Osteopathy is part of the medical art

How does an osteopath practise ?

Osteopathy is part of the medical art whose scope can clearly be defined with regard to a certain number of well-known pathologies. We can distinguish two main reasons to resort to osteopathic advice :

First it can be the spontaneous choice of the patient who voluntarily consults an osteopath when he/she suffers from a functional disturbance of the musculoskeletal system, a backache for example.
In this case, the process is initiated by the “good sense” of people.

The second reason is the clinical experimentation which shows the efficiency of osteopathy in a certain number of functional disorders.

The practice of osteopathy can sometimes be directly linked with the a-specific characteristic of osteopathy. It then opens the practice to the wide field of psychosomatic illnesses but without nevertheless claiming its monopoly. Yet it is quite possible that osteopathy, through neurophysiologic actions, can have an effect on some of these disturbances.

When a patient consults an osteopath, the reason is often linked with pain: backache, for example, caused by a functional disturbance of the musculoskeletal system.

The osteopath questions the patient first of all to eliminate any pathological process which would sooner or later require the intervention of another specialist. It is a diagnosis of exclusion.

In a clinical approach, the osteopath shows interest in orthopaedic and rheumatologic diagnosis, he/she looks for the quality of movement and he/she is interested in palpatory anatomy. Through this approach, he/she can look for the osteopathic dysfunctions before taking the decision to treat or to redirect the patient.


	"Osteopathic dysfunction is a neologism qualifying a mechanical dysfunction (a modification of stiffness), which affects a living structure (most of the time a joint), and which can be felt through touch." (Definition of the Sutherland College of Osteopathic Medicine, Namur)

It is defined as a reversible limited joint mobility. It is revealed through restricted joint amplitude within the three planes of space, it can be corrected by combining a joint decoaptation with a translatory manipulation in the opposite direction of the restriction.

Then depending on the case in hand, we need to choose among the different techniques: either functional techniques, or high-velocity and low amplitude techniques, or myotensive techniques, or a combination of these techniques.

If in all conscience, the osteopath decides to treat the patient, because the a-specific characteristic of his/her art is for him/her perfectly adapted to the situation and because he/she has all the reasons to hope for an improvement of the objective characteristics of the illness, he/she might in parallel and without expecting it observe the improvement of other pathological aspects of the patient, aspects which had first not been considered. For example, a patient treated for backache could show an improvement on his/her intestinal transit or sleep. It is what we call the a-specific aspect of osteopathy.

It is obvious that this observation would not in any case justify considering insomnia or constipation as an indication for osteopathic treatment. To assert such a thing, experimental protocols must exist that are based on physiopathological hypotheses, these hypotheses being backed up by arguments and then proven.

The medical institution often criticizes the “holistic” characteristic of osteopathy, claiming that holism is not scientifically founded. Such an assertion does not make much sense.

The definition of holism is the realization that any analytical approach of a whole does not give the comprehension of the whole. In other terms, the whole is not equal to the sum of all its parts. Scientifics have even called this “reductionism”, which is inherent to the scientific approach.

In medicine, it means that when a patient consults an osteopath, the latter can never in all conscience reduce the patient to his/her illness without ignoring that a whole range of parameters conditioning his/her “ill-being” defies all investigation.

This is the very principle of diagnosis and anamnesis, characteristic of any art of healing.

The clinical method must be “holistic”: it must take into consideration the psyche, the personality and the environment. What underlies or encompasses the osteopathic dysfunction must be taken into account.

The osteopath does not pretend to possess all parameters but he/she pretends to take into consideration the inevitable uncertainty of the human clinical study and the global expectations of the patient. It implies that during the osteopath’s training, great attention must be given to human sciences as much as to fundamental sciences. Analytic knowledge and a global approach are required and most of all, students need to learn how to manage doubt.

Training of osteopaths

In our society, osteopaths must take into consideration the socio-professional realities as well as the requirements of the osteopathic art. They will not seek to multiply the treatment techniques and will not try to substitute for all the medical techniques. It would be impossible anyway. Their hope is to find their place, to be complementary in the middle of various medical approaches, practices of the art of healing and health professions with a high degree of responsibility.

The training of the osteopath must therefore consist in :

A training of university level in modern biomedical sciences in order to learn the limits and the scope of the profession (as for dentists, for example).

It must be a complete curriculum, similar to the one taught in medicine but not necessarily identical. In the opinion of the Académie d’Ostéopathie de Belgique, all the courses on medication given to future physicians could be reduced for future osteopaths. On the other hand, human biomechanics, movement analysis, neurophysiology of touch should be more developed than in the present medical educational programme.

