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Somatic Dysfunction Assessment and Treatment in Osteopathic Research
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This entry is adapted from the peer-reviewed paper 10.3390/healthcare10010028

Osteopathic manipulative treatment (OMT) is a patient-centred, whole-body intervention aimed at enhance the person’s self-regulation. OMT interventions are focused on somatic dysfunctions (SD) that can be defined as an altered regulative function associated with inflammatory signs palpable in the body framework in different body regions. 

osteopathic manipulative treatment somatic dysfunction manual therapy osteopathic techniques

1. Introduction

Osteopathic manipulative treatment (OMT) is a patient-centred, whole-body intervention. It is aimed at enhancing the person’s self-regulation and favor the structure-function-environment relationship by applying five models as a guide for the osteopathic approach to diagnosis and treatment [1][2]. Osteopathy is recognised and regulated differently throughout the world [3]. In fact, in the USA there is an ongoing process to establish osteopathic principles to fulfill osteopathic recognition standards [4]; many countries, for example, Italy [5], are struggling to spread a shared benchmark for standardized core curriculum and core competence. In many European countries, efforts are being made to have osteopathy confirmed as a healthcare profession by identifying distinctive osteopathic competencies and producing evidence. As recently reported in a bibliometric analysis, osteopathic research has increased rapidly in recent years [6]. The main advantage for patients undergoing OMT is the effective relief of acute and chronic pain [7][8]; however, patients also report improvement of other non-musculoskeletal complaints [9][10]. Indeed, some of the latter are conditions and disorders that are closely associated with other neurological functions, including reduced time of hospitalization in a large population of preterm infants [11][12] and autonomic and neuroendocrine responses [13]. The mechanisms of action behind osteopathic interventions are being debated; however, recent studies have reported that one possible explanation of OMT effectiveness is that it modulates neurophysiological and cerebral activities [14][15][16]. Indeed, cerebral perfusion and heart rate variability changes were recently found in patients with low back pain after OMT [17]. Osteopaths often use many different techniques in the same session and different regions of the body are targeted by the intervention [6]. Since OMT techniques can have different effects on neurophysiological activities [18][19][20] their choice during treatment is a clinical judgment of the practitioner. OMT person-centred interventions should focus on somatic dysfunctions (SD) [21][22][23] detected in shared decision-making [24]. SD can be defined as an altered regulative function associated with inflammatory signs palpable in the body framework in different body regions that can be remote from the symptomatic area [25]. Although the clinical application of five models (biomechanical, respiratory/circulatory, neurological, biopsychosocial and bioenergetic) could provide a framework for interpreting the significance of a SD [21], thus guiding the osteopath through assessment and treatment, how osteopaths manage the decision-making process and why they choose one type of treatment over another is still unclear. Indeed, treatments can be performed following different paradigms by considering a whole-body assessment and treatment (i.e., black-box protocol) or only one or some regions of the body in a standardised or semi-standardised protocol. In any case, SD is considered to be a profession-specific approach because it defines the aim of an osteopathic evaluation and treatment (i.e., to improve a regulative function with a tailored touch delivered on an area of interest for patient and practitioner).
On the other hand, SD is also a potentially helpful concept for sharing the object of the osteopathic person-centred intervention with mainstream healthcare professionals because it is described in the International Classification of Diseases (ICD), which reports the different locations of body regions [21]. Nevertheless, the conceptual model that sustains SD, as well as its usefulness for the osteopathic profession, is still being discussed by the osteopathic community [26][27][28][29][30][31][32]. Understanding the role of SD is essential for many of those involved in the healthcare and education system [33].

