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Alex Evans BSc(Hons) Osteopathic Practitioner

Downtown Osteopathy, Vancouver
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World Health Organisation Benchmarks for Training in Osteopathy

The World Health Organisation has just released its benchmark in training in osteopathy document. This document is important for osteopathy in BC as it defines what an acceptable level of education in osteopathy is, as defined by a panel of world experts.

This document will help patients find osteopathic practitioners who have achieved a level of qualification suitable to practice osteopathy. This is important in BC as many different practitioners are claiming to offer osteopathy but are not qualified to do so by WHO standards. The Society for the Promotion of Manual Practicing Osteopathy (SPMPO) in BC applies these standards of education for membership.

The training I received at the British School of Osteopathy in London would meet these standards. The document does not address the issue of training for osteopathic physicians in the US which is unfortunate as this would serve to unify the profession more internationally.

I have reproduced and highlighted relevant parts of the document for my website to help my patients get a greater understanding of osteopathy and osteopathic training.

Benchmarks for Training in Osteopathy


Osteopathy was developed by Andrew Taylor Still, a physician and surgeon in the United States of America in the mid-1800s, who established the first independent school of osteopathy in 1892 (1,2).

Osteopathy (also called osteopathic medicine) relies on manual contact for diagnosis and treatment (3). It respects the relationship of body, mind and spirit in health and disease; it lays emphasis on the structural and functional integrity of the body and the body's intrinsic tendency for self-healing.

Osteopathic practitioners use a wide variety of therapeutic manual techniques to improve physiological function and/or support homeostasis that has been altered by somatic (body framework) dysfunction, i.e. impaired or altered function of related components of the somatic system; skeletal, arthrodial and myofascial structures; and related vascular, lymphatic, and neural elements (4).

Osteopathic practitioners use their understanding of the relationship between structure and function to optimize the body’s self-regulating, self-healing capabilities. This holistic approach to patient care and healing is based on the concept that a human being is a dynamic functional unit, in which all parts are interrelated and which possesses its own self-regulatory and self-healing mechanisms. One essential component of osteopathic health care is osteopathic manual therapy, typically called osteopathic manipulative treatment (OMT), which refers to an array of manipulative techniques that may be combined with other treatments or advice, for example on diet, physical activity and posture, or counseling. The practice of osteopathy is distinct from other health-care professions that utilize manual techniques, such as physiotherapy or chiropractic, despite some overlap in the techniques and interventions employed. As a hands on approach to patient care, osteopathy has contributed to the body of knowledge of manual therapies and complementary and alternative medicine.

Osteopathy is practiced in many countries throughout the world.In some countries, manual therapists use osteopathic techniques and claim to provide osteopathic treatment, although they may not have received proper training.  This document presents what the community of practitioners, experts and regulators of osteopathy considers to be adequate levels and models for training osteopathic practitioners, as well as for dispensers and distributors. It provides training benchmarks for trainees with different backgrounds, as well as what the community of practitioners of osteopathy considers being contraindications for safe practice of osteopathy and for minimizing the risk of accidents. Together, these can serve as a reference for national authorities wishing to establish systems of training, examination and licensure that support the qualified practice of osteopathy.

 
1. The basic principles of osteopathy

1.1 Philosophy and characteristics of osteopathy


Osteopathy provides a broad range of approaches in the maintenance of health and the management of disease. Osteopathy is grounded in the following principles for treatment and patient management:

  •     the human being is a dynamic functional unit, whose state of health is influenced by the body, mind and spirit;
  •     the body possesses self-regulatory mechanisms and is naturally self healing;
  •     structure and function are interrelated at all levels of the human body.

Within that framework, osteopathic practitioners incorporate current medical and scientific knowledge when applying osteopathic principles to patient care.

Osteopathic practitioners recognize that each patient’s clinical signs and symptoms are the consequences of the interaction of many physical and nonphysical factors. It emphasizes the dynamic interrelatedness of these factors and the importance of the patient-practitioner relationship in the therapeutic process. It is a patient–centred, rather than disease-centred, form of health care.

Structural diagnosis and osteopathic manipulative treatment are essential components of osteopathy. Osteopathic manipulative treatment was developed as a means of facilitating normal self-regulating/self-healing mechanisms in the body by addressing areas of tissue strain, stress or dysfunction that may impede normal neural, vascular and biochemical mechanisms.

