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Perspective

Tradition-Dismissive vs. Tradition Reconceptualization Approaches in Musculoskeletal Care: The Example of Osteopathic Care

by
Giandomenico D’Alessandro
1,2,3,
Christian Lunghi
1,*,
Giacomo Consorti
4,
Silvia Zanon
5,
Francesca Berti
6,
Matteo Turinetto
5,
Luca Di Pietrantonio
7,
Mauro Longobardi
8,
Rafael Zegarra-Parodi
1 and
Francesca Baroni
1
1
BMS Formation, 75116 Paris, France
2
Clinical-Based Human Research Department, Foundation Centre for Osteopathic Medicine (COME) Collaboration, 65121 Pescara, Italy
3
Research Department, A.T. Still Academy Italia (ATSAI), 70124 Bari, Italy
4
Osteopathy Track and Field Division, Istituto Superiore di Osteopatia, 20126 Milan, Italy
5
Istituto Superiore di Osteopatia, 20126 Milan, Italy
6
Independent Researcher, 20100 Milan, Italy
7
Accademia Italiana Osteopatia Tradizionale, 65125 Pescara, Italy
8
Independent Researcher, 00100 Rome, Italy
*
Author to whom correspondence should be addressed.
Appl. Sci. 2025, 15(7), 3828; https://doi.org/10.3390/app15073828
Submission received: 8 March 2025 / Revised: 27 March 2025 / Accepted: 29 March 2025 / Published: 31 March 2025
(This article belongs to the Special Issue Advances in Orthopedic Rehabilitation)
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Abstract

:
Background: Musculoskeletal conditions with multisystem comorbidities present significant challenges in terms of prevention and rehabilitation. Despite advances in instrumental technologies for diagnosis and treatment, a gap remains between biomedical research and practical application. Strengthening the therapeutic alliance involves improving patients’ understanding of diagnostics and treatment, while emphasizing face-to-face interactions. A team of healthcare professionals, promoting an integrated approach combining manual and movement therapies—such as physiotherapy, chiropractic, and osteopathic care—can bridge this gap, promoting well-being through a person-centered framework. Emerging research highlights the role of cognitive, neurophysiological, and sociocultural factors in body perception and health, emphasizing the need for inclusive, culturally sensitive care within osteopathic practice. Methods: We synthesize the available evidence and expert insights to address gaps in the literature. Our approach integrates conceptual analysis with emerging research, applying Driscoll’s reflective model to generate a practical framework rooted in osteopathic principles and clinical experiences. Results: We propose an integrative model incorporating narrative-based sense-making, shared decision-making, mindfulness, and active participation. By blending historical osteopathic principles with modern evidence, the model aims to enhance health resilience, reduce unnecessary interventions, and establish a holistic framework for prevention and rehabilitation. Conclusions: Integrating diverse approaches within osteopathic care refines clinical practices, ensuring a more person-centered, culturally sensitive, and holistic approach to musculoskeletal rehabilitation. This model bridges the gap between tradition and modern evidence, enhancing therapeutic outcomes and fostering an inclusive healthcare system.

