The French have a crush on osteopathy: 48% have used it over the past five years (source 1). 86% believe that this practice is beneficial for health and 82% even think that it should be reimbursed by Social Security (source 2). To meet this demand, in France the number of osteopaths has tripled in ten years. Today there are nearly 39,000, or 1 for approximately 1,748 inhabitants, the highest density in European countries (source 3).
But on the side of the doctors, practice divides. While some hospitals offer osteopathic consultations in rheumatology, oncology or pain management, others emphasize the lack of scientific evidence of its effectiveness.
Osteopathy is a manual therapy which considers that all parts of the body are interconnected by the tissues, and that a blockage in the ankles or knees can affect the cervical level, or a stomach problem can affect back pain. ” It’s a systematic approach : we often treat the whole body even if the patient comes to consult for a localized pain or symptom”, summarizes Philippe Sterlingot, president of the French Syndicate of osteopaths.
The osteopath looks for mobility restrictions in the joints, muscles or viscera, which can explain pain, digestive problems… He then tries to remove these blockages with the aim of providing support to the body, capable of “self-balancing”, even “self-healing” following these adjustments, in particular by producing analgesic or anti-inflammatory substances.
Dr. Christian Caldaguès, osteopathic general practitioner: If the physiological and biomechanical bases of osteoarticular osteopathy are well validated, craniosacral and visceral osteopathy are more controversial, because their theories have much less scientific basis.
Unlike massage therapists, osteopaths do not have the status of health professional. The profession is regulated by a decree of 2007, which sets the conditions and scope of practice of osteopathy. He states that she can prevent and treat functional disorders (musculoskeletal, digestive, respiratory, gynecological disorders, etc.), but not organic diseases, which require the intervention of a health professional. “An osteopath cannot claim to cure cancer, but he can take care of a patient with cancer to help him better support the side effects of treatment”, specifies Philippe Sterlingot.
If he is a doctor or a physiotherapist, is that better? While most osteopaths are “exclusive” (they do just that), 29% are also physiotherapists, 5% are doctors and a small number are midwives, nurses or podiatrists. They have received nearly 1,000 hours of osteopathy training. Unlike an osteopath, an osteopathic doctor can make a diagnosis and prescribe medication, additional tests or work stoppage if necessary. A physio-osteopath can establish a comprehensive rehabilitation strategy and prescribe medical devices such as knee braces.
Since 2014, a decree has set a common training standard for osteopaths, with 5 years of studies, or 5,000 hours of lessons, including 1,300 hours of practical teaching and 1,500 hours of internships. To practice, an osteopath must obtain his diploma in one of the schools approved by the Ministry of Health. However, it is not a diploma recognized by the State (DE): on the plate, the acronym DO simply means graduate in osteopathy. 30 schools were approved at the start of the 2022 academic year, including 2 with provisional approval pending the regularization of certain points. Philippe Sterlingot regrets that “some schools receive approval even though they do not meet the criteria set, in particular on the number of hours of practical training for osteopaths”.
The osteopath can perform “exclusively manual and external” manipulations. “Internal acts, vaginal and rectal exams are only authorized for doctors and midwives”, recalls Philippe Sterlingot. An exclusive osteopath should never suggest going through the rectum to realign the coccyx.
Dr. Caldaguès: In theory, a non-physician osteopath must request a medical certificate of absence of contraindication before manipulating the cervical vertebrae. In fact, it is rare, and we are fighting to ensure that this rule is better respected.
He can touch the cervical, massage or gently move the neck, but distrust if he makes them “crack” without medical advice.
Back pain is the number one reason for consultation. A review published in 2022 in the British Medical Journal concludes with a “possible” effectiveness of osteopathy for musculo-articular disorders (source 4). “Studies have shown efficacy on pain and mobility gain, with 3 to 4 sessions of 45 minutes spaced one to two weeks apart. But these results cannot be extrapolated to all osteopathic protocols”, specifies Professor Grégory Ninot, who evaluates non-drug interventions.
A study conducted in 2021 at Cochin Hospital on 400 low back pain patients (6 sessions spaced 2 weeks apart) proved to be more disappointing. “We compared osteopathic manipulations to sham manipulations,” explains Professor of Physical Medicine and Rehabilitation at Cochin Hospital Christelle Nguyen. Assessment: osteopathy does not do better than the placebo. Pain decreased by an average of 7 to 8 points on a scale of 1 to 100 in both groups and osteopathy did not reduce medication.
Several small studies published in scientific journals show a significant reduction in transit disorders and/or abdominal pain compared to a placebo (sham osteopathy) in people suffering from irritable bowel syndrome. But more often than not, the benefit is not maintained beyond 3 weeks.
According to the High Health Authority, osteopathy is one of the non-drug treatments that have shown improved quality of life in endometriosis and it can be offered. While there are currently no placebo studies, observational studies note that patients experience an improvement in their pain after a 45-minute session. The manipulations could help reduce tension around areas of fibrosis and tissue adhesion.
Effectiveness for headaches is uncertain, due to the lack of quality of the studies. “In patients who consult an osteopath, some note a improvement, but usually not long term : they will get better for 2 to 3 weeks, then the seizures come back”, observes Dr. Michel Dib, neurologist. The doctor regrets a very heterogeneous practice, without precise protocols. He does not recommend osteopathy to his patients because the result is not certain (an aggravation is also possible), and because according to him it is probably more indicated for tension headaches (related to muscle contractures around of the skull) than for migraines, of neurological origin.
If the bones of the skull have been deformed during childbirth, in the event of a “flat head”, regurgitation, colic or frequent crying, young parents are sometimes offered to take their infant to an osteopath. If a 2020 study shows a clear improvement in 3 sessions on the “flat head” syndrome, it did not compare osteopathy to the evolution in the absence of intervention. Same for reflux. Any manipulation before the age of 6 months requires, according to the law, a medical certificate “no contraindication to osteopathy”.
There are contraindications to osteopathy: phlebitis, coagulation problems, herniated disc with neurological signs, history of stroke… The risk of accident is low but it exists. Cases of fractures, herniated discs or strokes have been described. “And since it is not a health profession listed in the Public Health Code, there is no compulsory declaration of accidents”, underlines Professor Ninot. “The risk is also that patients consult their osteopath before going to the doctor and fall behind in treatment,” regrets Professor Nguyen.
Verdict: there is a lack of quality studies to confirm its effectiveness, beyond a possible placebo effect. But we can tryin addition to a medical consultation.
To read : 100 alternative medicines validated by science, Prof. Grégory Ninot and Brice Perrier, ed. Belin, €21.90.
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