The scope of practice of osteopathic practitioners varies by country. In general, osteopaths trained outside of the U.S. are not physicians, and are limited in practice to non-invasive manual therapies,* and may provide nutritional, postural, and other health advice. Conversely, U.S. trained osteopathic physicians practice the entire scope of modern medicine. To avoid confusion, the American Osteopathic Association recommends using the terms Doctor of Osteopathic Medicine|osteopathic physician (U.S.-trained only) and osteopathic medicine to distinguish individuals trained in osteopathic medicine in the United States from osteopaths trained in osteopathy, the restricted-scope form of practice outside of North America.*The use of osteopathy is not always based on science, and there is little evidence that osteopathy is effective in treating any medical condition other than lower back pain.*
HistoryThe practice of osteopathy began in the United States in 1874. The term "osteopathy" was coined by Andrew Taylor Still, MD, DO. Still was a physician and surgeon,*} Kansas state and territorial legislator,* a Slave and free states|free state leader,* and one of the founders of Baker University,* who lived near Baldwin City, Kansas at the time of the American Civil War. In Baldwin, he developed the practice of osteopathy.*Still named his new school of medicine "osteopathy," reasoning that "the bone, osteon, was the starting point from which [he] was to ascertain the cause of pathological conditions."* Still founded the American School of Osteopathy (now A.T. Still University of the Health Sciences) in Kirksville, Missouri|Kirksville, Missouri, for the teaching of osteopathy on 10 May 1892. While the state of Missouri granted the right to award the MD degree,* he remained dissatisfied with the limitations of conventional medicine and instead chose to retain the distinction of the DO degree.* In 1898 the American Institute of Osteopathy started the Journal of Osteopathy and by that time four states recognized the profession.* In 2012, the International Osteopathic Association approved June 22, the day osteopathy was founded by Dr. Still, as the World Osteopathy Day.
Osteopathic principlesThe osteopathic medical philosophy is defined as the concept of health care that embraces the concept of the unity of the living organism's structure (anatomy) and function (physiology). The following are the four major principles of osteopathic medicine:*
# The body is a unit. An integrated unit of mind, body, and spirit ("Man is Triune" – A.T. Still*) # The body possesses Homeostasis|self-regulatory mechanisms, having the inherent capacity to defend, repair, and remodel itself # Structure and function are reciprocally interrelated # Rational therapy is based on consideration of the first three principles These principles are not held by osteopathic physicians to be Scientific law|empirical laws; they serve, rather, as the underpinnings of the osteopathic philosophy on health and disease.
Techniques of osteopathic treatmentOsteopathic manipulative treatment (OMT in the U.S. or simply "osteopathic treatment" elsewhere) is the therapeutic application of manually guided forces by an osteopathic physician (U.S. usage) to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction.* Somatic dysfunction is defined as impaired or altered function of related components of the somatic (body framework) system: skeletal, arthrodial and myofascial structures and their related vascular, lymphatic and neural elements. Acute somatic dysfunction is an immediate or short-term impairment or altered function of related components of the somatic (body) framework. It is characterized in early stages by vasodilation, oedema, tenderness, pain, and tissue contraction. It is diagnosed by history and palpatory assessment of tenderness, asymmetry of motion and relative position, restriction of motion and tissue texture change.* Chronic somatic dysfunction is the impairment or altered function of related components of the somatic (body framework) system. It may be characterized by tenderness, itching, fibrosis, paresthesias, and tissue contraction.*
While there are many treatment techniques, OMT methods utilized may broadly be classified as active or passive and direct or indirect in nature.*
Scope of manual therapiesA small subdivision of UK osteopathic practitioners are known as "classical osteopaths". They follow teachings of John Martin Littlejohn and John Wernham. They refer to their practice as a style of whole or "total" body adjustment. They contend that structural strains and patterns, through effects on circulation, reflexes and sensory feedback, precede pathological tissue states due to the downrating of for example arterial microcirculation or lymphatic drainage. They claim that the treatment lead to successful patient outcomes in a great number of functional and pathological disorders, including infections and degenerative conditions. Traditionally, great emphasis is put on the clearance of the products of metabolism. The approach is contentious even within osteopathy, in a similar way to cranial osteopathy.