1. Introduction

Musculoskeletal conditions, particularly those with multisystem comorbidities, pose a significant challenge in terms of global prevention and rehabilitation [1,2,3]. Currently, advanced instrumental technologies provide valuable data to inform musculoskeletal rehabilitation [4,5] and manual therapy in clinical practice [6], both in diagnostic and therapeutic strategies. However, despite these technological advancements, a gap persists between biomedical research findings and their practical application in routine clinical settings. Furthermore, there is a need to improve patients’ understanding of these technological findings and the associated standardized interventions. Although technological tools are available, prioritizing face-to-face interactions when integrating technology into clinical encounters is essential, as it enhances the perception of personal attention in the patient–practitioner relationship [7]. To bridge the gap between patients and practitioners and strengthen the therapeutic alliance, an integrated treatment approach—combining manual and movement therapies—could be implemented. However, physiotherapy, chiropractic care, and osteopathic care must redefine their roles in delivering manual therapy, facilitating movement, alleviating pain, and enhancing overall well-being by adopting a person-centered care framework [8]. There is also a need for a practical framework to integrate verbal and nonverbal narratives, exploring relevant determinants of patient complexity, such as body representation and psychological, cognitive, and social factors, to facilitate shared sense- and decision-making [9,10]. As emerging evidence from cognitive, neurophysiological, psychological, and scientific research reshapes healthcare practices, these disciplines face increasing pressure to integrate early principles with person-centered, evidence-informed approaches [11]. Moreover, sociocultural factors influencing body perception and health are gaining recognition as crucial in optimizing therapeutic outcomes [11]. Advancing research is essential to refine manual therapy interventions across life stages, ensuring safe and effective care from pregnancy and child development to occupational health and age-related functional decline [12]. A key example of this ongoing reconceptualization is osteopathic care (OC) [13]. Indeed, within the osteopathic community, there is an ongoing debate surrounding osteopathic principles and conceptual models [14]. More precisely, this debate represents the twofold essence of osteopathic practice. Contemporary OC is shaped by two distinct yet interrelated perspectives, both striving to redefine theoretical and clinical osteopathic models [11,14]. Some “tradition-dismissive” authors argue that osteopathic practice largely relies on outdated and untested hypothetical theories, perpetuates a simplistic cause–effect approach (e.g., somatic dysfunction (SD) and structure/function treatment models), and should therefore be critically re-evaluated [14]. Furthermore, authors have claimed that osteopathic terminology, diagnostic labels, and the associated narratives may reflect ableist biases [15]. Others contend that such concepts, rooted in “anatomical possibilism”—the assumption of exaggerated, implausible, and unverified anatomical relationships—have reinforced the reductive “body-as-a-machine” paradigm [16]. Additionally, there are articles reporting that the communication of early osteopathic concepts to patients, such as SD, might serve as a profession-specific source of nocebo and other adverse effects [17]. This could inadvertently promote the medicalization of non-specific complaints, such as medically unexplained symptoms, and reinforce beliefs in the mechanistic explanations of non-specific pain or disability. This should also be supported from pedagogical and ethical points of view. Indeed, starting from an intersectional feminist perspective, authors have strongly criticized the use of the body to acquire knowledge, arguing that it is exclusive, harmful, and centered on normative standards of “normality” [18].
Conversely, advocates of a “tradition reconceptualization” approach, including osteopathic practitioners (OPs), researchers, and academics, advocate for the integration of technical rationality, informed by neurocognitive and social sciences, with professional artistry and clinical expertise grounded in early principles. Their aim is not to discard osteopathic early concepts but to reconceptualize them by addressing three essential needs: drawing from foundational origins, developing innovative and distinctive practical approaches, and articulating the entire process in a scientifically up-to-date manner [11,19,20,21]. For example, the perspective of “tradition-reconceptualization-minded osteopaths” considers the profession’s need to embrace the critical role of human diversity, as highlighted by “tradition-dismissive” authors; this can be effectively addressed by examining the historical development of culturally sensitive OC over time [22]. From a historical perspective, it should be mentioned that A.T. Still advocated for the osteopathic community to be forever free, regardless of sex, race, or skin color [23,24,25]. Osteopathic principles and their holistic approach serve as examples of social inclusion for contemporary OPs [11]. Additionally, it should be acknowledged that OC prioritizes function over aesthetics [19]. When aesthetics is considered, it is approached in a broad, scientific sense, related to patients’ pleasant–unpleasant perceptions and experienced as a “guide” to hypothesize what is optimal from a homeostatic and salutogenic perspective, as outlined by the neuroaesthetic-enactive paradigm (NEP) [19]. The application of the NEP in OC establishes an integrative approach that incorporates principles from neuroaesthetics and enactivism into the therapeutic interaction between osteopathic practitioners and patients. This paradigm highlights the significance of multisensory perception, embodied cognition, and aesthetic experience in shaping the therapeutic process. It reframes OMT as more than a biomechanical intervention, emphasizing its dynamic and interactive nature, where the patient and practitioner collaboratively create meaning, regulate physiological responses, and adapt through touch, movement, and sensory engagement. By applying NEP principles, the OP acknowledges how aesthetic perceptions—such as the patient’s sense of coherence between the delivered OMT and their embodied agency—enhance the patient experience, strengthen the therapeutic alliance, and optimize clinical outcomes through embodied sense-making and active inference [19]. The epistemological flexibility inherent in OC [11] allows the integration of diverse paradigms beyond the biomedical model, potentially offering a more expansive and inclusive biopsychosocial and existential framework for manual therapy [20]. This gives rise to a practice model in which the OP and patient collaborate within an active and participatory approach [21]. A comprehensive understanding of theories of consciousness and their influences on body representation from traditional to evidence-informed perspectives is crucial in evaluating how various therapeutic systems address health, illness, and disease management, focusing on OC and manual therapies. OC, drawing on its early Indigenous medicine legacy (e.g., Native American healing traditions, bonesetters’ craft, magnetic healing, and other early osteopathic influences) [22] and the subsequent adoption of person-centered and culturally sensitive models, emphasizes a conceptual approach in which the body is not merely an object of treatment. Instead, it is understood as an interconnected whole, where health is viewed as an expression of dynamic equilibrium that is also able to include patients’ existential perspectives [11]. A convergence point between the “tradition-dismissive” and “tradition reconceptualization” perspectives within the osteopathic debate is represented by enactivism [13]. This holistic and dynamic approach to cognitive science underscores the significance of embodied and embedded interactions between the organism and its environment, a concept that aligns with osteopathic principles, from traditional foundations to contemporary developments. (En)active inference has been proposed as a framework to inform clinical practice in osteopathy, physiotherapy, chiropractic, and other health professions that incorporate manual therapies [13].
It provides a pan-professional conceptual foundation, fostering an interprofessional approach to patients’ biobehavioral synchronization through effective communication, patient engagement, and nonverbal modalities such as touch and proximity [26]. Building upon this interdisciplinary foundation, it is essential to develop a distinctive osteopathic framework that systematically integrates these principles into clinical practice [22]. This article aims to examine the clinical significance and implications of the patient’s bodily, cognitive, and existential domains, with a particular emphasis on their clinical assessment and practical applications in everyday healthcare practice, using OP experiences as an example. The present perspective aims to develop a distinctive osteopathic framework that integrates neurocognitive and social sciences with foundational osteopathic principles, promoting a holistic and inclusive approach to musculoskeletal health. This framework will be informed by enactivism and emphasize patient engagement and biobehavioral synchronization. Additionally, it seeks to create a practical, integrated model that combines osteopathic manipulative treatment (OMT) with patient active participatory osteopathic approaches (PAOA), reinforcing a person-centered care approach to complement technological musculoskeletal rehabilitation. This framework aims to provide valuable support for all healthcare professionals involved in the patient’s overall management plan, including physicians, nurses, occupational therapists, and physiotherapists. It will also incorporate verbal and nonverbal narratives, considering patient complexity, body representation, and sociocultural factors, while fostering shared decision-making to optimize the therapeutic outcomes in musculoskeletal care.

2. Materials and Methods

2.1. Research Question

This perspective paper explores the following research question: “How can an integrative conceptual and practical framework that reconciles osteopathic tradition-dismissive and tradition reconceptualization approaches, while incorporating osteopathic principles informed by enactivism and related biobehavioral synchrony strategies, contribute to the development of a patient-centered osteopathic model that enhances the clinical application of bodily, cognitive, and existential domains; optimizes musculoskeletal health outcomes; and fosters interprofessional collaboration in clinical practice?”

2.2. Study Design and Theoretical Framework

This perspective paper was developed following established guidelines for the writing of commentaries, a methodological approach that is commonly used to explore emerging areas of inquiry in the absence of extensive empirical data [27]. To address the study objectives, the authors examined the existing literature on consciousness and body representation to bridge the academic divide between materialistic and non-materialistic perspectives in manual therapy. The theoretical framework was developed through a collaborative brainstorming process among a team of experts (G.D., F.B., C.L., and R.Z.-P.), each with over 10,000 h of experience in education, scientific research, and clinical osteopathic practice [28]. This process was grounded in clinical observations and informed by the best available evidence.

