
Colla law and includes osteopathy) but has not yet been implemented. In Brazil there is classification by
the Brazilian codex of Occupations of Brazilian Labour Ministry but it is not statutory for osteopaths or
osteopathic physicians. Canadian regulations vary depending on province; Quebec has voluntary regulation
for osteopaths, Ontario has voluntary regulation for osteopaths and osteopathic physicians and Alberta has
statutory regulation for osteopathic physicians only.
*Self-reported Belgian number updated to 1800 at the time of publication. All numbers included in this report are self-reported.
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Table 2 Recognition and Statutory Regulation by country
Country
Argentina
Australia
Austria
Belgium
Brazil
Canada
Caribbean
Croatia
Cyprus
Denmark
Egypt
Fed. States of Micronesia
Finland
France
Germany
Greece
Iceland
Israel
Italy
Japan
Lichtenstein
Malawi
Malta
Netherlands
New Zealand
Nigeria
Norway
Portugal
Republic of Ireland
Republic of Korea
Russia
Seychelles
Singapore
Slovenia
South Africa
Spain
Sweden
Switzerland
United Arab Emirates
United Kingdom
Unites States of America
Recognition
No
Yes
No
Yes
No
Varies by province
Varies by country
No
No
Yes
No
Yes
Yes
Yes
Yes (MD or Heilpraktiker qualification required)
No
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Yes (MD qualification required)
No
No
No
Yes
No
No
Yes
Yes
Yes
Yes (USA DO qualification required)
Statutory regulation
or registration
No
Yes
No
No
No
Varies by province
Yes
No
No
Yes
No
No
Yes
Yes
None specific to osteopathy
No
Yes
No
No
No
Yes
Yes
Yes
No
Yes
Yes
No
Yes
No
No
Yes
No
No
No
Yes
No
No
Yes
Yes
Yes
Yes
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3.3 Numbers of regulated registered, non-regulated and, or voluntarily
registered osteopathic physicians and osteopaths
Osteopathic physicians
Osteopathic physicians are registered as licensed medical professionals, we identified 117,559 registered
osteopathic physicians and or physicians who have additional training in osteopathic care who register
themselves as osteopaths with physician training.
Osteopaths
There were an estimated 79,302 osteopaths (Table 3). Thirteen countries had 45,093 (57%) osteopaths who
were both statutory regulated and registered. The remaining 34,209 (43%) osteopaths were either voluntarily
registered or estimated numbers of practicing non-registered osteopaths. Most osteopaths are statutorily
registered and regulated, osteopathy is not regulated in the central European countries of Germany, Italy and
Spain, these countries alone made up 27,685 or 35% of all osteopaths.
France has by far the most registered osteopaths; it has an estimated 33,000. France recognizes the practice
of osteopathy and the title. Osteopaths must register for a license to practice osteopathy from their Regional
Health Agency. In France osteopathy can be delivered by practitioners registered as other healthcare
professionals such as physiotherapists and midwives. It is recommended that osteopaths are trained to Masters
level but there are many practitioners who are registered as osteopaths who may have undertaken different
training, hence the high numbers of registered as osteopaths (33,000). A register of all osteopaths is held by
the French Health Ministry, but once registered there is no need to re-register, so many of those registered
may not be in active practice and may not have followed the current recommended Masters level courses
now preferred to register as an osteopath in France. There are two main, non-health department, osteopathic
registers: Le Syndicat Français des Ostéopathes (SFDO) (around 2,527 members) and OsteoFrance (around
3,500 members), indicating that there are a minimum of 6,000 actively practicing osteopaths in France.
Regulation responsibility is via the regional health agency issuing the license to practice and the two
professional bodies above who are recognized by the health minister to represent osteopaths.
Italy, Spain, and Germany also yield high numbers of practitioners but have voluntary registration and regulation
rather than statutory (13,600, 9,420 and 4,065 respectively). These figures represent a mixture of voluntary
registered and non-registered osteopaths. The United Kingdom (UK) has the largest number of statutory
regulated osteopaths (5,439), followed by Australia (2,741) and Portugal (1,352).
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Table 3 Osteopathic physicians and Osteopaths
Osteopathic physicians and/or medical
physicians with osteopathic training
(Statutory regulated)
Belgium 4
Burundi 1
Canada 37
Caribbean 0
Denmark 1
Ethiopia 1
Finland 3
France 2500
Germany 2547
Greece 1
Italy 250
Kenya Unknown
Malawi 2
Nigeria Unknown
Papua New Guinea 1
Russia 1500
Singapore Unknown
Slovenia 3
Spain 4
United Arab Emirates 2
United States of America 110,700
Zambia 2
Statutory regulated and
registered osteopaths
Australia 2741
Denmark 165
Finland 485
France 33,000
Iceland 6
Lichtenstein Unknown
Malta 11
New Zealand 735
Portugal 1352
South Africa 38
Switzerland 1086
United Arab Emirates 35
United Kingdom 5,439
Voluntary registered osteopaths
and non-registered osteopaths
Argentina 139
Austria 1000
Belgium 866*
Brazil 139
Canada 2900
Croatia Unknown
Cyprus15
Egypt 8
Fed. States of Micronesia 0
Germany 4065
Greece 35
Israel 90
Italy 13,600
Japan 96
Netherlands 700
Norway 372
Republic of Korea 101
Republic of Ireland 157
Seychelles Unknown
Singapore 50
Spain 9420
Sweden 456
*Self-reported Belgian number updated to 1800 at the time of publication. All numbers included in this report are self-reported.
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3.4 Number of osteopathic physicians and osteopaths compared with 2013
Since the OIA 2013 Global Report, the number of both osteopathic physicians and osteopaths has increased.
Osteopathic physicians
The OIA 2020 survey of 46 countries identified 117,559 osteopathic physicians worldwide compared with
87,850 recorded in the OIA 2013 Global Report; this is an increase of 34%. The majority of osteopathic
physicians continue to be in the United States where there are now approximately 110,700 on their register,
also a 34% increase from the OIA 2013 Global Report which reported 82,500 registered US osteopathic
physicians at that time.
Outside of the United States osteopathic physicians have a much lower representation compared with
osteopaths. Germany reported 2,547 osteopathic physicians on their register increasing their numbers by
11% since 2013. Osteopathic physicians registered in France increased significantly (56%) since 2013 reporting
approximately 2,500 currently on their register. Russia report in the region of 1,000 registered osteopathic
physicians, a decrease of 23% from the data that had been estimated in the OIA 2013 Global Report. There was
an increase in the last 7 years from 20 registered osteopathic physicians to 30 in Canada, and the numbers in
Italy remained much the same at 50. (Table 4)
Table 4 Registered osteopathic physicians by country (c =circa / approximately)
Country
United States
Germany
France
Russia
Italy
Canada
Others
Total
(*c.200 not registered)
2020 Registered
Osteopathic Physicians
110,700
2547
2500
c1000
c50*
30
>10
117,599
87,850
+34
Compared with 2013
OIA Global Report
82,500
2300
1600
1300
50
20
Difference compared
with 2013 data (%)
+34
+11
+56
-23
=
+50
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Osteopaths
In 2020 we identified 79,302 osteopaths worldwide compared with 43,000 recorded in the OIA 2013 Global
Report, demonstrating a significant increase in the profession of 84% over the last 7 years. France had the
greatest number of registered osteopaths by country in the world (33,000), followed by United Kingdom
(5,439), Germany (4,065) and Italy (3,600). Australia, Canada, Portugal, and Switzerland have between 1,000
and 3,000 osteopaths and a further eight countries have between 300 and 1,000 osteopaths on their registers.
In Spain, where there is the second largest number of non-registered osteopaths after Italy, there is neither
statutory nor voluntary regulation in place.
Examining the numbers of registered osteopaths more closely, there were decreases in the number of
registered osteopaths reported in Belgium, Spain, Italy, Germany, and South Africa. However, these decreases
should be regarded with caution as the numbers recorded in 2013 for these countries were mostly estimates
(Table 5).
Table 5 Registered osteopaths by country
Country
France
United Kingdom
Germany
Italy
Australia
Canada
Portugal
Switzerland
Belgium
New Zealand
Netherlands
Austria
Finland
Spain
Sweden
Norway
Denmark
Republic of Ireland
Brazil
Israel
Argentina
South Africa
Greece
Cyprus
All others
Total
*c = circa / around
2020 Osteopaths
33000
5439
4065
3600
2741
2000
1352
1086
866*
735
700
500
485
420
356
342
165
157
137
90
80
38
35
15
<15
78,562
43,000
+83%
Compared with 2013
OIA Global Report
17460
4211
c5000-7000
c5000-6000
1725
c1500
c400
c850
1539
c400
630
c500-600
c300
c600-800
c200
250
40
120
47
c75
unknown
49
30
11
-22
+17
+36
Difference compared
with 2013 data (%)
+89
+29
-32
-34
+59
+33
+238
+28
-44
+84
+11
=
+62
-40
+78
+37
+312
+31
+192
+20
*Self-reported Belgian number updated to 1800 at the time of publication. All numbers included in this report are self-reported.
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3.5 Age and gender profile of osteopathic physicians and osteopaths
Gender
Osteopathic physicians
In the USA, 42% of osteopathic physicians were female and in Russia 52%.
Osteopaths
There was an equal gender representation internationally for Australia (54% female), Belgium (42%), Brazil
(52%), Canada (50%), Germany (56%), New Zealand (55%), Switzerland (55%) and the UK (56%), there were
two exceptions: Argentina where 70% of osteopaths were female and Portugal where 30% were female.
Age
The age profile of osteopathic physicians and osteopaths showed many similarities across all regions with
50-70% of practitioners falling into the 30 to 49-year-old age bracket, the exception being Argentina where
two thirds of their osteopaths were between 40 and 59 years old. Data on the age of practitioners was not
requested in the previous OIA 2013 Global Report however the current survey compares with data analyzed
from published individual country surveys where 59% of respondents were between 30 and 49 years old
where reported (see Part II). Australia and Ireland have the youngest age demographic with the proportion
of osteopaths younger than 49 years old being 84% and 80% respectively. Table 6 shows the age profile of
osteopathic physicians and Table 7 osteopaths.
Table 6 Age profile of osteopathic physicians
18-29
Germany
Russia
United States
2.3%
7.7%
30-39
ca 10%
27.4%
41.2%
40-49
ca 20%
31.6%
22%
50-59
ca 30%
26.2%
14.4%
60-69
ca 20%
11.4%
10.9%
70+
ca 10%
1.15%
3.7%
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Table 7 Age profile of osteopaths
18-29
Argentina
Australia
Belgium
Brazil
Canada - Québec
New Zealand
Republic of Ireland
Slovenia
Spain
United Arab Emirates
United Kingdom
Switzerland
6%
27.65%
11.5%
3.43%
12.2%
11.84%
10%
0
?
20%
12.2%
6%
30-39
7.5%
33.9%
26.6%
34.3%
29%
25.17%
35%
67%
‘the majority’
10%
22%
30%
40-49
33.75%
22.36%
26.3%
28.6%
26%
29%
35%
33%
?
60%
26.6%
40%
50-59
33.75%
8.8%
18.2%
25.14%
19.85%
18.9%
8%
0
?
0
27.3%
20%
60-69
15%
5.7%
14.25%
8%
9.16%
12.93%
8%
0
?
0
10%
3.5%
10%
1.9%
0.5
70+
3.75%
1.6%
3.2%
0.6%
3.8%
2.18%
4%
0
Diagram 1. shows the average percentage of osteopathic physicians and osteopaths practicing in each age
group range. The age profile of osteopathic physicians is older than the osteopaths, but the skew is towards the
younger ages indicating a healthy supply of osteopathic physicians and osteopaths for the future sustainability of
the professions providing the professions can retain them.
Diagram 1. Age distribution of osteopaths and osteopathic physicians
Overall age distribution (%)
35
30
25
20
15
10
5
0
18-29
30-39
40-49
50-59
60-69
70+
Osteopaths
Osteopathic physician
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3.6 Cost and consultation information
Cost and number of consultations
Data on the cost and number of consultations per week was invited in the current OIA survey. In
countries where data was provided, the price range for an osteopathic physician consultation was US$ 53-158
(€45 - €134) and average cost was US$ 111 (€94). An osteopathic appointment was between US$ 43 - 158
(€36 - €134) and the average cost was US$ 85 (€72). The average number of consultations per week is 35 - 40
for osteopathic physicians and osteopaths (Table 8).
Self-referral for treatment
In all countries except for Republic of Korea, Slovenia, and Malawi, where certain conditions apply, self-referral
for consultation is permissible and commonplace. (Table 8)
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Table 8 Cost and number of consults
Country
Average osteopathy
consult cost ( in €)
40 U$D (36)
85 - 95 AUD$ (55)
51 - 60 € (55)
200,00 – 500,00 Rs$
(57)
80 - 135$ (70)
Unknown
500-1200 DKK (115)
60 – 85 € (72)
50 - 55 € (53)
70 - 120 € (95)
30 - 60 € (45)
60 - 100 € (80)
40 - 140 $NZ (52)
500 - 850 NOK (62)
50 € (50)
50 - 70 € (60)
150 USD (134)
3000 rubles (38)
135 - 160 S$ (94)
50 - 60€ (55)
150 USD (134)
3500 rubles (45)
Unknown
70 – 80 € (75)
free or 2 $
80 - 120 € (100)
600 - 1000 SEK (76)
AED 500 (121)
£45-52 (52)
Unknown
Unknown
60 - 80
31
Unknown
Unknown
20 - 30
70 – 120 € (95)
NA
20 - 50
30 - 60
50
50
20 - 35
5
20 - 35
35 - 70
20 - 50
5
20 - 35
Unknown
Unknown
normal practice
Yes
Only under
certain conditions
Only under
certain conditions
Yes
Yes
Yes
Yes
Yes
20 - 50
NA
60 - 180 € (120)
30
30
20
30
30
30 - 80
Average OP
Average number of
Average number
consult cost (in €) osteopathy consults/ of OP consults/
week
week
N/A
30
40
31 - 35
25 - 50
25 - 35
N/A
Can patients
self-refer?
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Only under
certain conditions
Argentina
Australia
Belgium
Brazil
Canada
CARICOM
Countries
Denmark
Finland
France
Germany
Greece
Italy
New Zealand
Norway
Portugal
Portugal
Republic of Ireland
Republic of Korea
Russia
Singapore
Slovenia
Southern Africa
(Malawi)
Spain
Sweden
United Arab
Emirates
United Kingdom
United States
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3.7 Training, education and continuing professional development
Number of Osteopathy Training Institutions and predicted 2020 graduates
There was a general trend across all countries where those with more statutory registered osteopathic
physicians and osteopaths had more training colleges. The United States was the only country that reported on
2020 graduate predictions for osteopathic physicians and estimated these at 7,136 from 38 schools, indicating
that educational institutions in the United States for osteopathic physicians were much larger in size than any
of the schools for osteopaths elsewhere (Table 9).
Although the OIA 2020 survey did not collect data on the size of the individual osteopathic training institution,
in many countries there is a college for every 15-20 osteopath students/graduates with a few exceptions.
Germany predicted double the number of osteopath graduates compared to Australia (500 vs 250), they
report having more than 70 schools compared with only 4 in Australia (Table 10).
Table 9 Educational institutions for osteopathic physicians
Country
France
Germany
Italy
Russia
Spain
United States
UK
Number of educational institutions
2
7-8
1
‘Many’
2
38
1 (post MD qual)
7136
5-10
Predicted number of graduates 2020
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Table 10 Educational institutions for osteopaths
Country
Argentina
Australia
Belgium
Brazil
Canada
Denmark
Finland
France
Germany
Greece
Italy
New Zealand
Norway
Portugal
Republic of Ireland
Republic of Korea
Spain
Sweden
United Kingdom
Number of educational institutions
5
4
5
5
c15
2
3
31
>70
1
c30
2
1
8
1
1
Estimated 10
1
10
200
17
230
25
50
1750
500
15
c500
10-25
35
100-120
15
Predicted number of graduates 2020
6
250
100
c100
Educational qualification
The OIA 2020 survey asked about minimum qualifications required to practice as an osteopathic physician
or osteopath.
