Experienced Osteopaths Research Articles

“What you feel under your hands”: exploring professionals’ perspective of somatic dysfunction in osteopathic clinical practice—a qualitative study

BackgroundDespite controversy regarding its validity and clinical usefulness, manual examination findings still have an important role for manipulative therapies. As an example, somatic dysfunction (SD) remains central to osteopathic practice.This study aims to explore the experienced osteopaths' attitudes concerning SD and its role in osteopathic practice. This qualitative research could contribute to building a consistent paradigm for manual intervention in all musculoskeletal manipulations.MethodsA thematic analysis with grounded theory elements was used. Data were collected through semi-structured interviews carried out between February and April 2021. A purposive sample of twenty professional osteopaths with past experience in osteopathic care was chosen to reflect the phenomenon's variety. The data analysis was done inductively and in tandem with the recruiting to keep track of data saturation.ResultsEleven osteopaths participated in the study. Three main themes emerged from the data analysis: (1) SD as a safe tissue-touch-based communication tool between operator and person complex adaptive health system; (2) The treatment of SD is shareable between osteopaths, other health professionals, and the patients involved in the therapeutic pathway improving body awareness and health; (3) The development of the SD concept in research and practice to better clarify osteopathic profession identity and definition.ConclusionsA panel of expert osteopaths consider the concept of SD as a valuable tool integrated into the osteopathic evaluation and treatment process. The shared concept and clinical application of SD is informed by person-centered care concepts and from the fields of neuroscience, cognitive and complexity science. Our study reports a common need among osteopaths to develop an evidence-based framework of SD to allow the best development of the osteopathic profession.

Most common infant health concerns in osteopathic practices in Germany. A survey

BackgroundIn Germany, more parents have been seeking help from osteopaths for their infants and children in recent years. This implies an increasing demand of reliable evidence regarding the effectiveness of osteopathic intervention for this group. ObjectiveTo identify the ‘typical’ (most common) health concerns of parents when presenting their infants (age 0–12 months) in pediatric osteopathic practices. MethodsFor the purpose of this survey, well-trained osteopaths who specialize in the treatment of children and infants were selected. A documentation form containing a list of the likely most common infant health problems, developed by means of systematic literature analyses, was provided to experienced osteopaths to assess which health problems were seen most frequently. ResultsEighty-one osteopaths were contacted, of which 64 (79 %) responded and returned the documentation form. Nine documentation forms could not be evaluated. The remaining 55 documentation forms included information on 2833 health concerns. Quantitatively, there was no dominant health problem, but five problems were found to be common: 21 % of the cases were idiopathic infant asymmetry, 17 % were plagiocephaly, 16 % were excessive crying, and 14 % were feeding and sleep disorders. All other problems were observed as far less frequent. In addition, osteopaths reported 423 other health concerns that were not specified in the documentation form. ConclusionsIn this survey, infants that were presented in osteopathic practices often had one or more of those five health problems mentioned above. A large observational trial is currently underway to document changes observed during osteopathic treatment of these health problems.

Moderate to Substantial Inter-Rater Reliability in the Assessment of Cranial Bone Mobility Restrictions.

Background: The World Health Organization benchmarks for osteopathic training consider cranial osteopathy as an important manual skill. Studies of cranial manual therapy have exhibited poor reliability. The aim of this study was to investigate the inter-rater reliability of the manual mobility tests of the spheno-occipital synchondrosis (SOS), and the temporal, parietal, and frontal bones, as assessed in osteopathic manual therapy. Methods: Twenty-one adults were assessed on a single day by three experienced osteopaths using a standard assessment protocol. Before data collection, the osteopaths participated in a consensus training, which included establishing the criteria for identifying a cranial bone mobility restriction; the application of the seven-step palpation method; a pretesting practice; a fine-tuning palpation training; and a calibration period before the assessment of the subjects. Three subjects were assessed simultaneously with the evaluators rotating to assess each subject. The evaluators were blinded to the subject by a curtain, and each other's assessments. Each bone was rated as restricted or not restricted. The authors applied the Landis and Koch classification to describe the magnitude of inter-rater reliability. Results: Moderate reliability was established for a lateral strain of the SOS (Fleiss' generalized kappa 0.48), substantial reliability was established for the other SOS strain patterns (Fleiss' generalized kappa 0.62-0.75), and almost perfect reliability for temporal, parietal, and frontal bone (Fleiss' generalized kappa 0.81-0.96). Conclusion: The results demonstrate consistency when three experienced osteopaths evaluate cranial bone mobility restrictions. The results highlight the importance of consensus training and rigorous methodology in manual therapy reliability studies.

