1. Director: National Council for Osteopathic Research
Prof. Dr. Dawn Carnes
Director: National Council for Osteopathic Research
Research consultant HEdS-Fribourg
To advance, facilitate and disseminate osteopathic and osteopathic relevant research, in order to promote practice that optimises patient care.

2. Presentation
I) Background: What is osteopathy ?
II) Evidence relevant to osteopathic practice and care
III) Other information and the future

3. I) Background Frequently asked questions: What is osteopathy?
Is osteopathy is safe?
Is osteopathy effective?

4. I) Background
What is osteopathy? Osteopathy is a form of manual therapy, it is a multi-component complex intervention using a variety of techniques and methods to optimise patient function, health, self-management and well-being. It is mainly delivered in the primary care health sector. (other definitions exist but there is no one accepted definition)

5. I) Background Osteopathic International Alliance Global Report (2013)
The profession:
2 types: osteopathic physicians (USA) and osteopathic practitioners
Osteopathic healthcare is now provided in every continent except
Antarctica and is practised in more than 50 countries.
43,000 osteopathic practitioners worldwide, the majority in France, Germany, Italy, UK, Australia, Belgium and Canada (38,000)
Osteopaths work mainly in private practice in primary care

6. I) Background Osteopathic International Alliance Global Report 2013
The patients:
33% of patients were between 31 and 50 years old, 23.4% were aged 18 and younger (8.7% are below the age of 2 years)
Patients seek help for pain both acute and chronic conditions
Low back pain most common complaint
Most patients self-refer and are self-funded

7. I) Background Osteopathic International Alliance Global Report 2012
Education:
Osteopathic education programmes exist in more than 25 countries.
Most offer a Master’s level qualification over 4-5 years (Australia moving back to BSc).
EU standards exist for minimum levels of training
(CEN 2015 Osteopathic healthcare provision)

8. I) Background Core curriculae include: Anatomy and physiology
Biochemistry and pharmacology
Biomechanics and exercise
Histology and embryology
Pathohysiology
Psychology, communication and self-managment
Clinical Research and Critical thinking and appraisal
Public health and epidemiology
Practical skills: Case history taking, Screening and Examination, Differential diagnosis, Treatment
1000 hours of clinical experience
(NHS and Health Education England - MSK core capabilities framework 2018)

9. I) Background Regulation:
Regulators role to: protect patients, uphold standards of practice, ensure quality of the education and training of osteopaths
Protected title
Statutory recognition in many countries
Osteopathic Practice Standards exist primarily for regulation
Health care delivery general standards apply
Fitness to Practice and Professional Conduct Committees
Key competencies to practice evaluated by osteopathic education institutions and awarding bodies

10. II) EVIDENCE Frequently asked questions: What is osteopathy?
Is osteopathy is safe?
Is osteopathy effective?
Questions are so huge, hard to answer.
For example:
Which part of osteopathic care is effective for whom, when and for what conditions ?
Bit like asking: is Brexit a good idea ?

11. II) EVIDENCE: Is it safe?
Systematic review:
Carnes D, Mars T, Mullinger B, Froud R, Underwood M.
Adverse events and manual therapy: a systematic review.
Manual Therapy Aug 2010; 15 (4):
8 prospective cohort studies showing fairly consistent findings for manual therapy and manipulation
RCT safety
Surveys
Concerns and complaints data

12. Sources of information
Carnes D. Analysis of insurance and complaints data UK
library/research-and-surveys/types-of-concerns-raised-about-osteopaths-and- services/
Carnes D, Mars T, Mullinger B, Froud R, Underwood M. Adverse events and manual therapy: a systematic review. Manual Therapy Aug 2010; 15 (4):
S.Vogel, T.Mars, S.Keeping, T.Barton, N.Marlin, R.Froud, S.Eldridge, M.Underwood, T. Pincus. Clinical Risk Osteopathy and Management Scientific Report: The CROAM study (2013).
and-surveys/the-croam-study-february-2013/

13. II) EVIDENCE: Is it safe ?
Minor adverse events common after the first treatment ~35-45% of patients, most resolve with 48, even more at 72 hours (over 90%)
Serious adverse events very rare:
<1 per 100,000 manipulation
1 per 50,000 – 100, 000 consultations
Adverse events more likely with cervical and lumbar manœuvres, in females and first time patients
VBI patients are more likely to seek clinical care prior to an incident
Most concerns and complaints revolve around poor communication

14. II) Effectiveness Osteopathic relevant research for: manual techniques
specific conditions (eg NSLBP, fibromyalgia)
patient practioner relations, shared decision making
orthopeadic / palpatory / diagnostic tests - reliability and validity
psychology of care and self-management
exercise advice and adherence
public / general health messages and advice

15. II) Effectiveness Low back pain
I Bernstein et al. Low back pain and sciatica: summary of NICE guidance
BMJ 2017; 356 doi:
Manual therapy recommended as part of a package of care that includes exercise and psychological support
(Manual therapists = osteopaths, chiropractors and physiotherapists)

16. II) Effectiveness General Evidence reviews:
A. Steel et al. Osteopathic manipulative treatment: A systematic review and critical appraisal of comparative effectiveness and health economics research. Musculoskeletal Science and Practice (2017) 27:
16 studies included for comparative effectiveness (n = 9) and economic evaluation (n = 7)
Some positive findings for low back and neck pain and preterm neonate recovery (length of hospital stay)
Studies need to be replicated in different settings and jurisdictions to verify current findings
Insufficient quantity and quality of comparative effectiveness and cost effectiveness research for policy decision making.

