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A comparison between two paradigms of clinical reasoning within the osteopathic profession: an Evidence-Based Practice model vs a Complexity model Which paradigm is more suitable for the practice of traditional osteopathy? Kevin Fairfield
OCTOBER 2012 Thesis presented to an international jury
Thesis advisor
Eric Sanderson DOMP
Acknowledgements
I would like to thank all the contributors throughout this process:
• I dedicate this osteopathic journey to my hero, my father Ian Fairfield, who passed away in
the middle of the program. Your guidance and inspiration will never be forgotten.
• Many thanks to Mr. Eric Sanderson, my thesis advisor, for all of his precious time,
valuable input and thorough direction; your feedback is always greatly appreciated.
• Mr. Guy Voyer, the pedagogical director at the Académie Sutherland d’Ostéopathie du
Québec. He has been instrumental as a mentor in my professional life and his
paradigm of complex thinking has taught me a lifelong lesson in healing. I will always be
grateful for meeting you.
• Mr. John Winkels, editor of this memoir. John is a good friend who appreciates the
complexities of the English language.
• Mr. Sam Gibbs, for his guidance and for introducing me to Mr. Max Girardin, D.O., who
devotes his life to complexity thinking and living.
• Mr. John D’Aguanno and Mr. Craig Harness, for all those late night osteopathic
philosophy sessions and sharing of resource material.
• Last but not least, my beautiful wife Alexandra and my two wonderful children, Alexa and
Justin whom inspire me more each and every day. Words can neither adequately describe
my love for you nor express my gratitude for your constant patience in my journey with
life-long learning.
Table of Contents ABSTRACT (ENGLISH) RESEARCH QUESTION (ENGLISH) RÉSUMÉ (FRANCAIS) OBJET DE LA RECHERCHÉ (FRANCAIS)
i ii iii iv
Chapter 1: Introduction 1
1.1. The Foundation of critical thinking in physiotherapy……………………………… 1.2. Hypothetical case scenario in problem-based tutorials…………………………….. 1.3. The next chapter in critical thinking – The journey in osteopathy………………… 1.4. Definition in both paradigms……………………………………………………….
2 3 4 5
Chapter 2: Methodology 10
2.1. Foundation…………………………………………………………………………….. 2.2. Qualitative methods to answer the research question………………………………….
2.2.1 Grounded Theory……………………………………………………………. 2.2.2 Phenomenology……………………………………………………………… 2.2.3 Historical…………………………………………………………………….. 2.2.4 Appropriateness of study design…………………………………………….. 2.2.5 Document review……………………………………………………………. 2.2.6 Immersion & Crystallization…………………………………………………
2.3. Qualitative Methodological Terminology…………………………………………….. 2.3.1 Saturation and Data collection………………………………………………. 2.3.2 Sampling…………………………………………………………………….. 2.3.3 Transparency………………………………………………………………… 2.3.4 Bias………………………………………………………………………….. 2.3.5 Data coding / Analytical rigour……………………………………………… 2.3.6 Overall rigour………………………………………………………………..
11 12 12 12 13 14 14 15 15 16 16 17 17 18
Chapter 3: Evidence-Based Medicine Paradigm 19
3.1 Evidence-Based Practice (EBM) Paradigm………………………………………….. 3.1.1 The definition of Evidence-Based Medicine………………………………… 3.1.2 The history of Evidence-Based Medicine…………………………………… 3.1.3 Alternative definition of EBM………………………………………………
3.2 Quantitative and Qualitative research methods………………………………………. 3.2.1 Levels of evidence: The hierarchy of evidence………………………………
3.3 The introduction of EBM in the academic curriculum……………………………... 3.4 The strengths of EBM………………………………………………………………. 3.5 The weaknesses of EBM…………………………………………………………… 3.6 Challenging the powers that be……………………………………………………... 3.7 Conclusions regarding EBM and osteopathy………………………………………..
20 21 22 23 24 26 30 31 34 39 41
12
Chapter 4: Complexity and the Scientific Revolution. Where does osteopathy fit in? 47
Complexity and the Scientific Revolution………………………………………………….. 4.2 Introduction to the roots of the Complexity movement…………………………... 4.3 The Scientific Revolution – The shift in the scientific paradigm of reasoning……
4.3.1 The world according to Darwin…………………………………………. 4.4 Definition of modern science……………………………………………………... 4.5 Three eras of science in medicine………………………………………………… 4.6 Fundamental principles of osteopathy: Understanding its traditional beliefs……
4.6.1 The prominence of diagnosis in osteopathy…………………………….. 4.6.2 Osteopathy’s role in the future of the medical world…………………….
4.7 Order and disorder………………………………………………………………… 4.8 Edgar Morin – “The Godfather of Complexity”…………………………………..
4.8.1 “Blind Intelligence”……………………………………………………… 4.8.2 Complexity and self-organization……………………………………….. 4.8.3 The paradigmatic turning point………………………………………….. 4.8.4 Emergence and self-organization………………………………………... 4.8.5 Principle of Disjunction…………………………………………………..
4.9 Holism……………………………………………………………………………. 4.10 Fragmentability…………………………………………………………………... 4.11 Information-feedback system……………………………………………………. 4.12 Open systems versus closed systems…………………………………………….. 4.13 Resilience………………………………………………………………………… 4.14 Robustness………………………………………………………………………... 4.15 Hierarchical systems……………………………………………………………... 4.16 Entropy…………………………………………………………………………… 4.17 Ambiguity………………………………………………………………………... 4.18 Attractors…………………………………………………………………………. 4.19 Linear minds in a non-linear world………………………………………………. 4.20 Complexity and clinical knowledge……………………………………………… 4.21 Suggestions for Complexity research methods…………………………………... 4.22 Summary of Complexity systems………………………………………………... 4.23 The 10 Principles of Complexity and how they relate to the osteopathic
profession………………………………………………………………………… 4.24 Osteopathic research……………………………………………………………... 4.25 Study design……………………………………………………………………… 4.26 Osteopathic education…………………………………………………………….
48 49 50 54 55 56 58 58 59 60 61 63 65 65 68 69 69 70 70 70 70 71 71 71 72 72 73 73 74 77 77 79 80 83
Chapter 5: Comparing EBM and Complexity models of low back pain 85
5.1 Appendix A – Osteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials 5.1.1 Critical appraisal checklist for systematic reviews………………………
5.2 Understanding osteopathic philosophy and reasoning and applying it in clinical practice…………………………………………………………………………...
5.3 Osteopathic reasoning using a Complexity paradigm of thinking for patients with low back pain………………………………………………………………………
5.3.1 Subjective assessment…………………………………………………… 5.3.2 Objective assessment…………………………………………………….. 5.3.3 Treatment of low back pain……………………………………………… 5.3.4 Conclusion………………………………………………………………..
86 88 89 89 90 90 91
Chapter 6: Conclusion 92
6.1 Conclusion…………………………………………………………………………. 6.2 What is the future of the Complexity movement?...................................................... 6.3 What is the future of osteopathy?.............................................................................. 6.4 Osteopathic instruction in schools…………………………………………………..
93 97 101 104
References 106
List of Tables, Figures & Appendices
1. Table 1A - Complication vs. Complexity terms…………………………………………. 2. Table 1B - Complication vs. Complexity definitions……………………………………. 3. Table 2 - Definitions of methodology terms used in Levels of Evidence Guidelines…… 4. Table 3 – Types of evidence……………………………………………………………... 5. Table 4 – Clinical Epidemiology Glossary………………………………………………. 6. Table 5 – Key features of a Complex System……………………………………………. 7. Figure 1 – Schematic review of polarization within the profession of osteopathy viewed
through the looking glass of the complex system theory………………………………… 8. Appendix A – Osteopathic manipulative treatment for low back pain: a systematic
review and meta-analysis of randomized controlled trials……………………………….
6 7 28 37 42 76 100 111
i
Abstract
The supposition you are about to read compares two very distinct models of clinical and critical
reasoning as they apply to the profession and practice of osteopathy: an evidence-based practice
model and a complexity model. Both of these models, or paradigms, will be discussed in detail
throughout this document, including but not limited to their respective strengths and weaknesses,
as well any key terminology. The framework of this paper is presented as a traditional
qualitative thesis. The author feels that this style of monograph is best suited to outline this
scholarly topic. This paper holds true to the author’s journey within the medical field as a health
care professional. Having been exposed to both the evidence-based and complexity paradigms
within the disciplines of manual physiotherapy and osteopathy, the author strives to explore (or
examine) the possibility of co-existence between the two models. Is one approach more
applicable than the other to the practice of osteopathy and /or more relevant as they pertain to
improving overall patient health?
ii
Research question
A comparison between two paradigms of clinical reasoning within the osteopathic profession:
An Evidence-Based Practice model vs. a Complexity model.
Which paradigm is more suitable for the practice of traditional osteopathy?
iii
Résumé
L’hypothèse dont il sera question dans les présentes compare deux modèles très distincts de
raisonnement clinique et critique applicable à la profession et à la pratique ostéopathiques, soient
un modèle de pratique factuelle et un modèle de complexité. Les définitions de tous les
principaux termes ainsi que les avantages et désavantages de chacun des modèles, ou
paradigmes, seront exposés. Le présent document consiste en une thèse qualitative classique.
L’auteur estime que ce style de monographie est la meilleure méthodologie pour traiter de ce
sujet érudit. Le présent mémoire reflète étroitement le cheminement de l’auteur dans le domaine
médical, à titre de professionnel de la santé. Ayant observé les deux paradigmes, soit celui de
pratique factuelle et du modèle de complexité, dans la pratique de l’ostéopathie et de la
physiothérapie manuelle, l’auteur explore (ou examine) la possibilité de la coexistence de ces
deux modèles. Une de ces approches convient-elle davantage à la pratique de l’ostéopathie et/ou
est-elle plus appropriée pour améliorer la santé des patients dans l’ensemble?
iv
Objet de la recherché
Comparaison de deux paradigmes de raisonnement clinique au sein de la profession
ostéopathique :
modèle de pratique factuelle vs modèle de complexité.
Quel paradigme est le mieux adapté à la pratique de l’ostéopathie traditionnelle?
1
Chapter 1: Introduction _____________________________________________________________________________
2
1.1 The foundation of critical thinking in Physiotherapy
The author’s journey began 15 years ago upon acceptance into the Bachelor of Health Sciences
in Physiotherapy program at McMaster University (1997). McMaster is world-renowned for the
distinctive teaching and learning environments within its various medical disciplines, including
the field of physical medicine. The traditional pedagogical approach to learning offered at
McMaster was not a lecture format, but rather a tutorial- and problem-based learning forum
whereby individual students became independent learners of the science of medicine. This
revolutionary approach allowed for the emergence of discussion and thought provoking ideas to
be shared amongst fellow classmates and colleagues within small group settings. This model of
independent study highlighted the complexity of progressive thinking and challenged traditional
modes of how medicine is taught and carried forward through practice.
Throughout the author’s physiotherapy training at McMaster, he was introduced to the
philosophy of evidence-based practice/medicine (EBP / EBM) and its importance in cultivating
the decision-making process for practicing clinicians. With the information age rapidly emerging
in the late 90s, McMaster University was an academic front-runner that recognized the necessity
of equipping medical practitioners and teachers with both well-designed resources and the
conceptual tools necessary to harness them.1 An emerging biomedical informatics community at
McMaster spawned the field of clinical epidemiology, under the leadership of one David Sackett. 2 The adopted research-driven approach to thinking taught students not only how to critically
appraise one’s findings, but also how to integrate the research and have it shape one’s final
decisions for patient care. Ultimately, students were taught that this was the only way to think.
In a sense, one was indoctrinated to think that the EBM paradigm was superior to other methods
when making critical decisions in physical medicine. The author embraced this paradigm of
thought, learning extensively over a continuous 24-month program of academics and clinical
placements. However, throughout the author’s educational endeavours, he questioned the
process of evidence-based practice and its application towards individual patient-therapist
interaction. To clarify how evidence-based practice was used to definitively summarize
1 Covell, D.G. et al., as quoted in Wyer, P.C., & Silva, S.A. Where is the wisdom? I – A conceptual history of
evidence-based medicine. Journal of Evaluation in Clinical Practice, 15 (2009) 893. 2 Covell, D.G. et al., as quoted in Wyer & Silva, Where is the wisdom? 893.
3
intervention strategies, the author will give the reader a quick glimpse into a typical problem-
based tutorial session.
1.2 Hypothetical case scenario in problem-based tutorials
A hypothetical case scenario was provided to a group of six or seven students, depending on the
segmentalized unit of study of the body (i.e. in orthopaedics, a low back pain case study would
be provided including the typical mechanism of injury and the patient’s health history). The
students were expected to independently study the subject in terms of anatomy and physiology
and conduct the necessary research to determine what the evidence would conclude about the
treatment intervention for the patient. The learning process was enlightening and the author
flourished in this group dynamic. However, some of the conclusions extrapolated within this
study format, specific to how the systems of the body were covered, were problematic.
First and foremost, the concept of the body’s ‘wholeness’ – being more than the sum of its parts
– was not integrated within this model of physiotherapy. Orthopaedic problems were addressed
using only orthopaedic solutions (the only approach offered in classical allopathic medicine).
The interrelationships of the body’s systems, including their unique influence on each other,
were not even considered or discussed. For example, a comparison of the patients’ symptoms to
their overall mechanical and fluidic status was not even a concept given consideration. Linking
the muscular, vascular, fascial, skeletal and neurological components that could potentially
influence the outcome of the problem was not fully explored /examined. As for the evidence-
based research role in each scenario, the abundance of documentation was more than
satisfactory, however, the conclusions drawn by the research were neither categorical nor did
they provide direction for the clinical practitioner. More often than not, the research lacked
definitive solutions, typically concluding with the predictable “more research is necessary”.
Much of what is taught in both physiotherapy school and the manual therapy community is based
upon the evidence-based practice paradigm, in order to ultimately achieve acceptance in the eyes
of the medical system as a whole. Many facets of allopathic and alternative medicine streams
focus on proving their very existence in an attempt to validate their professional territory. It is
this powerful validation process that drives health care professionals to perform high-level
research and then communicate their findings to clinical practitioners, all in an attempt to
4
improve clinical outcomes with patients. It is the author’s opinion that many who follow this
model wholeheartedly believe it is the only way to achieve the best success with clients. The
author himself was formerly one of these advocates, that is until he was introduced to the
traditional practice of osteopathic medicine and the teachings of Guy Voyer D.O.. Voyer
introduced the author to the complexity paradigm of thinking and its applications to the human
body and the world around us.
1.3 The next chapter in critical thinking – The journey in osteopathy
Over nine years ago, the author began a journey into the field of osteopathic medicine with the
Sutherland Academy of Osteopathy and the Académie Sutherland d’Ostéopathie du Québec,
with the intentions of building his clinical knowledge and level of expertise. That goal was
fulfilled and, to the author’s surprise, his entire approach to assessment, treatment and
knowledge of the complexities of the human body and spirit were enhanced dramatically. This
emergence of another level of comprehension is an extremely satisfying and humbling
experience.
It is this fundamental change in thinking, this shift in paradigm, that led the author to explore the
topic of his thesis and document the distinctive differences between the complexity and
evidence-based models and how they have helped shape the author’s professional and personal
life.
1.4 Definitions in both paradigms
The author would like to take this opportunity to provide some meaningful definitions of the
terminology that helped determine the framework of this paper.
Paradigm: A philosophical and theoretical framework of a scientific school or discipline within
which theories, laws and generalizations, and the experiments performed in support of them are
formulated; broadly: a philosophical or theoretical framework of any kind.3
3 Meriam-Webster On-Line Dictionary. An Encyclopaedia Britannica Co, 2012.
5
Evidence-Based Medicine: The conscientious, explicit and judicious use of current best
evidence in making decisions about the care of individual patients.4
Complexity: Something complex; the quality or state of being complex.5
Complex: Consisting of interconnected or interwoven parts.6
Complexus: This original Latin word signifies entwined.7
Within the first few lectures on the history and tradition of osteopathy at the Sutherland
Academy, the author was introduced to the philosophical differences between allopathic medical
thinking and osteopathic reasoning. A 1-page hand-out distributed to the students would
eventually help to change the author’s clinical decision-making skills, in addition to the depth
and breadth of his respect for human existence. The following is a copy of the handout that was
distributed to the class, outlining several terms in a comparative format (Table 1A). Table
1Bfollows, providing definitions for the terms in Table 1A.
4 Sackett D. Evidence based medicine: what it is and what it isn’t. BMJ; 312 (Jan 1996): 312, 71-72. 5 Merriam-Webster On-Line Dictionary, 2012. 6 Merriam-Webster On-Line Dictionary, 2012. 7 Merriam-Webster On-Line Dictionary, 2012.
6
Table 1A
Terms: Complication vs. Complexity
Complication vs. Complexity
Linear Interactive
Procedure Process
Dialectic Dialogue
Analytical Sense/Meaning
Definition How/Emergence
Repetition Synthesis
Prediction Turbulence
Program Objective/Goal
Control/Reference Relative/Reference
Integration Appropriation
Instruction Education
Absolute Possible
Probable Potential
Production Service
Repetition Rituals
Closed Open
Year 1 handout 1994 – Sutherland Academy of Osteopathy (Guy Voyer D.O.)
7
Table 1B
Definitions: Complication vs. Complexity
COMPLICATION
Terms Definitions
Linear Involving a single dimension; of the first degree with respect to one or more variables.
Procedure A series of steps followed in a regular definitive order; traditional or established way of doing things.
Dialectic
Discussion and reasoning by dialogue as a method of intellectual investigation; the logic of fallacy; any systematic reasoning, exposition or argument that juxtaposes contradictory or opposed ideas and usually seeks to resolve their conflicts.
Analytical Separating something into component parts or constituent elements.
Definition
A statement expressing the essential nature of something; sharp demarcation of outlines or limits.
Repetition The act or an instance of repeating or being repeated.
Prediction The act of predicting: forecast.
Program An outline of the order to be followed; a sequence of coded instructions.
Control/ Reference To check, test or verify by evidence or experiments; to have power over: RULE. Consultation of sources of information.
Integration The operation of finding a function that has a known differential.
Instruction A direction calling for compliance; an outline or manual of technical procedure.
Absolute Being governed by or characteristic of a ruler or authority.
Probable Supported by evidence strong enough to establish presumption but not proof.
Production Something not specifically designed or customized and usually mass-produced.
Closed Not open; rigidly excluding outside influence.
8
COMPLEXITY
Terms Definitions
Interactive Mutually or reciprocally active; a two-way communication system.
Process A continuing natural or biological activity or function.
Dialogue An exchange between people.
Sense / Meaning
Conscious awareness or perception; specialized function or mechanism by which one receives and responds to external or internal stimuli. Something intended.
How / Emergence In what manner or way: to what degree or extent. To become manifest; to rise from; to come into being through evolution.
Synthesis The composition or combination of parts or elements so as to form a whole.
Turbulence Great commotion or agitation; causing disturbance.
Objective / Goal
Involving or deriving from sense perception or experience with actual objects, conditions or phenomenon. The end towards which effort is directed.
Relative / Reference A thing having a relation to or connection with or necessary dependence on another thing. Consultation of sources of information.
Appropriation The act of getting something for a specific use or purpose.
Education
The field of study that deals mainly with methods of teaching and learning in schools.
Possible Being within the limits of ability, capacity or realization.
Potential Existing in possibility; capable of development into actuality.
Service Contribution to the welfare of others; the work performed by one that serves: a helpful act.
Rituals An act or series of acts regularly repeated in a set precise manner.
Open Have no enclosing or confining barrier: accessible on all or nearly all sides.
8
8 Merriam-‐Webster On-Line Dictionary, 2012.
9
Once the author internalized what was being said, even though it challenged his deeply
ingrained beliefs in the structured scientific thought process, he began to gradually change
his paradigm of thinking (both subjectively and objectively) when assessing patients. The
author started to observe and understand the human body in its wholeness, not the sum of its
parts. This statement sounds simple enough to integrate into clinical scenarios and many
health care professional would agree with the statement, however it allowed the author to
better appreciate the anatomical and physiological interrelationship of the eleven systems that
make up the human body (skeletal, muscular, fascial, cardiovascular, neurological,
respiratory, reproductive, hormonal, integumentary, immune and lymphatic systems). These
‘systems’ epitomize the complexity of the human body, its “container and contents” and the
means by which everything is enveloped in one functional system designed for dynamic
mobility, motility and stability. Together this mechanical and fluidic masterpiece is under
constant demands whereby adaptation and continual change are part of every moment and
experience. All of these systems of the body are working together in unison to maintain
optimal health and free oneself from disease. The human body has an amazing ability to heal
itself from the invasion of disease if given the chance; the right health care professional can
aid in the facilitation and governance of structure and function to compliment the body’s
natural ability.
10
Chapter 2: Methodology
_____________________________________________________________________________
11
2.1 Foundation
It was approximately two years ago when the author began thinking about the thesis process.
After much consideration, a research question was formulated: A comparison between two
paradigms of clinical reasoning within the osteopathic profession: An Evidence-Based Practice
model vs. A Complexity model. Which paradigm that is more suitable for the practice of
traditional osteopathy? The author wanted to capitalize on his experience learning these two
distinct concepts of thinking and to collectively compare and contrast them using a qualitative
format specific to the osteopathic field of study and clinical practice.
Two key methods typically predominate in the medical community with regards to research
driven protocols: the dominant positivism/quantitative movement and the interpretivism/
qualitative movement. For the purpose of this thesis, the interpretivism method was the obvious
choice to pursue because, for the traditional osteopathic practitioner, it offers a meaningful way
to gain insight by improving and redefining one’s comprehension of the body’s totality.
Qualitative research explores richness, depth and complexity of phenomenon. It is a method of
research that osteopaths can both understand and live by since its findings are not discovered by
means of statistical procedures and calculable measures.9 Qualitative research embraces the
belief that there is neither one truth, nor one consensus, that is necessarily achievable or an
essential goal. 10
Once the research question and general abstract was developed and approved, the author selected
Mr. Eric Sanderson, Osteopathic Manual Practitioner (DOMP) as a thesis advisor.
Collaboratively, the author and Mr. Sanderson began to quickly develop some of the core ideas
and concepts and potential research options. Once this initial step was complete, the next steps
were to determine the study design and to begin gathering data.
9 Strauss, A. & Corbin, J. Basics of qualitative research: General Theory procedures and techniques.
Newbury Park, CA: Sage Publication Inc. (1990), 17. 10 Johnson, R., & Waterfield, J. Making words count: the value of qualitative research. Physiotherapy
Research International, 9(3) 2004, 122.
12
2.2 Qualitative methods to answer the research question
2.2.1 Grounded Theory
The Grounded Theory method of qualitative study design captures the essence of this paper. It is
an emergent design, dependent on continuous data analysis.11 The first full year of this thesis
endeavour involved the ongoing collection of research articles and books about EBM and
Complexity. It was a judicious process of gathering, scrutinizing and organizing information
specific to the primary research question of this thesis.
2.2.2 Phenomenology
Phenomenology answers the question “What is it like to have a certain experience?” It seeks to
understand the phenomenon of a lived experience.12 The educational experience is the very
reason why the author selected this path. The author has had the luxury of being exposed to two
very different and distinctive paradigms of thought. While the author embraced the EBM
approach early on in his health care career as a physiotherapist, more recently the author has
adopted the Complexity approach in his apprenticeship as an osteopath. The author feels that his
first-hand experience with these two phenomena has provided a solid foundation that enables
him to share meaningful knowledge and opinions, and determine a viable / successful path that
one can take within the science of osteopathy.
2.2.3 Historical
The Historical method is “a systematic collection and objective evaluation of data related to past
occurrences in order to test hypotheses concerning causes, effects, or trends of these events that
may help to explain present events and anticipate future events”.13 This quote defines the
evolution of both theories (EBM and Complexity) and their applicability to the science and art of
osteopathy. Some practitioners rely on the evidence-based research approach to navigate their
critical thinking skills, while others rely on the entrenched foundations of clinical intuition and
complexity thinking. 11 Letts, L. et al. Guidelines for Critical Review Form: Qualitative Studies (Version 2.0) 2007, 3. 12 Letts, 2-3. 13 Gay, L.R. Analysis of Professional Literature Class 6 – Qualitative Research I. Education Research (5th Edition).
(New Jersey: Prentice Hall Inc, 1996), 2-3.
13
The author is of the opinion that this qualitative thesis offers a unique combination of the
Grounded theory, Phenomenology and Historical research design methods. Collectively, these
methods encapsulate deeply engrained beliefs and attitudes towards structured wisdom
concerning human nature, our existence and ultimately our survival within the universe.
2.2.4 Appropriateness of study design
This section questions the congruency of qualitative research based on an accepted definition of
‘appropriateness’, as identified by Letts et al.
1. The researcher expresses an interest in a point of view.14 For the purposes of this thesis,
this is the struggle between distinct methods of clinical reasoning in the osteopathic
profession: an EBM model of reasoning versus a Complexity Model of reasoning. Is one
method a superior, more relevant form of thinking for the traditional osteopath?
2. The researcher is seeking meaning and understanding via narrative form.15 This thesis
presents a detailed account of the history of both EBM and Complexity models and their
evolution in the decision-making realm of manual osteopathic medicine.
3. Seeks information from people who are experiencing or involved in the issue.16 The
author sought out the opinions of his physiotherapy colleagues (Mr. Alan Tram, MPT,
Mrs. Olga Boers, MPT) with regards to the most current EBM studies and trends. In
addition, the author gathered the opinions and received guidance from osteopathic
colleagues (Mr. Guy Voyer, D.O., Mr. Eric Sanderson, DOMP, Mr. Sam Gibbs, DOMP
and Mr. Max Girardin, D.O.) with regards to the Complexity material.
4. Qualitative research is oriented towards theory construction and the reasoning behind the
data analysis is inductive – the findings emerge from the data.17 The objective of this
thesis is to literally de-construct the most current and accepted research pertaining to both
paradigms of thought and to assess the relevance of each model to osteopathy in the 21st
century.
14 Letts, 4. 15 Letts, 4. 16 Letts, 4. 17 Letts, 4.
14
2.2.5 Document review
Document review is a flexible, open method by which the study and analysis of data (past and
present) help to provide the best way to answer the research question. It is a method that
requires the researcher to enter into an in-depth learning process to become a critical editor of all
necessary materials.18 This document review was accomplished through the rigorous application
of a variety of research strategies for the purpose of gathering a wide range of facts and figures
concerning EBM and Complexity. A literature review was performed using a variety of online
searches, while research pertaining to the topics of osteopathy, EBM and the complexity model
was gathered via a variety of university library resources. There was an abundance of published
material available on all of the topics listed above. The author attempted to focus his research
efforts, by utilizing some key search terms including, but not limited to:
• Evidence-Based Practice.
• Evidence-Based Medicine.
