Benchmarks for training

in traditional / complementary
and alternative medicine

Benchmarks for Training in Osteopathy

WHO Library Cataloguing-in-Publication Data

Benchmarks for training in traditional /complementary and alternative

medicine: benchmarks for training in osteopathy.

1.Osteopathic medicine. 2.Complementary therapies. 3.Benchmarking.

4.Education. I.World Health Organization.

ISBN 978 92 4 159966 5 (NLM classification: WB 940)

© World Health Organization 2010

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 Contents

Contents

Contents .......................................................................................................................... iii

Acknowledgements ........................................................................................................ v

Foreword........................................................................................................................ vii

Preface .............................................................................................................................. ix

Introduction ..................................................................................................................... 1

1. The basic principles of osteopathy ...................................................................... 3

1.1 Philosophy and characteristics of osteopathy.................................................. 3
1.2 Structure-function relationship models ............................................................ 4

2. Training of osteopathic practitioners.................................................................. 7

2.1 Categories of training programmes................................................................... 7
2.2 Core competencies ............................................................................................... 8
2.3 Benchmark training curriculum for osteopathy .............................................. 8
2.4 Adaptation of Type I to Type II programmes................................................ 10

3. Safety issues........................................................................................................... 15
3.1 Contraindications to direct techniques ........................................................... 15
3.2 Contraindications to indirect, fluid, balancing and reflex-based
techniques ........................................................................................................... 16

References....................................................................................................................... 19

Annex: WHO Consultation on Osteopathy, Milan, Italy,

26–28 February 2007: list of participants................................................................... 21

iii
Benchmarks for training in osteopathy

iv
 Acknowledgements

Acknowledgements

The World Health Organization (WHO) greatly appreciates the financial and
technical support provided by the Regional Government of Lombardy, Italy, for
the development and publication of the basic training documents, as part of the
implementation of collaborative projects with WHO in the field of traditional
medicine. The Regional Government of Lombardy kindly hosted and provided
financial support for the WHO Consultation on Osteopathy, held in Milan, Italy
in February 2007.

WHO also wishes to express its sincere appreciation to Dr Jane Carreiro, College
of Osteopathic Medicine, University of New England, Maine, United States of
America, for the preparation of the original text.

WHO acknowledges its indebtedness to over 200 reviewers, including experts

and national authorities as well as professional and nongovernmental
organizations, in 57 countries who provided comments and advice on the draft
text.

Special thanks are due to the participants of the WHO Consultation on

Osteopathy (see Annex) who worked towards reviewing and finalizing the draft
text, and to the WHO Collaborating Centre for Traditional Medicine at the State
University of Milan, Italy, in particular to Professor Umberto Solimene, Director,
and Professor Emilio Minelli, Deputy Director, for their support to WHO in
organizing the Consultation.

v
Benchmarks for training in osteopathy

vi
 Foreword

Foreword

The oldest existing therapeutic systems used by humanity for health and well-
being are called Traditional Medicine or Complementary and Alternative
Medicine (TM/CAM).

Increasingly, TM/CAM is being formally used within existing health-care

systems. When practised correctly, TM/CAM can help protect and improve
citizens’ health and well-being. The appropriate use of TM/CAM therapies and
products, however, requires consideration of issues of safety, efficacy and
quality. This is the basis of consumer protection and is no different, in principle,
from what underpins modern medical practice. Upholding basic requirements
for the modern practice of TM/CAM therapies can support national health
authorities in the establishment of adequate laws, rules, and licensing practices.

These considerations have guided the work of the Regional Government of

Lombardy in TM/CAM which was first included in the Regional Health Plan
2002-2004. Clinical and observational studies in the region of Lombardy have
provided a crucial step in the evaluation of TM/CAM. With the help of data
from these studies, a series of governmental provisions have been used to create
a framework for the protection of consumers and providers. The cornerstone of
this process was the first Memorandum of Understanding (MOU) for the
Quadrennial Cooperation Plan which was signed between the Regional
Government of Lombardy and the World Health Organization. The MOU
highlighted the need for certain criteria to be met including: the rational use of
TM/CAM by consumers; good practice; quality; safety; and the promotion of
clinical and observational studies of TM/CAM. When they were published in
2004, the WHO guidelines for developing consumer information on proper use of
traditional, complementary, and alternative medicine were incorporated into this first
MOU.

In the region of Lombardy, citizens currently play an active role in their health-
care choices. The awareness of the advantages as well as of the risks of every type
of care is therefore critical, also when a citizen actively chooses to use TM/CAM.
Consumers have begun to raise new questions related to the safe and effective
treatment by all providers of TM/CAM. For this reason, the Regional
Government of Lombardy closely follows WHO guidelines on qualified practice
of TM/CAM in order to guarantee appropriate use through the creation of laws
and regulations on skills, quality control, and safety and efficacy of products, and
clear guidelines about practitioner qualifications. The Regional Government of
Lombardy has also provided support and cooperated with WHO in developing
this series of benchmark documents for selected popularly used TM/CAM
therapies including Ayurveda, naturopathy, Nuad Thai, osteopathy, traditional
Chinese medicine, Tuina, and Unani medicine.

Modern scientific practice requires a product or a therapeutic technique to be safe

and effective, meaning that it has specific indications and evidence for care
supported by appropriate research. Practitioners, policy-makers and planners,

vii
Benchmarks for training in osteopathy

both within and outside ministries of health, are responsible for adhering to this,
in order to guarantee the safety and the efficacy of medicines and practices for
their citizens. Furthermore, safety not only relates to products or practices per se,
but also to how they are used by practitioners. Therefore it is important that
policy-makers are increasingly able to standardize the training of practitioners
for it is another fundamental aspect of protecting both the providers and the
consumers.