The Role of Mental Imagery in Osteopathic Palpation: a qualitative study

Background: Palpation constitutes a central element of osteopathic diagnosis and therapy. It is a complex tactile performance and as such also depends on cognitive factors. References by experienced osteopaths (EOs) suggest that the ability to visualise anatomical structures is essential during palpation. Scientific studies in this field can hardly be found. This study aimed to systematically determine what role mental imagery (MI) plays for osteopaths and especially what the benefits are when it is used spontaneously and deliberately. Material and Methods: The present study is a qualitative study. Nine interviews with EOs were carried out with the help of an interview guideline and analysed using a qualitative analysis of content using the software MAXQDA. Results: All EOs regarded MI as a tool as well as an interfering factor for palpation. Its supporting role was associated with the identification, recognition and comparing of anatomical conditions, with directing attention, with navigation and orientation. The limiting character showed up in distraction and deception by mental images. The results also revealed the situational use of MI as well as different mental images and influencing factors (e.g. visualisation training). Discussion: The study provides an insight into the application knowledge of EOs and shows some aspects of palpation, which have been subject to little research so far. Being aware of and understanding the role of MI as a top-down process in tactile-haptic perception should change the focus in palpation. The findings can be incorporated in daily practice as well as in the training system. To regard MI as a possible bias can lead to reassessment and realignment of reliability studies. This study offers a basis for other studies to work from to explore the nature of MI in the tactile-haptic perception of osteopaths. Keywords: mental imagery, palpation, osteopathy DOI: https://doi.org/10.35740/EJOR.2019.1.1.3

Diagnostic reasoning in osteopathy – A qualitative study

Background: The clinical reasoning processes which result in the formation of a diagnosis, are fundamental for safe, effective and efficient clinical practice and are central to professional autonomy and accountability. While research has identified the diagnostic reasoning approaches taken by a range of healthcare professions, there is limited understanding of how osteopaths formulate diagnoses in clinical practice.Objectives: The aim of this research was to explore the diagnostic reasoning of experienced osteopaths in the UK.Methods: A qualitative constructivist grounded theory approach was taken in this study, which was situated in the interpretive research paradigm. A total of seventeen face-to-face semi-structured interviews were conducted with twelve experienced osteopaths. Participants were purposefully and theoretically sampled to take part in this study. Data collection methods involved semi-structured interviews with participants and observation and video-recording of clinical appointments, which were followed by video-prompted reflective interviews. The constant comparative method of analysis was used to code and analyse data.Results: The findings suggest that when formulating a diagnosis practitioners adopted two diagnostic reasoning approaches, namely hypothetico-deductive reasoning and pattern recognition. In this study, there was interplay of these reasoning approaches as a result of the perceived level of complexity and degree of familiarity of the patient presentation.Conclusions: Experienced osteopaths adopted diagnostic reasoning approaches which are akin to other healthcare professions including medicine and physiotherapy. Metacognitive and reflexivity skills were central for safe and effective diagnostic reasoning. Further work is required to explore the transferability of these findings with practitioners of different levels of clinical experience and who work in different clinical settings.

Clinical decision-making and therapeutic approaches in osteopathy – A qualitative grounded theory study

There is limited understanding of how osteopaths make decisions in relation to clinical practice. The aim of this research was to construct an explanatory theory of the clinical decision-making and therapeutic approaches of experienced osteopaths in the UK.Twelve UK registered osteopaths participated in this constructivist grounded theory qualitative study. Purposive and theoretical sampling was used to select participants. Data was collected using semi-structured interviews which were audio-recorded and transcribed. As the study approached theoretical sufficiency, participants were observed and video-recorded during a patient appointment, which was followed by a video-prompted interview. Constant comparative analysis was used to analyse and code data.Data analysis resulted in the construction of three qualitatively different therapeutic approaches which characterised participants and their clinical practice, termed; Treater, Communicator and Educator. Participants' therapeutic approach influenced their approach to clinical decision-making, the level of patient involvement, their interaction with patients, and therapeutic goals. Participants' overall conception of practice lay on a continuum ranging from technical rationality to professional artistry, and contributed to their therapeutic approach. A range of factors were identified which influenced participants' conception of practice.The findings indicate that there is variation in osteopaths' therapeutic approaches to practice and clinical decision-making, which are influenced by their overall conception of practice. This study provides the first explanatory theory of the clinical decision-making and therapeutic approaches of osteopaths.

