International Journal of Osteopathic Medicine (2013) 16, 38e45

www.elsevier.com/ijos

Re-evaluating ‘osteopathic principles’

Stephen Tyreman a,b,*

a
British School of Osteopathy, 275 Borough High Street, London SE1 1JE, UK
b
Norwegian University College of Health Sciences, Campus Kristiania, PB 1155 Sentrum,
0107 Oslo, Norway

Received 23 February 2012; revised 1 August 2012; accepted 19 August 2012

KEYWORDS Abstract From its inception, ‘Principles of Osteopathy’ have been key statements
Osteopathy; defining the distinctive features of osteopathy and osteopathic medicine. In this
Osteopathic medicine; paper a brief historical review shows some of the ways these statements have been
Osteopathic principles; modified over a century in order to keep them relevant and meaningful. Despite
Professional identity; these attempts, it is claimed that such statements merely provide a rallying cry
Professional values for practitioners trying to remain faithful to a particular historic tradition and heri-
tage. Although it can be argued that a core thread runs through the various inter-
pretations of osteopathic principlesdviz., that the body is a unified, self-sufficient
entity that has the potential for resisting disease and maintaining health but that
this is dependent on structural integritydthe various ways this has been presented
as ‘osteopathic principles’ lacks academic credibility. In particular: 1. they are not
distinctive enough to differentiate osteopathy from other healthcare practices; 2.
they are ambiguous and imprecise and therefore open to a range of interpretations;
and 3. they fail to mention manual assessment and treatment, or issues around
movement and palpation, which are core elements of osteopathic practice. It is
further argued that a thorough evaluation of osteopathic professional values would
provide a more relevant and meaningful account of osteopathy and osteopathic
medicine.
ª 2012 Elsevier Ltd. All rights reserved.

* British School of Osteopathy, 275 Borough High Street, London SE1 1JE, UK.
E-mail address: S.Tyreman@bso.ac.uk.

1746-0689/$ - see front matter ª 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijosm.2012.08.005
Re-evaluating ‘osteopathic principles’ 39

Implications for clinical practice

Traditional osteopathic principles are now broadly incorporated into most healthcare practices
leaving osteopathy with a problem defining its distinctive contribution.

There is a need to clarify osteopathic terminology which for the most part is poorly defined and
ambiguous (what, for example, is meant by ‘somatic’?), if osteopaths are to communicate their
ideas effectively with other professions.

Osteopathic professional values, i.e., defining what osteopaths are trying to achieve through
practice and the contribution the profession makes to human society, offer a better and poten-
tially more explicit way of identifying osteopathy.

To understand osteopathic professional values will require careful examination of what ordinary
experienced osteopaths actually do in practice (rather than what they say they do).

Background built. To that end, they articulate what it is that

is distinct or perhaps unique about osteopathic
Osteopathy and osteopathic medicine face serious approaches to healthcare. The problem is that
challenges in identifying themselves within the sceptics both in and outside the profession are
broad field of healthcare. While this challenge is not persuaded that they continue to say anything
not unique to osteopathydone of the character- significant or relevant.
istics of a profession is its ability to reflect on Whether there is, or indeed can be, a set of
itself, its purpose and place in societydthey are principles that define osteopathy and guide prac-
particularly pertinent to osteopathy at the present tice, depends on a complex set of issues that are
time.1dthey are particularly pertinent to osteop- contentious, viz. whether the internal aims of
athy at the present time. In the United States of osteopathy are intrinsic, or change in response to
America (USA) there is pressure to justify osteo- external factors; whether A. T. Still ‘discovered’ or
pathic medicine as a profession separate from ‘invented’ osteopathy, or whether there is some
allopathic medicine.2,3 Bryan Bledsoe and others other way of describing his relationship with the
argue that osteopathy has had its day; what was practice he is associated with. In other words, is
relevant to 19th and early 20th Century medicine osteopathy a complete, self-sufficient, organic
no longer applies and osteopathy has become an praxis waiting to be fully uncovered and explained,
anachronism.4 It has also been suggested, in or something that evolves and develops in
response to pressure from MD students, that response to external factors, such as changing
Osteopathic Manipulative Therapy (OMT) should be healthcare needs and perceptions.
taught to allopathic medical students in order to
broaden the influence of osteopathy.5 Principles & values
Looking in at osteopathy, physiotherapy and
chiropractic in the United Kingdom (UK) from the The practice of osteopathy (together with the
outside, raises the question of what the differ- osteopathic emphasis in osteopathic medicine) has
ences are between these professions and whether been closely linked with sets of principles that are
they should be considered as a single profession of claimed to define its practice philosophy by
manual therapy. The recent BEAM trial into guiding clinical decision-making and describing the
effectiveness of manual therapy, for example, basic beliefs and tenets of the profession. These
looked at all three together,6 and there is have been refined and modified over the last 100
a growing collaboration between respective years, but broadly focus on two areas: the unified
educational establishments in the UK. nature of body structure and function; and the
Unsurprisingly many osteopathic practitioners basic self-sufficiency of the body in resisting and
feel threatened by these trends and want to combatting disease, given appropriate resources.
defend the idea that there is something distinc- On these principles, treatment is aimed at
tive about how osteopaths work, but are not sure restoring the appropriate structure-function
how to respond. A common reaction is to point to balance, facilitating the free flow of body
(and perhaps seek refuge behind) what are fluidsdnotably blood, lymph and cerebrospinal
commonly known as ‘osteopathic principles’ fluiddand ensuring appropriate neurological
because they represent the founding ideas on control. In addition, it is assumed that principles
which osteopathy and osteopathic medicine were guide rational decision-making.7
40 S. Tyreman

