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Individual Enquiry
Research Paper 2009
Title: The Philosophy of Osteopathy: A New Hope. Author: Jemma Nicole Mitchell, BSc (Hons) Supervisor: Jonathan Edis, BSc (Hons) The British School of Osteopathy
275, Borough High Street, London SE1 1JE
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Acknowledgements:
I would like to thank my supervisor Mr. Jonathan Edis for his interest and
guidance and Dr. Melanie Wright for her valued input into the data analysis
process. I would also like to thank Mr. Christopher Wilkes for his participation
in the pilot study and Mr. Will Podmore for his unfaltering library assistance. I
would also like to say a very special thank you to Mr. Walter Llewellyn
McKone for his inspiration, kindness and guidance.
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Abstract:
Due to the tragic misdirected course Osteopathy has taken from its inception
in 1874 until present, an enquiry was conducted to ascertain the osteopathic
content of the British Journal of Osteopathy from its inception in 1960 until its
demise in 2006. Results showed a significant decrease of 0.117 osteopathic
principles per year from 1960-1984. Osteopathic principles are a direct
emergence from the osteopathic philosophy, thus results indicated uncertainty
as to the philosophic foundations of our profession. Osteopathy’s origin is
placed in Goethean science demarcated by its phenomenological approach to
the natural world as opposed to the Cartesian philosophy that underlies
orthodox medicine. Unfortunately, the resulting evidence based medicine
culture seems to have polarised the osteopathic profession (Leach, 2008).
However, osteopathic evidence is gained through practitioner centred
experience of metamorphosis of natural phenomena upon interacting with the
patient, thus, Dr. Still’s, ‘mind, matter and motion’ concept can be viewed as
an over arching principle of osteopathy supported by the very philosophy of
osteopathy. From this foundation, osteopathy should strive to gain its
deserved status in the medico-political arena as an independent school of
‘science, practice and research’.
Keywords: Philosophy, Osteopathic philosophy, Principle, Osteopathic
principle, Osteopathy, Osteopath, Concept, Value (see appendix I).
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Introduction:
Ward et al (2003) state that viewpoints and attitudes arising from osteopathic
principles give osteopathic practitioners an important template for clinical
problem solving and patient education especially when confronted with
increasingly complex physical, psychosocial and spiritual problems affecting
individuals, and populations from a wide variety of cultures and backgrounds.
Thus, it is imperative that an osteopathic physician should mentally embrace a
set of principles when practicing osteopathy. The purpose of principles is to
trigger thought processes, which help the osteopath understand, make
decisions, and act appropriately when practicing (Kuchera & Kuchera 1994).
Indeed, Still (1910, p.28) states explicitly, “when we treat diseases of the
whole system we must have a foundation or fail.”
Indeed, Still was a man of principle working to a distinct philosophy of life
(Latey, 1993a) and held to be of fundamental importance to the operating
principles of osteopathy the notion of, ‘mind, matter and motion’ (Latey,
1993a) as osteopathic philosophy embodies this concept at its heart. Still
further abstracted from this that, the mind of the individual controls everything
about them and it can only maintain lasting health by getting in tune with the
mind of nature, or natural law and rhythm, that is both within and all around
the individual, and furthermore, that behind and throughout all of this lay the
mind of minds (Still in, Latey, 1993a).
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Source, Aim, Justification and Relevance of Research:
Excluding the Osteopathic Association of Great Britain (OAGB) newsletter,
born in 1957-1995 and renamed, Osteopathy today in 1995 until present, the
British Osteopathic Journal (BOJ) has been the most consistent osteopathic
publication within the osteopathic community in Britain from its birth in 1960
until 2006, when it was incorporated into the International Journal of
Osteopathic Medicine. Unfortunately, the BOJ ceased publishing from 1984
until 1987. However, due to its established continuance and its bearing as an
important tool for communication within the profession at the time, the BOJ
best represents osteopathy in Britain as a source to research the presence of
osteopathic principles in its literature through time. Analysing the BOJ as a
method to produce a true reflection of British osteopathic practice through
time is justified by the fact that Frosch (1987, in Edis 2001) assumes that
published articles reflect issues, which concern an association at the time.
The precedent for reviewing journals at six monthly intervals, to investigate
the history of a profession, was set by Riese (2000) and Edis (2001). Thus,
this enquiry endeavours to establish, to what extent the BOJ has incorporated
the osteopathic principles in its published work from 1960 to 1984 and from
1987 to 2006 in order to gauge the osteopathic content in the profession’s
manifestation throughout the century and furthermore, to deduce whether
there is a correlation between the year of publication and the number of
principles in each paper published and if so if there is an overlying trend
throughout the century. This has major relevance to present day osteopathy,
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due to the ongoing debate within the profession as to its philosophical
orientation (Boyd, 1991) and exact professional identity (Lucas & Moran,
2007). Subsequently, osteopathy is now struggling mightily to find a cohesive
and distinct voice within the healthcare community (Osborn, 2005).
Previous Research:
Retrospective research regarding the containment of osteopathic principles
and philosophy in published literature is scarce (see appendix II, for literature
search). However, with regard to the presence of osteopathic principles
present in the Journal of the American Osteopathic Association, Edis (2001)
found a dramatic decline in the 1960’s with a small recovery in the following
two decades until another low in the 1990’s. Gevitz (1988, in Edis, 2001)
highlights the fact that the osteopathic content of education declined in the
United States of America (USA) between 1930 and 1960 due to medicinal
advances in pharmacology and surgery resulting in medically trained staff
being drafted in to the teaching establishments, thus, indicating the presence
of external factors influencing osteopathy.
The Origin of the Osteopathic Principles:
Numerous versions of the osteopathic principles have emerged, and diverged,
since osteopathy’s inception in 1874 (Stark 2008). In 1922 the first attempt at
codifying the osteopathic philosophy into simple phrases was made by Louisa
Burns, the dean of the A.T. Still Research Institute, and each osteopathic
medical school representative, who codified four fundamental osteopathic
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principles (Gevitz 2006, see figure I). Subsequently, the Kirksville College of
Osteopathic Medicine (KCOM) reworked these in 1953 (see appendix IV)
concluding that the principles were distinctive but not the only features of
osteopathic diagnosis and treatment.
Figure I: The four principles of osteopathic medicine (see appendix IV)
codified by the A. T. Still institute, in the 1920’s, and revised in 1953 by KCOM
(Gevitz 2006).
The osteopathic principles should always be interpreted in the light of
knowledge of the time, as the original principles were (McKone 2001). Thus,
Sprafka et al (1981) quested to update and formulate a new set of osteopathic
principles in order to reinstate and apply the basic biological principles to
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osteopathic practice. Accordingly, the authors added two principles to the list
proposed at KCOM (see appendix V). Subsequently, Dowling & Martinke (in
DiGiovanna et al, 2005) formulated nine principles (see appendix VI), of which
the first four were developed from the list proposed by KCOM in 1953, the two
produced from Sprafka et al (1981), and the remaining three were formulated
accordingly. The resulting nine principles (see appendix VI) are poised in the
KCOM curriculum, and are widely taught throughout the international
osteopathic community, and thus will be the set of principles used to conduct
this enquiry.
Further Extension of Osteopathic Principles:
Rogers et al (2002) proposed revisions to the osteopathic principles to include
the importance of patient care, which insightfully embraces the patient with
the primary responsibility for his/her health in treatment through their
adherence to advise on sleep, stress, diet and exercise and other
environmental factors. The health benefits of this dynamic are in tune with the
definition of osteopathy (see appendix I) and also with Dr. Still’s fundamental
concepts of Osteopathy (see appendix III) which embody the idea of health,
as an adaptive and optimal attainment of physical, mental, emotional, spiritual
and environmental well being (Glover 2006) where all of the essentials of life
are provided, including, air, water, food, heat, light, protection, rest, whilst
reacting to the stresses of life in a positive manner (Kuchera & Kuchera
1994).
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However Rogers et al (2002) also propose the need for the incorporation of
evidence-based guidelines into the treatment programme. Similarly, Lucas &
Moran (2007) are in favour of the addition of ‘evidence and science’ as a
central principle of our tenets. However in both cases the mechanistic
scientific paradigm, that underpins the biomedical model, does not provide a
suitable philosophical framework on which to base osteopathic evaluation and
diagnosis (Green 2000) and so these authors are entirely misguided as to the
fundamentals of the osteopathic philosophy.
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Method:
Ethical Approval:
This enquiry was granted ethical approval, by The British School of
Osteopathy (BSO) Research Ethics Committee. Thus, due to the fact that
there were no participants in the study, neither confidentiality nor other ethical
issues needed further consideration.
Subsequently, the nine osteopathic principles were researched (see appendix
VI) and tabulated (see appendix VII) with an inclusive list of key phrases,
words and sentences extracted from appendix VI to be used in the data
collection process. This phraseology acted as a benchmark for what would be
accepted as representing the presence of such osteopathic principles in each
BOJ article reviewed.
Table I: A table to show the inclusion and exclusion criteria for article
selection.
Criteria Articles
Inclusion criteria BOJ articles from December 1960 to December 1984,
choosing the 1st paper from each journal, twice a year.
BOJ years 1987 to 2006 choosing the 1st paper from
each journal (published annually).
Exclusion criteria Osteopathic articles not published in the BOJ.
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Pilot Study:
A pilot study was conducted to assess the inter reliability of the data gathering
tool (see appendix VII) in the collection of data. Thus, the author and a
second reviewer separately assessed the occurrence of the nine osteopathic
principles (see appendix VII) in five randomly selected BOJ articles (see
references II). The results showed a total of 18 principles identified between
the reviewers and 15/18 of the principles were identically selected between
the reviewers, giving an 83% agreement rate (see Table II). The 3/18 (17%)
principles, which were not agreed upon between the reviewers, presented one
error of omission by reviewer 1 in article 4 and one error of commission by
each reviewer in article 5. From the high level of agreement between the
reviewers, the pilot study was deemed validated with regard to the coding
system’s credibility.
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Table II: A table to show the results of the pilot study, conducted by the
author and a second reviewer. The principles found are numbered 1 to 9,
each number representing one of the nine principles (see appendix VI).
Article Principles found (numbered 1 to 9)
Reviewer 1 Reviewer 2
1 6 6
2 1, 5, 9 1, 5, 9
3 1, 2, 3, 4, 5, 6, 7, 8, 9 1, 2, 3, 4, 5, 6, 7, 8, 9
4 2*
5 2, 4*, 6 2, 6, 8*
Total identified 16 17
*These principles were identified by only one of the reviewers.
Data Gathering Process:
Quarterly BOJ publications in Spring, Summer, Autumn and Winter
commenced from December 1960 until December 1984 when publications
were arrested. Recommencement of annual publications occurred from 1987
until 2006 thus two data samples were collected, firstly, from 1960-1984
(n=41) and secondly from 1987-2006 (n=28). The data samples were
gathered in a randomly systemised manner, whereby, two publications were
selected each year from 1960-1984 at six-monthly intervals, the December
issue was selected in 1960 and subsequent Summer and Winter publications
were selected until the year ending 1984, and yearly volumes were
systematically selected for the, 1987 to 2006, data sample. Subsequently, the
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first article from each BOJ publication was systematically selected for review.
Thus, each data set compiled from the two time periods were analysed
separately to maintain consistency. This provided a sample size of 69, giving
a credible scope of BOJ literature reviewed through the second half of the 20th
Century.
Inconsistencies in the BOJ publications meant that in instances where the
Summer publications were absent i.e. Summer 1962, 1971 and 1972; the
subsequent Autumn publications were selected systematically. However, if
the Autumn publication was absent then the consecutive Winter publication
was selected i.e. in 1978. Similarly, where the Winter publications were
absent i.e. Winter 1968, 1970, 1973, 1974, 1976, the consecutive Spring
publications were selected. Additionally, where consecutive Summer and
Autumn publications were absent i.e. 1968, 1975, 1980 and 1981, the
following Winter publications were selected. Additionally, when two
publications were produced in the same season i.e. Winter 1969, both
publications were selected. Finally, where consecutive Summer, Autumn and
Winter publications were absent, the following Spring publications were
selected, i.e. 1977 and 1979.