Osteopathic physician
Osteopathic physicians in the USA are trained and licensed to provide complete medical care equivalent to
medical doctors. US osteopathic physicians are eligible for graduate training, licensure, board certification and
hospital privileges. The training as a doctor in osteopathic medicine (DO) requires distinctive training and
demonstration of competencies in osteopathic principles and practices that includes osteopathic manipulative
treatment. In other countries, a physician with a medical degree can undertake postgraduate training in
osteopathy to work as a physician osteopath.
Osteopath
Training as an osteopath is offered on a part-time and full-time basis in many countries and the qualification
acquired at the end of the training can vary from undergraduate diploma to post-graduate Masters degree
depending on the country and college attended.
Many osteopathic training courses have evolved over the years and expanded their portfolios to attain
higher degree accreditation (Table 11). In countries where regulation is evolving recognized academic
qualifications are required for new graduates entering the profession, however existing practicing osteopaths
with many years of experience prior to regulation may apply to be registered practitioners without a formally
recognized qualification.
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Table 11 Minimum qualification currently required to register and practice as osteopath
Diploma
Argentina
Brazil
Canada
Germany
Spain
Bachelor
Australia
Brazil
Denmark
Finland
Greece
Italy
Portugal
Rep of Ireland
Singapore
Malawi
Sweden
United Arab Emirates
United Kingdom
Master
Belgium
France
Rep of Korea
Postgrad certificate/
diploma
New Zealand
Other*
Nigeria
Norway
Switzerland
*Nigeria – US DOs; Norway - 240 ECTS, BSC 3 years + 1 year DO; Switzerland - Medical board examination for license to practice.
Continuing Professional Development (CPD) requirements
As the recognition, registration and regulation conditions vary between countries, so do the CPD
requirements. In all countries where the profession is regulated and in many where it is not, CPD is an
obligatory requirement for continued registration which is evaluated and/or monitored. In some countries,
although CPD is formalized, it is voluntary and therefore not required for registration. In other countries there
are informal recommendations for CPD, or none at all (Table 12).
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Table 12 CPD requirements
Obligatory (conditional on
continued registration and
evaluated or monitored)
Australia
Belgium
Canada
Germany
New Zealand
Nigeria
Norway
Republic of Ireland
Southern Africa - Malawi
United Arab Emirates
United Kingdom
United States
* In Singapore registration with the national body from where qualification was granted must be maintained with the associated
CPD requirements.
Formal (voluntary but
formalized requirements,
explicitly stated)
Denmark
France
Greece
Italy
Sweden
Informal (voluntary suggested
requirements)
Brazil
Republic of Korea
Russia
Spain
None
Argentina
Portugal
Singapore *
Slovenia
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CPD for osteopathic physicians
Continuing professional development for osteopathic physicians is often defined by the national medical
organization with additional osteopathic requirements. In the USA, where the majority of osteopathic
physicians are trained and regulated, CPD requirements for osteopathic physicians vary depending upon
specialty/state of licensure, but in general, involves at least 20 hours of continuing medical education (CME)
per year, the American Osteopathic Association (AOA) require 120 credit hours in a three-year CME cycle.
Reporting of osteopathic CME credit to the AOA is the responsibility of the accredited AOA sponsor and is
not accepted directly from a physician. Sponsors have ninety days after the program to submit CME credits.
A certificate of attendance must be provided to the AOA Department of Member Services indicating the
total number of hours attended. Transcripts from other institutions (hospitals, CME trackers, etc.) are also
accepted if they contain the total number of hours. Submissions must include the physician’s name and AOA
identification number.
In Russia, state assessment is currently under development. Admission to postgraduate seminars is granted
if you have a diploma in osteopathy obtained under the program for at least 3500 hours. The employer is
responsible for directing physicians to continuing education. The employer verifies certificates of continuing
education. The educational institution is responsible for holding the final assessment when delivering the
document confirming continuing education. Documents confirming the completion of training are necessary
for the prolongation of the admission to the professional activity. These documents are entered in the Federal
Register of Documents on education and qualifications. Qualification will be taken into account in subsequent
accreditation held every 5 years; this is due to start in 2021.
The Federated States of Micronesia have a requirement of 50 contact hours every two years for general
practitioners and additional 25 contact hours for specialized physicians, which should be from their specialty
areas. Table 13 gives examples of other CPD schedules for osteopathic physicians.
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Table 13 CPD for osteopathic physicians
Country
Canada
Caribbean Countries
(18 hours medical specialist
presentations, 2 hours ethics
presentations)
Federated States of Micronesia
Germany
(also 250 hrs CME general medicine/
5 years)
One lecturer should be an Osteopath and the
CPD has to be certified by the VOD or EROP
Italy
Russia
(or 144 hours/5 years)
Malawi
United States
21-30 hours
20 hours min (depending on specialty/state of
licensure)
By Medical Council of Malawi
Reporting of osteopathic CME credits
to the AOA is the responsibility of the
accredited AOA sponsor.
40+ hours
40+ hours
CPD hours/year
Defined by activity, not hours.
11-20 hours
Medical Council requirement for renewal of
practicing certificate annually
50 hours/2 years (for GP’s) and 25 hours (for
specialized physicians).
21-40 hours
CPD monitoring
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CPD for osteopaths
Many countries have a formalized CPD structure in place for osteopaths even where it is not obligatory.
There are often recommendations around the type of CPD required for re-registration. For example, in Ireland
child protection training and first aid certificate is compulsory every two years, in addition to yearly 30 hours
with a minimum of 15 hours learning together. In Sweden, the Svenska Osteopatforbundet (SOF) provides
two courses a year which fulfill their CPD requirements if both are attended. UK osteopaths must undertake
90 hours CPD over a three-year period which cover the breadth of osteopathic practice; there must be an
objective activity completed, a communication and consent activity and towards the end of the three year cycle
a peer-discussion review. New Zealand, on the other hand, has a new high-trust model under review, where
the osteopathic council provides guidelines and osteopaths may choose what CPD relevant for them. There is
a small variation in the number of required hours for CPD but most countries stipulate between 21 and
40 hours (Table 14).
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Table 14 CPD for osteopaths
Country
Australia
CPD hours/year
21-30 hours
Other - please specify
CPD stipulations
Must be applicable to scope
of practice, including certain
mandatory topics.
Controlled and accredited,
following certain criteria
CPD monitoring and
evaluation
Record keeping obligations
for 5 years and random
audit by the regulator
External independent
organization
Belgium
Brazil
11-20 hours
31-40 hours
Not mandatory
Teachers used from the
countries where the
osteopathic profession is
regulated
Professional and Business
Development
Self-reported, with
random auditing.
Canada
11-30 hours
(where specified)
Multiple systems by
province/territory, most
based on points, not
hours.
Formally required
Denmark
Finland
France
Germany
Greece
Italy
New Zealand
21-30 hours
None
Has to be certified by the
VOD
Required for VOD
registration
40+ hours
31-40 hours
21-30 hours
40+ hours
21-30 hours
New high-trust model based
on relevance of CPD to
individual.
Self-declaration and
5% audit
Nigeria
Norway
21-30 hours
11-20 hours
20 credits (1 credit = at least 1 No specific way
hour CPD)
To cover specific topics such
as: communications, ethics,
clinical reasoning, techniques
Compulsory child protection
and first aid training (every 2
years) plus 30 hours/year CPD
2 seminars each 18 hours
recommended
Schools of Osteopathy
Two SOF courses a year, or
attendance of other approved
courses
License renewal is supported
by CPD evaluation
90 hours over a three-
year cycle
90 hours CPD over 3 years
to cover the breadth of
osteopathic practice and peer-
discussion review.
Annual declaration with
renewal of registration form
Online registration,
monitored by the association,
counting hours/activities.
Submitted with OCI
re-registering and evaluated
by the registrar.
No evaluation tools
Republic of Ireland
21-30 hours
Republic of Korea
Russia
Malawi
Spain
Sweden
31-40 hours
31-40 hours
21-30 hours
31-40 hours
21-30 hours
United Arab
Emirates
United Kingdom
11-20 hours
~ 30 hours
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4. CONCLUSIONS
When compared with the data from the OIA 2013 Global Report, the OIA 2020 survey shows an
overall expansion for both osteopaths and osteopathic physicians. The number of osteopaths practicing
worldwide has increased by 83% and osteopathic physicians has increased by 34%. There are a large
number of educational institutions which mostly deliver qualification of at least bachelor degree level.
The number of countries where osteopathy has statutory regulation has increased and in many more it
is recognized and regarded as a healthcare profession in its own right.
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APPENDIX
OIA Global Report update questionnaire 2020
Dear OIA member
The purpose of this questionnaire is to collect data to update elements of the OIA Global Report first
published in 2013 ( https://oialliance.org/resources/oia-status-report/)
The Global report has been very useful to the profession worldwide and has provided a valuable reference
source for osteopaths and osteopathic organizations.
The information you provide will be collated and analyzed by the National Council for Osteopathic Research
and University College of Osteopathy (UK). The data will be combined with a ‘best evidence’ update review
and will be produced and published as a report for use by yourself, your organization and the profession.
Please answer the questions with the most up to date information you have by 22nd May 2020.
If you represent more than one country or region please can you complete a separate submission for each
country or region.
We would like you to give your name and contact details in case we have any questions about your submission.
These details will not be used for any purpose unrelated to this survey and will be destroyed once the study is
complete.
We look forward to receiving your submission
Kind regards
Dr. William J. Burke, Chair
Osteopathic International Alliance
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The Osteopathic International Alliance is the leading organization for the advancement and unity of the
global osteopathic profession. As an ‘organization of organizations,’ the OIA unifies osteopathic medicine by
connecting schools, regulatory bodies, and regional, national, and multi-country groups.
The questionnaire is split into six sections:
A. About you and your country/region
B. Nature and type of regulation/registration
C. Demographics
D. Education
E. Continuing Professional Development
F. Other
A. About you and your country/region
1.Your name:
2.Your email:
3. The organization you represent (please complete a separate questionnaire for each organization
you represent):
4. The country or region you represent:
5. Estimated population size of country/ region you represent:
Date: Number
:
B. Nature and type of regulation
Is osteopathy a recognized and legitimate (osteopaths can practice legally) health care profession in your
country/region?
Yes / No / Other
1. Type of osteopathic regulation/recognition/registration in the country you represent:
a. For osteopaths
• Statutory (government or state regulated by law)
• Voluntary (not enforced by law)
• None
• Other (please describe)
b. For osteopathic physicians
• Statutory (government or state regulated by law)
• Voluntary (not enforced by law)
• None
• Other (please describe)
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2. How many regulators or registers for osteopaths and/or osteopathic physicians are there in your
country /region?
How many osteopaths are registered?
Number:
• Name:
• Name:
• Name:
C. Demographics
1. Number of registered osteopaths / osteopathic physicians in the organization you represent (as
mentioned in question 3):
•
2020 osteopaths =
•
2020 osteopathic physicians =
2. In 2020 (or from your most recent data) please provide the:
a. Date:
•
Number female osteopaths:
Number male osteopaths:
•
Age distribution of osteopaths:
o Female Male Total
•
Number 18 -29 years:
•
Number 30-39 years:
•
Number 40 -49 Years:
•
Number 50 – 59 years:
•
Number 60 +:
b. Date:
•
Number female osteopathic physicians:
Number male osteopathic physicians:
•
Age distribution of osteopathic physicians:
•
Number 18 -29 years:
•
Number 30-39 years:
•
Number 40 -49 Years:
•
Number 50 – 59 years:
•
Number 60 +:
D. Education
1. a. Number of osteopathic education institutions in your country / region for osteopaths
•
Number:
•
Comment:
b. Number of osteopathic education institutions in your country / region for osteopathic physicians
•
Number:
•
Comment:
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2. a. Number of osteopaths expected to graduate in 2020
•
Number:
•
Comment:
b. Number of osteopathic physicians expected to graduate in 2020
•
Number:
•
Comment:
3. a. Minimum level of education and or training required for registration / regulation /recognition as an
osteopath:
•
None
•
Diploma
•
Bachelor
•
Master
•
Osteopathic doctor/physician
•
PhD
•
Other (please describe)
•
Minimum level of education and or training required for registration / regulation /recognition as
an osteopathic physician:
•
None
•
Diploma
•
Bachelor
•
Master
•
Osteopathic doctor/physician
•
PhD
•
Other (please describe)
E. Continuing Professional Development (CPD)
1. a. Continuing professional development in your country/region for osteopaths
•
Obligatory (conditional on continued registration and evaluated or monitored)
•
Formal (voluntary but formalised requirements, explicitly stated)
•
Informal (voluntary suggested requirements)
•
None required
1. b. Continuing professional development in your country/region for osteopathic physicians
•
Obligatory (conditional on continued registration and evaluated or monitored)
•
Formal (voluntary but formalized requirements, explicitly stated)
•
Informal (voluntary suggested requirements)
•
None required
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2. a. How many hours per annum are required or suggested for CPD for osteopaths?
•
<10 hours
•
11-20 hours
•
21- 30 hours
•
31 -40 hours
•
41 +
3. a. Please describe any stipulations about organization and content of CPD?
4. a. How is CPD monitored and or evaluated?
b. How many hours per annum are required or suggested for CPD for osteopathic physicians
•
<10 hours
•
11-20 hours
•
21- 30 hours
•
31 -40 hours
•
41 +
3. b. Please describe any stipulations about organization and content of CPD?
4
b. How is CPD monitored and or evaluated?
F. Other
1. If you have other information about osteopathic practice in your country, please provide links or
information about how to access this information.
Or send separately by email to [email protected]
Box (free text)
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PART 2.
A profile of osteopathic healthcare:
A REVIEW OF LITERATURE
SUMMARY
• The final selection of surveys included reports from, Australia, Belgium, Canada, Germany,
Italy, Luxemburg, Netherlands, New Zealand, Spain, Switzerland, United States of America
(USA) and the United Kingdom (UK).
• Osteopathic physicians actively practicing in the USA were 42% female, 66% were
44 years old or younger, 57% work in primary care: 31% of these in family medicine and
7% in pediatrics.
• Osteopaths in Central Europe and the UK were most likely to work alone most or all of the
time (mean 61%), in 2013, 43% of osteopaths reported working on their own, with a further
14.1% reporting they worked with one partner.
• Osteopath qualifications varied between countries, Australian osteopaths were most likely to
have a post graduate degree (Masters or above).
• Osteopaths, regardless of country, typically see around 30 patients per week.
• Consultations are typically between 30 and 60 minutes.
• Just over half of all patients can get an appointment with an osteopath within one week.
• Most patient’s route to care is self-referral (79-95%).
• More females than males seek care from an osteopath (60:40).
• The age profile of patients treated by osteopaths has changed, in 2013 69% of patients were
aged between 21 and 70 years old, compared to 49.5% in this report. The percentage of
children below the age of 2 years increased from 8.7% in 2013 to 16.7%. Older patients
(>65 years) represented 15.1% compared to a mean of 9% in 2013.
• Low back and neck pain are the most common presenting complaints.
• Around a third of patients seek care for acute conditions.
• Osteopaths use a variety of manual techniques and report high frequencies of giving advice
and guidance about lifestyle, exercise and activity, diet, and ergonomics.
