Abstract
Osteopathy (manipulative care provided by foreign-trained osteopaths) emphasizes manual techniques as the cornerstone of patient care. Although osteopathic medicine has been well integrated into traditional health care systems in the United States, little is known about the role of osteopathy in traditional health care systems outside the United States. Therefore, it is incumbent on the osteopathy community to gather evidence in order to practice scientifically informed effective methods. This narrative review outlines the Cynefin framework for clinical reasoning and decision-making and encourages a broadening of the evidence base among osteopaths to promote health in an interdisciplinary care setting. This review also presents the concept of an osteopath's mindline, in which the osteopath combines information from a range of sources into internalized and collectively reinforced tacit guidelines.
Public health is achievable through the science and art of preventing disease, prolonging life, and promoting health.
1 The major causes of chronic illness and death can be directly related to excessive behavioral, environmental, and social stress.
2,3 To promote more holistic person-centered health care,
4,5 the theory of Adaptive Health Practice
6 was designed to incorporate a personalized approach to health care and to motivate behaviors needed to confront challenges to reducing those stresses.
7 To resolve complex illness, the World Health Organization suggests that health care systems should focus on improving different components of an individual's health over the disease that affects him or her
8 and integrating adjunctive approaches to traditional medicine.
9
Osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-trained osteopaths) is considered useful for conditions such as acute and chronic nonspecific low back pain, dysfunctional disorders in pregnancy, headaches, irritable bowel syndrome, and chronic respiratory disorders.
10 Osteopathic manipulative therapy has also been shown to reduce the length of hospital stay and costs in a large population of preterm infants
11 and to promote relevant neurophysiologic effects in terms of cortical plasticity.
12 Although positive effects were found in psychological, neurologic, and chronic inflammatory disease management,
13-15 as well as in the fields of gynecology and obstetrics,
16 further investigations with more pragmatic methods are recommended to obtain solid and generalizable results.
17,18 Moreover, the differences in osteopathic practice between the United States and the rest of the world need to be considered.
19,20 Osteopaths may need to implement new standards for osteopathic education and practice,
21 integrating evidence-informed and anecdotal perspectives
20 and paying attention to the distinct components and roles of the non-US osteopathic profession in modern integrative health care.
17,22
The Italian Register of Osteopaths produced the Italian Core Competencies Framework in Osteopathy, which is based on the Italian health care system and focuses osteopathic competencies on the important health needs of the population: promotion of health and prevention, management, and support of complex illnesses.
23 To achieve holistic and person-centered osteopathic care, it is crucial to contextualize evidence and use critical thinking to review traditional osteopathic principles and their application.
24 The framework of the 5 structure and function models
25,26 could be valuable to osteopaths for implementing scientific findings in practice and promoting an integrative approach
27 that could help patients become more resilient and autonomous promoters of their own health.
23 Although osteopathy has recently been recognized as a health profession in Italy, combining OMTh with traditional medicine has not yet occurred.
Implementation science is “the study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice . . . to improve the quality and effectiveness of health services.”
28 Complexity science, meanwhile, is “concerned with complex systems and problems that are dynamic, unpredictable and multi-dimensional.”
29 Both implementation and complexity science involve some properties of health care systems that favor more effective, evidence-informed integrated care.
30 Therefore, creating proposals and discussions about clinical reasoning and the distinctive role of osteopaths in health care processes is paramount to adapting an implementation science intervention to osteopathy. Working with the osteopathic community could facilitate ways to get osteopaths on board with an evidence-informed intervention by leading it, reflecting on progress among stakeholders, and providing feedback to participants to help embrace implementation over time. Osteopaths do not typically work with explicit codified knowledge or guidelines, but instead use knowledge in practice, combining information from a wide range of sources into internalized and collectively reinforced tacit guidelines, or
mindlines, to inform their practice.
31
In the present review, we sought to introduce a complex medical framework
32 in osteopathic models of care that provides a common language of reference and a multidimensional-complexity-informed model to draw appropriate conclusions for insight, decisions, and actions. Through this framework, we encourage deep reflection in the osteopathy community to establish a common clinical reasoning and decision-making process that aligns with risk-based thinking and promotes health in an interdisciplinary care setting. We also describe our mindlines
31 (
Figure 1) as an example of osteopathic practice that needs to be negotiated through a range of informal interactions in free-flowing communities of practice, experience with patients, and consensus workshops. The resulting construct will be a day-to-day evidence-informed practice based on socially constituted knowledge.
Pattern recognition and hypotheticodeductive reasoning are the foundations of the intuitive and the analytical systems, respectively.
53 Osteopaths, like other health care professionals, mainly adopt both pattern recognition and hypotheticodeductive approaches as part of their diagnostic reasoning, which depends on the perceived level of complexity of the patient presentation.