• Osteopathy and Evidence-Based Medicine.
• Complexity thinking.
• Osteopathy and Complexity.
• History of EBM.
• History of Complexity theory.
2.2.6 Immersion and Crystallization
The terms ‘immersion’ and ‘crystallization’ identify how one engages and applies oneself to the
research process: the collection, examination and interpretation of concrete material and data. In
the case of this thesis, it involves the scrupulous identification of common research patterns and
the amalgamation of all of the information pertaining to EBM and complexity. If one wants to
be true to their research question (in this case the two paradigms of critical reasoning), then all of
the gathered knowledge must be applicable, substantiated and reflect the way an osteopath thinks
and reasons about administering patient care. Upon collecting all of the relevant data, it became
clear that there is a strong movement within the osteopathic profession supporting the “validation
of therapy and treatment”. Osteopathy is following in the footsteps of many other healthcare 18 Letts, 6.
15
disciplines and the “supremacy of EBM” is one of the driving forces behind its conversion.
EBM is a paradigm designed to streamline “best practices” with reproducible results for the
masses. However, for the traditional osteopath, the application of both complexity theory and
reasoning in conjunction with EBM does appear to offer a complementary marriage, which can
help the profession flourish. An abundance of information is readily available, which explicitly
details the cohesiveness between complexity, osteopathy and patient-centered care. However,
one must answer the question “Is this competing paradigm socially acceptable in the 21st century,
an age of quantifiable medicine?”
2.3 Qualitative Methodological Terminology
2.3.1 Saturation and Data collection
When one is collecting data to satisfy a research question, saturation or duplication of material is
an important principle to consider to ensure that a thorough and exhaustive search has been
completed. For this thesis, a significant amount of data was collected. The utilization of
different methods for collecting similar data findings was accomplished via synthesized, filtered
and unfiltered sources. Examples of synthesized material sources included clinical practice
guidelines, and a variety of osteopathic publications and reference materials. Filtered sources
included systematic reviews, Meta-analysis, and a variety of critically-appraised articles. Lastly,
unfiltered sources used included the Google Scholar index and MEDLINE citations, abstracts,
journals and news sources. All efforts were made to ensure triangulation of data sampling and
information for maximum reassurance, validation and reliability (since no statistical analysis is
provided in this thesis regarding the author’s research strategies).
In addition to all of the published sources that were researched, compared and considered, peers
and professional colleagues were consulted for additional research ideas. Mr. Eric Sanderson
(thesis advisor), Mr. Guy Voyer (pedagogical director at the Académie Sutherland d’Ostéopathie
du Québec) Mr. Sam Gibbs (DOMP), Mr. Max Girardin (D.O.) and Mr. Craig Harness
(classmate) were the most influential participants throughout this process. The triangulation of
information stimulated interaction and dialogue that increased comprehension and overall
understanding regarding the research question.
16
2.3.2 Sampling
In qualitative research, sample strategies do not seek to achieve statistical representativeness but
must be sufficient enough to generate depth of information. In order to achieve this, purposeful
sampling was done deliberately to select information-rich research that will give rise to data
relevant to the research aims.19 To accomplish this objective of purposeful sampling, most of the
EBM history and foundation material was extrapolated from physiotherapy and osteopathic
journals. As for the complexity content and research, the majority of the historical and current
perspectives came from sources that address the relevance of the complexity model as it pertains
to human subsistence and health. In addition, other journals were used, which challenged the
dominance of EBM philosophies.
2.3.3 Transparency
When gathering material for a thesis, one of the main objectives in a qualitative paper is to allow
readers the opportunity to follow the same guidelines and methodology, access the same
resources, and to see if they arrive at the same conclusions as the author. This is the format of
transparency, whereby all data is readily available and the steps for a given monograph are
outlined. The author of this thesis feels that he is in a unique position, having been exposed to
both paradigms/schools of thought (EBM and complexity). Therefore, the research can be used
as an “instrument” whereby one’s own experiences are a primary tool for data collection.
Documentation of the researcher’s credentials and previous experience (as outlined in the
introduction of this thesis) should lend substantiation to the conclusions drawn in the thesis and
increase the reader’s confidence in the process.20
Transparency can be a challenge even for the osteopathic practitioner who has diligently
followed a single path of reasoning throughout their academic and practical career; and in
today’s medical climate, the biomedical and epidemiological dominance has pushed for this
transparency in the form of EBM. However, an understanding of the depth and breadth of
complexity science and how it applies to the osteopathic method of promoting and augmenting
19 Johnson & Waterfield, 124. 20 Letts, 8.
17
human healing, might be the only avenue that challenges the “power of validation” controlled by
the EBM approach.
2.3.4 Bias
It has been outlined throughout this paper that one of the strengths of a qualitative thesis is that it
allows for interpretation and creativity in its formulation and inferences. Yet another advantage
is the bias factor - the identification of assumptions and biases of the researcher. It is more
acceptable in a qualitative analysis than in a quantitative one. Given that the author has been
trained under the EBM model as a physiotherapist and the complexity model as an osteopathic
manual practitioner, certain biases are understood and accepted. This declaration is outlined in
this thesis and the researcher’s views about both phenomena are explicit.21
2.3.5 Data coding / Analytical rigour
Data Coding, also known as ‘analytical rigour’, is a method by which all the information
gathered is organized and logically synthesized into ideas and thoughts on paper. Categorization
is an important step of this method and fulfilled by creating multiple meaningful sections that
facilitate the understanding of the reader while forming the essential body of the thesis. In this
thesis, the segments were arranged as follows:
• Introduction to EBM and physiotherapy.
• Introduction to Complexity and osteopathy.
• History and evolution of EBM and reductionism.
• History and evolution of Complexity science.
• Clinical example of EBM – Meta-analysis of RCTs and critical appraisal.
• Clinical example of Complexity reasoning and osteopathy.
• Conclusion - what is the foreseeable future for osteopathy?
21 Letts, 8.
18
2.3.6 Overall rigour
While quantitative research embraces concepts such as validity and reliability, qualitative
research covets a different form of terminology, namely the four components of trustworthiness
(which ensure the quality of the findings and increase the reader’s confidence in those
findings).22 The four components of trustworthiness are outlined here:
Credibility: Collecting data over a prolonged period of time. In this case, information was
gathered over a two year period (Jan 2010 to present). A variety of research methods were used
to ensure triangulation and reduce bias. Research for this thesis included: books, journals,
university databases, multiple online search engines, professional healthcare colleagues and
instructors.
Transferability: Can the findings from this paper be transferred to other situations? The EBM
and Complexity paradigms are major topics of discussion within all disciplines of health care,
not just osteopathy. For both paradigms, the ultimate goal is to have a tool that will assist in
clinical decision-making abilities as they pertain to patient health.
Dependability: Outlines the consistency between the information gathered and the conclusions
drawn. The author’s intention is to bring to light the debate between EBM and Complexity and
their defining roles within the field of osteopathy. While one is more entrenched in the tapestry
of medicine (EBM) the question still remains “Can both paradigms co-exist? And if so, at what
level?”
Confirmability: Involves maintaining a neutral and bias-free thesis presentation. The author of
this thesis has been exposed to both paradigms of thought and has attempted to challenge the
EBM proponents with a different viewpoint, one that compels us to contemplate the question
“Are we following the methodology best suited to enhance patient care and ultimately heal our
clients.”
22 Letts, 9.
19
Chapter 3: Evidence-Based Medicine Paradigm
______________________________________________________________________________
20
3.1 Evidence-Based Practice (EBM) Paradigm
For an osteopath to successfully conceptualize the systems approach to assessing, diagnosing and
treating the human body, mind and spirit, it is integral to understand that the “whole is greater
than the sum of its parts”. The ultimate goal for any osteopathic clinician is to have a
comprehensive, well-rounded knowledge base when it comes to anatomy, physiology, pathology
and other key tools to proficiently apply that knowledge to each and every individual patient
scenario within the clinical setting.
A topic of much heated debate within the osteopathic ‘community’ is whether professional
expertise alone is sufficient in order to continually achieve optimal success over one’s clinical
lifetime. Traditional osteopaths that view the body in terms of its complexity and emergence
will respond with a resounding “Yes!” However, there are many other health care professionals
practicing the art of osteopathy that would disagree and take a less conventional stance. They
would argue that clinical performance will inevitably decline throughout one’s career in manual
medicine, even with continual educational development. Furthermore, the non-traditionalist
osteopath would acknowledge that learning and development extend beyond clinical knowledge;
the integration of evidence-based medicine practices is a key component in the attainment of
continual success.
The objective for the evidence-based practice paradigm is to incorporate a few simple skills that
involve meticulous research, critical evaluation of that research and finally integration of the
validated findings into practice, for the purpose of enhanced patient care. Early adoption of this
rigorous, methodical approach to medicine is recommended in the academic curricula of many
osteopathic schools. As with other fields of medicine (including chiropractic, physiotherapy,
allopathic medicine and all of its disciplines and specialties), the reason for this assimilation
towards EBM is to gain acceptance and approval that can be validated across the masses.
Therefore, a linear process has been established utilizing clinical trial formations as a way to
obtain medical results that would be applicable to a target population of people with a certain
disease.23 Since it would be virtually implausible to perform a study on all individuals within a
23 Akobeng, A.K. Confidence Intervals and p-values in clinical decision making Acta Paediatrica, 97 (2008) 1004-1007.
21
target population, a “sample” of the given population is commonly employed with the hope that
the overall results from that sample can be extrapolated to all individuals in that population. 24
3.1.1 The definition of Evidence-Based Medicine
Evidence-based medicine is the conscientious, explicit, and judicious use of current best
evidence, in making decisions about the care of individual patients. The practice of evidence-
based medicine involves the integration of individual clinical expertise with the best external
clinical evidence available from systematic research.25 This definition is the most accurate
description of what EBM should entail: relevant and current research accompanied by clinical
prowess. The question as to whether one’s research or clinical expertise should take precedence
is highly debated amongst osteopathic practitioners.
Clinical experience is acquired through the evolution of one’s efficient judgement decisions in a
clinical practice setting, over one’s career. The gradual development of this expertise is reflected
in many ways, especially through one’s ability to provide more effective and proficient diagnosis
and through the compassionate identification of individual patients’ predicaments, rights and
preferences when making clinical decisions about their care.26 As for understanding the research
aspect of this paradigm, one must consider the definition of relevant clinical research, as well as
how it is classified and valued. It has been stated that “new evidence from clinical research both
invalidates previously accepted diagnostic tests and treatments and replaces them with new ones
that are more powerful, more accurate, more efficacious and safer”.27 Jules Rothstein, a well-
known evidence-based research author, writes what he constitutes as evidence: “...evidence is not
faith or tradition. Evidence is viable findings from research, not theories underlying practice.
Evidence is data that shows whether treatments make a meaningful difference. Evidence is what
is published in credible and respected journals”.28
24 Akobeng, 1004. 25 Sackett, 71. 26 Sackett, 71. 27 Rich, N. Levels of Evidence. Journal of Women’s Health Physical Therapy, 29(2) 2005, 19. 28 Rich, 19.
22
3.1.2 The history of Evidence-Based Medicine
The origins and practice of evidence-based medicine (EBM) date back to the 19th century, when
standardization for the teachings and practices within the spectrum of medicine were slowly
adopted by all types of health care professionals. However, this ideology has made a significant
surge within all medical fields, including osteopathy, since the early ‘90s. Since its inception,
we have witnessed unprecedented growth and popularity of EBM (across a variety of medical
disciplines), in shaping clinical decisions. The current trend is that through epidemiology, we
have come to realize that medicine is more than practicing a learned experience, and that it may
be a matter of reasoning, critical thinking, and virtues embraced by different forms of
epidemiology, biostatistics and clinical disciplines themselves.29 This rise in biomedical
informatics has been driven by the explosion of published information related to health care.30
The increased accessibility of information has (at least partially) spawned a new wave of
electronic resources, search filters for large databases, and entirely new databases (e.g. Cochrane
Collaboration). Consequently, clinical research has become more readily available to clinicians
and health policy makers in a conveniently synthesized, pre-digested and accessible form.31
With the advent of both the “clinical trial and clinical research” surrounding the mandate for
proof of efficacy via controlled trials—as a condition for approval in allopathic and
pharmacological fields of medical science 32—has this evolution sparked the same demand for
“evidence” in other health care fields, like osteopathy? Are the research designs devised for
investigating the efficacy of pharmaceutical therapy appropriate for validating therapies that
have human interaction at their core?33 The author explored his thesis topic in an attempt to
answer these questions, and with the hopes of providing some direction for the practicing
osteopathic clinician.
The EBM model was developed because of two related but distinct imperatives: “the need to
harness and codify the upsurge of clinically relevant published research, and the need to develop
rubrics for the evaluation of such research that would facilitate literacy and informed
29 Jenicek, M. The hard art of soft science: Evidence-Based Medicine, Reasoned Medicine or both? Journal
of Evaluation in Clinical Practice, 12 (2006), 411. 30 Wyer & Silva, 892. 31 Wyer & Silva, 892. 32 Wyer & Silva, 892. 33 Johnson & Waterfield, 122.
23
consumption on the part of clinicians, and even the lay public”.34 The face of medicine,
including osteopathy, is changing. EBM has contributed to an evolution in critical thinking,
optimally facilitating improved patient management and care.
Socrates, one of the most celebrated philosophers and educators of all time, reminded us that
“the beginning of wisdom is the definition of terms”.35 Within the relatively short life of EBM,
there have already been a variety of definitions attempting to highlight the true meaning of this
paradigm to health care professionals.
3.1.3 Alternative definitions of EBM
According to Straus et al., “EMB is the entity which requires the integration of the best research
evidence with our clinical expertise and our patient’s unique values and circumstances”.36 This
hierarchy of evidence is supported by the advocates of EBM. It is the opinion of the author that
this is also an accepted methodology within many educational institutions and deemed to be
more important than clinical prowess alone.
Dr. Milos Jenicek, Professor, Department of Clinical Epidemiology & Biostatistics at McMaster
University, provides another definition of “evidence”: any data or information, whether solid or
weak, obtained through experience, observational research, or experimental work. This data or
information must be relevant and convincing to some degree either to the understanding of the
problem (case) or to the clinical decisions (diagnosis, therapeutic or care oriented) made about
the case. ‘Evidence’ is not automatically correct, complete, satisfactory and useful. It must first
be evaluated, graded and based on its own merit”. With Jenicek’s definition, the traditional
osteopath can feel comfort knowing that with their “global approach” to the body’s systems, and
their interrelationships, case by case studies and their individual successes should be the basis for
what should establish scientific merit.
‘Evidence’ is as old as medicine itself. Only the act of belief, and to some degree conviction,
faith, personal or others’ experience, or proclamation by authority, are being replaced by findings
from randomized double-blinded controlled trial(s) or systematic reviews. (definitions of these
34 Wyer & Silva, 893. 35 Jenicek, 411. 36 Jenicek, 411.
24
are outlined in Table 2, p. 38). In this sense, medicine and all of its tributaries will always be
evidence-based but it will be judged on different scales of credibility. Evidence - especially
medical evidence - has numerous characteristics: it is provisional, defeasible, emergent,
incomplete constrained, collective and asymmetric.37 It is for these reasons that medicine is
often viewed as the “hard art of soft science”, while the field of osteopathy is viewed as more of
a true grassroots science and a comprehensive art form.
The EBM paradigm is an open-ended system. It is evolutionary rather than revolutionary. It is
an extension of fundamental, field and clinical epidemiology with rich contributions coming
from biostatistics and the factual knowledge and experience of their practitioner and others.
Without these grounds, even such fundamental notions as probabilities, chances, likelihood
ratios, disease risk and aetiology, or effectiveness of interventions, would be meaningless.38
3.2 Quantitative and Qualitative research methods
It is worthwhile to note the differences between the two types of research methods that embrace
EBM, those being quantitative and qualitative research respectively. The term “evidence” as
used in quantitative research, conjures up notions of information or “available facts” that have an
independent existence, thus enabling a particular argument or hypothesis to be proved or refuted,
or its validity to be established. By contrast, qualitative research seldom appeals to notions of
“evidence”, relying on the product of analysis from empirical data as “findings” and then
applying alternate or additional criteria. This is reflected in the use of different terminology to
discuss validity and rigour.39 The term “findings”, with its explicit recognition of agency on the
part of the researcher, acknowledges the importance of the context in which data is generated,
interpreted and presented.40
Qualitative research generally aims to answer research questions which are rather different from
those addressed by quantitative research.41 “Qualitative research is essentially exploratory,
setting out to describe, understand and explain a particular phenomenon. It may address 37 Miles, A. et al. New perspectives in the evidence-based healthcare debate. Journal of Evaluation in Clinical
Practice, 6 (2000), 78. 38 Jenicek, 412. 39 Lincoln & Guba, as quoted in Barbour, R.S. The role of qualitative research in broadening the “evidence base” for
clinical practice. Journal of Evaluation in Clinical Practice, 6 (2000), 155. 40 Barbour, 155. 41 Barbour, 156.
25
“‘what?’, ‘why?’ and ‘how?’ but not ‘how many?’ or ‘how frequent?’ ”42 The qualitative
research method is considered “open-ended” in that it allows the researcher to concentrate on
issues which have salience for those being studied and thus allow different perspectives to be
explored.43 Qualitative samples tend to be much smaller, as this method attempts to reflect and
mirror the diversity within a given population or group; the approach does not attempt to get at
the “truth”, but rather it seeks to acknowledge the existence and study the interplay of “multiple”
views and voices.44 Within the scope of qualitative research, the objective is to study the
decision-making processes of clinicians and patients; to illuminate the multiplicity of meanings
attached to a particular set of circumstances by different individuals. However, critics of this
research method will point to the limitations of qualitative findings including its apparent
inability to provide evidence on prevalence, prediction, cause and effect, or outcomes and its
failure to statistically generalize findings.45 The author is of the opinion that these criticisms and
apparent limitations are not limitations at all, but rather advantages that support the osteopathic
views on complexity and medicine. Despite these questionable pitfalls, one of the major
strengths of this type of research method and the reason it correlates well with the osteopathic
philosophy of practice, is that it furnishes explanations that may be theoretically generalizable
and transferable.46 The impact of qualitative findings may be persuasive, although not amenable
to measurement, and its research has considerable potential to influence practice. In the
osteopathic community, this is of vital importance because it helps to ensure the adage that “the
whole is greater than the sum of its parts”.47
Understanding the differences between the two approaches to research outlined above,
quantitative on the one hand, being measurable and proven, and qualitative on the other hand,
being exploratory and open-ended, establishes a clearer path for which the discipline of
osteopathy should follow in its attempt for validation. The osteopathic profession needs to align
itself with these new and innovative qualitative research styles in order to fully integrate the
nuances and complexity of its approach and method of delivering health care to patients. The 42 Gantley et al., as quoted in Barbour, “The role of qualitative research in broadening the “evidence base” for
clinical practice, 156. 43 Barbour, 156. 44 Barbour, 156. 45 Barbour, 157. 46 Lincoln & Guba as quoted in Barbour, “The role of qualitative research in broadening the “evidence base” for
clinical practice, 158. 47 Barbour, 162.
26
very nature of how osteopaths interpret and manipulate the human body, its structure, its
mechanics, and its fluidics, makes for a challenging protocol regardless of its design.
3.2.1 Levels of Evidence: The hierarchy of evidence
Collectively, the levels of clinical evidence outlined below enable decision-making to be
optimized based on categories of research strength (from the strongest, most reliable, least biased
and trustworthy to the weakest, least reliable, most biased and untrustworthy). EBM pioneer Dr.
David Sackett outlines these levels of evidence as follows:
1A = Systematic Review of Randomized Controlled Trials (RCTs)
1B = RCTs with Narrow Confidence Interval
1C = All or None Case Series
2A = Systematic Review Cohort Studies
2B = Cohort Study/Low Quality RCT
2C = Outcomes Research
3A = Systematic Review of Case-Controlled Studies
3B = Case-Controlled Study
4 = Case Series, Poor Cohort, Case-Controlled
5 = Expert Opinion 48
Other authors, such as Hadorn and Rich have created even further confusion by identifying
oversimplified, graded levels of evidence that offer only three categories:
Level A = Well-conducted RCT with 100 patients or more (including multi-centre and meta-
analyses), well-conducted RCT with fewer than 100 patients (one institution and meta-analysis;
well-conducted study).
48 Rich, 19.
27
Level B = Well-conducted case-control study, poorly controlled or uncontrolled (including RCT
with one or more major or three or more minor methodological flaws), observation studies with
high potential for bias (case series with comparison to historical controls), case series or case
reports, conflicting evidence with more support.
Level C = Expert opinion. 49
Table 2 provides the reader with additional details regarding the categories and definitions of
each methodological guideline for evidence.
The two most common classifications upon which clinical decision-making is based are Levels
A and B. Of these classifications of evidence, Level C (Expert opinion) commonly receives
criticism as the weakest link, the most biased, the least reliable and the least trustworthy way of
conducting oneself as a health care professional. The traditional osteopathic clinician would
challenge the hierarchy described above (Levels A, B and C) on the grounds of what constitutes
“expert opinion”. Does expert opinion include those practitioners who have dedicated their lives
to lifelong manual therapy training? Does it include those who have dedicated themselves to a
lifetime of experience in anatomy, physiology, biomechanics or other related disciplines, similar
to a journeyman apprenticeship? Does expert opinion simply mean years of experience? Or is it
a combination of duration and practical experience? All of these questions need to be discussed
in order to properly define what characterizes “expertise”.
49 Rich, 19-20.
28
Table 2: Terminology and definitions used in Levels of Evidence Guidelines
Term Definition
Systematic review A systematic review is typically restricted to RCTs. Initially, a group
of reviewers will search the available literature via bibliographic
databases. The reviewers search for common terminology, navigate
the search results and retrieve copies of all articles specific to the
search criterion. Once the applicable articles are in-hand, they
proceed to critically evaluate the methodologies and content. The
final product is a synthesis of the research into a format that is
informative and relevant to practicing medical practitioners/clinicians.
The Cochrane Database of Systematic Reviews provides some
excellent examples of this methodology.
(http://www.cochrane.org/cochrane/revabstr/mainindex.htm)
Meta-analysis This method is a subset of systematic reviews, which uses statistical
methods to combine and analyze multiple investigations.
Randomized
controlled trials
When a study involves a randomized controlled procedure, subjects in
the study are indiscriminately allocated to each group included in the
study. Each subject has an equal chance of being assigned into an
intervention group, a control group, a placebo group or a sham
treatment group. This eliminates the over-representation of any one
characteristic in one group. If the randomization is correctly
performed, each group should be similar with respect to baseline
characteristics. Furthermore, this process eliminates any bias in the
assignments of individuals to groups. Without this method, it is
possible for a research study to assign the less-involved patients to the
intervention group and the more-involved patients to the control
group. Randomized controlled trials are known to be the ‘Gold
Standard’ for establishing the effects of a treatment.
29
Term Definition
Cohort studies The cohort study is also commonly referred to as a prospective study,
or a longitudinal study. This study design involves the selection of a
large population of people who have the same condition and/or
receive the same intervention, are followed over time and are
compared to a group not affected by the condition. This study
employs observation as the research method. The interventions are
not manipulated in cohort studies.
Matched case-
controlled study
This design involves the selection of two patients, or two groups of
patients, who have been exposed to two different interventions. The
investigator performs a retrospective analysis to determine which
patient or group of patients achieved a better outcome.
Outcome research For this design, a large group of individuals who receive the same
intervention are evaluated retrospectively for their outcomes.
Case-series These are reports on a series of patients with a pre-identified problem.
Case report This involves a report on the intervention and outcome for a single
patient or client.
50
For the traditional osteopathic clinician, the case report seems to be the model best-suited to
accurately represent the patient-therapist interaction and relationship. Despite being a
methodology at the lowest tier of the hierarchy for evidence-based guidelines, it is the opinion of
the author that, in practice, the case report method actually offers significant upside for both the
patient and clinician. The case report method has the potential to highlight each and every
encounter that the therapist has with their patient and the results can be tailored to that one
50 Rich, 20.
30
individual. In practice, an osteopath treats one patient at a time and should customize the
treatment based on the unique needs of the individual.
In consideration of the various levels of evidence offered, one may be inclined to ask whether or
not there is a universally accepted definition of “best evidence”. Best evidence comes from
research that includes the randomized assignment of subjects or participants. Double-blinded
design, where the actual treatment group is neither disclosed to the investigators nor the patients,
and the use of both a control and a placebo group are also necessary. This type of systematic
research significantly increases the confidence with which a medical practitioner can believe in
the effectiveness of a treatment. In addition, by virtue of the rigorous design of the study,
readers are more inclined to trust the research and believe wholeheartedly that it was the
treatment itself that caused the outcome and not some ancillary factor.51
3.3 The introduction of EBM in the academic curriculum
The body of mainstream health evidence is located in the “confined domain”, with the testing of
linear interventions on discrete individual parts with randomized controlled trials, which typifies
the evidence-based medicine tradition of clinical practice.52 Under this simple system, cause and
effect can be separated and by understanding their relationship, one can control outcomes, and
predict and prescribe behaviours in the form of guidelines, protocols and best practices.53
Currently, most medical schools (including osteopathic schools) are introducing the philosophies
of EBM and teaching new health care providers the various methods of harnessing these critical
thinking skills (Note: the preceding statement applies only to American medical schools where a
degree in osteopathy requires additional education following the completion of traditional
medical training. This is not the case in osteopathic programs here in Canada, where regulation,
governance and education have no formal medical affiliation; this process is not discussed in
detail as part of this thesis). The role of argument-based or reasoned medicine is often
highlighted as an important adjunct to EBM within osteopathic schools. Identified here are two
of the more traditional definitions of argument-based medicine, which emphasize its foundations:
51 Rich, 20. 52 Martin, C.M., & Felix-Bortolotti, M. W(h)ither complexity? The emperor’s new toolkit? Or elucidating the
evolution of health systems knowledge? Journal of Evaluation in Clinical Practice, 16 (2010) 416. 53 Martin, 416.
31
“... the intellectually disciplined process of actively and skillfully conceptualizing, applying, synthesizing, and or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication as a guide to belief or action.” 54
“... a higher order thinking skill which mainly consists of evaluating arguments. It is a purposeful, self-regulating judgement which results in interpretation, analysis, evaluation and inference, as well as explanations of the evidential, conceptual, methodological, or contextual considerations upon which the judgement is based.” 55
These definitions highlight the co-existence between EBM and the critical thinking skills that are
now key foundations within several university and college curriculums for medical programs and
other health related fields, such as osteopathy.