• More information is needed to fully describe the global osteopathic profession especially
about how patients respond to osteopathic care, what their experiences are and how satisfied
they are with the care they receive.
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CONTENTS
1
INTRODUCTION
2
THE REVIEW OF LITERATURE
3
DESCRIPTION OF OSTEOPATHIC HEALTHCARE
3.1 Practitioner characteristics
Practitioner age
Practitioner gender and time since qualifying
Osteopathic qualifications
3.2 Practice characteristics
Practice location
Time spent with patients
Referral pathways
3.3 Clinical Management of Patients
Appointment scheduling
Patients’ reasons for seeking osteopathic care
Timescale of complaint
Osteopathic therapeutic techniques
Treatment duration
3.4 Patient Profile
Age and gender of patients
Patient employment status
4
SUMMARY AND CONCLUSIONS
45
46
49
49
53
57
61
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1. INTRODUCTION
Osteopathic healthcare is based on the principle that the structure and functions of the body are closely
integrated, and that a person’s well-being is dependent upon the neurological, musculoskeletal, and visceral
structures working in balance together.
The approach was established in 1874 in the USA by Dr. Andrew Taylor Still; over the first half of the 20th
century osteopathic practice rapidly spread globally.
Osteopathic practitioners aim to assess and treat the ‘whole person,’ rather than just focusing on specific
symptoms or illnesses. This perception of the body as an integrated whole means that osteopathic healthcare is
often described as ‘person-centered’ rather than ‘disease-centered’ in its approach to the prevention, diagnosis
and treatment of illness and injury.
Central to the osteopathic approach is a range of ‘hands-on’ manual techniques (referred to as ‘osteopathic
manipulative medicine - OMM’ or ‘osteopathic manipulative treatment - OMT’) for assessment, diagnosis, and
treatment. These techniques help the practitioner to identify and treat various health conditions, including
musculoskeletal structural problems that, according to the osteopathic view, can influence the body’s
physiology, including the nervous system, circulation, and internal organs.
The osteopathic approach incorporates current medical and scientific knowledge when applying these
osteopathic principles to patient care. Scientific review and evidence-informed outcomes have a high priority in
patient treatment and case management.
There are two related professions that have emerged, osteopathic physicians and osteopaths. This is largely due
to different legal and regulatory structures around the world: osteopathic physicians (practicing osteopathic
medicine) are doctors with full, unlimited medical practice rights and can specialize in any branch of medical
care; osteopaths (practicing osteopathy) are primary contact health providers with nationally-defined practice
rights, and may not for example prescribe pharmaceuticals or perform surgery.
The title of osteopath is legally protected in some countries and requires statutory regulation under stringent
conditions, in other countries this is not the case and the practice of osteopathy is neither formally recognized
nor regulated. All osteopathic physicians are statutorily regulated.
Osteopaths are primary healthcare practitioners, as such, the osteopathic profession recognizes its
responsibility to diagnose and refer patients as appropriate when the patient’s condition requires therapeutic
intervention that falls outside the competence of an osteopath.
Since the publication of the OIA 2013 Global Report several country surveys of osteopathic practice have
been conducted. These surveys have collected data on characteristics of osteopathic practitioners (both
osteopathic physicians and osteopaths), their patients and the nature of their practice.
The aim of this study was to search for literature profiling osteopathic healthcare to describe: practitioner
characteristics, practice characteristics, clinical management, and patient profiles.
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2. THE REVIEW OF LITERATURE
The search for literature
A search was conducted for surveys, reports and profiles of osteopathy related practices using medical journal
databases. We also used our peer networks to identify non-published literature and PhD theses. Data collected
since the publication of the last OIA 2013 Global Report were included (2012 -2020) which were written in
English, or where the data was easily interpretable if written in another language.
We only included surveys conducted at a national or regional level profiling osteopathic physicians or
osteopaths and their patients. We excluded studies that were not nationally or regionally representative and
those that included subgroups of patients or specific types of osteopaths, for example from one education
institution. We included the most recent data and excluded studies which were superseded by more current
information. Data were extracted from the different surveys and where available were categorized and
organized to describe:
• Characteristics of the osteopathic physicians and osteopaths
• Characteristics of the practices of osteopathic physicians and osteopaths
• Clinical management and care of osteopathic physicians and osteopaths
• Osteopathic physicians’ and osteopaths’ patient characteristics
All data was presented equally regardless of methodology, size, or response rate of the included studies.
Survey selection
We found 14 relevant studies profiling osteopathic physicians and osteopath healthcare provision and their
patients. One from the United States of America (USA) described osteopathic physicians. The remaining
13 studies described osteopathy in Australia, Belgium, Canada, Germany, Italy, Luxembourg, Netherlands,
New Zealand, Spain, Switzerland, and the United Kingdom (UK).
Osteopathic physicians
One survey described osteopathic physician healthcare in the USA. The most recent Osteopathic Medical
Profession (OMP) report provided the data for the USA from 2019.
Osteopaths
We included the most recent survey from Australia, which was a comprehensive national workforce survey
(Adams
et al
2016). Belgium and Luxemburg were surveyed together in two cross-sectional, online, practitioner
surveys (van Dun
et al
2019 a and b), and along with the Netherlands in a third (van Dun
et al
2016). The
two more recent 2019 van Dun
et al
reports extracted different sets of data from the same survey known as
OPERA (Osteopathic Practitioners’ Estimates and RAtes) for Belgium and Luxemburg. The older 2016 report
had a high cross-sectional response rate across osteopaths in Belgium, Luxemburg and the Netherlands, only
the data for the Netherlands was extracted from this report The Canadian study was a regional snap-shot of
Quebec practitioner/patient practices (Morin & Aubin 2014).
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The OPERA project was developed as a European-based survey dedicated to profiling the osteopathic
profession across Europe (https://www.comecollaboration.org/research/projects/#). In addition to the Belgium/
Luxemburg surveys, it has also been used to produce two surveys from Italy (Cerritelli
et al
2019 and 2020)
and one of two reports from Spain (Alvarez
et al
2020). The second report from Spain is a smaller cross-
sectional survey which included practitioner and patient responses (Alvarez Bustins
et al
2018).
Extensive data was extracted from a recent unpublished doctoral thesis and associated summary report which
surveyed the complex nature of osteopathic healthcare practices across Germany (Dornieden 2019). The
most recent nationally representative Swiss report was a large cross-sectional survey of osteopaths and their
practice characteristics which achieved a high response rate (Vaucher
et al
2018). The most recent survey from
the UK was conducted in 2019, this was a national survey of practice with a patient record audit. There were
several other surveys but these pre-dated 2019 (Plunkett
et al
2020).
Finally, data about New Zealand osteopathic practices was extracted from a report examining the profile of
Complementary and Alternative Medicine (CAM) practices across several regions (Leach 2013). Data about
other countries from this report were not extracted as more recent updated studies were available about
these countries.
The surveys profiling osteopathic physicians and osteopaths, their practice and patients are described
in Table 1.
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Table 1 Survey selection
Country
Australia
Belgium-
Luxemburg-
Netherlands
Belgium-
Luxemburg
Belgium-
Luxemburg
Canada
Germany
Year
2018
2016
Author
Adams
et al
van Dun
et al
Project
ORION
Osteosurvey by CORPP
& SWOO
OPERA I
OPERA II
Quebec
DProf thesis
Method
Cross-sectional online practitioner
questionnaire
Online practitioner questionnaire
Total #
Osteo’s
2020
2050
# Respondents
Practitioner/patient
992 osteopaths
1069 osteopaths
Response
rate %
49.1
52.15
2019a
2019b
2014
2019
van Dun
et al
van Dun
et al
Morin & Aubin
Dornieden
et al
Cross-sectional online practitioner
survey
Cross-sectional online practitioner
survey
Cross-sectional prospective paper/
email-based survey
Survey
1529
1529
357 osteopaths
357 osteopaths
227 osteopaths
14,002 patients
23.34
23.34
60.1
14.1
13059 -
8331
surveyed
c4600-5600
c4600-5600
312
c4800-5900
1175 osteopaths
Italy
2019
2020
Cerritelli
et al
Cerritelli
et al
Leach
Alvarez
et al
OPERA-IT
OPERA-IT
Profile CAM
OPERA
Cross-sectional online practitioner
survey
Cross-sectional online practitioner
survey
Data collection by request or from
websites
Validated cross-sectional online
practitioner survey
Cross-sectional paper-based
practitioner/patient survey
Cross-sectional online questionnaire
and practice audit
Cross-sectional online practitioner
questionnaire
4816 osteopaths
4816 osteopaths
86%
86%
New Zealand
Spain
2013
2020
2018
517 osteopaths
36 osteopaths
314 patients
Est 10%
59% (36/61)
44.5%
Alvarez Bustins
et al
Standardized data
collection (NCOR)
Vaucher
et al
Practice review
GDK-CDS osteopaths
and assistants)
OsteoSurvey
OMP report of DOs
Switzerland
2018
1171
521 osteopaths
1144 patients
500 osteopaths
395 patients
UK
USA
2020
2019
Plunkett
et al
OMP
5300
121,006
9.4%
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3. DATA DESCRIBING OSTEOPATHIC HEALTHCARE
3.1 Practitioner characteristics
The majority of practitioners who responded to the surveys conducted were aged between 30 and 59 years
with in excess of 8 years’ work experience as an osteopath or osteopathic physician. Men and women were
equally likely to respond in most surveys completed.
Practitioner age
The age of osteopathic physicians in the USA indicated that 66% of those actively practicing were less than
45 years old and 30% between 46-65 years old (Table 2).
Practitioner gender and time since qualifying
In the USA, 42% of osteopathic physicians were female (Table 3).
For osteopath respondents, females outnumbered males in all countries except Belgium/Netherlands/
Luxembourg, Italy and Spain which had only 29%, 33% and 40% females respectively. However the overall mean
was a 51:49 split between males and females. The respondents were experienced osteopaths with eight years
or more of experience (Table 3).
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Table 2 Practitioner age
% of practitioner respondents by age group
Author and year
Osteopathic physicians
USA
Osteopaths
Australia
Belgium
Netherlands
Luxembourg
Germany
Italy
Spain
UK
Dornieden 2019
Cerritelli
et al
2019/2020
Alvarez
et al
2020
Plunkett
et al
2020
48 (median)
30-39
30-39
46-50 years (median)
21.7
9.8
9.5
40.03
53.3
12
23.24
31.5
31
12.38
3.6
40
2.33
1.1
4
9
0.33
0.3
Adams
et al
2018
van Dun
et al
2016
38
31.62 (30-39)
8
6
15
32
31
35
25
35
40
24
25
10
8
1.5
0
4
0.5
0
OMP 2019
66% <45
years
16.7% (45-
54)
12.9% (55
- 64)
Average
20-29
30-39
40-49
50-59
60-65
>65
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Table 3 Practitioner respondents by gender and time since qualifying
Country
Osteopathic physicians
USA
Osteopaths
Australia
Belgium- Luxembourg
Canada
Germany
Italy
Netherlands
Spain
Switzerland
UK
Author and Year
Male %
Female %
Practicing/mean time post grad
OMP 2019
Adams
et al
2018
Van Dun
et al
2019
Morin & Aubin 2014
Dornieden 2019
Cerritelli
et al
2019
Van Dun
et al
2016
Alvarez
et al
2020
Vaucher
et al
2018
Plunkett
et al
2020
53
42
69
34
43
67
65
60
45
41
42
58
31
66
57
33
35
40
55
59
8.7 years (mean)
<5 years 46%, >5 years 54%
11 years (median)
19-20 years (median)
11.4 years (mean)
Belgium 12.2 years (mean)
Luxembourg 8.1 years
0-10 years (51%) >11 years (49%)
8 years (median)
Osteopathic physician qualifications
Osteopathic physicians in the USA require a Should be Doctor of Osteopathic Medicine (DO). This means
that they are trained and licensed to provide complete medical care equivalent to medical doctors (MDs)
but they also have comprehensive training in osteopathic principles and practices including osteopathic
manipulative treatment.
Osteopath qualifications
Osteopathic qualification status varied depending on the country. A high proportion (>68.7%) of osteopaths
in Australia had a post graduate degree (Masters or PhD) in osteopathy. In central Europe the majority of
osteopaths were qualified at Certificate or Diploma level, however a large proportion of this group were
reported as having a previous academic degree, primarily in physiotherapy and sports science. Many osteopaths
also reported undertaking other professional roles including lecturing, research, physiotherapy and medical
physician. Where reported, osteopathy training was predominantly taken as a part-time course (Table 4).
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Table 4 Osteopathic qualifications
Country
Author and year
Previous academic
qualification (%)
Osteopathic
qualification
%
C.O./D.O.
BSc
21.6
Other
professional
roles (%)
Grad certificate/
diploma
MSc
>68.7
PhD
0.5
PT:FT
training
Volunteer (16) Clinical
Supervision (15.1)
Teaching (11.7) Prof Org
(10.8) Research (5.4)
80:20
Australia
Adams
et al
2018
Belgium-
Luxemburg-
Netherlands
Belgium-
Luxemburg
Germany
van Dun
et al
2016
Physio (85.25)
89.39
van Dun
et al
2019a
Dornieden 2019
Physio. (67)
Heilpraktiker (33) Med.
Doc. (11.6) Massage
Ther. (7.5)
(73.8) Sports Science
(36.4) Physio (25.3)
Physio (75)
Physio. (88.5)
93.6
2.7
2.7
Cert (71) Dip
(15)
4.1
Certificate
osteopathische
Verfahren (3.8)
5.9
0.1
66:34
94:6
Physio (43) Heilpraktiker
(32) Lecture (23)
PhysicianPhysician (20)
Italy
Spain
Cerritelli
et al
2019
Alvarez
et al
2020
Alvarez
et al
2018
94
61.2
5.4
8.3
67:33
4 yr PT
Physical Therapist (32)
Teaching (21)
20
Switzerland
Vaucher
et al
2018
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3.2 Practice characteristics
We only had data pertaining to USA osteopathic physicians about area of practice, most data was about
osteopaths in Europe and Australia.
Practice location
Just over half (56.5%) of osteopathic physicians in the USA work in primary care, with 31.4% working in family
medicine and 6.9% in pediatrics. Osteopaths in Europe were far more likely to work alone (range 41% to 64%)
than those in Australia where only 16.3% reported working on their own. Those not working alone worked
with a variety of other healthcare professionals including midwives, physiotherapists, doctors, dietitians but
mostly they worked with other osteopaths (Table 5).
Practice management and time spent with patients
There was good comparability across different surveys which collected information on amount of time
osteopaths spent with their patients. On average osteopaths worked 27 - 29.6 hours/week and saw between
20 and 38 patients per week. The reported length of time per consultation was 30 - 60 minutes for first and
follow-up appointments (Table 6).
Referral pathways
Referral pathways between osteopaths and other healthcare professions were common, particularly with
general practitioner/family physician, massage therapist and / or another osteopath. Osteopaths most
commonly referred out to GP’s and received referrals from GP’s although the majority of patients came
through self-referral (Table 7).