The practical application of this approach is based on several structure-function relationship models described below. Osteopathic practitioners use these to gather and structure diagnostic information and to interpret the significance of neuromusculoskeletal findings for the overall health of the patient. Osteopathy is thus not limited to the diagnosis and treatment of musculoskeletal problems, nor does it emphasize joint alignment and radiographic evidence of structural relationships. Osteopathy is more concerned with the manner in which the biomechanics of the musculoskeletal system are integrated with and support the entire body physiology.

Although manual techniques are used by various manipulative therapy professions, the unique manner in which osteopathic manipulative techniques are integrated into patient management, as well as the duration, frequency and choice of technique, are distinctive aspects of osteopathy. Osteopathic manipulative treatment employs many types of manipulative techniques, including spinal thrust and impulse techniques, as well as gentle techniques (1).

1.2 Structure-function relationship models


Five main models of structure-function relationships guide the osteopathic practitioner's approach to diagnosis and treatment. These models are usually used in combination to provide a framework for interpreting the significance of somatic dysfunction within the context of objective and subjective clinical information. The combination chosen is adapted to the patient’s differential diagnosis, co-morbidities, other therapeutic regimens and response to treatment.

1.2.1 The biomechanical structure-function model


The biomechanical model views the body as an integration of somatic components that relate as a mechanism for posture and balance. Stresses or imbalances within this mechanism may affect dynamic function, increase energy expenditure, alter proprioception (one's sense of the relative position and movement of neighbouring parts of the body), change joint structure, impede neurovascular function and alter metabolism (5-7). This model applies therapeutic approaches, including osteopathic manipulative techniques, which allow for the restoration of posture and balance and efficient use of musculoskeletal components.

1.2.2 The respiratory/circulatory structure-function model


The respiratory/circulatory model concerns itself with the maintenance of extracellular and intracellular environments through the unimpeded delivery of oxygen and nutrients, and the removal of cellular waste products. Tissue stress or other factors interfering with the flow or circulation of any body fluid can affect tissue health (8). This model applies therapeutic approaches, including osteopathic manipulative techniques, to address dysfunction in respiratory mechanics, circulation and the flow of body fluids.

1.2.3 The neurological structure-function model

The neurological model considers the influence of spinal facilitation, proprioceptive function, the autonomic nervous system and activity of nociceptors (pain fibres) on the function of the neuroendocrine immune network (9-15). Of particular importance is the relationship between the somatic and visceral (autonomic) systems. This model applies therapeutic approaches, including osteopathic manipulative techniques, to reduce mechanical stresses, balance neural inputs and reduce or eliminate nociceptive drive.

1.2.4 The biopsychosocial structure-function model


The biopsychosocial model recognizes the various reactions and psychological stresses which can affect patients' health and well-being. These include environmental, socioeconomic, cultural, physiological and psychological factors that influence disease. This model applies therapeutic approaches, including osteopathic manipulative techniques, to address the effects of, and reactions to, various biopsychosocial stresses.

1.2.5 The bioenergetic structure-function model


The bioenergetic model recognizes that the body seeks to maintain a balance between energy production, distribution and expenditure. Maintaining this balance aids the body in its ability to adapt to various stressors (immunological, nutritional, psychological, etc.). This model applies therapeutic approaches, including osteopathic manipulative techniques, to address factors which have the potential to deregulate the production, distribution or expenditure of energy (6,7,16).

2.1 Categories of training programmes


Regulating the practice of osteopathy and preventing practice by unqualified practitioners requires a proper system of training, examination and licensing.

Experts in osteopathy distinguish two types of training depending on prior training and clinical experience of trainees.

Type I training programmes are aimed at those with little or no prior health-care training, but who have completed high school education or equivalent. These programmes typically are four-year, full-time programmes. Supervised clinical training at an appropriate osteopathic clinical facility is an essential component, and students may be required to complete a thesis or project. (I completed this type of pathway at the British School of Osteopathy, a four year BSc(Hons) degree in Osteopathy).

Type II training programmes are aimed at those with prior training as health-care professionals. Type II programmes have the same aims and content as the Type I programmes, but the course content and length may be modified depending on the prior experience and training of individual applicants. In some cases, the development of a Type II programme may be a temporary step pending the development of Type I programmes in osteopathy.

Experts in osteopathy consider that acquiring appropriate mastery of osteopathy to be able to practise as primary-contact health-care professionals, independently or as members of a health-care team in various settings, requires time.