Since 2002, the Social-Health Plan of the Lombardy Region has supported the
principle of freedom of choice among different health-care options based on
evidence and scientific data. By referring to the benchmarks in this present series
of documents, it is possible to build a strong foundation of health-care options
which will support citizens in exercising their right to make informed choices
about different styles of care and selected practices and products.

The aim of this series of benchmark documents is to ensure that TM/CAM

practices meet minimum levels of adequate knowledge, skills and awareness of
indications and contraindications. These documents may also be used to facilitate
establishing the regulation and registration of providers of TM/CAM.

Step by step we are establishing the building blocks that will ensure consumer
safety in the use of TM/CAM. The Regional Government of Lombardy hopes
that the current series will be a useful reference for health authorities worldwide,
and that these documents will support countries to establish appropriate legal
and regulatory frameworks for the practice of TM/CAM.

Luciano Bresciani Giulio Boscagli

Regional Minister of Health Regional Minister of Family
Regional Government of Lombardy and Social Solidarity
Regional Government of Lombardy

viii
 Preface

Preface

There has been a dramatic surge in popularity of the various disciplines

collectively known as traditional medicine (TM) over the past thirty years. For
example, 75% of the population in Mali and 70% in Myanmar depend on TM and
TM practitioners for primary care,1 while use has also greatly increased in many
developed countries where it is considered a part of complementary and
alternative medicine (CAM). For instance, 70% of the population in Canada2 and
80% in Germany3 have used, in their lifetime, traditional medicine under the title
complementary and alternative medicine.

Integration of traditional medicine into national health systems

Traditional medicine has strong historical and cultural roots. Particularly in

developing countries, traditional healers or practitioners would often be well-
known and respected in the local community. However, more recently, the
increasing use of traditional medicines combined with increased international
mobility means that the practice of traditional medicines therapies and
treatments is, in many cases, no longer limited to the countries of origin. This can
make it difficult to identify qualified practitioners of traditional medicine in some
countries.

One of the four main objectives of the WHO traditional medicine strategy 2002-
2005 was to support countries to integrate traditional medicine into their own
health systems. In 2003, a WHO resolution (WHA56.31) on traditional medicine
urged Member States, where appropriate, to formulate and implement national
policies and regulations on traditional and complementary and alternative
medicine to support their proper use. Further, Member States were urged to
integrate TM/CAM into their national health-care systems, depending on their
relevant national situations.

Later in 2003, the results of a global survey on policies for TM/CAM conducted
by WHO showed that the implementation of the strategy is making headway.
For example, the number of Member States reporting that they have a national
policy on traditional medicine rose from five in 1990, to 39 in 2003, and to 48 in
2007. Member States with regulations on herbal medicines rose from 14 in 1986,
to 80 in 2003, and to 110 in 2007. Member States with national research institutes
of traditional medicine or herbal medicines rose from 12 in 1970, to 56 in 2003,
and to 62 in 2007.4

1
Presentation by the Governments of Mali and Myanmar at the Congress on Traditional
Medicine, Beijing, People’s Republic of China, 7-9 November 2008.
2
Perspectives on Complementary and Alternative Health Care, a collection of papers
prepared for Health Canada, Ottawa, Health Canada, 2001.
3
Annette Tuffs Heidelberg. Three out of four Germans have used complementary or
natural remedies, British Medical Journal 2002, 325:990 (2 November).
4
WHO medicines strategy 2008-2013 and Report from a WHO global survey on national
policy on traditional medicine and regulation of herbal medicines, 2005.

ix
Benchmarks for training in osteopathy

Ideally, countries would blend traditional and conventional ways of providing

care in ways that make the most of the best features of each system and allow
each to compensate for weaknesses in the other. Therefore, the 2009 WHO
resolution (WHA62.13) on traditional medicine further urged Member States to
consider, where appropriate, inclusion of traditional medicine in their national
health systems. How this takes place would depend on national capacities,
priorities, legislation and circumstances. It would have to consider evidence of
safety, efficacy and quality.

Resolution WHA62.13 also urged Member States to consider, where appropriate,

establishing systems for the qualification, accreditation or licensing of
practitioners of traditional medicine. It urged Member States to assist
practitioners in upgrading their knowledge and skills in collaboration with
relevant providers of conventional care. The present series of benchmarks for
basic training for selected types of TM/CAM care is part of the implementation
of the WHO resolution. It concerns forms of TM/CAM that enjoy increasing
popularity (Ayurveda, naturopathy, Nuad Thai, osteopathy, traditional Chinese
medicine, Tuina and Unani medicine).

These benchmarks reflect what the community of practitioners in each of these

disciplines considers to be reasonable practice in training professionals to
practice the respective discipline, considering consumer protection and patient
safety as core to professional practice. They provide a reference point to which
actual practice can be compared and evaluated. The series of seven documents is
intended to:
• support countries to establish systems for the qualification, accreditation
or licensing of practitioners of traditional medicine;
• assist practitioners in upgrading their knowledge and skills in
collaboration with providers of conventional care;
• allow better communication between providers of conventional and
traditional care as well as other health professionals, medical students
and relevant researchers through appropriate training programmes;
• support integration of traditional medicine into the national health
system.

The documents describe models of training for trainees with different

backgrounds. They list contraindications identified by the community of
practitioners, so as to promote safe practice and minimize the risk of accidents.