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Table 5 Practice location and set-up
Country
Australia
Belgium-
Luxemburg-
Netherlands
Germany
Italy
Author and Year
Adams
et al
2018
van Dun
et al
2016
Urban /
Suburb
81.8%
Rural/
Remote
18.2%
Works on own (most
or all of the time)
16.3%
Practice: Multi-practitioner
Works with: other osteopaths (64.8%) massage therapist (50.5%)
naturopath (9.5%) psychologist (19.3%) acupuncturist (19.0%)
Works with: Physiotherapists (64.4%), Other osteopaths (53.6%)
Dornieden 2019
Cerritelli
et al
2019
Cerritelli
et al
2020
58%
58.4%
Works with: other osteopaths (74%) Physiotherapists (68%)
Heilpraktiker (60%) Med Doc (24%) Midwife (13%)
Work with others 41.6%
Works with: other osteopaths (19.6) GP (8.1) Physiotherapists (23.3)
Psychologist (15.5) Dietitian (13.9) Medical Specialist (21.6)
Spain
Alvarez
et al
2020
Alvarez
et al
2018
41%
Works with: Physiotherapists (29%), Osteopath (28%), Dietitians (8%),
Podiatrists (8%) and Psychologists (7%)
Works with other osteopaths (61- 64%)
Work with others (49.7%)
Work with others (often or exclusively) (30%)
56.5% work in primary care: 31.4% family medicine, 18.1% internal
medicine and 6.9% pediatrics
Switzerland
UK
USA
Vaucher
et al
2018
Plunkett
et al
2020
OMP report 2019
71.4%
68.4%
37%
28%
54%
64%
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Table 6 Time spent with patients
Country
Author and Year
Patients/week - mean
(#NP)
Time: minutes with patient
Working hours
NP
Australia
Belgium-
Luxemburg
Canada
Germany
Italy
Netherlands
New Zealand
Spain
Switzerland
UK
Adams
et al
2016
van Dun
et al
2019
Morin & Aubin 2014
Dornieden 2019
Cerritelli
et al
2020
van Dun
et al
2016
Leach 2013
Alvarez
et al
2020
Alvarez
et al
2018
Vaucher
et al
2018
Plunkett
et al
2020
36 (5)
31 (7)
21-30 (mode)
46 - 60 mins
45 – 60 mins
45 mins (median) 30-90 (range)
45 mins
30 (1-5 NP/week 64%)
25-50 (estimated mode)
37
37
31-35
30 – 60 mins
55 mins
60 mins
46 – 60 mins
30-60 mins
FU
29.7
Hours/week - mean
28.3
Full Time : Part Time
52 mins
27
79.5% work
4-5 days/week
>35 hrs (56%) (2006 NZ
pop census)
60 : 40
45% : 55% (Women)
74% : 26% (Men)
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Table 7 Referral pathways
Country
Author
Referrals out (%)
GP
Med
specialist
Physio/
Massage
therapist
67.6%
Osteopath
Referrals in (%)
Podiatrist Further Self
tests
65.6%
55.9%
GP
Med specialist
Physio/
Massage
therapist
76%
Osteopath
Podiatrist
With
tests
Australia
Adams
et al
2018
Belgium-
Luxemburg-
Netherlands
van Dun
et al
2016
Germany
Dornieden
2019
Spain
Alvarez
et al
2020
Alvarez
et al
2018
88.5%
51%
89.3%
69.1%
47.5%
‘Most’
31% (incl. 41% (incl.
5
midwives) Dentist/
orthodontist)
>50% *
>50%*
>50%*
6.6 (incl.
Physiotherapists,
Heilpraktikers)
>50%*
88%
50% (incl.
Midwives)
50%*
40.5% (incl.
6.2%
Dentist/
Orthodontist)
>50%
75%*
7.7% (incl.
Physiotherapists,
Heilpraktikers)
80%*
95%*
78%
23%
(healthcare
professional)
18% referred by others to osteopath
15.1%
Xray
1.4%
MRI
18%
Switzerland
Vaucher
et al
2018
UK
Plunkett
et al
2020
9% referred to others by the osteopath
2.2 %
79%
56%
83%
29%
12.5%
7%
* regularly, often or always
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3.3 Clinical Management of Patients
The vast majority of patients seeking osteopathic care across UK and central Europe were seen within one
week although many UK patients were seen within one day. Patients in the UK were more likely to report pain
duration of less than 3 months. Musculoskeletal conditions (lower back and neck pain) account for the highest
proportion of patient complaints across all regions.
The reported range and diversity of techniques used by osteopaths was large with an apparent preference
for more gentle techniques such as osteopathy in the cranial field (OCF), visceral, functional, and bio-dynamic
techniques in central European countries compared with the UK and Australia where the preference appears
to be more towards structural techniques such as soft tissue manipulation (STM), articulation/mobilization and
spinal manipulation technique (SMT).
Appointment scheduling
Patients waiting time for an appointment was in the main less than one week (mean 54% range 18.9-75%) and
nearly 8% (range 0.85 – 16%) of all patients were seen within 24 hours of making contact with an osteopathic
clinic (Table 8).
Table 8 Appointment scheduling
Country
Author and Year
1 day (%)
2.5
0.85
3.5(same day)
13.4
9.8
16
1 week (%)
53.6
18.9
56
58.4
75
54.6
64
1-2 weeks (%)
31.8
25.9
30
16.2
25
NR
15
Belgium- Luxem-
van Dun
et al
2016
burg- Netherlands
Germany
Italy
Spain
Switzerland
UK
Dornieden 2019
Cerritelli
et al
2020
Alvarez
et al
2020
Alvarez
et al
2018
Vaucher
et al
2018
Plunkett
et al
2020
Patients’ reasons for seeking osteopathic care
Several surveys have collected data on the most commonly reported complaints by body region, condition
type, onset of symptoms and treatment outcome. Where reported, musculoskeletal conditions accounted for
the highest proportion of presenting complaints in osteopathic clinics, with two of the most recent surveys
recording as high as 81% (Vaucher
et al
2018 and Plunkett
et al
2020) and 94% (Alvarez Bustins
et al
2018) of
all presenting patients. Low back and neck related complaints are the most common reasons for seeking care,
followed by thoracic spine and complaints relating to the head and face (Table 9).
Pediatric conditions associated with unsettled babies was the second most common presenting problem
in several papers being reported in 40-60% of cases seen ‘often’ or ‘very often’ by osteopaths (Adams
et al
2018, van Dun
et al
2019b, Alvarez Bustin
et al
2018, Dornieden 2019). The same studies reported obstetrics,
gynecological and pregnancy related problems accounted for the third most common presenting patient group
at 30 – 45% of cases seen ‘often’ or ‘very often’ where reported.
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Table 9 Patients’ reasons for seeking osteopathic care/specific pain complaint (%)
Country
Australia
Author and Year Lumbar
Spine
Adams
et al
2018*
98.7%
Cervical
Spine
98%
Thoracic spine/
ribs/ chest
91.7%
Head/Face
Headache
90.1%
Pelvis
Upper Extremity
Shoulder 81%
Elbow 25%
Wrist 19%
Hand 12%
Lower Extremity
Hip 75%
Knee 50%
Ankle 34%
Foot 30%
Hip 41%
Knee 23.5% Ankle/
Foot 19.5%
11%
Hip/thigh 62%
Knee 55% Ankle/
Foot 35%
Abdomen
Belgium-
Luxemburg-
Netherlands
Canada
Germany
van Dun
et al
2016*
Morin & Aubin
2014
Dornieden 2019*
90%
86%
63%
57%
81%
68%
41%
14.5%
96%
12.8%
97.5%
7.1%
Upper back 88%
Chest 62%
9.1%
Head 75%
Face 19%
Headache
95.5%
4.7%
85%
Shoulder 7.9%
Upper limb 4%
88%
Visceral 5%
55.7%
Spain
Alvarez
et al
2020**
Vaucher
et al
2018
Plunkett
et al
2020
99%
97.5%
20%
19.3%
5%
Shoulder 64.5%
9%
7%
17.6%
15%
21.7%
3%
Thorax &
Abdomen
18.4%
Alvarez
et al
2018 13%
Switzerland
19.4%
13%
Head 19.5%
Headache
11.2%
UK
30%
15%
6%
9%
5%
~6%
~6%
*Reported as often/very often/always; **Reported as regularly/often/always; LBP – lower back pain
Timescale of complaint
Acute patients represented around a third of patients (mean 35%: range 27 - 45% of patients), over half of osteopathic patients seek care for
persistent chronic complaints (mean 50.5%). Sub-acute and chronic conditions made up 64% of complaints (range 52% - 73%) (Table 10).
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Table 10 Timescale of complaint %
Country
UK
Author and Year
Plunkett
et al
2012
Chronic
55% (>12 weeks)
Sub-acute
Chronic
12%
(5-12 weeks)
27% (1-6 months)
Acute
33% (1-4 weeks)
Spain
Alvarez Bustins
et al
2018
Vaucher
et al
2018
46% (> 6 months)
27% (< 4 weeks)
Switzerland
52%
45% (1-4 weeks)
Osteopathic manual techniques
Osteopathic practitioners use a wide range of techniques depending on their patient type and conditions being
treated. Data collected from surveys across the globe show information both in terms of what techniques
were popular across geographies and also particular technique preferences and trends within countries.
The techniques used most were articulation and mobilization, soft tissue manipulation (STM) and muscle
energy technique (MET). Spinal manipulative technique (SMT) and high velocity thrusts (HVT) were used less
frequently (Table 11). The surveys indicate that advice provision on exercise and physical activity, lifestyle, diet,
and ergonomics frequently featured as part of the osteopathic consultation (Table 11).
Consultations
Three studies reported information about number of consultations over time. In Switzerland 62% of patients
had 1 - 2 consultations per episode, in Spain this figure was 3 and a third of patients had completed their
course of care within one month. In the UK, the mean was 7 and mode 4 indicating a wide range for numbers
of consultations between patients (Table 12).
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Table 11 Osteopathic Techniques used in practice - %
Country, Author and Year
Australia
Adams
et al
2018
BeNeLux
van Dun
et al
2016**
62.4
Belgium
Luxembourg
van Dun
et al
2019b**
75
40
45
30
35
Germany
Dornieden 2019
Spain Alvarez
et al
2020*
Spain
Alvarez-Bustins
et al
2018
60
54.7
45.9
10.4
49.8
15.2
39.9
28
7
27.7
4
Switzerland
Vaucher
et al
2018
99
75
40
35
22
52
8
42
55
34.2
35.5
UK
Plunkett
et al
2020
69
74
34
29
10
23
5
15
5
1
57
70
4
Articulation/
Mobilization
Soft Tissue
Manipulation
Spinal Manipulation/
HVT
Muscle Energy Technique
Myofascial Release
Osteopathy in Cranial Field
Strain/ Counter-Strain
Functional Technique
Visceral Technique
Dry Needling /Acupuncture
Exercise /Physical Activity
Lifestyle Advice
Dietary
Ergonomic assessment
85.7
63.8
79.5
61.8
23.5
42.4
27.3
9.9
23.6
74
71
71
39
61
79.5
89
90.6
89.2
84.8
78
83.6
90.1
92.1
91.3
56.7
54.1
43.5
61.1
65.3
57.6
72.2
90.4
95.2
87.9
89
40
50
82
84
95/83
>74
77.6
77.5
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Table 12 Consultations
Country
Author and Year
# consultations
1
2
Mean
7
(mode 4)
3
31.3%
Treatment duration (%)
<1
month
1-3 months
>4
months
UK
Spain
Switzerland
Plunkett
et al
2020
Alvarez Bustins
et al
2018
Vaucher
et al
2018
30.4%
31%
54%
15%
3.4 Patient Profile
Gender
Across all surveys the findings showed that patients seeing osteopaths were more likely to be women than
men; Canada 62% were female, Spain 61%, Germany 61%, Switzerland 57%, and the UK 58%. In Belgium,
Netherlands and Luxembourg, osteopaths reported that their patients were evenly split between males
and females.
Age of patients
Osteopathy patient age profiles showed the majority of patients falling within the working adult category
of 20-65 years (mean 49.5%, range 19.6% - 72.45). The number of children, between 0 and 2 years old,
represented between 10 and 19.5%, the mean was 16.7% from Germany, Belgium/Netherlands/Luxembourg,
Spain, and Switzerland. In the UK 4.8% of patients were between 0 – 1 years old (Table 13). The recorded
number of older patients (>65 years) ranged from 9 – 24.3% (mean 15.1%) (Tables 13).
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Table 13 Patient Age Profile (% distribution of total within survey)
Country
Global
Germany
Belgium-
Netherlands
Luxembourg
Author and Year
OIA 2013 global
report
Dornieden 2019*
van Dun
et al
2016
(most likely to treat)
van Dun
et al
2019b*
<6 months
8.7% 0-2 yrs
10.1%
6–24 months
2-10 yrs
5.3%
11-20 yrs 21-30 yrs
9% 7-18
yrs
7.3%
3.1%
31-40 yrs 41-50
yrs
51-60
yrs
61-70
yrs
>71 yrs
9%
17.2%
>65 yrs
6.3%
>65 yrs
16.2%
>65 yrs
NR
Mean
yrs
NR
NR
NR
16% 19-30 32% 31-50 yrs
yrs
22.1% 21-40 yrs
32.1%
21% 51-70 yrs
7.1%
3.6%
6.4%
2.2%
28.1% 41-65 yrs
37% 41- 65 yrs
15.6%
8.7% <1
mth
NR
10.8%
1 mth -2 yrs
NR
10.8%
2 -12 yrs
NR
10.8%
12-18 yrs
NR
21.2% 18-40 yrs
21.4% 40-65 yrs
NR
Italy
Cerritelli
et al
2020 (age most
represented)
Alvarez
et al
2020*
Alvarez
et al
2018
89.1% 21-40 yrs
92.4% 41-64 yrs
NR
Spain
7.8%
<1mth:
NR
7.6%
9.8% 1-24 mths
NR
2.4%
11.8% 2-6 yrs
15.7% 6-12 yrs
NR
2.9%
17.6%
12-18 yrs
NR
5.7%
19.6% 18-65 yrs
NR
72.4% 21-65 yrs
62.5% 20 – 59 yrs
17.6%
>65 yrs
NR
9% >65
yrs
24.3%
>65 yrs
NR
40 yrs
45 yrs
50-59 yrs
(mode)
Switzerland
UK
Vaucher
et al
2018
Plunkett
et al
2020
4.8% <12 months
13.2% 0-19 yrs old
* regularly/often/very often/always - % of total; NR = not reported
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Patient employment status
Most patients seeking osteopathic care were employed or self-employed (58-85%) (Table 15).
Table 15 Patient employment status (%)
Country
Spain
Switzerland
UK
Author and
Year
Alvarez
et al
2018
Vaucher
et al
2018
Plunkett
et al
2020
Full-time
employed
44
45
85
Self-employed
14
13
Student
17
14
Children not
in school
Retired
8
Unemployed/
Home care
5
9
10
8
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4. SUMMARY AND CONCLUSIONS
Summary
To summarize, there was very little data about osteopathic physicians, the majority of data we were able to
extract was about osteopaths in central Europe, the UK and Australia.
Osteopaths had more available data to describe themselves and their practice. Respondents were 30-
50 years old with over eight years of experience working in osteopathy. Osteopath qualifications varied
between countries, Australian osteopaths were most likely to have a post graduate degree (Masters or above).
Osteopaths in Central Europe and the UK were most likely to work alone most or all of the time (mean 61%),
whilst in Australia osteopaths working alone represented 16.3%. Osteopaths regardless of country typically see
around 30 patients per week.
Patients were mostly of working age, but we estimate around 10% - 19% of patients seen by osteopaths are
young or very young children or infants (between 0 and 2 years old). More females than males seek care
from an osteopath (60:40) and most patients seek care for musculoskeletal complaints in the low back and
neck area.
Just over half of all patients can get an appointment with an osteopath within one week, and consultations are
typically between 30 and 60 minutes. Most patient’s route to care is self-referral (79-95%). Osteopaths use a
variety of manual techniques and report high frequencies of giving advice and guidance about lifestyle, exercise
and activity, diet, and ergonomics.
Comparison with the OIA Global Report 2013
In comparison with the 2013 OIA Global Report, some of the findings are similar but there are some
differences.
