The standards that define the provision of osteopathic education and health services [4,5] suggest that osteopaths must formulate a management interprofessional plan to help patients to understand the significance and potential effect of treatment. In addition, the osteopath promotes therapeutic education and encourages patients to understand the usefulness of physical activity, exercise, lifestyle, and diet from a multi-professional health care point of view [6,7].

Osteopathic health promotion and disease prevention appears more closely connected with therapeutic education exercises [6]. For the full recovery for patients, in addition to addressing the phases of repair and alleviation of symptoms [8], the treatment must also be centered on the enhancement of individual adaptability [9]. A management plan that provides active patient approaches alongside manipulative therapies is aimed at improving the quality of the program for the individual [8,9]. Passive or active mobilization techniques or dynamic movement challenges gradually applied after shared decision making with the patient can support recovery behavior from pain, physical incapacity, or movement-related anxieties [8]. The exercises in the osteopathic field are described as approaches directed towards managing SD in different domains [10,11] and directed towards personal energy management [12]. However, several studies [13,14,15] report that these approaches are still under debate in osteopathic training and practice It is not clear whether exercise and lifestyle advice are included as interprofessional practices or whether a complementary approach is within osteopathic practice. There is currently an absence of common clinical practice frameworks regarding the integration of exercise and lifestyle advice with hands-on approaches. This may lead to misunderstandings in both patients and other health professionals distorting the professional identity.

2. Fascia-Oriented Active Approach

Schleip and Muller [18] described the basic principles of the fascia-oriented active approach, which are proposed to be integrated into PAOA [9]. Sedentary lifestyle has been shown to cause the production of a network of multi-directional fibers, and to minimize the development of “crimps”, i.e., physical and electrical connections. Applying proper exercise leads to an improvement in connectivity in the organization of the tissue architecture. The central principles of PAOA oriented to the fascia are fascial remodeling, fascial recoil, dynamic stretching and fascial perception.

Fascial remodeling is the response of the arrangement’s network collagen fibers following a specific mechanical stimulus. Fascial active training, performed 1–2 times per week for 6–24 months, is able to affect this substitution [18].

Fascial recoil is the mechanism of elastic tissue return, stimulated through targeted active exercises, in which a preparatory phase increases the elastic tension of the fascial system, followed by a stage where the body releases the weight like a catapult [18]. Dynamic stretching oriented to the fascia consists of specific stretching performed regularly and long term in order to make the framework of the connective tissue more elastic [18]. Fascial perception consists of small and/or complex gestures used to increase awareness of perceptually ignored areas of the body, i.e., those that are related to interoceptive–proprioceptive sensory alterations [18].

3. Integrated Mental Imagery and Work-In Exercise

The musculoskeletal system represents an interoceptive body image and awareness generator. For this reason, it is preferable to use a tailored educative and cognitive approach, integrating hands-on treatment and experiential bodywork [19]. Mental imagery has been shown to have a beneficial effect on motor and cognitive output and other behavioral effects and to cause brain activity similar to what occurs with movement [20]. Mental imagery is a training method used in both prevention and rehabilitation. It can be used in combination with manual therapy or active exercise techniques to manage pain and enhance motor abilities, such as motor neuron stimulation and non-motor performance aspects, including for treatment of self-confidence and anxiety [20].

Mental imagery has already been integrated with osteopathic approaches and experiential bodywork [21,22]. For example, fascial unwinding, in which the operator starts activating slow, painless motion in the patient’s body using their hands with simultaneous use of mental imagery.

The patient follows their emergent movement, assisted by the practitioner, as the body is perceived as being unwound by ideomotor movement [21]; automatic movements are expressions of predominant ideas. Ideomotion is instinctive and unconsciously motivated activity or behavior, including excitomotor and sensorimotor actions [22].

The practitioner tries to improve interoception, including the perception of a myofascial contraction to be released and of a motor activity to be executed.

Osteopaths can do this by providing limited resistance to the patient’s action—not enough to stop it, but still enough to postpone and refine its expression. The restricted barrier of articulation or the stiffness of the soft tissue might be perceived by the patient due to the active and gentle “manual transfer” prompted by the placement of the practitioner’s hand in the regions involved [22]. In combination with integrated mental imagery or provided alone, the work-in mentality could be another complementary method to support the parasympathetic functions (rest/digestion/repair) of patients [23]. This consists of exercises performed following a breathing pattern with an oscillating harmonic rhythm. During the exercises, the attention is focused on the inherent feedback received by focusing on the amplified moving pattern of a body region or of the entire framework.

4. Mindfulness-Based Exercise

A recent review of functional magnetic resonance imaging research offers insight on the impact of combined hands-on therapy and mindfulness-based approaches on central sensitization and interoceptive shortfall conditions [24]. The interoceptive paradigm for osteopathy [25] reinforces the need for new approaches guided by practitioner [26] and patient mindfulness [27,28]. Mindfulness is often used as an umbrella term to characterize many practices, processes, and characteristics [24]. These focus on the non-directed process of managing attention to present experientail perceptions, such as thoughts, emotions, and sensations [29]. Different osteopathic approaches [28], such as body scan mindfulness practice, involve sequentially directing attention to various parts of the body, without judgment, to develop the regulation of somato-visceral perceptions, sensations, and cognitive judgments [28,29]. Moreover, the use of oscillation, vibration, and spontaneous myofascial and neurogenic tremors, both in osteopathy [30] and mindfulness-based practice [29], are today promoted to release stress and restore the body’s homeostasis.

5. Gamification and Problem-Solving in the Inter-Enactive Dyadic Approach

Gamification is an example of developing a team-spirit patient problem-solving atmosphere, where challenges can be discussed and improved in a task-oriented way [31]. Performing the active assistive exercises in a peaceful and fun way and using metaphors to describe the routine allows the information to become sub-cortical. PAOA is mainly partner-based, emphasizing novel environmental constraints, safety, and fun. During the execution of the exercises, the attention is focused on movement rather than activating the individual muscle. The participant’s body–brain unity is able to re-learn adaptation processes through exposure to new or challenging situations in a safe environment [31]. As argued by enactivists, embodied humans improve their sense-making by action-oriented relational strategies distributed throughout the brain–body–environment [32].

The enactive model describes a human sensory action cycle that drives structure and function adaptation to better match the environment [32]. The exteroceptive, proprioceptive, and interoceptive sensory systems support the brain in generating predictions about its external and internal environment and adaptive actions in order to maintain health [32]. The failure to process and integrate multisensory bodily signals followed by prediction errors may have relevance for the physiological regulatory process in health and disease [32].