Drafting and Consultation Process

The most elaborated material to establish benchmarks comes from the countries
where the various forms of traditional medicine under consideration originated.
These countries have established formal education or national requirements for
licensure or qualified practice. Any relevant benchmarks must refer to these
national standards and requirements.

The first stage of drafting of this series of documents was delegated to the
national authorities in the countries of origin of each of the respective forms of
traditional, complementary or alternative medicine discussed. These drafts were
then, in a second stage, distributed to more than 300 reviewers in more than 140
countries. These reviewers included experts and national health authorities,
WHO collaborating centres for traditional medicine, and relevant international

x
 Preface

and regional professional nongovernmental organizations. The documents were

then revised based on the comments and suggestions received. Finally, WHO
organized consultations for further final review, prior to editing.

Dr Xiaorui Zhang
Coordinator, Traditional Medicine
Department for Health System Governance
and Service Delivery
World Health Organization

xi
Benchmarks for training in osteopathy

xii
 Introduction

Introduction

Osteopathy was developed by Andrew Taylor Still, a physician and surgeon in

the United States of America in the mid-1800s, who established the first
independent school of osteopathy in 1892 (1,2).

Osteopathy (also called osteopathic medicine) relies on manual contact for

diagnosis and treatment (3). It respects the relationship of body, mind and spirit
in health and disease; it lays emphasis on the structural and functional integrity
of the body and the body's intrinsic tendency for self-healing. Osteopathic
practitioners use a wide variety of therapeutic manual techniques to improve
physiological function and/or support homeostasis that has been altered by
somatic (body framework) dysfunction, i.e. impaired or altered function of
related components of the somatic system; skeletal, arthrodial and myofascial
structures; and related vascular, lymphatic, and neural elements (4).

Osteopathic practitioners use their understanding of the relationship between

structure and function to optimize the body’s self-regulating, self-healing
capabilities. This holistic approach to patient care and healing is based on the
concept that a human being is a dynamic functional unit, in which all parts are
interrelated and which possesses its own self-regulatory and self-healing
mechanisms. One essential component of osteopathic health care is osteopathic
manual therapy, typically called osteopathic manipulative treatment (OMT),
which refers to an array of manipulative techniques that may be combined with
other treatments or advice, for example on diet, physical activity and posture, or
counselling. The practice of osteopathy is distinct from other health-care
professions that utilize manual techniques, such as physiotherapy or chiropractic,
despite some overlap in the techniques and interventions employed. As a hands-
on approach to patient care, osteopathy has contributed to the body of
knowledge of manual therapies and complementary and alternative medicine.

Osteopathy is practised in many countries throughout the world. In some

countries, manual therapists use osteopathic techniques and claim to provide
osteopathic treatment, although they may not have received proper training.

This document presents what the community of practitioners, experts and

regulators of osteopathy considers to be adequate levels and models for training
osteopathic practitioners, as well as for dispensers and distributors. It provides
training benchmarks for trainees with different backgrounds, as well as what the
community of practitioners of osteopathy considers being contraindications for
safe practice of osteopathy and for minimizing the risk of accidents. Together,
these can serve as a reference for national authorities wishing to establish
systems of training, examination and licensure that support the qualified practice
of osteopathy.

1
Benchmarks for training in osteopathy

2
 The basic principles of osteopathy

1. The basic principles of osteopathy

1.1 Philosophy and characteristics of osteopathy

Osteopathy provides a broad range of approaches in the maintenance of health

and the management of disease. Osteopathy is grounded in the following
principles for treatment and patient management:
• the human being is a dynamic functional unit, whose state of health is
influenced by the body, mind and spirit;
• the body possesses self-regulatory mechanisms and is naturally self-
healing;
• structure and function are interrelated at all levels of the human body.

Within that framework, osteopathic practitioners incorporate current medical

and scientific knowledge when applying osteopathic principles to patient care.
Osteopathic practitioners recognize that each patient’s clinical signs and
symptoms are the consequences of the interaction of many physical and
nonphysical factors. It emphasizes the dynamic interrelatedness of these factors
and the importance of the patient-practitioner relationship in the therapeutic
process. It is a patient–centred, rather than disease-centred, form of health care.

Structural diagnosis and osteopathic manipulative treatment are essential

components of osteopathy. Osteopathic manipulative treatment was developed
as a means of facilitating normal self-regulating/self-healing mechanisms in the
body by addressing areas of tissue strain, stress or dysfunction that may impede
normal neural, vascular and biochemical mechanisms.

The practical application of this approach is based on several structure-function

relationship models described below. Osteopathic practitioners use these to
gather and structure diagnostic information and to interpret the significance of
neuromusculoskeletal findings for the overall health of the patient. Osteopathy is
thus not limited to the diagnosis and treatment of musculoskeletal problems, nor
does it emphasize joint alignment and radiographic evidence of structural
relationships. Osteopathy is more concerned with the manner in which the
biomechanics of the musculoskeletal system are integrated with and support the
entire body physiology.

Although manual techniques are used by various manipulative therapy

professions, the unique manner in which osteopathic manipulative techniques
are integrated into patient management, as well as the duration, frequency and
choice of technique, are distinctive aspects of osteopathy. Osteopathic
manipulative treatment employs many types of manipulative techniques,
including spinal thrust and impulse techniques, as well as gentle techniques (1).

3
Benchmarks for training in osteopathy

1.2 Structure-function relationship models

Five main models of structure-function relationships guide the osteopathic

practitioner's approach to diagnosis and treatment. These models are usually
used in combination to provide a framework for interpreting the significance of
somatic dysfunction within the context of objective and subjective clinical
information. The combination chosen is adapted to the patient’s differential
diagnosis, co-morbidities, other therapeutic regimens and response to treatment.