Inconsistencies in the BOJ publications between 1987-2006 meant that in
instances where two volumes were published per year, both volumes were
selected systematically i.e.1990, 1991, 1992, 1994, 1996 and 2002. Similarly,
where there were three volumes published per year, each volume was
selected, i.e. 1993 and 1995. Finally, where annual publications were absent
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as in 1999 and 2005, articles could not be selected. Thus, in order to best
represent the part of the year each article was published in and to avoid any
confounding effects on the results, a seasonal nomenclature was formulated
for use in the data analysis (see Table III).
Table III: A table to show the Standard Nomenclature for each season.
Season Nomenclature (of a year)
Spring 0.25
Summer (or June) 0.5
Autumn 0.75
Winter (or December) +1
Data Analysis Process:
Data input into the SPSS statistical programme, occurred whereby the year,
from December 1960 to December 1984 and from 1987 to 2006, was
recorded as a number (see appendix VIII, column 5) incorporating a season
code (see appendix VIII, column 4), depending on whether it was a Spring,
Summer, Autumn or Winter publication (see Appendix VIII, column 3). Of
note, the second set of data from 1987 to 2006 was assigned a Summer
season code for consistency, as the season of publication was not specified in
the BOJ.
Subsequently, a score ranging from 0 to 9 was recorded reflecting the number
of principles found by the author (see Appendix VIII, column 6) in each
reviewed article (see Appendix VIII, column I). Thus, the year, a set of
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continual data, acted as the constant variable and the score, a set of ordinal
data, acted as the dependent variable. To deduce if a significant relationship
existed between the year of BOJ publication and the score of osteopathic
principles, a non-parametric Spearman’s Correlation test was performed on
the 1960-1984 data and again on the 1987-2006 data. A 2-tailed hypothesis
and 2-tailed probability value at the 95% level (P<0.05) was selected to
account for the possibility of a positive or negative correlation occurring
between the variables.
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Results:
The Spearman’s Correlation test performed on the 1960 to 1984 data
revealed a correlation coefficient Spearman’s Rho of –0.308, which was
statistically significant at P<0.05 for a 2-tailed hypothesis. Thus, there was a
weak negative correlation between the year and the score, thus the number of
osteopathic principles in each article decreased as the century progressed
from 1960<1985. However, the correlation coefficient was weak, indicating a
weak relationship between the two variables, thus articles containing the
highest number of principles were weakly correlated as coming from the
earlier years and articles containing the lowest number of principles were
weakly correlated to originating from the later years.
Since the correlation coefficient between score and year was significant, a
subsequent regression analysis was applied to the 1960-1984 data to deduce
the approximate degree of decline in principles with time (see graph I). A
significant regression was found with significant coefficients as they held a P
value< 0.05 (see Table IV & V). Table V reveals that R Square=0.119 which
represents a weak correlation between the coefficients, indicating that only
11.9% of the variation in score is explained by the year.
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Table IV: A table to show that the coefficients of the model were both
significant statistically at P <0.05.
Coefficient B S.E. P
Constant 232.621 100.511 .026
Year (x value) -.117 .051 .027
Table V: A table to show R2 =0.119, indicating a weak correlation between
the score and year.
R R2
Adjusted
R2
S.E. of
Estimate
0.344a .119 .096 2.354
Graph I: A graph to show the regression analysis on the 1960-1984 data.
y = -0.117x + 232.62
R2 = 0.119
0
1
2
3
4
5
6
7
8
9
10
1955 1960 1965 1970 1975 1980 1985 1990
Year
Sc
ore
The model obtained was: Score (number of principles) = -0.1167x + 232.62.
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This retrospective model (see graph I) indicates that there was a decline in
score (i.e. number of principles) of 1.17 every decade (or 0.117 every year) in
the core texts of BOJ publications between December 1960 and December
1984.
A second non-parametric Spearman’s Correlation test was conducted on the
1987-2006 set of data, the results of which revealed a correlation coefficient
Spearman’s Rho of –0.263, which was not statistically significant at p<0.05 for
a 2-tailed hypothesis. Therefore there was no significant correlation between
the year and the score between 1987 and 2006. Thus, the number of
principles in each article had no bearing to the time it was published.
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Discussion:
Relevance of results:
Osteopathy in Britain has changed dramatically through the 20th Century from
its inception in 1874 to the present day. The author’s attempt at philosophic
quantification of the BOJ content, in order to determine the extent of marriage
between osteopaths and their principles, reflected these changes in that there
was a significant decrease of 0.117 osteopathic principles per year in the BOJ
(or 1.17 principles per decade) between 1960 and 1984. This may have been
consequent to the great structural-mechanical period from 1920-1960
(Dummer 1988, see appendix X) which was responsible for the development
of a very mechanical bias in osteopathic diagnosis and technique, heavily
influenced by medicine’s advances in this period (Latey 1993c).
Consequently, barely 200 osteopaths were practicing in the UK by the mid
1960s (Latey 1993c). Thus, osteopathy suffered an eclectic degeneration that
lasted well into the middle of the century, culminating in the birth of classical
osteopathy, which emphasised single factors such as asymmetry and
vertebral joint lesions as the cause of disease. This indicated a naïve
mechanistic philosophical view of linear causation, which was far from Still’s
philosophy (Latey 1993c).
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Medico-Politics and Legislation: “We believe that our therapeutic house is
just large enough for osteopathy and that when other methods are brought in
just that much osteopathy must move out” (Still, 1910).
The government has been in alliance with the medical profession, as its major
source in the field of healthcare, since the 1960’s following its claims to
knowledge and expertise being based on the ‘scientific’ method (Green 2002).
In order to become recognised as a profession with a regulatory body,
osteopathy has had to adopt the scientific philosophy and evidence based
medicine (EBM) scientific methodology. Indeed, Cant (1996, in Edis 2001)
identified the need for osteopathy to embrace the ‘scientific paradigm’ in order
to become legitimised as a profession and be accepted in the political and
medical establishment, thus another reason for the demise in principles
echoed in the results between 1960 and 1984.
Indeed, as a result of the rejection of the 1931, 1933 and 1934 Osteopath
Regulation Bills, on the grounds of a perceived lack of medical research and
the accusation that osteopathic theory was unsupported by ‘scientific’
evidence (Collins 2005), a set of osteopathic reforms were set in motion in an
attempt to conform to orthodox medicine. Reforms included BSO curriculum
changes in 1950 (see appendix IX) and conformity to ‘a therapy founded on a
systematic body of knowledge that is accepted by the medical profession’ as
set out in the 1985 House of Lord’s debate. This conformity summated in
securing the full support of the medical profession at the King’s Fund meeting
in 1989, the culmination of which enabled the profession to gain status and
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statutory regulation by way of the Osteopaths Act of 1993. This was a further
step towards the application of EBM into osteopathic practice, which was
expected in order to justify the latter, and of course to the great demise of our
philosophy.
The Place of Evidence Based Medicine in Osteopathy:
The EBM culture seems to have polarised the osteopathic profession (Leach,
2008). Indeed, modern medicine is based on the process by which scientific
knowledge is acquired, which acts to minimise variables in order to make
them reproducible by others. However, osteopathy deals with many variables
in individual patients in specific non-replicable situations (Tyreman 2008a),
thus representing a body of knowledge that can only be partially captured by
scientific theory statements or assessed by scientific method. Thus, they are
based on completely different philosophies as scientific evidence per se acts
only to uncover one parameter of the body’s many differing profundities. Thus,
conventional clinical research protocols for the assessment of efficacy of most
chemical and physical therapeutic agents are ill suited for the assessment of
osteopathy (Korr, 1997). This injustice to osteopathy is seen in; The Royal
College of General Practitioners ‘Clinical Guidelines for the Management of
Acute Low Back Pain’ issued in 1996, which concluded that, ‘Manipulation
within the first 6 weeks can provide short-term improvement in pain’.
Of concern, Fryer (2008) postulates that EBM should be integrated into
teaching under the term ‘evidence informed osteopathy’ whereby individual
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techniques assessed for their validity, in addition to, accuracy and
reproducibility of physical and clinical tests were proposed. However,
validating a manual method in one measurement in the presence of many
dynamic variables in each patient is unfeasible to replicate, thus individual
techniques alone cannot be assessed and designated an efficiency score to
be replicable in all future circumstances. Indeed, “every circumstance of a
person’s life influences the function of every cell and system. Thus there is an
infinite variety of ways of being human and an infinite variety of influences on
biological functions. Thus, each part is each different from all others according
to whom it serves” (Korr, 1987). Thus, the osteopathic concept of scientific
evidence does not exist per se as it is not representative of the whole.
Contrarily, osteopathic evidence is gained through the practitioner centred
experience of metamorphosis of natural phenomena upon interacting with the
patient, in addition to patient reports on the change in their health (mind,
matter, motion dynamic). Fryer (2008) is further misguided as to the
foundations of osteopathy in stating, “our therapeutic and diagnostic
approaches lack high quality evidence and the educator has a duty to critically
examine evidence and incorporate it into their teaching of specific techniques
accordingly, as it is now expected from government bodies that health
professionals are well informed of current evidence, and are guilty of
academic dishonesty and the perpetuating of unscientific dogma if they fail to
do this.” It is not comprehended why negative connotations are thrown at
spectacles that are simply not understood.
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Osteopathic Education: “We have stopped treating our patients- we are
now techniquing them” (McKone, 2004).
Tyreman (2008a) notes implications for osteopathic education with regard to
the uncertainty of which osteopathic values should be passed on to students
and how this contrasts with the EBM, which is introduced into the curriculum.
Similarly, Teitelbaum et al (2003) in the USA asked, ‘to what degree are
osteopathic principles being taught in modern osteopathic medical
institutions?’ and they concluded that osteopathic principles were taught but
they were not applied and incorporated into their basic science teaching.
Indeed, Handoll (1992) and (Gevitz 2006) recognise that greater effort needs
to be made to incorporate osteopathic philosophy and principles into
undergraduate education.
Thus, a divide between what is taught and what is applied in the education
system may exist whereby the osteopathic philosophy is taught in theory but
not practiced with regard to the diagnostic and treatment thought processes
when interacting with the patient which is regrettably currently being reasoned
with a philosophy of unity in multiplicity as is so in orthodox medicine whereby
treatment approaches and management plans are sought with a set diagnosis
taking absolutely no account of the phenomena before them which they are a
witness to and thus being external to the experience of the practitioner-patient
interaction, but instead bombarding them with orthopaedic tests in set
parameters. Indeed, McKone, (2004) states that the idea of separateness is
fundamental to differential diagnosis, specific techniques to specific tissues,
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techniquing the body as a series of tissues out of context, which ultimately,
leads to a weak body response.
Osteopathic practice should not be a set of pre conceived methodologies
chosen due to similarities between cases, but instead, a newly formulated
host of dependable evaluative and manipulative methods based on
practitioner reasoning, with the principles in mind, in response to the unique
presenting clinical case. Thus, the academic setting is an essential basis for
educating osteopaths in the science and philosophy of osteopathy, the
profession’s foundation.
Still’s Influences:
An all-pervasive dominance of Germanic thought and language throughout
academia (Latey 1993) occurred following the 1848 emigration from Germany
(McKone, 2001). This had its own modes of discovery and conception and
thus was a science in its own right and it greatly influenced the American
culture and the development of the Still’s science of osteopathic philosophy
due to the notion that a disease could not be treated without knowledge of the
whole patient.