3.4 The strengths of Evidence-Based Medicine
There is a commonly held belief that amongst a significant number of health care providers there
is a “progressive decline in their knowledge of appropriate clinical practice and they often fail to
address (their) daily needs for clinically important knowledge (which) may lead to a progressive
decline in (their) clinical competency” 56 For years, the term “evidence” represented
extrapolations of pathophysiological principles and logic rather than established facts based on
data derived from comprehensive research protocols involving the treatment of patients. In
response to this evolution in EBM, clinicians have been advised that integrating research into
clinical decision-making is the only manner by which to halt this progressive deterioration in
clinical performance. Medical educators are increasingly recognizing the power of probabilistic
reasoning, which has shifted us from an older anecdotal standard to a newer epidemiological one
so that authoritarian medicine may be gradually yielding ground to authoritative medicine.57
The following five-step process can be applied in a clinical practice setting, in order to facilitate
one’s understanding of the EBM paradigm of thinking:
1. Form an answerable question. Identify need(s) for evidence (problem formulation).
54 Jenicek, 413. 55 Jenicek, 413. 56 Sackett, D., & Rosenberg, W. On the need for evidence-based medicine. Journal of Public Health Medicine 17(3)
(1995) 331. 57 Miles, A. et al. Evidence-based healthcare, clinical knowledge and the rise of personalised medicine. Journal of
Evaluation in Clinical Practice, 14 (2008) 640.
32
2. Seek out the best evidence to answer your question. This involves evidence production,
evidence finding and research synthesis.
3. Critically evaluate the literature used in your research.
4. Integrate the best evidence with your clinical expertise and the patient’s unique
circumstances.
5. Critique your performance. 58
This five-step task cycle has become the instructional model for EBM that has been universally
accepted and can be simplified as: “Ask, acquire, appraise and apply.” 59 Whenever there is
doubt within a clinical intervention involving a patient, the osteopath should perform diligent
research using accessible resources (i.e.: online search engines), identify which studies (or
literature, etc.) are current and meaningful, organize the relevant materials, exploit them through
meticulous critical appraisal skills, and retain the information for future reference.
The following are some of the most commonly shared expert opinions regarding the advantages
of adopting the EMB paradigm of reasoning:
• The information literacy model known as EBM emphasizes the need to critically review
and evaluate the quality of information obtained by performing electronic searches.
EBM has provided us with a complete package that combines clinically framed concepts
of critical appraisal together with streamlined electronic resources and databases required
for judicious access to new research information as it emerges.60
• The EBM model equates evidence with scientific evidence and supports clinical expertise
as an important factor when transitioning from research navigation into therapist–patient
interaction.61
• Utilizing the EBM paradigm to guide the decision-making process within the clinical
setting gives the practitioner an objective and observational reality – a “truth” to the
interventions being carried out.62
58 McMaster University Handout, 1997. 59 Wyer & Silva, 893. 60 Wyer & Silva, 896. 61 Miles, 78. 62 Miles, 78.
33
• The truth is out there, waiting to be revealed. The RCT has been developed as the key
weapon for medicine to produce objective, value-free knowledge. Mathematical models
of statistical and clinical significance weigh the importance of the evidence in these trials.
This ensures that the underlying findings of the trial(s) are reproducible.63
• Traditional research evaluation criteria were designed for quantitative inquiry.
Qualitative data are descriptive and unique to a particular context and therefore cannot be
reproduced time and again to demonstrate “reliability”. Instead of trying to control
extraneous variables, qualitative research takes the view that reality is socially
constructed by each individual and should be interpreted rather than measured; that
understanding cannot be separated from context.64
When one investigates the emergence of EBM and its increased acceptance into the global
medical community, it becomes apparent that there are a number of key events and people that
helped to bring this paradigm to the forefront of medical decision-making. The Cochrane
Collaboration, founded in 1993 in response to the call of Dr. Archie Cochrane—a pioneer in the
use of RCTs—was a key development for clinical disciplines such as osteopathy.65 This
organization compiles systemic research summarizing the highest level of evidence concerning
clinical practice. In addition, the impact of Alvan Feinstein, renowned clinician, researcher and
epidemiologist, in defining the principles of quantitative clinical reasoning, brought significant
awareness to the topic to clinical research. Dr. Feinstein’s writings are some of the most
commonly studied books in clinical epidemiology.66 Last but not least, a pioneer of the EBM
paradigm, David Sackett’s innovative teachings in the area of clinical appraisal have helped to
streamline the way health care professionals, including osteopaths, reason about patient care.67
All three of these people and the events surrounding their unique contributions, have helped
EBM rise to the forefront of medical and osteopathic decision-making, while reducing the
emphasis on unsystematic clinical experience and pathophysiological rationale.68
63 Sweeney, K., & Kernick, D. Clinical Evaluation: constructing a new model for post-normal medicine. Journal of
Evaluation in Clinical Practice, 8(2) (2002) 133. 64 Johnson & Waterfield, 123. 65 Wikipedia, 2012. 66 Wikipedia, 2012. 67 Guyatt, G, et al. Evidence based medicine has come a long way. BMJ (2004) 990-1. 68 Guyatt, 900-1.
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From a purely epidemiological perspective, it seems clear that the “evidence” for an EBM
approach is strong; it appears to be a logical path to follow for the osteopathic practitioner who
wants to ensure that treatment interventions are producing the desired therapeutic effect.
3.5 The weaknesses of Evidence-Based Medicine
On the other side of this debate are the commonly held criticisms of the EBM approach. While
there are many who support the EBM paradigm, there are also many who criticize this linear
method of analysis. Included here are some of the most commonly shared opinions regarding the
disadvantages of the EMB paradigm:
• One of the most common arguments against EBM is that it is a linear and overly
simplistic method of breaking down the “whole into its fragmented parts.” This approach
suppresses an osteopath’s way of thinking as well as their freedom within the clinical
setting. Without clinical expertise, daily clinical practice would become tyrannised by
evidence, for even high quality research may be inapplicable to or inappropriate for an
individual patient.69
• Science and clinical practice move in different directions. Science moves from
individual observations to theories and laws that can be generalized. It is clinical practice
that brings this generalized body of knowledge to the benefit of the individual patient, all
within the context of the relationship that is established between the osteopath and the
patient in the initial assessment and subsequent treatment sessions. Clinical practice is
therefore not a science but rather a human endeavour which utilizes science and good
science is necessary, but in and of itself, not the sole determinant factor of good clinical
practice.70
• “The hierarchy of evidence” has done nothing more than glorify the results of imperfect
experimental designs on unrepresentative populations in controlled research
environments, above all other sources of evidence which may be equally valid or far
more applicable in given clinical circumstances.71
69 Sackett, 72. 70 Miles, 78. 71 Miles, 79.
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• “At each level of complexity entirely new properties appear; and research on the whole cannot be extrapolated from research on its constituent parts.” 72
• The continual trend of science is to isolate objects, one from another, and isolate them
from their environment. The principle of scientific experimentation allows taking a
physical body in nature, isolating it in an artificial, controlled laboratory environment,
and then studying this object’s behaviours and variations. This makes it possible to know
only a limited number of qualities and properties at best.73
• Many critics reject that EBM encompasses both scientific evidence and clinical evidence;
the definition of EBM should include the multiple dimensions of evidence, including
scientific evidence, theoretic evidence, practical evidence, expert evidence, judicial
evidence and ethics-based evidence. All of these facets of evidence would strengthen the
overall spectrum of EBM.74 (Note: Definitions of these forms of evidence can be found
in Table 3 on pages 48-9).
• “The experimental testing of a scientific theory is not a mechanical, automatic process. There is no prescribed set of procedures we can go through, at the end of which we give the theory some stamp of approval that says it has passed its test. The process of testing a theory, like the process of making one up in the first place, is a never-ending process, and a creative, imaginative one. We have to exercise some subjective judgment about what kind of experimental evidence will make a real difference one way or another in our degree of belief.” 75
• The construction of scientific theories requires that mathematics be employed as the
language of science and not merely as a tool of analysis.76 The failure to appreciate the
fundamental epistemological and logical differences between these two roles underlies
the deep flaws in EBM; and at the heart of this debate is the highly-touted RCT that uses
mathematics (probability and statistics) solely as a tool of analysis rather than as the
language of science, and this affects the validity of causal claims. 77 Many areas of
medical research and knowledge involve models in which mathematics is used as the
72 Doll, W.E., & Trueit, D. Complexity and the health care professions. Journal of Evaluation in Clinical Practice,
16 (2006) 846. 73 Morin, E. Restricted Complexity, General Complexity. 21(37) (2008) 14. 74 Miles, 78. 75 Goldstein M, & Goldstein, I. (1984). The experience of science an interdisciplinary approach. (Plenum: New
York, 1984), 305. 76 Thompson, P.R. Causality, mathematical models and statistical association: dismantling evidence-based medicine.
Journal of Evaluation in Clinical Practice, 16 (2010) 267. 77 Thompson, 267.
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language in which to describe dynamical systems. These include physiology,
immunology, medical genetics, neurosciences and other similar fields. Epidemiology
and biostatistics are fields where RCTs are prominent and models of dynamic systems are
rare. Modern physics, astronomy, chemistry and biology make little use of RCTs. RCTs
fail to give answers to crucially important questions and EBM’s almost total reliance on
RCTs suggests that it is never in a position to provide answers.78
• Werner Heisenberg’s Uncertainty Principle (quantum theory) defines the limitations of a
science’s ability to measure systems and predict events. The act of observation
determines the observability of a system. The very act of measurement itself can never
be objective and observations merely reflect the mechanisms of the observing instrument,
rather than the nature of the system observed.79
78 Thompson, 273. 79 Sweeney & Kernick, 132.
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Table 3: Types of Evidence
Type of Evidence Description
Theoretical Evidence According to Albert Einstein, theories are “free creations of the
human mind”. They can apply to empirical or non-empirical
phenomenon. Theories are like a “road map” linking the ideology
to what is experienced and or observed. It defines the “facts” as
reasonable and credible. It “plants the seed” for idea generation and
speculation, where answers are not cut and dry, black or white.
Practical Evidence Evidence based on an individual’s interpretations of an experience.
This form of evidence cannot be reduced to the objectivity of
observable science or EBM. Instead, they transform beyond the
biomedical model and seek to navigate the complexity of the human
experience and human consciousness. These insights go beyond
what can easily be explained. Practical evidence offers situational
empathy to the patient as a whole, including how they live in their
particular environment and cope with their unique anxieties in life.
Practical evidence “gives context and perspective to the patients
predicament”. However, this approach is not without its limitations
including lack of transparency, personal bias, and lack of
accountability and reliability.
Expert Evidence Evidence based on the statements or actions of individuals or groups
whose authority as “experts” is vested in public recognition of their
knowledge, experience and reputation. Expert evidence and the
“trust me, I am the professional” approach can have the associated
risks of weak substance and misguidance, however, expert evidence
can also provide the building blocks to the answers that science
cannot always explain.
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Type of Evidence Description
Judicial Evidence Defines what is admissible or believable in the eyes of our judicial
system or in a court of law. This type of evidence is commonly
regarded as truthful and reliable. Judicial evidence can write the
standards of EBM, set boundaries for medical decision-making and
define the boundaries of the scope of practice for a particular
profession.
Ethics-Based Evidence Ethics-based evidence uses “moral knowledge” to answer questions
of what “ought” to be permissible or done. This moral foundation
has a history in society that is based on the beliefs and values of
what is good and right. The focus of morality is a social contract by
which individuals live their lives. 80
Consider the question, “Can linear thinking, mathematical calculations and man-made
experimental designs really extrapolate meaningful interpretations of human experiences in the
natural world?”
A strong argument can be made by the traditional osteopath that the patient-therapist encounter
during the initial assessment and follow up treatment interventions should not be based only
upon literature searches, probabilistic reasoning and standardized algorithms (which collectively
are referred to as “practice guidelines”).81
EBM has been referenced as a “recipe” or “cookbook” approach to the practice of osteopathic
manual medicine. Its rigid and structured parameters, involving adequate sample sizes, inclusion
and exclusion criteria and linear statistical analysis, does not represent the average clientele one
sees on a daily basis with multiple co morbidities and numerous system dysfunctions, both
mechanical and fluidic in nature.
80 Buetow, S., & Kenealy, T. Evidence-Based Medicine: the need for a new definition. Journal of Evaluation in
Clinical Practice, 6(2) (2000): 87-90. 81 Shahar, E. Evidence-based medicine: a new paradigm or the Emperor’s new clothes? Journal of Evaluation in
Clinical Practice, 4(4) (1998): 277.
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External clinical evidence, while informative, can never replace individual clinical expertise. It is
this expertise that determines whether the research in question applies to the individual patient at
all, and if it does apply, how it should be integrated into a clinical decision.82 The conclusions of
this type of research often leave the reader puzzled because they are unconvincing in their
findings, suggesting that “more research is needed” to make a reasonable and informed decision.
In addition, there is an inherent problem with the application of the results generated from these
studies in a clinical setting. This lack of implementation in a clinical setting has many reasons
including: a lack of self-directed learning with critical appraisal of research studies, poor results
from study methods, or a provider’s interests in other clinical specialties (i.e. manual therapy);
all of these reasons detract health care providers from staying up-to-date with research and EBM.
Given these and other obstacles, is the future of this type of modern science achievable and
realistic? The author is of the opinion that for the osteopathic profession, the answer is “No”.
Giving greater priority to research studies and the levels of evidence as opposed to experience or
expertise fails to acknowledge the multiple systems and variables that are encountered when
assessing and treating an individual patient. The experience and interaction between the patient
and the osteopath, from one treatment session to another, is ever-changing and in essence defines
medical intervention as an art rather than a quantifiable science.
Due to the inherent complexity and interrelationships of the eleven systems of the human body
(integumentary, skeletal, muscular, fascial, neurological, cardiovascular, pulmonary, digestive,
reproductive, endocrine and immune) both the osteopath’s input through manual therapy and the
output reaction from the patient’s body are often uncertain, and yet patterns emerge that cannot
be predicted on the basis of analysing the underlying parts.
3.6 Challenging the powers that be
It appears that EBM, by its very design, is telling the medical community to trust neither clinical
expertise, nor historical experience, nor “pathophysiologic rationale”. EBM proposes that
scientific evidence in medicine comes only from clinical research and the only type of clinical
82 Sackett, 72.
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research that provides truly reliable evidence for the effectiveness of proposed therapies is the
RCT.83
One must ask the question: “Is the evidence applicable to individual patients?” Specifically, one
should consider whether or not one’s patient is similar to those who responded well to treatment
in randomized, multiple blinded controlled clinical trials.84 The application of evidence to an
individual patient relies on the compatibility of the patient’s demographic and clinical
characteristics and on his or her clinical setting within the studies providing the evidence of
interest.
It is difficult for the medical practitioner to evaluate EBM as the leading paradigm for clinical
decision-making because many of the outcomes are hard to quantify. In the realm of osteopathic
medicine, the quantification of results is a difficult task since patient case loads are filled with
multiple problems that have gone unsolved by conventional therapies and allopathic
interventions. The “evidence” for these scenarios is either lacking or non-existent and often it is
the complexity approach used by the osteopath that helps to direct treatment down the right path
to recovery.
There are several important variables existing within a clinical environment, which cannot
simply be put under the epidemiological microscope or be measured by biostatistical analysis.
Dr. Milos Jenicek quotes Dr. David Isaacs (clinical professor) and Dr. Dominic Fitzgerald
(physician), who both make the case that there are several types of medicine, which EBM can
never entirely replace:
• Claim-based medicine: Blind, or as a justified conclusion of a logical argument.
• Faith-based medicine: Belief and trust in something.
• Experience-based medicine: As given by the active involvement of a recorded or
unrecorded individual in an activity or exposure to events or people over a period of time
that leads to an increase in knowledge and skills.
83 Worrall, J. Evidence: philosophy of science meets medicine. Journal of Evaluation in Clinical Practice, 16
(2010): 356. 84 Jenicek, 415.
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• Conviction-based medicine: Based on firmly held opinions and beliefs with or without
grounds.
• “Big-heart”-based medicine: As dictated by the health care professional’s compassion,
empathy and will to help and the affection for the human suffering.
• Reference (spoken and written word) -based medicine: As conveyed to listeners and
readers.
• Gut-feeling-based medicine: As instinctive and intuition-driven understanding into
decision-making.
• Authority-based medicine: Has the right or power, justified or not, to enforce rules or
give orders that are administrative or competency-based.85
All in all, these types of medicine (whether they yield satisfactory evidence or not) offer
important tangible and intangible considerations to the osteopathic practitioner to help the patient
in the healing process.
3.7 Conclusions regarding EBM and osteopathy
Where do osteopaths go from here? Like many other health care professions, mainstream
osteopathy is leaning towards the merits of the EBM paradigm. However, many traditional
osteopaths oppose this direction for the profession. The challenge is to determine whether the
EBM approach produces better results and benefits for patients than the alternative methods
being practiced today. Does this debate require a double-blinded randomized control trial
comparing the two paradigms? For the osteopath, does ‘best evidence’ imply the existence of
individual testimonials proclaiming their successes in healing? Or does it mean the “best
evidence” is in the form of documented clinical trials with smaller sample sizes, covering
multiple variances in patient characteristics (i.e. case studies only)? These are some of the
important questions that need to be discussed amongst the osteopathic profession in order to
ensure optimal success and health for our patient populations.
85 David Isaacs, Dominic Fitzgerald, as quoted in Jenicek, “The hard art of soft science,” 412.
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Table 4
Clinical Epidemiology Glossary
Term Definition ANOVA (Analysis of Variance)
A method of statistical analysis broadly applicable to a number of research designs, used to determine differences among the means of two or more groups on a variable. The independent variables are usually nominal, and the dependent variables are usually an interval.
Blind Assessment The evaluation of an outcome made without the evaluator knowing which results are from the test group and which are from the control or “gold standard”.
Blind(ed) Study A study in which observer(s) and /or subjects are kept ignorant of the group to which the subjects are assigned, as in an experimental study, or of the population from which the subjects come, as in a non-experimental or observational study. Where both observer and subjects are kept ignorant, the study is termed a double-blind study. The purpose of “blinding” is to eliminate sources of bias.
Co-interventions Interventions other than the treatment under study that may have been applied differently to the study and control groups. Co-intervention is a serious problem when double-blinding is absent or when the use of very effective non-study treatments is permitted.
Confidence interval (CI)
The CI gives a measure of the precision (or uncertainty) of study results for making inferences about the population of all such patients. The 95% CI is the range of values within which we can be 95% sure that the true value applies for the whole population of patients from whom the study patients were selected. Wide confidence intervals indicate less precise estimates of effects. CI is affected by sample size and by variability among subjects. The larger the trial’s sample size is, the larger the number of outcome events and the greater the confidence that the true relative risk reduction is close to the value stated: the confidence intervals narrow and precision is increased.
Confounding variables
A characteristic that may be distributed differently between the study and control groups and that can affect the outcome being assessed. Confounding may be due to chance or bias.
Content Analysis Is a form of analysis that counts and reports the frequency of concepts/words/behaviours held within the data. The researcher develops brief descriptions of the themes and meanings, called codes. Similar codes may be grouped together to form categories.
Efficacy A measure of the benefit resulting from an intervention for a given health problem administered to patients under ideal conditions (i.e. perfect compliance).
Empathic Neutrality A quality of qualitative researchers who strive to be non-judgemental when compiling findings.
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Term Definition Empirical Research “...the process of developing systematized knowledge gained from
observations that are formulated to support insights and generalizations about the phenomenon under study”.86
Exclusion criteria Stated conditions, which preclude entrance of candidates into an investigation even if they meet the inclusion criteria.
Follow-up Observation over a period of time of an individual, group, or initially defined population whose relevant characteristics have been assessed in order to observe changes in health status or health-related variables.
Generalizability The extent to which research findings and conclusions from a study conducted on a sample population can be applied to the population at large.
Gold standard Ideally, the criterion used to unequivocally define the presence of a condition; or practically, the method, procedure or measurement that is widely accepted as being the best available to detect the presence of a condition.
Grounded Theory Aims to generate a theory that is ‘grounded in’ or formed from the data and is based on inductive reasoning. This contrasts with other approaches that stop at the point of describing the participants’ experiences. In terms of data analysis, grounded theory refers to coding incidents from the data and identifying analytical categories as they emerge from the data, rather than defining them at the beginning.
Holistic perspective Taking almost every action or communication of the whole phenomenon of a certain community or culture into account in one’s research.
Likelihood ratio The likelihood ratio for a test result compares the likelihood of a given result in patients with disease to the likelihood of the same result in patients without disease.
Negative predictive value
The proportion of people who receive a negative test result who are truly free of the target disorder.
Outcome Measures Outcome measures must be able to discriminate among patients or health states at a designated point in time and be adept at assessing change over time. These measures provide information about a patient’s current state and whether a change has occurred since the previous assessment. Standardized measures have explicit instructions for administration and calculation.
Odds ratio The odds of the experimental group showing either positive or negative effects of an intervention or exposure, in comparison to the control group.
86 Lauer & Asher, as quoted in (http://writing.colostate.edu/guides/research/glossary/) (1988), 7.
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Term Definition P- value The possibility that any particular outcome would have occurred by
chance. Statistical significance is usually p < 0.05. Considered to be inferior to confidence intervals in determining significance of studies.
Power The ability of a study to demonstrate an association or causal relationship between two variables, given that an association exists. For example, 80% power in a clinical trial means that the study has an 80% chance of showing a statistically significant treatment effect if there really was an important difference between outcomes. If the statistical power of a study is low, the study results will be questionable (the study might have been too small to detect any difference). By convention, 80% is an acceptable level of power.
Predictive value (positive and negative)
In screening and diagnostic tests, this refers to the probability that a person with a positive test is a true positive (i.e. does have the target disease), or that a person with a negative test truly does not have the disease. The predictive value of a screening test is determined by the sensitivity and specificity of the test, and the prevalence of the condition for which the test is used.
Pre-test probability Probability of disease before a test is performed. Post-test probability Probability of disease after a test is performed. Reflexivity The open acknowledgement by the researcher of the central role the
researcher plays in the research process. A reflexive approach considers and makes explicit the effect that the researcher may have had on the research findings.
Relative risk The ratio of the probability of developing, in a specified period of time, an outcome among those receiving the treatment of interest or exposed to a risk factor, compared with the probability of developing the outcome if the risk factor or intervention is not present.
Reliability (Dependability and Auditability in qualitative studies)
The consistency of measurement. It is also concerned with error in measurement. If the extent to which measurement error is slight, then a measure is said to be reliable.
• Absolute reliability: quantifies measurement error. • Intra-rater reliability: the same rater performs all the
measurements. • Interrater reliability: two or more raters assess all patients. • Relative reliability: measures the ability to differentiate among
the objects of measurement (e.g. ICC – intraclass correlation coefficient from 0-1, the higher the score the more reliable).
• Test-retest reliability: patients provide responses on two or more occasions.
• Internal consistency: this type of reliability examines the extent to which responses to items are consistent.
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Term Definition Reproducibility The results of a test or measure are identical or closely similar each
time it is conducted. Rhetorical Inquiry “entails...1) identifying a motivational concern, 2) posing questions, 3)
engaging in a heuristic search, 4) creating a new theory or hypotheses, and 5) justifying the theory”.87
Rigor Degree to which research methods are scrupulously and meticulously carried out in order to recognize important influences occurring in an experiment.
Sample size Is the size of the population under study. Larger samples usually mean more precise results. Sample size usually depends on the purpose of the study, the population size from which the sample will be pulled, the level of precision, the level of confidence or risk that is acceptable, and the degree of variability in the attributes being measured.
Selection bias A bias in assignment or a confounding variable that arises from study design rather than by chance. This can occur when the study and control groups are chosen so that they differ from each other by one or more factors that may affect the outcome of the study.
Sensitivity Percentage of patients with a disease who have a positive test for the disease in question.
Specificity Percentage of patients without a disease who have a negative test for the disease in question.
Statistical significance
How likely the result of a study is due to chance. The probability that an event or difference occurred by chance alone.
T-Test A statistical test. A T-test is used to determine if the scores of two groups differ on a single variable.
Transferability The ability to apply the results of research in one context to another similar context. Also, the extent to which a study invites readers to make connections between elements of the study and their own experiences.
Triangulation The use of a combination of research methods in a study (i.e. surveys, interviews, observations etc.). It is a process by which the area under investigation is looked at from different perspectives. Used to ensure that the understanding of an area is as complete as possible or to confirm interpretation through comparison of different data sources.
87 Lauer & Asher, as quoted in (http://writing.colostate.edu/guides/research/glossary/) (1988), 5.
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Term Definition Validity The degree to which the results of a study are likely to be true,
believable and free of bias. This is entirely independent of the precision of the results and does not predict the results of one’s patients.
• Face validity: a test that appears to be measuring what it is intended to measure.
• Content validity: a test that comprehensively samples from the domain of interest.
• Construct validity: a test that provides results consistent with theories concerning the attribute of interest.
• Criterion validity: a test that provides results consistent with a gold standard for the attribute of interest.
Internal validity (Credibility and Truth Value in qualitative studies)
Refers to the integrity of the experimental design.
External validity (Transferability, Applicability and Fittingness in qualitative studies)
Refers to the appropriateness by which a study’s results can be applied to non-study patients or populations.
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88 American Academy of Family Physican (2012). Retrieved from
http://www.aafp.org/online/en/home/publications/journals/afp/afpebmglossary. Buckingham, J., Fisher, B., & Saunders, D. (2008) Evidence based medicine toolkit. EBM Toolkit. University of Alberta. Retrieved from http://www.ebm.med.ualberta.ca/Glossary.html. Qualitative research terms (n.d.). United Lincolnshire Hospitals. Retrieved from http://www.hello.nhs.uk/documents/Qualitative_Critical_Appraisal_Glossary.pdf Colorado State University (n.d.) Glossary of key terms. Colorado State University. Retrieved from http://writing.colostate.edu/guides/research/glossary/. Johnson & Waterfield, 123. Stratford P, 2009, McMaster University Reliability and Validity Design Module.
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Chapter 4: Complexity and the Scientific Revolution
Where does osteopathy fit in?
______________________________________________________________________________
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4.1 Complexity and the Scientific Revolution
When one attaches the adjective “complex” to a subject, it is reasonable to assume that the
subject is complicated, elaborate, intricate or sophisticated – anything but simple. Complexity,
in essence, does not suggest a definitive explanation, but rather it makes reference to the
difficulty of providing one. The “aura of complexity” defines a form of thinking, whereby all
doors will not and cannot be open in search for an answer - the right answer. Therefore, it
should come as no surprise that within the complexity paradigm of thinking, difficulty and
uncertainty will forever be present. It is for this reason that paradigms centred on simplistic
reasoning prevail in our society, centres of learning and in many schools of thought. Our
consistent quest for finality and all-encompassing solutions, coupled with our consistent
exposure to simple paradigms, leads us down a narrow path in search of simple answers to
simple problems, simple formulas for simple laws.89
In terms of its application to the osteopathic practitioner and in relation to the human body,
“complexity thinking” requires that one fully comprehends all of the associations between the
parts and the whole. The complexity practitioner recognizes that knowledge of the all the parts
is not complete and by the same token knowledge of the whole “as a whole” is not sufficient.