1.2.1 The biomechanical structure-function model

The biomechanical model views the body as an integration of somatic
components that relate as a mechanism for posture and balance. Stresses or
imbalances within this mechanism may affect dynamic function, increase energy
expenditure, alter proprioception (one's sense of the relative position and
movement of neighbouring parts of the body), change joint structure, impede
neurovascular function and alter metabolism (5-7). This model applies
therapeutic approaches, including osteopathic manipulative techniques, which
allow for the restoration of posture and balance and efficient use of
musculoskeletal components.

1.2.2 The respiratory/circulatory structure-function model

The respiratory/circulatory model concerns itself with the maintenance of
extracellular and intracellular environments through the unimpeded delivery of
oxygen and nutrients, and the removal of cellular waste products. Tissue stress
or other factors interfering with the flow or circulation of any body fluid can
affect tissue health (8). This model applies therapeutic approaches, including
osteopathic manipulative techniques, to address dysfunction in respiratory
mechanics, circulation and the flow of body fluids.

1.2.3 The neurological structure-function model

The neurological model considers the influence of spinal facilitation,
proprioceptive function, the autonomic nervous system and activity of
nociceptors (pain fibres) on the function of the neuroendocrine immune network
(9-15). Of particular importance is the relationship between the somatic and
visceral (autonomic) systems. This model applies therapeutic approaches,
including osteopathic manipulative techniques, to reduce mechanical stresses,
balance neural inputs and reduce or eliminate nociceptive drive.

1.2.4 The biopsychosocial structure-function model

The biopsychosocial model recognizes the various reactions and psychological
stresses which can affect patients' health and well-being. These include
environmental, socioeconomic, cultural, physiological and psychological factors
that influence disease. This model applies therapeutic approaches, including
osteopathic manipulative techniques, to address the effects of, and reactions to,
various biopsychosocial stresses.

4
 The basic principles of osteopathy

1.2.5 The bioenergetic structure-function model

The bioenergetic model recognizes that the body seeks to maintain a balance
between energy production, distribution and expenditure. Maintaining this
balance aids the body in its ability to adapt to various stressors (immunological,
nutritional, psychological, etc.). This model applies therapeutic approaches,
including osteopathic manipulative techniques, to address factors which have the
potential to deregulate the production, distribution or expenditure of energy
(6,7,16).

5
Benchmarks for training in osteopathy

6
 Training of osteopathic practitioners

2. Training of osteopathic practitioners

2.1 Categories of training programmes

Regulating the practice of osteopathy and preventing practice by unqualified

practitioners requires a proper system of training, examination and licensing.
Benchmarks for training have to take into consideration the following:
• content of the training;
• method of the training;
• to whom the training is to be provided and by whom;
• the roles and responsibilities of the future practitioner;
• the level of education required in order to undertake training.

Experts in osteopathy distinguish two types of training depending on prior

training and clinical experience of trainees.

Type I training programmes are aimed at those with little or no prior health-care
training, but who have completed high school education or equivalent. These
programmes typically are four-year, full-time programmes. Supervised clinical
training at an appropriate osteopathic clinical facility is an essential component,
and students may be required to complete a thesis or project.

Type II training programmes are aimed at those with prior training as health-care
professionals. Type II programmes have the same aims and content as the Type I
programmes, but the course content and length may be modified depending on
the prior experience and training of individual applicants. In some cases, the
development of a Type II programme may be a temporary step pending the
development of Type I programmes in osteopathy.

Experts in osteopathy consider that acquiring appropriate mastery of osteopathy

to be able to practise as primary-contact health-care professionals, independently
or as members of a health-care team in various settings, requires time. A typical
Type I programme would take 4200 hours, including at least 1000 hours of
supervised clinical practice and training. Osteopathic skills and physical
examination training must be delivered via direct contact. Other academic
curricular content may be delivered by various staff and in various training
formats. Training may be full-time, part-time or a combination of the two.

While training of the osteopathy focuses on those subjects and skills that form the
basis for the osteopathic approach, basic knowledge and understanding of the
common allopathic medical treatments available to patients are necessary for
competent practice as a primary-contact health-care practitioner. In addition, the
osteopathic practitioner must also understand the rationale behind common
standard treatment protocols; how the body responds to these treatments; and
how the protocols may influence the selection and implementation of osteopathic
treatment.

7
Benchmarks for training in osteopathy

All elements of the curriculum are delivered in the context of focusing on the
patient rather than the disease, viewing the patient as someone who seeks the
facilitation of their optimum health, and on the importance of the patient and
practitioner forming a therapeutic partnership.

2.2 Core competencies

Osteopathic practitioners share a set of core competencies that guide them in the
diagnosis, management and treatment of their patients and form the foundation
for the osteopathic approach to health care. The following are essential
competencies for osteopathic practice in all training programmes:
• a strong foundation in osteopathic history, philosophy, and approach to
health care;
• an understanding of the basic sciences within the context of the
philosophy of osteopathy and the five models of structure-function.
Specifically, this should include the role of vascular, neurological,
lymphatic and biomechanical factors in the maintenance of normal and
adaptive biochemical, cellular and gross anatomical functions in states of
health and disease;
• ability to form an appropriate differential diagnosis and treatment plan;
• an understanding of the mechanisms of action of manual therapeutic
interventions and the biochemical, cellular and gross anatomical response
to therapy;
• ability to appraise medical and scientific literature critically and
incorporate relevant information into clinical practice;
• competency in the palpatory and clinical skills necessary to diagnose
dysfunction in the aforementioned systems and tissues of the body, with
an emphasis on osteopathic diagnosis;
• competency in a broad range of skills of OMT;
• proficiency in physical examination and the interpretation of relevant
tests and data, including diagnostic imaging and laboratory results;
• an understanding of the biomechanics of the human body including, but
not limited to, the articular, fascial, muscular and fluid systems of the
extremities, spine, head, pelvis, abdomen and torso;
• expertise in the diagnosis and OMT of neuromusculoskeletal disorders;
• thorough knowledge of the indications for, and contraindications to,
osteopathic treatment;
• a basic knowledge of commonly used traditional medicine and
complementary/ alternative medicine techniques.