Indeed, Kuklick (2001) states, “It was not accidental that German
overwhelmed Scottish thought in the Northeastern philosophical circles soon
after Darwin published. Germany provided a basis for the rebuilding of religion
but also aided the new biology.” Through this new tide of thought, Still
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developed the philosophy of osteopathy and was likened to a naturalist with
highly developed senses, who was deeply receptive to the overwhelming
intricacy of natural phenomena by synthesising thought and not analysing
when witnessing natural phenomena (Wheeler, in McKone, 2001).
Unfortunately, this original philosophy has been undermined by the
mechanistic philosophy derived from Descartes.
Philosophy of Cartesian science: “We are prone to see what lies behind
our eyes, rather than what appears before them” (Huxley, in McKone, 2001).
The concept of rationality was established in the 17th Century, by physicists
such as Galileo and Newton and philosophers such as Descartes (Toulmin, in
McKone, 2001), which later formed the Cartesian-Newtonian linear causation
model. Rationality is represented in the modern scientific style of thinking,
which separates theory from fact by externalising an experience, asserting a
theory and verifying it through an experiment. Bortoft (1997, in McKone 2004)
explains that this analytic model, as a way to understand natural phenomena,
was based on the Copernican belief that experience through the senses was
illusionary and so must not be trusted but to be looked behind for ‘reality’ in
mathematical relationships. Thus, Descartes, theorised that what was real is
what could be handled by mathematics thus, he manipulated natural matter
based on their commonalities to produce a series of fixed certainties,
(McKone, 2001). This was the birth of modern science and it was defined by
empirical experiments concerned with measurements and exact results, which
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reduced the multi-dimensional functions of nature to linear mechanical
principles.
Thus, this Cartesian philosophy is useful in building a box, but not in treating a
patient. Indeed, Tucker (1919, in McKone 2001) states, “we think of
mathematics as existing in nature, since every quality of nature is definable
ultimately in terms of mathematics. But nothing could be further from the truth.
There is and can be no true mathematics in nature for the simple and perfect
reason that there are no uniform units in nature. No leaf is just like any other
leaf, no wave like any other wave.” Indeed there is no human like any other
human.
Indeed, this mathematical style of thinking, where observations of nature are
restricted to one mode, tends to decontextualise everything, whereby,
abstracted results are independent of space and time and so certainty is
divorced from experience (Bortoft, 1997). Thus, any particular case has no
interest in itself and is subsumed under the universal so that all differences
are removed to arrive at what is common (Bortoft 1997, In McKone 2004).
Unfortunately, intellectualisation loses the experience and becomes analytical
(McKone, 2001) and so this philosophy of unity in multiplicity that underlies
orthodox medicine today seems to have influenced the osteopathic arena with
regard to EBM.
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Philosophy of Phenomenology: Our Origin: “the senses do not deceive;
the judgement deceives” (Goethe, in McKone 2001).
Rene Dubos (1977) links Phenomenology with Osteopathy, “Neither
osteopathy nor surgery, let alone dentistry would have got very far by ignoring
it (the organic approach)…They are directly related to mental operations,
which are developed in the philosophy of Phenomenology, itself a post-
Cartesian outlook. Relating this method to current philosophy of science it
(osteopathy) cannot be judged in any way less powerful than Cartesian
science, for while the latter has no verification procedure, relying upon
falsification alone, Goethean science entails both falsification and verification,
and thus might even be said to be more complete that Cartesian. Again, the
only real problem with this approach is the fact that very few know of its
existence.”
Thus some qualities cannot be discovered mathematically. Indeed, “Life
processes operate in patterns not abstractions” (Hanson, 1958, in McKone
2001). From this, Goethe realised that there is no scientific method that has
an absolute foundation, which guarantees its own validity, as science itself is
a cultural-historical movement (Bortoft 1997). Thus, there exist other modes to
approach nature’s certainty, namely to start with experience. Indeed, Edmund
Husserl (1859-1938) developed a form of philosophy termed ‘phenomenology’
which gave credit to the consciousness of the first person when witnessing a
phenomenon by embracing the senses of sight, hearing, touch, smell and
taste in order to become sensitive to phenomena as they occur and so
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utilising a wide observable range in order to fully understand natural
phenomena (McKone, 2001).
Both Still and Goethe had phenomenological approaches towards man and
nature respectively and viewed the human being as the most exact instrument
to be studied, instead of creating instruments that distort our encounter with
the natural phenomena in their environment (McKone, 2001). This holistic
paradigm is non-external, and so allows the observer to become part of the
experience witnessed, whereby a total relationship to the surroundings is
achieved where no abstracted elements are considered (McKone, 2001).
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The link between Goethe and Still: ‘Multiplicity in Unity’, (McConnell, 1935).
Figure II: The link between Goethe’s science and its influence on Still’s
philosophy, embodied in the statement, ‘multiplicity in unity’ (McConnell,
1935).
“At this late date many seem to forget that a basic discovery of Dr. Still was the fact of
immunity... The osteopathic approach is so fundamentally different from that of any other
method,…In attempting to set aright a disordered mechanism, innumerable facts,
representative of multiform forces, are enlisted…The whole living structure (not just the
backbone) which embraces function, or vice versa, is something more than just the sum of
the parts; and the sum of the parts is not confined to one class of tissue, e.g.
bones…Where we, as osteopathic physicians, are negligent is in not giving sufficient time
and thought in reading, interpreting and analysing the body hieroglyphs…These signs
(are) comprehensively written throughout the tissues…One partially misleading
procedure… is that we too readily seek the mathematical coordinates of the osseous lesion
as a sort of standard index…overlooking the very environic forces which make the
segmental and organic changes possible…The environic forces, acting through the media
of the soft tissues by way of circulating fluids…are those which should be primarily
attacked in order to resolve the pathology…The practical everyday problem resolves itself
into what the individual measure of the particular case is. It is not a composite collective
one, but composite and unified, with multiplicity in unity. This is exactly what makes
osteopathy successful. Now, it is right in the functional strains and stresses of tissues that
there is a world, individually so, of detectable differences. Each one’s difference should be
sought, exposed and unravelled. This is what art should do. Herein rests the difference
between mediocrity and skill. No two treatments can be, or at least should be, the same;
for the impacts of environing forces necessarily vary.”
30
How to Treat: “Man cannot afford to be a naturalist, to look at nature directly,
but only with the side of his eye. He must look through her and beyond her.
To look at her is as fatal as to look at the head of Medusa. It turns the man of
science to stone.” (Thoreau, in McKone, 2001).
With regard to experiencing natural phenomena, Goethe explains that
everything we need to discover about the world is to be found by going into
experience directly as there is a depth within the world as it appears (Bortoft
1997, in McKone 2004). Indeed, Goethe viewed nature as a creation of varied
individual forms through the modification of one single organ, termed the
Urorgan, which can present itself as different manifestations. Furthermore, in
some sense, he viewed the entire plant kingdom as being one plant. Thus, he
brought the diversity back into unity from which it originally went forth (Steiner
1897, in Bortoft 1997).
Thus, the notion of difference in unity or self-difference of multiplicity in unity
emerged, whereby a human being is synonymous to the Urorgan, which
expresses itself in multiple forms, and similarly, that the Urorgan is expressed
in all human form. Thus, the Stillian approach viewed all patients as
expressing individual differences as normal within the human race and that all
human beings are expressed in the human form in a dynamic continuum of
space and time. Blake (1958, in Pietroni, 1984) conveys this concept
profoundly (see figure III).
31
Figure III: Blake’s (1958, in Pietroni, 1984) interpretation of the Holographic
paradigm.
Conversely, the scientific method applies commonalities between each
patient, for instance, back-pain as unity in multiplicity and then attempts to
apply common guidelines to them and rigid treatment plans, technique
protocols and medicinal prescriptions, which only creates an impoverished
unity that is reached by excluding difference in favour of what things have in
common, which is an ontological cul-de-sac from which nothing can come
from due to the fact that everything has been excluded from it (Bortoft 1997, in
McKone 2004).
McKone, (2004) reminds us that, “the osteopathic philosophy should be the
driving force in treatment i.e. a physician-centered medicine, and not
palpation or manipulation which comes at the end of the process, which
becomes a patient-centered manipulative approach.” Indeed, students have
been taught what to palpate instead of how to palpate. Similarly, Allen, (1937,
in McKone 2004) directs us away from the ‘taught-imitated’ technique towards
the mental activity of the practitioner. He highlights the fallacy of the constant
concern with the end to be gained above the consideration of the means
“To see a world in a grain of sand and a
heaven in a wild flower
Hold infinitely in the palm of your hand
And eternity in an hour”
32
whereby that end is attained. And so through a process of intuitive imitation
when learning technique, we have followed the trial and error method rather
than that of reason. Indeed, McKone (2001) wittingly states, “wholeness is a
consciousness and not an action, thus those who claim to treat holistically are
still using the Cartesian philosophy to reason and appreciate initially the
summation of parts (or actions) to form a sense of wholeness, thus
demonstrating unity in multiplicity. Indeed the mechanistic conscious manner
of piecing together a patient’s problems is simply poly-analytical
externalisation of the patient’s problems.’
This bears synonymous reasoning to Still’s approach to treatment which, “was
not descriptive but intuitional” (Latey, 1993a, see table VI), whereby the
practitioner’s determined attitude and intention are crucial to the outcome as
this acts to build an exact anatomical picture of all the shapes, dynamics,
balance of muscular forces and fluid that are felt throughout the patient using
the senses in the holistic paradigm and then to consider the units without
losing the former. Indeed, Still’s study of mankind was in man, whom he
observed first hand without preconceived theories.
33
Table VI: A table to show Still’s Practitioner-Centred approach to treatment
(adapted from Latey 1993a).
Phases of manual
treatment
Description
1 Feeling for ‘what is wrong’.
2 Feeling for ‘what is wanting to happen’.
3 Feeling ‘what is stopping it from happening’.
4 Feeling ‘how to remove obstacles and allow it to happen’.
5 Making a very determined effort to remove those obstacles.
6 Withdrawing to allow intrinsic processes to take over.
Mind, Matter and Motion/Life: “When matter is reduced to its greatest
degree of atomic fineness, then it can submit to any bodily form, because all
substances contain in kind that of all other kinds by nature (note similarity to
Urorgan), and can easily take the form of man, beast, bird or reptile, because
this fineness is equal to that of spiritual food or the motor powers of life. (i.e.
life is the combustion of the terrestrial substances within the body). When
matter passes beyond the degree of being atomized farther, then it is life, and
it acts and forms itself to suit the body of any being or the world.” (Still, 1902,
p.255)
Thus, the practitioner must think of the patient out into its environment, and
develop the sense of active absence when treating. Indeed, Still and Goethe
wanted us to bathe in the phenomenon and open our senses to receive the
environment into our consciousness (McKone, 2001) as all beings dwell in the
34
same environment, which is a dynamic, non-linear, timeless continuum. As
Still said in his philosophy of Osteopathy (in McKone, 2001), “An organism
and its environment are one…and consequently we cannot separate them
unaltered, and so cannot understand or investigate one apart from the
rest…the whole is in each moment of the present.” Still further states that,
Structure, composition and activity are inseparably blended together in life,
which corresponds to the following (see Figure IV),
Figure IV: Ludwig von Bertalanffy (1952, in McKone, 2001) insightful
interpretation of form and function.
Still romanticised of life as arising from the “conception by the terrestrial
mother from the celestial father” (Latey 1993a) i.e. life is the relation between
the terrestrial expanding into the celestial or vice versa. Thus, firstly, matter is
life retired from labour to rest, secondly, life is matter in motion (functioning
physiologically), which is a very finely prepared substance that is the all-
moving force of nature that moves all nature from worlds to atoms and finally,
mind is that life substance resulting from a union of matter endowed with
action (Still, 1902). Still eloquently portrays this in the following (see Figure V),
“This separation between a pre-established structure and processes occurring
in that structure does not apply to living organisms. For the organism is the
expression of an everlasting orderly process. What is described in morphology
as organic forms and structures, is in reality a momentary cross-section
through a spatio-temporal pattern. What are called structures are slow
patterns of long duration, functions are quick processes of short duration.”