A typical Type I programme would take 4200 hours, including at least 1000 hours of supervised clinical practice and training. Osteopathic skills and physical examination training must be delivered via direct contact. Other academic curricular content may be delivered by various staff and in various training formats. Training may be full-time, part-time or a combination of the two.

While training of the osteopathy focuses on those subjects and skills that form the basis for the osteopathic approach, basic knowledge and understanding of the common allopathic medical treatments available to patients are necessary for competent practice as a primary-contact health-care practitioner. In addition, the osteopathic practitioner must also understand the rationale behind common standard treatment protocols; how the body responds to these treatments; and how the protocols may influence the selection and implementation of osteopathic treatment.

2.2 Core competencies

Osteopathic practitioners share a set of core competencies that guide them in the diagnosis, management and treatment of their patients and form the foundation for the osteopathic approach to health care. The following are essential competencies for osteopathic practice in all training programmes:

  •     a strong foundation in osteopathic history, philosophy, and approach to health care;
  •     an understanding of the basic sciences within the context of the philosophy of osteopathy and the five models of structure-function. Specifically, this should include the role of vascular, neurological, lymphatic and biomechanical factors in the maintenance of normal and adaptive biochemical, cellular and gross anatomical functions in states of health and disease;
  •     ability to form an appropriate differential diagnosis and treatment plan;
  •     an understanding of the mechanisms of action of manual therapeutic interventions and the biochemical, cellular and gross anatomical response to therapy;
  •     ability to appraise medical and scientific literature critically and incorporate relevant information into clinical practice;
  •     competency in the palpatory and clinical skills necessary to diagnose dysfunction in the aforementioned systems and tissues of the body, with an emphasis on osteopathic diagnosis;
  •     competency in a broad range of skills of OMT;
  •     proficiency in physical examination and the interpretation of relevant tests and data, including diagnostic imaging and laboratory results;
  •     an understanding of the biomechanics of the human body including, but not limited to, the articular, fascial, muscular and fluid systems of the extremities, spine, head, pelvis, abdomen and torso;
  •     expertise in the diagnosis and OMT of neuromusculoskeletal disorders;
  •     thorough knowledge of the indications for, and contraindications to, osteopathic treatment;
  •     a basic knowledge of commonly used traditional medicine and complementary/ alternative medicine techniques.

2.3 Benchmark training curriculum for osteopathy

Basic science

  •     history and philosophy of science;
  •     gross and functional anatomy, including basic embryology, neuroanatomy and visceral anatomy;
  •     fundamental bacteriology, fundamental biochemistry, fundamental cellular physiology;
  •     physiology with special emphasis on the neuroendocrine immune network, the autonomic nervous system, the arterial, lymphatic and venous systems and the musculoskeletal system;
  •     biomechanics and kinetics.

Clinical science

  •     models of health and disease;
  •     safety and ethics;
  •     basic pathology and pathophysiology of the nervous, musculoskeletal, psychiatric, cardiovascular, pulmonary, gastrointestinal, reproductive, genitor-urinary, immunological, endocrine and otolaryngology systems;
  •     basic orthopaedic diagnosis;
  •     basic radiology;
  •     nutrition;
  •     basic emergency care.

Osteopathic science

  •     philosophy and history of osteopathy;
  •     osteopathic models for structure/function interrelationships;
  •     clinical biomechanics, joint physiology and kinetics;
  •     mechanisms of action for osteopathic techniques.
 
Practical skills

  •     obtaining and using an age-appropriate history;
  •     physical and clinical examination;
  •     osteopathic diagnosis and differential diagnosis of the nervous, musculoskeletal, psychiatric, cardiovascular, pulmonary, gastrointestinal, endocrine, genitor-urinary, immunological, reproductive and otolaryngology systems;
  •     general synthesis of basic laboratory and imaging data;
  •     clinical problem-solving and reasoning;
  •     understanding of relevant research and its integration into practice;
  •     communication and interviewing;
  •     clinical documentation;
  •     basic life-support and first-aid care.

Osteopathic skills

  •     osteopathic diagnosis;
  •     osteopathic techniques, including direct techniques such as thrust, articulatory, muscle energy and general osteopathic techniques;
  •     indirect techniques, including functional techniques and counterstrain;
  •     balancing techniques, such as balanced ligamentous tension and ligamentous articulatory strain;
  •     combined techniques, including myofascial/fascial release, Still technique, osteopathy in the cranial field, involuntary mechanism and visceral techniques;
  •     reflex-based techniques, such as Chapman’s reflexes, trigger points and neuromuscular techniques;
  •     fluid-based techniques, such as lymphatic pump techniques (1).