17. II) Effectiveness General Evidence reviews:
C. Clar et al. Clinical effectiveness of manual therapy for the management of musculoskeletal and non-musculoskeletal conditions: systematic review and update of UK evidence report. Chiropractic & Manual Therapies 2014, 22:12
Moderate positive/favourable evidence of effectiveness for:
Spinal and or thoracic manipulation and mobilisation for acute, sub-acute and chronic low back pain and neck pain
Manipulation and exercise for rotator cuff disorder;
Spinal manipulation and or mobilisation for cervicogenic headache, migraine and miscellaneous headache
Manipulation/mobilisation for several extremity joint conditions (carpal tunnel ankle sprains, plantar fasciitis)
Massage including myofascial release/strain/counterstrain for cancer care

18. II) Effectiveness
Clar et al 2014 continued: Inconclusive evidence of effectiveness for:
Osteopathic manual therapy for asthma
Spinal manipulation for paediatric nocturnal enuresis
Spinal manipulation for premenstrual syndrome
Cervical spinal manipulation for Stage 1 hypertension
Osteopathic manual therapy for Otitis media
Osteopathic manual therapy for pneumonia in elderly adults
Manipulation and mobilisation dysmenorrhoea, fibromyalgia, myofascial pain syndrome
Manipulation and mobilisation for mid back pain, sciatica, coccydynia, temporomandibular joint disorders, knee osteoarthritis

19. II) Effectiveness: Projects
PROMS – online national data collection project asking patients about the outcomes of their treatment Provision of an evidence for the profession (only as good as the input, need lots of data, lots of engagement): - We ask about the patient (for profiling our client base) - We ask how they do after treatment and how satisfied they are

20. National PROMS Database
(Unpublished data, study ongoing. N=~2000 patient datasets)
Reported global change after 1 week
8% reported being completely recovered,
55% reported being much improved,
26% reported being slightly improved, and
11% reported no change.
Reported global change after 6 weeks
78% of patients reported being completely recovered or reported being much improved,
15% reported being slightly improved, and
7% reported no change.

21. National PROMS Database
(Unpublished data, study ongoing. N=~2000 patient datasets)
Reported levels of satisfaction
91% reported their care as being very good,
8% as being fairly good,
1% as being neither good nor poor, and
1% as being fairly poor.

22. II) Effectiveness- Paediatric care
Evidence base - Paediatric care under scrutiny:
Carnes D, Plunkett A, Ellwood J, Miles C. Effectiveness of manual therapy for distressed, unsettled and excessively crying infants: a systematic review and meta-analyses. BMJ Open: 2017: 8(1)
Showed benefit of manual therapy for reduced crying time (of 1.27 hours per 24 hours) of for distressed unsettled and excessively crying infants
VERY limited evidence for effectiveness of osteopathic care for paediatric conditions (except for pre-term infants in hospital care setting)

23. III) Other info Spare capacity room for growth
UK ~8 osteopaths per 100’000 residents
France: ~30 osteopaths per 100’000 residents
Switzerland overall: ~16 osteopaths per 100’000 residents

24. III) Other info
Shortage of osteopaths in the future considering age profile
Should the profession wish to maintain its ‘market’ presence it may need to consider training more osteopaths
Attrition rates: osteopaths will be retiring over the next 5 years, plus others will leave the profession and or take career breaks and work part-time
Gender shift towards more female osteopaths (data indicates that women see 30% less patients than men)
Population growth

25. III) Other info Potential education and training gaps ?
Population aging profile but little training in the care of older people given
1 in 4 infants are taken to see an osteopath but there is little advanced practice training in this area
Increasing evidence for psychological, behaviour change and self- management interventions for long-term conditions, osteoapths are well placed to give this care but little training available
Increasing evidence for exercise interventions, osteopaths are well placed to give this care but little training available

26. III) Other info
Multidisciplinary care, multi-skilled practitioners and integrated care pathways
Osteopaths treat a range of conditions (not all musculoskeletal) using multiple types of interventions
Patient profile varied but nearly all treatment given in primary care, Can this role be expanded, for example include with primary care physician associate role with a musculoskeletal orientation ?

27. III) Future Role of osteopaths in the future health care arena:
Aging population
Increase in long term conditions
Reduction in GPs
10-20% of GP consultations are musculo-skeletal related
Plugging the gap in primary care health service provision a societal priority