2.3. Literature Search Strategy

A comprehensive literature search was conducted between July and December 2024 using MEDLINE (PubMed). To identify relevant search terms, the research team reviewed Medical Subject Headings (MeSH) and their corresponding subheadings related to osteopathic care (OC) and other manual therapies [29]. Eleven MeSH terms were deemed effective in retrieving the literature on manual therapy research: manipulation, osteopathic; osteopathic medicine; chiropractic; exercise movement techniques; exercise therapy; manipulation, orthopedic; massage; muscle relaxation; muscle stretching exercises; musculoskeletal manipulations; and traction.
These MeSH terms were supplemented with additional keywords relevant to the study’s focus, including: professional identity, interprofessional relations, medical rationalities, shared decision-making, therapeutic alliance, enactivism, allostasis, touch, synchrony, interoception, autonomic nervous system, traditional medicine, person-centered care, and evidence-based practice. The search was limited to articles published in English, with no restrictions on the study design, population, outcomes, or publication date.

2.4. Eligibility Criteria and Selection Process

No formal validity or quality assessments were performed, seeking to ensure a comprehensive exploration of the available literature. The selection process followed a two-stage approach, conducted independently by the authors (G.D., F.B., C.L., and R.Z.-P.). First, article abstracts were screened to assess their relevance to the research question. Second, full-text versions of the selected studies were reviewed using the same criteria. Additionally, the reference lists of the identified articles were examined, and a snowball sampling approach was employed to identify further relevant studies.

2.5. Reflective and Conceptual Framework Development

To facilitate the systematic development of a practical and shareable conceptual framework, the authors applied Driscoll’s reflective model [30] during a structured brainstorming process grounded in the literature research findings and clinical experience. This process comprised three key stages: (1) What?—identifying and summarizing key themes and insights from the literature; (2) So What?—analyzing the significance of these findings and assessing their relevance in developing a practical framework; (3) Now What?—outlining practical applications and implications for clinical practice and future research. The brainstorming sessions were conducted by a team of experts (all authors), drawing on their combined expertise in education, scientific research, and clinical osteopathic practice, with over 10,000 h of collective experience [28].

3. Results

Eighteen relevant articles [11,13,14,19,21,26,31,32,33,34,35,36,37,38,39,40,41,42] were reviewed to develop an integrative conceptual and practical framework that reconciles tradition-dismissive and tradition reconceptualization approaches in musculoskeletal care, while enhancing the clinical assessment and application of bodily, cognitive, and existential domains in osteopathic practice. The results are organized into two key subsections. The first subsection, supported by ten findings [11,13,14,26,31,32,33,34,35,36], explores the osteopathic dialog that fosters a unique identity from a dual perspective. The second subsection, supported by nine findings [11,19,21,37,38,39,40,41,42], outlines a four-step framework for the synchronization of the patient, osteopathic practitioner, and environment.

3.1. An Osteopathic Dialog Forges a Unique Identity from a Dual Perspective

This perspective article introduces an integrative conceptual and practical framework for the synchronization of the patient, OP, and environment. It offers a comprehensive perspective on distinctive OMT, highlighting both inter-professional collaboration and the unique competencies of OC.
The authors promote an osteopathic dialog to forge a unique identity from a dual perspective. Nowadays, the osteopathic community—encompassing both “tradition-dismissive” and “tradition reconceptualization” advocates—aims to move beyond the ongoing debate on renewed conceptual models of OC through the lens of enactivism [11,13,14,26,31,32,33,34,35,36]. From an enactivist perspective, therapeutic touch and hands-on techniques employed by chiropractors, physiotherapists, and OPs foster biobehavioral synchrony [31].
These approaches enhance body–mind alignment, impacting postural, autonomic, physiological, endocrine, and brain responses during social interactions and daily activities in the physical environment [31]. Already applied to other healthcare professions [34], recently, this conceptual model has been transversally proposed in musculoskeletal care in general [26], in pediatric care and neonatology [32], and in OC [33,34,35,36]. However, a practical framework for its implementation in OC, taking into account the distinctive features of OC itself (i.e., SD, osteopathic principles, osteopathic clinical reasoning), has yet to be established [37], although a theoretical proposal exists [13]. To initiate this process, a multidisciplinary panel of clinicians, researchers, and academics recently examined body representations and consciousness to define the core principles of an osteopathic model for patient–practitioner–environment synchronization.
Their approach ensures alignment with person-centered care, evidence-based frameworks, and traditional epistemological perspectives. Furthermore, the authors underscore the need for a structured practical framework to facilitate its application in clinical practice [37]. Building on the historical foundations of osteopathic principles and contemporary perspectives from both “tradition-dismissive” and “tradition reconceptualization” authors, we propose a structured rational approach that emphasizes the distinctive aspects of osteopathic practice while integrating interprofessional dimensions (Figure 1).