These ideas, although commonly assumed to 4. The body has the inherent capacity to defend
trace back to the founder, Andrew Taylor Still, are itself and repair itself.
not originaldPlato, for example made similar 5. When normal adaptability is disrupted, or when
kinds of claims in Phaedrusdand have been codi- environmental changes overcome the body’s
fied in a variety of ways the simplest of which capacity for self-maintenance, disease may
states: ensue.
6. Movement of body fluids is essential to the
1. Structure governs function maintenance of health.
2. The rule of the artery is supreme 7. The nerves play a crucial part in controlling the
3. The body contains its own medicine chest fluids of the body.
8. There are somatic components to disease that
However, these may not accurately express are not only manifestations of disease but also
Still’s view. Harold Hoover,8 writing in 1963, con- the factors that contribute to maintenance of
demned the way osteopathic medicine had adop- the diseased state.
ted what he terms ‘etiological medicine’ with its
focus on identifying and treating structural abnor- In the UK, prior to publication of The Osteo-
malities as causes of disease. He describes what he path’s Bill, the General Council & Register of
believes was Still’s true meaning and is highly Osteopaths (GCRO) published a similar set of
critical of some of the early osteopaths who, he statements in what they described as working
claims, failed to understand Still. He picks out principles of osteopathy as part of an attempt to
Hulett as a particular miscreant with the following: define the Competencies Required for Osteopathic
Practice (CROP).13
Hulett, in 1904,9 wrote: “Structure is disturbed,
More recently, a further, radical revision to the
Function must of necessity suffer as a result, i.e.,
‘osteopathic code of practice’ was published in the
disease follows. The physician can attempt to change
USA, which separated ‘Basic Tenets’ from ‘Princi-
either structure or function. Which shall it be?” and
ples for Patient Care’14:
went on to conclude that “.structural adjustment is
the only external or artificial factor that is justi-
Basic tenets
fied.” Other early leaders in the profession also
thought unrealistically, separating structure from
1. A person is the product of dynamic interaction
function with the neglect of function and with
between body, mind, and spirit.
emphasis on the structural cause of disease (p. 42).
2. An inherent property of this dynamic interac-
It seems that, despite Hoover’s protestations, tion is the capacity of the individual for the
Hulett’s view, that structural abnormality causes maintenance of health and recovery from
functional disorder, is the one that prevailed.10 disease.
The AOA principles currently taught by many 3. Many forces, both intrinsic and extrinsic to the
OMT departments in American osteopathic medical person, can challenge this inherent capacity
schools, are based on the first major revision in and contribute to the onset of illness.
195311: 4. The musculoskeletal system significantly influ-
ences the individual’s ability to restore this
1. The human being is a dynamic unit of function. inherent capacity and therefore to resist disease
2. The body possesses self-regulatory mechanisms processes.
that are self-healing in nature.
3. Structure and function are interrelated at all Principles for patient care
levels.
4. Rational treatment is based on these principles. 1. The patient is the focus for healthcare.
2. The patient has the primary responsibility for
In his contribution to the book on the philosophy his or her health.
of osteopathic medicine, Martinke develops these 3. An effective treatment program for patient
further and identifies eight ‘tenets’12: care is founded on these tenets and:
a. incorporates evidence-based guidelines,
1. The body is a unit. b. optimizes the patient’s natural healing
2. Structure and function are reciprocally inter- capacity,
related. c. addresses the primary cause of disease, and
3. The body possesses self-regulatory mecha d. emphasizes health maintenance and disease
nisms. prevention.
Re-evaluating ‘osteopathic principles’ 41