2.3 Benchmark training curriculum for osteopathy

Basic science
• history and philosophy of science;
• gross and functional anatomy, including basic embryology,
neuroanatomy and visceral anatomy;
• fundamental bacteriology, fundamental biochemistry, fundamental
cellular physiology;

8
 Training of osteopathic practitioners

• physiology with special emphasis on the neuroendocrine immune

network, the autonomic nervous system, the arterial, lymphatic and
venous systems and the musculoskeletal system;
• biomechanics and kinetics.

Clinical science
• models of health and disease;
• safety and ethics;
• basic pathology and pathophysiology of the nervous, musculoskeletal,
psychiatric, cardiovascular, pulmonary, gastrointestinal, reproductive,
genitor-urinary, immunological, endocrine and otolaryngology systems;
• basic orthopaedic diagnosis;
• basic radiology;
• nutrition;
• basic emergency care.

Osteopathic science
• philosophy and history of osteopathy;
• osteopathic models for structure/function interrelationships;
• clinical biomechanics, joint physiology and kinetics;
• mechanisms of action for osteopathic techniques.

Practical skills
• obtaining and using an age-appropriate history;
• physical and clinical examination;
• osteopathic diagnosis and differential diagnosis of the nervous,
musculoskeletal, psychiatric, cardiovascular, pulmonary, gastrointestinal,
endocrine, genitor-urinary, immunological, reproductive and
otolaryngology systems;
• general synthesis of basic laboratory and imaging data;
• clinical problem-solving and reasoning;
• understanding of relevant research and its integration into practice;
• communication and interviewing;
• clinical documentation;
• basic life-support and first-aid care.

Osteopathic skills
• osteopathic diagnosis;
• osteopathic techniques, including direct techniques such as thrust,
articulatory, muscle energy and general osteopathic techniques;
• indirect techniques, including functional techniques and counterstrain;
• balancing techniques, such as balanced ligamentous tension and
ligamentous articulatory strain;
• combined techniques, including myofascial/fascial release, Still
technique, osteopathy in the cranial field, involuntary mechanism and
visceral techniques;
• reflex-based techniques, such as Chapman’s reflexes, trigger points and
neuromuscular techniques;
• fluid-based techniques, such as lymphatic pump techniques (1).

9
Benchmarks for training in osteopathy

Practical supervised clinical experience

Osteopathic manipulative treatment is a distinctive component of osteopathy. It
requires both cognitive and sensory motor skills, and knowledge, and the
development of these clinical and manual skills requires time and practice.
Supervised clinical practice is an essential component of the training of
osteopathic practitioners and should take place in an appropriate osteopathic
clinical environment so that high-quality clinical support and teaching can be
provided. This will include a minimum of 1000 hours of supervised clinical
practice.

2.4 Adaptation of Type I to Type II programmes

The Type II programme is designed to enable other health-care professionals to

become qualified osteopathic practitioners. The syllabus and curriculum for Type
II programmes will vary depending upon the prior health-care training and
clinical experience of each individual student. Graduates of Type II programmes
must demonstrate the same competencies of osteopathy as graduates of Type I
programmes. This programme typically has a duration of 1000 hours, to be
adapted depending on the individual’s prior training and knowledge.

10
 Training of osteopathic practitioners

Table 1 - Indicative Type I programme structure

Phase 1 No. of
contact
Scientific and professional underpinning studies hours
Anatomy 150
Health-care studies and other health-care systems 5
ICT skills 2
Principles and philosophy of osteopathy 100
Neurology/neuroscience 32
Peripheral and spinal biomechanics 26
Physiology 140
Biochemistry 60
Nutrition 40
Palpatory skills and diagnosis 40
Phsychology/psychosomatics 5
Sociology 8

Research studies
Research methodology (quantitative and qualitative) including critical analysis 5

Clinical/professional studies
Applied clinical osteopathy 26
Radiological diagnosis and clinical imaging 6
Orthopaedics and trauma 8
Case-analysis studies 6
Professional practice management 2
Obstetrics and gynaecology 4
Paediatrics and osteopathic care of children 4
Osteopathic technique 150

Osteopathic clinical practice

Closely supervised osteopathic clinical practice in suitable clinical
environment(s) 20
Phase 2

Scientific and professional underpinning studies

Anatomy 70
Sociology 16
Health-care studies and other health-care systems 12
Principles and philosophy of osteopathy 50
Neurology/neuroscience 12
Pathology 50
Peripheral and spinal biomechanics 100
Applied physiology 140
Exercise physiology 10
Emergency support skills/first-aid 10
Clinical methods and procedures 60
Palpatory skills and diagnosis 34
Psychology/psychosomatics 10

Research studies
Research methodology (quantitative and qualitative) 18
Critical analysis 7
Research ethics 4