3.2. Four-Step Framework for Patient–Osteopathic Practitioner–Environment Synchronization

Nine of the articles included in this perspective paper were used to support a four-step framework for patient–practitioner–environment synchronization, which consists of (1) narrative-based sense-making and decision-making (Table 1) [11,37,38], (2) touch-based shared sense-making and decision-making (Table 2) [19,37,39], (3) hands-on mindfulness-based OMT (Table 3) [19,21,39,40], and (4) patient active participatory osteopathic approaches (PAOA) (Table 4) [41,42].
To guide shared decision-making and participatory actions in the rational practice of the patient–practitioner synchronization model, the Cynefin framework (CF) could be implemented. The CF is a fascinating approach, as it acknowledges the intricate, multi-layered nature of patient care, integrating complexity science within OC [11,38,40]. By framing the osteopath–patient interaction within the CF, this method helps to differentiate between domains that require different types of interventions, whether simple, complicated, complex, chaotic, or aporetic. It specifically supports the management of the patient’s evolving condition, considering both the clinician’s clinical expertise and the patient’s unique experiences and responses to previous treatments.
During the first step, i.e., narrative-based sense-making and decision-making (Table 1), the CF helps to navigate logical disjunctions in the osteopath–patient dialog, clarifying why certain treatments have or have not worked in the past and why new approaches are being proposed [11,37,38]. The implementation of the CF in clinical reasoning aligns with the “Two-Eyed Seeing” approach [11], emphasizing epistemological flexibility by integrating biomedical principles with psychological, emotional, and existential aspects of health. This perspective views the body as a medium for human experience and interconnectedness, addressing not only musculoskeletal pain but also broader psychosocial factors influencing MSK function. This framework supports patient-centered care and aligns with patients’ values and expectations, particularly within a prevention-oriented model. This shared decision-making process allows both the OP and the patient to actively understand the condition and choose the right treatment path [11,38].
In the second step, a touch-based shared sense-making and decision-making process is employed. This process integrates both verbal and nonverbal dialog, including osteopathic touch guided by NEP [19]. This approach aims to create a “positive surprise” that updates the brain’s generative model. By engaging in this process, both the OP and the patient actively participate in understanding the patient’s condition and selecting the most appropriate treatment paths. This collaborative approach fosters a deeper connection and ensures that the treatment plan is aligned with the patient’s needs and preferences (Table 2) [19,37,39].
Within the third and fourth steps, the OC implements hands-on, mindfulness-based OMT and PAOA as intertwined strategies (Table 3 and Table 4) [21,40,41,42]. Top-down, bottom-up, manipulative passive, and active participatory strategies are integrated into the OC framework. These approaches function synergistically to address both the physiological and behavioral aspects of patient care, fostering a holistic approach that aligns with osteopathic principles and person-centered care [19,21,39,40,41,42]. By combining these methods, the framework ensures a comprehensive treatment plan that considers the patient’s active involvement, as well as the practitioner’s expert guidance. The top-down approach, i.e., mindfulness strategies (informed by osteopathic principles), can work together with bottom-up strategies (which involve empowering the patient to take an active role in their healing process).
Combining passive OMT with PAOA [41], as in the case of functional neuromyofascial activity (FNA) [21,42], allows for a dynamic, holistic, evidence-informed, and personalized approach. PAOA integrates OMT with various motor, cognitive, and behavioral strategies [41]. It includes FNA, in which the patient performs a movement body scan—focusing on bodily sensations—to assess and self-assess functional motor abilities. This approach enables both the patient (as an active agent) and the OP (along with other healthcare professionals) to recognize local and global compensatory movement patterns characterized by dysfunctional movements in specific body regions or across the entire body [21,42].
The structure of FNA is designed to make somatic aspects associated with alterations in motor function—such as SD—perceptible and comprehensible not only to patients but also to healthcare professionals who are not trained in the osteopathic palpatory diagnostic process (OPDP). Additionally, FNA provides valuable insights into the rationale for applying different types of OMT, including interventions in distant areas of the body, even while the patient is in motion, actively performing an FNA routine. A key component of the proposed method is the inclusion of “FNA snacks”, a time-efficient and well-tolerated routine performed periodically or daily, to promote the integration of smooth and effortless movement into the patient’s everyday life [21,42].
Such integrated OC, which is personalized based on SD findings, recognizes the musculoskeletal system as a bridge that interconnects and influences all other bodily systems (i.e., neurologic, biomechanical, respiratory–circulatory, metabolic–energetic, and behavioral) [39,40]. By integrating these different strategies, the OP can craft OC that responds to the complexity of each patient’s needs, navigating the unpredictability of health processes while ensuring that care remains patient-centered and adaptable. This creates a nuanced, flexible model of treatment that considers the complexity of human health beyond linear protocols, which can represent a valuable model for all healthcare professionals.

3.3. Clinical Scenario

The following clinical vignette, modified from Zegarra-Parodi et al., 2024 [11], outlines examples of patient–practitioner interactions that illustrate how the four-step framework for patient–osteopathic practitioner–environment synchronization can be adapted and applied in real-world clinical practice. Ricardo was a 44-year-old man who grew up in an urban area of South America and had been living in Europe for the past 12 years, working as a yoga instructor. In addition, he launched a podcast to promote health and well-being. Shortly after moving, he began experiencing acute episodes of spinal and leg pain, accompanied by persistent paresthesia. He also reported symptoms of irritable bowel syndrome, anxiety, sleep disturbances, widespread pain, and fatigue. Additionally, he experienced low conviviality, as he only visited his family once a year. The patient had a four-month history of recurrent pain, which his general practitioner classified as chronic leg pain with low back pain. Ricardo underwent multiple medical investigations, including a colonoscopy, MRI, and seasonal blood tests, all of which yielded no significant findings.
The proposed treatment was based on evidence-based treatments for chronic pain [43] and on a novel paradigm for treating intractable pain [44]. It included ultrahigh-frequency dorsal root ganglia stimulation [44] and pain medications (i.e., weak opioids for one week, anticonvulsants for one week, antidepressants and non-steroidal anti-inflammatory drugs for one week; in consultation with the physician, the patient decided to discontinue the pharmacological therapy, stating that there were no improvements associated with it, while complaining of undesirable side effects such as fatigue and altered attentiveness). This was combined with physical therapy, including manual therapy, pain education, and psychologically informed counseling using Acceptance and Commitment Therapy [45], which addressed the emotional challenges of living far from his family in a different cultural environment. Ricardo also reported familiarity with specific native healing practices used in rural communities, which he found beneficial in treating physical ailments and managing psychological distress. In addition, he mentioned that breathing exercises, meditation, and music played a crucial role in his stress management. However, due to his pain, Ricardo felt uncomfortable teaching yoga at this stage of his life. Seeking relief after another episode of nonspecific acute exacerbation of spinal and leg pain, Ricardo visited an osteopath. Unlike previous practitioners, the osteopath recommended a preventive session three months after the patient was symptom-free to assess his musculoskeletal function, evaluate the associated psychosocial triggers, and propose an integrated approach to OC, incorporating OMT and PAOA.
Figure 2 outlines the potential applications of the four-step framework for patient–osteopathic practitioner–environment synchronization driven by the CF. This approach helps to better align OC, integrated within the comprehensive treatment program, with Ricardo’s values and expectations, thereby facilitating shared decision-making in this complex clinical scenario. The OP employs a whiteboard, a sheet of paper, or the screen of an electronic device to visually depict the decision-making and sense-making process informed by the CF, in order to more effectively apply the four-step framework for the synchronization of the patient, osteopathic practitioner, and environment. This method helps practitioners to facilitate self-reflection in patients, enabling them to view unclear health issues from different angles, thus enhancing their understanding. Consequently, the patient can reinterpret perplexing aspects by categorizing them into different domains (e.g., simple, complicated, complex, chaotic) and applying appropriate osteopathic reasoning (Figure 2A). The practitioner documents Ricardo’s internal conflicts and unclear body perceptions related to his chronic low back and leg pain and unexplained symptoms in the central section of the sheet (Figure 2B). With the practitioner’s support, Ricardo re-evaluates these confusing elements, reallocating them to different domains and gaining insight into the reasoning and actions that can be applied. This allows him to make sense of past treatments and engage in shared decision-making about the proposed OC implementing the four-step framework for patient–osteopathic practitioner–environment synchronization (Figure 2C). Thanks to the narrative-based sense-making and decision-making process (the first step of the four-step framework), the sequence of the overall expert opinion and evidence-based orthopedic rehabilitation—encompassing pharmacological treatment, physiotherapy, and psychologically informed counseling—is represented within the simple and complicated domains (Figure 2C,D, orange and blue rectangle). This representation helps Ricardo to better understand the previous treatment and appreciate the improvements achieved. It follows a touch-based shared sense-making and decision-making process (i.e., the second step of the four-step framework), with OPDP informed by NEP to formulate the personalized OC. Based on the results of the structure/function correlation test (SFCT), it includes both steps 3 and 4 with a combination of hands-on mindfulness-based OMT and PAOA.
For example, in osteopathic encounters 1 to 3, following OPDP with negative results from SFCT, meaning that OMT applied to SD-related body areas did not show any improvement in the following symptom-oriented physical examination (SPE), functional physical examination (FPE)—including manual assessment tests of central sensitization (CS), a two-point discrimination test (TPD), and Waddell’s sign (WS)—and familiar symptoms (FS), the reasoning and actions are represented in the chaotic domain (Figure 2F, green rectangle). Consequently, the OP proposes a maximalist approach, which involves various types of passive manual techniques and global body positioning, such as preferential fascial patterns, to support the musculoskeletal system and enhance the biomechanical–postural, neurological, and psychological adaptability. Then, in osteopathic encounters 4 to 6, based on OPDP with positive results from SFCT, meaning that OMT applied to SD-related body areas shows improvements in SPE, FPE (CS, TDP, WS), and FS, the reasoning and actions are represented in the complex domain (Figure 2E, yellow rectangle). Consequently, the OP implements minimalist OMT and PAOA. The minimalist approaches focus on SD-related regions, meaning the areas of the body that evoke a patient-emergent pattern, which also illustrates the relationship between body functioning, the patient’s ability to perform daily activities, and elements of the body framework. The OC is then complemented by Ricardo’s requests to implement synchronized music therapy and the topical application of safe essential oils during the OMT.