Interestingly, reference to the structure-function editorial in the Journal of the American Osteo-
relationshipdthe main focus of Hulett’s princi- pathic Association admits to the lack of distinc-
plesdhas gone altogether, but there is explicit tiveness in osteopathic over allopathic medicine.2
reference to the person rather than mere body. Howell had drawn the same conclusion in an
editorial in the New England Journal Of Medicine
a few years earlier:
Comment
At its birth, osteopathy was a radical concept,
From the above there appears to be a degree of rejecting much of what allopathic medicine claimed
consensus about what underlies osteopathic was new and useful. Today, osteopathic medicine
thinking, though the more recent versions focus on has moved close to the mainstreamdclose enough
very different health elements in the broader that in general it is no longer considered alternative
contexts of psychology and spirituality (however medicine. . The paradox is this: if osteopathy has
spirituality is to be interpreted). become the functional equivalent of allopathy,
There is insufficient space to undertake what is the justification for its continued existence?
a detailed critical analysis, but at least three And if there is value in therapy that is uniquely
fundamental problems can be identified by exami- osteopathicdthat is, based on osteopathic manip-
nation of these principles: their broad accept- ulation or other techniquesdwhy should its use be
ability; the lack of detail and ambiguity of the limited to osteopaths?16
statements; and the failure explicitly to acknowl- Apart from his disingenuous assumption that it
edge the significance of movement/motion and the is osteopathy that has moved closer to allopathic
role of palpation and touch in osteopathic practice. medicine rather than the other way round, it is
hard to fault Howell’s argument. Whether treat-
The distinctiveness of osteopathic principles ment outcomes are a better measure of distinc-
tiveness is a point for debate. Nevertheless unless
Perversely, the first difficulty is the plausibility of osteopathy can come up with something that
osteopathic principles. They come across as really is unique or clearly distinct or can identify
reasonable, rational and in keeping with current a special niche for itself within healthcare as
healthcare thinking, which they are, and this is some within chiropractic have called for,17 it is
the problem. When Andrew Taylor Still first put going to be difficult to counter these arguments.
his ideas forward, they contrasted with the There will be pressure from stakeholders outside
heroic, ineffective, and dangerous medicine of the profession, such as government and insurance
his day, which included purging, elementary companies, who prefer a smaller number of
surgery, and prescribing substances like mercury organisations to deal with. They are not inter-
and arsenic.15 Medicine today is very different. ested in traditions or the niceties of philosophical
The current understanding of human structure arguments.
and function is closer to Still’s original ideas. It might be claimed that although each principle
There is a better understanding of homeostasis on its own cannot claim uniqueness, put together
and immunity; we know about endorphins and as a set they do. But this is difficult to accept
other body substances that combat environ- without identifying what the relating principle is,
mental threats. Patient-centred care is promoted i.e., what emerges from the set that is not evident
across the whole of healthcare even if its practise from examining each individual principle, or what
leaves much to be desired. Environmental factors is the overlying principle holding them together?
and life-style are well attested as significant The idea that these tenets define the uniqueness
health factors. These ideas are now givens within of osteopathy does not stand up to scrutiny. The
mainstream medicine. point is not that they are wrong, simply that they
It is self-evident that structure and function are are so evidently correct they are not distinctive.
inter-related; it is a basic mechanical principle Osteopathy must come up with something else if it
that an item’s structure affects its function; is to demonstrate its claim to be a distinctive
within biology it is recognised that modified profession. Nurses, allopathic doctors, occupa-
function can result in changes to body structure. tional therapists or anaesthetists could follow
No-one questions the fact that healthy cell func- osteopathic principles and claim, not that they are
tion requires good nutrition and good nutrition osteopaths, but that they are good nurses, doctors
requires good body fluid movement; no-one etc. In other words, in the current medical
doubts that integrated body function requires an climate, osteopathic principles look like principles
effective nervous system, and so on. Gevitz in an of good healthcare practice.
42 S. Tyreman