ResearchSeveral large studies in the U.K. have produced evidence that demonstrates positive clinical and cost effectiveness of manipulation in the management of lower back pain, the latest being the U.K. Back pain Exercise And Manipulation (UK BEAM) trial. The physical manipulation condition of the U.K. BEAM trial involved "... a package of techniques representative of those used by the U.K. chiropractic, osteopathic, and physiotherapy professions."* In a 2005 meta-analysis and systematic review of six randomized controlled trials of Osteopathic manipulative medicine|osteopathic manipulative treatment (OMT) that involved blinded assessments of lower back pain in ambulatory settings, it was concluded that OMT significantly reduces low back pain, and that the level of pain reduction is greater than expected from placebo effects alone and persists for at least three months.* A 2013 systematic review and meta-analysis of five randomized controlled trials concluded that existing evidence suggests that OMT may improve lower urinary tract symptoms in adult women such as urinary incontinence (involuntary leakage of urine), nocturia (waking up at night to urinate), and urinary hesitancy, but called for further study with additional large, rigorous randomized controlled trials.*The NIH's National Center for Complementary and Alternative Medicine states* that overall, studies have shown that spinal manipulation can provide mild to moderate relief from low-back pain and appears to be as effective as conventional medical treatments. In 2007 guidelines, the American College of Physicians and the American Pain Society include spinal manipulation as one of several treatment options for practitioners to consider using when pain does not improve with self-care.* Recent research into spinal manipulation for low-back pain has begun to look at the effects of different forms of manipulation, as well as treatment duration and frequency. Studies have found that spinal manipulation provides relief from low-back pain at least over the short term (i.e., up to 3 months), and that pain-relieving effects may continue for up to 1 year. Spinal manipulation is generally a safe treatment for low-back pain. Serious complications are very rare.*
Additionally, U.S. osteopathic physicians and academic researchers have conducted preliminary research to determine the efficacy of manual techniques to manage and/or co-manage conditions such as asthma* and acute otitis media in children,* and pulmonary infection.*
CriticismAccording to the National Health Service (England)|U.K. National Health Service, the use of osteopathy is not always based on science, and there is no good evidence that osteopathy is effective for any health condition other than back pain and helping recovery after hip or knee operations. There is no good evidence that osteopathy is an effective treatment for asthma, painful periods, shoulder pain, headaches or migraines, sinusitis, stress or depression, even though it is sometimes used for these conditions.*
Osteopathy around the worldThe osteopathic profession has evolved into two branches, non-physician manual medicine osteopaths and full scope of medical practice Doctor of Osteopathic Medicine|osteopathic physicians. These groups are so distinct that in practice they function as separate professions. In recent years, the profession has actively attempted to enhance exchange and dialogue between them. The regulation of non-physician manual medicine osteopaths varies greatly between jurisdictions. In Australia, the UK, and New Zealand the non-physician manual medicine osteopaths are regulated by statute and practice requires registration with the relevant regulatory authority. In Canada the Canadian Manual Osteopathy Examining Board administers osteopathic board exams. The International Osteopathy Examining Board (IOEB) administers osteopathic board exams in countries without one such as China, Brazil, India, Iran, Mexico, & Germany. The Osteopathic International Alliance has a country guide with details of registration and practice rights and the International Osteopathic Association has a list of all accredited osteopathic colleges.* In certain countries such as Canada and the USA they may not provide diagnosis as this is a regulated act.* Since 2010 the number of European style osteopaths has increased exponentially worldwide largely due to National Academy of Osteopathy offering an online diploma program in osteopathic manual practice. In 2012, the National University of Medical Sciences located in Madrid, Spain has started offering an online Doctor of Osteopathy, Master of Science in Osteopathy, Master of Art in History of Osteopathy, PhD in Osteopathic Clinical Rehabilitation, MSc in Geriatric Osteopathy, MSc in Pediatric Osteopathy, MSc in Osteopathic Radiology, and a Bachelor of Science in Osteopathy degree program worldwide.*Several international and national organizations exist relating to osteopathic education and political advocacy. One such organization, the World Osteopathic Health Organization (WOHO),* permits individual membership by both "restricted scope manual therapist" osteopaths and "full scope of medical practice" osteopathic physicians. Similarly, there is also an international organization of organizations for national osteopathic and osteopathic medical associations, statutory regulators, and universities/medical schools offering osteopathic and osteopathic medical education, known as the Osteopathic International Alliance (OIA).*The following sections describe the legal status of osteopathy and osteopathic medicine in each country listed.