4. Discussion

The four-step framework for patient–osteopathic practitioner–environment synchronization, as outlined to date, imbues the shared therapeutic experience with new philosophical and scientific significance. It facilitates the formation of an interactive dyad, fostering the emergence of an intersubjective analytical third—a concept originating from psychology [46]. This concept finds resonance within osteopathy, both in its classical form [47] and in its contemporary evolving models [20].
Through this framework, an ecological niche is created, wherein the therapeutic relationship acts as an amplifier of the patient’s agency. The originality of the proposed framework is in its inclusion of the updated use of SD, osteopathic principles, and osteopathic clinical reasoning and its rooting in adaptability. Indeed, the four-step framework is inherently adaptable because (1) it is situation-specific, (2) it leverages the co-constructed and continuously evolving patient–practitioner relationship as the primary instrument for both diagnosis and treatment, and (3) it relies on active listening that is both empathetic and scientifically grounded. Moreover, the proposed framework provides practitioners with a renewed capacity for action, allowing for a less automated and rigid approach, which may help to prevent boredom, burnout, and decreased professional performance [48]. Drawing on three of the “5E” principles of enactivism [36,49], the practitioner becomes embedded (serving as an additional environmental resource for the patient), enactive (actively participating in the patient’s actions), and extended (integrating beyond traditional clinical boundaries). The latter is particularly significant as it represents the only human extension within an increasingly high-tech rehabilitation setting [50,51], where the instruments themselves already function as “extensions” of the assistant/guide/motivation of the patient’s movement, as in the case of virtual reality and robotics [52]. It offers a challenge to an “object-centric strategy”, which focuses on designing physically realistic virtual experiences, by introducing a complementary “action-predicated” approach that prioritizes the simulation of virtual experiences with a primary emphasis on pragmatic functionality [53]. With this perspective, the practitioner, rooted in scientific principles, is encouraged to become more flexible, intuitive, participative, and creative. This is crucial considering that each practitioner brings with him his biobehavioral complexity as an biopsychosocial individual [37]. A research agenda to implement the proposed framework is presented below. At the same time, it is possible to obtain some insights into the potential results that this kind of approach could yield. Indeed, although this is the first time that this framework has been proposed in a coherent and practical fashion, there are three main aspects of our framework that have already shown their clinical usefulness: (1) the use of SD/OPF or the presence of OPDP, (2) the holistic approach derived from osteopathic principles, and (3) the individualization of each person and each treatment of a given person. By critically analyzing the osteopathic literature published so far, it is found that there are four main examples that demonstrate this concept. In a very recent systematic review and meta-analysis including nine randomized clinical trials, Ceballos-Laita et al., 2024 [54] found that OMT was not superior to a sham or placebo in patients with neck or low back pain. There were several methodological flaws in the review, such the lack of coherence between the inclusion criteria and the included studies and the arbitrary choice to not consider the inclusion of a more objective outcome, namely the number of co-interventions required to reduce the pain. However, after carefully re-reviewing the nine included studies, it is found that only one out of nine studies [55] considered all three of the above-presented main aspects that are at the basis of our paradigm. Five out of nine studies [56,57,58,59,60] performed OC by only relying on one aspect (SD/OPF), without implementing holistic approach and without performing individualized OC; three out of nine studies [61,62,63] did not use any of the three main aspects. According to the forest plot presented by the authors of the meta-analysis, Schwerla et al., 2008 [55] was the most effective study, demonstrating the intrinsic value of OC. A second example is another meta-analysis [64] that analyzed the length of stay and the costs of preterms undergoing OC compared to preterms receiving only the usual care. Five RCTs (four Italian and one Austrian) were included. The results showed that all four Italian studies [65,66,67,68] reduced the preterms’ length of stay. Unfortunately, the Austrian study [69] showed that, in the OMT group, the preterms’ length of stay was 34 days greater compared to the control group (100 vs. 66 days). The difference in performing OC in the Italian vs. Austrian studies is clear, but both are noteworthy.
In the four Italian studies, OC was conducted according to the three main aspects (SD/OPF, holistic approach derived from osteopathic principles, and individualization). In contrast, in the Austrian study, a visceral treatment was performed in a standardized way for each preterm. It is worth noting that the author referenced SD; however, there appeared to be a misinterpretation of the concept: “In the present study, delayed meconium excretion of the preterm infant was defined as the SD to be treated”. A third example is Licciardone et al., 2004 [70], who added OC in a cohort of 30 elderly patients (mean age 69.2 years) who underwent surgery for knee or hip fractures alongside conventional rehabilitation. Comparing the osteopathy cohort with a cohort of matched patients undergoing only rehabilitation, the osteopathy group showed a worsened length of stay (15.4 days for the OC group vs. 12.3 days for the control group, p = 0.09; considering all osteoarthritis patients, 14.9 days for the OC group vs. 9.3 days for the control group, p = 0.001). Furthermore, there was a statistically significantly better outcome in favor of the control group regarding the mental health subscale of the SF-36 and the locomotion subscale of the Functional Independence Measure. Finally, the rehabilitation efficiency was found to be better in the control group compared to the OC group (2.6 vs. 2.0, respectively, p = 0.01). Despite the strong methodological basis of the RCT, which made it coherent with the very recent suggestion regarding the placebo control [71], it did not include a genuine “osteopathic” counterpart.
The authors of the above study write, “Participants were evaluated by an OMT specialist to identify areas of SD [...] Treatments were performed by undergraduate fellows” [70]. This represents a form of fragmented practice in which the practitioner remains disengaged from the evaluation and diagnostic process, thereby losing the significant aspect of biobehavioral synchronization. Furthermore, the protocol established that only locoregionally operated somatic regions would be treated, referring to poorly specified “surrounding areas”. This approach did not include the three main aspects that are at the basis of the proposed paradigm. In this regard, we acknowledge that the limitations in adhering to the holistic nature of OC in the mentioned studies may have resulted from the pursuit of the highest possible methodological rigor in the research design. However, a gap between research and practice persists, particularly in studies involving complementary and integrative medicine (TCIM), including OC. It is now widely recognized that advancing evidence-informed decision-making and policy institutionalization in TCIM requires conceptual frameworks and models specifically tailored to the unique characteristics of traditional medicine—its worldviews, knowledge systems, and practices [72]. Finally, Tamburella et al., 2002 [73] showed the positive results of adding OC characterized by (1) the use of SD/OPF, (2) a holistic approach, and (3) individualization in the critical context of the neurorehabilitation department. In their RCT, seven patients suffering from neurogenic bowel dysfunction secondary to spinal cord injury received four weekly sessions of OMT. Six matched patients received four manual placebo sessions that followed the principles of equality assumption [74] and the touch equality assumption [71]. The Neurogenic Bowel Dysfunction Scale score was significantly improved only in the OMT group when comparing the follow-up versus both observation periods (p = 0.011, small effect size) and both baselines (p = 0.040, moderate effect size). Considering the OC performed, SDs were detected in the whole body and then balanced one by one to determine the primary order of treatment. Taken together, these literature examples suggest the potential role of OC performed in a manner that is practically formalized by our framework.