54,55 The recommendations on perceptual training described in several articles
53,55,56 can be gradually applied by osteopaths who adopt domains of complexity to aid with decision-making. When the patient-osteopath relationship is located in the simple domain, an osteopath is anchored with routine and previously used patterns. Osteopaths seek confirmation with tried and tested ways of diagnosis and management. Liem
53 reported that there is little room for experimentation and originality within the simple domain.
Osteopaths operating in the complicated domain must be open and inquisitive. In the complex domain, osteopaths move out of their limited frame of reference and attempt to see the world through the patient's eyes because being empathetic with patients may bring radical new insights.
53 In the chaotic domain, osteopaths begin to perceive the fullness of information that emerges at each moment of perception and can draw from their reliable and trustworthy intuition to evolve and foster innovation at all levels.
53
Improving the awareness and development of intuitive processes in practical decision-making of both osteopaths and osteopathic students should be introduced in teaching and learning processes. The introduction to these concepts will improve “reliance on intuition” or “problem-oriented” strategies and launch CF to develop clinical reasoning in osteopathic education.
53,56
The CF is a useful tool for classifying a system's complexities and its environment. The framework does not tell us how to solve problems or give a solution. Instead, the CF points out in which domain the patient-osteopath relationship is located, and it gives no suggestions for shifting domains. The most interesting element in the CF is the differentiation between the complicated and the complex domains. The analytical approach adopted in the complicated domain does not work in all cases because the osteopath is required to stick to the analytical model. This is the typical guideline-focused approach aimed to manage an aspect of a disease on the basis of protocols derived from research studies and established treatment recommendations.
54
On the contrary, the osteopath applying clinical reasoning in the complex domain has no model available to predetermine all aspects of the process. Treatment is directed to all components related to the patient's adaptive capacity (eg, fascial system alterations, somatic dysfunctions, behavioral habits) that emerge as clinically relevant for the patient's presentation and state of health. In the complex domain, both patient and osteopath can share a high-value experience, which can be investigated through the patient's narrative and understood by decoding a metaphorical language: not just what the patient says but what the patient does not say and what the patient's body language communicates. The complex domain calls for the recognition of system behavior patterns that may evoke adequate models of salutogenic interaction with the whole person. Consequently, it is up to the osteopath to understand the complexity of the person–environment–health system and use their skills to contextualize the available scientific literature in their clinical practice. In particular, osteopaths should refer to research studies that address the effects of OMTh and related manipulation sources on physical parameters and physiological functions involved in causes, maintenance, or aggravation of different disorders.
Clinical and diagnostic reasoning must be better understood and incorporated into osteopathic practice and education to ensure patient safety and optimal care.
56 Osteopathic educational institutions should actively promote the basic understanding of the dual-process theory and facilitate this process. The institutions should also include case-based learning approaches during training and postgraduate mentorship programs to reinforce the acquisition of clinically relevant patterns (
Table 2).
56 Because decision-making habits of osteopaths remain relatively unexplored, it is necessary to design experimental and qualitative research to obtain a common framework and develop teaching programs and clinical practice.
55 Therefore, as proven by other health-related practice research such as ergonomics,
57 the CF could also be a powerful tool for advancing decision-making processes and establishing practiced based in complexity science in the field of osteopathy.
32
Table 2.
Allostatic Overload Index Involved in the Decision-Making Process in the Practice of Osteopathya
Identifiers | Examples |
Markers | |
Biomarkers | Neuroendocrine, metabolic, immunologic markers42,43 |
Psychomarkers | Body perception questionnaire-short form44; depression, anxiety and stress scales45; salutogenesis index (sense of coherence questionnaires)39 |
Life markers | Social Readjustment Rating Scale46 |
Self-Regulation Systems Functional Tests | |
Biomechanical | Postural control test47 |
Neurologic | Manual assessments of central sensitization48 and autonomic nervous system tone49 |
Respiratory-circulatory | Manual assessment of respiratory motion50 and examination of the amplitude of the peripheral pulses, considering its relationship with arterial stiffness49 |
Metabolic | Gastrointestinal distress signs49 |
Psychosocial | Waddell signs51 |
Table 2.
Allostatic Overload Index Involved in the Decision-Making Process in the Practice of Osteopathya
Identifiers | Examples |
Markers | |
Biomarkers | Neuroendocrine, metabolic, immunologic markers42,43 |
Psychomarkers | Body perception questionnaire-short form44; depression, anxiety and stress scales45; salutogenesis index (sense of coherence questionnaires)39 |
Life markers | Social Readjustment Rating Scale46 |
Self-Regulation Systems Functional Tests | |
Biomechanical | Postural control test47 |
Neurologic | Manual assessments of central sensitization48 and autonomic nervous system tone49 |
Respiratory-circulatory | Manual assessment of respiratory motion50 and examination of the amplitude of the peripheral pulses, considering its relationship with arterial stiffness49 |
Metabolic | Gastrointestinal distress signs49 |
Psychosocial | Waddell signs51 |
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