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Osteopathy: effectiveness and safety for musculoskeletal pain and overview of training and quality requirements. AIHTA Project Report No.: 144 2022
Gassner, L. [2]
Hofer, V. [2]

Journal: HTA Austria – Austrian Institute for Health Technology Assessment GmbH Date: 2022/11, Pages: 152, type of study: systematic review

Free full text   (https://eprints.aihta.at/1416/1/HTA-Projektbericht_Nr.144.pdf)

Keywords:

foot pain [2]
shoulder pain [24]
neck pain [132]
back pain [493]
fibromyalgia [31]
musculoskeletal system [28]
health technology assessment [1]
systematic review [297]
OMT [2951]
osteopathic manipulative treatment [2973]

Abstract:

Background: Osteopathy aims to holistically improve and support all health aspects. Mainly patients with musculoskeletal conditions and pain are treated. Internationally, there is little formal, routinely gathered information about the osteopathic practice. Osteopathy has no consistent regulation, education, and practice standards. In Austria, osteopathy is unregulated, but regulations are being discussed or have already been introduced in other countries. Currently, os- teopathic services are not covered by health insurance in Austria. Due to the increasing supply and demand of osteopathic treatments for different indications, the question arises whether the public sector should pay for the services of osteopaths in the future. However, the effectiveness and safety of osteopathy in treating musculoskeletal pain remain unclear. Therefore, this systematic review aims to summarise the evidence on the effectiveness and safety of osteopathy in treating musculoskeletal pain (part 1) and to describe current training and quality requirements for European osteopaths (part 2). Methods: For part 1, a systematic literature search for randomised controlled trials (RCTs) was conducted in five databases. 964 citations were identified and screened by two researchers independently. 35 relevant references were iden- tified. For each body region and disease, we selected the best available evidence assessed by the ‘Cochrane Collaboration’s tool’ version 1. We included 15 RCTs from the systematic search for the analysis and synthesis, covering the following body regions and diseases: neck, neck or (lower) back (mixed population), shoulder, knee, foot, fibromyalgia and osteoporosis. Additionally, we summarised a recent systematic review and meta-analysis for chronic non-specific low-back pain, which we critically appraised using the AMSTAR 2 tool (A MeaSurement Tool to Assess systematic Reviews). For the country selection of part 2, we chose the German-speaking countries Austria, Switzerland and Germany as well as other European countries that met the following inclusion criteria: existence of a national association for osteopaths, legal regulation for the practice of osteopathy existing or currently in progress, population of >5.5 million. A targeted manual search for training and quality requirements for osteopaths in the ten selected countries was con- ducted in different sources (e.g. PubMed, Trip medical database). Experts were contacted to further identify and complete the country’s information. Results: The results of this review suggest that osteopathic treatment represents a safe therapeutic choice for musculoskeletal pain in the analysed eight body regions and diseases, as only very few patients reported minor adverse events. Statistically significant inter-group improvements in favour of the osteopathic group indicate that osteopathy can be considered in patients suffering from neck pain as short- and mid-term (up to 3 months) effects, and some clinically meaningful reductions in pain were observed. However, long-term effects are missing, and the results for other outcomes, such as functionality or quality of life, were inconclusive. For chronic low back pain, a recent systematic review and meta-analysis concluded that osteopathic treatment reduced pain immediately after treatment and at the mid-term follow-up (FU) (i.e. 3 months). Functionality was improved immediately after treatment but not at the FU assessment. It seems that foot pain can possibly be reduced in the mid-term by osteopathic treatment. Also, a clinically meaningful improvement was found. For shoulder pain, short-, mid-, and long-term inter-group effects could be observed in one study but not in the other trial. However, pre-post improvements and clinically meaningful intra-group improvements in the osteopathic treatment group were found in the other study. The results for all other body regions and diseases (i.e. neck or (lower) back, knee, osteoporosis, fibromyalgia) are inconclusive, no or only immediate effects were found, or the evidence is insufficient to make a statement. No statistically or clinically significant deteriorations occurred due to osteopathic interventions. Concerning the regulatory status and quality requirements, ten countries (Austria, Germany, Switzerland, Norway, Denmark, France, Italy, Finland, Portugal and the United Kingdom) were analysed. A legal regulation exists in seven countries, and the title ‘osteopath’ is fully protected in six of the ten countries. However, different training and study options for osteopathy exist in the included countries, varying in their curricula. A Bachelor of science as a minimum of education is prescribed in five countries. Osteopaths particularly work in private practices, and osteopathic therapies are mainly covered by private insurance. The European Federation & Forum for Osteopathy (EFFO), the osteopaths’ lead professional associations and regulatory author- ities, aims to establish regulation, standards, and recognition for osteopaths. Two international standards exist for osteopathy: the World Health Organisation (WHO) Benchmark for Training in Osteopathy and the European Standard on osteopathic healthcare provision (EN16686). Discussion: Most patients consult osteopaths because of pain in the musculoskeletal system. Neck and low back pain represent the largest proportion. The WHO also stated in a recent report that neck and back pain is the main cause of years lived with disability worldwide. The results of this review strengthen the evidence that osteopathic treatment represents a safe therapeutic choice, as only very few patients reported minor adverse events. Osteopathy can be considered in patients suffering from neck and low back pain. Further published systematic reviews and meta-analyses underline this finding. It seems that also shoulder and foot pain can possibly be reduced by osteopathic treatments. To evaluate the validity of the synthesis from the 15 included studies, we compared the main results (i.e. of the primary outcome pain) with the excluded studies, which did not reveal any significant deviations. Statistically significant effects can be found in all categories of length of FUs; also in two of three studies after only one session of osteopathy. The RoB of the 15 in- cluded RCTs was unclear to high. Serious limitations of the studies were given due to the lack of patient and assessor/therapist blinding. However, the nature of osteopathy hardly allows blinding those who deliver or receive it. The systematic review on chronic non-specific low back pain was rated with high overall confidence; however, none of the included RCTs showed a low RoB. Heterogeneity of the included RCTs, such as professions involved, comparison, number of sessions, treatment period and FUs, might have influenced the results. Furthermore, many different outcome measurements were used for assessing the outcomes. In seven of the 15 included RCTs, clinically meaningful improvements were observed. However, in literature, the range of the minimal clinically important difference values is broad. Discrepancies and variations of techniques were observed even inside the same typology of intervention. Though, it is essential to consider that a certain degree of variability in manual interventions is predictable in practice. This fact is even more notable in osteopathic treatment with its holistic approach because diagnosis and treatment processes are entirely based on palpatory findings. Osteopathic techniques vary in their application and frequency from country to country. It is, therefore, not known whether the treatment approaches used in different countries are comparable. The ten analysed European countries have different training and quality requirements for osteopaths. However, in most of these countries – in contrast to Austria – legal regulation is in force, and the title ‘osteopath’ is protected. Conclusion According to the current evidence, osteopathy can improve neck and low back pain in the short- and mid-term and possibly reduce shoulder and foot pain, while there is uncertainty about its effectiveness for pain in other body regions and diseases. Regulations of the osteopathic profession are crucial to increase trust in osteopathy and ensure the safety of patients. However, before reimbursing osteopathic treatments, regulation is needed, and the title of osteopaths needs to be protected. Based on the set international standards, training and quality requirements must be adapted for Austria to meet the international standards for osteopathy. The information collected in this report as well as the Benchmark documents should be used to inform and guide the regulatory process in Austria.

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