Working practices
In 2013, 43% of osteopaths reported working on their own, with a further 14.1% reporting they worked with
one partner. From our data 61% of central European and UK osteopaths work on their own some or all of the
time. Consultation duration remains the same between 30 and 60 minutes.
Patient age profile
The age profile of patients treated by osteopaths has changed. In 2013, 69% of patients were aged between
21 and 70 years old, we found a reduction in this age group to 49.5% (range 19.6% to 72.4%). Conversely,
we found an increase in the percentage of children below the age of 2 years, in 2013 this figure was 8.7%
compared to 16.7% (range 10% to 19.5%). The recorded number of older patients (>65 years) ranged from
9 – 24.3% with a mean of 15.1% compared to a mean of 9% in 2013.
Patient presentations
The nature of patient presenting complaints, locations (low back and neck pain are the most common) and
duration of complaint prior to the consultation (around a third have acute conditions) remain the same as do
the types of techniques used to treat patients.
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Conclusions
More information is needed to fully describe the global osteopathic profession. In addition to describing
osteopathy and osteopathic medicine, we need more information about how patients respond to osteopathic
care, what their experiences are and how satisfied they are with the care they receive.
References
Included studies:
Adams J, Sibbritt D, Steel A, Peng W. 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 Serv Res. 2018;18(1):352.
Alvarez G, Roura S, Cerritelli F, Esteves JE,Verbeeck J, van Dun PLS. The Spanish Osteopathic Practitioners
Estimates and RAtes (OPERA) study: A cross-sectional survey. PLoS One. 2020;15(6):e0234713.
Alvarez Bustins G, López Plaza P-V, Carvajal SR. Profile of osteopathic practice in Spain: results from a
standardized data collection study. BMC Complementary and Alternative Medicine. 2018;18(129).
American Osteopathic Profession (AOA). Osteopathic Medical Profession Report. 2019.
Cerritelli F, van Dun PLS, Esteves JE, Consorti G, Sciomachen P, Lacorte E,
et al.
The Italian Osteopathic
Practitioners Estimates and RAtes (OPERA) study: A cross sectional survey. PLoS One. 2019;14(1):e0211353.
Cerritelli F, Consorti G, van Dun PLS, Esteves JE, Sciomachen P,Valente M,
et al.
The Italian Osteopathic
Practitioners Estimates and RAtes (OPERA) study: How osteopaths work. PLoS One. 2020;15(7):e0235539.
Dornieden R. Exploration of the characteristics of German osteopaths and osteopathic physicians: Survey
development and implementation: University of Bedfordshire; 2019.
Leach MJ. Profile of the complementary and alternative medicine workforce across Australia, New Zealand,
Canada, United States and United Kingdom. Complement Ther Med. 2013;21(4):364-78.
Morin C, Aubin A. Primary reasons for osteopathic consultation: a prospective survey in Quebec. PLoS One.
2014;9(9):e106259.
Osteopathic International Alliance. OSTEOPATHY AND OSTEOPATHIC MEDICINE, A Global View of Practice,
Patients, Education and the Contribution to Healthcare Delivery. 2013.
Plunkett A, Fawkes C, Carnes D. UK osteopathic practice in 2019: A retrospective analysis of practice data.
2021
MedRXiv DOI 10.1101/2021.01.28.21250601v1
van Dun P,Verbeeck J, Esteves JE, Cerritelli F. Osteopathic Practitioners Estimates and Rates (OPERA) Study
Belgium - Luxemburg: Part I. 2019a.
van Dun P,Verbeeck J, Esteves J, Cerritelli F. Osteopathic Practitioners Estimates and Rates (OPERA) Study
Belgium - Luxemburg: Part II. 2019b.
van Dun PLS, Nicolaie MA,Van Messem A. State of affairs of osteopathy in the Benelux: Benelux Osteosurvey
2013. International Journal of Osteopathic Medicine. 2016;20:3-17.
Vaucher P, Macdonald RJD, Carnes D. The role of osteopathy in the Swiss primary health care system: a practice
review. BMJ Open. 2018;8(8):e023770.
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Other relevant publications reviewed for this report
Burke SR, Myers R, Zhang AL. A profile of osteopathic practice in Australia 2010-2011: a cross sectional survey.
BMC Musculoskelet Disord. 2013;14:227
Channell MK, Wang Y, McLaughlin MH, Ciesielski J, Pomerantz SC. Osteopathic Manipulative Treatment for
Older Patients: A National Survey of Osteopathic Physicians. J Am Osteopath Assoc. 2016;116(3):136-43.
Dubois J, Bill AS, Pasquier J, Keberle S, Burnand B, Rodondi PY. Characteristics of complementary medicine
therapists in Switzerland: A cross-sectional study. PLoS One. 2019;14(10):e0224098
Evren S, Bi AY, Talwar S,Yeh A, Teitelbaum H. Doctors of osteopathic medicine (DO): a Canadian perspective.
Can Med Educ J. 2014;5(1):e62-4.
Fawkes CA, Leach CM, Mathias S, Moore AP. A profile of osteopathic care in private practices in the United
Kingdom: a national pilot using standardized data collection. Man Ther. 2014;19(2):125-30
Fawkes C, Leach J, Mathias S, Moore A. The Standardised Data Collection Project – Standardised data collection
within osteopathic practice in the UK: development and first use of a tool to profile osteopathic care in 2009.
London: National Council for Osteopathic Research; 2010.
Kier A, George M, McCarthy PW. Survey based investigation into general practitioner referral patterns for
spinal manipulative therapy. Chiropr Man Therap. 2013;21:16
Leach MJ, Sundberg T, Fryer G, Austin P, Thomson OP, Adams J. An investigation of Australian osteopaths’
attitudes, skills and utilization of evidence-based practice: a national cross-sectional survey. BMC Health Serv
Res. 2019;19(1):498.
Leach MJ. Profile of the complementary and alternative medicine workforce across Australia, New Zealand,
Canada, United States and United Kingdom. Complement Ther Med. 2013;21(4):364-78.
Leach CM, Mandy A, Hankins M, Bottomley LM, Cross V, Fawkes CA,
et al.
Patients’ expectations of private
osteopathic care in the UK: a national survey of patients. BMC Complement Altern Med. 2013;13:122
National Council for Osteopathic Research. Patient Reported Outcome Measurement (PROMs) in osteopathic
practice – summary report of adult data collection. 2019a.
National Council for Osteopathic Research. Patient Reported Outcome Measurement (PROMs) in osteopathic
practice – summary report of pediatric data collection. 2019b.
Orrock P. Profile of members of the Australian Osteopathic Association: Part 2 – The patients. International
Journal of Osteopathic Medicine. 2009:14-24
Steel A,Vaughan B, Orrock P, Peng W, Fleischmann M, Grace S,
et al.
Prevalence and profile of Australian
osteopaths treating older people. Complement Ther Med. 2019;43:125-30.
Sundberg T, Leach MJ, Thomson OP, Austin P, Fryer G, Adams J. Attitudes, skills and use of evidence-based
practice among UK osteopaths: a national cross-sectional survey. BMC Musculoskelet Disord. 2018;19(1):439
Tamber MS, Nikas D, Beier A, Baird LC, Bauer DF, Durham S,
et al.
Congress of Neurological Surgeons
Systematic Review and Evidence-Based Guideline on the Role of Cranial Molding Orthosis (Helmet) Therapy
for Patients With Positional Plagiocephaly. Neurosurgery. 2016;79(5):E632-E3
Vogel S, Mars T, Keeping S, Barton T, Marlin N, Froud R,
et al.
Clinical Risk Osteopathy and Management
Summary Report, The CROaM Study
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The British School of Osteopathy in collaboration with Barts and the London, Warwick Medical School, Royal
Holloway; 2012
Wardle JL, Sibbritt DW, Adams J. Referrals to chiropractors and osteopaths: a survey of general practitioners in
rural and regional New South Wales, Australia. Chiropr Man Therap. 2013;21(1):5.
Wilkinson J, Thomas K, Freeman J, McKenna B. Day-to-day practice of osteopaths using osteopathy in the
cranial field, who are affiliated with the Sutherland Cranial College of Osteopathy (SCCO): A national survey by
means of a standardised data collection tool. International Journal of Osteopathic Medicine. 2014;04(008).
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PART 3.
Osteopathy:
EVIDENCE AND
SAFETY SUMMARY.
SUMMARY
•
Evidence about effectiveness and safety of osteopathic care is needed to inform osteopathic
clinical practice and decision making. It also helps the wider healthcare community and
patients understand the practice of osteopathy.
•
Some research is specific to osteopathy and other research whilst not delivered by osteopaths
in an osteopathic setting is still relevant to osteopathy.
•
Osteopathy is a multi-component therapy consisting of touch, exercise, public health and
lifestyle advice, education and psychological reassurance and wellbeing support, research in all
these fields has potential relevance to the care osteopaths deliver.
•
Research evidence from guidelines and systematic reviews that illustrate moderate positive
level of evidence or above, or where the reviews present statistically significant positive benefit
is of interest.
•
There is a growing positive evidence base of beneficial effects of interventions delivered in a
manual therapy setting for pain reduction, function, range of motion and reduction in disability,
return to work, quality of life and satisfaction for the following musculoskeletal conditions:
low back pain (in adults and children, and for women during and after pregnancy), neck pain,
shoulder dysfunctions, hip and knee osteoarthritis, heel pain and pulled elbow in children.
•
There is also positive outcome evidence for the treatment of headaches and for length-
of-hospital-stay in pre-term infants. There is promising, but less certain evidence, for the
treatment of irritable bowel syndrome, lymphatic drainage as part of breast cancer care and
infantile colic.
•
The evidence presented is from some of the most commonly cited and referenced publications,
the list is not exhaustive and is liable to change as more research is published and more
findings emerge.
•
There is much research information that is inconclusive due to the lack of research rigor and
potential risk of bias or that the sample sizes (number of people studied in the research) are
too small to enable us to be confident about the findings.
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CONTENTS
1
INTRODUCTION
2
APPROACH
3
OUTCOME RELATED EVIDENCE
4
SAFETY AND ADVERSE EVENTS
5
CONDITION RELATED EVIDENCE
6
PROMISING AREAS OF EVIDENCE
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1. INTRODUCTION
People seek osteopathic care for a variety of reasons and there is sufficient demand for osteopathic care
across the world that sustains and drives the global profession forward. There is a need to consider the
evidence relevant to osteopathic care to inform clinical practice and decision making and to help the wider
healthcare community, patients and the public increase their understand of the practice of osteopathy. Evidence
is normally presented in terms of effectiveness (does it work), efficacy (how does it work) and safety (will it
harm). Effectiveness is not always a straightforward concept, we must consider effectiveness of what, for what,
for whom, when and under what circumstances.
The focus of this report was to consider the evidence about manual therapies and treatments or interventions
that have a positive benefit for patients (outcomes) for various conditions. Commonly measured outcomes
relate to recovery, pain, function, range of motion, disability, return to work, global change, recurrence,
psychological wellbeing, quality of life, experience of care, and satisfaction. Evidence about safety or harm was
also considered, the evidence pertaining to the risk of treatment allows clinicians, patients and commissioners
of health services to make decisions about care.
Some research was specific to osteopathy and other studies, whilst not undertaken by osteopaths in an
osteopathic setting, were still relevant to osteopathy. Practitioners from different manual therapy disciplines
share many of the same techniques, such as mobilization, manipulation, muscle energy and soft tissue
techniques even though they may be applied in a different way. In addition, osteopathy is a multi-component
therapy consisting of touch, exercise, public health and lifestyle advice, education, psychological reassurance, and
wellbeing support; research in all these fields has potential relevance to the care osteopaths deliver.
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2. APPROACH
The main research evidence presented here was from guidelines and systematic reviews published from 2010
and later. The rationale for this decision was that guidelines and systematic reviews are based on multiple
studies and their results are combined to understand the strength of the evidence in terms of quality and level
of effectiveness. Information that illustrates moderate positive level of evidence or above or where the reviews
present statistically significant positive benefit was of most interest.
High quality or strong evidence yields conclusions that are unlikely to change with more research, as the
research is high quality and consistent across studies. Moderate level evidence is less certain and may be liable
to change with more research as the evidence may be of mixed quality and, or with some mixed results but
mostly positive and or statistically significant favorable results.
The evidence presented is from some of the most commonly cited and referenced publications. The list is
not exhaustive and is liable to change as further research is published and more findings emerge. There was
much research information that was inconclusive due to the lack of research rigor, potential risk of bias, or
that sample sizes (number of people studied in the research) are too small to enable us to be confident about
the findings.
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3. OUTCOME RELATED EVIDENCE
There is a growing positive evidence base of beneficial effects of interventions delivered by manual therapists
including osteopaths for pain reduction, function, range of motion and reduction in disability, return to work,
quality of life, experience, and satisfaction for the following musculoskeletal conditions: low back pain (in
adults and children, and for women during and after pregnancy), neck pain, shoulder dysfunctions, hip and
knee osteoarthritis, heel pain and pulled elbow in children. There is also positive outcome evidence for the
treatment of headaches and for length of hospital stay in pre-term infants. There is promising but less certain
evidence for the treatment of irritable bowel syndrome, lymphatic drainage as part of breast cancer care and
infantile colic (See Table 1).
Table 1. Evidence summary of beneficial effects with manual therapy (varied between
manipulation, mobilization, soft tissue manipulation, muscle energy techniques and
combinations)
(Shaded orange areas indicate a positive moderate to strong evidence base, blue boxes indicate
moderate to low quality evidence)
Condition (with positive
and or moderate level
evidence or higher)
Adult low back pain
Pediatric low back pain
Pregnancy related low back,
pelvic pain
Post-partum low back and
pelvic pain
Neck pain
Headaches
Shoulder dysfunctions
Elbow pain
Hip osteoarthritis
Knee osteoarthritis
Heel pain (plantar fasciitis)
Infantile colic
Infant pulled elbow
Preterm infants
Breast cancer care (upper
extremity lymphatic drainage)
Irritable bowel syndrome
Length of
hospital stay
Reduction in
crying time
Pain reduction
Function/
ROM*/
disability
Return to
work
Quality of life
Satisfaction
with care
Other
Coordination
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Pain reduction
The main reason people seek osteopathic care is because they have pain (OIA Global Report 2013). For
research purposes, pain is often classified as acute, sub-acute (present from 6 – 12 weeks) and chronic or
persistent (present for 13 weeks or more) and distinguished by traumatic or non-traumatic onset. Pain is
a complex phenomenon and can be modulated by both the peripheral and central nervous systems, the
emotional centers of the brain. Therefore, both manual and non-manual components of care may impact on
outcome (Estevez
et al
2020).
There is a good level of evidence to support the use of manual therapy in the treatment and management of
low back pain. This is reflected in guidance from the UK where manual therapy is recommended as part of a
package of care and in Europe and the USA for non-specific acute, sub-acute and chronic low back pain and
sciatica.
In addition, a number of other studies have shown pain reduction outcomes for the treatment of neck pain,
non-spinal joints (shoulders, hips, knees, feet, elbows) and for headaches and Irritable Bowel Syndrome.
Function, range of movement and reducing disability
Function has been shown to be more, or equally as important as pain in patient outcome expectations
(Carnes, Ashby Underwood 2007). Functional ability - that is, the ability to do a task - is a key determinant of a
successful outcome for patients, often meaning that patients can return to work or manage everyday tasks of
daily living. Proxy indicators of function are ‘range of movement,’ reduced disability, improvement, days off sick
and return to work. Evidence of benefit and/or improvement of function and/or range of movement has been
shown for the low back pain, neck pain and shoulder dysfunction, hip and knee osteoarthritis, heel pain, for
those with headaches, and for upper limb mobility with lymphatic drainage as part of breast cancer care.