35
Figure V: (Still, 1902, p.225), Still’s description of Life in Matter as a dynamic
continuum manifesting itself in mind, matter and/or motion.
Relevance to Treatment:
Thus, there is a continuum to nature whereby matter metamorphosis into
life/motion and mind which are all interchangeable in man and all of nature,
further highlighting the osteopathic philosophy and Goethe’s concept of
multiplicity in unity. Thus, it is important to see and experience man in his
phenomenological expression of form and function out into the environment.
Thus, during the practitioner- patient interaction, we should reason why they
can no longer compensate between celestial and terrestrial (motion, mind and
matter), and diagnose and treat them accordingly i.e. the arterial/celestial
force (due to its eminent motion/life) should be brought to act with full force
upon the terrestrial/matter (McKone, 2007). Thus, the infamous principle, the
rule of the celestial is supreme.
Furthermore, Milne (1956) philosophises that if we are to derive any real
understanding of health and disease in our study of men, we must not confine
“Thus man’s body is a form given by celestial life to the terrestrial life that is reduced back from the living matter to a man, world, or being, with form of a being given by the celestial forces acting on living matter whilst in the living state of matter, so fine that the atoms blend and become a unit, or melt and become one being or body of living matter, with quality equal to all qualities of life, wisdom, and material substances, never to return to their original state, either as matter or life.”
36
our observations to his internal structures, but to the outer world in which he is
placed and his interactions with it (see Figure VI).
Figure VI: The concept of man’s interaction with the environment (Milne, 1956).
Thus, ‘mind, matter and motion’ can be viewed as an over arching principle of
osteopathy supported by the very philosophy of osteopathy i.e. that
osteopathy is a science that is primarily concerned with the Lebenswelt, Life-
world (McKone, 2001). Indeed, Kuchera & Kuchera (1994) state that there
needs to be some method of understanding life, in order to have positive
health, the dilemma to which is answered in this over-arching principle.
Lost direction: Finding our Foundation: “The reason why the adult no
longer wonders (as does a child) is not because he has solved the riddle of
life, but because he has grown accustomed to the laws governing his world
picture…he who has reached the stage where he no longer wonders about
anything, merely demonstrates that he has lost the art of reflective reasoning.”
(Planck, in McKone, 2001).
Osteopathy continues to function primarily as a system of manual medicine in
Canada, Britain, Australia and New Zealand (Baer 2009). Sadly, some
osteopaths have come to practice under an empty name due to their divorce
from the phenomenological philosophy, and instead have acted as clinicians
“Man, nature and his social milieu, are the trinity of medicine, and the three are indeed one.
To the true physician there is no solid medium, but only motion and amorphous Man.”
37
of the Cartesian philosophy, thus collapsing into an alternative paradigm of
existence and consequently have found it difficult to produce representative
Osteopathic research, i.e. “faith without works” as Patterson (2006) aptly
remarks. However, it is understood that this was unintentional and necessary
at the time in order to gain status and legislation.
However, osteopathy’s philosophy originates in Goethean science, which is
fortunately being unearthed. Thus, the osteopathic profession should embrace
the vitalistic osteopathic scientific paradigm and be averted to the mechanistic
analytical scientific paradigm (McKone 2001). From this foundation,
osteopathy should strive to gain its deserved status in the medico-political
arena as an independent school of ‘science, practice and research’
demarcated by its phenomenological approach to the natural world. Indeed,
“the osteopathic scientific paradigm is as sound as the analytical modern
scientific paradigm. The two paradigms complement each other…within the
same paradigm” (McKone, 2001). Indeed, “Medicine is certainly not the
exclusive province or private property of any particular profession, any more
than education belongs to the teachers” (Korr, 1962). Thus in answer to, “Can
osteopathy muster its own self-healing capabilities to heal its wounds?”
(Essig-Beaty, 2008), the answer is definitely, “yes”. Similarly, Dummer’s
(1988) fourth evolutionary stage (see appendix X) predicts a return to a
holistic model based on Still’s concepts, due to the presence now of the same
phenomena that preoccupied Still in his day.
38
The Principle to Progress: “Our science is young, but the laws that govern
life are as old as the hours of all ages” (Still 1902 p.62).
Due to the fact that the osteopathic principles are a direct emergence from the
osteopathic philosophy, the author proposes a medium to which the osteopath
can embrace, understand and apply the osteopathic principles in reasoning as
a philosopher of osteopathy, in order to practice as Still’s science and
philosophy of osteopathy intended, by instilling the phenomenological
Goethean inspired paradigm, which understands truth as a fluid and
convertible entity, into ones cognition and utility. In order to achieve this goal,
an overruling principle could translate as follows (see Figure VII),
Figure VII: An attempt by the author to reintroduce the osteopathic
philosophy into the osteopath by way of an overarching principle.
An osteopath must aim to so truly embed the concept of multiplicity in
unity in his or her mental realms when, coming into knowledge of the
natural world and reasoning at all times, whether it be in the educational or
practical realms of diagnosis, research &/or osteopathic practice, whereby
the practitioner-patient system should come into a state of active absence in
order to become part of a shared experience witnessed with the patient, out
into the dynamic multiform and multifunctional spatio-temporal processes
we call the environment, thus forming a total relationship to natural
phenomena as they interchange between mind, matter and motion and thus,
achieving the evidence and rewards of philosophising, and practicing the
science of osteopathy as a healing art in treatment of dysfunctions and
diseases.
39
A Unified Osteopathic Future: “Give me the age of God and I will give you
the age of osteopathy.” (Still, in Essig-Beaty, 2008).
Clapp (1949) printed the ‘Osteopathic Oath’ in an effort to cohere Osteopathy
(see figure VIII) which acts as a guide to the profession’s actions when
conducting osteopathic practice. Indeed, Tyreman (2008a) believes that all
professionals should adopt agreed osteopathic behaviours driven by values in
osteopathic practice. Thus, the integration of the Osteopathic Oath in training
in accordance with the comprehension of the osteopathic philosophy and
principles and their role in practice in association with a thorough knowledge
of the natural sciences will provide a means for the production of competent
osteopathic philosophers in the practice of our science.
The Osteopathic Oath
I do hereby affirm my loyalty to the profession I am about to enter.
I will be mindful always of my great responsibility to preserve the health and the life of my patients, to retain their confidence and respect both as a physician and a friend who will guard their secrets with scrupulous honour and fidelity, to perform
faithfully my professional duties, to employ only those recognised methods of treatment consistent with good judgement and with my skill and ability, keeping
in mind always nature’s laws and the body’s inherent capacity for recovery.
I will be ever vigilant in aiding in the general welfare of the community, sustaining its
laws and institutions, not engaging in those practices which will in any way bring shame or discredit upon myself or my profession. I will give no deadly drugs to any,
though it be asked of me.
I will endeavour to work in accord with my colleagues in a spirit of progressive co-operation, and never by word or by act cast imputations upon them or their rightful
practices.
I will look with respect and esteem upon all those who have taught me my art. To my College I will be loyal and strive always for its best interests and for the interests of
the students who will come after me. I will ever be alert to adhere to and develop the principles of Osteopathy as taught by Andrew Taylor Still.
40
Figure VIII: The Osteopathic Oath (adapted from Clapp 1949). In bold are
the phrases that highlight the undertones of the osteopathic philosophy and
our duties as practitioners to be philosophers of our science and practice.
Future Research:
With regard to this enquiry, it would be of interest to research the BOJ for its
content of mechanical principles, thus gauging the extent of the Cartesian
Philosophy’s influence in the osteopathic community through time. From the
results here, a subsequent increase of Cartesian-Newtonian thought process
and philosophy would be expected through the 20th Century. However, it is
thought that time would be better spent in promoting the osteopathic
philosophy to the curriculum and wider international community due to the fact
that as Dubos (1977) states, ‘very few know of its (Goethean approach)
existence’. However, we now know of our truly bracing and novel
philosophical platform which provides the endowment of reasoning skills, with
regard to health and disease, so that we can now confidently apply the art of
osteopathic science in practice, and so here rests our osteopathic identity.
.
Future Osteopathic Research With Regard to Evidence Based Medicine:
EBM hierarchy of evidence is short sighted and ranks evidence not according
to effectiveness but according to study method, (Bluhm 2005, in Fryer 2008).
This author clearly understands the essence of osteopathy. Indeed Avis &
Freshwater (2006, in Fryer 2008) agree that EBM undermines the role of
41
clinical judgement and individual expertise. Similarly, Leach (2008) states that
evidence from random controlled trials are limited, not adequately reflecting
osteopathic practice. However, pragmatic randomised trials where one health
service model is compared to another to assess the package of care, as was
done in the BEAM (UK BEAM Trial team, 2004) and ROMANS (Williams et al
2003) trials represent better methodologies to reflect the efficacy of
osteopathy in the EBM arena (‘the better of two evils’). However, true
osteopathic research would consist of practitioner-patient views directly
representative of the natural world and experience reports of those natural
phenomena interactions and case reports/studies on the many differing
patterns of the body in space and time all of which Still (1910) describes in his
book, ‘Osteopathy: Research & Practice’.
Weaknesses of Research:
Keeping in mind that only two issues per year were reviewed in the
BOJ, it is difficult to make any fully claimable conclusions or
assumptions based on the data from sampled issues (Riese, 2000).
Intra reliability was deemed unnecessary to perform as the author’s
knowledge of the score given to each article was known and thus,
results from this would be bias.
Publication bias was a factor as the BOJ was the only journal to be
reviewed and so the results cannot be extrapolated to the contents of
other osteopathic publications. However, although the results were
obtained from only one journal source, and may not be representative
of all osteopathic literature, the lack of reinforcement of osteopathic
42
principles in just one journal should act as an important flag to the
profession.
The editors decision to use articles from the same author on a regular
basis may have biased the BOJ content i.e. Dove, Smith, Barrett,
Miller. However this is also a valuable factor in determining osteopathy
at the time.
Conclusion:
1. A decrease of 0.117 osteopathic principles per year in the BOJ
between 1960 and 1984 is synonymous with the ongoing debate of
‘lost osteopathic identity’.
2. There is a need for re-education and implementation of the osteopathic
philosophy among osteopathic colleges in order to produce a resulting
united osteopathic identity. Thus, the concept of ‘mind, matter and
motion’ can be viewed as an over arching principle of osteopathy
supported by the very philosophy of osteopathy.
3. Osteopathic practice should not be a set of pre conceived
methodologies chosen due to similarities between cases grown from
the Newtonian concept of an objective reality, but instead, a newly
formulated host of dependable evaluative and manipulative methods
based on practitioner reasoning, with the principles in mind, in
43
response to the unique presenting clinical case based on the
phenomenological philosophy.
4. From this foundation, osteopathy should strive to gain its deserved
scientific acceptance and status as an independent school of science &
practice.
5. This needs to permeate the understanding of evidence in medical
science (Leach 2008) so that an osteopathic concept of evidence is
accepted as true and representative of the natural world giving
reverence to osteopathic philosophers’ organic participatory ideas
(McKone, 2004), case studies and patient views.
Author’s closing remark:
Osteopathy is a philosophy, a science and an art. Its philosophy is
based on the concept of multiplicity in unity, the way in which its science
is conceived. Its science is the coming into knowledge of the world we
are in, which together form the osteopathic principles are applied artfully
in osteopathic practice. Its art is the application of the practitioner’s many
possible philosophising avenues in his/her knowledge of the natural
world being immersed in active absent practice as a witness in the
presence of the multiform presenting patient out in its forever changing
environment and the multi-manifest ways in which these practitioner-
patient interactions can occur and be ever integrated with each other.
44
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Still, A, T (1902) Philosophy and Mechanical Principles of Osteopathy.