2. Current Insights

Despite a shared set of core competencies reported by the Osteopathic International Alliance, it included detecting SD for the osteopathic diagnosis [34]. The results of the present work highlight the fact that the consideration of SD in osteopathic practice is not the same throughout the world. For example, in the USA there is an explicit mention of SD in the Core Competencies document prepared by the American Association of Colleges of Osteopathic Medicine, in conjunction with all U.S. Osteopathic Medical Schools [35]. In Europe, primarily because of the different stages of recognition and regulation processes in the different countries, SD is not always mentioned in the requested standard of practice of the professions. For example, in Italy, osteopathy has recently been recognised by law and regulated as a health profession able to manage health conditions that require interventions for prevention and maintenance of health through osteopathic treatment of SDs [36]. Conversely, there is no mention of SD in the U.K.’s osteopathic practice standard [37]. In the presented report, the studies in which authors implemented a validated system for recording, collecting and evaluating clinical findings, SDs are clearly labelled. The American Academy of Osteopathy’s Louisa Burns Osteopathic Research Committee designed, published, distributed and highly recommended the SOAP to the osteopathic profession for research, training, and clinical practice [38]. It is an easy-to-use, validated system for recording, collecting and evaluating clinical findings, osteopathic musculoskeletal examinations, enumerating any SDs found, documenting any osteopathic techniques used and reporting patient response to treatment [38]. Despite this, the SOAP note is hardly used in the selected studies. Similarly, most of the studies do not use the clinical signs identified to date to detect SD, i.e., those represented by the acronym TART: tenderness, asymmetry, restricted motion, tissue texture abnormalities. In addition, one of the most widely used and recognised international disease classification systems, the ICD, which identifies SD as a “biomechanical lesion not elsewhere classified” by identifying the relevant body regions where it might be located (skeletal regions), is not yet used by the osteopathic practice community to align with other healthcare professions with respect to clinical classification. The non-homogeneity of the osteopathic evaluation, taking into account the SD collected in this work, highlights the need to use other methods that clarify the clinical signs collected during the osteopathic physical examination, to make them more reliable, valid, understandable by other healthcare professions and accessible during osteopathic education. For this reason, some osteopaths have begun to propose and study new models revisiting the clinical signs that are useful for detecting SD, while maintaining the real context of osteopathic clinical practice. For example, Bergna et al. [32] suggested “motion variability” as a clinical sign to be considered in the objective examination characterising osteopathic practice that is useful for clinical reasoning and directing OMT. The definition of SD refers to an altered regulative function associated with inflammatory signs palpable in the body framework [39]. Rather than a disease, it is regarded as a factor that contributes to and maintains patient symptoms [7]. In recent years, osteopathic researchers have referred to SD as a neurologically active area, region or a generalised body pattern to be used by osteopaths to deliver the effects of touch and other hands-off procedures to improve the patient’s agency [24]. Nevertheless, there is still a trend to use the term “osteopathic lesion” inside the osteopathic community, illustrating the adoption and misappropriation of a biomedical word and the potential nocebo effect on symptoms [33].
Concerning the different considerations of the concept of SD found in the included studies, it should be mentioned that, in 2020, authors from outside the U.S., i.e., the European, Australasian and Brazilian communities of practice, published their contributions to a debate about osteopathic conceptual models, including the concept of SD [26][27][28][29][30][39][40][41][42][43]. On one hand, Esteves et al. mentioned SD as a non-relevant clinical entity [26]; on the other hand, different authors discussed updating the concept and renovating the old theoretical substrate, not necessarily removing it [27][29][30][39][40][41][42][43][44]. They claimed that it is possible to gain a conceptual osteopathic approach that uses SD as a reconditioned model by implementing new evidence-based knowledge, such as allostasis and interoception, involving (en) active model and strategies, integrating patient-centred communication, shared decision-making self-management, and educational coaching [27]. All authors agreed that the time has arrived to build teamwork among global osteopathic communities to produce a shared vision and reduce the gap between scientific knowledge and osteopathic tradition. There is an opportunity to move forward from pseudo-scientific concepts and adopt a person-centred and evidence-informed osteopathic practice [26][27][44][45].
Regarding intervention, the results show the heterogeneity of the osteopathic techniques reported in the included studies regarding intervention. Across included studies, the OMT techniques selected by practitioners highlighted a preponderance of soft tissue techniques, such as myofascial and muscular energy techniques. On the contrary, very few studies reported the choice of biodynamic osteopathy in the cranial field. All of the main osteopathic approaches reported in the Glossary of Osteopathic Terminology were reported [39]. Moreover, there is a common trend to use a “black box design” to consider osteopathic manipulative treatment as that set (not exactly reproducible) of diagnostic tests and techniques designed for patient treatment. This method is much more linked to everyday clinical reality, in which clinicians summarize approaches for administering person-centred osteopathic care [45].