Return to work
We only found evidence for expedited return to work for those with low back pain who have received manual
therapy as part of a package of care (NICE 2016).
Quality of life, satisfaction with care and other outcomes
There is evidence of positive effect on quality of life with treatment for post-partum low back pain, neck pain
and headaches and satisfaction with care specifically for treatment for neck pain and headache. Some positive
evidence has been cited for reduced crying time after treatment for infants with colic and for reducing length
of hospital stay for pre-term infants (Lanaro
et al
2017).
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4. SAFETY AND ADVERSE EVENTS
Five reviews published since 2010 have concluded that the risks of serious adverse events with manual therapy
is very low (Carnes
et al
2010, Clar
et al
2014, Dreihuis
et al
2019, Paige
et al
2017, Rubinstein
et al
2019).
However, around half of patients may experience mild transient aches and soreness after treatment.
5. CONDITION RELATED EVIDENCE
The most compelling evidence is found for the treatment of low back pain, neck pain, headaches, shoulder and
peripheral joints disorders.
Low back pain
One of the most common painful conditions is low back pain (WHO 2012). Manual therapy, including that
given by osteopaths, is recommended in the UK by the National Institute of Health and Clinical Excellence
to reduce symptoms including pain as part of a package of care for acute, sub-acute and chronic low back
pain and sciatica (NICE 2016). Spinal manipulation is recommended by the US American College of Physicians
and the American Pain Society (Chou
et al
2007) and in the European Union Guidelines on Low Back Pain
(Airaksinen
et al
2006) for acute non resolving low back pain and chronic low back pain. The Scottish National
Guidance for chronic pain also recommends that manual therapy should be considered for short-term relief
of pain for patients with chronic low back pain (SIGN 2013). Recommendations in guidelines are usually based
on high quality randomized controlled trials evidence of effectiveness and expert opinion and consensus.
Table 2 shows that there is considerable evidence of benefit for manipulation, mobilization and soft tissue
manual techniques of beneficial effects for pain and function/range of movement. A summary of evidence for
different manual therapy techniques and outcomes is shown in Table 2.
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Table 2. Low Back Pain: Evidence of benefit
Intervention
Spinal manipulation
Mobilization
Muscle energy technique
Osteopathic care
Soft tissue / Massage
Pain
1,2,3,4,5*,6,7,8,10
1, 2, 3, 5*, 10
9
11
5*,6,7
Function, disability,
range of movement
1,3,5*,6,8,10
1, 3, 5*, 10
9
11
5*
Return to Work
5*
5*
Coordination
1
1
5*
1. American Physical Therapy Association 2012, 2. Brontfort
et al
2010, 3. Coulter
et al
2018, 4. Furlan
et al
2012, 5.* NICE UK 2016 (As
part of a package of care), 6. Paige
et al
2017, 7. Qaseem
et al
2017, 8. Rubinstein 2019, 9. Thomas
et al
2019, 10. USA Department of
Veterans Affairs 2017, 11.Verhaeghe
et al
2018
Neck pain
A number of guidelines and reviews recommend manual therapy (including spinal manipulation and
mobilization) and exercise, as a treatment for patients with neck pain for the reduction of pain and disability
and improvement in function and or range of movement.
Table 3. Neck Pain: Evidence of benefit
Intervention
Spinal manipulation
Mobilization
Manual therapy
Manual therapy with Exercise
Muscle energy technique
Soft tissue massage
Pain
1,2,4, 6,7
1,2, 4, 6, 7
3,5,10
1, 8
9
6
Function, disability, range
of movement
1,2,4,7
1,2, 4,7
1, 8
Satisfaction
Quality of life
7
8
1. American Physical Therapy Association 2016, 2. Brontfort
et al
2010, 3. Coté
et al
2019, 4. Coulter
et al
2019, 5. Franke
et al
2017, 6.
Furlan
et al
2012, 7. Gross
et al
2010, 8. Miller
et al
2010, 9. Thomas
et al
2019, 10.Vincent
et al
2013
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Headaches
Moderate quality evidence shows that manual therapies have a beneficial outcome for pain and function,
including improvement in range of movement and reduction in disability (Table 4).
Table 4. Evidence of benefit for headaches
Intervention
Spinal manipulation
Mobilization
Osteopathic manual therapy
Manual therapy
Manual therapy with
exercise
Pain
1,2,5,8, 10
1,2,5,8
4
3,9,11
7
Function, disability, range of movement
1,2,8
1,2,8
3
Quality of life
3,9
1. American Physical Therapy Association 2017, 2. Brontfort
et al
2010, 3. Cumplido-Trasmonte
et al
2017, 4. Cerritelli
et al
2017, 5.
Chaibi
et al
2017, 6. Clar
et al
2014, 7. Coté
et al
2019, 8. Coulter
et al
2019, 9. Falsiroli
et al
2019, 10. Fernandez
et al
2020, 11.Yaseen
al 2018
Shoulder pain and dysfunction
There are many reasons for shoulder pain and shoulder dysfunction, the main disorders investigated are
adhesive capsulitis (frozen shoulder) and rotator cuff dysfunction. Studies investigating the effects of manual
therapies, particularly mobilization, stretching in combination with exercise indicate beneficial effects for pain
and function (Table 5).
Table 5. Evidence of benefit for shoulder pain/dysfunction
Intervention
Mobilization
Stretching and exercise
Manual therapy with exercise
Pain
1,2
1,2
1,2
Function, disability range of movement
1,2
1,2
1,2
1. American Physical Therapy Association 2014, 2. Clar
et al
2014
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Extremity joint pain
Table 6. Extremity joint pain
Condition
Elbow pain
Hip osteoarthritis
Knee osteoarthritis / patellofemoral
pain syndrome
Heel pain / plantar fasciitis
Intervention
Mobilization and exercise
Manipulation and mobilization
Manipulation, mobilization and exercise
Manipulation, mobilization, exercise and soft tissue
Pain
1
1
1
1, 3
2
Function, disability,
range of movement
1
1
1
1, 3
1. Brontfort
et al
2010, 2. Pollack
et al
2018, 3. Clar
et al
2014
Pediatric Care
There is moderate to high quality evidence to show benefit of osteopathic treatment for pre-term infants on
length of hospital stay (Parnell
et al
2019, Lanaro
et al
2017) and low to moderate quality evidence of benefit of
manual therapy-based treatment for infants with ‘colic’ for reducing crying time (Carnes
et al
2018). In addition,
one review indicates some evidence of effectiveness for ‘pulled elbow’ in children and for low back pain in
school age children (Table 7). Only low-quality evidence exists for most other manual therapy-based treatment
for infants and children therefore no conclusions can be made about effectiveness.
Table 7. Evidence of benefit for pediatric care
Condition
Infantile colic
Low back pain
Pulled elbow
Premature infants
Intervention
Manual therapy
Manual therapy
Manual therapy
Osteopathic manual treatment
Pain/
Recovery
Reduced crying
time
1
Length of
hospital stay
2
2
2,3
1. Carnes
et al
2018, 2. Parnell
et al
2019, 3. Lanaro
et al
2017
Women’s Health
Pregnant and postpartum women
There is low-to-moderate quality evidence that supports osteopathic manual treatment for pelvic, girdle and
low back pain during pregnancy and postpartum. This could be attributed to non-specific effects as when
manual therapy was compared to sham it was not superior but when manual therapy was compared to usual
care or relaxation it was superior (Table 8).
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Table 8. Evidence of benefit for low back pain during and after pregnancy
Condition
Low back pain during pregnancy
Low back pain post-partum
Intervention
Osteopathic manipulative treatment
Manual therapy, exercise, and education
Osteopathic manipulative treatment
Pain
1,2,3
4
1
Function
1
4
1
1. Franke
et al
2017, 2. Hall
et al
2016, 3. Ruffini
et al
2016, 4. van Benton
et al
2014
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5. PROMISING AREAS OF EVIDENCE
Breast cancer care
Promising evidence exists for the use of manual therapy post breast cancer surgery. One study indicated that
soft tissue massage therapy as an adjunctive therapy as part of a package of breast cancer care for shoulder
and upper limb function was beneficial post-surgery for upper limb function (Clar
et al
2014). A further study
showed that there was some additional benefit to including manual therapy with upper limb compression
bandaging for lymphatic drainage management (Ezzo
et al
2015).
Irritable Bowel Syndrome (IBS)
One review of osteopathic care for the treatment of IBS indicated that whilst the scientific quality of studies
was limited there was enough combined data to indicate some potential benefit of osteopathic care for pain
and function for those with IBS (Muller
et al
2014).
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6. CONCLUSIONS
Overall, the research field for effectiveness is encouraging and the risks of harm are low for manual therapy
care. There will be further emerging evidence in the future as the research intensifies in this field and more
pooling of results are done. There is growing acknowledgment that the active components of care may be
multiple, and that manual therapy is more than just hands-on care and has contextual active elements of
benefit.
Osteopaths deliver a multicomponent package of care that, in addition to manual therapy, includes: health
examination, screening and diagnosis and, where appropriate, referral, advice and guidance, reassurance,
psychological support, self-management, general health guidance and behavior change encouragement for
healthier lifestyles.
More research and novel research methods are needed to explore effects and outcomes that are important to
patients. This may include placing more emphasis on some of the ‘softer’ outcomes of care such as quality of
life, satisfaction, and experience of care for healthier lives and better wellbeing.
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Volume 35: 1 - 4 DOI: https://doi.org/10.1016/j.ijosm.2020.01.003
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et al.
Manual lymphatic drainage for lymphedema following breast cancer
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Falsiroli Maistrello L, Rafanelli M, Turolla A. Manual Therapy and Quality of Life in People with Headache:
Systematic Review and Meta-analysis of Randomized Controlled Trials. Curr Pain Headache Rep.
2019;23(10):78. Published 2019 Aug 10. doi:10.1007/s11916-019-0815-8
Fernandez, M, Moore, C, Tan, J,
et al.
Spinal manipulation for the management of cervicogenic headache:
A systematic review and meta-analysis. Eur J Pain. 2020; 00: 1–16. https://doi.org/10.1002/ejp.1632
Franke H, Franke JD, Fryer G. Osteopathic manipulative treatment for chronic nonspecific neck pain: A
systematic review and meta-analysis’ International Journal of Osteopathic Medicine 2015 Dec;18 (4):255–267
https://doi.org/10.1016/j.ijosm.2015.05.003
Franke H, Franke JD, Belz S, Fryer G. Osteopathic manipulative treatment for low back and pelvic girdle pain
during and after pregnancy: A systematic review and meta-analysis. J Bodyw Mov Ther. 2017;21(4):752-762.
doi:10.1016/j.jbmt.2017.05.014
Furlan AD,Yazdi F, Tsertsvadze A,
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A systematic review and meta-analysis of efficacy, cost-effectiveness,
and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based
Complement Alternat Med. 2012;2012:953139. doi:10.1155/2012/953139
Gross A, Miller J, D’Sylva J,
et al.
Manipulation or mobilization for neck pain: a Cochrane Review. Man Ther.
2010;15(4):315-333. doi:10.1016/j.math.2010.04.002
Hall H, Cramer H, Sundberg T,
et al.
The effectiveness of complementary manual therapies for pregnancy-
related back and pelvic pain: A systematic review with meta-analysis. Medicine (Baltimore). 2016;95(38):e4723.
doi:10.1097/MD.0000000000004723
Lanaro D, Ruffini N, Manzotti A, Lista G. Osteopathic manipulative treatment showed reduction of
length of stay and costs in preterm infants: A systematic review and meta-analysis. Medicine (Baltimore).
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2017;96(12):e6408. doi:10.1097/MD.0000000000006408
Miller J, Gross A, D’Sylva J,
et al.
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Paige NM, Miake-Lye IM, Booth MS,
et al.
Association of Spinal Manipulative Therapy With Clinical Benefit
and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis JAMA. 2017;317(14):1451-1460.
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Parnell Prevost C, Gleberzon B, Carleo B, Anderson K, Cark M, Pohlman KA. Manual therapy for the pediatric
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Rubinstein S, de Zoete A, van Middelkoop M, Assendelft WJJ, de Boer MR,
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asymptomatic subjects: a systematic review. Chiropr Man Therap 27, 35 (2019). https://doi.org/10.1186/s12998-
019-0258-7
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2017. https://www.guidelinecentral.com/share/summary/5ac2fc58a3e7a#section-420
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Vincent K, Maigne JY, Fischhoff C, Lanlo O, Dagenais S. Systematic review of manual therapies for nonspecific
neck pain. Joint Bone Spine. 2013;80(5):508-515. doi:10.1016/j.jbspin.2012.10.006
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Article
Low Back Pain
American Physical Therapy Association. Guideline for the
diagnosis and treatment of low back pain. 2012.
https://www.guidelinecentral.com/share/
summary/52d56300204e0#section-society
Conclusions
Strong level of evidence supporting Manual Therapy for low
back pain and back related buttock or thigh pain. Recommend:
Thrust manipulative procedures to reduce pain and disability.
Thrust manipulative and non-thrust mobilization procedures to
improve spine and hip mobility and reduce pain and disability.
Trunk Coordination, Strengthening, and Endurance Exercises to
reduce low back pain and disability in patients with sub-acute and
chronic low back pain with movement coordination impairments
and in patients post–lumbar microdiscectomy.
Spinal manipulation/mobilization is effective in adults for: acute,
sub-acute, and chronic low back pain.
Bronfort G, Haas M, Evans, R Leininger B, Triano J. Effectiveness
of manual therapies: the UK evidence report. Chiropr Osteopat
2010 Feb 25;18:3. doi: 10.1186/1746-1340-18-3.
Coulter ID, Crawford C, Hurwitz EL,Vernon H, Khorsan R,
Booth MS, Herman PM. Manipulation and Mobilization for
Treating Chronic Low Back Pain: A Systematic Review and
Meta-Analysis. Spine J 2018 May;18(5):866-879. doi: 10.1016/j.
spinee.2018.01.013. Epub 2018 Jan 31.
Furlan AD,Yazdi F, Tsertsvadze A,
et al.
A systematic review and
meta-analysis of efficacy, cost-effectiveness, and safety of selected
complementary and alternative medicine for neck and low-back
pain. Evid Based Complement Alternat Med. 2012;2012:953139.
doi:10.1155/2012/953139
There is moderate-quality evidence that manipulation and
mobilization are likely to reduce pain and improve function for
patients with chronic low back pain; manipulation appears to
produce a larger effect than mobilization. Both therapies appear
safe. Multimodal programs may be a promising option.
Manipulation and mobilization effectiveness is variable depending
on symptom duration, outcome, comparator, whether there
is exercise or general practitioner care and follow-up period.
Although this variability can be considered as ‘inconsistent
findings,’ the overall evidence suggests that manipulation and
mobilization are an effective treatment modality compared to
no treatment, placebo, physical therapy, or usual care in reducing
pain immediately or at short-term after treatment for low back
and neck pain.
Provide people with advice and information, tailored to their
needs and capabilities, to help them self-manage their low
back pain with or without sciatica, at all steps of the treatment
pathway. Consider a group exercise program (biomechanical,
aerobic, mind–body or a combination of approaches). Consider
manual therapy (spinal manipulation, mobilization or soft tissue
techniques such as massage) as part of a treatment package
including exercise, with or without psychological therapy.
Consider psychological therapies using a cognitive behavioral
approach as part of a treatment package including exercise, with
or without manual therapy (spinal manipulation, mobilization or
soft tissue techniques such as massage). Consider a combined
physical and psychological program. Promote and facilitate return
to work or normal activities of daily living.
National Institute of Health and Clinical Excellence (NICE)
UK. Low back pain and sciatica in over 16s: assessment and
management. NICE guideline [NG59] 30 November 2016. https://
www.nice.org.uk/guidance/ng59
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Paige NM, Miake-Lye IM, Booth MS,
et al.