The successful osteopathic provider understands that there must be a mutual implication of the
whole-part relationship.
At the turn of the century, world-renowned theoretical physicist Stephen Hawking made a
profound statement that propelled complexity forms of thinking to the forefront of science: “I
think the next century will be the century of complexity”. Hawking was making reference to the
emergent and transdisciplinary domain of complexity wisdom.90 This “new science” involving
complexity reasoning is anything but “new” to disciplines like physics, chemistry and
osteopathy. The great thing about this methodology is that there is no “gold standard”, no hard
and fast rules that encompass all there is to know about complexity. The complexity paradigm
aims to embrace, blend and elaborate upon the insights of any and all relevant domains of human
89 Morin, E. On Complexity. (Cresskill, NJ: Hampton Press Inc., 2008), 84. 90 Davis, B., & Sumara, D. Complexity and Education; Inquires into Learning, Teaching and Research. (New York:
Routledge., 2006), 3.
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thought. Complexity thinking does not rise above, but rather rises among other discourses,
incorporating multiple schools of thought.91
Under the umbrella of complexity theory, change is everywhere, and stability and certainty about
most things in life are rare. Complexity is all about adaptation, evolution and constant
development for survival. It challenges the domains and foundations of reductionist models and
linear predictability, embracing the holistic, the organic and the interconnectedness of the
relationships around us.92 For the healthcare professional that studies and practices the art of
traditional osteopathy, these characteristics exemplify the grassroots ideology of complexity
theory.
4.2 Introduction to the roots of the Complexity movement
If one traces the origins and meanings of the term complexity, one will discover numerous
descriptions of a similar nature: encompassing, encircling, embracing, comprising, plaited
together, interwoven. The term “complexity” is commonly used as the opposite of the term
“simplicity”. Its meaning pertains to the holistic, global or non-linear form of intellect necessary
to comprehend a phenomenon.93
“All things, even the most separated from one another, are imperceptibly linked one to the other, all things assist and are assisted, cause and are caused.” 94
Quotes such as the one above and certain key concepts of the complexity model have emerged
throughout history over the last 2000 plus years (between 300 BC to the present) where several
thinkers and events planted the seeds of complexity. These groundbreaking philosophies
contributed to the early development and eventual metamorphosis of the complexity paradigm,
as we know it today.
Let’s start at the beginning with one of the foremost influential philosophers of our time
(especially in the western world), Aristotle (384-322 BC), who gave us great insight into
medicine, metaphysics, mathematics and biology. Some of Aristotle’s primary contributions to
science involved the formulation of “logic” and the introduction of concepts such as the “Laws
91 Davis & Sumara, 8. 92 Mason, M. Complexity Theory and the Philosophy of Education. (UK: Wiley-Blackwell, 2008), 16. 93 Mason, 63. 94 Blaise Pascal, as quoted in Edgar Morin, Realism and Utopia. Diogenes, 209, (2006), 140.
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of Identity”. He coined some of the most famous phrases, many still applicable today, such as
“the whole is more than the sum of its parts”, and “movement is life”. It was this type of logic
and reasoning that were important factors in the formulation of his original four natural elements
(earth, water, air and fire) and the holistic thinking of his time. These beliefs ring true to the
essence of osteopathic medicine and the complexity movement pertaining to human existence
and the world we live in.
For many centuries, this “natural philosophy” described the study of the physical universe and
was the focal point for science and educators such as Aristotle. Like most concepts pertaining to
the study of life and universal existence, there was an evolution of thought – a gradual
ideological shift – that took hold during the 16th and 17th centuries. This shift in thinking
represented a movement from the descriptive-metaphysical Aristotelian concept of the universe
to a mathematical-positivistic Galilean concept of the world.95
4.3 The Scientific Revolution – The shift in the scientific paradigm of reasoning
If we fast-forward through the shift in scientific and intellectual thought during the 15th, 16th and
17th centuries, we have the birth of “The Scientific Revolution”. There are many contributors to
the development of modern science and the eventual paradigm and ideological shift that became
more reductionist, fixed, stable and universal.
Leonardo Da Vinci (1452-1519), the Italian scientist, anatomist and artist was a major
contributor to scientific inquiry by reinforcing a rational and systematic approach to
experimentation with repeated observations to ensure reliability and accuracy. His
methodological approach to science was a huge step from the Dark Ages into the modern era of
medical thinking.96
William Gilbert (1540-1603) and Francis Bacon (1561-1626) are two English scientists whose
work solidified the methodology behind the scientific revolution by dispelling superstition and
religious fervour and reinforcing rational scientific inquiry and inductive reasoning based on
repeated testing and proof. Both challenged the Aristotelian view of the world and the
95 Von Bertalanffy, L. The History and Status of General Systems Theory. The Academy of Management Journal,
15(4), (1972), 408. 96 Jon Balchin, Quantum Leaps: One Hundred Scientists Who Changed the World, (London, Arcturus Publishing
Limited, 2010), 37.
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metaphysical baggage that came with it in order to transition with the evolving reductionist
movement.97
The contributions of Galileo Galilei (1564-1642), the Italian mathematician, helped to forge the
modern scientific approach to experimentation with mathematical analysis. Galileo would
breakdown the whole into its essential parts, do research trials and analyse the results with
mathematical expressions.98
René Descartes (1596-1650), described by many as the first truly “modern” mathematician and
philosopher, was responsible for the scientific movement away from uncertainty to one of
certainty. Descartes was more concerned with mind / body dualism and exploring the laws of
thinking and inquiry; he believed that there should be rules for the direction of the mind, to orient
people towards a particular way of thinking; disjointing the thinking subject and the thing being
thought of; a focus on simple, reductionist thought processes.99 He adopted more of a
mechanistic interpretation of the natural world and the human body – with the mind and body
being isolated from one another, as distinct entities.100
Sir Isaac Newton (1642-1727), the English mathematician and physicist, was yet another key
figure. Newton’s discoveries regarding the laws of nature, attraction and motion have left what
some would argue to be the most significant legacy of all time. He utilized his mathematical
expertise to formulate scientific principles and standards for modern physics. The tools and
principles proposed by Newton shed new light on man’s ability to observe and measure natural
phenomena. Newtonian mechanics explore the development of the laws of nature and focus on
prediction, order and determinism. This helped shape the age of experimentation within the
scientific methodology, where systems were compartmentalized into their simplest forms.
Newton explained that the world is composed of essential building blocks called atoms, that
these atoms exist independent from their environment and the study of their behaviour could help
predict the future of the system as a whole.101
97 Balchin, 43-4. 98 Balchin, 46. 99 Morin, Xxvi & 3. 100 Balchin, 54-5. 101Morin, xxx.
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Within Newton’s world, matter (atoms) and energy were the rulers of absolute space and time.
By understanding the location, mass and speed of matter within the universe, the prophecy of the
future was inevitable and absolute. Every event in life and all living things that thrive within the
universe could be predicted and mapped out. Through the application of Newton’s science, a
complex set of events could be understood only when broken down into their elementary
interactions.102 This deterministic view of the world according to Newton was coined “the
triumph of necessity”. Simple rules and precise laws were fundamental to this paradigm of
thought regarding our universe; anything outside this order was considered disorder, and its
complexity was a mere flaw in our knowledge base.103 With Newtonian mechanics, there existed
a clockwork phenomenon of order, causality and stability in the world with measurable cause
and effect relationships.
Newton’s ideas regarding our existence within the universe were unmatched in the scientific
community, helping to define a “new scientific method” of experimentation. The ultimate goal
within the sciences became the search for irrefutable results that involved calculations and
measurements, backed by research methods that were sound, quantifiable, objective and
reproducible. Fast-forward to the 21st century and it becomes clear that the legacy of Newtonian
mechanics helped to shape the very climate for the emergence of EBM and helped to define our
expectations of the osteopathic profession as it strives to establish credibility within the eyes of
the medical community.
In the infancy of the Scientific Revolution, Galileo, Descartes and Newton all made early
contributions to the concept of “simple systems”, through their studies and analysis of the
interaction between small numbers of variables. The purpose of such studies was to reduce
mechanical phenomenon to basic laws and elementary particles. These studies triggered the
beginning of the reductionist movement towards human existence within the universe. The
contributions of these key leaders in the scientific community acted as a springboard for the
“analytic methodology”, whereby all phenomena within the universe are fragmented into their
most elementary parts, in order to definitively calculate life and the events that shape it.104
102 Laszlo, E. The Systems View of the World: A Holistic Vision for Our Time. (Cresskill, NJ: Hampton Press Inc.,
(1996), 7. 103 Morin, xxxi. 104 Davis & Sumara, 9-10.
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However, all of the scientists outlined above acknowledged a limitation central to this
methodology: At any given time, there are multiple variables that can either positively or
negatively influence life, and the rudimentary calculations of simple systems cannot begin to
explain more complex phenomena. As a result, a more elaborate system of thought was
required: the “complicated system of analysis”. Together all of these ideas helped to shape the
very foundations of critical thinking and specialization within organized institutions (such as
universities and other centres for higher learning). It is these very same establishments that
(today) help to establish the dogma of higher learning.
In opposition to Descartes and many who held steadfastly to the beliefs of traditional philosophy,
German philosopher Immanuel Kant (1724-1804) believed that dogmatic rationalism was too
constraining to describe the human predicament.105 Kant presented the scientific community
with an understanding of organic form and of the patterns produced by the interaction of
components; the self-organizing interaction of the parts of the organism.
“In machines, parts exist for each other, whereas in organisms they also exist by means of each other in the sense of producing one another. We must think of each part as an organ that produces the other parts, so that each reciprocally produces the other...because of this the organism will be both an organized and self-organizing being.” 106
During the scientific revolution, there were several competing ideologies surfacing and a second
wave to the science evolution emerged with the laws of thermodynamics (4 laws in all, but with
special emphasis on the second law). This 2nd law, coined the “principle of irreversibility”,
challenged the beliefs of the reversible world that Newton described. Irreversibility meant that
every event that happens in life has a temporal relationship and cannot be “undone” or
“changed.” 107 In the mid-19th century, Rudolf Clausius (1822-1888) added a familiar concept,
termed ‘entropy’, to this law of thermodynamics to describe the disorder and randomness of a
system.108 Only in an open system is entropy fully realized, where time, the external
environment and all of the intrinsic variables that make up an organism co-exist and constantly
adapt to optimize existence.
105 Sweeney & Griffiths, 24. 106 Sweeney & Griffiths, 25. 107 Morin, xxxii. 108 Morin, xxxii.
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For the osteopathic practitioner, the order–disorder paradox is constantly being evaluated and
balanced to assist in the body’s ability to heal itself. This principle of entropy should be
embraced in order to help explain how manual input (whether mechanical or fluidic) re-
organizes the human systems’ function and vitality.
4.3.1 The world according to Darwin
Charles Darwin’s (1809-1882) world was one of evolution and progression, unlike Newton’s,
which was static, and Clausius’, which was decaying. Darwin outlined that human life started
out as simple micro-organisms (which we now know is anything but simple) and eventually
evolved into a system of complex entities. It was his principle of natural selection that
highlighted “interaction” between time and life. The presence of order-disorder and organization
all have a complex relationship with interaction;109 and it is this interplay that allows an open
system, like human life to adapt to change, nurture, survive and thrive in a world of complexity
and uncertainty. The common theme in his infamous body of works concerns an organism’s
ability to survive in its environment; and it is this interaction that allows for the emergence of
new behaviour and new forms of organisms.110
In the 19th century, newer, more complicated methods of analysis were being developed using
statistical methods and probability, yet the fundamental concept that everything in life is fixed
and can be reduced to the sum of its parts, still permeated the consciousness of the scientific
community. This prediction-oriented endeavour of modern science was driven to measure and
calculate that which, in essence, is not calculable.
French Mathematician Henri Poincaré (1854-1912) stated:
“Even if it were the case that natural laws no longer held any secret for us, we could still only know the initial situation approximately. If that enables us to predict the succeeding situation with the same approximation, that is all we require, and we should say the phenomenon had been predicted, that is governed by laws. But it is not always so; it may happen that small differences in the initial conditions produce great ones in the final phenomenon. A small error in the
109 Morin, xxxiii. 110 Sweeney, K., & Griffiths, F. Complexity and Healthcare: An Introduction. (Abingdon, UK: Radcliffe Medical
Press Ltd., 2002), 26
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former will produce an enormous error in the latter. Prediction becomes impossible.” 111
Poincaré was driving at the idea that the systems of the universe that encompass life are
dynamic, adaptive and self-organizing. As these concepts evolved over time, the final system
(defined by American scientist and mathematician Warren Weaver) emerged into the limelight of
scientific inquiry: “the complex system”. Weaver developed a classification system for simple,
complicated and complex systems.112
4.4 Definition of modern science
As identified earlier in this thesis, the definition of “science” has undergone significant change
over many centuries, gradually shifting from a narrow focus to include a broader spectrum of
meanings today. The volatility of the definition lies in the fact that it is not clear where one
draws the line between science and pseudo-science? Today’s “science”, or rather the modern
definition of the term, is in accordance to Thagard’s demarcation criteria (named after Canadian
philosopher of science, Paul Thagard from the University of Waterloo):
• Uses correlation thinking (e.g. A regularly follows B in controlled experiments).
• Seeks empirical confirmations and disconfirmations.
• Practitioners care about evaluating theories in relation to alternative theories.
• Uses highly consilient (i.e. explains many facts) and simple theories.
• Progresses over time: develops new theories that explain new facts.113
In consideration of the above definition of science, it is a commonly held belief, rightly
or wrongly, that science is the “supreme arbiter of truth, objectivity and rationality”.
Therefore any knowledge within this field is held in higher regard than other types of
knowledge and it is this privileged position of science that can sometimes lead to fraudulent
use of the term “science”.114
111 Davis & Sumara, 9. 112 Davis & Sumara, 9. 113 Richardson, K., & Cilliers, P. What is Complexity Science? A View from Different Directions. Emergence,
3(1), (2001), 9. 114 Richardson & Cilliers, 19.
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4.5 Three eras of science in medicine
• Normal science – based on logical positivism; there is a single universal condition
that can be understood and validated; the paradigm of certainty.
• Post-Modern science – the process of knowing becomes important; truth is socially
constructed, contingent, provisional, influenced by power and social context.
• Post-normal science – distinguishes complicated systems from complex adaptive
systems. Reductionism no longer is a valuable tool for understanding the latter. The
interaction of the parts of a system becomes crucial. Some systems are better
understood by standing back and observing patterns of behaviour.115
The question this author would like to pose is whether “science” is the only objective
paradigm of the world we live in? Is the objectivity of science merely a myth? Within the
scope of the scientific community, many people work within a rather rigid set of rules,
unable to explore these important questions. This has resulted in an upsurge of innovation on
the technological side of scientific inquiry and a withering away of any appreciation for the
value of exploring the philosophical side, to keep it in harmony with the technology.116 The
scientific model, specifically the EBM model, is almost universally accepted without much
debate, while the complexity paradigm is all about stepping outside the boundaries set by the
classical scientific community; it’s about incorporating different frameworks that retain the
knowledge of science and its belief structure but involves the encoding, decoding and
mapping of the environment around us.117
According to the French philosopher, Edgar Morin, Classical Science rejects the Complexity
Paradigm based on three key principles:
1. The principle of universal determinism – knowing all past events and predicting all
future events.
2. The principle of reduction – knowing any composite from only the knowledge of its
basic constituting elements.
115 Sweeney & Kernick, 135. 116 Mikulecky, D. C. The Circle That Never Ends: Can Complexity Be Made Simple? Complexity in Chemistry,
Biology, and Ecology. Springer, (NY, NY, 2003), 100. 117 Mikulecky, 101.
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3. The principle of disjunction – isolating and separating cognitive difficulties from one
another, leading to the separation between disciplines, which have become secluded from
each other.118
Throughout its evolution, classical science has become so entrenched in the principles of
rejection described above, that its philosophy is viewed as superior, and any other paradigm,
such as “complexity”, has taken on an air of ambiguity and mystification.
In today’s science-based research, complexity (or systems theory) is gradually being renamed
“complexity science” to fit in or assimilate with research-based ideologies, however the
traditional definition of science remains the same: A collection of established principles on the
nature of the universe and the particular methods of investigation and verification by which those
principles are established. These methods are organized around the standard of proof through
replication: Hypotheses become facts and theories become truths, as researchers are able to
demonstrate that predictable and repeatable results can be obtained. 119 This is where the
traditionalist of osteopathy would disagree, in an attempt to reinforce the holistic reasoning of
life and their surrounding environment. Unfortunately, science has been true to its roots in
“separating one thing from another”, by “splitting, rending, cleaving and dividing” the known
entities that exist in the universe.120
When one begins to scrutinize the all-encompassing definition of “science”, it becomes clear
that, in actuality, the definition is lacking. Gaps exist, which can be filled by the complexity
paradigm; specifically, the standards of replication. For many years, disciplines such as biology,
geology and astronomy have identified that the universe is neither fixed nor finished, but rather it
seems to be evolving, and not in a predictable manner or fashion. Science made a shift from an
emphasis on dichotomization to one of bifurcation. The difference between the two is as
follows: To dichotomize is to generate two independent and unambiguously defined pieces;
bifurcation on the other hand is “two-pronged” or “forked” allowing for growth into two
branches, as opposed to fragmentation into two pieces.121
118 Morin, 1. 119 Davis & Sumara, 17. 120 Davis & Sumara, 31. 121 Davis & Sumara, 31-2.
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4.6 Fundamental principles of osteopathy: Understanding its traditional beliefs
According to Andrew Taylor Still, the founder of osteopathy, the practice of osteopathy is based
on a few key ideas. The first of these philosophies is the natural self-sufficiency of the human
body; the second is that normal structure and normal function go hand in hand.122 Still’s ideas
were not entirely new, in fact throughout history many of the scientific community’s greatest
physicians held many of these same virtues. For example, Hippocrates claimed that the whole
aim of the science of medicine must be to study natural processes and facilitate them “so that the
sick man may conquer the disease with the help of the physician.”123 By understanding the
complexity of the human body and all of the systems that support its existence and health, the
osteopathic practitioner is a unique professional in the field of health care. The role of the
traditional osteopath is not so much to combat the various disease states that afflict the human
body, as it is to promote health and assist the body’s innate ability to defy or overcome
disease.124
“Osteopathy is based on the perfection of Nature’s work. When all parts of the body are in line, we have health. The work of the osteopath is to adjust the body from the abnormal to the normal, then the abnormal condition gives place to the normal, and health is the result of the normal condition.” 125
Osteopathy is the most comprehensive evaluation and treatment discipline in the manual therapy
world; it can make this bold claim because osteopaths are “generalists of the body”. A well-
trained and educated osteopath understands the entire human body (inside and out) through the
application of palpation skills (i.e. 10-finger osteopathy) and intimate intention, induction,
replication and duplication of anatomy, physiology and pathology.
4.6.1 The prominence of diagnosis in osteopathy
Osteopathy aims to develop a new science of diagnosis, in addition to the traditional methods of
diagnosis by palpation, auscultation and percussion. This new diagnosis necessitates a refined
and sensitive tactician. A complete understanding of the human anatomy includes knowledge of
122 Proby, J.C. Essay On Osteopathy: Its Principles, Application and Scope.
Osteopathic Institute of Applied Technique (1955), 7. 123 Proby, 7. 124 Proby, 9. 125 Littlejohn, J.M. Osteopathy... Explained. Boston Institute of Osteopathy, (1900), 5.
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the system from the standpoint of “educated touch “, so that proper discrimination may be made
between the normal and the abnormal. The osteopath is trained to excel in the art of touch, to the
extent that one can gain significant insight through delicate manipulation of the human body.
The basis of this highly refined tactile education is found in the physiological structure and
specialized activity of the minute nerve fibers and neuro-muscular organs in the fingers. At the
basis of all the senses lies the essential principle of sensibility, so that in the education of the
senses, this sensibility may be acutely specialized.126
4.6.2 Osteopathy’s role in the future of the medical world
Science is in a constant state of flux, making significant strides with unprecedented regularity,
reaching new heights and making groundbreaking discoveries at an accelerated pace. However,
many of these rapid changes and new discoveries have also been accompanied by much scrutiny;
no science or art more so than that of medicine. The process of rapid change has demanded that
the scientific community address and answer some very important questions. Should osteopathy
become merely a specialty? Should it remain a separate entity developing parallel to general
medicine? Or will its contribution to the facts of disease and therapy eventually be of the
greatest service if osteopathy becomes incorporated into the system of scientific medicine.127
How does osteopathy coalesce with the emergence of EBM?
As a discipline that embraces the complexity model of analyzing the human body and its disease
processes, osteopathy should challenge (but not reject) the logic behind experimental medicine
where research protocols are the norm in defining the legitimacy of therapeutic interventions.
Osteopaths value the fundamental idea that the whole is more than the sum of its parts and are
determined to champion this holistic philosophy. Osteopathy should stand its ground, based on
its beliefs that a thorough understanding and expertise in anatomy, physiology and similar
disciplines are crucial to the successes witnessed in the clinical setting, where, by comparison,
EBM fails to produce similar results in the same environment.
In the realm of health care, one must clearly identify the criteria of scientific merit. To provide a
comprehensive account of the objectives of science, one must accept certain general standards of
126 Littlejohn, 29. 127 Tucker, E., & Wilson, P. (1936). The Theory of Osteopathy. (Kirksville, Mo: The Journal Printing Co., 1936), 8.
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judgement. Good science fulfills these purposes; bad science does not.128 There is no universal
recipe for success for all science and all scientists, any more than there is for all cakes and all
cooks. There is much in science, which cannot be created according to set rules and methods at
all. Even the general nature of science itself suggests a constant state of development. Our
standards of judgment are liable to amendment, and vary from one field of study to another; and,
in some cases, it actually happens that a strong point in one theory turns out – in a different
context – to be a weak point in another.129
Science has numerous aims and endeavours, and its progression has emerged through many
difficult stages. It is therefore futile to look for a single, all purpose “scientific method”; the
growth and evolution of scientific thought depends not on a single philosophy or method, but
rather a broad range of distinctive inquiries. Science as a whole – the activity, its aims, its
methods and ideas – evolves by variation and selection.130
The main focus of science is the search for knowledge and the desire to make the course of
nature not only predictable but also intelligible. This has ultimately given rise to the journey for
making rational observations based on patterns and connections. We are confronted by some
difficult questions, namely “what patterns of thought and reasoning establish scientific
understanding?” and “what factors determine which theories or explanations yield greater
understanding?”131
4.7 Order and disorder
“For many centuries, science has been dominated by the Newtonian and thermodynamic paradigms, which present the universe as either a sterile machine, or in a state of degeneration and decay. Now there is the paradigm of the creative universe, which recognizes the progressive, innovative character of physical processes. The new paradigm emphasizes the collective, cooperative, and organizational aspects of nature; its perspective is synthetic and holistic rather than analytic and reductionistic.” 132
128 Toulmin, S. (1961). Foresight and Understanding: An Enquiry into the Aims of
Science. (New York: Harper & Row Publishers, 1961), 15. 129 Toulmin, 15. 130 Toulmin, 17. 131 Toulmin, 99. 132 Paul Davies as quoted in Morin, E. On Complexity. (Cresskill, NJ: Hampton Press Inc., 2008), xxix.
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The above quote from theoretical physicist Paul Davies highlights a philosophical shift, a
different way of thinking about not only the universe we live in but also with regards to the
entirety of human existence and its emergence within this universe; it is a paradigm shift towards
a more complex perspective, one consistent with the philosophy and teachings of Edgar Morin.
4.8 Edgar Morin – “The Godfather of Complexity”
Edgar Morin (1921) is a French philosopher and sociologist whose work spans many disciplines
(ecology, education, systems theory, media studies, etc.) but it is his transdisciplinary ideologies,
in making the connection between the soft and hard sciences with complexity concepts, that have
influenced readers around the globe. A summary of the Morin’s transdisciplinary concepts are
outlined below:
1. Inquiry-driven: developing knowledge that (a.) relies heavily on investigation and (b.)
has an outcome that will be more active and creative in the world.
2. Construction of knowledge: the underlying assumptions that form the paradigm through
which disciplines and perspectives construct knowledge.
3. Organization of knowledge: to understand the simple thought process derived from
reductionist and disjunctive paradigms; and the gradual shift to a complex thought process
derived from the interconnectiveness of the systems of the world.
4. Integration of the knower in the process of inquiry: to thoroughly understand and
comprehend an individual’s assumptions and thought process and how they evolve and
emerge through the different constructs of knowledge.133
In the world of osteopathic medicine, this transdisciplinary approach makes perfect sense in that
it allows for inquiry and investigation, something performed everyday within the clinical setting
when attempting to solve a patient’s problems and assist the natural healing process of the body.
The osteopath is constantly probing for information by asking questions, and thinking outside the
box within the complex realm of possibility in an effort to provide a differential diagnosis. The
osteopath’s foundation of knowledge and distinct perspective of the patient as “a whole being” is
unique to the health care field, and all-inclusive in its vision and outlook.
133 Morin, xxvi.
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Reductive and/or analytical approaches to health care issues can neither account for, nor provide
sufficient comprehension of, complex and interrelated phenomena. Instead of accepting a
particular finding as “unknown” or considering the possibility of limitations within one’s thought
process, the reductionist will separate or isolate phenomenon from their intrinsic environment
and use the logic of “either/or.” 134
In comparison to many other health care professionals, osteopaths are unique in their approach
and analysis of human health and disease. The philosophy of traditional osteopathy embraces
the realization that with order comes disorder, with equilibrium comes disequilibrium; there is
constant interaction between the two for life to exist and function. Osteopaths practice and
provide care in an integrated manner, one that recognizes the principle of continuity and
contiguity within the human body. The osteopath acknowledges that there is a constant
interaction between two or more opposing variables, enabling life to exist and function. The
human body and spirit have a remarkable ability to organize and reorganize, to heal itself and be
free from disease; osteopathic intervention, combined with patient awareness and participation,
can not only facilitate the healing process but also expedite recovery and enhance patient health.
By leveraging the body’s inherent ability to heal, and in recognition of the body’s constant state
of flux, the osteopath can resolve much of the ambiguity and multiplicity unique to the disorders
experienced by patients and create order so that healthy structure can govern healthy function.
According to Morin:
“We need a kind of thinking that reconnects that which is disjointed and compartmentalized, that respects diversity as it recognizes unity, and that tries to discern interdependencies. We need a radical thinking (which gets to the root of problems), a multidimensional thinking, and an organizational or systemic thinking”.135
The above quote by Edgar Morin epitomizes what traditional osteopathy stands for. At the heart
of osteopathy is the concept of thinking outside the box, in an effort to understand the
complexity behind the interrelationships of the multiple systems of the human body, and
ultimately, to promote optimal health. Morin asks the osteopath to challenge the deeply
ingrained educational beliefs of the traditional medical model.