Then considering the a-specific nature of the art, which the osteopath is aware of and claims to use, it is essential that human sciences be particularly developed in the curriculum, for different reasons:

First, developing a critical mind is essential in order to avoid esoteric deviations which sometimes come from the history of the profession. Only History lets us know what pertains to History and enables us to be critical of what happened yesterday. Still, the founder of osteopathy is not a god, he is a founder and his words are not the “Bible”. Detachment is indispensable and implies the necessity of courses in epistemology, history and philosophy of sciences. A thesis is also required at the end of the studies in accordance with the scientific method.

Next is the concern of efficacy. The importance of quality in the relationship practitioner-patient also requires studying psychology, psychosomatics and cultural anthropology.
Then: ethics. Touch has a strong symbolic connotation from an affective point of view. It is fundamental to manage this aspect. It requires courses in ethics.

Finally there is the practical training. Let’s not forget that osteopathy is also and primarily a practice, like surgery. The multiplicity of masters is essential. Pluralism in the approaches brings more quality. It is one of the first conditions. It is important for a student to be confronted during his/her training to different masters’ practice before he/she can develop his/her own practice. Once more, this is true for all practitioners of a medical specialty.

Education

Basic principles and ethics

Osteopathic studies must train health practitioners with a high level of responsibility, that is to say men (and women) with ethical responsibility, with a big heart for the suffering being and with empathy: for a health practitioner with a high level of responsibility, the physical and biological integrity of “the other” is of utmost importance !

To be that much open to others does not leave much place for corporatism but it is nevertheless very present in the medical profession (osteopaths included). Most of all, it leaves out the possibility to teach that the defense of our ideas is more important than the pragmatic interest for the patient. In other terms, the thought of Still or Sutherland cannot be taught without any reference to history. The risk would be to fall in fanatic dogmatism, in a medical ideology out of reality, which we still too often meet in certain osteopathic colleges.

Only sects always try to justify their fancies through a tradition we cannot avoid without risking the wrath of God. A longstanding tradition leads to sectarism, to the idea we found the “truth”, like a chosen people or a people of initiates. Such a vision does not leave any place to the patient’s reality. His/her reality has to submit to the dominant theory. To teach the history of a profession, one needs to think about it intelligently because only in history is “hermeneutics” possible, the interpretation of the “truths” of a time in the context of this period, in the context of the technological possibilities and the socio-economical realities of the time when these truths were put forward.

Education has thus to be oriented on the praxis of osteopathy because the osteopathic therapeutic approach is based on traditional techniques whose everyday experience shows their value for the health of our patients and for which, until we find proof to the contrary, no iatrogenous effects have been found.
The lack of rigorous explanations of our clinical effects does not justify, in such a context, that we should abandon our techniques, even our “cranial” techniques! It is not because there is no satisfactory explanation that their action should be suspended. Fortunately, medicine has not waited for the mechanisms governing the aspirin’ s effect to be explained or for the genetic mechanisms governing the antibiotics’ effect to be understood to prescribe them. However, the fact that our techniques are meant for the health of our fellow citizens implies the moral obligation to investigate how our clinical effects work.
The recognition of the empirical characteristic of our knowledge forces the schools to give a very accurate training in basic medical matters. The training needs to be regularly updated and to be taught by competent people. To confront reality, students need an exhaustive clinical training. They will also learn the principles of the scientific method. So they will be able to develop a critical mind and to make their own contribution to the comprehension of their art.

It is nevertheless is in the interest of everyone and most of all in the patient’s interest to do everything possible to question whether our actions are relevant and to seek an answer in strict scientific methods, whatever level of the pathology we address. But in medicine, scientific cold rigour cannot be sufficient; it cannot be with complete impunity a substitute for the medical art. Already in his time, “Doctor” Rabelais reminded us that “science without conscience is ruin of the soul”, the necessary “objectivation” of the patient that Experimental and Reductionist sciences have implied, may not deny, to the only benefit of the illness, the ill “subject” itself. Osteopathy as it was handed down to us, regains all its wealth in helping medicine with its subjectivising and globalist clinical philosophy to become, according to the words of Jean-Pierre Lebrun, “the science to treat subjects”.

The hand of the osteopath is in perpetual dialogue with corporeity, which often brings to the surface occulted elements which are nevertheless determining factors in a better comprehension of the patient. It immediately leads to the conclusion that a psychological training is really necessary for our students who must be able to manage all this information. This systemic and holistic dimension of our clinic is certainly the major contribution of osteopathy to the medical practice.
In conclusion, no matter the origin of the movement, there is only one way which can guide us and on which the academic and pedagogical reflection on the education of medicine can be based: the patient’s interest is superior. Such an approach will triumph over all forms of corporatism. It is indispensable because it is based on ethics.

Extracts from the article by Yves Lepers, DO “L’enseignement de l’ostéopathie et ses fondements éthiques” in 1997 in the journal of the SBO – UP “About Osteoapthy”, special student number.