AustraliaOsteopaths are primary contact health professionals who, in their own practice, make independent judgments in the examination, diagnosis, treatment, prevention and care of conditions of the human body to the extent of their individual competence. Osteopaths work in private practice, and the majority of private health insurance providers cover treatment performed by osteopaths.* Publiclly funded health care in Australia (Medicare (Australia)|Medicare) does not cover the cost of treatment by osteopaths, except when patients hold a referral under the enhanced primary care plan.
The Osteopathy Board of Australia* is part of the Australian Health Practitioner Regulation Agency.* Osteopathy is not recognised as a medical profession in Australia, and as such, osteopaths are not permitted to practice medicine. In addition internationally trained osteopaths are not granted registration rights in Australia.*
Three publicly funded Australian universities now offer degrees in osteopathy: RMIT University (officially The Royal Melbourne Institute of Technology),* Victoria University, Australia|Victoria University,* and Southern Cross University.*
CanadaTraining in osteopathic medicine is not available in Canada. U.S.-trained Doctors of Osteopathic Medicine/osteopathic physicians are licensed as full physicians with the provincial Colleges of Physicians and Surgeons.* The Ontario Medicine Act 1991 states that "No person other than a member (registered with the College of Physicians & Surgeons) shall use the titles "physician" or "surgeon",a variation or abbreviation or an equivalent in another language. 1991, c. 30, s. 9 (1)." and "No person other than a member shall hold himself or herself out as a person who is qualified to practise in Ontario as a physician or surgeon or in a specialty of medicine. 1991, c. 30, s. 9 (3)." Membership in the College of Physicians and Surgeons requires that members are physicians trained in the full scope of medical practice.* Similar title protection laws have been enacted in Alberta* and British Columbia.* The Canadian Osteopathic Association* has been representing osteopathic physicians in Canada for more than 80 years and has enabled near-uniform licensing across Canada for US-trained osteopathic medical graduates.
Manual (non-medical) osteopathy (also known as European style osteopathy, traditional osteopathy or osteopathic manual practice) is not a regulated profession in Canada yet but the profession is working actively to get manual osteopathy regulated.* The Canadian Manual Osteopathy Examining Board (CMOEB) aims to "establish and maintain uniform high standards of excellence in the manual osteopathy profession and education, primarily but not exclusively by preparing and administering to qualified applicants examinations of superior quality . . . and to advance the manual osteopathy profession when in the best interests of manual osteopathy testing".* Manual osteopaths who pass exams administered by the CMOEB are permitted to join the International Osteopathic Association (IOA) and receive a certificate of registration.
The first self-identified college of manual (non-medical) osteopathy in Canada opened in 1981. There are now 12 manual osteopathy schools in Canada, teaching in Halifax, Montreal, Quebec City, Toronto, Hamilton, Vancouver, Ottawa, London, Winnipeg, Calgary and Edmonton. Eight of these schools are accredited and approved by the Canadian EHP insurers (National University of Medical Sciences, National Academy of Osteopathy, Canadian College of Osteopathy, Canadian Academy of Osteopathy, Canadian Osteopathic College, Collège d'Études Ostéopathiques, Centre Ostéopathique du Québec, Southern Ontario College of Osteopathy.)