134 Morin, xxiii. 135 Morin, vii.
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Within this section of the paper, the author will explore the multifaceted paradigm of complexity
thinking and reasoning, examining how this model aligns itself to the critical thinking approach
taken by the traditional osteopath when assessing and treating patients. The complexity model is
often viewed as a “paradigm of simplicity” because it takes a transdisciplinary approach to the
organization of knowledge rather than the traditional reductive and disjunctive approach
common to many health care disciplines. The complexity paradigm challenges many of the
commonly held opinions and beliefs faced by osteopathy and other health care professions with
regards to EBM.
“For the systems theorist, human beings are part of a homogeneous, stable, theoretically knowable, and therefore, predictable system. Knowledge is the means of controlling the system. Even if perfect knowledge does not yet exist, the equation: the greater the knowledge the greater the power over the system is, for the systems theorist, irrefutable.136
The traditional osteopath would concur with Morin’s statement, in its application to the
grassroots foundation with what the profession originally stands for, which emphasizes the
crucial need to learn and develop expertise in all aspects of health and all of the manual therapy
skills that accompany it. The goal of the osteopath here is to internalize the relationships
between the systems of the body, which collectively construct “the whole”: one mind, one body
and one spirit. In today’s osteopathic environment (especially in the United States) this ideology
is commonly considered secondary to the need to justify patient outcomes with a research-based
methodology.
4.8.1 “Blind Intelligence”
Edgar Morin describes blind intelligence as the phenomenon whereby science destroys unities
and totalities. It involves the isolation of all objects from their surrounding environment in an
attempt to better predict, evaluate and quantify human existence. Blind intelligence is the term
coined to describe linearizing complexity to forms of simplicity.137 It is this very concept of
simplification that impacts the medical community through the segmentalization and formation
of hyper-specializations for all of its disciplines. This fragmentation process however does not
apply to the traditional osteopathic philosophy of education and clinical practice (which is the
136 Morin, 248. 137 Morin, 4.
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holistic and comprehensive approach to the human body and its disease processes). The approach
of the practicing osteopath is unique in comparison to other medical disciplines; the osteopath
believes that complexity embraces not only all that is certain, but also all that is uncertain with
life, health and disease. For the osteopath, complexity enables one to view the fabric and
structure of the human body and all of its constituent parts as inseparable and interconnected,
creating “the whole” as an entity that thrives in an ever-changing environment.
Osteopaths view living beings not only as complex systems, but also as open systems. Every
part of the human body, every molecule and every cell undergoes a process of constant change
and renewal even though our physical structure and foundation appear to be the same. Our
interaction with the external environment is intimate and therefore impossible to predict and
calculate under normal circumstances. Methodologically, trying to study open systems is a very
difficult task to conceptualize because there are too many variables to measure in a self-eco-
organizing system like the human body and the world we live in.
There is an interesting paradox that exists between the self-organizing living system and the
simply organized artificial machine. It is the artificial machine where we see reliable elements,
however as a whole, much less reliable than its isolated parts. In fact if you have a mechanical
dysfunction affecting the parts, the whole breaks down. This is not the same reality for the self-
organizing living system, whereby the parts are not as reliable as the whole.138
...“We see that in an organism, the molecules, as well as the cells, die and are renewed, to the point that the organism remains identical to itself even though all of its constituent parts have been renewed. There is, then, as opposed to the artificial machine, great reliability of the whole and weak reliability of the parts”.139
138 Morin, 17. 139 Morin, 17.
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4.8.2 Complexity and self-organization
For centuries, the culture of western science and medicine has been to simplify our complex
world into rudimentary units, with the goal of trying to quantify our health using statistical
calculations. We seek concrete answers to the many questions that we have regarding the
diseases we endure. Complexity science is searching for these very same answers, however it
looks beyond the quantitative methodology and investigates a qualitative point of view, whereby
random phenomenon, chance and uncertainty are embraced and the limits of our ability to make
bold predictions are recognized. The complexity paradigm of thinking is one that embraces
creativity and the self-eco-organized being, whereas classical science rejects the accidental, the
unexplainable, the individual.140 In today’s health care environment, medical practitioners
commonly separate the subject from the object in order to enhance the impartiality of the
information under study.
“The object is knowable, determinable, isolatable, and by consequence, manipulable. It holds objective truth and, because of this, is all for science; the subject, however is the unknown because it is indeterminate, because it is a mirror, because it is foreign, because it is a totality”.141
4.8.3 The paradigmatic turning point
The EBM paradigm that dominates our critical thinking in medicine is both reductionist and
quantitative. EBM is reductionist in the sense that its foundations of reasoning are clear, distinct
and segmentalized. Ultimately, EBM and reductionist science have a “divide and conquer”
mentality that is deemed acceptable in critical thinking forums. EBM is quantifiable because its
method of reasoning and conclusions are reproducible and calculable. This quantitative rationale
and reasoning is designed to maintain equilibrium while limiting contradiction or deviation.
Reductionist thinking wants us to “keep it simple”, to take a complex idea and break it down into
layman’s terms and follow a straightforward path of reasoning. Multiple problems in a system
were and are tackled piecemeal.142 To this day in the medical community, including the
140 Morin, 33. 141 Morin, 25. 142 Ahn, A.C., et al. The Limits of Reductionism in Medicine: Could Systems
Biology Offer an Alternative? PLos Med, 3(6), e208.doi/10.1371/journal.pmed.0030208 (May 23, 2006).
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osteopathic profession, the EBM paradigm maintains a stronghold on the decision-making taught
at institutions of higher learning and practiced in a clinical setting.
In contrast to EBM, the complexity paradigm of thinking, accepts order and disorder, harmony
and disharmony, and the co-existence of the subject and the object. Osteopathic practitioners
who follow the complexity paradigm embrace the uncertainty of life and the challenges that it
brings. It is the commitment to lifelong learning through education and clinical apprenticeship in
manual therapy that allows the well-informed osteopath to interpret a patient’s layers of
dysfunction, and help facilitate their road to recovery and optimal vitality.
Historically, when one is faced with contradiction in one’s reasoning, it signifies error and
minimizes the strength of conviction; however, under a complexity perspective, this same
contradiction opens up the doors for a deeper understanding of our reality that sometimes is
beyond human comprehension.143 The totality of knowledge, the completion of our
understanding, is not plausible, but rather it is ravelled in layers, in depths that cannot be
measured and statistically analyzed. So in essence, complexity theorists don’t want to abandon
the foundations of science and EBM, but rather they want to challenge the unjustified faith
everyone has in the analytical methods.144
Traditional osteopathic thinking shares the viewpoints inherent in the complexity paradigm in a
way that leaves them vulnerable to criticism from the rest of the medical community. The strong
push for quantitative data and the search for answers based on measuring a few interacting
variables within the universe we live in are commonplace in mainstream health care. Yet, while
isolation of the subject from the object and its environment is the foundation for following EBM,
this approach is viewed as unacceptable in the eyes of the well-informed osteopath. Osteopaths
recognize there is almost no predictive value to the complex phenomena of everyday life.
Osteopathy seeks to comprehend the relationships between the many systems of the body and the
intrinsic and extrinsic experiences confronted by patients. It is with this understanding that the
osteopath can provide effective intervention and measure his or her success.
143 Morin, 45. 144 Davis & Sumara, 25.
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New ideas in the field of science, new theories and new discoveries, happen each and every day.
Consider the comparison of an individual grain falling into a pile, where the grain is an idea, and
the pile is the collective knowledge of the scientific community. New scientific ideas are
constantly falling into the “pile” of knowledge. A new idea may stick, and add to the growing
structure, or it may place a portion of the knowledge under such stress that the idea (and other
ideas) will topple. The toppling effect may stop quickly or may run for a long while — the
avalanche has no inherent or expected size. The smallest of scientific revolutions are happening
every day, and may involve only a few key ideas. In fact, much like the single grain, they may
be virtually invisible, just like the tiny earthquakes going on all the time beneath our feet. By
contrast, the largest revolutions may wipe away much of science as we know it, and are liable to
happen at any moment.145
Traditional osteopathy, much like the metaphor of the grain and the pile, recognizes the potential
for rapid and radical change within the scientific community. There is a potential revolution in
our midst as the medical community shifts towards research, technology and testing as the
driving force behind both education and clinical practice.
There are some key principles that govern the osteopath’s approach to the practice of manual
medicine:
• “Comprehensive Generalists”: Osteopaths approach patient care as “comprehensive
generalists”, leveraging a thorough understanding of anatomy, physiology and
pathophysiology, acknowledging all of the interrelated systems of the human body and
the effects that the external world has upon them.
• 10-finger osteopathy: The application of “educated touch” through 10-finger osteopathy
helps the practitioner to assess and treat patients utilizing their palpatory skills. In a
sense, this approach harkens back to the traditional, pre-technological treatment methods
used more than 100 years ago.
• System-based Exercise: The osteopath prescribes system-based exercises as a method of
treatment. For example: ELDOA (Etirements Longitudinaux avec Decoaptation Osteo-
Articulaire) or LOADS (Longitudinal Osteo Articular Decopatation Stretches).
145 Davis & Sumara, 48-9.
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These invaluable skill sets remain extremely relevant and effective to this day. The fact that
osteopaths continues to rely on these methods to improve patient health, sets them apart from
much of the medical community. A quote from the famous American naturalist, conservationist
and author John Muir, serves as a good summary of the osteopathic understanding of treatment:
“when we try to pick out anything by itself, we find it hitched to everything else in the
universe”.146
The following principles fall under the umbrella of the complexity paradigm and help it take
shape as a future model of critical reasoning for the osteopathic profession.
4.8.4 Emergence and self-organization
Edgar Morin defined emergence as “qualities and properties that appear once the organization of
a living system is constituted, qualities that evidently do not exist when they are presented in
isolation”.147 Systems like the human body possess the property of self-organization – the ability
to structure themselves, to create new structure, to learn, diversify, and complexify.148
To the osteopathic practitioner, the principles of emergence and self-organization are
synonymous. When one has taken the time to assess the mechanical and fluidic systems of the
body, has identified the many lesions (primary, secondary, tertiary, etc.) and begins treatment,
one really doesn’t know how the human body is going to respond to the change of input one is
creating. Each patient is unique (and somewhat unpredictable) given that the osteopath may
generate different reactions and/or responses when delivering the same treatment method to
multiple individuals. An individual patient’s “sensitivity” may be unknown for the first few
visits. One cannot predict the number of treatments it may take to resolve any one issue since
each patient is complex and unique, with distinct problems and aliments in terms of acuteness or
chronicity. Emergence and self-organization are remarkable processes that represent a real
opportunity for the osteopath, who can tap into and facilitate the body’s inherent, organic ability
to heal.
146 Davis & Sumara, 57. 147 Morin, 5. 148 Meadows, D. H. Thinking in Systems. (White River Junction, Vermont: Chelsea Green Publishing, 2008), 81.
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The notion of emergence implies that within a complex system of events (and an ever- changing
environment) a critical point will be reached, known as a “critical mass”, signifying that a
transitional phase is reached and a sustainable autocatalytic state occurs.149 What this means to
the osteopathic clinician is that as one assists the body in the healing process, there is a point in
the treatment when the auto-normalization of the body takes over and makes the necessary
corrections and adaptations to maintain the new and improved state of healthy being. There is a
“changing of the guard” if you will, with the mapping or patterning that takes place in the
physical and the neurological systems of the body. Utilizing manual therapy skills and exercise
prescription, the osteopath establishes a mutual interaction and exchange of information with
their patients in an attempt to mould and enhance the plasticity of their body’s self-organization.
4.8.5 Principle of Disjunction
In explaining the Principle of Disjunction, Edgar Morin identifies that separation (between
objects, disciplines and notions, between subject and object of knowledge), should be substituted
by a principle that maintains the distinction, but that tries to establish the relation.150 For the
osteopath, there is a need to accept both the order and disorder that surround us and acknowledge
their interconnectedness. Secondly, one must recognize that if the order and disorder are
internalized, they will inevitably alter the way one views the world in which we live.
4.9 Holism
The term “holistic” was first coined by the founder of the League of Nations, one Jan Smuts, in
the mid-1920s as a means of describing everything pertaining to human behaviour. Smuts’
definition was profoundly and fundamentally different from the prevailing views of the
reductionist perspective. In a sense, Smuts’ “holism” was an antidote to the reductionist
epistemology, which underlies modern scientific thought.151 However under the complexity
paradigm (and for the traditional osteopath), holism represents an ideology that is built into the
very fabric of existence, as a thinking process and a medical discipline.
149 Mason, 33. 150 Morin, 7. 151 Carlson, R.J. Holism and Reductionism as Perspectives in Medicine and Patient
Care. The Western Journal of Medicine, 131 (1979): 467.
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4.10 Fragmentability
The term “fragmentability” pertains to the reduction of systems to their material parts, leaving
recognizable material entities as the end results. A system is not considered to be fragmentable
if something essential about the system is destroyed when it is reduced to its separate parts. The
human body is a classical example of a complex system that has interdependent functional
components, so therefore, by definition, it is not fragmentable.152
4.11 Information-feedback system
Systems of information-feedback control are fundamental to all life and human endeavours.153
Throughout the patient-osteopath interaction process, there is a constant flow of information-
feedback (positive and negative) as various states of disease, re-patterning and re-programming
of the patient’s body transforms their health status.
4.12 Open systems versus closed systems
All living systems of the world, especially the human species, are essentially classified as open
systems whereby there is an intrinsic relationship between the body and the external
environment. These types of dynamic systems require input and output for feedback. Open
systems create an equation of equilibrium and a constant interaction with their surroundings;
inputs and outputs are equal. In contrast, closed systems do not have an interchange with the
environment, but rather they are isolated from the outside world, entirely cut off from external
factors; there is no interaction.
4.13 Resilience
Resilience is the ability to spring back into shape or to return to an original position after being
stretched or pressed. This is also known as elasticity. Resilience is a measure of a system’s
ability to survive and persist within a variable environment.154 Resilience arises from a rich
structure of many feedback loops that can work in different ways to restore a system, even after a
large perturbation.155 The human body is an astonishing example of a resilient system. It can
152 Mikulecky, 108. 153 Meadows, 25. 154 Meadows, 76. 155 Meadows, 76.
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fend off thousands of different kinds of invaders, it can tolerate wide ranges of temperature and
variations in food supply, it can reallocate blood supply, repair sprains and strains, and gear up or
slow down metabolism. Resilient systems are neither static nor constant over time, but rather
they are dynamic.156 During treatment, the osteopath is affecting all of the different systems of
the body, increasing the resilience of the human body, improving its ability to fight disease, and
enabling the patient’s health to flourish.
4.14 Robustness
Robustness is defined by the ability to maintain stable functioning despite various perturbations.
Natural systems such as the human body demonstrate an uncanny ability for robustness, which is
necessary for survival and evolution. Robustness is attained by the mechanisms of feedback
control, structural stability, redundancy, modularity and adaption.157
4.15 Hierarchical systems
All living organisms are arranged in hierarchies. Hierarchies evolve from the bottom up (cell,
organ, organism and so forth). The purpose of the upper layers of the hierarchy is to serve the
functions of the lower layers.158 Osteopaths influence all levels of the human systems’ hierarchy
through local and global intervention, and through mechanical and fluidic treatment. One of the
more common beliefs of the osteopathic profession highlights this hierarchical system; “micro-
movements produce macro-function”.
4.16 Entropy
The term entropy comes from the Greek word “entropia” meaning “a turning toward” and was
coined by Clausius to describe the Second Law of Thermodynamics (discussed previously in this
thesis, under the section on Order and Disorder). Entropy describes the tendency of a closed
system, at equilibrium, to move from a state of higher available energy and asymmetric order
(low entropy) to a state of lower available energy and symmetric disorder (high entropy); most
living organisms generally begin at a state of low entropy and grow in the opposite direction
156 Meadows, 77. 157 Ahn, 7. 158 Meadows, 84-5.
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towards greater order and complexity.159 In other words, entropy is a measure of uncertainty
and/or complexity within a living system. A high value of entropy means that a large amount of
information is needed to describe an outcome for which there is a great deal of uncertainty, and
therefore complexity is high.160
4.17 Ambiguity
One of the most challenging aspects of being an osteopath, and for that matter any health care
professional, is the ambiguous nature of one’s daily work. Providers need to understand that
there are different ways to approach the same problem, that there is no right answer to a
situation, no magic formula for best practice, no assurance that any particular act or practice will
yield the results that we desire.161 Like a detective, the osteopath should approach this ambiguity
as a “missing clue” and enthusiastically pursue the “culprit”, the inherent cause of the patients
aliment; in a sense hypothesizing, speculating as to the underlying reasons for disease processes.
Osteopaths confront circumstances of uncertainty head on and adapt with their unique clinical
knowledge and complex ways of thinking about the body and disease. The osteopath realizes
that when dealing with patients in a time-oriented interaction, new levels of thought emerge and
new insights are created; these insights loop back on themselves and raise consciousness to a
new height.162
4.18 Attractors
Comprehensive predictability is lacking within complex systems. However, patterns of
behaviour do exist, which provide clues about the system. These patterns are referred to as
“attractors” - they have a unique characteristic of reproducibility known as “patterns of points”.
In the clinical setting, osteopathic practitioners recognize attractors and patterns of mechanical
and visceral restrictions that afflict the body and its surrounding tissues, using precision
palpation skills. These attractors go undetected when using conventional diagnostic testing
instruments. 159 Topolski, S. Understanding health from a complex systems perspective. Journal of Evaluation in Clinical
Practice, 15 (2009): 750. 160 Costa-Santos, C., et al. Complexity and categorical analysis may improve the interpretation of agreement studies using continuous variables. Journal of
Evaluation in Clinical Practice, 17 (2011): 512. 161 Doll & Truiet, 846. 162 Doll & Truiet, 846.
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4.19 Linear minds in a non-linear world
Linear relationships are understandable; linear equations, solvable. Linear systems have an
important modular virtue: they can be taken apart and then put back together. The pieces of the
system add up. Non-linear systems on the other hand (generally) can neither be solved nor put
back together. Nonlinearity means that the very act of playing the game has a way of changing
the rules. This factor of odd changeability makes nonlinearity difficult to calculate, but it also
creates rich and abundant qualities of behaviour that never occur in linear systems.163 This
dynamic changeability, with infinite possibilities and opportunities, encapsulates the essence of
how the traditional osteopath views medicinal therapy and treatment. It is with an appreciation
for changeability and an unyielding commitment to challenge mainstream thought, that the
osteopath aims to promote well being amongst their patient population.
4.20 Complexity and clinical knowledge
Osteopathic practitioners view their interactions with the human body as a complex process and
challenge the perception of what constitutes scientific knowledge, research and the application of
the “scientific method”. The results that one interprets from appraising current research need to
bring to light the methods used rather than treating the individual patient with a generalized
approach. The effects of population-based studies and their interventions cannot be considered
as predictable outcomes for individuals. The osteopathic practitioner therefore needs to come up
with new ways that embrace the intimate relationships between individuals, such as the
qualitative methodological approaches, and specifically case study analysis.164
Nicolis and Roughgarden suggest that “Practicing medicine required interpretive skills –
recognising the patterns of symptoms and signs that are the essence of an expert clinical method.
These methods of knowing have more in common with the social sciences, economics and law
than the physical sciences. They believe that we should acknowledge the richness and
complexity of the social interaction that sits at the heart of the therapist-patient relationship and
move away from measurement and reductionist methods”.165
163 Meadows, 91. 164 Sweeney & Griffiths, 69. 165 Sweeney & Griffiths, 70.
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4.21 Suggestions for Complexity research methods
Under a complexity paradigm of thought, osteopathy should adopt a research methodology that
includes: case studies that are qualitative, participatory, multi-perspective and collaborative (self-
organized) and partnership-based forms of research, premised on interactionist, qualitative and
interpretative accounts.166 This framework highlights the “new science of qualities” alongside the
current trend of quantities and is therefore relevant to the osteopath. The reason for having a
distinctive set of research criteria (different from the protocols currently being used) is that under a
complex system, too many variables co-exist and cannot be sufficiently or accurately portrayed under
the current modelling system of research.
When conducting research about osteopathic manual therapy, its interventions and treatment results,
one has to understand the broad scope of its intentions. Osteopaths view the human body, mind and
spirit as an open system, one that provides feedback, is adaptable, capable of self-organization, and
emerges towards a state of optimal health. Osteopaths know that when one treats a patient’s disease
states under a complexity system, the inevitable occurrences of change, unpredictability and
disequilibrium should be embraced in order to optimize survival. In addition, clinical osteopathic
practitioners who apply “complex adaptive systems” to treat patients understand the need to balance
the intrinsic systems of the body while accounting for any adjustments by the extrinsic environment
that influence the body. Traditional osteopaths who view the human body as a collection of interrelated
systems, which are evolving, dynamic, mechanical and fluidic, understand that under an EBM
paradigm, the manipulation of variables in a controlled environment does not provide an accurate
depiction of clinical results and can consequently be very misleading.
Therefore, as a measure to improve the research methodology behind studying human endeavours, the
author has outlined a few suggestions that might be more appropriate in capturing the essence of the
osteopathic-patient encounter.
Qualitative study design: Complexity research methodology focuses on small groups of individuals,
attempting to capture the richness of individual experiences.167 Supporters of quantitative studies
criticize the qualitative study design for not being generalizable across large population domains.
166 Mason, 3. 167 Mason, 153.
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However, since the traditional osteopathic practitioner assesses and treats each patient as a unique case,
the “bottom up” results of qualitative studies (as opposed to “top down” results) are the preferred
method of reasoning. The individual human being is thought of as a dynamic system, where genetic,
environmental, biological, sensory, emotional and conscious processes all continually work together to
keep the person healthy.168
Cross-sectional and comparative analysis: These forms of analysis are used to identify important
types of patterns and linkages and outline the flexibility of the variables and measurements being
studied.169
The application of complexity research and forms of thinking (and deduction outright) challenges the
“gold standard of research methodology” with randomized controlled trials. Classical experimental
methods, abiding by the need for replicability and predictability, may not be entirely accurate and
advantageous since, in a complex world with complex phenomenon, results are never clearly replicable
or predictable.170 To atomize phenomenon into measurable variables without embracing multiple
interacting elements, is to miss synergies and the significance of the whole.171
Complexity offers principles; it does not substitute for thoughtfulness. Complexity presents additional
or alternate ways of thinking about the organization of the world, while simultaneously pointing to the
impossibility of accuracy in knowledge and prediction. The author believes this is one of its greatest
advantages. By engaging the paradigm with an open mind, complexity can foster reflection and
thoughtfulness, to the benefit of both the patient and osteopath. By accepting complexity as conceptual
and theoretical, one can engage in an imaginative, creative process that enables the osteopath to convert
complex ideas into particularities. Complexity does not offer tried and true research “recipes”, but
rather a framework to consider alternatives and ask meaningful questions. Through a researcher’s
engagement with complexity, in combination with a detailed osteopathic intervention and researching
preferences, one can evolve appropriate complexity-informed research approaches and strategies.172
168 Mason, 160. 169 Mason, 154. 170 Mason, 25. 171 Mason, 25. 172 Mason, 177.
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Table 5
Key features of a Complex system
COMPLEX SYSTEMS - KEY FEATURES
1. Consist of multiple components. These systems are only understood by observing the rich interaction of these components, and not merely understanding the system’s structure.
2. The interaction between components can produce unpredictable behaviours.
3. Have a life history and are sensitive to initial conditions or patterning.
4. Interact with and are influenced by their environment.
5. The interactions between elements of a complex system are non-linear. Small inputs may have large effects, and vice versa. It is this nonlinear interconnectivity that places fundamental limitations on one’s ability to validate the models of complex systems.
6. Interactions between elements of the system generate new properties, called “emergent behaviours” of the system, which cannot be explained by studying the elements of the system.
7. Emergent behaviour cannot be predicted.
8. Are open systems: when observed, the observer becomes part of the system.
9. The elements of complex systems interact dynamically by exchanging energy or information.
10. Operate at conditions far from equilibrium.
11. Have memory or history that is captured at both microscopic and macroscopic levels.
12. Have no boundaries. Boundaries are inferred only as a way to allow one to begin to make sense of one’s surroundings.
13. Are incompressible, that is, it is impossible to have an account of a complex system that is less complex than the system itself without losing some of its aspects.
173 174 175
173 Sweeney & Griffiths, 2. 174 Cilliers, P. What Can We Learn From a Theory of Complexity? Emergence 2(1) (2000): 24. 175 Richardson, K., et al. Complexity Science: A “Gray” Science for the “Stuff in
Between”. Emergence, 3(2) (2001): 7-8.
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4.22 Summary of Complex systems
The patterns of complex systems represent dynamic components and resultant interactions that
are unpredictable. The whole is irreducible and the cause and effect cannot be separated because
they are intimately intertwined and highly contextualized. Unlike “best practice” models,
complex systems acknowledge multiple layers of dynamic knowledge. Such knowledge cannot
validly and reliably be organized into simple or complicated “evidence-based guidelines”.176
The practice and philosophy of traditional osteopathy embraces this dynamic approach known as
complexity. Osteopathy internalizes the belief that our existence and our environment are ever-
changing and active, never static. Too many of life’s tangible and intangible variables (work,
stress, finances, etc.) impact our physical, psychological and spiritual well-being to be accurately
represented and quantitatively predicted by population-focused research criteria.
“There are no easy answers or simple solutions, because complexity science, by design, does not pretend to offer them. Instead, it offers diverse avenues for discovering what may end up being a multiplicity of answers that are differentially sensitive to and grounded in specific circumstances, conditions, people, times and places. Therein lies the real promise of the complexity science tapestry”.177
4.23 The 10 principles of Complexity and how they relate to the osteopathic profession
1. Self-Organization: The tendency to spontaneously create order. It cannot be
predetermined in any quantifiable way, or even planned, but it has a definitive impact on
the healing process of the body.
2. Emergence: Is the property of complex systems through which self-organization takes
place.
3. Connectivity: There are varying degrees of connectivity. Not all connections are
equally strong. Yet all of the systems of the body (barring certain disease states) are in
continuity and contiguity with each other. One of the objectives of the osteopathic
practitioner is to facilitate this interconnectedness.
176 Martin et al, 416. 177 Richardson & Cilliers, 17.
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4. Interdependence: The connectedness of the body causes the systems to be
interdependent on each other. This influence is both internal (within the body) and
external (caused by the environment).
5. Feedback: In complex systems, small perturbations can amplify to cause a huge impact.
Alternatively, relatively large perturbations may have minimal impact. This reciprocal
feedback system underscores a famous osteopathic saying “micro-movements produce
macro-function”.
