Osteopathy: effectiveness and safety for musculoskeletal pain and overview of training and quality requirements

Research area: Rehabilitation and occupational therapy

Duration: April 2022 – November 2022
Language: English with German summary

Publication: HTA Project Report No. 144: https://eprints.aihta.at/1416

Background: Osteopathy is based on the concept that the body is an integrated whole. It is used to prevent, diagnose, and treat diseases and injuries (e.g., inner organs, musculoskeletal, nervous, and circulatory systems) [1]. Osteopathy is a patient-centred primary health care discipline developed in the United States and brought to Europe in the early 1990s [2, 3]. Osteopathic treatment can be preventive, curative, palliative or adjuvant, and osteopathic, medical, and scientific knowledge is used for practice [3]. According to the World Health Organization (WHO), osteopathy relies on manual contact for diagnosis and disease treatment [4]. It involves analysing and evaluating the structural and functional integrity of the body. The aim is to improve and support all aspects of health holistically [3].

A common medical indication of osteopathy is pain in the musculoskeletal system, such as neck pain or rheumatism. Chronic pain, in particular, is considered one of the most prevalent and complex problems faced by health professionals. Pain can have a negative impact on the psychological and social well-being of those affected [5].

The recognition and regulation of the practice of osteopathy vary widely from country to country [4]. In Austria, osteopathy is currently not a social insurance benefit, but the supply and demand are steadily increasing.

Aim of the project and research questions (RQ): The project's objective is to provide decision support for the reimbursement of osteopathy. The project aims

• to summarise the evidence on the effectiveness and safety of osteopathy in treating musculoskeletal pain (part 1) and
• to provide an overview of the training and quality requirements and regulation of the osteopathic profession in Europe (part 2).

The following research questions will be answered:

• RQ1: How effective and safe is osteopathy compared to no therapy or alternative therapy (e.g., sham therapy, physiotherapy, massage) in treating musculoskeletal pain in adults?
• RQ2: What are the current training and quality requirements for osteopaths in Europe? Who is allowed to offer osteopathy, and what qualifications do osteopaths need?

Methods: The following methods are used to answer the two research questions:

RQ1: Results on the evidence of efficacy and safety of osteopathy for pain of the musculoskeletal system

• For the localisation of 'low back pain': presentation and description of the systematic review and meta-analysis by Dal Farra et al. 2021 [6]
• For all other localisations: systematic search for RCTs (e.g. in Embase, MEDLINE, Cochrane Library, PEDro)
• Quality assessment of RCTs using the Cochrane Collaboration's Risk of Bias (RoB) Tool
• Clustering of evidence according to a) localisation of pain, b) acute vs chronic and data extraction
• Synthesis

Inclusion criteria for RQ1:

Description	Project scope
Population	Adults (male, female; over 18 years) with musculoskeletal pain in various locations Inclusion: e.g., musculoskeletal pain (neck/cervical pain, shoulder/pelvic pain etc.), rheumatic conditions of the musculoskeletal system (ankylosing spondylitis, fibromyalgia etc.), postoperative pain, chronic/persistent pain Exclusion: neurological pain (e.g., migraine)
Intervention	Osteopathy – alone or in addition to other interventions Inclusion: craniosacral therapy, osteopathic manipulative treatment/medicine, cranial osteopathy, myofascial release, osteopathic visceral manipulation Exclusion: manual therapy, chiropractic, spinal manipulative therapy / spinal manipulation[1], electrotherapy treatment[2]
Control	Standard of care and no osteopathy (e.g., waiting list, no care, sham treatment, massage, physiotherapy, conservative therapy, other non-surgical treatment, pharmacological treatment) Exclusion: surgical treatment
Outcomes	Effectiveness: Pain relief Symptom improvement or recovery Functional status Quality of life Accompanying symptoms of pain (e.g., dizziness, visual disturbances, tinnitus, numbness, tingling, paralysis) Return to work / absence from work Safety: Adverse events Side effects
Study design Publication period Languages	RCTs until May 2022 English, German

RQ2: Overview of current training and quality requirements for osteopaths in Europe

• Targeted hand search for training and quality requirements for osteopaths in selected countries (e.g. in PubMed, Google Scholar, TRIP Database, osteopathic institutions)
• If applicable, contact experts to further identify and complete the country's information
• Tabular presentation, synthesis and description of the identified training and quality requirements at a country level within Europe

Inclusion criteria for RQ2:

Description	Project scope
Interest	Regulation of the osteopathic profession in Europe
Countries	Selected European countries (e.g., Germany, Switzerland)
Categories of interest	Regulation: e.g., osteopathy located in primary health care, protected title ‚osteopath', existing national associations of osteopathy, available official documents related to regulation Education: e.g., education level required to practise, type of education offered Practice of osteopathy: e.g., reimbursement, private practice, restrictions to practise
Study design Language	Any kind of publication (e.g., evaluation reports, curricula, educational/study programmes) English, German

The workflow is organised according to the principle of dual control (LG, VH), and the results are subject to an internal and external review.

Schedule and milestones:

Time period	Task
April 2022	Scoping, finalising the project protocol
May 2022	Writing the background chapter, systematic search in several databases, targeted hand search RQ2, contacting experts on RQ2 if applicable, selection of literature for RQ1 + RQ2
June 2022	RoB assessment and control, data extraction RQ1 + RQ2 and control
July/August 2022	Writing the methods chapter, writing results on RQ1 + RQ2
September 2022	Writing the discussion of the overall report, internal review
October 2022	Writing the summary, external review
November 2022	Publication

References:

[1]     Osteopathic International Alliance. Global review of osteopathic medicine and osteopathy. 2020 [cited 26.04.2022]. Available from: https://oialliance.org/the-oia-global-report-global-review-of-osteopathic-medicine-and-osteopathy-2020/.

[2]     J. Ellwood and D. Carnes. An international profile of the practice of osteopaths: A systematic review of surveys. International Journal of Osteopathic Medicine. 2021;40:14-21.

[3]     European Federation and Forum for Osteopathy. Regulation of the Osteopathic Profession in Europe. An Overview. 2021 [cited 26.04.22]. Available from: https://www.effo.eu/regulation-in-europe/.

[4]     World Health Organization. Benchmarks for training in traditional / complementary and alternative medicine. World Health Organization. 2010 [cited 27.04.2022]. Available from: https://apps.who.int/iris/handle/10665/44356.

[5]     M. Saracutu, J. Rance, H. Davies and D. J. Edwards. The effects of osteopathic treatment on psychosocial factors in people with persistent pain: a systematic review. International Journal of Osteopathic Medicine. 2018;27:23-33.

[6]     F. Dal Farra, R. G. Risio, L. Vismara and A. Bergna. Effectiveness of osteopathic interventions in chronic non-specific low back pain: A systematic review and meta-analysis. Complementary Therapies in Medicine. 2021;56:102616.