Limitations and Future Directions

In line with policy recommendations to enhance person-centered care, the four-step framework for patient–osteopathic practitioner–environment synchronization proposed in this perspective aims to empower patients and improve the care quality.
However, we acknowledge potential challenges in disseminating and implementing this framework in real-world settings, as existing patient-centered models continue to emphasize the prioritization of individual needs and preferences [75]. As with other healthcare professionals, we recognize key barriers to person-centered care, including entrenched traditional healthcare structures that are difficult to change, skepticism among professionals, and challenges in developing effective interventions [75]. Addressing these obstacles requires strong organizational support, leadership, training, and active engagement from both professionals and patients to ensure successful integration into routine clinical practice [75]. A comprehensive investigation is essential in designing the implementation of the proposed framework. This research will help to inform policymakers and health system decision-makers, fostering the sustainable adoption of person-centered care. This perspective article highlights the need for a future research roadmap to advance osteopathic biobehavioral synchronization by integrating early professional skills with evidence-based knowledge to foster innovative clinical approaches. The first step in this roadmap aims to define the unique contributions of OC by outlining the proposed framework and reviewing existing research. This will be achieved through a scoping review and the development of an integrative hypothesis paper. The second step seeks to expand the current knowledge by observing real-world clinical practices, focusing on accurate data collection, hypothesis generation, and the enhancement of individualized OC.
This will be accomplished through case reports following the CARE guidelines, which help to reduce bias, increase transparency, and identify early indicators of effective treatments tailored to specific patients. The third step involves exploring the clinical value of the proposed practical framework for prevention at multiple levels, including primary, secondary, tertiary, and quaternary prevention. This will be assessed through a range of epidemiological studies, including case reports, ecological studies, cross-sectional studies, case–control studies, cohort studies, and experimental studies. The fourth step focuses on investigating the physiological mechanisms underlying biobehavioral synchronization, utilizing both real-world and lab-based observational studies. To preserve the distinctiveness of the osteopathic patient biobehavioral synchronization framework, the fifth step will involve employing a Delphi panel and consensus conference. Mentorship, consensus workshops, and continuing professional development will also be integral in teaching and implementing this framework within the professional community.
Through these five steps, this roadmap will guide the future development and clinical application of osteopathic biobehavioral synchronization.

5. Conclusions

The proposed framework positions OC as a key facilitator of biobehavioral synchronization, promoting self-regulation, adaptability, and overall health resilience. By offering a distinctive and culturally sensitive approach to health perception, promotion, and maintenance, it addresses contemporary healthcare challenges while enhancing inclusivity and the quality of care. Additionally, it highlights the importance of interprofessional collaboration, emphasizing the value of teamwork among healthcare professionals (e.g., OPs and physiotherapists). Ultimately, this integrated and interprofessional approach aims to safeguard health by preventing disease onset (primary prevention), detecting and managing complications at various stages (secondary and tertiary prevention), and reducing unnecessary medical interventions and overprescription (quaternary prevention), while also supporting psychosocial and functional rehabilitation.