6. Far from Equilibrium: The world around us is constantly changing or at least requires
significant effort to be kept the same. This effort does not refer to maintenance, but
rather the effort required to manage or avoid change.
7. Space of Possibilities: Complexity suggests that to thrive (not just survive), an entity
needs to explore its options and generate variety. Complexity theory also proposes that
the search for a single “optimum” strategy may neither be possible nor desirable. In a
complex system like the human body, it is not possible to explore all possibilities that are
available. Quite simply, there are always more possibilities than what we have time to
explore.
8. Co-evolution: A process whereby every entity constantly undergoes an evolution to a
new order, irreversibly changing. To initiate change, something as complex as the human
body does not require intervention. It is constantly evolving to new order through co-
evolution.
9. Historicity & Time: The body has a memory, a history of its experiences. These
memories, both positive and negative, are deep-seated and evolve over one’s existence.
Some of these experiences are easy to adjust and influence, while others are more
difficult to change.
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10. Path dependence: Over time, the decisions people make can have an impact that will
determine whether certain courses of action are possible. Past choices define future possibilities
and options. There is however a degree of unpredictability along this path.178
4.24 Osteopathic research
For the osteopath working in the community alongside other manual therapists and medical
practitioners, the EBM paradigm appears to be streamlining decision-making and patient care.
All of these disciplines are moving towards standardization of care models and research
protocols that try to validate the efficacy of their treatment interventions. Although this initiative
seems straightforward and just, the conclusions that are drawn from these population-based
studies are very often inconclusive.
Traditional osteopaths understand the limitations of the EBM methodology and would rather are
inclined to adopt a more holistic approach to understanding disease, human strife and struggles;
in essence accepting that diversity of expression is what complexity embraces and what
reductionism ignores. Reductionism dismisses the circular interplay between the material body
and the impalpable mind, spirit, feeling, and belief.179 Throughout this paper, there has been a
recurrent theme outlining the dominance of objective, quantifiable and reproducible
methodologies that have taken precedence in osteopathy and the rest of the medical disciplines
around the world. The subjective experiences, the immense and unique constellation of factors
in and around the patient, are often seen as too “soft” for the scientific community; yet rather
favour linear causality – one way cause-effect relationships.180 It is this segmentalized
framework within the reductionist paradigm that fails to meet the requirements of osteopathic
research. The totality of the human systems, their interactions, their interconnectedness
(physical, chemical, mental, emotional, social and environmental) is what research studies
should embrace if they are to stay true to the roots of the founding fathers of osteopathy. What is
more, when the human body is restored to its context, new light is cast on each part: properties,
178 Van Thinking 10-day Online Course on Complexity Thinking. 179 Korr, I. M. Osteopathic research: The needed paradigm shift. JAOA, 91(2) (1991): 162. 180 Korr, 162.
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functions and interactions emerge that are not evident in isolation but only realized as a whole
unit.181
One of the major creeds of the osteopathic profession is “the body’s powerful ability to heal
itself”. A body comprises all of the homeostatic, defensive, and healing functions, the capacity
for self-repair and regeneration.182 It is the role and responsibility of the osteopathic healer to
support these natural functions of the body so that the patient can heal naturally, from the inside
out. It is these intrinsic mechanisms present within the human body that allow for the recovery
from disease, a process that osteopaths attempt to complement. This key understanding of the
body’s wholeness, and its natural abilities to recover, is at the core the very definition of
osteopathy, especially in comparison to other health care providers. It would seem logical then,
that our research design methods should embrace these very ideas.
4.25 Study design
A study design is needed that can accurately assess the effect of treatment, the impact that
treatment has on the total person and make possible comparisons with other systems of care.183
Most clinical trials are designed to assess the effects of therapy on a given clinical problem. The
therapy however, is often so uniform and standardized that its effect is hardly, if at all,
influenced by the person who prescribes or administers it. It matters a great deal, however, who
administers the osteopathic intervention, when one considers the experience, training, treatment
techniques, choice of diagnostic reasoning, etc.184 This variability is further compounded by
variation in response, not only between individual patients but also between visits, and even from
moment to moment as the osteopath treats and assesses tissues, considers a patient’s responses
with to each technique, and then selects and applies succeeding manoeuvres accordingly; there is
a feedback system between patient and therapist at all times, a “silent dialogue” in which each
responds to the other’s changing input.185
In traditional clinical trials, the methodology behind randomization of patients is that they are
representative of the existing population. Subjects are then divided into experimental and control 181 Korr, 162. 182 Korr, 162. 183 Korr, 167. 184 Korr, 167. 185 Korr, 167.
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groups; this is the foundation of how the study is designed and compartmentalized. This format
attempts to compensate statistically for unavoidable sources of ambiguity, such as the variability
scenarios in the underlying effects of therapy intervention described above. Ironically, it is these
unpredictable variations in the patients’ responses (or lack of responses), from one treatment
session to another, which osteopathy endorses as changes that must be embraced in the ongoing
search for a more representative research style.
Another inaccuracy that should be highlighted from the osteopathic perspective is the arbitrary
and spontaneous improvements and recovery that sometimes occurs in patients, in the absence of
treatment.186 To compensate for such occurrences, a placebo or sham treatment is administered
to the members of the control group, who are matched as closely as possible (by age, sex, clinical
status, etc.) to the experimental group, who are in fact receiving the real treatment intervention.
Both groups of patients and their evaluating research staff are “blinded” from the group
allocation process and the treatment application (i.e. who is getting what?).187 In any case such
as this, the “placebo therapy” appears to be virtually identical to the real therapy and a
favourable response by the placebo group to the placebo therapy is deemed the “placebo effect”.
This has to be taken into statistical consideration in the assessment of efficacy of the treatment
being tested.188
To the traditional osteopathic practitioner, the response to the placebo effect” (or any noted
improvements by patients to the sham intervention) is still an active response of the patient’s
intrinsic healing mechanism and is a very complex and interesting phenomenon that is difficult
to explain and rationalize. These positive effects can be justified by the numerous intangibles
that occur within human species including their dynamic emotional and spiritual beliefs. For
example, confidence in the treatment protocol, optimistic attitudes and belief structure, positive
outlook, faith and hope are all factors that cannot be discounted within the complex realm of
healing. The osteopath must acknowledge and embrace the possibility that each individual
patient is capable of such “natural” potential. Osteopaths want to encourage these and other very
real emotional experiences and not suppress them simply due to their ambiguousness. A manual,
hands-on relationship with the patient throughout the treatment process is of optimal importance
186 Korr, 167. 187 Korr, 167. 188 Korr, 167.
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to the osteopath. The palpation and intimate physical and social contact, the direct
communication (both verbal and non-verbal), the confidence factor elicited by both parties, in
particular by the experienced practitioner, are all of vital importance and yet, they are changeable
and unpredictable from one treatment session to another. Therefore, that which is regarded as a
nuisance and source of error from one perspective is viewed as an essential source of clinical
results from the osteopathic perspective.189
How can one objectively measure all of these intangibles that are of extreme relevance within a
research study? Is it possible? It is here that there exists a very real dilemma for osteopaths who
are pressured to “show efficacy” to the rest of the medical community, so that it can be analyzed
and likely scrutinized.
It is widely believed that to properly measure osteopathic treatment interventions, there should
be changes to study design, which can be tailored to what is actually occurring in the clinical
setting. The design has to somehow incorporate the patient-therapist interaction and ongoing
relationship since this is integral to the underlying success of the treatment. This cannot be
separated, blinded, and/or mathematically calculated because too many uncontrolled variables
exist within a one-to-one interaction, let alone multiple patient interactions. This is the reality of
the clinical environment in which the osteopath operates. Therefore, in order to have an
experimental study design that reflects the true treatment environment of the practicing
osteopath, some realistic suggestions have to be presented for discussion:
1. Use of case-by-case studies that focus on the individual patient-therapist interaction and
results.
2. Osteopathic techniques and manual hands-on interventions cannot be standardized and
uniform; their “dosages” cannot be confined.
3. The “placebo response” is an important factor, an inseparable aspect of the patient’s
changing profile towards the osteopathic care they are receiving.190
In consideration of the obvious constraints that exist with designing research in line with the
reality of osteopathic practice, there are a few models that may be better aligned with this
189 Korr, 168. 190 Korr, 168.
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particular medical discipline. The first is the Medical Outcome Study (MOS). In the MOS, there
are six categories of criteria for clinical outcomes, each of which includes a number of
quantitatively assessable items that are collectively amendable to a high degree of reliability for
statistical analysis:
• Physical functioning (ability to perform a variety of physical activities).
• Role (ability to carry out daily activities such as housework, vocational work).
• Socialization (ability to conduct social and group activities, visiting with friends).
• Mental health (general mood or affect, sense of well-being).
• Health perception (self-rating of current health in general).
• Bodily pain.191
Other research protocols and designs that are worth investigating and encapsulate the complexity
behind osteopathic reasoning are intra-subject (so called “N of 1”) and inter-subject designs
involving smaller sample sizes of individual patients or emphasis on a clinical trial involving a
single case study.192 Lastly, if a comparison study wants to be conducted involving traditional
osteopathy and allopathic medical care then longitudinal studies on comparative outcomes, such
as incidence of minor illnesses and disabilities and of various diseases, degrees of recovery, etc.
would be of great interest and value.193
4.26 Osteopathic education
Academic institutions offering courses in osteopathy typically follow one of two paths: They
either adopt an EBM philosophy and this paradigm is deeply integrated into the practices and
teachings (i.e. those offered at many universities and private colleges) or they implement the
complexity paradigm as the preferred approach to osteopathy (i.e. such as that offered through
the Académie Sutherland d’Ostéopathie du Québec). Complexity science offers an antidote to
the fragmentation of professional health education; it provides a different way of understanding
the medical practice, and the education process that is essentially preparation for that practice.194
191 Korr, 169. 192 Korr, 169. 193 Korr, 169. 194 Mennin, S. Complexity and health professions education. Journal of Evaluation
in Clinical Practice, 16 (2010): 835.
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“Educators in all fields need to rethink not only the model used for instruction but also the “very concept of model”. Some prefer the dynamic, ambiguous interplay of complex events that draw more on metaphor than on model. Where models provide a single representation, metaphors provides alternative ways of understanding that hinge upon the unique conditions of each situation and the participants and objects involved. Ambiguity is necessarily embraced as a fundamental aspect of complex systems, of the messiness of “lived” experience, rather than as something to be eliminated or controlled”.195
Each practitioner has their own unique style of grasping concepts, retaining and duplicating
medical information and applying the information in a clinical practice setting. However, the
context and the actual learning process in osteopathy have to be dynamic, collaborative and
productive. The problem-based tutorials commonly taught in many academic institutions today
are a prime example of this dynamic approach to learning. That being said, the author is of the
opinion that more emphasis should be given to the craft, art and science of osteopathy, more
approaches provided that encourage students to think differently, to think “outside the box”; the
ability to integrate (in a meaningful way) all of the information pertaining to the systems of the
body and their unique interrelationships, is a key component of an osteopath’s success when
solving the many problems that can afflict human life.
Osteopaths are health care professionals who think differently, do things differently and bring
different approaches when looking at the injuries of the body. Traditional osteopaths are trained
to process information and examine for causation and not to focus solely on patient
symptomology. These differences are integrated as an emergent property in reasoning and
understanding of self-organization (in terms of a patient’s health and as a healing practitioner).
The author has experienced first-hand the positive influence of both problem-based and group
tutorial sessions as effective means of learning the medical concepts pertaining to disease and
dysfunction. However, in some cases, there was a strong EBM component to this learning
process, which unfortunately proved to be very ineffective in streamlining favourable evidence
towards therapeutic interventions. It is time to take this group learning format and integrate a
new conceptual shift by allowing complexity science and paradigms of thinking to gain
pedagogical traction and have a positive influence on schools of osteopathy.
195 Mennin, 835.
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Chapter 5: Comparing EBM and Complexity models of low back pain
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5.1 Appendix A - Osteopathic manipulative treatment for low back pain: a
systematic review and meta-analysis of randomized controlled trials.
It is the intention of the author to clarify the differences in logic and reasoning between the
osteopath following the EBM philosophy versus the one following that of complexity thinking.
In this chapter, the author will review one of the most common clinical conditions encountered
by osteopaths, low back pain. The author will compare and contrast the EBM and Complexity
approaches, their unique interpretations of the condition, and ultimately the inconsistencies of
their findings. See Appendix A or visit http://www.biomedcentral.com/1471-2474/6/43 to
read the article.
5.1.1 Critical appraisal checklist for systematic reviews
This critical appraisal checklist for systematic reviews is used as a guideline for the health care
professional to evaluate the validity and reliability of the research articles; ultimately, to make
the determination as to whether the collaborative results of the studies support a clinical
intervention that can be effectively utilized for patient care.
Are the results valid?
QUESTION YES CAN’T TELL NO Did the review explicitly address a sensible clinical question?
Yes – to assess the efficacy of OMT (osteopathic manipulative technique) as a complementary treatment for low back pain.
Was the search for relevant studies detailed and exhaustive?
Yes – search strategies (timetables, databases and search terms) were clear and outlined in an on-line appendix.
Were the primary studies of high methodological quality?
Yes – six randomized controlled trials (RCT’s) of OMT were included.
Were assessments of studies reproducible?
Yes.
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What are the results?
QUESTION YES CAN’T TELL NO Were the results similar from study to study?
Yes – OMT significantly reduced low back pain.
What are the overall results of the review?
OMT is an effective tool for the treatment of low back pain.
How precise were the results?
Confidence interval of 95% for short-term, intermediate-term and long-term follow up. Both best-case and worst-case scenarios demonstrated a greater reduction in pain with OMT. The meta-analysis results are quite robust as indicated by the comprehensive sensitivity analyses.
How can one apply the results to patient care?
QUESTION YES CAN’T TELL NO How can I best interpret the results to apply them to the care of patients in my practice?
Taking manual therapy courses in osteopathic spinal manipulation is an effective tool to have in treating low back pain.
Were all clinically important outcomes considered?
Yes.
Are the benefits worth the costs and potential risks?
The benefits of OMT were outlined for low back pain.
Potential risks were not outlined.
196 197 198
196 Critical Appraisal Skills Programme (CASP), Public Health Resource Unit, Institute of Health Science, Oxford. 197 Oxman AD, Cook DJ, Guyatt GH. Users’guides to the medical literature. VI. How to use an overview. JAMA 272 (1994): 1367-1371. 198 Oxman AD, Cook DJ, Guyatt GH. Users’ guides to the medical literature.1E. Summarizing the Evidence. AMA (2002): 155-173.
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Additional critical appraisal information not outlined in the critical appraisal checklist:
Advantages
• Exclusion criteria / eligibility criteria was provided.
• Each eligibility trial was independently reviewed by two of the researchers in order to extract data on methodological characteristics. Conflicting data were resolved by consensus.
• Potential study limitations were outlined and accounted for.
• Study was not funded by party of interest.
Disadvantages
• No clear definition/description of what Osteopathic Manipulative Treatment (OMT) entails.
• Confusion as to the type of spinal manipulation used (distraction, translation, extension, flexion techniques).
• Confusion as to what defines low back pain (lumbar spine, sacroiliac, pelvic, sciatica, hormonal).
• Inter-rater reliability issues with regards to treatment intervention (different osteopathic practitioners, from experienced clinicians to students).
• The study didn’t discuss the risks and or benefits of OMT.
5.2 Understanding osteopathic philosophy and reasoning and applying it in clinical
practice
To grasp the true essence of the osteopathic profession, it is important for one to embrace the
teachings of Andrew Taylor Still, the founder of osteopathic medicine. Still believed in the
philosophy of a solid foundation in anatomy and physiology as the basis for sound medical
practice. He emphasized the importance of the intense study of the “human machine”.199
Practicing osteopaths generally agree that there are a handful of crucial beliefs that distinguish
them from other health care professionals: 199 Northup, G.W. A compilation of the thoughts of George W. Northup, DO, on the philosophy of osteopathic
medicine. JAOA, 98(1) (1998): 53.
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• The body is a unit; the person is a unit of body, mind and spirit.
• The body is capable of self-regulation, self-healing and self-maintenance.
• Structure and function are interrelated and interdependent.
• Rational therapy is based on an understanding of the body unity, self-regulatory
mechanisms, and the interrelationship of structure and function.
• Motion is the chief means for maintaining physiological harmonies. The motion and
activity of every cell and every organ in the body have rhythmical movements.200 201
5.3 Osteopathic reasoning using a Complexity paradigm of thinking for patients with
low back pain
Traditional osteopathic clinicians who practice under the umbrella of the complexity paradigm
have a very methodical examination process when assessing and treating patients, possibly one
that is more thorough than health care providers in many other disciplines. First and foremost,
osteopaths have a temporal relationship that is critical to their success, in that they allocate a
significant amount of time to the patient-therapist encounter. Depending on the dysfunction or
disease state that the patient is experiencing, the osteopathic practitioner will typically allocate
between 45 minutes and 1 hour of assessment and/or treatment to facilitate in the healing
process. In addition, the scope of the relationship is holistic and comprehensive. Consider the
following example of a typical osteopathic examination (using the complexity paradigm) of low
back pain and the rationale applied to treat the patient:
5.3.1 Subjective assessment
It is common for health care professionals who practice manual medicine to ask their patients
detailed questions, as a means to investigate potential sources of a disease or dysfunction (i.e.
location of pain, current and past pain patterns, mechanism of injury, VAS – visual analog scale
for measuring pain intensity and irritability, aggravating and easing factors, etc.). However, the
osteopath will go beyond peripheral investigative techniques, performing a more elaborate
assessment, one that includes an evaluation of the 11 systems of the body. Following the 200 Northup & Peterson, 53. 201 Lyne, S.T. Osteopathic Philosophy of the Cause of Disease. JAOA, 100(3) (2000): 181-2.
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rigorous methodology of the complexity paradigm, the osteopath is often able to discover the
root cause of various disorders not typically considered by many other medical disciplines or
found using diagnostic technologies. For example, surgical interventions such as hysterectomies,
C-sections, appendix and gallbladder scars may be linked to visceral restrictions that cause many
of the hidden pelvic and spinal disorders. Osteopaths are always digging beyond the surface for
information from the patient’s past, even as far back as their birth, to determine if any of their
“life experiences” can shed light on the holding patterns that contribute to their dysfunction. In a
sense, the osteopath views the patient much like one would view an iceberg, where only a small
amount is visible on the surface, but a huge percentage of the whole remains out of sight.
5.3.2 Objective assessment
When it comes to the objective assessment and the physical palpatory exam (some refer to this as
the beginning of the 10-finger osteopathy experience), the osteopath will often evaluate the entire
body, from head to toe. Osteopaths are less concerned with the symptomology of the patient and
more focused on causation, the culprit(s) behind the symptoms, and not the effect itself. During
a thorough low back examination, the osteopath will perform an in-depth assessment of the
descending and ascending forces that act upon and influence the body’s centre of gravity. One
will perform weight-bearing and non weight-bearing assessments of the pelvic axes (22 in all)
for quality of sacroiliac, pelvic mobility and alignment. This manual therapy approach is a true
osteopathic expression of complexity thinking based upon a theoretical and biomechanical
model. All of the biomechanical links above and below the pelvis are assessed using active and
passive movement techniques to rule-in and rule-out articular asymmetries. All fascial and
connective tissue chains are evaluated for length, tension, suppleness and pliability (i.e. 9 chains
in the lower appendages and 9 in the upper appendages, all converging with each other and
connected to the framework of the body trunk proper). In addition, the osteopath will perform an
evaluation of the four diaphragms of the body, (pelvic, thoracic, cervico-thoracic and cranial)
and their connections with the viscera of the abdomen and thorax.
5.3.3 Treatment of low back pain
Depending on what is discovered during the objective assessment, the osteopath will determine
the optimum course of treatment. Cases of low back pain are commonly caused by a pelvic
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dysfunction or sacroiliac mechanical restriction with accompanied visceral and fascial
immobility. In such cases, the osteopath can provide various manual therapy techniques such as
osteo-articular pumping and mechanical and fluidic visceral normalization to restore the normal
physiology, alignment and mobility of the pelvis and the body in general. After each treatment
session, reinforcement exercises (i.e. ELDOAs, MFS) are given to the patient to facilitate the
auto-normalization process of healing.
5.3.4 Conclusion
Each patient that seeks treatment from a traditional osteopath will typically receive some
variation of this detailed assessment in order to comprehensively evaluate the patient’s “being”
(i.e. how they are living in their body). Information pertaining to all aspects of “the container
and its contents” is then interpreted to determine what follow-up treatment intervention strategies
will be performed. This process (or one similar) is completed for each treatment session in order
to evaluate the progression of the patient with each organic intervention. This detailed
preliminary analysis, which is part of the initial assessment, integrates the complexity process of
thinking in a manner that is specific to the osteopathic clinician and the unique systematic
methodology they are trained to perform. The complex osteopathic methodology, including the
deduction of how a physical body, comprising many different yet interrelated systems, can be
examined using palpation skills and an exhaustive expertise in anatomy, physiology and
pathology, is very unique to the health care profession. In the opinion of the author, the
complexity paradigm deployed by the osteopathic practitioner is one of the most thorough
approaches to manual therapy analysis that exists today in the world of medicine.
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Chapter 6: Conclusion
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6.1 Conclusion
There has been no substantiated article (published or otherwise) showing the superiority of the
EBM approach or paradigm of thinking for the field of osteopathic medicine. In order to qualify
as a “paradigm”, EBM would need to develop a theoretical structure with explanatory power and
extensive empirical corroboration, which it has not done.202 Osteopathy, with its unique
understanding of all the interrelated systems of the body, is a profession that also recognizes the
importance of the various intangibles that are so vital to successful medical treatment (i.e.
listening, compassion, reassurance and empathy for patients’ hopes, fears and anxieties).
Unfortunately, many of these key factors are neglected by EBM in a clinical practice setting. In
today`s current paradigm of EBM reasoning, scientific judgement and experimentation are the
main objectives. The dominance of this method has led to a “devaluing of the personal” and the
desire to develop formal mechanisms for making all serious decisions.203 This is not only
depersonalizing the provider-patient relationship, but also abandoning a valuable part of the
treatment equation. This is a common sentiment amongst those traditional osteopathic
practitioners who look beyond the studies and trials that try to generalize outcomes for individual
treatments and interventions. The osteopathic community is fully aware of the gap that currently
exists between the recommendations of EBM and what actually occurs on a daily basis in a
clinical practice. Osteopaths use a case-by-case reasoning process, exploring the nuances of the
patient, rather than a generalized global perspective, which often has no relevance to individual
circumstances. The following comparison of the practicing clinician and the practicing
statistician clarifies the polarity of the two methods:
“The mind of the doctor quoted and the mind of the statistician quoted – the first is concerned to make a decision in the interest of the individual patient, whereas the second appears preoccupied with the concept of ‘patient groups’. The first is worried about the fallibility of scientific knowledge and possible heterogeneity by personal identity, whereas the second denies any heterogeneity until ‘proven’ otherwise... the doctor is not sure about his treatment decision for a single
202 Miles et al, 622. 203 Miles et al, 625.
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patient and the statistician has no doubt about how all patients should be treated”.204
It is the opinion of the author that one of the key problems that still exist today is the reluctance
of EBM to alter the “hierarchy of evidence” criteria, keeping the “gold standard” of RCTs as the
primary protocol to follow while other methods, such as expert opinion are at the bottom of the
list. What seems like “best practice” for a statistician or epidemiologist does not have the same
“criterion of validity” for the traditional osteopathic clinician; to the former, medicine is a
deterministic science that strives to be “black and white”, while for the latter, medicine is a
science and an art form that celebrates the many unpredictable and emerging shades of grey.
It would be constructive for health care professionals to look at science as the currency of their
discourse, sometimes the strongest weapon in their armoury, and at other times a wolf in the
sheep’s clothing of evidence-based medicine.205 Much of what we have learned about the human
body, its processes, diseases, treatments and interventions, is based upon a reductionist
philosophy dating back to the 16th and 17th century. Interestingly, complexity thinking,
considered by many traditionalists to be a “new” paradigm, has been around for far longer than
most of the medical community can appreciate (100 plus years); it has done so outside the
spotlight of mainstream medicine. Still, there is a common misconception that complexity is a
philosophical problem and not a scientific one. In a bizarre way, this is both true and false.
Complexity reasoning has a philosophical background, often enveloped in chaos and difficult to
comprehend and express and yet under scientific inquiry, firmly embraced in the annals of
medical ideology (studying the intricacies of the body is an extremely complex endeavour). The
intelligence of the complexity paradigm is apparent in its ability to explore the field of
possibilities, without restricting it by what is formally probable.206 Complexity invites us to
reform, even revolutionize our way of thinking and question our thought process, especially in
the field of manual medicine.
Throughout this paper, the author has identified that reductionism and linearity have served the
scientific community well. The application of complexity paradigms of thinking is not an
argument against EBM. It is possible to embrace the world of research and apply it to the
204 Miles et al, 629. 205 Sweeney & Griffiths, xi. 206 Morin, 25.
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complex world we live in. Utilizing the best available evidence to support an intervention
largely based on clinical expertise is wise, however in a clinical setting, the results of EBM apply
only to a small percentage of the osteopath’s patients.207 Within the many disciplines of health
care, providers all remain disciples of Descartes and Newton (at least to some extent), relying on
the linear notion of causality and separating the mind from the body.208 Despite our criticism of
the EBM paradigm of thinking within the field of medicine, especially osteopathy, there is no
doubt as to their influential role in the medical advances spanning many centuries.
There is an urgent need in the medical field to address the health status of the individual person
as a “whole” being. Health, sickness and suffering are all part of the essence of the human
being; osteopathic clinicians who have been trained to treat and take care of the whole person
know that we embrace all of the dimensions of the human person: physical, psychological,
spiritual and social.209 It is the responsibility of the osteopathic profession to re-introduce within
medicine the person-centred, holistic model of care that was ingrained within the traditions of the
field before the advent of biomedical reductionism in medical theory and practice and its over-
reliance on science in the overhaul of patient care.210
In today’s day and age, there is a prevailing obsession with statistics and numbers, placing
greater value on what can be measured and “proved” than on what cannot be quantified.
Quantity has taken precedence over quality.211 There is something in the human mind that is
attracted to straight lines, not curves, to whole numbers, not fractions, to uniformity, not
diversity, and to certainties, not mysteries.212 The manual practice of traditional osteopathy
encourages curves and fractions, avoids making assumptions and discourages cutting corners
when it comes to patient management and facilitating the healing process.
“What we need is not better research data but better philosophy... we need to rediscover or remember what we know about the healing craft that is not tied to a specific context”.213
207 Sweeney & Griffiths, 71. 208 Sweeney & Griffiths, xxi. 209 Miles, A. Towards a Medicine of the Whole Person – knowledge, practice and
holism in the care of the sick. Journal of Evaluation in Clinical Practice, 15 (2009): 888. 210 Miles, 888. 211 Meadows, 175-6. 212 Meadows, 181. 213 Sweeney & Griffiths, 164.