Regarding osteopathic management in complex scenarios, it has been reported that person-centred osteopathic care is described as including tailored and symptom-based approaches [46]. Both whole body and segmental strategies are tailored to patients’ needs and individual responsiveness to the different types of osteopathic touch administered on regions of interest for both patients and osteopaths, i.e., SD. According to the structure/function models, the aim is to improve postural control, modulate autonomic neural overload, improve gastrointestinal function, breathing patterns, drainage and supply of body fluids, control stress components and augment reaction to biopsychosocial stressors [47][48]. Symptom-based approaches are considered in the treatment plan, i.e., administering appropriate techniques according to research studies conducted in a similar clinical context, not necessarily focusing osteopathic touch on SD. A possible explanation of the different percentages of focusing on SD in the available studies could be related to the aims of the interventions. In some cases, depending on person-centred tenets, the osteopathic approaches are more concentrated on improving and maintaining health and individual adaptability to the environment. In other studies, the strategy focuses on symptoms related to the patient’s chief complaint to deliver an evidence-informed practice.
The results confirm that the osteopathic patient demographics include a wide range of the general population, i.e., ranging from children to working-age adults and older adults, as reported in other studies [49]. Although studies in children have considered DS, professionals need to adapt the SD-based approach for infants and children. For example, one of the classical palpatory findings based on tenderness is not helpful in neonatal management because it is not possible to have feedback from newborns [50].
With respect to the time frame, the duration and frequency of osteopathic treatments were consistent with the data summarized in the osteopathic guidelines [8] and in a recent systematic review [51]. The differences in duration between 15 min to 1 h could be related to the different focus of the osteopathic intervention administered in the studies included in this work, i.e., a complex person-centred osteopathic intervention requires assessing regions of interest in the osteopathic patient dyadic relationship [24]. The shared decision-making process, which is based on verbal and non-verbal communication (i.e., on proximity and touch) usually takes a considerable amount of time [48]. Conversely, the administration of a single technique or a standardised approach is faster.
Differences in terms of treatment plan duration and follow-up could depend on the different outcomes of the studies (i.e., the experience of pain or functional status), primarily because the subjective experience of pain might respond to treatment sooner than function [39]. Moreover, the improvement of individual agency and comorbid psychological factors in patients with physical conditions and a high allostatic load requires a complex personalised intervention rather than a single technique [52].
Half of the selected studies reported the use of SD to guide OMT and most of them did not use standardised treatment protocols. Moreover, although the “dosage” of treatments proposed indicates the non-uniformity of osteopathic clinical procedures in research, there was no evidence that an appropriate “posology” was proposed for each patient’s condition. The subjectivity of person-centred care requires continuous adaptations in assessment and treatment to support human variability; however, the lack of standards can complicate research and, therefore, the understanding of the mechanisms of action in osteopathy. Furthermore, the heterogeneity of studies reveals a confusing synthesis of information that does not contribute to patient safety and the generalisation of findings leading to treatment efficacy. For this reason, the Template for Intervention Description and Replication (TIDieR) [53] was developed. This is a checklist which ensures that the characteristics of the intervention used are reported in the best possible way. Gerard Alvarez et al. [54] suggested that the TIDieR should be used in the field of manual and manipulative therapies, where the proposed therapies are administered with a high degree of customisation and variability. To overcome these difficulties, in 2007 the American Academy of Orthopaedic Manual Physical Therapists [55] set up a task force to standardise terminology in manual therapy, starting with the nomenclature of manipulative intervention, in order to make it more internationally usable. Chaitow [56] tried to classify the forces of the techniques used to characterise them with different descriptors (i.e., direction, force, velocity, amplitude, etc.).
To the best of the researchers' knowledge, this is the first literature analysis aimed to investigate the role and use of SD by considering many studies. The relevance of SD in osteopathic practice varies from country to country. Depending on the specific SD, the assessment and treatment modality should consider a whole body, loco-regional or segmental approach. SD should be considered as a clinical value that assists in the clinical assessment and guides the decision-making process of osteopathic practitioners.
According to recent reviews [6][9][57][51] a large amount of heterogeneity emerged from osteopathic research, particularly concerning treatment modalities. As previously discussed, authors of the included studies considered various protocols in terms of manipulative techniques, period of treatments, frequency and intensity of sessions and, lastly, adopted rationale toward SD. This fact represents an important barrier both to demonstrate the osteopathic manipulation effectiveness and to provide specific guidelines to clinicians. From another point of view, it should be considered how osteopathic medicine is traditionally characterized by a tailored approach on the single person rather than to the disease [1][2]; thus, a complete standardization becomes difficult, in the clinic as well as in research.

3. Conclusions

The background provided above could involve many osteopathic researchers, educators, and practitioners in a consensus conference to work towards consistency, plausibility, generalisability, relevance and expected applicability of SD. Further studies should be designed to better understand why and how to choose the different assessment and intervention modalities to approach SD.

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