Author Contributions

Conceptualization, G.D., F.B. (Francesca Baroni), C.L. and R.Z.-P.; methodology, G.D., F.B. (Francesca Baroni), C.L. and R.Z.-P.; writing—original draft preparation, G.D., F.B. (Francesca Baroni), C.L. and R.Z.-P.; writing—review and editing, M.L., M.T., L.D.P., S.Z., F.B. (Francesca Berti), F.B. (Francesca Baroni), C.L., G.D., G.C. and R.Z.-P.; supervision, M.L., M.T., L.D.P., S.Z., F.B. (Francesca Berti), F.B. (Francesca Baroni), C.L., G.D., G.C. and R.Z.-P.; project administration, C.L.; funding acquisition, R.Z.-P. and C.L. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

G.D., F.B., C.L., and R.Z.-P. report competing interests, because they provide continuing professional development courses on the clinical relevance of osteopathic principles and practices in contemporary care. G.C., M.L., M.T., L.D.P., S.Z. and F.B. declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
ANRActive Neuromyofascial Release
CFCynefin Framework
CSCentral Sensitization
FNAFunctional Neuromyofascial Activity
FPEFunctional Physical Examination
FSFamiliar Symptoms
NEPNeuroaesthetic-Enactive Paradigm
OCOsteopathic Care
OMTOsteopathic Manipulative Treatment
OPOsteopathic Practitioner
OPDPOsteopathic Palpatory Diagnosis Process
OPFOsteopathic Palpatory Findings
PAOAPatient Active Participatory Osteopathic Approaches
SDSomatic Dysfunction
SFCTStructure/Function Correlation Test
SPESymptom-Oriented Physical Examination
TPDTwo-Point Discrimination Test
WSWaddell’s Sign