Association of Spinal
Manipulative Therapy With Clinical Benefit and Harm for Acute
Low Back Pain: Systematic Review and Meta-analysis JAMA.
2017;317(14):1451-1460. doi:10.1001/jama.2017.3086
In this systematic review and meta-analysis of 26 randomized
clinical trials, spinal manipulative therapy was associated with
statistically significant benefits in both pain and function, of on
average modest magnitude, at up to 6 weeks. Minor transient
adverse events such as increased pain, muscle stiffness, and
headache were reported in more than half of patients in the
large case series. Meaning: Among patients with acute low back
pain, spinal manipulative therapy was associated with modest
improvements in pain and function and with transient minor
musculoskeletal harms.
Recommendation 1: Given that most patients with acute or sub-
acute low back pain improve over time regardless of treatment,
clinicians and patients should select non-pharmacologic
treatment with superficial heat (moderate-quality evidence),
massage, acupuncture, or spinal manipulation (low-quality
evidence). Recommendation 2: For patients with chronic low
back pain, clinicians and patients should initially select non-
pharmacologic treatment with exercise, multidisciplinary
rehabilitation, acupuncture, mindfulness-based stress reduction
(moderate-quality evidence), tai chi, yoga, motor control exercise,
progressive relaxation, electromyography biofeedback, low-level
laser therapy, operant therapy, cognitive behavioral therapy,
or spinal manipulation (low-quality evidence). (Grade: strong
recommendation).
SMT as good as other recommended treatment and better than
non-recommended treatment for function and pain.
Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines
Committee of the American College of Physicians. Noninvasive
Treatments for Acute, Subacute, and Chronic Low Back Pain:
A Clinical Practice Guideline From the American College of
Physicians. Ann Intern Med. 2017;166(7):514-530.
Rubinstein S, de Zoete A, van Middelkoop M, Assendelft WJJ,
de Boer MR, van Tulder MW. Benefits and harms of spinal
manipulative therapy for the treatment of chronic low back pain:
systematic review and meta-analysis of randomized controlled
trials. BMJ. 2019; 364: l689. doi: 10.1136/bmj.l689
Thomas E, Cavallaro A.R, Mani D.
et al.
The efficacy of muscle
energy techniques in symptomatic and asymptomatic subjects: a
systematic review. Chiropr Man Therap 27, 35 (2019). https://doi.
org/10.1186/s12998-019-0258-7
MET are effective in improving reported pain, disability, and joint
range of motion in both asymptomatic subjects and symptomatic
patients. The studies evaluated in this review have provided
evidence that MET are specifically effective for alleviating chronic
pain of the lower back and neck and chronic lateral epicondylitis.
There is also evidence supporting MET as a beneficial therapy
for reducing acute lower back pain and improving the related
disability indexes. However, further evidence is needed to
confirm MET as an effective treatment for plantar fasciitis and
other musculoskeletal disorders. A definitive protocol for MET
application, due to the heterogeneity of the results, could not
be identified, and a future evaluation of the parameters of MET
prescription is suggested.
For patients with chronic low back pain, the Work Group
suggests offering clinician-directed exercises. For patients with
acute or chronic low back pain, the Work Group suggests
offering spinal mobilization/manipulation as part of a multimodal
program.
In conclusion, there is some evidence suggesting that osteopathic
care may be effective for people suffering from spinal complaints.
USA Department of Veterans Affairs. Clinical Guidance for the
diagnosis and treatment of low back pain Sept 2017. https://www.
guidelinecentral.com/share/summary/5ac2fc58a3e7a#section-420
Verhaeghe N, Schepers J, van Dun P, Annemans L. Osteopathic
care for spinal complaints: A systematic literature review. PLOS
ONE 2018 13(11): e0206284. https://doi.org/10.1371/journal.
pone.0206284
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2707038_0086.png
Neck Pain
American Physical Therapy Association Guideline for the
diagnosis and treatment of neck pain. 2017. https://www.
guidelinecentral.com/share/summary/5a5d86f293537#section-420
Manual manipulation, mobilization and exercise and advice
(moderate to weak) for benefits to pain and disability/function:
Neck Pain with Mobility Deficits. Neck Pain with Movement
Coordination Impairments Neck Pain with Headaches Neck
Pain with Radiating Pain
Thoracic manipulation/mobilization is effective for acute/
sub-acute neck pain. Outcomes improved pain and range of
movement,
Neck pain and headaches are very common co-morbidities in
the population. Tension-type and cervicogenic headaches can be
treated effectively with specific exercises. Manual therapy can be
considered as an adjunct therapy to exercise to treat patients
with cervicogenic headaches. The management of tension-type
and cervicogenic headaches should be patient-centered.
Studies published since January 2000 provide low-moderate
quality evidence that various types of manipulation and/or
mobilization will reduce pain and improve function for chronic
nonspecific neck pain compared to other interventions. It
appears that multimodal approaches, in which multiple treatment
approaches are integrated, might have the greatest potential
impact. The studies comparing to no treatment or sham were
mostly testing the effect of a single dose, which may or may not
be helpful to inform practice. According to the published trials
reviewed, manipulation and mobilization appear safe. However,
given the low rate of serious adverse events, other types of
studies with much larger sample sizes would be required to
fully describe the safety of manipulation and/or mobilization for
nonspecific chronic neck pain.
The 3 reviewed studies had low risk of bias. Moderate-quality
evidence suggested OMT had a significant and clinically relevant
effect on pain relief (MD: −13.04, 95% CI: −20.64 to −5.44) in
chronic nonspecific neck pain, and moderate-quality evidence
suggested a non-significant difference in favor of OMT for
functional status (SMD: −0.38, 95% CI: −0.88 to 0.11). No serious
adverse events were reported.
Manipulation and mobilization effectiveness is variable depending
on symptom duration, outcome, comparator, whether there
is exercise or general practitioner care and follow-up period.
Although this variability can be considered as ‘inconsistent
findings,’ the overall evidence suggests that manipulation and
mobilization are an effective treatment modality compared to
no treatment, placebo, physical therapy, or usual care in reducing
pain immediately or at short-term after treatment for low back
and neck pain.
Moderate quality evidence showed cervical manipulation and
mobilization produced similar effects on pain, function, and
patient satisfaction at intermediate-term follow-up. Low quality
evidence suggested cervical manipulation may provide greater
short-term pain relief than a control (pSMD -0.90 (95%CI:
-1.78 to -0.02)). Low quality evidence also supported thoracic
manipulation for pain reduction (NNT 7; 46.6% treatment
advantage) and increased function (NNT 5; 40.6% treatment
advantage) in acute pain and immediate pain reduction in chronic
neck pain (NNT 5; 29% treatment advantage). Optimal technique
and dose need to be determined.
Bronfort G, Haas M, Evans, R Leininger B, Triano J. Effectiveness
of manual therapies: the UK evidence report. Chiropr Osteopat
2010 Feb 25;18:3. doi: 10.1186/1746-1340-18-3.
Côté P,Yu H, Shearer HM,
et al.
Non-pharmacological
management of persistent headaches associated with neck pain:
A clinical practice guideline from the Ontario protocol for
traffic injury management (OPTIMa) collaboration. Eur J Pain.
2019;23(6):1051-1070. doi:10.1002/ejp.1374 F
Coulter ID, Crawford C,Vernon H,
et al.
Manipulation and
Mobilization for Treating Chronic Nonspecific Neck Pain: A
Systematic Review and Meta-Analysis for an Appropriateness
Panel. Pain Physician. 2019;22(2):E55-E70.
Franke H, Franke JD, Fryer G. Osteopathic manipulative
treatment for chronic nonspecific neck pain: A systematic
review and meta-analysis’ International Journal of Osteopathic
Medicine 2015 Dec;18 (4):255–267 https://doi.org/10.1016/j.
ijosm.2015.05.003
Furlan AD,Yazdi F, Tsertsvadze A,
et al.
A systematic review and
meta-analysis of efficacy, cost-effectiveness, and safety of selected
complementary and alternative medicine for neck and low-back
pain. Evid Based Complement Alternat Med. 2012;2012:953139.
doi:10.1155/2012/953139
Gross A, Miller J, D’Sylva J,
et al.
Manipulation or mobilization for
neck pain: a Cochrane Review. Man Ther. 2010;15(4):315-333.
doi:10.1016/j.math.2010.04.002
86
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2707038_0087.png
Miller J, Gross A, D’Sylva J,
et al.
Manual therapy and exercise for
neck pain: A systematic review [published online ahead of print,
2010 Jun 1]. Man Ther. 2010;doi:10.1016/j.math.2010.02.007
Of 17 randomized controlled trials included, 29% had a low
risk of bias. Low quality evidence suggests clinically important
long-term improvements in pain (pSMD-0.87(95% CI:-1.69,-
0.06)), function/disability, and global perceived effect when manual
therapy and exercise are compared to no treatment. High quality
evidence suggests greater short-term pain relief [pSMD-0.50(95%
CI:-0.76,-0.24)] than exercise alone, but no long-term differences
across multiple outcomes for (sub)acute/chronic neck pain with
or without cervicogenic headache. Moderate quality evidence
supports this treatment combination for pain reduction and
improved quality of life over manual therapy alone for chronic
neck pain; and suggests greater short-term pain reduction
when compared to traditional care for acute whiplash. Evidence
regarding radiculopathy was sparse.
MET are effective in improving reported pain, disability, and joint
range of motion in both asymptomatic subjects and symptomatic
patients. The studies evaluated in this review have provided
evidence that MET are specifically effective for alleviating chronic
pain of the lower back and neck and chronic lateral epicondylitis.
There is also evidence supporting MET as a beneficial therapy
for reducing acute lower back pain and improving the related
disability indexes. However, further evidence is needed to
confirm MET as an effective treatment for plantar fasciitis and
other musculoskeletal disorders. A definitive protocol for MET
application, due to the heterogeneity of the results, could not
be identified, and a future evaluation of the parameters of MET
prescription is suggested.
Manual therapies contribute usefully to the management of
nonspecific neck pain. The level of evidence is moderate for
short-term effects of upper thoracic manipulation in acute neck
pain, limited for long-term effects of neck manipulation, and
limited for all techniques and follow-up durations in chronic neck
pain.
Thomas E, Cavallaro A.R, Mani D.
et al.
The efficacy of muscle
energy techniques in symptomatic and asymptomatic subjects: a
systematic review. Chiropr Man Therap 27, 35 (2019). https://doi.
org/10.1186/s12998-019-0258-7
Vincent K, Maigne JY, Fischhoff C, Lanlo O, Dagenais S. Systematic
review of manual therapies for nonspecific neck pain. Joint Bone
Spine. 2013;80(5):508-515. doi:10.1016/j.jbspin.2012.10.006
Headaches
American Physical Therapy Association Guideline for the
diagnosis and treatment of neck pain. 2017. https://www.
guidelinecentral.com/share/summary/5a5d86f293537#section-420
Bronfort G, Haas M, Evans, R Leininger B, Triano J. Effectiveness
of manual therapies: the UK evidence report. Chiropr Osteopat
2010 Feb 25;18:3. doi: 10.1186/1746-1340-18-3.
Cerritelli F, Lacorte E, Ruffini N,Vanacore N. Osteopathy for
primary headache patients: a systematic review. J Pain Res.
2017;10:601-611. Published 2017 Mar 14. doi:10.2147/JPR.
S130501
Manual manipulation, mobilization and exercise and advice
(moderate to weak) for benefits to pain and disability/function:
Neck Pain with Headaches
Spinal manipulation/mobilization is effective in adults for: migraine
and cervicogenic headache; cervicogenic dizziness. Outcomes
improved: pain and function
The results from this systematic review show a preliminary
low level of evidence that OMT is effective in the management
of headache. However, studies with more rigorous designs and
methodology are needed to strengthen this evidence. Moreover,
this review suggests that new manual interventions for the
treatment of acute migraine are available and developing.
A total of seven RCTs were identified, i.e. one study applied
physiotherapy ± temporomandibular mobilization techniques and
six studies applied cervical spinal manipulative therapy (SMT). The
RCTs suggest that physiotherapy and SMT might be an effective
treatment in the management of CEH, but the results are difficult
to evaluate, since only one study included a control group that
did not receive treatment
Chaibi A, Russell MB Manual therapies for cervicogenic
headache: a systematic review. Journal of Headache Pain. 2012;
13(5):351-359
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Clar, C., Tsertsvadze, A., Court, R.
et al.
Clinical effectiveness of
manual therapy for the management of musculoskeletal and non-
musculoskeletal conditions: systematic review and update of UK
evidence report. Chiropr Man Therap 22, 12 (2014). https://doi.
org/10.1186/2045-709X-22-12
Côté P,Yu H, Shearer HM,
et al.
Non-pharmacological
management of persistent headaches associated with neck pain:
A clinical practice guideline from the Ontario protocol for
traffic injury management (OPTIMa) collaboration. Eur J Pain.
2019;23(6):1051-1070. doi:10.1002/ejp.1374 F
Moderate evidence ratings for spinal mobilization for
cervicogenic headache and mobilization for miscellaneous
headache.
Neck pain and headaches are very common co-morbidities in
the population. Tension-type and cervicogenic headaches can be
treated effectively with specific exercises. Manual therapy can be
considered as an adjunct therapy to exercise to treat patients
with cervicogenic headaches. The management of tension-type
and cervicogenic headaches should be patient-centered.
Studies published since January 2000 provide low-moderate
quality evidence that various types of manipulation and/or
mobilization will reduce pain and improve function for chronic
nonspecific neck pain compared to other interventions. It
appears that multimodal approaches, in which multiple treatment
approaches are integrated, might have the greatest potential
impact. The studies comparing to no treatment or sham were
mostly testing the effect of a single dose, which may or may not
be helpful to inform practice. According to the published trials
reviewed, manipulation and mobilization appear safe. However,
given the low rate of serious adverse events, other types of
studies with much larger sample sizes would be required to
fully describe the safety of manipulation and/or mobilization for
nonspecific chronic neck pain.
We identified a total of 10 RCTs, 7 of which were included
into the meta-analysis. For HIT-6 scale, meta-analysis showed
statistically significant differences in favor to manual therapy both
after treatment (mean difference (MD) - 3.67; 95% CI from - 5.71
to - 1.63) and at follow-up (MD - 2.47; 95% CI from - 3.27 to -
1.68). For HDI scale, meta-analysis showed statistically significant
differences in favor to manual therapy both after treatment
(MD - 4.01; 95% CI from - 5.82 to - 2.20) and at follow-up (MD
- 5.62; 95% CI from - 10.69 to - 0.54). Other scales provided
inconclusive results. Manual therapy should be considered as
an effective approach in improving the quality of life in patients
with TTH and MH, while in patients with CGH, the results were
inconsistent. Those positive results should be considered with
caution due to the very low level of evidence.
Manual therapy has positive effects on pain intensity, pain
frequency, disability, overall impact, quality of life, and cranio
cervical range of motion in adults with tension-type headache.
None of the techniques was found to be superior to the others;
combining different techniques seems to be the most effective
approach.
Seven trials: Short-term, significant, small effect favoring SMT for
pain intensity (mean difference [MD] −10.88 [95% CI, −17.94,
−3.82]) and small effects for pain frequency (standardized mean
difference [SMD] −0.35 [95% CI, −0.66, −0.04]). There was no
effect for pain duration (SMD − 0.08 [95% CI, −0.47, 0.32]). There
was a significant, small effect favoring SMT for disability (MD −
13.31 [95% CI, −18.07, −8.56]). For CGHA, SMT provides small,
superior short-term benefits for pain intensity, frequency and
disability, but not pain duration, however, high-quality evidence in
this field is lacking. The long-term impact is not significant.