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51
Medicine: Philosophy, principles and practice. Blackwell Science Ltd.
p.84-5.
Stone, C. (1999). Science in the Art of Osteopathy: Osteopathic
principles and practice. Ch. 4 and 10. Nelson Thornes. Available from:
http://books.google.co.uk/books?id=zQ-jA0VJrtcC [Accessed:
04/09/08].
Teitelbaum, H., S., Bunn, W., E., Brown, S., A., and Burchett, A., W.
(2003) Osteopathic Medical Education: Renaissance of Rhetoric?
JAOA. 103(10):489-490.
Tucker, E., E. (1919) Dr. Still, the metaphysician. JAOA. 19(9):486-94.
Tyreman, S. (2008a) Valuing osteopathy: What are (our) professional
values and how do we teach them? IJOM. 11:90-95.
Tyreman, S. (2008) Commentary on ‘Is there a place for science in the
definition of osteopathy’? IJOM. 11:102-105.
UK BEAM Trial Team. (2004). United Kingdom back pain exercise and
manipulation (UK BEAM) randomised trial: effectiveness of physical
treatments for back pain in primary care. Br Med J. 329:1377
Ward, R. C., Sefinger, M. A., King, H., Jones, J. M., Rogers, F. J. and
Patterson, M. M. (2003). Foundations for Osteopathic Medicine.
Chapter 1. 2nd Ed. Lippincott Williams & Wilkins. Philadelphia.
Wernham, J (2006) The Body Adjustment: Theory and Practice.
Professional Development, Postgraduate Studies in Classical
Osteopathy Foundation Course.
Wernham, J (1996) Classical Osteopathy. The Basic Principles of
Osteopathy. J. Martin Littlejohn. p. 35. Reprinted Lectures from the
52
Archives of the Osteopathic Institute of Applied Technique. Published
by The John Wernham College of Classical Osteopathy.
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Linck, P., et al. (2003). Randomized osteopathic manipulation study
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20:662-9.
53
References II: Article references for the pilot study selected at random from
the BOJ:
1. Barrett, J. (1962) Capsulitis of the hip joint. The Journal and
proceedings of the Osteopathic Association of Great Britain. 1(6-7): 1-2
2. Miller, R., F. (1963) Levator scapulae symptoms. The British
Osteopathic Journal. 2(4): 1-5
3. Dove, C., I. (1967) A History of the Osteopathic vertebral lesion. The
British Osteopathic Journal. 3(3): 2-17
4. Barrett, J. (1969) A study of inversion of the foot. The British
Osteopathic Journal. 4(3): 1-6
5. Smith, A., E. (1973) Osteopathic Diagnosis. The British Osteopathic
Journal. 6(1): 2-9
54
References III: BOJ article references (n=69) from which data was gathered
and subsequently used for data analysis: (Note that between reference 41
and 42 the BOJ ceased publications from December 1984 until November
1987).
1. Dove, C., I. (1960) The place of Medical Diagnosis in Clinical
Osteopathy. BOJ. 1(1): 1-13.
2. Crowder, C., H. (1961) Postural Education in Osteopathic Practice. The
Journal and proceedings of the Osteopathic Association of Great
Britain. 1(3): 1-11.
3. Dove, C., I. (1961) The Physiological Basis of the Osteopathic Concept
of Visceral Disease. The Journal and proceedings of the Osteopathic
Association of Great Britain. 1(5): 1-24.
4. Barrett, J. (1962) Capsulitis of the hip joint. The Journal and
proceedings of the Osteopathic Association of Great Britain. 1(6-7): 1-
2.
5. Smith, A., E. (1962) A survey of the muscular changes associated with
some of the common sacro-iliac lesions. The Journal and proceedings
of the Osteopathic Association of Great Britain. 1(8): 1-3.
6. Crowder, C., H. (1963) Spasmodic asthma and its osteopathic
management. BOJ. 2(2): 1-10.
7. Miller, R., F. (1963) Levator Scapulae Symptoms. BOJ. 2(4): 1-5.
8. Smith, A., E. (1964) Sacroiliac lesions: a consideration of their
aetiology and symptomatology. BOJ. 2(6): 1-4.
9. Barrett, J. & Tyrie, M. (1965) Sciatica in young patients. BOJ. 2(7): 1-5.
55
10. Crawford, D., A., H. (1965) Dupuytren’s contracture. BOJ. 2(8): 1-6.
11. Hewitt, P., M. (1966) Cervical Spondylosis. BOJ. 3(1): 2-5.
12. Jackson. P., A. (1966) The sacral base plane. BOJ. 3(2): 2-11.
13. Dove, C., I. (1967) A history of the Osteopathic Vertebral Lesion. BOJ.
3(3): 2-17.
14. Crawford, D., A., H. (1967) An investigation into the number of
practicing osteopaths in the United Kingdom. BOJ. 3(4): 1-13.
15. Chapman, A., E. & Troup, J., D., G. (1968) Training for heavy manual
work. BOJ. 4(1): 2-10.
16. Barrett, J. (1969) The frozen shoulder. BOJ. 4(2): 2-4.
17. Barrett, J. (1969) A study of inversion of the foot. BOJ. 4(3): 1-6.
18. Tyrie, M. (1970) Head Pain. BOJ. 4(4): 2-13.
19. Stoddard, A. (1971) Spinal Osteochondritis. BOJ. 5(1): 2-9.
20. Smith, A., E. (1971) Osteopathic Diagnosis. BOJ. 5(2): 2-8.
21. Smith, A., E. (1972) Osteopathic Diagnosis- Standing Examination.
BOJ. 5(3): 2-7.
22. Smith, A., E. (1972) Osteopathic Diagnosis- Sitting Examination. BOJ.
5(4): 2-8.
23. Smith, A., E. (1973) Osteopathic Diagnosis. BOJ. 6(1): 2-9.
24. Stoddard, A. (1973) Mechanics of the Spine. BOJ. 6(2): 3-10.
25. Leahy, J. (1974) Georgia D.O wins suit to use M.D suffix. BOJ. 7(1): 3-
7.
26. Middleton, H., C. (1974) Osteopathic Diagnosis and treatment
prescription. BOJ. 7(2): 4-12.
56
27. Michigan C.O.M Advanced study group (1975) The piriformis muscle
syndrome. BOJ. 8(1): 3-12.
28. Burton, A., K. (1975) The need for Osteopathic Research. BOJ. 8(2): 3-
9.
29. Salter, D., C. (1976) Some aspects of the prognostic detection of
referred clinical signs. BOJ. 9(1): 3-26.
30. Stoddard, A. (1977) Acute Spinal Pain. BOJ. 10(1): 3-9.
31. Good, A., B. (1978) Spinal joint blocking. BOJ. 11(1): 4-19.
32. Smith, C. (1978) Treatment approaches for the Frozen Shoulder
Syndrome. BOJ. 11(2): 3-8.
33. Droz-Georget, J., H. (1980) High-Velocity Thrust and Pathophysiology
of segmental dysfunction. BOJ. 12(1): 2-17.
34. Miller, R. (1980) Intercosto-Brachial Nerve neuralgia. BOJ. 12(2): 4-13.
35. Burton, A., K. (1981) Sitting; Theoretical Consideration of the problem
and potential solutions. BOJ. 13(1): 2-21.
36. Barker, M., E. (1982) Back pain in general practice: A practical
classification. BOJ. 14(1): 1-7.
37. Mason, G., N., G. (1982) Factors predisposing towards injury in rugby
football. BOJ. 14(2): 77-82.
38. Sandler, S., E. (1983) The physiology of Soft Tissue Massage. BOJ.
15(1): 1-7.
39. Dyer, C., D. (1983) Visco-elastic insoles in long distance walking. BOJ.
15(2): 79-83.
40. Burton, A., K. (1984) A pilot study of electromyography and office chair
design. BOJ. 16(1): 1-5.
57
41. Miller, R. (1984) The prone sleeper’s spine. BOJ. 16(2): 61-68.
(British osteopathic Journal ceased publishing between December
1984 and November 1987).
42. Dove, C., I. (1987) The place of Medical Diagnosis in Clinical
Osteopathy. BOJ. 1: 1-7.
43. Ferguson, A. (1988) Cranial Osteopathy- A New Perspective. BOJ. 2:
3-7.
44. Watkins, R., N. (1989) A Communication Perspective for Osteopathy.
BOJ. 3: 5-18.
45. Frymoyer, J., W. (1990) Medical Progress- Back pain and Sciatica.
BOJ. 4: 2-13.
46. Meale, T., W., Dyer, S., Browne, W., Townsend, J., and Frank, A., O.
(1990) Low Back Pain of Mechanical Origin: Randomised Comparison
of Chiropractic and Hospital Treatment. BOJ. 5(2): 3-13.
47. Istamatyadis, Y. (1991) Measured Vertical Traction: A Lumbar Traction
Method, used for the Treatment of Lumbago and Sciatica. BOJ. 6(1): 3-
11.
48. Wernham, J. (1991) The Osteopathic Lesion Theory. BOJ. 7: 3-11.
49. Norfolk, D. (1992) Personality factors in the aetiology of disease. BOJ.
8: 3-11.
50. Randell, P. (1992) The Crisis of Clinical Theory Supporting Osteopathic
Practice. A Critique and New Proposal. BOJ. 9: 5-7.
51. Standen, C., S. (1993) The Future of Osteopathy. BOJ. 10: 6-8.
58
52. Richards, J. (1993) Lumbo-sacral Dysfunction in Occupational
Motorcyclists. BOJ. 11: 7-10.
53. Dunham, M. (1993) The Practice of Osteopathy as seen from the
patient’s point of view. BOJ. 12: 7-8.
54. Nathan, B. (1994) Philosophical notes on Osteopathic Theory- Initial
Observations. BOJ. 13: 8-16.
55. Vogel, S. (1994) Research- the future? Why bother? BOJ. 14: 6-10.
56. Korth, S. (1995) Chronic Neurological Dysfunction in Children. BOJ.
15: 7-9.
57. Pointon, R. (1995) Judgement in Osteopathy. BOJ. 16: 5-8.
58. Stone, C. (1995) The Osteopathic Management of urinary bladder
dysfunction. BOJ. 17: 6-8.
59. Stone, C. (1996) The Extrinsic Mechanisms of Continence: a
discussion paper. BOJ. 18: 8-10.
60. Podmore, W. (1996) Why Osteopaths Should Support Immunisation.
BOJ. 19: 7-10.
61. Burtt, R. & Walters, N., J. (1997) Dentists & General Prize 1997, I:
Overtraining Syndrome In Rugby Union. BOJ. 20: 7-13.
62. Sandler, S. (1998) Report on a survey to look into the incidence of
acute musculo-skeletal pain and the phases of the menstrual cycle.
BOJ. 21: 7-10.
63. Lederman, E. (2000) Facilitated Segments: a Critical Review. BOJ. 22:
7-10.
64. Monro, M. (2001) Patient priorities in Osteopathic care. BOJ. 23: 7-14.
59
65. Carnell, L., Nicholls, B. and Gibbons, P. (2002) A study of the referral
patterns of General Practitioners to Osteopaths, Chiropractors and
Physiotherapists in Victoria. BOJ. 24: 6-12.
66. Swain, C. (2002) An Investigation into the different usage of
Osteopathic Terminology. BOJ. 25: 5-12.
67. Climent, G. & Goss-Sampson, M. (2003) Quiet Stance: The act of
Standing Upright, a literature review with implications for Osteopathic
Practice. BOJ. 26: 6-11.
68. West, C. (2004) An Investigation into backpack habits and back pain in
14-year-old schoolchildren. BOJ. 27: 6-14.
69. Edwards, D. (2006) The General Osteopathic Council Standard of
Proficiency-a consumer’s perspective. BOJ. 28: 7-16.
60
Appendix I: A table to show the keywords used in this study and their
respective definitions.