Practical supervised clinical experience

Osteopathic manipulative treatment is a distinctive component of osteopathy. It requires both cognitive and sensory motor skills, and knowledge, and the development of these clinical and manual skills requires time and practice. Supervised clinical practice is an essential component of the training of osteopathic practitioners and should take place in an appropriate osteopathic clinical environment so that high-quality clinical support and teaching can be provided. This will include a minimum of 1000 hours of supervised clinical practice.

3. Safety issues

Osteopathic practitioners have a responsibility to diagnose and refer patients as appropriate when the patient’s condition requires therapeutic intervention that falls outside the practitioner's competence. It is also necessary to recognize when specific approaches and techniques may be contraindicated in specific conditions.

Osteopathic practitioners consider that a contraindication to OMT in one area of the body does not preclude osteopathic treatment in a different area. Likewise, a contraindication for any specific technique does not negate the appropriateness of a different type of technique in the same patient. Absolute and relative contraindications for OMT are often based upon the technique employed in each particular clinical situation.

The contraindications identified by the community of osteopathic practitioners are regrouped in function of the osteopathic techniques considered: these can be direct, indirect, combined, fluid and/or reflex-based (1). Direct techniques, such as muscle energy, thrust and articulatory manoeuvres, pose different risks from indirect, fluid and reflex-based techniques. There is only little published evidence on which techniques should be avoided in specific conditions. Osteopathic practitioners use their understanding of the pathophysiology of the patient’s condition and the mechanism of action of the technique to establish absolute and relative contraindications that are biologically plausible.

References
1. Gevitz N. The DOs: Osteopathic Medicine in America, 2nd ed. Baltimore, Johns Hopkins University Press, 2004.
2. Trowbridge C. Andrew Taylor Still 1828-1917, 1st ed. Kirksville, MO: the Thomas Jefferson University Press, 1991.
3. World Osteopathic Health Organization. Osteopathic glossary. (www.woho.org, accessed 19 April 2008).
4. American Association of Colleges of Osteopathic Medicine. Glossary of Osteopathic Terminology. (http://www.aacom.org, revised 2002).
5. Hruby RJ. Pathophysiologic models: aids to the selection of manipulative techniques. American Academy of Osteopathy Journal, 1991, 1(3):8-10.
6. Rimmer KP, Ford GT, Whitelaw WA. Interaction between postural and respiratory control of human intercostal muscles. Journal of Applied Physiology, 1995, 79(5):1556-1561.
7. Norré ME. Head extension effect in static posturography. Annals of Otology, Rhinology, and Laryngology, 1995, 104(7):570-573.
8. Degenhardt BF, Kuchera ML. Update on osteopathic medical concepts and the lymphatic system. Journal of the American Osteopathic Association, 1996,
96(2):97-100.
9. Donnerer J. Nociception and the neuroendocrine-immune system. In: Willard FH, Patterson M, eds. Nociception and the neuroendocrine-immune
connection: Proceedings of the 1992 American Academy of Osteopathy International Symposium. Indianapolis, American Academy of Osteopathy, 1992:260-273.
10. Emrich HM, Millan MJ. Stress reactions and endorphinergic systems. Journal of Psychosomatic Research, 1982, 26(2):101-104.
11. Ganong W. The stress response - a dynamic overview. Hospital Practice, 1988, 23(6):155-158, 161-162, 167.
12. Kiecolt-Glaser JK, Glaser R. Stress and immune function in humans. In: Ader R, Felton DL, Cohen N, eds. Psychoneuroimmunology, 2nd ed. San Diego, CA,
Academic Press, 1991:849-895.
13. McEwen BS. Glucocorticoid-biogenic amine interactions in relation to mood and behavior. Biochemical Pharmacology, 1987, 36(11):1755-1763.
14. Van Buskirk RL. Nociceptive reflexes and the somatic dysfunction: a model. Journal of the American Osteopathic Association, 1990, 90(9):792-794, 797-809.
15. Willard FH, Mokler DJ, Morgane PJ. Neuroendocrine-immune system and homeostasis. In: Ward RC, ed. Foundations for osteopathic medicine, 1st ed.
Baltimore, Williams and Wilkins, 1997:107-135.
16. Winter DA et al. Biomechanical walking pattern changes in the fit and healthy elderly. Physical Therapy, 1990, 70(6):340-347.