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Osteopaths need to remember their roots and re-evaluate what skills contribute to their unique
ability to heal. Under the large and diverse umbrella of medicine, there are numerous disciplines
of healing but all providers share a common goal: to promote optimal health and freedom from
disease. The question the author proposes is this: “What ‘medicine’ exactly is being alluded to
in the term “evidence-based medicine?” It appears that all facets of clinical medicine, including
osteopathy, are under the microscope of EBM, specifically those practitioners who are involved
in therapeutic interventions. However, there are several other areas of medicine that are exempt
from this EBM validation arena such as biology, chemistry, genetics and several other
disciplines. Should osteopathy be added to this list of exceptions to the rule of EBM?
The more one investigates, the more one is left with many questions pertaining to EBM. Is
“evidence-based medicine” merely convenient vernacular, a catchphrase for the medical field?
Is evidence-based medicine truly a definitive shift from one paradigm to another? And if so,
does such a shift represent a progression, a regression or a conversion? According to 20th century
philosopher and scientist Thomas Kuhn, a paradigm shift in science is infrequent. Kuhn states
that:
“One accepts a new scientific paradigm because one believes that adopting it will better solve the unsolved scientific problems of the present, not because one knows that the new paradigm is any better than the old paradigm”.214
Given this evidence-based climate of what defines medicine, including osteopathy and many
other health care professions in the twenty-first century, there seems to be an illusion of certainty
that rides on the coat tails of this paradigm of thinking. Certainty is seen as the “Holy Grail” of
science, providing comfort and surety, despite the fact that science itself is based on doubt, and
that good medical practitioners always leave a door open for an alternative explanation to their
findings. The “million dollar question” in this heated debate is whether or not modern medicine,
with all of its accolades and extraordinary discoveries, is truly more effective than traditional
medicine.215
214 Shahar, E. Evidence-based medicine: a new paradigm or the Emperor’s new
clothes? Journal of Evaluation in Clinical Practice, 4(4) (1998): 279. 215 Sturmberg, J.P. The illusion of certainty – a deluded perception? Journal of
Evaluation in Clinical Practice, 17 (2011): 507.
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Within the various disciplines of the scientific community, there are a wide range of treatment
methods. This diversity of methods should continue to exist outside of any hierarchical ranking
or status. The scientific community benefits from both mathematical equations and narrative
descriptions. Perhaps one is more appropriate than the other under certain circumstances, but
one should not be seen as more “scientific” than the other. As long as science is focused on
finding answers, gathering new information, and increasing knowledge, humanity will need both
words and symbols, both simulations and descriptions. It means that a well-constructed
philosophical argument can further our scientific understanding in a similar way to that of a
beautiful equation.216
In the 21st century, the osteopathic profession needs to educate the scientific community with its
own unique approach to solving the problems of disease. This objective of integrating the
philosophy of complex thinking into mainstream science is an uphill battle, especially when
attempting to shift an entire movement that is already positioned at the opposite end of the
philosophical spectrum. Osteopaths embrace the potential uncertainty that is part of any
interactions with patients and their dysfunctions; they understand that when working within a
complexity framework, the guidelines are not black and white and the education of patients and
their families on simplified cause and effect models can be problematic. Within health care,
there is inevitably a certain degree of uncertainty, misdiagnosis and error in clinical judgment. It
is the responsibility of the osteopath to clearly communicate with patients and to provide
solutions that meet their unique health care needs. The osteopath sees the world as dynamic, in a
process of constant change, with the whole system in a continual state of flux, with probability
replacing certainty and interpretation replacing prediction.217
6.2 What is the future of the Complexity movement?
There clearly appears to be a division between the traditional osteopathic way of thinking and the
mainstream reductionist perspective, with regards to the optimal delivery of health care. The
main objective of the powerful EBM movement is to promote a paradigm of validation that seeks
“the ultimate truth” using algorithms and statistical calculations, while dismissing scientific
curiosity and/or any form of uncertainty. Proponents of EBM believe that knowledge that can be
216 Richardson & Cilliers, 12. 217 Doll & Trueit, 846.
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established and measured is the only compelling knowledge and the only knowledge worth
promoting. Complexity theorists on the other hand would argue that the rigid approach of EBM
is in contradiction to the true spirit of scientific discovery, and that health problems are not
solved based on the mathematical results of studies, but rather through human interaction and
patient-specific care. While science has made enormous strides in understanding the universe,
the next great uncharted frontier is the phenomenon of complexity science.
Throughout the processes of data collection, collaboration and idea generation for this thesis, the
author came across two excellent examples of the complexity movement that are directly
applicable to the osteopathic reasoning process. The first of these examples is an EVOST study
(EVOST is an acronym for Evolutionary Osteopathy) and the second is the Santa Fe Institute.
EVOST, or “Evolutionary Osteopathy”, refers to evolutionary medicine in the field of
osteopathy. This philosophical approach focuses on knowledge, consciousness and questioning.
The EVOST study is not concerned with knowledge in the sense of simply acquiring
information, but rather knowledge in the sense of “knowing”, a conviction in understanding how
the human body functions and adapts to life’s encounters.218 This form of medicine stems from
the Darwinian “theory of micro-evolution and (his) natural selection principles”, which have
various practical medical applications; for instance Gastro-enteric medicine, internal medicine,
psychology and osteopathy. The affiliates at EVOST have elaborated upon the 4 major
osteopathic ideologies (described on page 89-90 of this thesis from a complexity perspective.
The following is a summary of EVOST’s modified, complexity-specific ideologies:
1. Human organisms are complex adaptive systems that self-organized and evolved in
“Form”, with consciousness, mind and spirit as emergent behaviour, as an indivisible
whole.
2. Complex adaptive systems like human organisms demonstrate health maintenance and
resilience by means of self-regulation, self-repair mechanisms and replication;
individually and as a species.
218 Girardin, M., & Hoppner, J.P. (2012). Retrieved from http://evost.org/.
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3. Self organization, micro- and macro-evolution composes interrelated structure and
function as “Form”, while natural selection favours the best adapted “Form” to the
environmental conditions.
4. Rational treatment is based upon an understanding of the complex adaptive systems and
the basic principles on which they behave, being: “Form” unity, “Form” resilience (self-
maintenance and replication) and “Form” adaptation to the environmental conditions.219
See Figure 1 - Complex adaptive systems matrix.
219 Girardin, M & Deslee, E. & Cortoos, J.M. (2008). De-Still-ed Osteopathy: Methodological Essay on Osteopathic
Thought and Terminology. EVOST (2008): 23.
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Figure 1
Schematic review of polarization within the profession of osteopathy
Viewed through the looking glass of the Complex Systems Theory
The “traditional vitalist” approach uses an obsolete terminology.
Complexity is seen as a whole.
Loses sight of the validation by a lack of scientific approach to the details
(local agent relation).
The “scientific reductionist” approach, valid and quantifiable.
Complexity and emergence are left aside because they are ungraspable and unquantifiable.
Loss of the holistic view tends to reject philosophy and resulting concept.
The red oval (in the figure above) represents the Gordian knot, or the battle front on which the two factions confront.220
220 Girardin et al, 24.
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The Santa Fe Institute is a private, non-profit transdisciplinary research community where
researchers have organized and defined the science of complex adaptive systems (CAS). Its goal
is to expand the boundaries of scientific understanding, to discover, comprehend and
communicate the common fundamental principles of CAS that underlie the most profound
challenges facing the global scientific community today . The institute is of the opinion that
time-honoured methodologies and perspectives have stifled innovative thinking and have led to
overall stagnation under a reductionist regime. The founders of the Santa Fe Institute recognized
that no scientific platform existed from which questions could be presented about emergent,
adaptive and co-evolving behaviours. The Institute feels that complexity science is widely
accepted as a worthy scientific endeavour.221
The Institute’s philosophy of complex systems and its research efforts seem to be very congruent
with the practices of traditional osteopathy. It would be an appropriate marriage (the merging of
osteopathy and the Institute’s approaches) of hybrid intellect incorporating complexity research
and case-controlled studies regarding osteopathic treatment and intervention; this blended
philosophy could provide a new direction of problem-driven science.
The Santa Fe Institute is a complexity research and education centre representing leading
scientists from various disciplines: sponsored research, publications, working paper
Fellowships, community and education outreach programs and various professional development
courses.
6.3 What is the future of osteopathy?
How will science, EBM and complexity thinking evolve in the future? There is plenty of room
in the scientific and osteopathic communities for clinicians to provide “speculative imagination,
scrupulous honesty, mathematical command, logical perspicuity as well as experimental
inventiveness and ingenuity”.222 All of these are relevant within the overall framework of
osteopathy, medicine and science.
221 Santa Fe Institute. (2012). Mission and vision. Santa Fe Institute. Retrieved from
http://santafe.edu/about/mission-and-vision/ 222 Toulmin, 115.
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The question asked in this paper is “Which paradigm of thinking (EBM or complexity) is best
suited for the osteopathic profession?” Here we have two rival ideologies which possess some
similar characteristics but also some very fundamental differences. There is certainly a place for
biomedical and mathematical statistics in various fields of medicine; osteopathy is not one of
those fields. Osteopathy is about expanding the viewpoints of the medical community and
allowing for conceptual innovations in the treatment of patients. It should come as no surprise
then that osteopathy dismisses the rigid structure of research protocols that cannot answer the
difficult questions that continue to emerge within the human body. Mathematical forecasting
and prediction fail to encompass the multiple variables (intrinsic and extrinsic) affecting the
systems of the human body, whereas osteopathy and complexity thinking leverage a non-
exclusive methodology, and at least make a conscientious effort to accurately account for all
changes and variables. Current scientific methodology prefers a quantitative approach because
its results can be calculated into an authoritative result. Its main objective is to arrive at non-
decomposable elementary units that can be grasped clearly and distinctly, on their own. The
logic of the West is a homeostatic logic, destined to maintain the equilibrium of the discourse by
banning contradiction or deviation; it controls and guides all developments of thinking.223 A
fundamental shift towards a complexity paradigm of thinking, would encourage greater
acceptance of imagination and creativity amongst health care practitioners, enable the
osteopathic profession (at a grassroots level) to challenge the edifice of EBM and promote an
environment of individualized, dynamic and patient-focussed care. Osteopathic practitioners
recognize that despite science and philosophy being separate entities, they are inevitably linked
in a way that is not commonly being instructed in today’s healthcare environment. Too much
specialization, fragmentation and compartmentalization exists, thereby overlooking the need to
focus attention on the individual patient as a whole person.
Having been trained as a physiotherapist at McMaster University (one of the world’s foremost
authorities in EBM and problem-based learning), the author has had the privilege of learning the
ins and outs of EBM and applying this theory in a private practice setting, and in patient
treatments and interventions. It was not until the author was introduced to the profession of
osteopathy and the complexity paradigm of thinking that he began to question some of the deep-
223 Morin, 34.
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rooted educational beliefs that stem from reductionist foundations. Health care providers have
learned well how to separate the many different parts of the body from the whole and in doing
so, further disconnect “the subject from the object, and the object from the environment”. This
has lead to an evolution of specialization in medicine that inevitably isolates one’s way of
thinking about and communicating with the individual, the patient, and the client. However, the
traditionally trained osteopath understands the flaws in the way the medical system has trained
them and therefore offers a unique insight into the “wholeness” of the systems that make up
human beings and the disease states that impact us.
“The science of autonomy is founded on the new vision of the physical universe. This universe is no longer subject solely to deterministic order, but obeys the rules of the game of order/disorder/organization. For the last hundred years, in all sectors, physics recognizes chance and works with chance. Henceforth we see the universe in terms of probability and improbability, and we have discovered that it is in the zones of improbability that innovations, the pilot-fish of becoming, can arise. In fact, therefore, our physical, biological, and anthropo-social universe, the universe of our existence and understanding, is a mix/combination of order (laws, regularities, constants structures, probabilities) and disorder (chance, agitations, random meetings, collisions, dispersions). This apparent incoherent universe is nevertheless the only one where we can conceive of becoming and innovation. We cannot see how change and the new could arise in a totally deterministic universe; we cannot see organization in a totally random universe”.224
After considerable exposure to both paradigms of thinking and the frequent application of both
paradigms in clinical patient care settings as a health care provider (both a physiotherapist and an
osteopath), the complexity concept of assessing, treating and making clinical decisions ranks far
superior in patient outcome management. Osteopaths understand the logic / reasoning behind
looking at humans as self-organizing beings.
“On our planet, we are essentially living beings – are systems that are not only closed (protecting their integrity and their identity) but also open to their environment, from which they derive matter, energy, information, and organization. Self-organizing beings, therefore, are self-eco-organizing beings, which leads to this fundamental complex idea: all autonomy constitutes itself in and through ecological dependence. As far as we are concerned, our ecological independence is not only natural but social and cultural as well”.225
224 Morin, 112. 225 Morin, 113.
104
In his quote above, Edgar Morin brings to light the advantage that osteopaths possess through
their methodology, in comparison to other health care professions: everything that makes up the
human body and its systems are interrelated, and nothing is ever truly isolated in the universe. It
is therefore of the greatest importance to have optimal knowledge of the parts that make up the
whole and knowledge of the whole that is comprised of many parts. It is the responsibility of
osteopaths to study and become experts in the anatomy, physiology, and pathophysiology of all
the systems of the body and to become masters of the manual therapy skills that accompany
them.
6.4 Osteopathic instruction in schools
It is the humble opinion of the author that our educational system has been structured around a
linear analytical approach to learning and that it is this ideology that is embraced by EBM.
Students and osteopathic clinicians alike need to be encouraged that learning is a lifelong
process, and that the appreciation of intuition and the promotion of creative thinking are what
make osteopaths distinctive in their global approach to (and perspective of) the human body and
its health and disease processes. Learning is a complex activity and has to be instructed as such.
A famous quote of Chinese philosopher Zhuanghi, dating back to the 3rd and 4th centuries, says:
“A good butcher changes his knife once a year, because he slices flesh. A mediocre butcher changes his knife once a month, because he hacks at bone. Close observation of a skilled artisan at work, such as a master butcher, reveals an internal coherence to the execution of the skill. It is economical, fluid, elegant and – paradoxically restrained. The knife’s edge seems to “fall” into the meat. The best artisans are at one with their tools and the objects of their work – they do not force. Indeed, there is a sense of minimal interference from the hands, a kind of “lifting off, where the tool does the work. Paradoxically, while “grip” may seem key to control tools, it is “release” that distinguishes the expert from the novice. The novice’s grip is taut and fearful, where the master butcher shows “ease and relaxation” in the heat of work. It is to this level of expertise that every novice aspires, in any trade of profession”.226
Students of osteopathy, as well as current practitioners, should strive to achieve the level of
expertise noted in Zhuanghi’s quote. Osteopathic practitioners should continually look to refine
their skills, and wholeheartedly internalize complexity as the philosophy of their professional
226 Bleakley, A. Blunting Occam’s razor: aligning medical education with studies of complexity. Journal of
Evaluation in Clinical Practice, 16 (2010): 849.
105
career. Osteopaths should embrace the clinical intuition they possess as long as its foundation is
based upon sound, concrete medical knowledge. It is the unwavering dedication to education in
one’s discipline that is the constant reminder that we are all apprentices; journeymen on a
mission of lifelong learning, striving to perfect our craft and, in time, become masters.
106
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Appendix A:
Osteopathic manipulative treatment for low back pain: a systematic
review and meta-analysis of randomized controlled trials
______________________________________________________________________________
BioMed Central
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BMC Musculoskeletal Disorders
Open AccessResearch articleOsteopathic manipulative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trialsJohn C Licciardone*1, Angela K Brimhall2 and Linda N King3
Address: 1Osteopathic Research Center, University of North Texas Health Science Center, Fort Worth, TX 76107, USA, 2Department of Family Medicine, University of North Texas Health Science Center, Fort Worth, TX 76107, USA and 3Gibson D. Lewis Health Science Library, University of North Texas Health Science Center, Fort Worth, TX 76107, USA
Email: John C Licciardone* - [email protected]; Angela K Brimhall - [email protected]; Linda N King - [email protected]
* Corresponding author
AbstractBackground: Osteopathic manipulative treatment (OMT) is a distinctive modality commonly used byosteopathic physicians to complement their conventional treatment of musculoskeletal disorders.Previous reviews and meta-analyses of spinal manipulation for low back pain have not specifically addressedOMT and generally have focused on spinal manipulation as an alternative to conventional treatment. Thepurpose of this study was to assess the efficacy of OMT as a complementary treatment for low back pain.
Methods: Computerized bibliographic searches of MEDLINE, EMBASE, MANTIS, OSTMED, and theCochrane Central Register of Controlled Trials were supplemented with additional database and manualsearches of the literature.
Six trials, involving eight OMT vs control treatment comparisons, were included because they wererandomized controlled trials of OMT that involved blinded assessment of low back pain in ambulatorysettings. Data on trial methodology, OMT and control treatments, and low back pain outcomes wereabstracted by two independent reviewers. Effect sizes were computed using Cohen's d statistic and meta-analysis results were weighted by the inverse variance of individual comparisons. In addition to the overallmeta-analysis, stratified meta-analyses were performed according to control treatment, country where thetrial was conducted, and duration of follow-up. Sensitivity analyses were performed for both the overalland stratified meta-analyses.
Results: Overall, OMT significantly reduced low back pain (effect size, -0.30; 95% confidence interval, -0.47 – -0.13; P = .001). Stratified analyses demonstrated significant pain reductions in trials of OMT vsactive treatment or placebo control and OMT vs no treatment control. There were significant painreductions with OMT regardless of whether trials were performed in the United Kingdom or the UnitedStates. Significant pain reductions were also observed during short-, intermediate-, and long-term follow-up.
Conclusion: OMT significantly reduces low back pain. The level of pain reduction is greater thanexpected from placebo effects alone and persists for at least three months. Additional research iswarranted to elucidate mechanistically how OMT exerts its effects, to determine if OMT benefits are longlasting, and to assess the cost-effectiveness of OMT as a complementary treatment for low back pain.
Published: 04 August 2005
BMC Musculoskeletal Disorders 2005, 6:43 doi:10.1186/1471-2474-6-43
Received: 08 November 2004Accepted: 04 August 2005
This article is available from: http://www.biomedcentral.com/1471-2474/6/43
© 2005 Licciardone et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
BMC Musculoskeletal Disorders 2005, 6:43 http://www.biomedcentral.com/1471-2474/6/43
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BackgroundHistorically, low back pain has been the most commonreason for visits to osteopathic physicians [1]. More recentdata from the Osteopathic Survey of Health Care in Amer-ica has confirmed that a majority of patients visiting oste-opathic physicians continue to seek treatment formusculoskeletal conditions [2,3]. A distinctive element oflow back care provided by osteopathic physicians is oste-opathic manipulative treatment (OMT). A comprehensiveevaluation of spinal manipulation for low back painundertaken by the Agency for Health Care Policy andResearch in the United States concluded that spinalmanipulation can be helpful for patients with acute lowback problems without radiculopathy when used withinthe first month of symptoms [4]. Nevertheless, becausemost studies of spinal manipulation involve chiropracticor physical therapy [5], it is unclear if such studies ade-quately reflect the efficacy of OMT for low back pain.
Although the professional associations that representosteopaths, chiropractors, and physiotherapists in theUnited Kingdom developed a spinal manipulation pack-age consisting of three common manual elements for usein the UK Back pain Exercise and Manipulation (UKBEAM) trial [6], there are no between-profession compar-isons of clinical outcomes [7,8]. It is well known thatOMT comprises a diversity of techniques [9] that are notadequately represented by the UK BEAM trial package.Professional differences in spinal manipulation are morepronounced in research studies, where chiropractors havefocused almost exclusively on high-velocity-low-ampli-tude techniques [10]. For example, a major trial of chiro-practic manipulation as adjunctive treatment forchildhood asthma used a high-velocity-low-amplitudethrust as the active treatment [11]. The simulated treat-ment provided in the sham manipulation arm of this chi-ropractic trial, which ostensibly was thought to have notherapeutic effect, had a marked similarity to OMT[10,12]. Further, because differences in professional back-ground and training lend themselves to diverse manipula-tion approaches, clinicians have been warned aboutgeneralizing the findings of systematic reviews to practice[13].
In addition to professional differences in the manual tech-niques themselves, osteopathic physicians in the UnitedStates, unlike allopathic physicians, chiropractors, orphysical therapists, can treat low back pain simultane-ously using both conventional primary care approachesand complementary spinal manipulation. This representsa unique philosophical approach in the treatment of lowback pain. Consequently, there is a need for empiricaldata that specifically address the efficacy of OMT for suchconditions as low back pain [14]. The present study wasundertaken to address this need by conducting a system-
atic review of the literature on OMT and performing ameta-analysis of all randomized controlled trials for lowback pain performed in ambulatory settings.
MethodsSearchA search of the English language literature was performedthrough August 2003 to identify reports of randomizedcontrolled trials of OMT. We searched MEDLINE, OLDM-EDLINE, EMBASE, MANTIS, OSTMED, Alt Health Watch,SciSearch, ClinicalTrials.gov, CRISP, and the CochraneCentral Register of Controlled Trials. A detailed descrip-tion of the search strategy is provided in the Appendix [seeAdditional file 1]. Additionally, reports were sought fromrelevant reviews or meta-analyses of spinal manipulation[9,15-32] and manual searches of reference citations inthe reviewed literature sources.
SelectionThe search bibliographies and relevant reports werereviewed by the authors to identify randomized control-led trials involving OMT in human subjects. To assess theefficacy of OMT in primary care, eligibility was limited torandomized controlled trials of OMT performed by osteo-paths, osteopathic physicians, or osteopathic trainees thatincluded blinded assessment of low back pain in ambula-tory settings. Trials that involved manipulation underanesthesia, industrial settings, or hospitalized patientswere not included. Because there is potential confusionregarding the type of manipulation performed in some tri-als [33], the reported methods in each trial were carefullyreviewed to assess eligibility for the meta-analysis. Over-all, seven studies known or purported to involve OMT forlow back pain were reviewed and excluded for not meet-ing all eligibility criteria [34-40]. A subsequent source [41]indicated that an osteopathic manipulation techniquewas used in the Irvine study [42]. Although several of thesix included OMT trials were identified in multiple bibli-ographic databases, five [42-46] were indexed inMEDLINE. The Cleary [47] trial was identified exclusivelythrough the Cochrane Central Register of ControlledTrials.
Data extractionEach eligible trial was independently reviewed by two ofus to abstract data on methodological characteristics,OMT and control treatments, and low back pain out-comes. Conflicting data were resolved by consensus.
Trial characteristicsAs shown in Table 1, the six OMT trials were conductedbetween 1973 and 2001 in the United Kingdom or theUnited States [42-47]. Two of the six trials each includedtwo control treatments [43,46], thus providing eight OMTvs control treatment comparisons. The trials generally
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Table 1: Summary of trials.
Hoehler 1981 [42] Gibson 1985 [43] Cleary 1994 [47]
Years conducted 1973–1979 ... 1991–1992Country United States United Kingdom United KingdomSetting University clinic Hospital outpatient clinic Ambulatory clinicNo. of subjects randomized 95 109 30*Comparison OMT vs soft tissue massage and sham
manipulationOMT vs short-wave diathermyOMT vs detuned short-wave diathermy
OMT vs sham manipulation
Subjectcharacteristics
Age, yMean ± SD OMT, 30.1 ± 8.4
Controls, 32.1 ± 9.8OMT, 34 ± 14Short-wave diarthermy controls, 35 ± 16Detuned short-wave diathermy controls, 40 ± 16
Overall age range, 50–60
Sex% male OMT, 59
Controls, 59OMT, 49Detuned short-wave diathermy controls, 68Short-wave diarthermy controls, 53
OMT, 0Controls, 0
Type of low back pain Referred patients with acute or chronic low back pain
Referred patients with low back pain of greater than 2 months' and less than 12 months' duration
Recruited subjects with chronic low back pain in conjunction with menopausal symptoms
OMT protocolTechnique High-velocity, low-amplitude thrust
onlyVariety of techniques Low-force techniques
No. of treatmentsMean ± SD OMT, 4.8 ± 2.7
Controls, 3.9 ± 2.54, per protocol 10, per protocol
Outcomes assessment Blinded Blinded Assessment independent of treatment, blinding not specified
No. of pain contrasts 3 6 (3 for each of the two OMT vs control treatment comparisons)
1
Type of pain outcome Dichotomous pain outcomes Dichotomous pain outcomes Dichotomous pain outcomeTiming of pain contrasts
Short-term First treatment and mean, 20–30 days following randomization
2 and 4 weeks ...
Intermediate-term Mean, 41–51 days following randomization
... ...
Long-term ... 12 weeks 15 weeksAndersson 1999 [44] Burton 2000 [45] Licciardone 2003 [46]
Years conducted 1992–1994 ... 2000–2001Country United States United Kingdom United StatesSetting Health maintenance organization Hospital orthopedic department University clinicNo. of subjects randomized 178 40 91Comparison Usual care and OMT vs usual care
onlyOMT vs chemonucleolysis Usual care and OMT vs usual care and
sham manipulationUsual care and OMT vs usual care only
Subject characteristicsAge, y
Mean ± SD OMT, 28.5 ± 10.6Controls, 37.0 ± 11.0
Overall, 41.9 ± 10.6 Usual care and OMT, 49 ± 12Usual care and sham manipulation controls, 52 ± 12Usual care only controls, 49 ± 12
Sex% male OMT, 41
Controls, 44Overall, 48 Usual care and OMT, 31
Usual care and sham manipulation controls, 43Usual care only controls, 35
Type of low back pain Patients with low back pain of 3 or more weeks' and less than 6 months' duration
Recruited patients with low back pain and sciatica; mean duration, 30 and 32 weeks in OMT and chemonucleolysis groups, respectively
Recruited subjects with low back pain of at least 3 months' duration
OMT protocol
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were comparable in their methodology, with the possibleexception of the Cleary [47] trial. Twenty contrasts werereported in the six trials (a contrast refers to a within-trialcomparison between OMT and a control treatment withrespect to a low back pain outcome at a given point intime). Following randomization, nine contrasts were
reported within one month (short-term outcomes),another seven contrasts were reported within threemonths (intermediate-term outcomes), and the remain-ing four contrasts were reported within 12 months (long-term outcomes).