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Figure 1. Integrating tradition and innovation: a structured approach to osteopathic reasoning.
Figure 1. Integrating tradition and innovation: a structured approach to osteopathic reasoning.
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Figure 2. A clinical application of the four-step framework for patient–osteopathic practitioner–environment synchronization guided by the Cynefin framework. Abbreviations: symptom-oriented physical examination (SPE), functional physical examination (FPE), familiar symptoms (FS), osteopathic palpatory findings (OPF), structure/function correlation test (SFCT), manual assessment tests of central sensitization (CS), two-point discrimination test (TPD), Waddell’s sign (WS), neuroaesthetic-enactive paradigm (NEP), osteopathic palpatory diagnosis process (OPDP), osteopathic manipulative treatment (OMT), patient active participatory osteopathic approaches (PAOA), osteopathic care (OC), functional neuromyofascial activity (FNA), active neuromyofascial release (ANR).
Figure 2. A clinical application of the four-step framework for patient–osteopathic practitioner–environment synchronization guided by the Cynefin framework. Abbreviations: symptom-oriented physical examination (SPE), functional physical examination (FPE), familiar symptoms (FS), osteopathic palpatory findings (OPF), structure/function correlation test (SFCT), manual assessment tests of central sensitization (CS), two-point discrimination test (TPD), Waddell’s sign (WS), neuroaesthetic-enactive paradigm (NEP), osteopathic palpatory diagnosis process (OPDP), osteopathic manipulative treatment (OMT), patient active participatory osteopathic approaches (PAOA), osteopathic care (OC), functional neuromyofascial activity (FNA), active neuromyofascial release (ANR).
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Table 1. The first step of the four-step framework for patient–osteopathic practitioner–environment synchronization: narrative-based sensing and decision-making processes.
Table 1. The first step of the four-step framework for patient–osteopathic practitioner–environment synchronization: narrative-based sensing and decision-making processes.
StepConceptDescription
1. Narrative-based sensing and decision-making processesHistorical legacy and osteopathic principlesEarly osteopaths utilized metaphorical language, visual narratives, and storytelling to enhance the understanding of anatomy for both patients and OPs. Anatomy was often presented through metaphors to stimulate mental imagery, making complex concepts more accessible and engaging.
Contemporary knowledgeOPs adopt a phenomenological approach to highlight patients’ lived experiences and body awareness, informing personalized treatment decisions. By applying a biopsychosocial–spiritual framework, OPs encourage positive behaviors and foster a deeper connection with patient narratives.
Rational practiceThe CF serves as a visual tool for the navigation of complex patient narratives by categorizing issues into simple, complicated, complex, and chaotic domains. OPs utilize pattern recognition, expert opinion, and evidence-based strategies to facilitate shared sense-making and inform personalized decision-making. By applying a Two-Eyed Seeing approach, they integrate patient experiences of illness with biomedical factors of disease, fostering a holistic and personalized approach to care.
Distinctive aspectsAn osteopathic application of the CF involves integrating patient and OP experiences through verbal and nonverbal narratives, such as touch-based interactions, to guide shared decision-making in selecting personalized approaches.
Interprofessional elementsConsidering the enactivist perspective, touch-based interactions are utilized to enhance patient engagement and facilitate sense-making through sensory–motor learning.
Table 2. The second step of the four-step framework for patient–osteopathic practitioner–environment synchronization: touch-based shared sense- and decision-making processes.
Table 2. The second step of the four-step framework for patient–osteopathic practitioner–environment synchronization: touch-based shared sense- and decision-making processes.
StepConceptDescription
2. Touch-based shared sense- and decision-making processesHistorical legacy and osteopathic principlesHealing is a natural process, and OMT enhances rather than creates self-regulation. The concept of SD informs a whole-body touch-based strategy to improve natural motion, blood flow, fluid dynamics, and nerve function.
Contemporary knowledgeClinical encounters, resembling rituals, aim to enhance the patient’s body awareness through touch and unspoken communication, fostering meaningful interaction. These multisensory experiences transform illness narratives into lived experiences, enabling participants to recognize emergent patterns and collaboratively determine treatment strategies with the OP.
Rational practiceBy applying the NEP, OPs and patients collaboratively evaluate and select healing strategies through OPDP. Areas related to SD serve as an interface for physiological and biological touch effects. Adjustments in the type and intensity of touch are tailored to the patient’s response, bridging gaps in their understanding and transforming diagnosis and treatment into meaningful experiences. Assessment involves both verbal and nonverbal dialog, aiming to create a “positive surprise” that updates the brain’s generative model.
Distinctive aspectsThe OP applies the NEP to facilitate shared decision-making during OPDP. By integrating patient and OP experiences evoked through verbal and nonverbal touch-based interactions, they select personalized manipulative and educational treatment approaches.
Interprofessional elementsAs with other professionals like chiropractors and physiotherapists, OPs use touch-based strategies not only to meet patient expectations but also as a means of nonverbal communication, sending meaningful signals to the patient’s brain.
Table 3. The third step of the four-step framework for patient–osteopathic practitioner–environment synchronization: hands-on mindfulness-based OMT.
Table 3. The third step of the four-step framework for patient–osteopathic practitioner–environment synchronization: hands-on mindfulness-based OMT.
StepConceptDescription
3. Hands-on mindfulness-based OMTHistorical legacy and osteopathic principlesEarly osteopathic practices integrated touch-based therapeutic traditions, including bone-setting, magnetic healing, and early hypnosis. These elements have evolved into a modern osteopathic approach that incorporates mind–body and mindfulness strategies, maintaining their foundational principles in a contemporary clinical context.
Contemporary knowledgeThere is increasing interest in researching the potential effects of combining top-down and bottom-up multimodal mind–body therapies—such as OMT pain neuroscience education, and clinical hypnosis—on chronic pain and disability. The integration of manual therapies with mindfulness-based techniques is widely acknowledged in modern practice for its ability to improve patients’ awareness, attention, and interoception.
Rational practiceOMT, combined with body–mind synchronization and rhythmic movement-based strategies, utilizes both cognitive and sensory–motor mechanisms to facilitate therapeutic touch through top-down and bottom-up integration.
Distinctive aspectsInformed by the NEP, osteopathic practice highlights unique perspectives that include assessment and intervention rooted in SD. This serves as a communicative entry point, from the patient’s skin through the central nervous system to consciousness and body representation.
Interprofessional elementsOMT is administered similarly to those used by other manual therapy professionals, as they are also defined by considering evidence from studies conducted in clinical contexts that align with the patient’s condition.
Table 4. The fourth step of the four-step framework for patient–osteopathic practitioner–environment synchronization: patient active participatory osteopathic approaches (PAOA).
Table 4. The fourth step of the four-step framework for patient–osteopathic practitioner–environment synchronization: patient active participatory osteopathic approaches (PAOA).
StepConceptDescription
4. Patient active
participatory osteopathic approaches 		Historical legacy and osteopathic principlesSince its origins, OC—informed by Indigenous healing heritage and foundational principles—has combined passive OMT with active patient involvement, incorporating lifestyle recommendations such as diet, exercise, and leisure activities to promote self-care and cultivate an internal locus of health.
Contemporary knowledgeHealth professionals, including OPs, can enhance patient health education by integrating self-care strategies and multi-professional competencies, supported by appropriate training. This approach fosters an internal locus of control, empowering individuals to take responsibility for their health and engage in proactive behaviors, which is crucial in improving clinical outcomes.
Rational practiceThe implementation of FNA in osteopathic practice allows OPs and patients to assess functional motor abilities and identify areas of dysfunction through a simplified scoring system and body scans focused on bodily sensations. FNA heightens the awareness of functional capabilities and guides touch-based treatment decisions, even for distant body areas. It introduces “FNA snacks”, time-efficient daily routines designed to improve movement, coordination, and self-organization. These routines help individuals to track their progress and create self-guided strategies to enhance their functional movements in daily life. OPs apply OMT with patients, from infants to the elderly, while in motion to enhance movement synchronization with their environment.
Distinctive aspectsWhile applying PAOA, OPs, unlike other manual therapists, deliver personalized OMT as the patient performs functional movements, aiming to engage them in both assessment and treatment.
Interprofessional elementsOPs employ interdisciplinary strategies, including lifestyle, exercise, and ergonomic advice. PAOA are guided by the principles of developmental psychology and motor rehabilitation. Mindful movement strategies, such as FNA and Walking FNA, are tailored to aging populations to enhance mobility and health. To enhance a salutogenic OC strategy, the OP delivers educational information verbally, complemented by visual summaries and graphics presented on a screen or in print (e.g., the physical activity pyramid and food pyramid as self-care coping strategies). Additionally, they integrate manual therapy with complementary approaches like yoga, essential oils, and synchronized music listening to further enhance therapeutic outcomes.
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D’Alessandro, G.; Lunghi, C.; Consorti, G.; Zanon, S.; Berti, F.; Turinetto, M.; Di Pietrantonio, L.; Longobardi, M.; Zegarra-Parodi, R.; Baroni, F. Tradition-Dismissive vs. Tradition Reconceptualization Approaches in Musculoskeletal Care: The Example of Osteopathic Care. Appl. Sci. 2025, 15, 3828. https://doi.org/10.3390/app15073828

AMA Style

D’Alessandro G, Lunghi C, Consorti G, Zanon S, Berti F, Turinetto M, Di Pietrantonio L, Longobardi M, Zegarra-Parodi R, Baroni F. Tradition-Dismissive vs. Tradition Reconceptualization Approaches in Musculoskeletal Care: The Example of Osteopathic Care. Applied Sciences. 2025; 15(7):3828. https://doi.org/10.3390/app15073828

Chicago/Turabian Style

D’Alessandro, Giandomenico, Christian Lunghi, Giacomo Consorti, Silvia Zanon, Francesca Berti, Matteo Turinetto, Luca Di Pietrantonio, Mauro Longobardi, Rafael Zegarra-Parodi, and Francesca Baroni. 2025. "Tradition-Dismissive vs. Tradition Reconceptualization Approaches in Musculoskeletal Care: The Example of Osteopathic Care" Applied Sciences 15, no. 7: 3828. https://doi.org/10.3390/app15073828

APA Style

D’Alessandro, G., Lunghi, C., Consorti, G., Zanon, S., Berti, F., Turinetto, M., Di Pietrantonio, L., Longobardi, M., Zegarra-Parodi, R., & Baroni, F. (2025). Tradition-Dismissive vs. Tradition Reconceptualization Approaches in Musculoskeletal Care: The Example of Osteopathic Care. Applied Sciences, 15(7), 3828. https://doi.org/10.3390/app15073828

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