A qualitative grounded theory study of the conceptions of clinical practice in osteopathy – A continuum from technical rationality to professional artistry

How practitioners conceive clinical practice influences many aspects of their clinical work including how they view knowledge, clinical decision-making, and their actions. Osteopaths have relied upon the philosophical and theoretical foundations upon which the profession was built to guide clinical practice. However, it is currently unknown how osteopaths conceive clinical practice, and how these conceptions develop and influence their clinical work. This paper reports the conceptions of practice of experienced osteopaths in the UK.A constructivist grounded theory approach was taken in this study. The constant comparative method of analysis was used to code and analyse data. Purposive sampling was employed to initially select participants. Subsequent theoretical sampling, informed by data analysis, allowed specific participants to be sampled. Data collection methods involved semi-structured interviews and non-participant observation of practitioners during a patient appointment, which was video-recorded and followed by a video-prompted reflective interview.Participants' conception of practice lay on a continuum, from technical rationality to professional artistry and the development of which was influenced by their educational experience, view of health and disease, epistemology of practice knowledge, theory–practice relationship and their perceived therapeutic role.The findings from this study provide the first theoretical insight of osteopaths' conceptions of clinical practice and the factors which influence such conceptions.

Clinical reasoning and therapeutic approaches of experienced osteopaths

BackgroundClinical reasoning refers to the decision-making processes which occur during practice. Over the last thirty years research in the health sciences has explored the clinical reasoning processes of a number of health professions such as medicine, nursing, occupational therapy and physiotherapy. As the osteopathic profession continues to grow, osteopaths are increasingly considered to be important providers of neuromusculoskeletal care. However, there has been minimal research into the clinical reasoning processes and therapeutic approaches used in osteopathy. The aim of this research was to explore the clinical reasoning processes of osteopaths in the UK, and to construct an explanatory theory of clinical reasoning in osteopathy. MethodsA total of 12 UK registered osteopaths participated in this grounded theory study, which was situated in the interpretivist research paradigm. Purposive sampling was used to initially select participants. Subsequent theoretical sampling, which was informed by data analysis, allowed specific participants to be sampled. Data was collected from interviews with 9 participants, which were audio-recorded and transcribed. As the study approached theoretical sufficiency, data collection methods involved non-participant observation and video-recording of 3 further participants during a patient appointment, which was followed by a reflective interview prompted by the video-recording. The constant comparative method was used to code and analyse interview transcripts to construct a substantive theory to explain the therapeutic approaches and clinical reasoning of experienced osteopaths. FindingsParticipants took one of three distinct therapeutic approaches, termed; ‘Treater’, ‘Communicator’ or ‘Educator’ which characterised their overarching clinical behaviour. The approaches were developed from participant's conception of practice which was based on the antecedent conditions of their; educational experiences, professional and clinical experiences, personal values and beliefs, views of health and disease and professional identity. The three therapeutic approaches resulted in varying levels of patient involvement in the clinical reasoning process and consequently different therapeutic outcomes. Participant's approach to clinical reasoning ranged from ‘practitioner-led’ with a low level of patient involvement; ‘mutual negotiation’ with an equal level of patient involvement; or ‘patient-led’ with a high patient involvement. The process of diagnosis construction involved participants moving between hypothetico-deductive reasoning and pattern recognition and verification. Participants could adapt their therapeutic approach in response to the patient's preferences, expectations and the patient's ongoing response. The ability to adapt varied between study participants and was influenced by their conception of practice, working context and time factors. ConclusionsThe findings indicate that osteopaths have distinct therapeutic approaches to practice which influence the level of patient involvement in the clinical reasoning process. The clinical reasoning of the experienced osteopaths in this study extended beyond traditional diagnostic reasoning, and suggests that clinical reasoning in osteopathy is characterised as a continuous and dynamic process during patient interaction. These findings provide an explanatory theory of the therapeutic approaches and clinical reasoning of experienced osteopaths, which has implications for osteopathic clinical practice, education and research. Further research is required to determine the transferability of the substantive theory.