11
Benchmarks for training in osteopathy

Clinical/professional studies
Case-history taking and patient communication 9
Applied clinical osteopathy 20
Differential and clinical diagnosis and clinical problem solving 20
Radiological diagnosis and clinical imaging 20
Orthopaedics and trauma 14
Case-analysis studies 15
Osteopathic evaluation and patient management 38
Professional ethics 6
Osteopathic technique 150
Nutrition & clinical dietetics 6

Osteopathic clinical practice

Closely supervised osteopathic clinical practice in suitable clinical
environment(s) 140

Phase 3

Scientific and professional underpinning studies

Anatomy 40
Health-care studies and other health-care systems 8
Pathology 18
Peripheral and spinal biomechanics 100
Pharmacology 20
Principles and philosophy of osteopathy 21
Physiology 6
Neurology/neuroscience 24
Clinical laboratory techniques 4
Palpatory skills and diagnosis 6
Sociology 4
Psychology/psychosomatics 100

Research studies
Research methodology (quantitative and qualitative) including critical
statistics 36
Critical analysis 10
Dissertation/research paper 100

Clinical/professional studies
Case-history taking and patient communication 7
Differential and clinical diagnosis and clinical problem solving 100
Professional ethics 6
Radiological diagnosis and clinical imaging 50
Orthopaedics and trauma 60
Paediatrics and osteopathic care of children 100
Osteopathic sports care 20
Case-analysis studies 18
Applied clinical osteopathic technique 150
Ergonomics 10
Osteopathic evaluation and patient management including reflective practice 13
Gynaecology and obstetrics 40
Rheumatology 12
Osteopathic care of the elderly 12
Nutrition & clinical dietetics 6

12
 Training of osteopathic practitioners

Osteopathic clinical practice

Closely supervised osteopathic clinical practice in suitable clinical
environment(s) 370
Phase 4

Scientific and professional underpinning studies

Anatomy 6
Principles and philosophy of osteopathy 11
Pathology 15
Peripheral and spinal biomechanics 9
Pharmacology 40

Research studies
Research methodology (quantitative and qualitative) 29
Critical analysis 5
Dissertation/research paper 200

Clinical/professional studies
Case-history taking and patient communication 6
Differential and clinical diagnosis and clinical problem solving 20
Professional ethics 8
Radiological diagnosis and clinical imaging 18
Gynaecology and obstetrics 12
Dermatology 20
Orthopaedics and trauma 6
Case-analysis studies 9
Paediatrics and osteopathic care of children 12
Applied clinical osteopathic technique 150
Professional practice management 50
Osteopathic evaluation and patient management 18

Osteopathic clinical practice

Closely supervised osteopathic clinical practice in suitable clinical
environment(s) 470

13
Benchmarks for training in osteopathy

14
 Safety issues

3. Safety issues

Osteopathic practitioners have a responsibility to diagnose and refer patients as

appropriate when the patient’s condition requires therapeutic intervention that
falls outside the practitioner's competence. It is also necessary to recognize when
specific approaches and techniques may be contraindicated in specific conditions.

Osteopathic practitioners consider that a contraindication to OMT in one area of

the body does not preclude osteopathic treatment in a different area. Likewise, a
contraindication for any specific technique does not negate the appropriateness
of a different type of technique in the same patient. Absolute and relative
contraindications for OMT are often based upon the technique employed in each
particular clinical situation.

The contraindications identified by the community of osteopathic practitioners

are regrouped in function of the osteopathic techniques considered: these can be
direct, indirect, combined, fluid and/or reflex-based (1). Direct techniques, such
as muscle energy, thrust and articulatory manoeuvres, pose different risks from
indirect, fluid and reflex-based techniques. There is only little published evidence
on which techniques should be avoided in specific conditions. Osteopathic
practitioners use their understanding of the pathophysiology of the patient’s
condition and the mechanism of action of the technique to establish absolute and
relative contraindications that are biologically plausible. On that basis the lists
below have been established.

3.1 Contraindications to direct techniques

Direct techniques, may use thrust, impulse, muscle contraction, fascial loading or
passive range of motion, to achieve tissue response. They can be applied
specifically to a joint or nonspecifically to a larger area of the body. Often an area
that should not be treated using a direct technique may safely and effectively be
treated using an alternative technique, e.g. indirect, fluid or reflex-based. There
are absolute and relative contraindications to direct techniques.

Systemic conditions that constitute absolute contraindications to direct

techniques
• suspected bleeding disorder;
• prolonged bleeding times;
• anticoagulant pharmacotherapy without recent evaluation of therapeutic
level;
• clotting abnormalities;
• congenital or acquired connective tissue diseases that result in
compromised tissue integrity;
• compromised bone, tendon, ligament or joint integrity, such as might
occur in metabolic disorders, metastatic disease and/or rheumatoid
diseases.

15
Benchmarks for training in osteopathy

Systemic conditions that constitute relative contraindications to direct

techniques
• osteoporosis;
• osteopenia.

Absolute contraindications to direct techniques specifically applied at a local

site
• aortic aneurysm;
• open wounds, skin derangement, recent surgery;
• acute hydrocephalus;
• hydrocephalus without diagnostic workup;
• acute intracerebral bleed;
• acute cerebral ischemia, including transient;
• suspected cerebral arterial-venous malformation;
• cerebral aneurysm;
• abdominal pain;
• acute cholecystitis with suspected leakage or rupture;
• acute appendicitis with suspected leakage or rupture;
• acute or subacute closed head injury;
• acute intervertebral disc herniation with progressive neurological signs;
• suspicion or evidence of vascular compromise;
• suspected vertebral artery compromise;
• known congenital malformation;
• acute cauda equine syndrome;
• ocular lens implant (early post-operative period);
• uncontrolled glaucoma;
• neoplasm;
• suspected bone compromise, such as osteomyelitis, bony tuberculosis, etc,
or risk of same.