Coulter ID, Crawford C,Vernon H,
et al.
Manipulation and
Mobilization for Treating Chronic Nonspecific Neck Pain: A
Systematic Review and Meta-Analysis for an Appropriateness
Panel. Pain Physician. 2019;22(2):E55-E70.
Falsiroli Maistrello L, Rafanelli M, Turolla A. Manual Therapy and
Quality of Life in People with Headache: Systematic Review
and Meta-analysis of Randomized Controlled Trials. Curr
Pain Headache Rep. 2019;23(10):78. Published 2019 Aug 10.
doi:10.1007/s11916-019-0815-8
Cumplido-Trasmonte C, Fernández-González P, Alguacil-Diego
IM, Molina-Rueda F. Manual therapy in adults with tension-
type headache: A systematic review Neurologia. 2018;S0213-
4853(18)30013-6. doi:10.1016/j.nrl.2017.12.004
Fernandez, M, Moore, C, Tan, J,
et al.
Spinal manipulation for the
management of cervicogenic headache: A systematic review and
meta-analysis. Eur J Pain. 2020; 00: 1– 16. https://doi.org/10.1002/
ejp.1632
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Yaseen K, Hendrick P, Ismail A, Felemban M, Alshehri MA.
The effectiveness of manual therapy in treating cervicogenic
dizziness: a systematic review. J Phys Ther Sci. 2018;30(1):96-102.
doi:10.1589/jpts.30.96
Three out of the four articles were deemed to have high
methodological quality, while the fourth was rated as moderate
quality. The attributed level of evidence was moderate (level 2).
[Conclusion] Manual therapy is potentially effective for managing
cervicogenic dizziness. Further research is recommended to
provide conclusive evidence.
Shoulder Dysfunction
American Physical Therapy Association. Shoulder pain
and mobility deficits: adhesive capsulitis: clinical practice
guidelines 2014. https://www.guidelinecentral.com/share/
summary/535eab230c8e4#section-420
Weak level of evidence for: Joint Mobilization primarily directed
to the glenohumeral joint to reduce pain and increase motion
and function in patients with adhesive capsulitis.
Moderate level of evidence for: Stretching Exercises with
adhesive capsulitis.
Moderate (positive) evidence for use of manual therapy
combined with exercise in the treatment of rotator cuff
disorders (change from inconclusive (favorable) evidence in
UK evidence report). Outcomes: pain range of movement and
function.
Clar C, Tsertsvadze A, Court R.
et al.
Clinical effectiveness of
manual therapy for the management of musculoskeletal and non-
musculoskeletal conditions: systematic review and update of UK
evidence report. Chiropr Man Therap 22, 12 (2014). https://doi.
org/10.1186/2045-709X-22-12
Pediatrics
Carnes D, Plunkett A, Ellwood J,
et al
Manual therapy for unsettled, distressed and excessively crying
infants: a systematic review and meta-analyses BMJ Open
2018;8:e019040. doi: 10.1136/bmjopen-2017-019040
We found moderate strength evidence for the effectiveness
of manual therapy on: reduction in crying time (favorable:
−1.27 hours per day (95% CI −2.19 to –0.36)), sleep
(inconclusive), parent–child relations (inconclusive) and global
improvement (no effect). The risk of reported adverse events
was low: seven non-serious events per 1000 infants exposed
to manual therapy (n=1308) and 110 per 1000 in those not
exposed.
Fifty studies investigated the clinical effects of manual therapies
for a wide variety of pediatric conditions. Moderate-positive
overall assessment was found for 3 conditions: low back pain,
pulled elbow, and premature infants. Inconclusive unfavorable
outcomes were found for 2 conditions: scoliosis (OMT) and
torticollis (MT). All other condition’s overall assessments were
either inconclusive favorable or unclear. Adverse events were
uncommonly reported. More robust clinical trials in this area of
healthcare are needed.
5 trials enrolling 1306 infants met our inclusion criteria. Although
the heterogeneity was moderate (I = 61%, P = 0.03), meta-
analysis of all five studies showed that preterm infants treated
with OMT had a significant reduction of LOS by 2.71 days (95%
CI -3.99, -1.43; P < 0.001). Considering costs, meta-analysis
showed reduction in the OMT group (-1,545.66&OV0556;,
-1,888.03&OV0556;, -1,203.29&OV0556;, P < 0.0001). All studies
reported no adverse events associated to OMT. Subgroup
analysis showed that the benefit of OMT is inversely associated
to gestational age. The present systematic review showed the
clinical effectiveness of OMT on the reduction of LOS and costs
in a large population of preterm infants.
Parnell Prevost C, Gleberzon B, Carleo B, Anderson K, Cark
M, Pohlman KA. Manual therapy for the pediatric population: a
systematic review. BMC Complement Altern Med. 2019;19(1):60.
Published 2019 Mar 13. doi:10.1186/s12906-019-2447-2
Lanaro D, Ruffini N, Manzotti A, Lista G. Osteopathic
manipulative treatment showed reduction of length of stay
and costs in preterm infants: A systematic review and meta-
analysis. Medicine (Baltimore). 2017;96(12):e6408. doi:10.1097/
MD.0000000000006408
Pregnancy and Postpartum Complaints
Franke H, Franke JD, Belz S, Fryer G. Osteopathic manipulative
treatment for low back and pelvic girdle pain during and after
pregnancy: A systematic review and meta-analysis. J Bodyw Mov
Ther. 2017;21(4):752-762. doi:10.1016/j.jbmt.2017.05.014
Of 102 studies, 5 examined OMT for LBP in pregnancy and 3 for
postpartum LBP. Moderate-quality evidence suggested OMT had
a significant medium-sized effect on decreasing pain (MD, -16.65)
and increasing functional status (SMD, -0.50) in pregnant women
with LBP. Low-quality evidence suggested OMT had a significant
moderate-sized effect on decreasing pain (MD, -38.00) and
increasing functional status (SMD, -2.12) in postpartum women
with LBP. This review suggests OMT produces clinically relevant
benefits for pregnant or postpartum women with LBP.
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van Benten E, Pool J, Mens J, Pool-Goudzwaard A.
Recommendations for physical therapists on the treatment
of lumbopelvic pain during pregnancy: a systematic review. J
Orthop Sports Phys Ther. 2014;44(7):464-A15. doi:10.2519/
jospt.2014.5098
A total of 22 articles (all randomized controlled trials)
reporting on 22 independent studies were included. Overall,
the methodological quality of the studies was moderate. Data
for 4 types of interventions were considered: a combination of
interventions (7 studies, n = 1202), exercise therapy (9 studies,
n = 2149), manual therapy (5 studies, n = 360), and material
support (1 study, n = 115). All included studies on exercise
therapy, and most of the studies on interventions combined with
patient education, reported a positive effect on pain, disability,
and/or sick leave. Evidence-based recommendations can be made
for the use of exercise therapy for the treatment of lumbopelvic
pain during pregnancy.
11 articles reporting on 10 studies on a total of 1198 pregnant
women were included in this meta-analysis. The therapeutic
interventions predominantly involved massage and osteopathic
manipulative therapy. Meta-analyses found positive effects for
manual therapy on pain intensity when compared to usual care
and relaxation but not when compared to sham interventions.
24 studies were included (total sample=1840), addressing
back pain and low back functioning in pregnancy, pain and
drug use during labour and delivery, infertility and subfertility,
dysmenorrhea, symptoms of (peri)menopause and pelvic
pain. Overall, OMT can be considered effective on pregnancy
related back pain but uncertain in all other gynecological and
obstetrical conditions. Although positive effects were found, the
heterogeneity of study designs, the low number of studies and
the high risk of bias of included trials prevented any indication on
the effect of osteopathic care.
Hall H, Cramer H, Sundberg T,
et al.
The effectiveness of
complementary manual therapies for pregnancy-related
back and pelvic pain: A systematic review with meta-analysis.
Medicine (Baltimore). 2016;95(38):e4723. doi:10.1097/
MD.0000000000004723
Ruffini N, D’Alessandro G, Cardinali L, Frondaroli F, Cerritelli F.
Osteopathic manipulative treatment in gynecology and obstetrics:
A systematic review. Complement Ther Med. 2016;26:72-78.
doi:10.1016/j.ctim.2016.03.005
Irritable Bowel Syndrome
Müller A, Franke H, Resch KL, Fryer G. Effectiveness of
osteopathic manipulative therapy for managing symptoms of
irritable bowel syndrome: a systematic review. J Am Osteopath
Assoc. 2014;114(6):470-479. doi:10.7556/jaoa.2014.098.
All studies reported more pronounced short-term improvements
with OMT compared with sham therapy or standard care only.
These differences remained statistically significant after variable
lengths of follow-up in 3 studies. Low risk of bias. The present
systematic review provides preliminary evidence that OMT
may be beneficial in the treatment of patients with IBS. However,
caution is required in the interpretation of these findings
because of the limited number of studies available and the small
sample sizes
Extremity Joints
Bronfort G, Haas M, Evans, R Leininger B, Triano J. Effectiveness
of manual therapies: the UK evidence report. Chiropr Osteopat
2010 Feb 25;18:3. doi: 10.1186/1746-1340-18-3.
Tennis elbow (mobilization and exercise) for pain and function,
hip osteoarthritis (manipulation and mobilization) for pain,
function and range of movement, knee osteoarthritis and
patellofemoral pain syndrome (manipulation, mobilization and
exercise) for pain and function, plantar fasciitis (manipulation,
mobilization and exercise) for pain and function: all moderate
strength, positive evidence.
A total of six relevant RCTs were found: two examined the
effectiveness of joint mobilization on plantar heel pain and four
the effectiveness of soft tissue techniques. Five studies showed a
positive short-term effect after manual therapy treatment, mostly
soft tissue mobilizations, with or without stretching exercises for
patients with plantar heel pain, compared to other treatments.
Moderate and high-quality RCTs indicate soft tissue mobilization
is an effective modality for treating plantar heel pain. Outcomes
of joint mobilizations are controversial.
Pollack Y, Shashua A, Kalichman L. Manual therapy for plantar heel
pain. Foot (Edinb). 2018;34:11-16. doi:10.1016/j.foot.2017.08.001
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Breast Cancer Care
Clar C, Tsertsvadze A, Court R.
et al.
Clinical effectiveness of
manual therapy for the management of musculoskeletal and non-
musculoskeletal conditions: systematic review and update of UK
evidence report. Chiropr Man Therap 22, 12 (2014). https://doi.
org/10.1186/2045-709X-22-12
Ezzo J, Manheimer E, McNeely ML,
et al.
Manual lymphatic
drainage for lymphedema following breast cancer treatment.
2015. Cochrane Database of Systematic Reviews. https://doi.
org/10.1002/14651858.CD003475.pub2
Moderate (positive) evidence for the effectiveness of massage
techniques involving manual therapy elements in breast cancer
survivors and terminal cancer patients for range of movement
and function of the arm.
When women were treated with a course of intensive
compression bandaging, their swelling went down about 30% to
37%. When manual lymphatic drainage (MLD) was added to the
intensive course of compression bandaging, their swelling went
down another 7.11%. Thus, MLD may offer benefit when added
to compression bandaging. Examining this finding more closely
showed that this significant reduction benefit was observed in
people with mild-to-moderate lymphedema when compared to
participants with moderate-to-severe lymphedema. Thus, our
findings suggest that individuals with mild-to-moderate BCRL
are the ones who may benefit from adding MLD to an intensive
course of treatment with compression bandaging.
Adverse Events
Carnes D, Mars T, Mullinger B, Froud R, Underwood M. Adverse
events and manual therapy: a systematic review. Manual Therapy.
2010; 15(4):355-63.
Eight prospective cohort studies and 31 manual therapy RCTs
were accepted. The incidence estimate of proportions for minor
or moderate transient adverse events after manual therapy
was approximately 41% (CI 95% 17-68%) in the cohort studies
and 22% (CI 95% 11.1-36.2%) in the RCTs; for major adverse
events approximately 0.13%. The pooled relative risk (RR) for
experiencing adverse events with exercise, or with sham/passive/
control interventions compared to manual therapy was similar,
but for drug therapies greater (RR 0.05, CI 95% 0.01-0.20) and
less with usual care (RR 1.91, CI 95% 1.39-2.64).
Mild-to-moderate adverse events of transient nature (e.g.,
worsening symptoms, increased pain, soreness, headache,
dizziness, tiredness, nausea, vomiting) were relatively frequent.
Evidence from high, medium, and low-quality systematic
reviews specifically focusing on adverse events suggested that
approximately half of the individuals receiving manual therapy
experienced mild-to-moderate adverse event which had
resolved within 24–74 hours. Evidence indicated that serious
(or major) adverse events after manual therapy were very rare
(e.g., cerebrovascular events, disc herniation, vertebral artery
dissection, cauda equine syndrome, stroke, dislocation, fracture,
transient ischemic attack). Evidence on safety of manual therapies
in children or pediatric populations was scarce; the findings from
two low quality cohort studies and one survey were consistent
with those for adults that transient mild to moderate intensity
adverse events in manual treatment were common compared to
more serious or major adverse events which were very rare.
Severe harms were relatively scarce, poorly described and likely
to be associated with underlying missed pathology. Gentle,
low-velocity spinal mobilizations seem to be a safe treatment
technique in infants, children, and adolescents.
Clar C, Tsertsvadze A, Court, R.
et al.
Clinical effectiveness of
manual therapy for the management of musculoskeletal and non-
musculoskeletal conditions: systematic review and update of UK
evidence report. Chiropr Man Therap 22, 12 (2014). https://doi.
org/10.1186/2045-709X-22-12
Driehuis F, Hoogeboom TJ, Nijhuis-van der Sanden MWG,
de Bie RA, Staal JB. Spinal manual therapy in infants, children
and adolescents: A systematic review and meta-analysis on
treatment indication, technique and outcomes. PLoS One.
2019;14(6):e0218940. Published 2019 Jun 25. doi:10.1371/journal.
pone.0218940
Paige NM, Miake-Lye IM, Booth MS,
et al.
Association of Spinal
Manipulative Therapy With Clinical Benefit and Harm for Acute
Low Back Pain: Systematic Review and Meta-analysis JAMA.
2017;317(14):1451-1460. doi:10.1001/jama.2017.3086
Minor transient adverse events such as increased pain, muscle
stiffness, and headache were reported in more than half of
patients in the large case series. Meaning: Among patients with
acute low back pain, spinal manipulative therapy was associated
with modest improvements in pain and function and with
transient minor musculoskeletal harms.
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Rubinstein S, de Zoete A, van Middelkoop M,
Assendelft WJJ, de Boer MR, van Tulder MW. Benefits and harms
of spinal manipulative therapy for the treatment of chronic low
back pain: systematic review and meta-analysis of randomized
controlled trials. BMJ. 2019; 364: l689. doi: 10.1136/bmj.l689
Cost Effectiveness
Furlan AD,Yazdi F, Tsertsvadze A,
et al.
A systematic review and
meta-analysis of efficacy, cost-effectiveness, and safety of selected
complementary and alternative medicine for neck and low-back
pain. Evid Based Complement Alternat Med. 2012;2012:953139.
doi:10.1155/2012/953139
Low risk of adverse events
The reported events in RCTs were mostly moderate in severity
and of transient nature (e.g., increased pain). In one RCT,
after 2 weeks of treatment, patients with neck pain receiving
manipulation were not at significantly increased risk for having
an adverse event compared to patients receiving mobilization
(OR = 1.44, 95% CI: 0.83, 2.49). In another RCT, the proportion
of patients with neck pain having adverse events was similar in
manipulation versus Diazepam groups (9.5% versus 11.1%).
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Osteopathic International Alliance
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Chicago, IL 60611 USA
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