The effects of experience on the inter-reliability of osteopaths to detect changes in posterior superior iliac spine levels using a hidden heel wedge

The use of palpation to diagnose musculoskeletal dysfunction is commonly taught within osteopathy and other manual therapies. However the clinical tests used to detect sacroiliac joint dysfunction have not shown good reliability. To investigate the inter-examiner reliability of osteopaths to detect asymmetries of the posterior superior iliac spine (PSIS), and to determine if inter-examiner reliability was affected by the level of practitioner experience. Fifteen final year osteopathic students (n = 15), fifteen third year osteopathic students (n = 15) and ten experienced osteopaths (n = 10) manually palpated the levels of the PSIS in one model nine consecutive times. A hidden 5 mm heel wedge was used to alter the height of the PSIS which was hidden from the examiners. Scores were analysed using Fleiss Kappa (Fκ) statistics and one way analysis of variance on ranks (ANOVA). All three groups produced Fκ results below 0.4 (0.025-0.065), indicating poor inter-examiner reliability. Fκ values less than 0.4 are considered to be clinically unreliable. ANOVA testing did not show any significant difference between groups. This study showed 'poor' inter-examiner reliability in detecting asymmetries of the PSIS. This is in accordance with other studies in the field. It is suggested that the inclusion of this osteopathic model within osteopathic education should be reviewed.

Reliability of physical examination to assess asymmetry of anatomical landmarks indicative of pelvic somatic dysfunction in subjects with and without low back pain

Objective To investigate the intra-examiner and inter-examiner reliability of physical examination to identify asymmetry of selected anatomical landmarks indicative of pelvic somatic dysfunction in subjects with and without low back pain using experienced osteopaths and final year students of osteopathy. Methods Four examiners (two students, two osteopaths) examined a sample of symptomatic ( n = 5) and asymptomatic ( n = 4) subjects for symmetry of anatomical landmarks indicative of pelvic somatic dysfunction. Two assessments of symmetry and alignment of the posterior superior iliac spine (PSIS), sacral sulcus, sacral inferior lateral angle (ILA) in posterior–anterior (ILA-P) and inferior–superior (ILA-I) directions, anterior superior iliac spine (ASIS), and medial malleoli were performed on every subject by all four examiners. Intra-examiner and inter-examiner reliability was analysed with kappa ( κ) and reported in conjunction with observed agreement ( P o). Results Estimates of intra-examiner reliability ranged from κ = −0.29 to 1.0 (PSIS κ = −0.29 to 0.39; sacral sulcus κ = −0.28 to 0.83; ILA-P κ = −0.29 to 0.44; ILA-I κ = −0.29 to 0.34; ASIS κ = 0.25–0.63; medial malleoli κ = 0.20–1.0) and were higher than estimates of inter-examiner reliability. Inter-examiner reliability estimates ranged from κ = −0.38 to 0.51 (PSIS κ = −0.38 to 0.35; sacral sulcus κ = −0.34 to 0.26; ILA-P κ = −0.18 to 0.51; ILA-I κ = −0.13 to 0.36; ASIS κ = −0.13 to 0.50; medial malleolus κ = −0.05 to 0.49). The median observed agreement between examiners for each anatomical landmark ranged from 33 to 50%. Osteopaths were more reliable on measures of the inferior lateral angle (ILA-P), while students were more reliable on measures of the sacral sulcus. Conclusion In this study, the reliability of physical examination for anatomical landmarks indicative of pelvic somatic dysfunction was generally found to be low. Differences between the reliability of experienced osteopaths and final year osteopathy students were negligible. Examiners were most reliable in their assessment of the ASIS and medial malleolus; however, these estimates were not consistent and were too low to be considered clinically useful.

The effectiveness of acupuncture for non-specific low back pain - a randomised, double-blind, placebo controlled trial with 3-month follow-up

How practitioners conceive clinical practice influences many aspects of their clinical work including how they view knowledge, clinical decision-making, and their actions. Osteopaths have relied upon the philosophical and theoretical foundations upon which the profession was built to guide clinical practice. However, it is currently unknown how osteopaths conceive clinical practice, and how these conceptions develop and influence their clinical work. This paper reports the conceptions of practice of experienced osteopaths in the UK.A constructivist grounded theory approach was taken in this study. The constant comparative method of analysis was used to code and analyse data. Purposive sampling was employed to initially select participants. Subsequent theoretical sampling, informed by data analysis, allowed specific participants to be sampled. Data collection methods involved semi-structured interviews and non-participant observation of practitioners during a patient appointment, which was video-recorded and followed by a video-prompted reflective interview.Participants' conception of practice lay on a continuum, from technical rationality to professional artistry and the development of which was influenced by their educational experience, view of health and disease, epistemology of practice knowledge, theory–practice relationship and their perceived therapeutic role.The findings from this study provide the first theoretical insight of osteopaths' conceptions of clinical practice and the factors which influence such conceptions.