Key words Definitions
Philosophy A set of principles serving as a basis for making judgements and
decisions (Chambers Concise Dictionary & Thesaurus, 2001).
Osteopathic
philosophy
A unifying set of ideas for the organisation of scientific knowledge
in relation to all phases of physical, mental, emotional and spiritual
health, along with distinctive patient management principles and
thus, forms the basis for osteopathic medicine’s distinctive
approach to healthcare (Ward et al 2003).
Principle A fundamental truth or law as the basis of reasoning or action (The
Concise Oxford Dictionary of Current English, 1990). A rule or law
concerning the functioning of natural phenomena or mechanical
process (American Heritage Dictionary, 1969).
Osteopathic
principle
A biologic, behavioural, or clinical rule or law that is given special
diagnostic and management emphasis by osteopathic physicians
because it exemplifies the osteopathic philosophy of health and
illness (Sprafka 1981, p.33).
61
Osteopathy An established system of clinical diagnosis and manual treatment
in which a caring approach to the patient and attention to individual
needs are of primary importance. In particular, it is concerned with
the inter-relationship between the structure of the body and the
way in which it functions and is therefore an appropriate form of
therapy for many problems affecting the neuro-musculo-skeletal
systems. (British Osteopathic Association, 2007, in Lucas &
Moran, 2007).
A ‘whole body’ system of manual therapy, based on unique
biomechanical principles, which uses a wide range of techniques
to treat musculo-skeletal problems and other functional disorders
of the body. (Australian Osteopathic Association, 2007, in Lucas &
Moran, 2007).
Osteopath A person who has achieved the nationally recognised academic
and professional standards within his/her country to independently
practice diagnosis and treatment based upon the principles of
osteopathic philosophy. Individual countries establish the national
academic and professional standards for osteopaths practicing
within their countries. (American Association of Colleges of
Osteopathic Medicine, 2006, in Lucas & Moran 2007).
Concept An abstract idea or notion (Stedman’s Concise Medical Dictionary
for the Health Professionals, 2001).
Value Descriptions or conditions that are both a guide to human action
and are subject to praise or blame within a human community
(Sadler 1997, in Tyreman 2008)
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Appendix II: Literature Search: A table to show the databases searched for
research into the principles of osteopathy.
Database Key words Number of articles
found
Science Direct Osteopathy and Principles 2,231
OstMed Osteopathy and Principles 318
Psych Info Osteopathy and Principles 20
Highwire Press Osteopathy and Principles 412
PubMed Osteopathy and Principles 1,523
63
Appendix III: A. T. Still’s fundamental concepts of Osteopathy can be
organized in terms of health, disease, and patient care. (Adapted from Ward
et al 2003, p. 5).
Health
I. Health is a natural state of harmony.
II. The human body is a perfect machine created for health and activity.
III. A healthy state exists as long as there is normal flow of body fluids and
nerve activity.
Disease
IV. Disease is an effect of underlying, often multifactorial causes.
V. Illness is often caused by mechanical impediments to normal flow of
body fluids and nerve activity.
VI. Environmental, social, mental and behavioural factors contribute to the
aetiology of disease and illness.
Patient Care
VII. The human body provides all the chemicals necessary for the needs of
its tissues and organs.
VIII. Removal of mechanical impediments allows optimal body fluid flow,
nerve function, and restoration of health.
IX. Environmental, cultural, social, mental and behavioural factors need to
be addressed as part of any management plan.
64
X. Any management plan should realistically meet the needs of the
individual patient.
65
Appendix IV: The four osteopathic principles adapted from, ‘The Special
Committee on Osteopathic Principles and Osteopathic Technic, KCOM,
1953’.
I. The body is a unit. The person represents a combination of body, mind,
and spirit.
II. The body is capable of self-regulation, self-healing, and health
maintenance.
III. Structure and function are reciprocally inter-related.
IV. Rational therapy is based upon an understanding of body unity, self-
regulatory mechanisms, and the inter-relationship of structure and
function.
66
Appendix V: The five Principles of Osteopathy by Sprafka et al (1981). Italics
show the two principles added to the KCOM list.
I. The body is a unit.
II. The body is capable of self- regulation.
III. Structure and function are reciprocally inter-dependent.
IV. The body is capable of maintaining health and avoiding disease when it
is maximally able to adapt to its environment. This capability may be
maintained when structural relations are normal, environmental
conditions are favourable, and nutrition is adequate.
V. When normal adaptability is disrupted or when environmental changes
overcome the body’s capacity for self-maintenance, disease may
ensue.
67
Appendix VI: Osteopathic principles, I-IX (DiGiovanna et al, 2005), with an
inclusive account of their foundations.
Osteopathic
Principles
Foundations
I. The body is a
unit.
The first osteopathic principle is one of Still’s original principles and
encompasses the phenomenon that each body component has an
anatomical, mechanical and physiological relationship with the rest of
the body and so every sub division of the body which functions within
itself has in a greater functional role to fulfil with regard to the greater
interest of the body, thus, the human body functions as an integral
whole. Systems of communication, including the nervous, arterial,
venous, lymphatic, endocrine, immune, cerebrospinal and
musculoskeletal act together to integrate the whole to function as a
unit. ‘To comprehend this engine of life, it is necessary to constantly
keep the plans and specifications before the mind. A complete
knowledge of all parts, with their forms, sizes, and places of
attachment is gained and should be so thoroughly grounded in the
memory that there can be no doubt of the use or purpose of the great
or small parts and what duty they have to perform in the working of
the engine [unit]’ (Still, 1902 p.34).
Still (1902) states, ‘The spinal cord throws out millions of nerves to all
organs and parts which are supplied with the elements of motion and
sensation. All these nerves terminate in the great system, the fascia’.
Interestingly, all body parts are united, sustained nutritionally and
supported by fascia as it extends throughout the entire body
surrounding each muscle, bone, joint, vein, nerve, and organ thus
providing a major conduit throughout the body in which reside a
profuse network of somatic and autonomic nerves (Kuchera &
Kuchera 1994) in addition to arterial, venous and lymphatic vessels.
Still (1902) stated, ‘Its nerves are so abundant that no atom of flesh
fails to get nerve and blood supply there from’. Additionally, fascia
enables gliding between muscles and ligaments without friction. ‘It
penetrates even its own finest fibres to supply and assist their gliding
elasticity’ (Still, 1902), again emphasising its major importance in
68
unifying the body as a whole.
Interestingly, Korr (1987) proposed the extension of this principle
beyond the body to the person and to body/mind interplay and unity,
as it is the person, which is the environment in which the parts exist
and operate. Kuchera & Kuchera (1994) write that the mind and body
of the person produce their respective psychological attitudes and
physical abilities and that the soul develops the spiritual person. Thus
insinuating that each patient’s physical body interacts with its mental
and spiritual inner works; thus, the health of each of these factors
affects the others (Kuchera & Kuchera 1994). Thus, if there is an
abnormal detail in a body, mind or spirit component it must be made
to assume an integrative relationship with the unit body if the
condition is to be resolved and the patient stabilised (see mind,
matter, motion in discussion for the osteopathic philosophical insight).
II. Structure and
function are
interrelated.
Still (1902 p.33) aptly demarcates the essence of this principle in the
following, ‘If we follow the effects of abnormal straining of ligaments
[structure], we will easily come to the conclusion that derangements
of one hundredth part of an inch are often probable of those parts of
the body over which blood vessels and nerves are distributed…The
blood vessels carrying the fluids for the construction and sustenance
of the infinitely fine fibres, vessels, glands, fascia and cellular
conducting channels to nerves and lymphatics, must be absolutely
normal in location before a normal physiological action can be
executed in perfect harmony with the health-sustaining machinery of
the body. If a nerve or vessel should be disturbed, we would expect
delay and a subsequent derangement in the workings of the
laboratory of nature’.
Thus, the physical formation of any body part and the functions that
they each perform have an intimate and reciprocal relationship in the
sense that they are reliant on each other in order to achieve optimal
health. Stone (1999) describes the major constituents of the body,
which include, the skin, nerves, muscle, ligaments, fascia, synovium,
tendons, inter-vertebral discs, cartilage, blood and lymphatic vessels,
69
bone and visceral organs (Cartesian thought process). Interestingly, if
the construct of any of these body parts is abnormal perhaps due to
degenerative, traumatic or emotional events, congenital or
developmental abnormalities, metabolic or endocrine disarray,
infective agents, neoplastic or inflammatory processes, autoimmune
conditions or functional changes (Stone, 1999), then dysfunction will
result in that body part affected. (see Urorgan concept under, How to
Treat, in Discussion for osteopathic insight).
III. The body
possesses self-
regulatory
mechanisms.
Still (1908) studied the nature of health, illness and disease, and
concluded that, ‘God had certainly placed all the principles of motion,
life and all its remedies to be used in sickness within the material
house in which the spirit of life dwells’. The body’s self- regulating
systems constantly monitor the functioning of the whole body through
feedback mechanisms, which maintain homeostasis in concert with
the environment. The theorised mechanisms include firstly, the
neurocrine signalling system which functions by way of neurons
within the CNS. Secondly, the endocrine system which consists of
several organs including, the thyroid and parathyroid glands, the
heart, striated muscle, skin, adipose tissue, the stomach and
duodenum, the liver and pancreas, the kidneys, adrenal glands,
testes, ovaries, placenta, and uterus (Cartesian thought process)
which are all integrated by the release of their respective hormones in
order to regulate processes including growth, metabolism,
development of puberty, tissue function and mood (Collier et al 2006).
Thirdly, the neuro-endocrine system processes that integrate
peripheral and central information with regard to a particular sub
system. It consists of the hypothalamus, pineal body, anterior,
posterior and intermediate pituitary lobes which themselves constitute
neurones that synthesise and secrete particular hormones which
encompasses the CNS’s capacity to launch the first in a long
sequence of cellular events that control an endocrine sub system of
communication and thus acts as an autonomous pulse generator.
Fourthly, paracrine signalling systems function to secrete signalling
molecules that act on target cells which reside near to the signal
releasing cell and thus auto regulate sub systems. Fifthly, autocrine
systems act to release chemical messengers, which bind and act on
70
the same cell of release and finally, intracrine systems are those
cells, which release signalling molecules that act within a cell. Thus,
the Cartesian model theorises that the body is a dynamic array of
fluctuating micro systems, which are conducted and harmonised by
the body’s self- regulating mechanisms.
IV. The body
has the
inherent
capacity to
defend and
repair itself.
The ancient Latin phrase, ‘Vis medicatrix naturae’ originally depicted
the body’s self- healing capacity. Still, (1910 p. 36) avowed that each
body part is subject to the general law of demand, supply,
construction and renovation in order to achieve normal functioning,
thus indicating that within the body are found all the necessary
mechanisms, including, homeostatic, protective, regenerative,
eliminative, and compensatory means needed to promote and restore
health. Still (1902 p. 31) eloquently conveys the essence of this
principle, ‘[Chemistry] gives us the reasons why food is changed in
the body into bone, muscle and so on… Chemistry is one thing and
physiology is the witness that it is a law in man as it is in all nature.
Osteopathy believes that all parts of the human body act on chemical
compounds, and from the general supply manufacture the
substances for local wants. Thus, the liver builds for itself the material
that is prepared in its own division laboratory’. Wernham (1996)
reiterates that ‘the body takes the raw materials from the field of
nature and uses these basic substances in the preparation of new
substances and in the preparation of forces’. Thus, it seems that a
healing reconstructive environment requires constant molecular and
anatomic turnover in the guise of food and water and of equal
enormity that metabolic produce of cellular activity needs to be
excreted.