Absolute contraindications to direct techniques that specifically involve thrust

or impulse applied at a local site
• specific technique at the site of surgical internal fixation of the joint;
• compromised bone or joint stability, such as might occur focally in
neoplasm, metastatic disease, suppurative arthritis, septic arthritis,
rheumatoid diseases, osteomyelitis, bony tuberculosis etc;
• acute fracture;
• bony or intramuscular haematoma or abscess.

Relative contraindications to direct techniques that specifically involve thrust

or impulse applied at a local site
• intervertebral disc herniation;
• strained ligaments at the site;
• acute acceleration-deceleration injury of the neck.

3.2 Contraindications to indirect, fluid, balancing and reflex-based

techniques

Indirect, fluid, balancing or reflex-based techniques may be applied specifically

to a joint or non-specifically to a larger area of the body. These techniques do not

16
 Safety issues

engage the restrictive barrier. They may include fascial and soft-tissue loading or
unloading, hydraulic pressures, phases of respiration and cranial or postural
adjustments, as part of the application of the technique. Relative
contraindications to indirect techniques usually concern the clinical-temporal
profile of the problem.

Absolute contraindications to indirect, fluid, balancing or reflex-based

techniques applied at a local site
• acute hydrocephalus without diagnostic workup;
• acute cerebral bleed;
• acute intracerebral vascular accident;
• suspected cerebral arterial-venous malformation;
• cerebral aneurysm;
• suspected acute peritonitis;
• acute appendicitis or other visceral disease with suspected leakage or
rupture;
• recent closed head injury.

Relative contraindications to any indirect, fluid, balancing or reflex-based

technique applied at the local site
• metastatic disease;
• neoplasm;
• closed head injury.

17
Benchmarks for training in osteopathy

18
 References

References

1. Gevitz N. The DOs: Osteopathic Medicine in America, 2nd ed. Baltimore, Johns
Hopkins University Press, 2004.

2. Trowbridge C. Andrew Taylor Still 1828-1917, 1st ed. Kirksville, MO: the
Thomas Jefferson University Press, 1991.

3. World Osteopathic Health Organization. Osteopathic glossary.

(www.woho.org, accessed 19 April 2008).

4. American Association of Colleges of Osteopathic Medicine. Glossary of

Osteopathic Terminology. (http://www.aacom.org, revised 2002).

5. Hruby RJ. Pathophysiologic models: aids to the selection of manipulative

techniques. American Academy of Osteopathy Journal, 1991, 1(3):8-10.

6. Rimmer KP, Ford GT, Whitelaw WA. Interaction between postural and
respiratory control of human intercostal muscles. Journal of Applied
Physiology, 1995, 79(5):1556-1561.

7. Norré ME. Head extension effect in static posturography. Annals of Otology,

Rhinology, and Laryngology, 1995, 104(7):570-573.

8. Degenhardt BF, Kuchera ML. Update on osteopathic medical concepts and

the lymphatic system. Journal of the American Osteopathic Association, 1996,
96(2):97-100.

9. Donnerer J. Nociception and the neuroendocrine-immune system. In:

Willard FH, Patterson M, eds. Nociception and the neuroendocrine-immune
connection: Proceedings of the 1992 American Academy of Osteopathy International
Symposium. Indianapolis, American Academy of Osteopathy, 1992:260-273.

10. Emrich HM, Millan MJ. Stress reactions and endorphinergic systems. Journal
of Psychosomatic Research, 1982, 26(2):101-104.

11. Ganong W. The stress response - a dynamic overview. Hospital Practice, 1988,
23(6):155-158, 161-162, 167.

12. Kiecolt-Glaser JK, Glaser R. Stress and immune function in humans. In: Ader
R, Felton DL, Cohen N, eds. Psychoneuroimmunology, 2nd ed. San Diego, CA,
Academic Press, 1991:849-895.

13. McEwen BS. Glucocorticoid-biogenic amine interactions in relation to mood

and behavior. Biochemical Pharmacology, 1987, 36(11):1755-1763.

14. Van Buskirk RL. Nociceptive reflexes and the somatic dysfunction: a model.
Journal of the American Osteopathic Association, 1990, 90(9):792-794, 797-809.

19
Benchmarks for training in osteopathy

15. Willard FH, Mokler DJ, Morgane PJ. Neuroendocrine-immune system and
homeostasis. In: Ward RC, ed. Foundations for osteopathic medicine, 1st ed.
Baltimore, Williams and Wilkins, 1997:107-135.

16. Winter DA et al. Biomechanical walking pattern changes in the fit and
healthy elderly. Physical Therapy, 1990, 70(6):340-347.

