So how do we justify our approach as cost effective?  

a drug may contain multiple ingredients and  testing those ingredients in isolation may not give you many clues regarding the drug's effectiveness, moreover, if the drug has been designed specifically for that patient, it may not tell you how well that combination will work for another patient, in addition there is the placebo effect

Is it time to recognise that the placebo as a reference against which to measure non-chemical interventions is nonsense?  When we try and break down a complex and unique intervention into individual elements so that they can be tested against someone having ostensibly a similar experience minus that intervention that becomes so artificial it is pseudoscience and importantly disregards the nature of osteopathy.  Osteopathy is not defined by 'cracking' joints or by craniosacral therapy or by any particular technique.  It is not the same thing to everyone...which makes things very difficult...but it is not about the techniques used, at least not at a granular level.

Without looking up the latest agreed definition (which probably comes from the US where they do both more..and less... as osteopaths than the UK tradition)  I would say that at its heart osteopathy is about using non-pharmaceutical techniques to treat people with dysfunctions that are  largely (but not exclusively) musculoskeletal.    A T Still the originator of osteopathy created it in response to the deaths of three of his children from meninigitis and saw it as a full system of medicine in opposition to the brutal heroic medicine practiced at the time and believed that a body free of osteopathic lesions would be a body that could resist disease in all its forms.  There are many possible applications for osteopathy and the boundaries of what it is appropriate to say we treat are contentious...so lets start with the basics...musculoskeletal issues.

Whilst I said that osteopathy is not the sum of the techniques used I think it is useful to think about they might constitute:

• soft-tissue techniques (to work on muscles etc, perhaps massage, MET, stretches)
• articulation (repeated and gently increasing movements through a joint's range of motion)
• techniques applied to joints and muscles (functional, strain-counterstrain, Still techniques perhaps medical acupuncture)
• exercise prescription
• lifestyle advice
• referal to other specialists
• retraining concious  thinking about health beliefs (it is safe to move, I am not my pain)
• retraining the nervous system to allow movement (subconcious it is safe to move)
• manipulations/high velocity thrusts ('cracking' joints to overide inappropriate guarding)
• cranial osteopathy / involuntary motion / craniosacral
• pharmaceutical intervention  - only applicable to osteopaths who are also medcal doctors, few in the UK, nearly all in the US

All bar the last three are fairly uncontentious within our community and would to a greater or lesser extent be part of the armoury of most osteopaths.   There are; however, schisms about the last three, such that I would argue adherents to each provide a subtantially different service to those who don't, so whilst I don't believe in testing different techniques separately I do think there is some mileage in testing the major types of osteopath separately .

I want to separate out pharmaceutical intervention.  It doesn't form much of UK practice whereas it is almost ubiquitous in the US.  It is not part of the uniqueness of osteopathy even if at some time it would be useful to understand how effective co-treatment could be.

Cranial osteopaths and those who use lots of manipulations are almost mutually exclusive, both eyeing the other with a degree of suspicion and in the middle there are osteopaths who may use little or none of either and can sometimes be quite sniffy about both

Where I am heading with this is that it would be useful to classify osteopaths into different cohorts, in order to assess their effectiveness for patients with particular and that perhaps the faultlines broadly fall into three categories

1. Those who often use manipulations and rarely use cranial osteopathy
2. Those who often use cranial osteopathy and rarely use manipulations
3. Those who rarely use either

These could be worked up into statements about the type osteopathy we practice and osteopaths could be encouraged to choose the statement that best suits them.

Then, part two,  we need to work out what they are treating, and in this we should avoid over medicalisation.  Luckily this is already happening.  Diagaoses such as non-specific low back pain are more honest than trying to pin the cause on a particular structure or tissue, at least when there has been no trauma 

Thirdly there are different cohorts of patients, do we split them by age, lifestyle factors, health beliefs, chronicity, co-morbitities etc

It's a pretty complicated matrix but in my opinion if we want to truly test how effective an osteopathic approach to treatment is then that is what we need to work towards , in the meantime my fear is that a less granular approach risks throwing the baby out with the bathwater and that would be a terrible shame...and not evidence based medicine

Osteopathy, when performed at least moderately competently is reactive, not prescriptive.  The osteopath is constantly monitoring the structure, the tissue on whch they are working feeling for a return to normality, or the sense that no further change will be forthcoming, the technique, used by the practitioner to achieve the change may well be constantly changing fractionally in response to the perceived needs of the patient's body.

Moreover osteopathy tends to treat very widely, both physically, 'the knee may have a strain of the medial collateral ligament but is that because there is a problem with foot and ankle mechanics and that is causing a gait pattern thatcauses that or is preventing it from healing...is that also then causing an assymetry in the back which may be leading to other problems?'...and beyond, 'is this patient cycling and reinforcing this bad pattern, have they recently split up with their partner and sleeping on the sofa and the poor sleep is affecting their recovery?' (note I am not saying we do the work of counsellors but we do provide a listening ear).

This creates a problem.  How do we measure the effectiveness of interventions so that we can compare and understand what works and what doesn't?  Our interventions are complex and multifaceted.  What is the active ingredient in osteopathy and what is placebo?  How do we determine which part of our treatment is effective and which part is a waste of our time and the patient's, insurance company or NHS's money?

It is made all the more complicated by the fact that osteopathy is a broad church.   There are some osteopaths who only use very gentle techniques such as functional techiques and cranial osteopathy, others including me prefer, where it is safe to put some force through a joint or work on it persistantly until it starts moving.  I've had effective treatments from both modalities but I've also had patients who have had multiple 'gentle' treatments to no effect and have improved massively from one treatment using more direct techniques.  Is that down to the previous osteopath's personal competence, the general effectveness of those 'gentle' techniques or just a mismatch between that patient's need and the type of treatment they got...That may include some element of 'placebo' as they felt like I was doing something, whereas they were not convinced the other treatment did.   (I do treat more gently when the patient doesn't want or isn't appropriate for a direct approach...and sometimes refer when I tihnk they would be better suited elsewhere).

So how do we measure osteopathy?   More on that next time