Additionally, protective capabilities exist in adjoining body parts at
MS, visceral, neurological, chemical and psychological levels, which if
needed to, contribute to the amendment of neighbouring damaged
areas, by way of increasing their functional responsibilities in order to
maintain regional health. Selye (in Kuchera & Kuchera, 1994)
indicates that a person with an increased allostatic load (Stone 1999)
may not show immediate signs and symptoms of dysfunction despite
the fact that homeostasis has shifted towards new parameters of
71
function that are more detrimental to health than before. Indeed, as
each physical, psychological and spiritual challenge is inflicted onto
the body’s adaptive capabilities, subsequent challenges are met by
the body’s homeostatic mechanisms, which adapt to the new
environmental circumstances in order to permit normal functioning,
this is the concept of compensation and plasticity within the person.
V. When normal
adaptability is
disrupted, or
when
environmental
changes
overcome the
body’s capacity
for self-
maintenance,
disease may
ensue.
‘Disease is the result of anatomical abnormalities followed by
physiological discord’, (Still, 1910). Thus, disease is a product of the
body’s inability to further adapt to a situation due to abnormal
structure or function or the product of adverse environmental factors
that overcome the body’s defences. Still (1902 p.28) succinctly states,
‘If the fish should change place with the bird, it would surely die and
become extinct… That element that sustains animal life belonging to
each is abundantly supplied and dwells in its peculiar environment.
Suppose we should move the heart up to the cranial cavity and the
brain down to the place now occupied by the liver, and the liver to the
position of the lungs, and placed the lungs on the sacrum; what would
you expect but death?’ Furthermore, Littlejohn states (in Wernham
1996) that, ‘order is the law of life and that harmony is the principle of
the body architecture and the body activities. Anything that throws
this order and harmony into a condition of disorder is a productive
cause of disease’. Thus, if unfavourable environmental circumstances
occur when the body has already adapted maximally to multiple
insults, the subsequent challenge will cause the homeostatic,
protective, regenerative, reparative, eliminative, adaptive and
defensive mechanisms to disband in that region or have an
exaggerated response and so render them inefficient and so
dysfunction and disease occurs with prevailing symptoms which may
be referred to other structures, which in different circumstances may
have been adequately met by the body’s homeostatic mechanisms.
VI. Movement of
body fluids is
essential to the
maintenance of
health.
“Perfect health is the natural result of pure blood” (Still, 1902, p.52).
This principle is often quoted as the widely accepted idiom, ‘the rule
of the artery is supreme’ and is one of Still’s original principles. Still
also held importance to unimpeded flow of the great system of
lymphatics as, ‘it is the source of construction and purity’ (Still, 1902,
p.68). Additionally, Still describes the cerebro-spinal fluid as, ‘the river
72
of life’ (Still, 1899) and states that it is the highest known element
contained in the human body. Furthermore, Still conveyed that the
flow of body fluids was under the control of the nerves that innervated
the blood vessel walls and the heart, thus, ‘healthy tissue is tissue in
which the blood circulation and nerve force are correlated’ (Littlejohn,
in Wernham, 1996). Of equal importance, Still (1902) states that,
‘blood must not be allowed to flow to the part by wild motion. Its flow
must be gentle to suit the demands of nutrition; otherwise… we lose
the benefits of the nutritive nerves.’ Thus, vessel circulation must be
unobstructed, otherwise inadequate flow, tissue anoxia and injurious
metabolites may permit and disease may prevail, with tissue atrophy
as an end product of mechanical derangement. Still elucidates,
‘Abdominal tumours only form when some channel of drainage is shut
off… to remove a growth of any organ in the abdomen, we must line
up the body in good form for the appropriation of the arterial blood by
the organ to which it was sent out by the heart, then fix all the vessels
of drainage, turn the nerves loose and the work will be done’ (Still
1902 p35).
VII. The
nervous system
plays a crucial
part in
controlling the
body.
‘The lungs move, thus you find motor nerves; they have feeling, thus
the sensory nerves; they grow by nutrition, thus the nutrient nerves.
They move by will or without it; thus they have a voluntary and
involuntary system’ (Still, 1902, p.63).
Integration within the nervous system (NS) is mediated through the
MS system, the neuro-visceral (ANS) system, the neuro-emotional
(limbic) system and the neuroendocrine-immune system (Stone
1999). The neural, endocrine and immune systems communicate
through their respective neuro-regulators, hormones and immuno-
regulators. Stone (1999) lists a cohort of reflex loops, which include,
somato-somatic, somato-emotional, viscero-visceral, viscero-somatic,
somato-visceral and viscero-emotional which exist in the body as
unanimously functioning entities in health and disease which are
multi-directional thus implying that segmental dysfunction in a
sclerotome, viscerotome, angiotome, myotome, or dermatome has
the potential to affect the other, in addition to affecting emotional or
immune responses (an example of counterfeit holism, see McKone
73
2001. p. 38).
Stone (1999) explains that adaptive neural processing occurs when
increased summative and temporal nociceptive afferents entering the
dorsal horn at a named segment following injury induce inter-neuronal
plasticity whereby excess excitatory or inhibitory synapses are
synthesised leading to sensitisation or depression at that SC segment
thus directly influencing segmental reflex activity with regard to the
segmental efferents in addition to amending ascending signals.
Ascending pathways can thus become reinforced and consequent
higher centre adaptation occurs such that descending influences on
segmental cord activity summates at a few SC levels to adversely
affect the segmental efferents to the end tissue. Thus, sympathetic
vasomotor efferents to a named angiotome may be modified by
dysfunction in a related segment within the MS system through a
somato-visceral reflex. Sammut & Searle-Barnes (1998) state that
this may be observed clinically as increased skin temperature locally,
moisture, tenderness and/or oedema.
In addition to Korr’s 1967 evidence of the neurotrophic functions of
nerves on their target tissues (American Academy of Osteopathy,
1979), dorsal root reflexes exist whereby neurogenic inflammation is
the result of retrograde inflammatory mediator signals from the
afferent fibre to the tissue where the noxious stimulus originated from
(Bagust et al, 1993, in Stone 1999) and thus may be the mechanism
underlying visceral dysfunctions such as asthma (Shelhamer et al
1995, in Stone 1999) and irritable bowel syndrome (Accarino et al
1995, in Stone 1999). Furthermore, Stone (1999) states that afferent
fibres conveying information from an injured somatic structure may in
addition to causing neurogenic inflammation in somatic tissues may
also trigger visceral cell bodies through shared connections to cause
neurogenic inflammation in the segmentally related organ, which is
termed neurogenic switching (Meggs, 1993).
VIII. There are
somatic
Korr (in Kuchera & Kuchera 1994) highlights that the majority of the
efferent output and afferent input from and to the CNS is directed to
74
components to
disease that not
only are
manifestations
of disease but
also are factors
that contribute
to maintenance
of the diseased
state.
and from the MS system which in accordance with cerebral control
provide the ultimate instrument of human action and behaviour, thus
the CNS is very much occupied with motion (Korr 1987). Indeed,
circulatory, respiratory, digestive and metabolic systems function
primarily to serve the demands of the MS system, thus, giving reason
to Korr’s reference to the neuro-MS system as the “machinery of life”
thus emphasising its importance in the maintenance of health and its
role in disease. ‘A neuromusculoskeletal component is present in
every dysfunction or disease’ (Kuchera & Kuchera 1994). The
somatic component of the disease process may be caused by direct
somatic injury resulting in somato-somatic reflexes or in response to
visceral pathology through viscero-somatic reflexes. Thus, somatic
signs and symptoms in the dysfunctioning neuro-MS system (somatic
dysfunction) may be detected and act as grounding diagnostic clues
as to whether the disease process is primarily MS derived or whether
they have arisen secondary to visceral dysfunction (Kuchera &
Kuchera 1994) (Nb. Evidence of conformity to EBM).
Littlejohn (Wernham 1996) explains how a somatic dysfunction can
translate into a maintaining factor of a disease. Initially, an acute
injury strain, a postural change and/or changes in atmosphere and
climatic conditions may cause soft tissue changes in muscles, fascia
and/or cartilage through somato-somatic reflexes. Secondary
changes in hard tissues such as bones, ligaments and tendons are a
consequence if this state is prolonged, which leads to the interruption
of blood and nerve pathways to anatomically related tissues. This
may cause in conjunction, somato-visceral reflexes to further maintain
a disease process due to the fact that an area of somatic dysfunction
acts as a ‘neurological lens’ (Korr 1976, in Sammut & Searle- Barnes
1998) in amplifying responses to any ongoing reflex activity in the
segment and so potentially modifying the visceral efferents.
Interestingly, if the somatic dysfunction remains indefinitely, it may
“burn a memory pattern” within the CNS through neural adaptive
processing so that when the initial irritating MS influence is removed,
the legacy of the somatic dysfunction may continue to grow in
severity (Patterson, in Kuchera & Kuchera, 1994) (see mind, matter
75
and motion, in discussion, for osteopathic relevance).
IX. Rational
treatment is
based on the
previous
principles.
‘My object is to make the osteopath a philosopher and place him on
the rock of reason’ (Still 1910) in order to rationalise from the effect to
the cause of all abnormalities. A physician who only treats the
disease is merely treating an effect and may have no great impact on
the cause. ‘When you fully comprehend and travel by the laws of
reason, confusion will be a stranger in all your combats with disease.’
(Still, 1910 p. 39). In every patient encounter, the osteopath filters the
results obtained from the patient’s history, physical examination and
any other tests through the “philosophic lens” formed by the principles
of osteopathy. If the philosophy is used to integrate the basic science
information and clinical experiences, the patient will receive
osteopathic care (Kuchera & Kuchera 1994).
Palpation identifies dysfunctional areas in the guise of tissue
changes, treatment results in restoring the relationship between the
patient with its environment with minimal intervention in conjunction
with the principles in mind to correlate body structures in order to
affect their functions and so facilitate the body’s inherent healing
mechanisms through the medium of newly adapted techniques,
advice on diet regulation and/or environmental modifications. ‘When
you have adjusted the human body to the degree of absolute
perfection, all parts in place, none excepted, then perfect health is
your answer. Nature has no apology to offer. It does the work if you
know how to line up the parts; then food and rest are all that is
required’ (Still 1910, p.25).
Still (1902, p28) explains, ‘the practical osteopath must be very
exacting in adjusting the system. He must know that he has done his
work right in all particulars, in that the forms, great and small, all
through the body, must be infinitely correct, with the object in view,
that the necessary fuel and nutriment of life that is now in the hands
of Deity may be adjusted to the degree of perfection that it was when
it received the first breath of individualized life. We do hope to
understand the forms and functions of the parts of the human body to
76
a saving degree of knowledge and apply that knowledge in such a
skilful manner that abnormal conditions demanding the use of the
knife will not occur such as tumours on and in the body or stones in
the bladder and gall sac, which form when some function fails to keep
lime and chalk and other substances in solution as Nature
intended…By producing better drainage through the veins and
excretory channels, we prove our ability as surgeons by using
Nature’s knife. Osteopathy is surgery from a physiological standpoint.
The osteopathic surgeon uses ‘the knife of blood’ to keep out ‘the
knife of steel’’.
77
Appendix VII: A table of the 9 Osteopathic principles and their corresponding
accepted phraseology. Phraseology is extracted from Appendix VI. A ‘tick’ is
to be marked in the ‘Present’ column if the principle exists in the associated
journal article (see references III).
Osteopathic
principle
Accepted Phraseology Present
The body is a
unit
The body is a unit/whole
Body unity
The body functions as an integral whole/unit
Body components have a relationship with the rest
of the body
Body parts have a subservient role to the greater
interest of the body
Sub divisions of the body function as a whole
Reference to body, mind, spirit unity
Integrative relationship of body parts
Systems of communication integrate the whole
body i.e. nervous, arterial, venous, lymphatic,
cerebrospinal, fascial, muscular and/or connective
tissue.