20
 Annex

Annex: WHO Consultation on

Osteopathy, Milan, Italy,
26–28 February 2007: list of participants

Participants

Dr Peter B Ajluni, President-Elect, American Osteopathic Association, Chicago,

Illinois, United States of America

Mr Peter Arhin, Director, Traditional and Alternative Medicine Directorate,

Ministry of Health, Accra, Ghana

Dr Iracema de Almeida Benevides, Consultant and Medical Advisor, National

Policy of Integrative and Complementary Practices, Ministry of Health, Brasilia -
DF, Brazil

Dr Boyd Buser, Dean and Vice President, Health Services (Interim), UNECOM,
Biddeford, Maine, United States of America [Co-Rapporteur]

Dr Jane E. Carreiro, Associate Professor and Chair, Department of Osteopathic

Manipulative Medicine, College of Osteopathic Medicine, University of New
England, Biddeford, Maine United States of America [Co-Rapporteur]

Mr Nigel Clarke, Chairman, General Osteopathic Council, London, United

Kingdom

Mr Etienne Cloet, Principal, Sutherland College, Heuvelland, Belgium

Dr Saverio Colonna, President, Association of Osteopathic Physicians, Zola

Predosa, Italy

Ms Madeleine Craggs, Chief Executive & Registrar, General Osteopathic Council,

London, United Kingdom

Mr John Crosby, Executive Director, American Osteopathic Association, Chicago,

Illinois, United States of America

Mr Vince Cullen, Head of Development, General Osteopathic Council, London,

United Kingdom

Dr Kilian Dräger, President, German Physicians Society for Osteopathy,

Hamburg, Germany

Dr Raimund Engel, Forum for Osteopathic Regulation in Europe (FORE), c/o

Wiener Schule für Osteopathie, Wien, Austria

21
Benchmarks for training in osteopathy

Professor Ferruccio Ferrario, Dean, Medicine and Surgery Faculty, State

University of Milan, Milan, Italy

Dr Armand Gersanois, President, European Federation of Osteopaths,

Strasbourg, France

Dr Léon Ranaivo-Harimanana, Head, Clinical Trial Department in the Centre

National d'Application des Recherches Pharmaceutiques, Antananarivo,
Madagascar

Dr Mona M. Hejres, Education Medical Registrar, Office of Licensure and

Registration, Ministry of Health, Manama, Kingdom of Bahrain

Dr Augusto Henriques, Representative of Osteopathy, Official Portuguese Inter-

Ministerial Commission to Study and Propose the Regulation of Osteopathy,
Oledo, Portugal

Dr Kenneth H. Johnson, Interim Associate Dean, Clinical Affairs, University of

New England, College of Osteopathic Medicine, Biddeford, Maine, United States
of America

Dr John Licciardone, Osteopathic Research Center, University of North Texas

Health Science Center, Fort Worth, Texas, United States of America

Dr Alfonso Mandara, Director, High Institute of Osteopathy, Milan, Italy

Mrs Linda L. Mascheri, Director, Division of State Government & International

Affairs, American Osteopathic Association, Chicago, Illinois, USA

Professor Emilio Minelli, WHO Collaborating Centre for Traditional Medicine,

Centre of Research in Bioclimatology, Biotechnologies and Natural Medicine,
State University of Milan, Milan, Italy

Dr Dmitry Mokhov, President, Register of Osteopaths of Russia, Saint-

Petersburg, Russian Federation

Ms Marianne Montmartin, International Affairs Committee, Registre des

Ostéopathes de France, Merignac, France

Dr Mahmoud Mosaddegh, Dean, Traditional Medicine and Materia Medica

Research Center, Shahid Beheshti University of Medical Sciences, Teheran,
Islamic Republic of Iran

Dr Michael Mulholland-Licht, President, World Osteopathic Health

Organization, Balgowlah, Australia

Dr Ray Myers, Head, Discipline of Osteopathy, School of Health Sciences,

Portfolio of Science Engineering and Technology, RMIT University, Victoria,
Australia [Co-Chairperson]

Dr Reza Nassiri, Professor and Chair, Department of Clinical Pharmacology,

Director of International Affairs, Lake Erie College of Osteopathic Medicine,
Erie, Pennsylvania, United States of America

22
 Annex

Dr Susanne Nordling, Chairman, Nordic Co-operation Committee for Non-

conventional Medicine, Committee for Alternative Medicine, Sollentuna, S-191,
Sweden [Co-Chairperson]

Dr Vegard Nore, Senior adviser, Norwegian Directorate for Health and Social
Affairs, Department for Community Health Services, Oslo, Norway

Ms Emma-Jane Roberts, Rivonia, Geautang, South Africa

Professor Umberto Solimene, Director, WHO Collaborating Centre for

Traditional Medicine, Centre of Research in Bioclimatology, Biotechnologies and
Natural Medicine, State University of Milan, Milano, Italy

Dr Clive Standen, Associate Head, School of Health & Community Studies,

Unitec, Auckland, New Zealand

Dr Olga Steggerda, Member, Russian Register of Osteopaths, Riga, Latvia

Mr Philippe Sterlingot, President, Syndicat Français des Ostéopathes, Nantes,

France

Dr Yong-Jun Wang, Director, Orthopaedics Department, Longhua Hospital,

Shanghai University of Traditional Chinese Medicine, Shanghai, China

Mr Michael Watson, Chief Executive, British Osteopathic Association, Luton,

United Kingdom

Dr Ingunn Backe Wennberg, President, Norsk Osteopat Forbund, Drammen,

Norway

Dr Monica Wong Man-ha, Principal Medical and Health Officer, Department of

Health, Wanchai, Hong Kong SAR, China

Local Secretariat

Dr Simon Andrew Duncan, President, European Osteopathic Union, Biella, Italy

WHO Secretariat

Dr Samvel Azatyan, Technical Officer, Department of Technical Cooperation for

Essential Drugs and Traditional Medicine, World Health Organization, Geneva,
Switzerland

Dr Xiaorui Zhang, Coordinator, Traditional Medicine, Department of Technical

Cooperation for Essential Drugs and Traditional Medicine, World Health
Organization, Geneva, Switzerland

23