Ambiguity and lack of detail 312). The notion of the body as a mechanicaldalbeit
complicated and self-regulatingdstructure that can
The second problem is the lack of precision in the be adjusted in accordance with biomechanical and
principles. Terms are not defined and are used in physiological principles is now struggling to survive.
different ways. Is structure equivalent to anatomy, The idea that a human being is “a biomechanism, an
and function to physiology? Does the term ‘governs’ organic machine”24 has been a fundamental part of
in Still’s original version of the relationship between osteopathy and its demise is a major challenge for
structure and function have the same meaning as the profession. With notable exceptions, few oste-
‘reciprocally inter-related’? What exactly does opaths today are engaging with the broader
‘somatic’ mean? In most medical usage, it simply academic community in thinking about touch and
refers to ‘the body’dsomaddistinct from ‘the embodiment, yet, they seem to offer great potential
mind’dpsyche. Osteopathic usage distinguishes for understanding many of the more subtle effects of
between soma (meaning body framework) visceral osteopathic interventions.
(meaning internal organs or ‘support mechanisms’) Neither do traditional osteopathic principles
and psyche. It is then unclear as to where substances explicitly mention quality of movement/motion in
such as blood, lymph, nerve and so on fit. Perhaps patients. Range and quality of movement/motion
with a great deal of work it is possible to develop is a key focus for diagnosis and treatment. Move-
these ideas in a distinctively osteopathic way, one ment is one of the primary characteristics of life.
that is clearly different from other professions and Why do the principles not provide guidance about
adds value to patient care, but at the moment these what ‘good’ movement and motion is? How do we
well-sounding but unfocused statements fail to know when it has been achieved? How do move-
convey meaning to those outside the profession. ment, structure and function relate together? The
answer to this may be implicit within the princi-
What osteopaths do ples, but it is certainly not explicit. There is now
a large literature on the issue of embodiment that
Surprisingly, none of the principles mention what rarely features in osteopathic thinking.
osteopaths spend most time doing and a large There may be good reasons for these omissions.
proportion of their education learning. There is no For A. T. Still and the early osteopaths, using hands
mention of palpation or touch, which, outside the to treat was simply self-evident. Hands were the
USA, is virtually synonymous with osteopathy. In only tools of choice. Life in a rural community was
the USA, OMT, the osteopathic part of osteopathic dependent on using hands; technology was rare
medicine, is largely hands-on, though, relative to and rudimentary. But times have changed and
the European model, more limited. In the UK it today fewer healthcare workers use touch in
would be difficult to call oneself an osteopath and diagnosis and treatment and not as frequently as
never touch a patientdpatients expect osteopaths osteopaths do.
to treat them manually. The same is true for Psychological and emotional implications of
Europe generally and other parts of the World. touch and movement were not recognised in the
Osteopathic skills, whether unique or not, are early days of osteopathy, at least, not in the ways
based on directly applied manual techniques with we understand them now.
minimal or no additional tools. Development of On a political level US osteopathic medicine is
manual skills is a key assessment criterion in committed to maintaining full medical practice
osteopathic undergraduate programmes. Highly rights even if it means that only 5e20% of osteo-
skilled technicians are lauded and emulated within pathic physicians use OMT.25 Less than 1% of the
the profession and, frequently become influential osteopathic profession board are certified in OMM
leaders.18 Why then are expert manual skills not or neuromusculoskeletal medicine. To define
promoted as distinctive? osteopathic medicine in terms of treatment
Today our understanding of the significance of modality or specific treatment objectives would
touching people is different from how it was at the restrict practice and be unacceptable to the
turn of the last Century. Not only is there a literature majority of the profession.
from psychology and sociology about the emotional The failure to include fundamentals such as
effects of touch (and its lack), philosophy has movement and touch may be restricting our
explored the meaning of the body for patients and understanding of the essence of osteopathic
practitioners.19e22 A. T. Still was adamant that, “the practice. Here I am deliberately distinguishing
human body is a machine run by the unseen force practice from theory. I am arguing that it is time to
called life”,23 that man (sic) is “an engine” (p. 324) move on from the slogans of principles to under-
and that “an osteopath is only a human engineer” (p. stand professional values.1
Re-evaluating ‘osteopathic principles’ 43