Reference to any of the above
Structure and
function are
interrelated
Structure and function are interrelated
Structure affects the function of a body part
Function affects the structural formation
Abnormal structure of a body part results in its
dysfunction
Dysfunction can cause structural abnormalities
The reciprocal relationship of structure and function
Reference to any of the above
The body
possesses
self- regulatory
The body possesses self- regulatory mechanisms
Feedback mechanisms exist to monitor body
functions
78
mechanisms Endocrine mechanisms regulate body functions
Nervous mechanisms regulate body functions
Neuro-endocrine mechanisms regulate sub
systems
Paracrine mechanisms auto-regulate sub systems
Autocrine regulating mechanisms exist
Micro-systems/sub-systems are controlled by
regulating mechanisms
Homeostasis is achieved through regulating
mechanisms
Reference to any of the above
The body has
the inherent
capacity to
defend and
repair itself
The body has the inherent capacity to defend and
repair itself
Vis medicatrix naturae/ healing force of nature
The body’s self-healing capacity/ mechanism
Communicative, protective, regenerative,
reparative, eliminative, excretory, adaptive
compensatory and/or defensive mechanisms exist
to maintain health through defence and repair.
Adjoining parts including, chemical, cellular,
anatomical, physiological, psychological, immune
and emotional systems compensate and adapt if
dysfunction occurs
The body has physical, psychological and spiritual
adaptive mechanisms
Reference to any of the above
When normal
adaptability is
disrupted, or
when
environmental
changes
overcome the
body’s capacity
When normal adaptability is disrupted, or when
environmental changes overcome the body’s
capacity for self-maintenance, disease may ensue
‘Disease is the result of anatomical abnormalities
followed by physiological discord’1
When the reservoir of compensation is used up,
somatic dysfunction and disease follow
The inability to further adapt causes disease
1 Still (1910)
79
for self-
maintenance,
disease may
ensue
Adverse environmental/climatic factors can
overcome the body’s defences and lead to disease
Disorder and disharmony in the body cause
disease
Failure of the homeostatic mechanism/dysfunction
leads to disease
After maximal adaptation, a further insult may
cause a failure of the communicative, protective,
regenerative, reparative, eliminative, excretory,
adaptive, compensatory and/or defensive
mechanisms leading to disease
Reference to any of the above
Movement of
body fluids is
essential to the
maintenance of
health
Movement of body fluids is essential to the
maintenance of health
The rule of the artery is supreme
The rule of the artery is absolute, universal and
must be unobstructed
Unimpeded flow of the lymph, venous, arterial,
nervous and/or cerebrospinal fluid/ body fluids is
essential for health
Importance of the neurotrophic functions of nerves
in health
Nutrition/health depends on unobstructed
circulation and/or vessel paths
‘Perfect health is the result of pure blood’2
‘Healthy tissue is tissue in which the blood
circulation and nerve force are correlated’3
Fluid/blood flow must not be turbulent for health to
exist
Reference to any of the above
The nervous
system plays a
crucial part in
controlling the
The nervous system plays a crucial part in
controlling the body
Interference with nerve supply causes loss of/
altered control
2 Still (1902, p.52)
3 Littlejohn (in Wernham 1996)
80
body Somatic motor/efferent, somatic sensory/afferent,
viscero-motor/sympathetic/parasympathetic,
viscero-sensory/afferent and/or nutritive nerves
exist for communication/control
The autonomic (neuro-visceral), limbic (neuro-
emotional) and/or neuroendocrine-immune
systems exist as an integrative/controlling function
Somato-somatic, somato-emotional, somato-
visceral, viscero-somatic and/or viscero-emotional
reflex loops exist in bodily communication/control
Dysfunctions in a sclerotome, viscerotome,
angiotome, myotome, and/or dermatome can
segmentally affect each other and/or emotional and
immune responses/control
A nervous dysfunction can cause referred pain,
facilitation, summation, neural adaptive processing,
tissue memory formation, neurogenic inflammation,
neurogenic switching and/or act as a ‘neurological
lens’
Reference to any of the above
There are
somatic
components to
disease that
not only are
manifestations
of disease but
also are factors
that contribute
to maintenance
of the diseased
state
There are somatic components to disease that not
only are manifestations of disease but also are
factors that contribute to maintenance of the
diseased state
‘A neuro-musculoskeletal component is present in
every dysfunction or disease’4 and maintains the
disease state
Disease states exhibit somatic dysfunction which
maintain the disease
The somatic component to disease can be caused
by somato-somatic and/or viscero-somatic reflexes
Changes in tissue tone, texture, composition,
tension, mobility, motility, rhythm, elasticity,
extensibility, resistance, and/or asymmetry depict
4 Kuchera & Kuchera (1994)
81
somatic components to the disease state which
also maintain it
Hardening, thickening, swelling, calcification,
rupture, tearing, laxity, straining, spraining,
contracture, sclerosis, fibrosis, atrophy,
hypertrophy, hyperplasia, necrosis and/or
degeneration of somatic structures are a sign of
disease and contribute to the disease state
Somatic dysfunction can translate into a
maintaining factor of a disease through
interruption/obstruction to a body part
Reference to any of the above
Rational
treatment is
based on the
previous
principles
Rational treatment is based on the previous
principles
The osteopath uses the ‘philosophical lens’ in
practice to reason
‘My object is to make the osteopath a philosopher
and place him on the rock of reason’5
Osteopathic philosophy, science and clinical
experiences are used in the application of
treatment (Cartesian philosophy thought process,
see, How to Treat, in Discussion)
The osteopath reasons from the effect to the cause
of the disease
Treatment occurs with the osteopathic
principles/tenets in mind
Treatment integrates the body, promotes
body/mind/spirit unity, advises on diet,
environmental and climatic factors, correlates the
structure- function relationship, aims to restore the
body’s regulating mechanisms, aims to restore the
protective, defensive, communicative,
regenerative, reparative, excretory, eliminative,
adaptive and/or compensatory mechanisms, aims
5 Still (1910, p.65)
82
to restore the body’s self-healing capacity, aims to
remove obstruction and/or irritations with minimal
intervention, acts to address/ remove maintaining
and predisposing factors to disease, aims to invoke
order and harmony within the body, aims to
rebalance/restore symmetry/homeostasis to the
body system and/or applies anatomical and
physiological knowledge to dysfunction and
disease
Osteopathy is surgery from a physiological
standpoint6
6 Still (1902, p.28)
83
Appendix VIII: A table to show the article number reviewed (see references
III, for article references 1-69), the year of its publication, the season it was
published in, the designated season code, the resulting year to be used for
data analysis and the score of osteopathic principles assigned by the author.
Article Full Year Season Season code Year Score
1 1,960 Winter 1.00 1961.00 6
2 1,961 Summer 0.50 1961.50 7
3 1,961 Winter 1.00 1962.00 9
4 1,962 Autumn 0.75 1962.75 1
5 1,962 Winter 1.00 1963.00 3
6 1,963 Summer 0.50 1963.50 5
7 1,963 Winter 1.00 1964.00 3
8 1,964 Summer 0.50 1964.50 2
10 1,965 Summer 0.50 1965.50 0
9 1,965 Winter 1.00 1966.00 0
12 1,966 Summer 0.50 1966.50 5
11 1,966 Winter 1.00 1967.00 1
14 1,967 Summer 0.50 1967.50 0
13 1,967 Winter 1.00 1968.00 9
15 1,968 Spring 0.25 1968.25 1
16 1,969 Winter 1.00 1970.00 0
17 1,969 Winter 1.00 1970.00 0
84
18 1,970 Summer 0.50 1970.50 4
19 1,971 Spring 0.25 1971.25 1
20 1,971 Autumn 0.75 1971.75 2
22 1,972 Autumn 0.75 1972.75 4
21 1,972 Winter 1.00 1973.00 3
23 1,973 Spring 0.25 1973.25 3
24 1,973 Summer 0.50 1973.50 1
25 1,974 Spring 0.25 1974.25 0
26 1,974 Summer 0.50 1974.50 3
27 1,975 Spring 0.25 1975.25 3
28 1,975 Winter 1.00 1976.00 0
29 1,976 Summer 0.50 1976.50 1
30 1,977 Spring 0.25 1977.25 1
31 1,978 Spring 0.25 1978.25 1
32 1,978 Winter 1.00 1979.00 1
33 1,980 Spring 0.25 1980.25 2
34 1,980 Winter 1.00 1981.00 0
35 1,981 Winter 1.00 1982.00 0
36 1,982 Summer 0.50 1982.50 2
37 1,982 Winter 1.00 1983.00 3
38 1,983 Summer 0.50 1983.50 7
39 1,983 Winter 1.00 1984.00 0
40 1,984 Summer 0.50 1984.50 0
41 1,984 Winter 1.00 1985.00 2
85
42 1,987 Summer 0.50 1987.50 6
43 1,988 Summer 0.50 1988.50 7
44 1,989 Summer 0.50 1989.50 7
45 1,990 Summer 0.50 1990.50 1
46 1,990 Summer 0.50 1990.50 0
47 1,991 Summer 0.50 1991.50 1
48 1,991 Summer 0.50 1991.50 8
49 1,992 Summer 0.50 1992.50 2
50 1,992 Summer 0.50 1992.50 4
51 1,993 Summer 0.50 1993.50 0
52 1,993 Summer 0.50 1993.50 2
53 1,993 Summer 0.50 1993.50 1
54 1,994 Summer 0.50 1994.50 8
55 1,994 Summer 0.50 1994.50 0
56 1,995 Summer 0.50 1995.50 6
57 1,995 Summer 0.50 1995.50 0
58 1,995 Summer 0.50 1995.50 5
59 1,996 Summer 0.50 1996.50 4
60 1,996 Summer 0.50 1996.50 1
61 1,997 Summer 0.50 1997.50 2
62 1,998 Summer 0.50 1998.50 1
63 2,000 Summer 0.50 2000.50 4
64 2,001 Summer 0.50 2001.50 4
65 2,002 Summer 0.50 2002.50 0
86
66 2,002 Summer 0.50 2002.50 1
67 2,003 Summer 0.50 2003.50 4
68 2,004 Summer 0.50 2004.50 2
69 2,006 Summer 0.50 2006.50 0
87
Appendix IX: A table to show transitory events in Osteopathic history from
1931 to 1993 (adapted from Collins 2005).
Year Event
1931,
1933,
1934.
Parliamentary regulation and registration attempts failed.
1936 Formation of The General Council and Register of Osteopaths (GCRO) and
the OAGB to define standards of education.
1938 The BSO became recognised as an established institution for teaching
osteopathy and assisted in the development of an institute of osteopathic
research to meet the ideal of the select committee.
1950 BSO curriculum was shifted from Littlejohn’s classical osteopathy to a
rational approach.
1966 Further BSO curricula changes were seen.
1971 The Department of Health set out instructions of what was needed to
achieve Statutory Registration of Osteopathy.
1976 Private members’ Bill for the Statutory Registration of Osteopaths. Rejected
by both the government and the GCRO as the latter was not consulted.
1977 Osteopaths opposed parliamentary proposal for osteopathy to exist as a
Profession Supplementary to Medicine.
1983 Formation of the Research Council for Complementary Medicine to build
bridges between orthodox and complementary medicine. However,
orthodox practitioners initiated the majority of research projects.
88
1985 House of Lords debate outlined the criteria for Health Care practitioners to
fulfil in order to gain statutory recognition.
1986 A Bill for statutory recognition of Osteopathy- Unsuccessful.
1989 The King’s Fund meeting, consisting of osteopathic, medical and
representatives from the Department of Health, produced a draft
Osteopaths Bill in 1991.
1993 The Osteopaths Act.
89
Appendix X: The four evolutionary states of osteopathy (Dummer 1988).
Evolutionary State
of Osteopathy
Description
1. The formative and primarily developmental stage from
1872 to 1920+
2. The great structural-mechanical period from 1920+ to
1960
3. The cranial/functional phase from 1960 to 1975
4. The middle-way, holistic model which gives equal
emphasis to the dynamic structural-functional –
functional-structural aspects in diagnosis and
technique.