Technique Variety of techniques, individualized to patient
Variety of techniques, individualized to patient
Variety of techniques, individualized to subject
No. of treatmentsMean ± SD 8, per protocol Mean for OMT, 11; range 6–18 7, per protocol
Outcomes assessment Blinded Blinded BlindedNo. of pain contrasts 1 3 6 (3 for each of the two OMT vs
control treatment comparisons)Type of pain outcome Pain scale Pain scales Pain scalesTiming of pain contrasts
Short-term ... 2 weeks 1 monthIntermediate-term 12 weeks 6 weeks 3 monthsLong-term ... 12 months 6 months
OMT denotes osteopathic manipulative treatment.*A total of 30 subjects with menopausal symptoms were randomized; however, only 12 subjects had low back pain.
Table 2: Summary of analyses.*
Meta-Analyses Sensitivity Analyses
Overall Median Contrasts Best-case and worst-case scenarios4 possible combinations of contrasts including one control treatment per trialCleary [47] trial excludedAll 20 contrasts
Stratified Median ContrastsA. Control Treatment
1. Active treatment or placebo control Best-case and worst-case scenarios2 possible combinations of contrasts including one control treatment per trialCleary [47] trial excludedAll 16 contrasts
2. No treatmentB. Country Where Trial was Performed
3. United Kingdom Best-case and worst-case scenarios2 possible combinations of contrasts including one control treatment per trialCleary [47] trial excludedAll 10 contrasts
4. United States Best-case and worst-case scenarios2 possible combinations of contrasts including one control treatment per trialAll 10 contrasts
C. Duration of Follow-Up5. Short-term Best-case and worst-case scenarios
All 9 contrasts6. Intermediate-term 4 possible combinations of contrasts including one control treatment per trial7. Long-term 2 possible combinations of contrasts including one control treatment per trial
Cleary [47] trial excluded
*There were insufficient contrasts to perform sensitivity analyses for the no treatment stratified analysis. For the short-term stratified analysis, the median contrast was defined to be that corresponding to the eighth combination when effect sizes for the 16 possible contrast combinations were rank ordered from least to greatest. For the intermediate-and long-term stratified analyses, the median contrasts defaulted to the all-contrasts analyses because there were no repeated measures within these time intervals in any trial. All possible contrast combinations were included in the sensitivity analyses for intermediate-and long-term follow-up because of the limited numbers of combinations for these analyses.
Table 1: Summary of trials. (Continued)
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The methodological quality of four of the OMT trials [42-45] was independently confirmed in a recent systematicreview that included a best evidence synthesis incorporat-ing eight explicit quality criteria, including similarity ofbaseline characteristics of subjects or reporting of adjustedoutcomes; concealment of treatment allocation; blindingof subjects; blinding of providers or other control forattention bias; blinded or unbiased outcomes assessment;subject dropouts reported and accounted for in the analy-sis; missing data reported and accounted for in the analy-sis; and intention-to-treat analysis or absence ofdifferential co-interventions between groups in studieswith full compliance [13]. The Cleary [47] trial was noteligible for this review because it did not include a suffi-ciently large number of subjects. Although the Licciardone[46] trial was not eligible for the review because it waspublished after the closing date of December 2002, it hasbeen characterized as an innovative and important trialwith many rigorous design features [48], and morerecently has been identified as an evidence-based supple-ment relative to the previous review from the CochraneLibrary [49].
Quantitative data synthesisWe used the effect size, computed as Cohen's d statistic, toreport all trial results [50]. A negative effect size repre-sented a greater decrease in pain among OMT subjects rel-ative to control treatment subjects. Dichotomous painmeasures were transformed to effect sizes by first comput-ing the relevant P-value and then determining the effectsize and 95% confidence interval (CI) that would obtainunder the assumption of a two-tailed t-test for measuringthe standardized mean difference between OMT and con-trol treatments in the relevant number of subjects [50].The meta-analysis results were weighted by the inversevariance for each OMT vs control treatment comparison.The Q statistic was used to test the homogeneity of trialsincluded in each analysis [51].
The overall meta-analysis included the eight OMT vs con-trol treatment comparisons. Four of the six trials, involv-ing six of the eight OMT vs control treatmentcomparisons, each reported three contrasts [42,43,45,46](Table 1). The median contrast, as identified by the inter-mediate effect size among the three reported pain out-comes for a given OMT vs control treatment comparison,was used to represent the pain outcome for each of thesesix comparisons. These median contrasts were thencombined with the lone contrasts reported in each of thetwo remaining OMT vs control treatment comparisons[44,47]. Based on the similarity among trials (Table 1), afixed-effects model initially was used to perform meta-analysis and the results were then compared with those ofa random-effects model.
Flowchart of trialsFigure 1Flowchart of trials.
Potentially relevant
reports identified during
original searches (n=389)
Excluded reports (n=268)
· Not related to osteopathic
manipulative treatment
· Duplicate reports
· False drops
Screened reports based
on available title, subject,
heading, or abstract (n=121)
Excluded reports (n=75)
· Not related to osteopathic
manipulative treatment
· Did not meet randomized
controlled trial criteria
Retrieved reports for
detailed evaluation (n=46)
Excluded reports (n=29)
· Not related to osteopathic
manipulative treatment
· Did not meet meta-analysis
inclusion criteria
Evaluated reports for low
back pain outcomes (n=17)
Excluded reports (n=11)
· Antibody response to
hepatitis B vaccine
· Bronchial asthma
· Bronchiolitis
· Fibromyalgia
· Menstrual cramps
· Muscle contraction headaches
· Shoulder pain
· Otitis media
· Pancreatitis
· Pneumonia
· Post-operative atelectasis
Included randomized controlled
trials (n=6): 8 osteopathic
manipulative treatment vs
control treatment comparisons
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A series of sensitivity analyses were then performed. First,to address the possibility of bias by using the median con-trasts method, analyses were repeated using the best-caseand worst-case scenarios for the six relevant OMT vs con-trol treatment comparisons [42,43,45,46]. Second, toaddress the possibility of bias by including comparisonsinvolving the same OMT group vs two different controltreatment groups in two trials [43,46], analyses wererepeated using only one OMT vs control treatment com-parison for each of these trials. Each of the four possiblecombinations of contrasts was analyzed. Third, the analy-sis was repeated after excluding the Cleary [47] trial.Finally, an analysis was performed using all 20 low backpain contrasts. Similar analyses were performed after strat-ifying trials according to control treatment, country wherethe trial was performed, and duration of follow-up.
As summarized in Table 2, there were 43 analyses per-formed, including the overall meta-analysis, seven strati-fied meta-analyses, and 35 sensitivity analyses. Meta-analysis was performed only when there were at leastthree contrasts available for data synthesis. Database man-agement and analyses were performed using the Compre-hensive Meta-Analysis software package (Version 1.0.23,Biostat, Inc, Englewood, NJ 07631, USA).
ResultsOverall analysesThe search for reports is summarized in Figure 1. A totalof 525 subjects with low back pain were randomized inthe eligible trials. The overall results are presented in Fig-
ure 2. There was a highly significant reduction in painassociated with OMT (effect size, -0.30; 95% CI, -0.47 – -0.13; P = .001). The Q statistic was non-significant, thussupporting the assumption of homogeneity among trials.The primary sensitivity analyses are presented in Table 3.Using a random-effects model, the results were virtuallyidentical to those observed with a fixed-effects model.There were 729 (36 × 12) possible combinations of con-trasts for analysis based on three contrasts for each of sixOMT vs control treatment comparisons [42,43,45,46] andone contrast for each of the two remaining OMT vs con-trol treatment comparisons [44,47]. The efficacy of OMTfor low back pain was supported in both the best-case(effect size, -0.37; 95% CI, -0.55 – -0.20; P < .001) andworst-case (effect size, -0.18; 95% CI, -0.35 – 0.00; P =.046) scenarios. Similarly, when each trial was limited toone OMT vs control treatment comparison, OMT wasfound to be efficacious in each of the four analyses. OMTalso demonstrated significantly greater low back painreduction than control treatment in analyses with theCleary [47] trial excluded and with all 20 contrastsincluded.
Stratified analysesThe results of stratified meta-analyses are presented inTable 4. There was a significant reduction in low back painassociated with OMT in trials vs active treatment or pla-cebo control (effect size, -0.26; 95% CI, -0.48 – -0.05; P =.02), independent of fixed-effects or random-effectsmodel specification. There were 243 (35 × 11) possiblecontrast combinations based on three contrasts for each
Effect size for low back painFigure 2Effect size for low back pain. CI denotes confidence interval; OMT, osteopathic manipulative treatment. Overall effect size, -0.30; 95% CI, -0.47 – -0.13; P = .001.
Control No. of subjects
Source, year treatment
Hoehler 1981 [42] Active and placebo 56 39 17
Gibson 1985 [43] Active treatment 38 27 12
Gibson 1985 [43] Placebo control 39 33 14
Cleary 1994 [47] Placebo control 8 4 2
Andersson 1999 [44] No treatment 83 72 29
Burton 2000 [45] Active treatment 20 20 8
Licciardone 2003 [46] Placebo control 32 19 9
Licciardone 2003 [46] No treatment 42 17 9
Overall 318 231 100
Effect size (95% CI)WeightControlOMT
-2.00 -1.00 0.00 1.00 2.00
Favors OMT Favors Control
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of five OMT vs control treatment comparisons[42,43,45,46] and one contrast for another remainingOMT vs control treatment comparison [47]. Both the best-case and worst-case scenarios demonstrated a greaterreduction in pain with OMT than active treatment or pla-cebo control, although the worst-case results did notachieve statistical significance. OMT was found to signifi-cantly reduce pain in the remaining analyses that limitedOMT vs active treatment or placebo control comparisonsto one per trial, excluded the Cleary [47] trial, andincluded all 16 contrasts. The OMT vs no treatment con-trol comparisons were observed in trials in which all sub-jects received usual low back care in addition to theirallocated treatment (ie, OMT and usual care vs only usualcare) [44,47]. For these trials, the all-contrasts model (ie,the only model with sufficient contrasts for data synthe-sis) demonstrated a highly significant reduction in painwith OMT.
Trials in both the United Kingdom (effect size, -0.29; 95%CI, -0.58 – 0.00; P = .050) and the United States (effectsize, -0.31; 95% CI, -0.52 – -0.10; P = .004) demonstratedsignificant reductions in low back pain associated withOMT. In the sensitivity analyses, effect sizes were generallyof comparable magnitude in both countries, althoughresults in American trials consistently achieved statisticalsignificance as a consequence of the larger sample sizes inthese trials (Table 4).
There were significant reductions in low back pain associ-ated with OMT during the short-term (effect size, -0.28;95% CI, -0.51 – -0.06; P = .01), intermediate-term (effectsize, -0.33; 95% CI, -0.51 – -0.15; P < .001), and long-term(effect size, -0.40; 95% CI, -0.74 – -0.05; P = .03) follow-
up periods. Sensitivity analyses for temporal outcomesdemonstrated that intermediate-term results consistentlyachieved statistical significance, generally because of thegreater number of subjects in these analyses (Table 4). Theresults of the meta-analyses and sensitivity analyses arefurther summarized in Figure 3.
DiscussionEfficacy of osteopathic manipulative treatmentThe overall results clearly demonstrate a statistically sig-nificant reduction in low back pain with OMT (Figure 2).Further, the meta-analysis results are quite robust as indi-cated by the comprehensive sensitivity analyses (Figure3). Stratified meta-analyses to control for moderator vari-ables demonstrated that OMT significantly reduced lowback pain vs active treatment or placebo control and vs notreatment control. If it is assumed, as shown in a review[52], that the effect size is -0.27 for placebo control vs notreatment in trials involving continuous measures forpain, then the results of our study are highly congruent(ie, effect size for OMT vs no treatment [-0.53] = effect sizefor OMT vs active treatment or placebo control [-0.26] +effect size for placebo control vs no treatment [-0.27]).
It has been suggested that the therapeutic benefits of spi-nal manipulation are largely due to placebo effects [53]. Apreponderance of results from our sensitivity analysessupports the efficacy of OMT vs active treatment or pla-cebo control and therefore indicates that low back painreduction with OMT is attributable to the manipulationtechniques, not merely placebo effects. Also, as indicatedabove, OMT vs no treatment control demonstrated painreductions twice as great as previously observed in clinicaltrials of placebo vs no treatment control [52]. Thus, OMT
Table 3: Overall results.
No. of Subjects
Model No. ofContrasts
OMT Control EffectSize
95% CI P
Median contrastsFixed-effects model* 8 318 231 -0.30 -0.47 – -0.13 .001Random-effects model 8 318 231 -0.31 -0.49 – -0.13 .001
Best-case scenario 8 293 220 -0.37 -0.55 – -0.20 <.001Worst-case scenario 8 298 221 -0.18 -0.35 – 0.00 .046Median contrasts, one OMT vs control treatment comparison per trial
Gibson [43] active treatment control and Licciardone [46] placebo control 6 237 181 -0.30 -0.49 – -0.10 .003Gibson [43] active treatment control and Licciardone [46] no treatment control
6 247 179 -0.39 -0.59 – -0.20 <.001
Gibson [43] placebo control and Licciardone [46] placebo control 6 238 187 -0.26 -0.45 – -0.06 .01Gibson [43] placebo control and Licciardone [46] no treatment control 6 248 185 -0.35 -0.54 – -0.15 <.001
Median contrasts, Cleary [47] trial excluded 7 310 227 -0.29 -0.47 – -0.12 .001All contrasts 20 727 520 -0.29 -0.40 – -0.17 <.001
CI denotes confidence interval; OMT, osteopathic manipulative treatment.*Test for homogeneity, P = .37.
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Table 4: Stratified results.
No. of Subjects
Model No. ofContrasts
OMT Control EffectSize
95% CI P
OMT vs. Active Treatment or Placebo Control
Median contrastsFixed-effects model* 6 193 142 -0.26 -0.48 – -0.05 .02Random-effects model 6 193 142 -0.26 -0.48 – -0.05 .02
Best-case scenario 6 174 132 -0.34 -0.57 – -0.11 .004Worst-case scenario 6 183 134 -0.07 -0.29 – 0.16 .54Median contrasts, one OMT vs control treatment comparison per trial
Gibson [43] active treatment 5 154 109 -0.33 -0.58 – -0.08 .01Gibson [43] placebo control 5 155 115 -0.26 -0.51 – -0.02 .03
Median contrasts, Cleary [47] trial excluded 5 185 138 -0.24 -0.47 – -0.02 .03All contrasts 16 534 400 -0.21 -0.34 – -0.08 .002
OMT vs. No Treatment Control
All contrasts 4 193 120 -0.53 -0.76 – -0.30 <.001Trials Performed in the United Kingdom
Median contrastsFixed-effects model* 4 105 84 -0.29 -0.58 – 0.00 .050Random-effects model 4 105 84 -0.30 -0.63 – 0.02 .06
Best-case scenario 4 105 88 -0.36 -0.64 – -0.07 .01Worst-case scenario 4 100 83 -0.11 -0.40 – 0.19 .48Median contrasts, one OMT vs control treatment comparison per trial
Gibson [43] active treatment 3 66 51 -0.46 -0.83 – -0.09 .02Gibson [43] placebo control 3 67 57 -0.30 -0.66 – 0.05 .10
Median contrasts, Cleary [47] trial excluded 3 97 80 -0.26 -0.56 – 0.04 .09All contrasts 10 294 247 -0.23 -0.40 – -0.06 .01
Trials Performed in the United States
Median contrastsFixed-effects model* 4 213 147 -0.31 -0.52 – -0.10 .004Random-effects model 4 213 147 -0.32 -0.57 – -0.06 .01
Best-case scenario 4 188 132 -0.38 -0.61 – -0.16 .001Worst-case scenario 4 198 138 -0.22 -0.44 – 0.00 .050Median contrasts, one OMT vs control treatment comparison per trial
Licciardone [46] placebo control 3 171 130 -0.24 -0.47 – -0.01 .04Licciardone [46] no treatment control 3 181 128 -0.36 -0.59 – -0.14 .002
All contrasts 10 433 273 -0.33 -0.48 – -0.18 <.001Short-Term Follow-Up
Median contrastsFixed-effects model* 5 181 130 -0.28 -0.51 – -0.06 .01Random-effects model 5 181 130 -0.31 -0.61 – -0.01 .046
Best-case scenario 5 196 142 -0.41 -0.62 – -0.19 <.001Worst-case scenario 5 181 136 -0.10 -0.32 – 0.12 .38All contrasts 9 357 258 -0.23 -0.39 – -0.07 .01
Intermediate-Term Follow-Up
Median (all) contrastsFixed-effects model* 7 283 209 -0.33 -0.51 – -0.15 <.001Random-effects model 7 283 209 -0.36 -0.63 – -0.10 .01
Median contrasts, one OMT vs control treatment comparison per trialGibson [43] active treatment and Licciardone [46] placebo control 5 209 161 -0.31 -0.52 – -0.10 .004Gibson [43] active treatment and Licciardone [46] no treatment control 5 209 158 -0.45 -0.65 – -0.24 <.001Gibson [43] placebo control and Licciardone [46] placebo control 5 209 166 -0.25 -0.46 – -0.05 .02Gibson [43] placebo control and Licciardone [46] no treatment control 5 209 163 -0.39 -0.59 – -0.18 <.001
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may eliminate or reduce the need for drugs that can haveserious adverse effects [44].
Because osteopathic physicians provide OMT to comple-ment conventional treatment for low back pain, they tendto avoid substantial additional costs that would otherwisebe incurred by referring patients to chiropractors or otherpractitioners [54]. With respect to back pain, osteopathicphysicians make fewer referrals to other physicians andadmit a lower percentage of patients to hospitals thanallopathic physicians [1], while also treating back painepisodes with substantially fewer visits than chiropractors[55]. Although osteopathic family physicians are lesslikely to order radiographs or prescribe nonsteroidal anti-inflammatory drugs, aspirin, muscle relaxants, sedatives,and narcotic analgesics for low back pain than their allo-pathic counterparts, osteopathic physicians have a sub-stantially higher proportion of patients returning forfollow-up back care than allopathic physicians [56]. In theUnited Kingdom, where general practitioners may referpatients with spinal pain to osteopaths for manipulation,it has been shown that OMT improved physical and psy-chological outcomes at little extra cost [57].
In our study, the effect sizes for OMT in the United King-dom, where osteopaths are not licensed physicians, weregenerally comparable to those in the United States, whereOMT is provided by licensed physicians. This consistencysuggests that the results truly reflect the effects of OMTitself, and not other elements of low back care. It is notsurprising that osteopaths in the United Kingdomachieved pain reduction with OMT similar to that of theirphysician counterparts in the United States. The trainingof osteopaths in the United Kingdom is highly focused onOMT, whereas osteopathic physicians undertake amedical curriculum that necessarily relegates OMT to oneof many therapeutic approaches, albeit a fundamentalone for osteopathic practitioners. Regardless of the career
training path of the provider, it appears that OMTachieves clinically important reductions in low back pain.
Potential limitationsThere are several potential limitations of this study thatshould be addressed. First, as with any meta-analysis, theindividual trials varied somewhat with respect to method-ology, including trial setting, subject characteristics, OMTand control treatment interventions, and pain measures(Table 1). Such heterogeneity has been commonlyobserved in previous meta-analyses of spinal manipula-tion, including a recent meta-analysis performed in col-laboration with the Cochrane Back Review Group [31].The latter study addressed potential heterogeneity by pre-senting stratified results according to chronicity of lowback pain, type of control group, and duration of follow-up. This approach is analogous to the methods used inour study. Further, it should be noted that the assumptionof homogeneity among trials was not rejected statisticallyin any of our eight overall or stratified median contrastsmeta-analyses.
Second, because five trials each included repeated painmeasures and two trials each included two control treat-ments, there was no unique set of independent outcomesfor meta-analysis. Such interdependencies were noted tobe a problem in an early meta-analysis of spinal manipu-lation [15]. We used the median contrasts method toaddress this problem because the median outcome repre-sents an observed outcome that is easy to compute and isless vulnerable to extreme observations than other meas-ures of central tendency. Further, sensitivity analysis wasused to assess the range of possible combinations of out-comes. Thus, for the overall meta-analysis, there were 729potential contrast combinations. Of these, both the best-case and worst-case scenarios demonstrated statisticallysignificant results favoring OMT, thereby providing une-quivocal evidence for the efficacy of OMT. Robust find-
Long-Term Follow-Up
Median (all) contrastsFixed-effects model* 4 87 53 -0.40 -0.74 – -0.05 .03Random-effects model 4 87 53 -0.41 -0.82 – -0.01 .046
Median contrasts, one OMT vs control treatment comparison per trialLicciardone [46] placebo control 3 55 38 -0.23 -0.65 – 0.19 .28Licciardone [46] no treatment control 3 55 34 -0.64 -1.08 – -0.20 .01
Median contrasts, Cleary [47] trial excluded 3 79 49 -0.36 -0.72 – 0.01 .054
CI denotes confidence interval; OMT, osteopathic manipulative treatment.*Tests of homogeneity, P = .45 and P = .06 for active treatment or placebo control, and no treatment control groups, respectively; P = .32 and P = .26 for trials in the United Kingdom and the United States, respectively; and P = .14, P = .06, and P = .28 for short-term, intermediate-term, and long-term follow-up, respectively.
Table 4: Stratified results. (Continued)
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ings were also observed for trials performed in the UnitedStates and for intermediate-term outcomes.
Third, because there were a relatively small number of eli-gible trials, there were not sufficient contrasts for certainanalyses and some results were imprecise. The latter phe-nomenon likely obviated the statistical significance ofsome results. Nevertheless, it is important to note that thedirection of results favored OMT in each of the 43 meta-analyses and sensitivity analyses presented herein (Figure3).
Fourth, there exists the possibility that the results ofunpublished trials of OMT for low back pain may havealtered significantly the conclusions of this study. Toaddress this issue, we performed file drawer analysis bycomputing the fail-safe N [58]. This represents thenumber of unpublished trials of OMT for low back painthat would have met our inclusion criteria, and that alsowould have demonstrated an effect size averaging ≥ -0.10,which is assumed to reflect clinically insignificant levels ofpain reduction. A total of 16 unpublished trials (assumingone control group per trial) with, in the aggregate, clini-
cally insignificant pain reduction outcomes would havebeen needed to obviate the significance of our results.Only recently has government funding for research in thearea of complementary and alternative medicine becomemore widely available, in response to the public's interestin such treatments. Historically, it is highly unlikely that16 trials of OMT for low back pain would have been spon-sored, conducted, and subsequently not published.
Finally, this study focused only on the efficacy of OMTwith respect to pain outcomes. Generic health status,back-specific function, work disability, and back-specificpatient satisfaction are other recommended outcomedomains [59] that were not assessed because the includedOMT trials did not consistently report these data.
ConclusionThe present study indicates that OMT is a distinctivemodality that significantly reduces low back pain. Thelevel of pain reduction is greater than expected from pla-cebo effects alone and persists for at least three months.Additional research is warranted to elucidate mechanisti-cally how OMT exerts its effects, to determine if OMT ben-
Summary of meta-analysis resultsFigure 3Summary of meta-analysis results. A denotes all-contrasts model; B, best-case scenario model; C, Cleary [47] trial excluded model; M, median contrasts model; NT, no treatment control; OMT, osteopathic manipulative treatment; W, worst-case sce-nario model. 1, 2, 3, and 4 indicate alternative models restricted to one OMT vs control treatment comparison per trial. A dia-mond indicates the inclusion of the relevant contrast or observation of the stated result. Sensitivity analyses are shaded in gray. Results are presented for each of the 43 analyses, including the overall meta-analysis, seven stratified meta-analyses, and 35 sensitivity analyses.
NT
Comparison Duration of
Source, year treatment follow-up M B W 1 2 3 4 C A M B W 1 2 C A M M B W 1 2 C A M B W 1 2 A M B W A M 1 2 3 4 M 1 2 C
Hoehler 1981[42] Active and placebo Immediate � � � � � � � � � � � � � � � � � �
Hoehler 1981 [42] Active and placebo 20-30 Days � � � � � � � � �
Hoehler 1981 [42] Active and placebo 41-51 Days � � � � � � � � � � �
Gibson 1985 [43] Active treatment 2 Weeks � � � � � � � �
Gibson 1985 [43] Active treatment 4 Weeks � � � � � � � � �
Gibson 1985 [43] Active treatment 12 Weeks � � � � � � � � � � � � � � � �
Gibson 1985 [43] Placebo control 2 Weeks � � � � � � � �
Gibson 1985 [43] Placebo control 4 Weeks � � � � � � � � � � � � � � � �
Gibson 1985 [43] Placebo control 12 Weeks � � � � � � � � �
Cleary 1994 [47] Placebo control 15 Weeks � � � � � � � � � � � � � � � � � � � � � � �
Andersson 1999 [44] No treatment 12 Weeks � � � � � � � � � � � � � � � � � � � � �
Burton 2000 [45] Placebo control 2 Weeks � � � � � � � � � � � � � � � � � � � � �
Burton 2000 [45] Placebo control 6 Weeks � � � � � � � � � � �
Burton 2000 [45] Placebo control 12 Months � � � � � � � � � �
Licciardone 2003 [46] Placebo control 1 Month � � � � � � � �
Licciardone 2003 [46] Placebo control 3 Months � � � � � � � � �
Licciardone 2003 [46] Placebo control 6 Months � � � � � � � � � � � � � � � �
Licciardone 2003 [46] No treatment 1 Month � � � � � � � � � � � �
Licciardone 2003 [46] No treatment 3 Months � � � � � � � �
Licciardone 2003 [46] No treatment 6 Months � � � � � � � �
Number of contrasts in analysis 8 8 8 6 6 6 6 7 20 6 6 6 5 5 5 16 4 4 4 4 3 3 3 10 4 4 4 3 3 10 5 5 5 9 7 5 5 5 5 4 3 3 3
Direction of effect favors OMT � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �
Statistically significant effect � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �
Reversal of significance with random-effects model � � �
Test of homogeneity is statistically significant � � �
Overall analysis
Active/placebo ShortUnited Kingdom United States Long
Stratified analyses
Control treatment Country where trial was performed Duration of follow-up
Intermediate
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efits are long lasting, and to assess the cost-effectiveness ofOMT as a complementary treatment for low back pain.
Competing interestsThe author(s) declare that they have no competinginterests.
Authors' contributionsJCL, AKB, and LNK conceived and designed the study.LNK performed the literature searches. JCL and AKBextracted the data. JCL performed the statistical analyses.JCL, AKB, and LNK interpreted the data and drafted themanuscript. JCL will act as guarantor for the paper. Theguarantor accepts full responsibility for the conduct of thestudy, had access to the data, and controlled the decisionto publish. All authors approved the final manuscript.
Additional material
AcknowledgementsThis research was supported in part by a grant (No. D56HP00170) from the Health Resources and Services Administration, United States Depart-ment of Health and Human Services. The funding organization had no role in the design, conduct, and reporting of this study.
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Additional File 1this file provides the timetable, databases, and search terms used to iden-tify relevant studies for the meta-analysis.Click here for file[http://www.biomedcentral.com/content/supplementary/1471-2474-6-43-S1.doc]
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