Osteopathic values espouse as professional values may not be matched

by examining what practitioners actually do, and to
John Sadler defines values as “descriptions or be sure about what a profession’s real values are,
conditions that are both (i) a guide to human i.e., what it is that drives and motivates their prac-
action and (ii) are subject to praise or blame tice, requires analysis of what is done rather than
within a human community.”26 Values are the how it is explained. There has actually been very
fundamentals of professions; they are what unites little research in this area, probably because it would
their members into thinking like lawyers, teachers, involve professionals being scrutinised for what they
or doctors. They are therefore implicit in state- do, which is a very sensitive issue. Identifying
ments such as principles, which purport to define differences between espoused and practised values
or explain (some aspect of) a profession. In this might be perceived as criticism. Not least, some of us
respect, values underpin and inform principles. hide behind theory and principles rather than face up
When UK osteopathy was becoming a statutorily to the fact that at times we deviate from what the
recognised profession in the late 1990s, osteop- theories or principles tell us.
athy was simply defined as ‘Osteopathy is what The Oxford philosopher J. L. Austin, makes an
osteopaths do’. A few years previously, in an even stronger point when he argues that the values
article describing the Principles and Concepts for and concepts underlying professional practice are
Osteopathic Healthcare programme at the British so complex that it is difficult to articulate them
School of Osteopathy, I suggested something meaningfully through language.30 Expert profes-
similar: that “what osteopathy is, is contained sionals acquire and develop practice values and
within the practice and mental activities of oste- mores over many years through engaging with
opaths.”27 The argument was that osteopathy, colleagues and from encountering numerous
medicine and all professions encounter the same examples in practice. On Austin’s account, under-
problems of definition encountered by a range of standing osteopathy, or teaching, or medicine,
commonly used concepts. How do you define time, entails looking at the ways practitioners describe
colour or game in such a way that it reflects every what they actually do using ordinary language
use of those terms? The philosopher Ludwig Witt- rather than the theories that they claim explains
genstein suggested that these kinds of terms what they do. His argument is that what he terms
represent families of objects whose attributes are “ordinary language”, “the first word” on the matter
shared through language and conversation.28 In “embodies . the inherited experience and acumen
other words, although we find it difficult to of many generations of men” (sic.) (p. 185). The
explicitly define a concept like ‘game’, we are concepts embodied in the acts of practice and the
able use it meaningfully in language. It is famil- meanings given to them in theories, are both covert
iarity with hundreds of examples of games that and different. Theories are necessary in teaching
constructs a composite image in our minds of what for introducing a neophyte to the complexities of
kind of thing it is (though its meaning is individual a profession and for communicating with other
to each person depending on their personal expe- professionals, but they can never capture the rich
rience). These images do not describe any partic- and subtle meanings entailed by practice.
ular game, and no single game can claim to be the ‘Osteopathic Principles’ no longer define oste-
exemplar, though some will conform more closely opathy as a distinct healthcare profession. If there
to the ‘ideal’ than others. is something distinctive and of value in osteopathic
Although there is individual variation depending practice we need to look again at what expert
on personal experience, we are able to use concepts osteopathic practitioners actually do, particularly
and communicate with each other because we share those who claim to offer something special and
a common experience through use. How we practice innovative. Analysing their acts should provide
therefore informs our concept of what it is we do a more accurate picture of the values and mores
and the theories developed to explain it. they exemplify than devising theoretical accounts
The point was that what we understand osteop- that (history teaches) will be wrong. From these
athy (and medicine) to be, “emerges from the values, together with the best of evidence-based
collective practice of osteopaths (and doctors)” (p. medicine (EBM), analysis of current health issues
12). The educationalist Donald Schön examined and patients’ needs and expectations, we can start
professional practice values and distinguished afresh to redefine ‘osteopathic principles’.
between espoused and practised values.29 He argued But maybe defining ‘principles’ is no longer
that what a professional body (such as the General a worthwhile task; perhaps they are little more than
Osteopathic Council), or a single practitioner, may a comfort-blanket for a relatively young profession?
44 S. Tyreman

Or, more threateningly, perhaps osteopathy no Acknowledgement

longer has anything distinctive to offer to health-
care; everything in osteopathy can be provided I am grateful to Christian Fossum for comments and
through other practices. This has to be a risk that we corrections to the first draft of this paper. However,
take when we set out on the task of affirming our I retain full responsibility for the content.
identity. It is a risk worth taking and we have no
alternative if osteopathy is to play any part in future References
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