European UnionThere is no universal regulatory authority for the practice of osteopathy or osteopathic medicine within the European Union; it is on a country by country basis. The UK's General Osteopathic Council, a regulatory body set up under the country's Osteopaths Act 1993 has issued a position paper on European regulation of osteopathy.*
In Austria and Switzerland, osteopathic practitioners are Doctor of Medicine|MDs or physiotherapists who take additional courses in osteopathy after completing their Medical education|medical training or physical therapy training.
FranceOsteopathy is a governmentally recognized profession and has title protection, autorisation d'utiliser le titre d'ostéopathe.* The most recent decree regarding osteopathy was enacted in 2007.*
GermanyGermany has both osteopathy and osteopathic medicine. There is a difference in the osteopathic education between non-physician osteopaths, physiotherapists, and medical physicians.
Physiotherapists are a recognized health profession and can achieve a degree of "Diploma in Osteopathic Therapy (D.O.T.)." Non-physician osteopaths are not medically licensed. They have an average total of 1200 hours of training, roughly half being in manual therapy and osteopathy, with no medical specialization before they attain their degree. Non-physician osteopaths in Germany officially work under the "Heilpraktiker" law. Heilpraktiker is a separate profession within the health care system. There are many schools of Osteopathy in Germany; most are moving toward national recognition although such recognition does not currently exist.* In Germany there are rules (at the country level) under which persons (non-physicians) may call themselves Osteopath.*Osteopathic physicians in Germany achieve a degree of "D.O.- DAAO" or "D.O.M.", from the DAAO and DGOM respectively. Osteopathic physicians in Germany are fully licensed with at least 6,500 hours in medical school 6 years, at least 7,000 hours in specialty training, which is 3 to 6 years, plus at least 680 hours of training in manual medicine and osteopathy before attaining their degree. German physicians who have obtained the degree designation Dr. med., and who have completed their medical education and specialty training in areas such as general practise, orthopaedics, neurology, internal medicine, etc. can earn a Diploma in Osteopathic Medicine, either a DO-DAAO from the DAAO (German-American Academy for Osteopathy), a DOM™ from the DGOM (German Society of Osteopathic Medicine), or an MDO (Medical Doctor of Osteopathy) from the DGCO (German Society for Chirotherapy and Osteopathy) if additional educational requirements are met. The additional education includes a 320-hour program in manual medicine and an additional minimum of 380 hours in osteopathic medicine, which together makes a minimum of 700 hours. The osteopathic medicine course is limited to physicians only.*The scope of practise for a US-trained osteopathic physician in Germany is unlimited. A foreign physician may apply for licensure with the regional medical authorities, the Health Ministry, which represents the state in which the applicant intends to work. The regional state health ministry has information regarding the types of medical providers needed in that area and therefore grants work permits to licensed physicians depending on the specialty of the foreign physician.*
New ZealandThe practice of osteopathy is regulated by law, under the terms of the Health Practitioners Competence Assurance Act 2003* which came into effect on 18 September 2004. Under the Act, it is a legal requirement to be registered with the Osteopathic Council of New Zealand (OCNZ),* and to hold an annual practicing certificate issued by them, in order to practice as an osteopath. Each of the fifteen health professions regulated by the HPCA Act work within the "Scope of Practise" determined and published by its professional Board or Council. Osteopaths in New Zealand are not fully licensed physicians. In New Zealand, in addition to the general scope of practice, osteopaths may also hold the Scope of Practice for Osteopaths using Western Medical Acupuncture and Related Needling Techniques.*In New Zealand a course is offered at Unitec New Zealand|Unitec.* Australasian courses consist of a bachelor's degree in clinical science (Osteopathy) followed by a master's degree. The Unitec New Zealand double degree programme is the OCNZ prescribed qualification for registration in the scope of practice: Osteopath, Australian qualifications accredited by the Australian and New Zealand Osteopathic Council are also prescribed qualifications.
Osteopaths registered and in good standing with the Australian Health Practitioner Regulation Agency – Osteopathy Board of Australian are eligible to register in New Zealand under the mutual recognition system operating between the two countries. Graduates from programs in every other country are required to complete an assessment procedure.*The scope of practice for US-trained osteopathic physicians is unlimited on an exceptions basis. Full licensure to practice medicine is awarded on an exceptions basis following a hearing before the licensing authorities in New Zealand. Both the Medical Council of New Zealand* and the Osteopathic Council of New Zealand [OCNZ]* regulate osteopathic physicians in New Zealand. Currently, the country has no recognized osteopathic medical schools.*
United KingdomThe practice of osteopathy has a long history in the United Kingdom. The first school of osteopathy was established in London in 1917 by John Martin Littlejohn, Ph.D., M.D., D.O., a pupil of A.T. Still, who had been Dean of The Chicago College of Osteopathic Medicine. After many years of existing outside the mainstream of health care provision, the osteopathic profession in the UK was finally accorded formal recognition by Parliament in 1993 by the Osteopaths Act.* This legislation now provides the profession of osteopathy the same legal framework of statutory self-regulation as other healthcare professions such as medicine and dentistry.
The General Osteopathic Council (GOsC) regulates the practice of osteopathy under the terms of the Osteopaths Act 1993. Under British law, an osteopath must be registered with the GOsC to practice in the United Kingdom.* The General Osteopathic Council has a statutory duty to promote, develop and regulate the profession of osteopathy in the UK. It fulfills its duty to protect the interests of the public by ensuring that all osteopaths maintain high standards of safety, competence and professional conduct throughout their professional lives. In order to be registered with the General Osteopathic Council an osteopath must hold a recognized qualification that meets the standards as set out by law in the GOsC's Standard of Practice.* This Act provides for "protection of title" A person who, whether expressly or implication describes himself as an osteopath, osteopathic practitioner, osteopathic physician, osteopathist, osteotherapist, or any kind of osteopath is guilty of an offence unless he is registered as an osteopath. There are currently approximately four thousand osteopaths registered in the UK.*
In the United Kingdom, courses in Osteopathy have recently become integrated into the university system. Instead of receiving a Diploma in Osteopathy (DO), with or without a Diploma in Naturopathy (ND), graduates now become Masters or Bachelors of Osteopathy, or Osteopathic Medicine, (BOst or MOst) or else Bachelors of Science (BSc) in Osteopathy or Osteopathic Medicine, according to the institution attended:* in this case osteopathy and osteopathic medicine are synonymous, but these degrees do not lead to prescribing rights.
The recognition of osteopathy also means that doctors can now refer patients to osteopaths for treatment with the transfer of clinical responsibility rather than simply delegating the responsibility for care, as is the case with other healthcare professionals. It may or may not be a covered benefit under the National Health Service depending on where in the UK you may live.*Osteopathic medicine is regulated by the General Osteopathic Council (GOsC) under the terms of the Osteopaths Act 1993 and statement from the GMC. The London College of Osteopathic Medicine,* teaches osteopathy only to those who are already physicians.
Foreign-trained osteopathic physicians, who are registered with the GMC and GOsC, hold both a full medical practise and osteopathic license. Each applicant will have to pass the Professional and Linguistic Assessment Board test (PLAB) and work for one supervised year in the National Health Service (NHS). Following that year, the applicants will be able to apply for full registration (unsupervised practice or private practice). If the physician is already a specialist, postgraduate training will need to be separately recognized by the GMC.*
United StatesLicensure or registration of non-physician osteopaths is not permitted anywhere in the United States. European style osteopaths are prohibited from calling themselves osteopaths. In contrast, osteopathic physicians earn the degree of Doctor of Osteopathic Medicine (D.O.), a degree equivalent, though different in certain aspects, to that of Doctor of Medicine (M.D.).*
Osteopathic medicine in the United States has always meant a physician trained in and entitled to the full scope of medical practice. Osteopathy or osteopath as written in some U.S. state and federal laws refers only to osteopathic medicine or osteopathic physicians, respectively.* With the increased internationalization of the profession, these older terms have fallen out of favor as generally accepted use due to the confusion they may cause.*